Helen Fredeking
Technical Director,
Centers for Medicare and Medicaid Services
United States Department of Health and Human Services
Thank you Mr. Brown, oh Charlie, okay. I want to particularly thank you because I have been introduced many times in my life and I think you may be one of the first people who ever pronounced my name right, so thank you. I also want to thank all of you for inviting me to spend some time with you talking about one of my favorite subjects, which is quality of care for Medicare and Medicaid beneficiaries.
I was asked to discuss some of CMS's quality activities that could directly relate to various state activities and to talk specifically about a couple of topics which is a feeding assistant regulation that we have just put out as a proposed rule and also about the general topic of abuse. I'll cover both of those topics but before I get to it I have some other points to share with you. I know that Mr. Scully was your luncheon speaker. I don't know if he said it today but often in his speeches he says something like quality is his number one priority for CMS, and as one that's been at CMS for a very long time and before that HCFA, it's interesting to see how the agency's focus on quality has evolved over all these years. Before the mid 1980's basically we were a claims processing organization and a payment organization but after the mid 80's came along and some lawsuits, the agency began to take some responsibility for issues related to quality of care.
Since that time there's been a growth in these kinds of initiatives. The peer review organizations moved from being organizations that looked at cases for whether they were appropriately being utilized in terms of care in hospitals, to organizations that are focused on trying to come up with ways for improving quality of care throughout the country. In fact their new name is Quality Improvement Organizations.
In the late '90's the organization began to move to a whole area of campaign for consumers and Mr. Scully, as I'm sure he shared with you today, has continued that effort and increased that effort to provide better and better information for consumers.
From my position working in the world of survey and certification, I tend to classify CMS's activities for improving quality in these categories. The first one is consumer information, which as we say, can educate consumers on what to consider in making choices for care and where to get information to provide some information to them.
Second category would be provider improvement activities, which are QIO's, or formerly the PRO's, but there are also kinds of quality improvement activities sponsored by either CMS or CMS in conjunction with state agencies throughout the country. There's the Regulatory Oversight Activity, which is survey and enforcement activities and in this area I'll try to update you on a number of things that are going on. There are policy initiatives, which have changed over the years and there's some I'll tell you about that have to do with quality of care.
On the consumer choice, since the late '90's, CMS has had really an active program going in terms of providing better information for consumers. The nursing home initiative, which as I say I'm sure Mr. Scully mentioned and I won't go over some of the things, but I don't know if he told you the kind of measures that were put out as part of the nursing home initiative and I'll try to share with you a few more details that he probably didn't discuss.
In the pilot state project, it was initiated at the end of April, there were measures of quality for both long term and short term stays in facilities. For long term the measures were decline and activities of daily living; prevalence of pressure sores; prevalence of weight loss; inadequate pain management; prevalence of infection, and use of physical restraints. The short stay ones that were developed, and those were for people in the facility somewhere under 20 days, would be prevalence of delirium; inadequate pain management again and improvement in walking. The ones that were published in the paper were pain and pressure sores, I believe. Those are the ones, the pain and pressure sore ones, are the ones that the QIO's will work with in various facilities and provide training and support programs over the next couple of months.
In addition to the quality measures, we used to call them indicators and now I'm getting used to the new terminology, in addition to those the CMS website on nursing homes has enormous amounts of information. It has all the survey results. It has all kinds of information on how to choose nursing homes; long-term care planning approaches. It also has information on other provider types that can be helpful in making quality choice. For instance there's information on ESRD, or end stage renal disease quality measures, and we expect fairly shortly that there will be some measures up on home health agencies. So the performance measures, useful for both the consumer in making choices but also for the Quality Improvement Organization in helping to identify facilities that might want some help in improving their performance. The QIO's will review the performance information; will reach out to various facilities and if the facility chooses to work with the QIO, then the QIO will provide support and training to the facility to help them deal with some of the problems that perhaps brought about their lower scores on some of the measurements.
We also have some best practices information that's on our website and that area is growing and the issue there is to try to provide links or summaries of many of the standards of care in practices that are developed by organizations all over the country, and rather than have some of our facilities as well as some of our staff and surveyors not know where to get them, this is an effort to try to make them accessible so that as they make decisions about care they have access to the appropriate and current standards of practice.
I just want to share with you about home health. In home health we've had an initiative going on for several years and the purpose is to bring about improvement in care. It's a demonstration project with the University of Colorado who has worked with a number of home health agencies identifying performance problems and helping them, working with them and bringing about improvement. The results, they've now done a final report on that and they have been very successful and they can show from year to year improvements in terms of the outcomes of care. So that bodes well I hope for what's happening in nursing homes and some of Mr. Scully's other quality initiatives. Over the next couple of years we expect that the QIO's will become more and more involved.
The performance measures used for consumer information and quality improvement are calculated based on information submitted to CMS and the states by the nursing homes and the home health agencies. The nursing homes conduct assessments and use information from that assessment for care planning and then that information, known as the MDS, is submitted to the state and then on to CMS, and the same process goes on for home health agencies.
Since many of the critical program initiatives for both nursing homes and home health are based on the MDS and OASIS data. It's critical that we do as much as possible to assure the accuracy of that information. One of CMS's most recent initiatives is an effort to improve the accuracy of the MDS and the OASIS data and this will be a long term process we know but we have started it, it's known as the Data Assessment and Verification or what probably you will hear from now on is we call it the DAVE project, DAVE. We started it about 6 months ago, had a contractor called the Computer Services Corporation and they have a number of subcontractors and essentially they will use a three-pronged approach for improving the quality of the MDS and OASIS data. There will be on-going data analysis using the enormous data bases that we have millions and millions of assessments and we developed some protocols for doing those reviews with APT Associates and the University of Colorado. So this will be a major sort of a data analysis looking at the information, looking for trends using the protocols. Somebody once called them plausibility analysis, identifying areas where its possible that there could well be a problem in the accuracy of the data.
In addition, there will be an off-site review and that is where the contractor will collect from nursing homes, records and review those records to see if they match or if they support the type of assessment information that was submitted by the facility.
The on-site reviews, we will also have reviews that will take place at the nursing homes where the contract team will go into the facility and do assessments following facility people and trying to identify whether they understand how to accurately conduct an assessment.
The final piece of this pronged approach is one where it's educational, where we will begin to identify trends or areas that are potentially problematic and feed that information back to the nursing facility so that they can begin to look at it and decide whether they need to take corrective action.
We're going to start this process carefully. We are now starting with two beta states, within the next couple of months and we'll have two states and we'll begin to expand over the next year. We'll look at each step along the way and make sure that we are functioning in the way that makes the most sense.
As it unfolds, we understand how critical it is to coordinate with the states. This is especially true for those states, which have their own PPS system for Medicaid and a lot of those states have their own auditing capabilities and they range from very extensive auditing to fairly limited activity. So we will almost work on a state-by-state basis, the DAVE will, with the states as we proceed in this process. I guess that since Medicare and Medicaid payment is based on this data, performance measures are based on this data; a lot of performance improvement activity that the DAVE contract is probably one of the more important initiatives that we have undertaken over the last 5 or 6 months because it will indeed support the underpinnings of all these other activities. So that's the DAVE.
One of the issues that I wanted to talk some about today is also the regulatory oversight activities. The areas that I'm going to talk about are the survey results, particularly abuse, because there was a concern expressed by some of you about some issues around abuse. I'll share with you some of the initiatives that are going on for accuracy and consistency of findings; some of the federal oversight programs, some issues related to state initiatives and some studies that are going on.
If you will flip to my map here: I didn't know exactly what the issues were around abuse that you wanted to talk about or you wanted to hear about, so I sort of have a general discussion on that topic. The federal definition for what is abuse in nursing homes or other institutional settings like ICFMR's really is about the same and it says like abuse means willful, which is a key word, infliction of injury and reasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Over the last number of years there has been about the same level of problems or deficient findings found as a result of abuse and it's spread throughout the nation. As you can see, it goes from less than 1% to about 6% and that is sort of the lightest of the blues in those states and so that's the range that we, for instances where we have verified that there has been indeed abuse. And this one is for nursing homes; the next one is for somebody else. That's been pretty stable; it hasn't changed that much over the last number of years.
QUESTION: What about the dark blue?
Indeed, what is the dark blue. I can't read my paper here. It's 1.7% - 2.3%. We have, by the way for any of you who want it, in one of our other educational activities, we have posted on our web site about a 250 page data compendium.
QUESTION: Could you please tell us the definition of abuse again?
The federal definition of abuse means any willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in harm, pain or mental anguish. There's some little variation depending on the provider type around that, but usually the term, at least from the federal perspective, the term willful is included in this definition. So from our perspective if you have a person who is, for instance, a resident in a nursing home who is severely cognitively impaired and that person flips out and hits another resident, we wouldn't consider that abuse because it was not willful. But it would be, perhaps the facility itself, should have done some other things in care planning or dealing with that individual. So as I say, the federal definition that I think is the key is the term willful as part of that definition.
QUESTION: For the states that are zero, I find that hard to understand because _________ states there that are white, that says we don't have any of this happening and I just have a question, is that really lack of data or is it that they really don't have that going on.
Well you're getting to one of my next pieces of my presentation, which has to do with national consistency. The data is what we have. The data that I'm showing you here is based on what states have reported. So it's not like we haven't used all the information we have. I think there may be questions about whether indeed there's never been something identified there and in a minute I'll talk a little bit about the whole issue of how you deal with the area of national consistency.
QUSTION: I could say something. Iowa is pretty good, but we're not perfect.
There has been a lot of publicity having to do with abuse. Recently there's been a GAO study and there's also been a couple of studies that have come out of Congress and in those studies they indicate that there's been this massive national rise in the wake of abuse and I want to talk about that to clarify where those numbers come from. In about 1998, 1999, as the public and the Congress continued to be concerned about abuse and nursing home care and ICFMR care, we realized that, from a survey perspective, dropping into a facility now and then you were not going to usually run across somebody knocking somebody else over the head. So if we wanted to do a better job at preventing abuse that we should begin to look at the kind of processes that the facility has in place to make sure abuse is not happening. So in 1999, we began putting in and perceived some guidelines and survey protocols that focused more on whether or not the facility had in place the kind of procedures, policies and had implemented them that would increase the likelihood that there was no abuse or very minimal abuse in that facility. So things like, had they been doing criminal background checks, had there been training, were they providing for their staff, that kind of thing. There are quite a number of areas we looked at. What happened is that we had those areas, as the surveyors went out, there was an increase in the kinds of deficient practices that were found in those areas. This is for ICFMR's, but the same thing is true in nursing homes, and if you look at the outcome deficiencies, which are the ones on the left, those are very low and those were the ones where there was actual evidence of somebody abusing somebody else and that was verified and validated.
The one on the right, you can see there is a big change over the years and those are the ones where we begin looking at the procedures in place and as we looked at those we found that those procedures weren't always being comprehensively implemented. So some of the reports that come out combine those two sets of information and come up with a finding that there has been a major increase in abuse and care in nursing homes and ICFMR's. I just wanted to share with you sort of the factual information behind some of those statements that you'll be hearing or have heard.
As I said there have been a lot of studies lately having to do with abuse. There's one in the last couple of months from GAO. There was another one from Congress. From GAO there was a finding that we were not quickly reporting allegations of abuse to law enforcement agencies. So we have taken steps to notify all the states that they needed to do that as quickly as possible and not hold back on that.
They believe that we weren't adequately enforcing the federal prohibition against hiring convicted abusers and we're doing more training and trying to look into ways we can do a better job there.
There's a whole issue, I don't know how many of you know about the nurse aide registry. Anybody here every heard of it? Oh, a couple. Well I'll just tell you briefly what it is. It is a list where if a nursing facility knows of somebody abusing residents, then that person is to be reported to the state and if it is validated that they then indeed do it their name goes on something called the nurse aide registry and the facilities are to check and if they find that a person's name is on the registry for that reason then they should not be hiring them to provide care. That process has been pretty much a state operated process but there a number of issues related to the registry that I don't think that either we, or the states, have found a really adequate way of solving them. One of them is that very often nursing facilities, if they found somebody that is perhaps looking like they're abusing someone, they would fire the person rather than report them and that therefore, you often don't that person on your list.
The other issue because GAO thought we should do more on getting them on the list quickly is that once a person is accused of being an abuser then they have certain rights under law for due process and that process, until that's completed, their name doesn't get on the list. So it's kind of a difficult process issue to work through and I think we'll just continue working at it.
There have been a lot of studies done on nursing homes and other things that we do by GAO, the inspector general, the reporters, just about anybody likes to do studies on this general topic. But there are a couple of themes that continue to come up in these studies. One of them is that there is inconsistency in how states are doing everything from assessing deficiencies, to reporting, to training people, there's quite a _______ where there's inconsistencies and the different studies expect or recommend that the federal government be more proactive in doing things to try to decrease the inconsistencies. They also push on the federal government to do a better job at overseeing the state performance in the operation of the survey and certification program. I just wanted to share with you today some things that are going on that kind of relate to these two topics. One is, the state performance standards. We have, again after having them years ago and stopping, some performance standards that states must meet. Their reviews are conducted by our regional offices and then reports are prepared. The first report for 2001 will be available very soon, although the states themselves have their own information about their particular states performance.
We are working on improving on-site review activity of state surveys by having better observational surveys. We're beginning to use contractors in addition to our regional offices to do reviews of performance. We are working on ways to develop protocols where they're more automated in the sense of data driven and allow for somewhat less flexibility in decision making: that they provide better direction into what is and is not a problem.
We work on more training programs. We plan to do a study on inappropriate variability and we're developing better protocols for, in addition to nursing homes, home health agencies and at the moment, ESRD facilities.
One area that has been really hammered on I guess and continues to be is how we are doing with the whole area of responding. We, being we the states and everybody else, responding to complaints lodged by beneficiaries or their family or perhaps other people, staff in the facility.
We have a new tracking system that's going to be going out very shortly and we are trying to increase our activity for improving the whole complaint process. One thing that we have noticed in this, that the number of complaints is going up fairly rapidly and the kinds of things people are complaining about tends to be more serious it seems on the surface than it used to be. And that could either be that indeed they are more serious or people have learned to express them in a way that is more accurate in terms of the problems.
We're doing some other studies. We're doing analyses of our enforcement processes and to what degree they work, or which ones people believe work best. We're doing an analysis required by Congress on something called the informal dispute resolution process. There's a belief that they're not independent enough and so we're looking to see if we can do a study to see how they can be more independent.
We're developing quality of life indicators. I don't know if Mr. Scully mentioned it but in truth, most people when they're going out to choose say a nursing home or another institution for care, the number one thing on their mind is probably not pressure sores or pain management; those they assume that they're going to do a good job at. What they're most concerned about are things that have to do with what we call the quality of their life, whether people respond to them, whether they're treated with dignity, those kinds of things. They're very hard to get a handle on in terms of gathering information and making calculations but we do have a study being run by the University of Minnesota and it is on trying to develop performance measures for quality of life type issues. And a similar thing is taking place by the University of Wisconsin for trying to develop performance measures for ICFMR's or for people with DD.
Another issue that continues to blossom, I would call it, is that there tends to be more state run initiatives of various type and some of those are I would say that have sort of gone to another ground in terms of their inventing this and their ability, effort to improve care. Most of them we don't hear about, at least in our home office, we don't learn about until they're well underway. We keep looking for some way to keep track of what different states are proposing in terms of changing things because we want to make sure that as those laws are going through the process, there's not a conflict between the state and the federal law. So that's an issue that we probably need to find ways to work with states and you better on over time.
I was going to talk about a few policy initiatives and the first one that you all asked me to talk about a little bit was the paid feeding assistant proposed rule. Currently the law or our regulations basically say that nursing home workers who have not completed 75 hours of nurse aide training or RN's, LPN's, or trained C.N.A's are not supposed to be feeding people in nursing homes. However it's interesting the law does allow volunteers with not much description of their background to participate in feeding. This has been an issue that's been of concern to a lot of states and to the industry for a number of years and there have been legislative proposals to try to revise it, so they have not gone anywhere and have died over in Congress. But this time we have developed a proposed rule or change in regulation to deal with that. And this is an area that Secretary Thompson is particularly concerned about.
The new proposed rule, which went out about the end of March, makes a few points. It allows a nursing home to use a feeding assistant but they must meet the state and the facility requirements for training. If they do that then they can feed a resident, if the resident doesn't have a clinical condition that would require an RN or someone like that for taking care of them. The training of the feeding assistant must include such things as techniques for feeding, response to resident behavior, resident rights, how to recognize changes, infection control, those kinds of things.
The nursing home is expected to keep a record of who it has as a feeding assistant and it must report to the state any incidents of abuse that they have identified and the state must keep a record of that. So that's the proposed rule that has gone out for you and at the state level it would allow you to choose or not to choose whether or not you wanted to put some additional state requirements in place. From the rule as it's proposed, the state could allow the facility to develop their own requirements for training or the state could impose state level requirements for training of the feeding assistants, as long as they met these basic requirements I spoke of earlier. By the end of May is when the comments are due on that. We've already heard from a number of consumers that they're very concerned about it and will continue to take a position of non-support for this whole concept. So it's difficult to know what will happen once we get all those comments in.
Are there any particular points or concerns that you all had?
QUESTION: [inaudible]
Well there may be a Maryland law that keeps that, but the federal law allows it.
QUESTION: I'm a little bit concerned that there is opposition to that because there are such dramatic shortages right now of personnel in nursing homes. You're talking about patients getting fed or not getting fed. I think when it comes down to it maybe the most difficult patients wouldn't come under that category for feeding, but it's really important to have somebody there, particularly on the evening shift when the staff is the lowest. Could you explain where the opposition is coming from and what the opposition is?
I haven't yet seen their comments on this particular regulation but since we have proposed this several times before, what the positions were before, is that if we began to have lower standards for people who are caring for residents than the minimum of 75 hours of training, it will indeed result in less care, that's one. A second issue they're concerned about is that facilities will then begin to have transportation assistance and transferring assistance and a whole range of things that will not ever provide someone with an integrated look at the kind of care that's being received by the resident. Now those are the two that are the concerns that I remember the most. It's also the union; some of the union people have been opposed to it in the past. I can't remember any other reasons but I'm sure if you call some of them they would probably be glad to share with you and I'll give you some names afterwards if you want.
QUESTION: Is that training going to apply to family members?
Not unless you pay them.
QUESTION: Well I mean the volunteer requirements because, just in my own experience, personal experience I know of one retired RN who went in for lunch 5 days a week to feed her mother who was a stroke victim; a husband who lived about two doors down from a nursing home that had every meal with wife. He actually just paid the nursing home and he ate with her and the janitor of our church goes and feeds his son every night who was a motorcycle accident victim.
Right, I mean there is no requirement that is apply to the volunteers; however, I would think that if I were a nursing facility and had a fairly limited amount of training I might very well offer it to the volunteers because it perhaps would make them more skilled at what they're doing.
QUESTION: Also they're not required?
We never have required it; not in the past. We've never required volunteers to have any kind of training. I believe that was part of the original law. I mean not a regulatory thing, I think it was part of the law and so it's never been a requirement. I would think that they would be more likely to be more interested in doing it if it were not 75 hours and so by offering it they might find it helpful.
QUESTION: I hear very frequently in any of the facilities that if you're going to regulate us then pay for it and of course we don't. What is your response to that?
Well, the varying studies and I'm not an expert on all the money things but the studies that look at it from a Medicare perspective there is an indication that Medicare is basically paying for good care in nursing homes. The concern becomes the Medicaid amount. I can't remember who wrote it but Mr. Scully had one of his analysts write an article that was published not too long ago that looked at the payment rates in terms of the Medicare, Medicaid split and so there certainly is an argument that a lot of people are making that in many places the Medicaid rates are causing higher Medicare and private pay rates.
QUESTION: Whenever I talk to nursing home people, it's always the regulation ________ qualified staff on patient care and ________. Is your office looking at that differently I know the regulations are there but how do you make it more effective so that actually people that are doing skilled nursing _______________________ always doing the regulatory work.
That is a concern I've heard on and off over time and I have two or three answers to it. Sometimes it's really not our regulation that is causing that to take place. One thing that we discovered, for instance, when we implemented the MDS some time ago and some of the others that they didn't drop things that they had in place before. We are also looking at some of the things that we're doing in terms of like collection of resident assessment data and over time we're going to try to see if we can find more efficient ways to collect that information for us and for the facility so they can use it better because we do believe it is important for them to use in care planning and to try to use the new systems of the world, you know, this little hand held thing you walk around with, thing like that. But as people bring up that issue, the more specificity they give, sometimes you can identify that perhaps they're doing something that's not even necessary for them to do from a regulatory perspective. Then finally sometimes states have their own sets of rules. One of the things that we find on a world of life safety codes for instance in terms of the variability, the federal rules there are pretty flexible. The state rules are much more restrictive in terms of what people can do. I guess the bottom line is try to figure out, get them to talk to somebody who knows what the rules are.
QUESTION: [inaudible]
Yes, the state and federal may conflict or the state may be fairly extensive beyond the federal.
QUESTION: Let me piggyback a little bit on that. I'd go a lot further. I think one of the most terrific things we have frankly is the way we've tried to regulate nursing homes and it's not a modern quality approach at all. I was in the middle a few years ago when we tried to point out to people that an overreaction to restraints was causing deaths and I even visited the then HCFA organization and just ran into a real buzz saw. But I would suggest and I know because I've talked to many of the colleagues here about this, I think that there is a collection of knowledge and experience that maybe what we ought to do is follow up from here and work with and let me just give you sort of three major areas. One was mentioned in paper work and I can give you very specific verse of paper work, the most recent is the OASIS system and I can tell you about people who are ready to leave the industry. Almost more important than pay these days, the frustration with the regulation of paper work has more people leaving the industry than even pay. I can give you cases of people who were so frightened to death of auditors coming in. So I think one of the issues is paper work and there is I think lots of room for improvement.
Another one that we tried to bring in as a proposal was to make a survey process that was more rational. Today it's sort of one size fits all. You can be the most perfect nursing home in the world but you get surveyed the same frequency and we suggested that what we ought to do is apply the resources where the most help is needed and do more for places that really need the help more frequently. My thesis is this: there may be a few cases on your map there where there are really horrific things that happen and I don't have any sympathy for that, but 95%+ are the people who are doing darn good jobs in a very difficult situation. Our system is set up sort of as a police force that sort of assumes guilt instead of really assuming that most people want to do well and would be happy to work with. I think I heard recently, some announcement someplace coming out of CMS that said you were open to a more consultive approach on surveys, which by the way in the past, we've been told absolutely not. You're not allowed to do any kind of consult; that you're required to be hard nosed police force.
The final one I think to sort of turn this thing upside down and to use techniques used in the industry as far as real qualities are concerned. I can show you a demonstration project for developmentally disabled where it's instead of worrying about the clipboard; instead of worrying about all kinds of checklists and one more rule, that kind of thing, it really is a consumer focus and there's a scientific approach to it. But the thesis is, is that if you have people who are well served and happy and you can find out through them, their families, all kinds of things, then paper work and most of the micro, there's still base regulations. I really think we need a major, major change in the way we're trying to manage quality because the micro regulation; let's beat them up because we found one bad place or a couple of bad places and everybody has to be treated the same, is very counterproductive.
Okay, thank you. I would just make a couple of points. Just so you know the timing of when surveys are conducted, and you were talking about trying to have the better places be looked at less frequently, that's very clear on the statute so any change there would have to come through a statutory change. Various people have proposed it; it just hasn't gone too far.
The consumer focus, that's one of the things, I think kind of what you said last, is really where these quality measures and the performance measures and what I talked about at the University of Minnesota where we're trying to do quality of life measures. I mean as you get better and better outcomes that you can measure, then how you get to that outcome becomes less and less important and it is less and less important to go on site. So one of the things that we have been building for a number of years is an information base where it could be used eventually once it's sophisticated enough so that you could identify outliers in terms of good and bad based on the data you've collected and the analysis that you're able to do on that data.
QUESTION: [inaudible]
He's doing the quality of life piece for us, it's actually his wife, oh I guess she's Dr. too, Dr. and Dr. Gain. They're doing the quality of life piece for us but other universities throughout the country, Colorado and Wisconsin, are doing some of the other performance measure development things and that has been and continues to be a big emphasis. I'm looking forward to that also.
QUESTION: Sen. Maggie Tinsman, Iowa. I just caution the federal government to be very careful about putting restrictions on the use of volunteers. A whole host of things have been in volunteers and to start saying that volunteers need to have certain amount of training before they can feed their own loved one or whatever; we know, at least in Iowa in our nursing homes, the more volunteers we have in a particular nursing home, that's where the quality is. It's kind of like in the school systems. We found out more parental involvement the better the quality of the school; the same thing with nursing homes. If we can get more volunteers, even if they're not relatives; if they relatives, they're the best, but if they're not relatives then the volunteer piece is what makes it quality and they don't need to have a lot of training at all. The fact that they are willing to give up their time and their energy is what makes it a really quality nursing home. I'd be very careful about letting others say whether it's the unions or whether it's other people saying that this is not something that you want to increase.
Oh, perhaps I misspoke but volunteers are in no way covered by any of these rules. The only thing I was mentioning over here, a facility could offer it to a volunteer if they wanted to but volunteers have never been covered by the requirements for the nurse aide and are not covered by these. If the volunteer volunteers want that kind of training, then that would be what we were talking about.
I had a couple of other points up there that I just wanted to share with you which are sort of big policy issues for us, before I get off the stage here. One of them has to do with forensic issues in ICFMR's. There are a unique type of population of people who are mentally retarded or have some other related condition and may need active treatment services and therefore may be eligible to be in an ICFMR but also demonstrate criminal like behaviors that are so serious as to pose a clear and present danger to other people. Various states have different ways of who they admit to an ICFMR and these types of people are becoming more and more part of that population and they could be court commitments, voluntary admissions, as an option to going to prison; they could be awaiting trail. They could be found incompetent to stand trial so there are different combinations of how they get there. In some instances these people are integrated with the other clients or residents in the facility and they pose a potential danger there. In other situations they're kind of locked up like a lock up unit and that has another set of issues related to the rights of people in this benefit. So this is an issue that continues to grow for us. We've been working with some state representatives and the Association for State that represents the state departments who serve people with mental disabilities, so that group we've been working with. But it is an issue and it's an issue that there have been some people badly hurt because this is not something that's been well worked out and so you may hear of this or it may come to confront you in your daily work and I just wanted to mention it to you.
Another issue that you probably know or you may know about is that there have been some regulations issued for individuals who are mentally ill and receiving Medicaid payment and they're in something called a psychiatric hospital for people under 21 and that there had been a number of deaths. There were several expose kind of articles written in the papers a couple of years ago and as a result of all that there was a regulation issued, this winter some time, that basically said that had issues on how they are to handle people in restraints and it asked that they begin to attest, that's the first stage that these facilities attest to the state, that they are indeed meeting the regulatory requirements. I'm not sure what will happen after this but I assume it is an issue that _______ attempts. It seems to blow up every couple of years and become a real problem for people.
The final thing I wanted to speak about for a moment, and you might put this other chart up, is that we did a study, with the first part published last year and the second part published this year, on the appropriateness of developing nurse staffing ratios for nursing homes. Congress mandated it and we worked on it. They were concerned about the link between staffing and quality. In the phase two study, which we just released a month or so ago, we used ten states with about 5,000 nursing homes and we had several researchers from all throughout the country who did the study. What they found, if you can see the chart, that although that for short stay residents, there are some numbers below which the quality of care goes down in terms of resident care in nursing homes and those numbers differ according to whether it's a long stay type facility or a short stay type facility and those tend to be places that are hospital based, so people are sicker.
So they found that although no quality improvements are observed for staffing levels above these numbers, below the numbers there was an incremental increase in quality as you rose to that number. Now, this is a very complicated issue, as you well know, and there are certainly reservations about what these numbers tell us. The data that we had was self-reported in many ways by the facility. There are a lot of problems in establishing any kind of ratios and there are a variety of issues relating to what are quality-shifting opinions.
Right now what we're doing in terms of next steps is to look at how we could obtain better and more accurate staffing information and also we are continuing to look and study the whole nurse aide training. But I'm telling you about it because very often some of the different advocacy groups and so on get access to this study and do different campaigns in your state related to establishing state level ratios. So it is now up on the CMS website and all umpteen pages of it and so if you have any need for that, you can get the whole background to that study.
Well these were just some of the issues that I had that I thought you might have some interest in. Are there any thoughts or comments about anything I talked about or any other issue that I might be able to help you on?
QUESTION: We had a question over here as to the interpretation of this. Does it mean that for those facilities that staff at the 2.4 ______ for resident data, 81% of them were below standard in terms of quality?
No, what it means is if that standard was applied the 2.4, then 81% of the facilities in the nation would fail that standard; that they did not meet that staffing level.
QUESTION: Well how could you apply it here?
That piece doesn't; the numbers in the middle do. The way the study was done they looked at outcomes of care and related it to the staffing.
QUESTION: [inaudible]
In the middle where you have the 2.40 and 1.15, etc.
QUESTION: [inaudible]
I think you got me there. I don't really know; I honestly don't know the answer to that question. If you want to give me your name I'll find out and get it to you.
END
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