Long Term Care: Federal and State Regulations
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Both the federal and state governments regulate long-term care services and facilities. The standards are set by agencies that pay for services, monitor quality of care, and establish rules for licensing staff.
It is important to understand what standards are monitored and how a particular facility or agency measures up to the requirements. Particularly important, of course, is the number of problems noted by government surveyors or through public complaints.
Home care agencies: There are different types of home care agencies with different regulatory oversight. In order for a home care agency to be paid by Medicare and Medicaid, it has to be approved by CMS (Centers for Medicare & Medicaid Services).
These agencies provide skilled nursing care, personal care, and therapies from professionals such as physical, occupational, speech, and respiratory therapists. Social-work services are also available. Home Health Compare is a CMS website that gives you information on specific agencies and how they are doing with meeting federal standards.
Many but not all states license home care agencies that provide personal care services. Check the website of your state department of health to see whether all home care agencies are licensed and what they require in terms of background checks and training.
Most states do not regulate companion agencies that provide nonmedical services such as preparing meals, homemaker services, and personal care, although the number that do monitor them is increasing. You will have to exercise due diligence about the agency’s practices regarding background checks of employees, training, and other issues.
Assisted-living facilities: The federal government doesn’t have standards for independent living or assisted-living facilities. (A final CMS rule of January 2014 sets standards for states that include assisted living facilities in their Medicaid home- and community-based services waivers. States have a transitional period to ensure that they meet the standards.)
These facilities are subject to various state regulations, which include building and safety codes. Some are licensed under different categories of congregate living. Because they do not provide medical services (except in a specific nursing unit), they are not generally regulated by departments of health.
Nursing homes: Nursing homes are subject to federal and state regulation, with specific requirements about staffing, training, prevention of abuse and neglect, reporting incidents of poor quality, and other standards. A CMS website, Nursing Home Compare, allows you to search by facility name.
State governments also regulate nursing homes, and many department of health websites also provide information on the results of their surveys. This information is also available on Nursing Home Compare.
Quality Improvement Organizations (QIOs): Part of the CMS structure, each state has a designated QIO that is responsible for ensuring and improving quality of care and for reviewing complaints. If, for example, you feel that you are being discharged from a hospital too quickly, you can appeal the decision to the local QIO.
Most people don’t know about these organizations, but they can be very helpful in resolving problems. This directory of QIOs will help you find the right one.
Long-term care ombudsmen: Ombudsmen (the term comes from Swedish) investigate complaints and negotiate solutions to problems in nursing homes and assisted-living facilities.
These or other comparison sites are useful as a starting point but they do not provide all the information you need, and the sources on which they base their reviews may be incomplete or outdated.