Nursing Home Rules: The Front Line of Change

Article excerpt

State nursing home regulations make dull reading. Their plotlines are obscured by their very form: sections on definitions, content embodied in dated and numbered internal paragraphs and subparagraphs, amendments over time, and multiple cross-references to other parts of state administrative code or statutes. Nonetheless, buried in state law pertaining to nursing homes is an important and sometimes gripping story of how states have struggled to shape the quality and future of residential care and adapt to competing modern demands for accountability and creativity.


In March 2005, we began a time-consuming and complex task: identifying, compiling and comparing all state regulations pertaining to nursing homes to show how they promote or hinder resident autonomy and quality of life. The resulting website, NH Regulations Plus (NHRegsPlus), is a seemingly endless work in progress located at www.hpm.u As we develop this website, we hope that detailed examination and comparison of state nursing home regulations will pave the way for a discussion of the ideal set of regulations, not only for nursing homes but also for their newer residential care cousins, assisted living settings.

It is undoubtedly easier to complain about nursing home regulations than to read them. A close reading reveals provisions that seem obvious, such as "toilet paper in a suitable dispenser must be provided within reach of each toilet," as well as rules that seem archaic: "Oil lanterns and other open-flame methods of illumination are prohibited." Ambiguous and vague stipulations abound. For example, states require such elements as "a cheerful space," "a satisfactory bedstead," "a comfortable space" and "good condition linens" in nursing homes. Within the regulatory minutiae are many rarities and oddities, as well as some language that holds out promise for resident autonomy. (See "The States of Minutia" adjacent on this page.)

In 2005 and 2006, we analyzed how all states elaborate on the federal regulations and on any additional new categories of state regulations. In spring 2007, we began a reexamination process to determine whether and how, if at all, state regulations had changed during those two years.

The relevant forces of change include:

* Gradually changing federal nursing home regulations (states must meet federal minimums but may develop more stringent regulations);

* Pressuring nursing homes to promote culture change that would transform them into individualized care settings where residents could exercise autonomy and establish real homes;

* Encouraging nursing homes to present a public record of excellent clinical outcomes, including low to nonexistent levels of new pressure wounds, malnutrition, and falls and other accidents.


Nursing homes have been the object of congressional scrutiny, journalistic exposé, advocacy attention and reform efforts ever since Medicare and Medicaid legislation in 1965 generated a huge expenditure of public money for nursing home care. The federal rules governing nursing homes today largely stem from the most far-reaching effort at regulatory reform embedded in the federal Omnibus Budget Reconciliation Act of 1987. Those amendments to the Social Security Act established 14 federal standards covering such concerns as residents' rights; admission, transfer and discharge rights; resident behavior and facility practices, including physical and chemical restraint, freedom from abuse, and reporting requirements for suspected staff abuse; and quality of Ufe, with language establishing residents' right to dignity and containing specific provisions for social services and activity departments. This detailed law also prescribed standards relating to resident assessment, quality of care, nursing services, dietary services, physician services, infection control, special rehabilitation services, physical environment and administration. …