NURSING HOME TECHNICAL ASSISTANCE PROJECT

RICHARD P. KUSSEROW

INSPECTOR GENERAL

OAI-12-88-01240 
June 1988  Office of Inspector General

The mission of the Office of Inspector General 
(OIG) is to

promote the efficiency, effectiveness and integrity of

programs in the United states Department of Health and Human

Services 
(HHS). It does this by developing methods to 
detect and prevent fraud, waste and abuse. 
Created by 
1976 , the Inspector General keeps both the 
statute  in 
Secretary and the Congress fully and currently informed about 
programs or management problems and recommends corrective
action. 
by conducting audits
The OIG performs its  mission 
investigations and inspections with approximately 1 
200 staff

strategically located around the country.

Office of Analysis and Inspections

produced by the Office of Analysis
This special report  is 
tahned  OInIsGpe.c tions (OAI), one of the three maj or offices wi thin
The other two are the Office of Audit and the 
Office of Investigations. The 
OAI conducts inspections which
are typically short term studies designed to determine 
program effectiveness, efficiency and vulnerability to fraud

or abuse.

, entitled "
This inspection Nursing Home Technical Assistance
proj ect 
" was conducted to determine which of the nursing 
home data collected by the Health Care Financing 
Administration consumers consider most crucial in evaluating 
patient. 
these nursing homes for admission of a 
The report
was prepared by the headquarters Health Care Branch
, Office
of Analysis and Inspections with the assistance of regional 
IX. 
offices I through  Participating in this report were the
following people:

Headquarters 
Consul tant 
Barry Steeley (proj 
ect Leader)  Michael Hendricks

Mark Krushat 
, M.

Carolyn Mullen
, M. P .
 TABLE OF CONTENTS

. i

EXECUTIVE SUMRY. 
BACKGROUND  . 1

METHODOLOGY.  . 2

MAJOR FINDINGS 
. 4

RECOMMENDATIONS. 
. 8

APPENDIX A 
. A-I

APPENDIX B 
. B-1

APPENDIX C . 
. C-l

APPENDIX D . 
. D-l
 EXECUTIVE SUMARY 
The Health Care Financing Administration  planning
(HCFA)  is 
to publish information on some 16, 000 nursing homes that care
for Medicare or Medicaid patients. The maj or purpose of this
release will be to provide consumers with a tool that can be 
used in the evaluation and selection of a nursing home. In 
order to ensure that the final release does include the 
information that potential users consider most crucial
, HCFA
is asking relevant organizations to suggest which of the 
elements from the Medicare/Medicaid Skilled Nursing Facility 
and Intermediate Care Facility Survey Report (HCFA Form 519)
they consider most important. The Office of Inspector
General 
(OIG) was asked to collect the opinions of potential 
users of this information at the local level. 
The OIG conducted a total of 341 interviews nationwide. The

respondents were almost evenly divided between discharge

planners, senior citizens, family members of current nursing

home residents, physicians, and staff members of the Area

Agencies on Aging. Urban respondents numbered 181, with 160

rural respondents. By choosing those indicators on the HCFA

survey report that seemed both important and representative 
items: 
we developed a document containing 63 individual 
related to characteristics of nursing home residents and 44 
potential indicators of quality. The respondents were asked
to indicate on a 5-point scale how important they would rate 
each of these 63 indicators. Analysis of this data enabled
us to determine the relative importance of each item to the 
respondents and thus to rank each indicator. 
The ranking of these indicators had no clear lines of

demarcation 
, except that all items related to patient 
characteristics ranked lower than those related to quality 
respondents. 
indicators across all categories of 
There were 
indications that this was in part due to the respondents 
lack of understanding of the significance of the patient 
characteristics indicators. In addition, respondents made
many suggestions regarding important information on nursing 
surey 
homes that is not included in the HCFA  report. We
recommend that HCFA consider including this information 
which is detailed in this report, in the nursing home
release. 
We also found that the respondent physicians and discharge

planners tended to rate all of the items lower than did the 
other respondents. However, each category of respondent
reported a need for easily accessible, objective information
on nursing homes. 
Thus we recommend that HCFA assign high
priori ty to 
the nursing home information release.  , "

BACKGROUND 
In December 1987, the Health Care Financing Administration

(HCFA) publicly released data on the mortality rates of

Medicare beneficiaries, broken down by hospital and

diagnosis. 
This action was part of a major HCFA initiative 
to increase information available to consumers in order to

permi t them to make informed decisions concerning

al ternative approaches to satisfy their health care needs. 
The HCFA is planning in the near future to publish

information on some 16, 000 nursing homes that handle Medicare 
or Medicaid patients. The main purpose of this release, 
which will be drawn from the annual inspection reports
submi tted to HCFA by the state survey agencies, is to provide
the consumer with a tool that can be used in the evaluation 
and selection of a nursing home. This is in full accord with 
HCFA' s commitment to sharpen competition among medical care 
givers. As Dr. William L. Roper, Administrator of HCFA 
commented in a recent "Washington Post" interview  If you
believe in a more competitive health care system, you have to
believe in giving people appropriate information so they can 
make choices... 
The data set available to HCFA containing the necessary 
nursing home information is maintained in the 
Medicare/Medicaid Automated Certification System (MACS), and
elements. 
contains approximately 700 data  The publication
of all this information would be counter-productive, and
would only serve to confuse the consumer seeking an effective 
method of comparing nursing homes. Therefore 
, HCFA is
planning to limit the information released to those 
indicators that consumers will find most relevant and useful 
in their search for appropriate nursing home care. 
In order to ensure that the final release does include the

information that potential users consider most crucial
, HCFA

asking the nursing home industry, both Houses of 
is 
Congress, the American Association of Retired Persons (AARP),
and other relevant organizations to suggest data elements 
important. 
which these organizations believe are most  Since 
is also concerned that local input be actively
HsCFoA lici ted
, the Office of Inspector General (OIG) was asked to
collect the opinions of potential users of this information
at the local level. 

This inspection collected information regarding the value of 
certain measures of nursing home performance in the 
selection of a nursing home by a potential resident and 
other interested parties. The source document for these 
measures , HCFA form 519, is the Medicare/Medicaid Skilled 
Nursing Facility and Intermediate Nursing Facility Survey
Report. 
This report is completed annually, or as needed  and serves as a record of findings made by a team of medical

professionals during a physical examination of each

Medicare/Medicaid certified nursing home, including record

review and patient interviews as well as observations of

nursing care and techniques.

Additional forms document deficiencies in care, passing of
medications , food service, etc. The information reported in
all of these forms provides the basis for corrective action 
required of nursing homes found to be deficient. 
Information on over 700 requirements is reported
, ranging
from whether the kitchen is adequately ventilated to whether 
there is sufficient nursing staff and adequate disaster
planning. 
OBJECTIVES 
This inspection is intended to provide HCFA with input from 
the expected users of the nursing home data, including
senior citizens, family members, discharge planners 
physicians and staff members of the Area Agency on Aging
(AA). 
The major objectives of this inspection were: 
To determine which of the patient characteristic and 
quality indicator data elements contained in MMCS are 
considered the most important by potential users of the

information. 
To collect further comments from these same

respondents regarding other data that might be

included in the information release to ensure that

this proj ect is of maximum usefulness.

To gather suggestions on the format of the 
information release which might enhance its clarity 
and usefulness to the consumer. 
METHODOLOGY 
In an effort to provide information representative of 
concerns nationwide, each of the 8 Office of Analysis and 
Inspections I regional offices was to select 40 respondents 
for a total of 320 interviews. Four different sites, two 
urban and two rural, were selected judgmentally within each 
region. The urban sites were to represent different segments 
of a city, either geographic or socioeconomic, while the 
rural sites were to be separate, although they could be
adj acent to the urban site or each other.  At each site, ten respondents were to be contacted. These 
included two hospital discharge planners with separate case 
loads; two senior citizens not currently living in nursing 
homes; two family members of senior citizens who had entered 
a nursing home with the last three months; two physicians who 
treat patients in nursing homes; and two staff members of the 
, including the local ombudsman. The actual number of 
341. This included 72 discharge planners, 
respondents was 
68 senior citizens, 65 family members, 67 physicians (54 
associated with a nursing home and 13 who did not treat 
AA 
nursing home patients); 66 staff members of  and 3 other
parties. 
Because survey respondents could not be expected to evaluate

lists of hundreds of technical data entries, discussions were

held among OIG staff familiar with quality reviews to

4etermine which items should form the list which respondents
would be asked to evaluate. In some instances, related
elements were. collapsed into a larger area of inquiry. 
other instances, the OIG workgroup thought the requirements

while important, would mean little to a layperson as an

indicator of quality. The list finally arrived at contained

63 individual items, 19 related to characteristics of the 
home  s residents and 44 to potential indications of quality. 
A review document was created which listed the 63 items 
related them to the source document and provided a scale for
ranking them. (See appendix A. ) A 5-point scale asked each
respondent to determine if the item was of little or no
importance 
, some importance, moderate importance, great 
importance or very great importance in choosing a nursing
home. 
The staff went through the list of resident 
characteristics and quality indicators with all consenting
respondents. 
Urban respondents numbered 181, with 160 rural respondents.

In most regions, urban and rural respondents were evenly 
represented. However, in the New York and Atlanta regions 
urban respondents were 75 and 60 percent of the respective 
totals, while in the Chicago region, rural respondents 
contacted. 
represented 61 percent of those 
Field work was undertaken starting March 29, 1988 and 
completed by April 7, 1988. The respondents were informed of 
the nature of the study, asked if they would agree to 
participate and oriented to the review document. They were 
asked to circle on the review document the rating they would 
item. 
give each  This rating from one to five was to indicate 
hcowh iompoortsanitn tghat  apa rtnicuulrars diantag it ehm owoumld ebe .t o them in The raw data consisted of the respondents ' ratings of the
data elements on the quality indicators and patient
characteristics instruments. 
These categorical responses
were subj ected 
to an analysis using ridi ts. In this 
analysis, each item in the instrument was assigned a value 
would be given higher

that indicates the probability that  it 
ratings than all the other items. By ranking each item

according to its ridi t value, we were able to determine the

item. 
relative importance of each  (For a more detailed 
description of this analysis, see appendix B.

MAJOR FINDINGS 
Our interviews with discharge planners and physicians 
indicated that many of these professionals, with a 
responsibili ty for directing Medicare beneficiaries to 
nursing homes, were making these crucial decisions 
based on inadequate information. The physicians
responding often had access to little or no objective
data. 
Many discharge planners interviewed had not 
recently been in a nursing home, and often were 
unaware that the HCFA survey reports were available. 
Each category of respondent, whether discharge

AA staff 
planners, physicians  , senior citizens or 
family members, conveyed the belief that the 
publication of nursing home data would be a valuable

tool that would help anyone involved in choosing a

nursing home.

All patient characteristics items ranked lower than

the quality indicators items across all cl 
asses of
respondents. 
This finding seems to reflect the lower priority that

patient characteristics are given by potential nursing

home consumers. However, many respondents

particularly senior citizens and Iamily members, 
stated that they were not clear about the significance

of many of these items. For example, would a high

number of patients with decubiti indicate that the

home was experienced in giving. care in such cases, or

would it rather mean that patients were badly

neglected? Does a large number of patients with

catheters indicate that this kind of patient can be

easily accommodated, or could it show that

catheterization was used for the convenience of staff?

There were further comments that, in the absence of

adequate information on staff/patient ratios, no

meaningful conclusions about the sui tabili ty of
nursing home could be drawn from patient
 data. If 
characteristic 
patient characteristic data 
are to be included in the information releases, these 
should be accompanied by careful explanations of their 
potential significance. 
The professional respondents (physicians and discharge

planners) tended to rate all of the items lower than

did the other respondents.

Those professionals with experience in making nursing 
home placements may have developed their own criteria 
for evaluating facilities, leading them to rely less 
on this additional information. In addition, several 
respondents, especially discharge planners, commented 
that the indicators in the survey were basic 
standards which they assumed all certified nursing 
homes wouLd meet. They saw the number of complaints 
or citations as more relevant factors in nursing home
choice. It 
was further pointed out that for many 
patients, particularly those whose care is paid for by
Medicaid , the overriding criterion would be whether or 
available. 
not a bed was actually 
The ten highest ranking data elements follow in order

of ranking:

The facility notifies the resident'

physician in the event of significant

s health status.

change in the resident' 
Drugs are administered in accordance with
wri tten 
orders of the attending physician. 
E8rgency services are available and 
provided to each resident who required

emergency care. 
Emergency power is available where life

support systems are used.

A written consent is required for

edxpearimeyntal. re search. 
Nursing service is provided 24 hours a

Residents are allowed to communicate

privately with individuals of their

choice, and send/receive personal mail

unopened.  Each resident receives care to prevent

skin breakdown and receives necessary care

to promote healing.

The facility is maintained free from

insects and rodents.

10.	 A resident is sedated or physically restrained 
only when authorized by a physician. 
For a complete and detailed ranking by item and
respondent type 
, see appendix C. 
In addition, there was considerable feedback on the

need to include information that goes beyond the scope

of the. HCFA survey reports. This includes general

explanatory information
, as well as additional 
specific data elements describing further resident

characteristics or indicating expected quality of

care. 
The additional information requested fell into 
the following categories.

General information to be contained in an

introduction or appendix:

A clear definition of skilled nursing

facilities. 
An explanation of Medicare and Medicaid

regulations for nursing home coverage

including what services are covered, how

much will be paid and how beneficiaries can

qualify. 
Names, addresses and phone numbers of
addi tional resources that consumers can
contact for further assistance. 
These 
staff 
would include both State and local 
and ombudsmen, as well as local social 
service departments. 
A checklist of further questions families

should ask of any nursing home under

consideration. This was considered 
particularly important as the information

release will be limited to data readily 
tal 
available to HCFA, and thus many vi 
indicators will not be included in the 
individual profiles. It was also suggested

that HCFA update and reissue its helpful

1978 booklet  How to Select a Nursing Home
 A description of the process of inspection

licensure and certification of nursing

homes. 
An explanation of resident rights that are

required by 1 
aw . 
Addi tional specific indicators that might be 
included in the individual facility profile: 
staff/patient ratios. This was cited as the
most important indicator of -
quality by many
pshtyasifcfi.a ns, discharge planners and AAA
In addition, more specific 
information on staffing. was requested, such 
as types of training required, levels of 
nursing care, ratio of staff to special 
care patients, extent of registered nurse
( RN) coverage and weekend/evening/night 
coverage. 
Sanction/Compliance history. Many
respondents indicated that it would be 
useful to know if a nursing home had been
ci ted for 
compliance violations in previous 
years 
, what the violation were, and if these
were corrected appropriately. In addition 
information could be provided on any 
sanctions that had been imposed, including
loss of license. 
Other factors hcoon:s idered important in the choice 
of a nursing 
Respondents listed many other criteria that 
they felt should be included in a thorough 
assessment of a nursing home. However, HCFA 
does not have facility-specific data on most 
of these criteria; perhaps they could be 
included in the check list for consumers 
that was suggested above. The suggested
addi tional factors are listed in appendix 
Suggestions as to format: 
Include State averages (or acceptable

minimums or ranges) to serve as a baseline

for comparison with a particular nursing

home  s rating on individual data elements.  Use percentages, ratios or rankings, where

possible, to clarify the ratings of the

individual facilities.

Give a brief explanation of the significance

of those data elements that might not be

clear to a nonmedical consumer.

RECOMMENDA T IONS 
The HCFA should assign high priority to the nursing

home information release. It is clear from the OIG

survey that accessible and objective data on nursing

homes would be useful to the public.

In developing the format of the information release

HCFA should incorporate some of the suggestions of the

survey respondents. 
consider incIln upadritincugla:r , 
HCFA should
facilities. 
A definition of skilled nursing 
An explanation of Medicare/Medicaid coverage

regulations for nursing homes.

A list of additional resources that consumers can

contact for further assistance.

A check list of questions families should ask of 
any nursing home under consideration. (Many 
suggestions for this list are included in 
appendix D. 
A description of the process of inspection and

licensure of nursing homes.

An explanation of resident rights that are

required by law.

InfOrmation 
detailed as possible, on 
as
staff/patient ratios in each home.

The sanction and compliance history of each

facili ty.

state averages, or acceptable minimums or ranges

to serve as a baseline for the evaluation of

individual nursing homes.
 Percentages 
, ratios or rankings
, where Possible
to clarify the ratings of the individual

facilities. 
Other guides to choosing a nursing home should be
referenced. 
These would include those published by
non-Government agencies or by other branches of

Government.  APPENDIX A
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I R S T APPENDIX B
 Nursing Home Technical Assistance proj ect 
Analysis Using RIDITS

The data collected in the Nursing Home Technical Assistance
proj ect 
(NHTAP) consists of categorical responses
quali 
tatively ordered from 1 (Little or No Importance) to 5 
(Very Great Importance). Data in this form can be thought of 
as an arbitrary categorization of some underlying but 
unmeasured, continuous distribution. This is the only
assumption necessary to preform a ridi 
t analysis. No other 
assumptions about the distribution of the data, such as an 
underlying normality, are required. In the ridi t analysis 
each item in the questionnaire is assigned a value that is
interpretable as a probability. 
That is, the value 
associated with each item is the probability that a randomly

chosen response for that item has a value greater than that

from the pred fined standard group.

The term ridi t is an acronym for  relative to an identified
distribution. '1 A 
standard reference group is constructed
and then a mean ridi t is computed for each item in the 
questionnaire using the reference group as the comparison
group. 
For this analysis, the reference group is the total 
number of responses, by category, for all items across all 
respondents. The response distribution of each item is 
items. 
therefore compared to the response distribution of all 
This will allow us to then rank order the mean ridi t for each 
i tern and essentially determine the relative importance of 
each item. That is, the item with the highest mean ridit was 
consistently given more extreme values (responses in 
categories 4 and 5) more often than any other item. 
The following table shows the construction of the relative

or standard, group. 
Relative Distribution 
Response Category  Num.  Ridi t 
No Response  155 
Li ttle or No Importance  , 508  035 
Some Importance 458  105 
Moderate Importance  986  209 
Great Importance  268  403 
Very Great Importance  108  763 
Total  483 
Total (less No Response)  328  The total of the Num. column is equal to the number of items

(341). 
( 63) times the number of respondents  Each entry under 
the Num. column gives the number of times that value was
given to any item by any respondent. 
Under the column headed 
Ridi t, each entry is the proportion of responses in all of 
the lower categories plus half the number of responses in 
category). 
This 
that category (excluding the No Response 
table also summarizes the responses of the entire group of 
study. 
respondents interviewed for this 
The following example shows how the mean ridi 
t is calculated 
for a given item. This calculation is carried out for all 
items in the questionnaire. 
Calculation of Mean Ridi t for Item F6

Total Patient Census?"

Res  onse Cate  Num.  Ridi t  Num.  Ridi t 
No Response

Li ttle or No Importance  035

Some Importance  105

Moderate Importance  209  19.

Great Importance  O. 403  29.

Very Great Importance  763  35.

Total  338  92. 
Mean  Ridi t =  (92. 3/338)  273 
This result indicates that the responses to Item F6 (Total 
Patient Census?) would have a more extreme value than the 
total of the responses only 27% of the time. 
Wi th the ridi t analysis one can partition the data set in 
any meaningful w y and recalculate ridi ts. The average
values for these partitions 
, across items, will always be 
500. Thus, one can produce an ordered relationship among
the items using the mean ridi 
t per item in a distribution 
free manner. 
Attached is a listing of each item on the questionnaire with
the mean ridi t for each item. Six ridi t values 
have been 
calculated. The first is across all category of respondents

and the list of items is sorted, descending, by this value.

The next five values are the ridits, for each item

calculated for discharge planners, senior citizens, family

members, physicians, and AAA staffers, respectively.
 ----+----+----+----+
The following stem and leaf plot (a modified histogram) 
demonstrates the clustering of the ridi ts obtained in this
analysis. 
stem Leaf 
6 555578

6 00011222334444

5 555666788999999

5 011223344

4 9

023 
66667777999 
444 
This figure plots the ridi t 
values for all 63 items in the 
questionnaire. For example, there are 6 values fbigetuwereen.  . 65
and  . 68 . This is shown on the top line of the  The 
Stem ' gives you the value in the first position following 
the decimal point and the ' Leaf '  gives you the value of the 
second digit following the decimal point. Thus there are
four values of . 65, one value of . 67 and one value of . 68. 
Those items falling into the lower cluster (from 0. 2 to 0. 
are the first 17 items of the questionnaire. This would 
indicate that the census type of information is of the least
importance. 
This finding held up across all of the
respondent types. 
This last table shows the average ridi t by respondent type.
For this table, a ridi 
t was calculated for each respondent 
across all items. This allows us  to compare the ranking 
behavior of each type of respondent.

90%  c. I. 
Type of Respondent  - Num.  Avg.  Ridi t  Lower  Upper 
Discharge Planner 
Senior Citizen 
Family Member
Physician  O. 
AAA Staff 
Other 
Total 
341  The results indicate that, on the whole, the nonprofessional
respondents 
, senior citizens and family members, as well as
the AA staff , tended to rate the all of the .
i terns as more 
important than did the professional respondents, physicians

and discharge planners. 
1. Fleiss Statistical Methods for Rates and
Proportion, sJo eseph L., 
, New York: John Wiley & Sons 
B-4
 APPENDIX C
 Ridi ts by Item and Respondent Type

Tag  Item Name	 Tot  Disch Sen. Fam.
Plan cit. 
Mem.  MDs 
F90	 THE FACILITY NOTIFIES THE  684 0. 688 0. 123 0. 679 0. 679 0. 700 
RESIDENT I S PHYSICIAN IN THE 
EVENT OF SIGNIFICANT CHAGE 
THE RESIDENT I S HEALTH STATUS. 
F174 DRUGS AR ADMINISTERED IN  673 0. 660 0. 696 0. 688 0. 688 0. 681 
ACCORDANCE WITH WRITTEN ORDERS

OF THE ATTENDING PHYSICIAN. 
F100 
EMRGENCY SERVICES 	 653 0. 660 0. 686 0. 661 0. 661 0. 637 
AVAILABLE AND PROVIDED TO EACH

RESIDENT WHO REQUIRES

EMRGENCY CAR.

F336 EMERGENCY POWER IS AVAILABLE  650 0. 638 0. 664 0. 697 0. 697 0. 644 
WHERE LIFE SUPPORT SYSTEMS 
USED. 
F54	 A WRITTEN CONSENT IS REQUIRED  646 0. 620 0. 660 0. 645 0. 645 0. 694
FOR EXPERIMENTAL RESEACH. 
Fl13 NUING 
SERVICE IS PROVIDED 24 0. 646 0. 672 0. 629 0. 672 0. 672 0. 634
HOUR A 
DAY. 
F82	 EACH RESIDENT IS ALLOWED TO  644 0. 643 0. 667 0. 617 0. 617 0. 693
COMMICATE PRIVATELY WITH

INDIVIDUALS OF THEIR CHOICE

AND SEND/RECEIVE PERSONAL MAIL

UNOPENED. 
Fl16 EACH RESIDENT RECEIVES CAR TO 0. 639 0. 665 0. 631 0. 651 0. 651 0. 640
PRENT 
SKIN BREDOWN 
AND 
RECEIVE NECESSARY CAR 

PROMOTE HEALING. 
-F 
F347 THE FACILITY IS MAINTAINED  638  626  668  668  668  635
FRE - INSECTS AND RODENTS. 
F7l	 A RESIDENT IS SEDATED OR  637  618  675  638  638  684 
PHYSICALLY RESTRAINED ONLY 
WHEN AUTHORIZED BY PHYSICIAN. 
F249 A SUFFICIENT MEDICAL RECORD IS 0. 634 0. 622 0. 637 0. 655 0. 655 0. 675 
MAINTAINED FOR IDENTIFICATION 
DIAGNOSES AND TREATMENT FOR 
EACH RESIDENT. 
C-l
 Ridi ts by Item and Respondent Type

Tag  Item Name  Tot  Disch Sen. Fam.
Plan cit. 
Mem.  MDs AM 
F3l3 ALL COMMON RESIDENTS  632 0. 608 0. 673 0. 657 0. 657 0. 629 
ARAS 
CLEAN, SANITARY, AND FREE OF 
ODORS . 
F60	 EACH RESIDENT IS ALLOWED TO  623 0. 635 0. 620 0. 592 0. 592 0. 713 
SUBMIT COMPLAINTS AND 
FRE 
RECOMMNDATIONS  FROM 
RESTRAINT, COERCION,

DISCRIMINATION, OR REPRISAL.

NUE 
F128 THERE IS A REGISTERED  622 0. 617 0. 629 0. 679  679  623 
THE DAY TOUR, SEVEN DAYS A

WEEK. 
F288 EACH RESIDENT ROOM HAS A  616  643  631 0. 605  605  650 
FUCTIONAL CALL SYSTEM. 
F98	 PHYSICIAN PLAS AND  SUPERVISES  610  597  638  617  617  609 
CA. 
RESIDENT I S 
NUE 
F130 A LICENSED  IS DESIGNATED 0. 606 0. 602 0. 620 0. 644 0. 644 0. 596
AS THE CHAGE NUE AT ALL 
TIMES. 
F330 DIETETIC SERVICE PERSONNEL  605 0. 573 0. 627 0. 651 0. 651 0. 617 
PRACTICE HYGIENIC FOOD 
HADLING TECHNIQUES. 
F64	 THE NUING HOME DOES NOT  596 0. 579 0. 641 0. 568 0. 568 0. 648 
CO-MINGLE RESIDENT FUDS WITH

ANY OTHER FUDS.

AR 
F3 5 6 	ALL EMPLOYEES  TRAINED IN  596  575  668  659  659  591 
PREPARDNESS FOR ANY DISASTER. 
F156 REHABILITATIVE NUSING CAR IS  591  625  580  576  576  632 
PERFORMD FOR EACH RESIDENT 
WHO REQUIRES SUCH SERVICE. 
F48	 RESIDENT IS INFORMD IN  591 0. 592 0. 653 0. 575 0. 575 0. 686 
WRITING OF SERVICES AND 
CHAGES AND NON-COVERED

SERVICES.

F85	 EACH RESIDENT IS ALLOWED TO  591 0. 599 0. 625 0. 556 0. 556 0. 634 
RETAIN AND USE THEIR PERSONAL 
POSSESSIONS. 
C-2
 Ridi ts by Item and Respondent Type

Tag  Item Name  Tot  Disch  Sen.  Fam. 
Plan , Cit. 
Mem.  MDs 
F178 MENUS MEET THE SPECIAL  589  580 0. 621  613  613  638 
NUTRITIONAL NEEDS OF EACH 
RESIDENT IN ACCORDANCE WITH 
PHYSICIANS ORDERS. 
F76	 EACH RESIDENT IS GIVEN PRIVACY  588  589  617  561  561  659 
DURING TREATMNT. 
F163 EACH RESIDENT IS PROVIDED WITH  587  589  590  617  617  603 
THE APPROPRIATE AMOUNT OF FOOD 
AND FLUID AND THEIR ACTAL

INTAK IS 
MONITORED.

F3 09 SINGLE ROOMS WITH PRIVATE  582 0. 578  628  587  587  585 
TOILET AND HADWASHING 
FACILITIES AR AVAILABLE FOR 
RESIDENT' S REQUIRING 
ISOLATION. 
F193 AT LEST THRE MEALS 	 577  590  587  576  576  603 
SERVED DAILY AT REULA HOUR. 
F316 A COMFORTABLE ROOM TEMPERATU  569  530  595  628  628  584 
AL 
IS MAINTAINED IN AR.R ESIDENT 
ROOM AND COMMON 
F78	 EACH RESIDENT GIVES WRITTEN  565 0. 572 0. 601 0. 554 0. 554 0. 612 
CONSENT BEFORE RECORDS 
RELEED. 
F227 SERVICES AR PROVIDED, AS  561 0. 597 0. 525 0. 560 0. 560 0. 639 
ET THE

APPROPRIATE, TO 	
SOCIAL AND EMOTIONAL NEEDS OF

THE RESIDENTS.

F283 EACH RO M IS EQUIPPED WITH OR 0. 558 0. 538 0. 625 0. 581 0. 581 0. 561 
COIENLY WCATED

TOILET AND BATHING FACILITIES.

F216 THE LABELING OF DRUGS INCLUDES 0. 552 0. 544 0. 629 0. 596 0. 596 0. 554 
CAUTIONARY INSTRUCTIONS AS 
WELL AS AN EXPIRATION DATE 
WHEN APPLICABLE. 
F276 THE DINING ROOM IS CLEAN,  549 0. 522 0. 589 0. 602 0. 602 0. 534 
ORDERLY, AND OF ADEQUATE SIZE. 
C-3
 Ridi ts by Item and Respondent Type

Tag  Item Name  Tot	 Disch  Sen. Fam. 
cit. 
Plan  MDs AA 
Mem. 
F219 ALL LABORATORY SERVICES AR
 547 0. 506 0. 629 0. 603 0. 603 0. 525 
PROVIDED ONLY ON THE ORDERS OF

PHYSICIANS. 
F157 THERE IS AN ONGOING EVALUATION
 543 0. 576 0. 528 0. 544 0. 544 0. 608 
OF EACH RESIDENTS

REHABILITATIVE NUSING NEEDS 
INCLUDING ASSISTANCE AND

INSTRUCTION IN THE ACTIVITIES

OF DAILY LIVING. 
F2 3 2 AN ONGOING PROGRA OF  535 0. 587 0. 488 0. 509 0. 509 0. 607 
MEANINGFUL ACTIVITIES IS FOR

EACH RESIDENT. 
F44	 RESIDENT IS INFORMD IN  534 0. 527 0. 620 0. 494 0. 494 Or649 
WRITING OF RIGHTS, RULES, AND 
AMNDMENTS. 
F286 EACH RESIDENT'S ROOM HAS A
 531 0. 503 0. 575 0. 574 0. 574 0. 550 
COMFORTABLE AND FUCTIONAL BED

AND CHIR, PLUS A CABINET AND

LIGHT. 
F212 PHACISTS REIEW THE DRUG  523 0. 513 0. 539 0. 555 0. 555 0. 578 
REGIMEN OF EACH RESIDENT, AT 
LEST MONTLY. 
F53  RESIDENT CA REFUSE TRETMNT. 0. 523 0. 520 0. 548 0. 460 0. 460 0. 641

F28l THE RESIDENT ROOM MEETS
 511 0. 495 0. 612 0. 517 0. 517 0. 490 
MINIMU SIZE STANDARD (i. e. , 
100 SQ. FT. FOR SINGLE ROOMS,

80 SQ. FT. PER RESIDENT IN

MULTIPLE RESIDENT ROOMS).

F2 39 EACH RESIDENTS I NEEDS  505 0. 519 0. 503 0. 488 0. 488 0. 595 
PLA 
ADDRESSED IN A WRITTEN 
CAR . 
F62	 RESIDENTS AR ALLWED TO  496 0. 443 0. 547 0. 462 0. 462 0. 578 
MAAGE THEIR OWN FINANCIAL 
AFFAIRS . 
F35	 THE NUBER OF RESIDENTS WITH  487 0. 400 0. 545 0. 501 0. 501 0. 572 
DECUBITI (BEDSORES)? 
C-4
 Ridi ts by Item and Respondent Type

Tag  Item Name  Tot  Disch  Sen. Fam. 
cit. 
Plan 
Mem.  MDs 
F34  THE NUBER OF RESIDENTS WHQ 380  297  513  384  384  439 
AR 
DISORIENTED? 
F30  THE NUBER OF RESIDENTS WHO 329  298  419  315  315  369 
AR 
COMPLETELY BEDFAST? 
F36  THE NUBER OF RESIDENTS WITH  320  269  398  343  343  334 
BOWEL AND BLADDER RESTRINING? 
F38  THE NUBER OF RESIDENTS WHO  297  293  378  285  285  300 
REQUIRE INTRVENOUS 
THERAPY/BLOOD TRASFUSIONS? 
F32  THE NQBER OF RESIDENTS WHO 292  239  354  254  254  367 
AR 
AMBULATORY? 
F37  THE NUBER OF RESIDENTS WHO  292  292  381  290  290  276 
REQUIRE SPECIAL SKIN CAR? 
F29  THE NUBER OF RESIDENTS WHO  287  243  383  303  303  328 
REQUIRE FEEDING ASSISTANCE? 
TOTAL RESIDENT CENSUS?  273  270  344  259  259  345 
F31  TH HUBER OF RESIDENS WHO 269  217  353  278  278  301 
AR 
CHIRBOUND? 
F17  THE NUBER OF RESIDENTS WHO  269  199  350  341  341  290 
REQUIRE TOILETING ASSISTANCE? 
F39  TH NUER OF RESIDENTS WHO  267  236  297  283  283  303 
REQUIRE NO ASSISTANCE WITH 
ACTIVITIES OF DAILY LIVING? 
F26  TH HUBER OF RESIDENTS WHO  263  252  339  229  229  269 
HAVE PARNTERA FEEDINGS? 
USIDEM CENSUS BROKE DOWN BY  260  277  308  243  243  326 
WHETHER THE RESIDENT IS 
MEDICAR, MEDICAID, OR PRIVATE 
PAY? 
F21  THE NUBER OF RESIDENTS WHO  259  191  360  323  323  262 
REQUIRE TRASFER ASSISTANCE? 
F40  THE NUBER OF RESIDENTS WHO  258  187  320  308  308  277 
SELF-ADMINISTER DRUGS? 
C-5  Ridi ts by Item and Respondent Type

Tag  Item Name  Tot  Disch  Sen.  Fam.

cit. 
Plan 
Mem.  MDs

THE NUBER OF RESIDENTS WHO  243  181  323  308  308  263

REQUIRE BATHING ASSISTANCE?

F22  THE NUBER OF RESIDENTS WHO  241  182  309  233  233  255

HAVE CATHETERS?

F13  THE NUBER OF RESIDENTS WHO  236  o. 166  320  321  321  235

REQUIRE DRESSING ASSISTANCE?

C-6
 APPENDIX D
 Suggestions for a Check List to be Used by, Potential Nursing 
Home . Residents and Family. Members 
Financial Concerns 
What are the rates and charges for nursing home care? 
What services are included in the per diem room rate? Are 
there additional charges for laundry, incontinence care

feeding, medications, special diet, special equipment?

Are there any special financial requirements, especially for

Medicaid patients? 
Are large " donations " required before a patient will be
accepted? (This 
would be a  illegal practice. 
How long is the wait for authorization of payment or
coverage? 
Are advance payments required until insurance coverage is

approved? 
What is the ratio of private beds to Medicare/Medicaid beds?

Can a resident be switched from private pay to Medicaid, if

necessary? 
Are patients segregated by financial status?

in the 
What is the cost of maintaining a bed if resident  is 
hospi tal?

In what manner a e residents ' funds co-mingled with each

other?

Facili ty Characteristics

Does the home participate in Medicare/Medicaid?

Is a bed available, and if not, how long is the waiting list?

What is the average length of stay for Medicare, Medicaid and

private patients?
 Is the nursing home part of a chain or independently owned?

a nonprofit or for-
Is it 
profit facility?

Does the home have an affiliation with a medical school?

Are there special units for heavy care

patients?  , such as for Alzheimer 
Is the facility located in a safe neighborhood? 
Is the facility accessible to the family 
s home?

Is there public transportation available?

What is the ethnic or religious affiliation of the home?

Does the home accommodate religiQus and cultural differences?

Are religious services held and what religious hOlidays are

observed? 
Is there community support for the home?
invol ved in  Are volunteers 
visits to the home? 
What hospital would the patient be sent to in an emergency? 
What are the environmental/structural features of the 
facility, e.g. elevators
, types of showers
, whirlpoOls? 
Are adequate security measures in place
outside door and staff name tags?  , such as locked 
Does the facility have a door monitoring system to control 
confused patients who might roam? 
Is locked storage provided for valuables? 
Does tha facility look clean and smell clean? 
Is the facility s atmosphere "
homey " or institutional? 
Are there outside areas sui 
table for Walking and visiting?

Facili ty Policies 
What are the visiting hours? 
Are chores such as bathing,
dressing and feeding done before the guests arrive? 
How are "living wills
" handled by the facility?

D-2
 Who assumes guardianship if the patient becomes incompetent

and family members cannot take on this responsibility?

What is the policy on "no codes

What input does the responsible party have regarding measures

to extend the life of the patient?

Is there an organized policy or system to investigate theft

from patients? 
Are tips allowed or forbidden?

Is alcohol allowed and how is its use controlled?

Quali ty of Care

Does the home have a medical director?

Does the facility use physician assistants?

Is dental care available?

Is a podiatrist available?

Are there lab and x-ray facilities on site or easily

accessible? 
Is there screening for tuberculosis?

Are immunizations stressed?

Are patients evaluated periodically for discharge to their

homes or to lesser care facilities?

Is the treatment .plan reviewed periodically and updated to

meet current patient needs?

Can the patien  current private physician continue to treat

the patient at the nursing home?

Is assistance given in finding a physician who will treat a

patient at the nursing home?

Are patients unable to use a call system monitored

frequently? 
What is the nature of interaction between staff and
residents? Are staff 
members kind and respectful to
patients? 
D-3
 Are residents clean, well-groomed and appropriately dressed?

Are there open communications between the nursing home and

the family?

Is the menu varied and are there choices of food available at

every meal?

Do the menus take into account the special needs of the

patients 
, such as food allergies, or a preference for

vegetarian or kosher meals?

How often are patients bathed each week?

How is laundry handled and how often?

How is drug intake regulated?

- Are appropriate social , cultural and recreational acti vi ties 
available for residents?

Residents 
' Rights and Privileges 
Are there resident committees to represent the residents

interests or a patient advocate system?

Are residents allowed to attend sessions planning their care?

Do patients have access to personal medical information?

Are pets allowed to live in/visit the facility?

Are patients allowed to leave the building and
, if so, under

what circumstances and supervision? 
Can patients maiqtain relationships outside the facility and
make vis! 
ts to the senior center, church or the hairdresser? 
Does the home provide transportation to and
from these
acti vi ties? 
Are there sign-in/out policies that limit the duration of

outside visits and is there a curfew?

Can residents have their own phones?

Can married couples share the same room and are they given

appropriate privacy?

Is care given in selecting compatible roommates and does the

resident have any choice of roommate?

0-4  Are residents allowed and encouraged to wear street clothes

when appropriate?

staffing 
Is there a full-time activity director on staff?

Are rehabilitation services available from in-house staff or

from contract/consultant staff?

How often does the physical therapist visit?

Is there a resident social worker who can provide counseling?

Are a barber and a beautician available for the residents?

What is the percentage of staff from temporary agencies?

What is the staff turnover rate?

What are the staffing ratios by level of care?

What is the actual staffing on evening, night and weekend

shifts? 
What are the skill levels of staff?

What training do aides receive?

Is there bilingual staff when appropriate?

Are the staff pay scales high enough to attract qualified

staff? 
What is the number of employees that have been charged or

suspected of abuse or theft?

Resident Characteristics 
Are there age limits on patients accepted?  What is the

average age?

Are AIDS patients accepted?

Is the nursing home able to care for patients on a

ventilator? 
What is the percentage of residents with Alzheimer s disease
senili ty or 
other severe mental impairment? 
D-5  Are disoriented residents separated from other residents?

What is the physical condition of other residents?

Are patients separated by degree of physical limitation?

How many patients have bedsores? Did they have them before

coming to the home and is appropriate care given?

What are the number of restrained patients?

D-6