The original contract specified a 22-month study. The contract completion date was subsequently extended 7 months.

U.S. Senate Special Committee on Aging. 1974. Nursing Home Care in the United States: Failure in Public Policy. Washington, D.C.: U.S. Government Printing Office.

Mendelson, Mary Adelaide. 1974. Tender Loving Greed.

Moss, Frank, and Val Halamanderis. 1977. Too Old, Too Sick, Too Bad—Nursing Homes in America. Germantown, Maryland: Aspen Systems Corporation.

Arkansas Legislative Joint Performance Review Committee. 1978. Nursing Home Study—1978: Evaluation of State Regulation of the Nursing Home Industry.

Commission on California State Government Organization and Economy. 1983. The Bureaucracy of Care: Continued Policy Issues for Nursing Home Services and Regulation.

Auditor General of California. 1982. The Department of Health Services. Long-Term Care Facilities.

Colorado Attorney General's Office. 1977. Report of the Attorney General Concerning the Regulation of the Nursing Home Industry in the State of Colorado.

Governor's Blue Ribbon Nursing Home Commission. 1976, 1980. Report of the Blue Ribbon Committee to Investigate the Nursing Home Industry in Connecticut.

Office of the Inspector General, Florida Department of Health and Rehabilitative Services. 1981. Nursing Home Evaluative Report.

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Illinois Legislative Investigating Commission. 1984. Regulation and Funding of Illinois Nursing Homes.

Maryland Commission on Nursing Homes. 1973. Report of the Governor's Commission on Nursing Homes.

Plante and Moran Consultants Inc. 1981. Michigan Department of Public Health, Bureau of Health Care Administration, Division of Health Facilities Certification and Licensure Management and Operations Review.

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New Jersey State Nursing Home Study Committee. 1978. New Jersey Report on Long-Term Care.

New York State Moreland Act Commission. 1975. Regulating Nursing Home Care: The Paper Tigers.

New York State Moreland Act Commission. 1976. Long-Term Care Regulation: Past Lapses, Future Prospects.

Ohio General Assembly Nursing Home Commission. 1978. A Program in Crisis: An Interim Report.

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Spalding, Joy. 1985. A Consumer Perspective on Quality Care: The Residents' Point of View. Analysis of Residents' Discussions. National Citizens' Coalition for Nursing Home Reform. Washington, D.C.

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The terms ''patients'' and "residents" often are used interchangeably when referring to the recipients of care in nursing homes. The current federal regulations pertaining to Skilled Nursing Facilities use the term "patients." The Intermediate Care regulations refer to "residents." The committee prefers the term "residents" for those being cared for in nursing homes because it more clearly conveys the idea that most people admitted to nursing homes live in them for many months or years.

The committee received testimony to this effect from dozens of witnesses at the public meetings it conducted in Philadelphia, Atlanta, Dallas, Minneapolis, and Los Angeles in September 1984. Similar testimony was recorded in public hearings conducted by the HCFA in 1978.

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These pressures are attributable primarily to demographic trends—the rapid growth in the numbers of very old and very frail elderly persons in the population, and the constraints on nursing home bed supply which have resulted in a nursing home bed shortage in most parts of the country. Unfortunately, good recent data to demonstrate the increasing proportion of heavy-care residents are not available. The last national nursing home survey was conducted in 1977. The National Center for Health Statistics now plans to conduct its next national survey of nursing homes in 1986. The most recent analysis of the available data is contained in: U.S. General Accounting Office. 1983. Medicaid and Nursing Home Care: Cost Increases and the Need for Services Are Creating Problems for the States and the Elderly. Report to the Chairman of the Subcommittee on Health and the Environment, Committee on Energy and Commerce, U.S. House of Representatives. GAO/IPE-84-1, October 21, 1983.

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Estimated. The actual fraction may be larger. In states with "medically needy" programs, many of the residents with private incomes below the "medically needy" eligibility ceiling share the costs of nursing home care with Medicaid.

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Dobrof, R. 1977. Social Work Consultation in Nursing Homes. National Association of Social Workers, Contract No. HRA 230-75-0203. Washington, D.C.

Gehrke, J., and S. Wattenberg. 1981. Assessing Social Services in Nursing Homes. Health and Social Work 6:274-282. [PubMed: 7262690]

Mercer, S., and D. Garner. 1981. Social Work Consultation in Long-Term Care Facilities. Health and Social Work 6:5-13. [PubMed: 7262694]

Brody, E. 1974. A Social Work Guide for Long-Term Care Facilities, National Institute of Mental Health, Contract No. HSM-42-71-76, Rockville, Maryland.

Jorgerison, L. A., and R. Kane. 1976. Social Work in the Nursing Home: A Need and an Opportunity. Social Work in Health Care 1:471-482. [PubMed: 828309]

Mercer, Susan, and Rosalie A. Kane. 1979. Helplessness and Hopelessness Among the Institutionalized Aged. Health and Social Work 4:9-116. [PubMed: 107091]

Pearman, L., and J. Scares. 1976. Unmet Social Service Needs in Skilled Nursing Facilities. Social Work in Health Care 1:457-470. [PubMed: 1019804]

U.S. Senate, Special Committee on Aging. December 1974. Nursing Home Care in the United States: Failure in Public Policy. An Introductory Report. Senate Report No. 93-1420. 93rd Congress, 2d Session.

Vladeck, B. 1980. Unloving Care: The Nursing Home Tragedy. New York: Basic Books.

Waxman, H., E. Carner, and G. Berkenstock. 1984. Turnover and Job Satisfaction Among Nursing Home Aides. The Gerontologist 24(5):503-509. [PubMed: 6500272]

Iowa State Department of Health, Division of Health Facilities. December 1982. Quantity of Health Care in Iowa Nursing Homes: Results from the ICF Outcome-Oriented Survey.

Thomas, W. H., and L. Schlesinger. December 1984. Steps to Real Nursing Home Reform. Paper presented to workshop on management incentives conducted by Institute of Medicine Committee on Nursing Home Regulation.

U.S. General Accounting Office. October 14, 1982. Audit of Medicaid Costs Reported by Autumn Hills Convalescent Centers, Houston, Texas. Washington, D.C.: GAO/HRD-83-9.

Smith v. O'Halloran, 557 F. Supp. 289 (D. Colo. 1983), rev'd sub nom. Smith v. Heckler, 747 F.2d 583 (10th Cir. 1984).

Health Care Financing Administration, Health Standards Quality Bureau. 1981. Unpublished analysis of 1981 MMACS data.

Systemetrics, Inc. December 1983. The MMACS Long-Term Care Data Base: Construction of a New Research File and an Assessment of Its Quality and Usefulness.

Shaughnessy, P. W., R. Schlenker, and I. Yslas. 1983. Case Mix, Quality, and Cost: Major Findings and Implications of the Colorado Nursing Home Study. Center for Health Services Research, University of Colorado Health Sciences Center. Denver, Colorado.

Kurowski, B., and P. W. Shaughnessy. 1983. The Measurement and Assurance of Quality. Chapter IV in Long-Term Care: Perspectives from Research and Demonstrations. R. J. Vogel, editor; and H. C. Palmer, editor. (eds.). Washington, D.C.: Health Care Financing Administration, U.S. Department of Health and Human Services.

Schneider, D., and A. O'Sullivan. 1980. Quality Assurance for Long-Term Care: Revising the Periodic Review. Schneider and Associates. Troy, New York. Mimeograph.

Massachusetts Department of Public Health. 1984. Quality Assurance by Sampling: First Annual Report. August 29, 1983-February 14, 1984. Unpublished.

Wisconsin Department of Health and Social Services, Division of Health. 1979. Annual Report: Nursing Home Quality Assurance Project, FY 1978-1979. Madison, Wisconsin.

Colorado Department of Health, Medical Care Licensing and Certification Division. 1980. ''QC'' Factors, a Relationship Between Computerization, Patient Care, and the Regulatory Process. Denver, Colorado.

Illinois Department of Public Health and Medicus Systems Corporation. November 1976. Regulatory Use of a Quality Evaluation System for Long-Term Care. Final report to Department of Health, Education, and Welfare, Contract #HSM 110-73-499.

Ohio Nursing Home Commission. 1979. A Program in Crisis: Blueprint for Action. Final Report of the Ohio Nursing Home Commission. Ohio General Assembly. Columbus.

Shanks, N., et al. 1983. Evaluation of the Reimbursement Provisions of Amended Substitute House Bill 176. A Report to the Ohio Department of Public Welfare. Center for Health Services Research, University of Colorado Health Sciences Center. Denver.

Lee, Y. S., and S. Braun. 1981. Health Care for the Elderly: Designing a Data System for Quality Assurance. Computers, Environment, and Urban Systems 6(Spring):49-82.

Lee, Y. S. 1984. Performance of Intermediate Care Facilities in Iowa: A Preliminary Analysis. Performed for the Iowa Department of Health, Division of Health Facilities [or Nursing Homes and Quality of Health Care: The First Year of Results of an Outcome-Oriented Survey. Journal of Health and Human Resource Administration 7(Summer): 32-60 ].

Bisenius, M. F. 1984. Quality of Health Care in Iowa Nursing Homes: Results from the ICF Outcome-Oriented Survey, December 1, 1982-November 20, 1983. Iowa State Department of Health, Division of Health Services, Des Moines.

New York Department of Health. May 1984. Report to the Governor and the Legislature on the New Surveillance Process for New York State Residential Health Care Facilities. Office of Health Systems Management. Albany, New York.

Mathematica Policy Research, Inc. January 1985. Evaluation of the State Demonstrations in Nursing Home Quality Assurance Processes. Final report.

DiBernardis, J., and D. Gitlin. November 1979. Identifying and Assessing Quality Care in Long-Term Care Facilities in Montana. Report to the Department of Social Rehabilitation Services, State of Montana, under Contract No. 80-070-0016. Center of Gerontology, Montana State University. Bozeman.

Donabedian, A. 1980. Explorations in Quality Assessment and Monitoring. Vol. 1: The Definition of Quality and Approaches to Its Assessment. Ann Arbor, Michigan: Health Administration Press.

Glascock, J. 1985. The Modified Survey Process—Traditional Survey Process Evaluation Project. Seattle, Washington: The Hesperides Group.

Rehabilitation Care Consultants. Evaluation of the Iowa Outcome-Oriented Survey Process.

U.S. Department of Health and Human Services. 1983. Inventory of Surveyors of Medicare and Medicaid Programs, United States, 1983. Health Care Financing Administration, Health Standards and Quality Bureau. Unpublished, Baltimore, Maryland.

Association of Health Facility Licensure and Certification Agency Directors. October 1983. Summary Report: Licensure and Certification Operations.

U.S. Department of Health and Human Services. 1980. Proceedings of Symposium on Integration of Health and Safety Survey and Inspection of Care Review. Health Standards and Quality Bureau, Baltimore, Maryland.

U.S. Department of Health and Human Services. May 1984. Inspection of Care Report. Health Care Financing Administration, Health Standards and Quality Bureau. Baltimore, Maryland.

U.S. Department of Health and Human Services. 1981. Unpublished data from research in progress. Health Care Financing Administration, Office of Research and Demonstrations. Washington, D.C.

Health Care Financing Administration, Medicare Medicaid Automated Certification System. 1981. Unpublished analysis.

Institute of Medicine, Committee on Nursing Home Regulation. December 1984. Case Studies of Nursing Home Regulation in Six States. Unpublished Reports.

National Association of Attorneys General. February 1978. Enforcing Quality of Care in Nursing Homes. Committee on the Office of Attorney General.

U.S. Senate. February 9, 1970. Medicare and Medicaid: Problems, Issues, and Alternatives. Report of the staff to the Senate Committee on Finance, 91st Congress, 2d Session. Committee print.

Health Care Financing Administration. 1981. Provider Certification State Operations Manual. Unpublished manual.

U.S. Department of Health and Human Services. 1984. Survey and Certification National Review. Unpublished Briefing Materials. Health Standards and Quality Bureau, Health Care Financing Administration.

Casper, S. K., and R. E. Burke. February 1985. Policy Recommendations for the Survey Process. Prepared for the Institute of Medicine Committee on Nursing Home Regulation.

Jost, Timothy S. December 1984. Enforcement of Quality Nursing Home Care in the Legal System. Prepared for the Institute of Medicine Committee on Nursing Home Regulation.

Mathematica Policy Research, Inc. January 1985. Evaluation of the State Demonstrations in Nursing Home Quality Assurance Processes. Final report.

Institute of Medicine. 1984. Survey of State Health Facility Licensure and Certification Agency. (See Appendix C for a report on the survey.)

Data from Medicare Medicaid Automated Certification System on terminations during fiscal years 1983 and 1984. 1983-1984. Health Care Financing Administration, Health Standards and Quality Bureau.

U.S. Federal Register. February 21, 1985. Medicare and Medicaid Programs: Intermediate Sanction of Long-Term Care Facilities. 50(35):7191-7198. [PubMed: 10299898]

Association of Health Facility Licensure and Certification Agency Directors. 1983. Licensure and Certification Directors. Unpublished summary report.

Minnesota General Statutes. 1982. Nursing Homes, section 144A.01.

Johnson, Sandra H. January 7, 1985. Evaluation of the Use of Intermediate Sanctions by the States and Recommendations for State and Federal Enforcement Policies. Prepared for the Institute of Medicine Committee on Nursing Home Regulation.

Holder, E. L., and B. W. Frank. December 1984. Resident Participation in Nursing Homes: A Key to the Improvement of Life in Nursing Homes and Improvement in the Nursing Home Regulatory System. Prepared for Institute of Medicine conference.

Institute of Medicine, Committee on Nursing Home Regulation, Public Meetings. October-December 1984.

Institute of Medicine, Committee on Nursing Home Regulation. 1985. Survey of State Licensure and Certification Directors. (Appendix C contains a summary of the findings of this survey.)

U.S. Department of Health, Education, and Welfare, Administration on Aging. May 1975. Program Instruction 75-30.

U.S. Congress. 1985. Older American's Act of 1965, as amended in 1984. Washington, D.C.: U.S. Government Printing Office.

Testimony before House Select Committee on Aging, Committee on Human Services. September 10, 1985.

Buford, A. D. 1984. Advocacy for the Nursing Home Resident: An Examination of the Ombudsman Function and Its Relationship to Licensing and Certification Activities in Ensuring Quality of Care. Prepared for the Institute of Medicine Conference on Nursing Home Regulation.

Institute of Medicine, Committee on Nursing Home Regulation. 1984. Consumer Workshop.

Meeting of State Long-Term Care Ombudsmen, Philadelphia, Pennsylvania, November 1984.

Kosberg, J. I. October 1984. Advocacy Organizations for Nursing Home Residents: A National Study.

U.S. Department of Health, Education, and Welfare, National Center for Health Statistics, July 1979. National Nursing Home Survey: 1977 Summary for the United States. HEW Pub. No. 79-1794.

U.S. Office of Management and Budget. April 27, 1984. Circular 1-12: Cost Principles for Non-Profit Organizations; Lobbying Revision, Federal Register 49(83):18260-18277.

Zischka, P. C., and I. Jones. February 1984. Volunteer Community Representatives as Ombudsmen for the Elderly in Long-Term Care Facilities. The Gerontologist 24(1):9-15. [PubMed: 6698421]

Barney, Jane L. March 1974. Community Presence as a Key to Quality of Life in Nursing Homes. American Journal of Public Health 64(3):265-268. [PMC free article: PMC1775425] [PubMed: 4811770]

Dobrof, Rose. December, 1984. Community Involvement: An Approach to Enhancement of Quality of Life in Nursing Homes. Unpublished paper prepared for Institute of Medicine Committee on Nursing Home Regulation.

Zwick, Daniel. November 1984. The HCFA Proposal to Accord "Deemed States" to Nursing Homes Accredited by JCAH. Unpublished paper prepared for the Institute of Medicine Committee on Nursing Home Regulation.

Weisfeld, N. 1984. Accreditation, Certification, and Licensure of Nursing Home Personnel: A Discussion of Issues and Trends. Unpublished paper.

Aiken, L. H., M. Mezey, J. Lynaugh, and C. Buck. March 1985. Teaching Nursing Homes: Prospects for Improving Long-Term Care. Journal of the American Geriatrics Society 33(3):196-201. [PubMed: 3919077]

Pattee, J. December 1984. Physicians Serving Nursing Homes. Unpublished paper prepared for Institute of Medicine Committee on Nursing Home Regulation.

Adams, Carl, and Julia Powell. 1980. Patient Assessment Computerized. National Health Corporation. Murfreesboro, Tennessee.

Gustafson, D. H., and D. Zimmerman. December 1984. The Potential for Incentives to Improve Quality of Care in Nursing Homes. Prepared for Institute of Medicine Committee on Nursing Home Regulation.

Institute of Medicine, Committee on Nursing Home Regulation. 1984. Report on Management Workshop.

Association of Health Facility Licensure and Certification Directors. 1983. Survey.

In Rhode Island, the state licensure and certification agency obtained voluntary agreement from all nursing home operators to maintain up-to-date standard resident assessment data on all residents. These data were to be used by state surveyors for sampling purposes in testing the new Health Care Financing Administration PaCS survey instrument. Although it was not suggested by the state agency, about half of the nursing homes immediately began entering the data into their own computers and offered to transmit it by telephone to the regulatory agency to facilitate sampling by the surveyors.

Urban Systems Research and Engineering, Inc. 1984. Short-Term Evaluation of Medicaid: Selected Issues. Unpublished Report. Cambridge, Massachusetts.

U.S. General Accounting Office. October 1983. Medicaid and Nursing Home Care: Cost Increases and the Need for Services Are Creating Problems for the States and the Elderly.

Levit, K.R., H. Lazenby, D. R. Waldo, and L. M. Davidolf. Fall 1985. National Health Expenditures, 1984. Health Care Financing Review 7(1):20. [PMC free article: PMC4191515] [PubMed: 10311395]

Schlenker, R. 1984. Nursing Home Reimbursement, Quality, and Access—A Synthesis of Research. Paper commissioned by Institute of Medicine.

Texas is a major exception. It has statewide occupancy rates below 85 percent, although this is not true in a couple of the larger cities. Texas also pays among the lowest Medicaid nursing home rates in the country.

Bayo F., and J. Fabler. 1980. United States Population Projections for OASDI Cost Estimates, 1980. Social Security Administration, Office of the Actuary: Actuarial Study No. 82, SSA Pub. No. 11-11529.

Morris, J. M., S. Morris, and S. Sherwood. 1984. Assessment of Informal and Formal Support Systems in High Risk Elderly Populations. Pp. 223-253 in Functional Assessment in Rehabilitation Medicine. C. V. Granger, editor; and G. E. Gresham, editor. (eds.). Baltimore, Maryland: Williams and Wilkins.

Curtis, R. E., and L. R. Bartlett. 1984. The. High Cost of Long-Term Care Squeezes State Budgets. Generations 9(1):22-25. [PubMed: 10311059]

Powell, Julia. 1984. The Systematic Use of Patient Assessment Data for Managing Nursing Homes. Paper commissioned by National Academy of Sciences/Institute of Medicine Committee on Nursing Home Regulation.