Origins and Purpose of the Landmark 1987 Act
The roots of the federal nursing home reform law, also known as the Nursing Home Reform Act (NHRA) of 1987, trace back to mounting concerns over substandard care in long-term care facilities. Prior to this legislation, standards for nursing homes were minimal and enforcement was often weak or nonexistent. A pivotal 1986 study, commissioned by Congress and conducted by the Institute of Medicine (now the National Academy of Medicine), exposed pervasive and systemic issues of abuse and neglect. The study's recommendations formed the foundation for the NHRA, which was ultimately passed as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).
The primary purpose of this landmark legislation was to improve the quality of life and quality of care for residents in nursing homes receiving federal funding from Medicare and Medicaid. It was a monumental shift in how the nation viewed and regulated long-term care, legally expecting facilities to help each resident "attain and maintain her highest practicable physical, mental, and psycho-social well-being". The law sought to ensure that residents were treated with dignity and that their rights were respected, shifting the focus from simply housing the elderly to actively promoting their health and well-being.
The Comprehensive "Residents' Bill of Rights"
A cornerstone of the federal nursing home reform law is the establishment of a comprehensive Residents' Bill of Rights. These rights were designed to empower residents and give them a voice in their own care and living arrangements. This component of the law is perhaps the most significant in protecting seniors from mistreatment and neglect. Some of the key rights include:
- Right to Freedom from Abuse and Restraints: Residents have the right to be free from verbal, sexual, physical, and mental abuse, as well as corporal punishment and involuntary seclusion. Physical or chemical restraints can only be used under a physician's order for a specific medical symptom, never for staff convenience or discipline.
- Right to Dignity and Respect: Every resident is to be treated with dignity and consideration for their individuality and preferences.
- Right to Participate in Care: Residents have the right to participate in developing and reviewing their own care plans and to be fully informed of their medical condition, treatment, and potential changes in care.
- Right to Privacy: This includes privacy in their room, during personal care, and when communicating with family and visitors.
- Right to Voice Grievances: Residents can voice complaints about care without fear of retaliation.
- Right to Association: Residents have the right to form and participate in resident and family groups.
Requirements for Quality of Care and Services
Beyond establishing resident rights, the federal nursing home reform law mandates that facilities provide a range of specific services to ensure high-quality care. Compliance with these requirements is essential for a facility to remain eligible for Medicare and Medicaid payments.
Key service and quality requirements include:
- Resident Assessments: Comprehensive, standardized assessments must be conducted for each resident upon admission and regularly thereafter to evaluate their functional capacity and needs.
- Comprehensive Care Plans: Based on the assessments, a written care plan must be developed by an interdisciplinary team, including the resident and/or their family.
- Sufficient Staffing: Facilities must employ sufficient staff to provide proper care. While specific ratios can vary, the law mandates an adequate number of personnel to meet resident needs.
- Dietary and Nutritional Services: Residents must be provided with proper nutrition and hydration.
- Social and Rehabilitation Services: Facilities must provide necessary social and rehabilitation services to meet residents' needs.
- Infection Control: Strong infection control policies are mandated to prevent the spread of illness.
Enforcement and Oversight Mechanisms
For the NHRA to be effective, Congress established a rigorous system of federal oversight and enforcement. This system is managed by the Centers for Medicare & Medicaid Services (CMS) at the federal level, with states responsible for conducting inspections and investigations.
Key enforcement mechanisms include:
- Unannounced Surveys: State agencies must conduct unannounced, on-site surveys of nursing homes at least once every 15 months. These surveys evaluate the facility's compliance with federal standards, including quality of care, resident rights, and quality of life.
- Complaint Investigations: The law requires states to investigate any complaints made against a nursing home.
- Enforcement Actions: Facilities found to be non-compliant may face serious sanctions, including fines, denial of Medicare/Medicaid payments, and even termination of federal funding. The severity of the penalty is based on the nature and scope of the deficiency.
Comparison: Before and After the Reform Law
The table below highlights some of the dramatic changes ushered in by the federal nursing home reform law of 1987.
| Aspect of Care | Before NHRA (Pre-1987) | After NHRA (Post-1987) |
|---|---|---|
| Focus | Often custodial care; minimal federal standards | Focus on resident well-being; mandates "highest practicable" well-being |
| Resident Rights | Lacked codified, federal protections for residents | Established a comprehensive Residents' Bill of Rights |
| Use of Restraints | Physical and chemical restraints often used for convenience | Severely restricts restraint use; requires doctor's order for medical reasons only |
| Care Planning | Assessments and care plans were often inconsistent or inadequate | Mandates regular, comprehensive assessments and individualized care plans |
| Oversight | Limited and often announced inspections; weak enforcement | Regular, unannounced surveys; robust enforcement and penalties |
Ongoing Relevance and Challenges
While the federal nursing home reform law was a significant achievement, its implementation and enforcement face ongoing challenges. Ensuring that all nursing homes consistently meet the required standards remains a complex issue, and cases of abuse and neglect, while less prevalent, still occur. Modern challenges include adapting regulations for new models of care, addressing staffing shortages, and ensuring that enforcement mechanisms remain effective in a changing healthcare landscape. The law’s principles, however, continue to provide the framework for protecting the most vulnerable members of society.
For more comprehensive information on the NHRA and related policies, consult the resources available on the Center for Medicare Advocacy website. This organization is a valuable resource for understanding the nuances of Medicare and long-term care policy.
Conclusion: A Foundation for Quality Care
The federal nursing home reform law stands as a crucial piece of legislation that redefined the standards of care and protection for senior citizens in long-term care facilities. By establishing a federal Residents' Bill of Rights, mandating comprehensive care planning, and creating a strong enforcement system, the act aimed to end a history of neglect and abuse. While not a perfect solution, it provides a powerful legal framework to ensure that residents can live with dignity, respect, and receive the highest possible standard of care in their final years. Understanding this law is essential for anyone involved in the care of a loved one in a nursing home, providing a tool to advocate for their rights and well-being.
