The Origins of the Federal Nursing Home Reform Act
Before the 1980s, regulation and oversight of nursing homes were often inconsistent and inadequate across the United States. Mounting public concern over documented cases of elder abuse, neglect, and poor quality of care led Congress to address the issue. In 1986, the Institute of Medicine (now the National Academy of Medicine) released a landmark report titled "Improving the Quality of Care in Nursing Homes." The report's findings documented systemic failures and made broad recommendations for reform.
These recommendations became the foundation for the nursing home quality initiative included within the Omnibus Budget Reconciliation Act of 1987, more commonly known as OBRA '87. The law was widely supported and signed by President Ronald Reagan, ushering in a new era of federal standards for nursing homes that participate in the Medicare and Medicaid programs.
Key Provisions and Resident-Centered Philosophy
At its core, OBRA '87 established a new standard of care rooted in the philosophy of promoting and maintaining a resident's “highest practicable physical, mental, and psychosocial well-being”. This shift from simply providing custodial care to ensuring a high quality of life was monumental. It places a strong emphasis on individual dignity, self-determination, and the resident's right to make choices about their own care and daily life.
The Residents' Bill of Rights
A cornerstone of the legislation is the creation of a comprehensive Resident's Bill of Rights. This set of federal protections and guarantees empowers nursing home residents and their families. Key rights include:
- Right to Dignity and Respect: Residents must be treated with dignity and respect, free from verbal, sexual, physical, and mental abuse, as well as corporal punishment and involuntary seclusion.
- Right to Freedom from Restraints: The law explicitly limits the use of physical and chemical restraints. Facilities cannot use restraints for discipline or staff convenience; they can only be used with a physician's order and for a specific medical purpose.
- Right to Participate in Care: Residents have the right to participate in planning their care and treatment, and to refuse medical treatment.
- Right to Privacy: This includes privacy during treatment, in personal affairs, and in their own room.
- Right to Voice Grievances: Residents have the right to voice complaints about their care or facility operations without fear of retaliation.
- Right to Association: Residents can meet with family and friends and participate in social, religious, and community activities.
Comprehensive Care Planning and Assessment
To ensure person-centered care, OBRA '87 mandates a standardized, comprehensive assessment of every resident using a tool called the Resident Assessment Instrument (RAI). The Minimum Data Set (MDS) is a key component of the RAI.
- Initial Assessment: An assessment must be conducted upon admission.
- Regular Updates: Residents must be reassessed at least annually and whenever a significant change in their condition occurs.
- Care Plan Development: Based on the assessment, an interdisciplinary team develops a comprehensive, written plan of care with input from the resident and/or their family.
This structured approach ensures that care is tailored to each individual's needs, rather than being a one-size-fits-all solution.
Enhanced Standards and Enforcement
OBRA '87 went beyond resident rights to establish higher federal standards for the quality of care provided by facilities. It required nursing homes to provide an array of services, including nursing, dietary, social, and rehabilitative services, to help residents maintain their highest possible level of function.
Increased Staffing Requirements
The legislation included new, though sometimes debated, staffing requirements. This included requiring a Registered Nurse (RN) to be on duty at least 8 hours a day. It also mandated a minimum of 75 hours of training and a competency test for certified nursing assistants (CNAs), who provide much of the direct care.
Stricter Enforcement Mechanisms
To hold non-compliant facilities accountable, OBRA '87 overhauled the federal enforcement system. It gave states a wider range of graduated sanctions, moving beyond the all-or-nothing approach of just cutting off funding. These sanctions can include:
- Monetary penalties
- Appointment of temporary state management
- Denial of payment for new admissions
- Termination of Medicare or Medicaid participation
States are required to conduct unannounced, regular surveys of facilities at least every 15 months to ensure compliance.
A Comparison of Nursing Home Regulation
| Feature | Before OBRA '87 | After OBRA '87 |
|---|---|---|
| Focus of Care | Primarily institutional, medical care. | Resident-centered, focused on physical, mental, and psychosocial well-being. |
| Resident Rights | Few explicit federal protections. | Comprehensive Residents' Bill of Rights with enforceable protections. |
| Restraint Use | Widespread use of physical and chemical restraints for convenience. | Heavily restricted, requires physician's order and medical justification. |
| Care Planning | Often inconsistent, based on staff observations. | Mandated standardized assessment (RAI/MDS) and interdisciplinary care plans. |
| Enforcement | Primarily the all-or-nothing threat of terminating federal funding. | Graduated sanctions, including fines and denial of payment, for non-compliance. |
| Survey Process | Often predictable and focused on paperwork. | Unannounced, irregular surveys with direct observation and resident/family interviews. |
The Lasting Legacy and Current Challenges
The Federal Nursing Home Reform Act or Obra 87 brought about undeniable positive change. Studies have shown significant declines in restraint and antipsychotic drug use, along with improvements in resident care and involvement. It solidified the rights of nursing home residents and provided a legal framework for accountability.
However, challenges remain. Despite the reforms, issues with inadequate staffing and instances of poor care persist, as highlighted by reports from the U.S. Government Accountability Office (GAO) over the years. The ongoing evolution of resident demographics and acuity levels means that the standards and their enforcement require constant attention and refinement.
Today, OBRA '87 serves as the foundational standard for quality in long-term care, and families can use its provisions to advocate for their loved ones. For more information on residents' rights and quality of care, families can consult the National Consumer Voice for Quality Long-Term Care.
