'IIIIIIIIIIIIlIIIIIIIIIIIII TH ESlS 22w LIBRARY ' Michigan State University This is to certify that the dissertation entitled Regulatory Enforcement: Do External Environmental Factors or Internal Agency Factors Influence Nursing Home Inspectors' Activities? presented by Lucinda Marie Deason has been accepted towards fulfillment of the requirements for Ph.D. mgmem Political Science flay/07% Major professor I)ate .f;’//i’/;//((:Z:57 MSU is an Affirmative Action/Equal Opportunity Institution 0-12771 PLACE IN RETURN BOX to remove this checkOUt from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE b DATE DUE DATE DUE Eli-'2 2‘38 9% UT 11m mus-p.“ REGULATORY ENFORCEMENT: DO EXTERNAL ENVIRONMENTAL FACTORS OR INTERNAL AGENCY FACTORS INFLUENCE STATE NURSING HOME INSPECTORS’ ACTIVITIES? By Lucinda Marie Deason A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Political Science 2000 D0 EXTERX.\ FACTORS l.\'iil-l TEES tliwc.’ v *~, . . ,N _ i ._-.. .4; Add . ‘v I 1‘33? he tc‘.’ I I T"‘Y“.~"_‘..* in In ‘r.‘§‘~.‘-~‘ t" 1' ‘Ilv‘: SI . - k;.l.5h ~,~:X" \ Q. :r A.“ ‘84 -- i I h bl h“, ‘ |~u } i .‘ _ “r . \Ibfi‘.‘ \UOI"' c I .‘| 3"? .fig. . 1'” . l ‘ m h: :Y‘TJT-i‘jsn‘ "h f L' “’5 .I \i «i '7’ ‘ «J a (at. . 5‘4‘ ‘.,". . .‘ ' \ W . I‘.‘ 3. ' l I\‘\.\. 1r C. 4 .3:\ q“; ‘r I.- I-Pf.~-. . v-. “‘A‘ 4"... I .“- n. P. x I .* V. -c\ .fl‘ll .- 94".. .4... \ ABSTRACT REGULATORY ENFORCEMENT: DO EXTERNAL ENVIRONMENTAL FACTORS OR INTERNAL AGENCY FACTORS INFLUENCE STATE NURSING HOME INSPECTORS’ ACTIVITIES? By Lucinda Marie Deason This dissertation will help scholars examining the external environmental and internal agency factors influencing regulatory agencies implementing the OBRA 87 nursing home reform laws. Numerous federal and state laws have been adopted and implemented to improve the quality of care that residents receive in nursing homes across the United States throughout the history of this policy arena. The impact of these laws has improved patient care, yet many problems persist that have caused residents to physically suffer or die. For instance, in 1987 Congress enacted a series of nursing home reform laws in the Omnibus Budget Reconciliation Act (OBRA 87), which expanded the focus of inspections to include assessing residents’ outcomes, reduced usage of physical and chemical restraints on residents, and expanded the range of sanctions that could be imposed on nursing homes not complying with the provisions of the laws. State inspection agencies implemented the OBRA 87 nursing home reform laws, and the results showed a reduction in the usage of physical and chemical restraints. Yet, significant problems persist, with poor or fatal resident outcomes and few sanctions being imposed on facilities not complying with the nursing home reform laws. For example, in 1997, poor implementation of the OBRA 87 enforcement laws resulted in 30 percent of nursing home residents suffering or dying from malnutrition based on expert testimony at US. 3:21: beams IAn _ a" 71': hrs mg Au. . _] i.‘ 751m lit mm. Tn: Iraq... 2:131. In‘xr‘pl 1"“ If : 15ml en: 1: . . H -, ~_' 'L .“fi‘ V, k. . I'. -.\~.i.,._\ ‘ \ ‘5 L1 :5 ‘13.. .. 1,. i. "‘1 £4.33 VJLJ‘“ -~-O-‘O. o ' \ , I; h[.-?«' “tugu' lL‘. Iii bt\-\ Senate hearings (American Association of Retired Persons’ Bulletin, 1997). The Health Care Financing Administration estimates that approximately 40 percent of nursing home residents are malnourished nationally (PRNewswire, 1999). The triangulation approach was employed, whereby the results of a case study, survey, in-person interviews, and regression analyses were conducted to assess the impact that external environmental factors and internal agency factors exert on inspection agencies across the states over the period 1991 through 1998. The results of the three studies conducted for this dissertation indicate that executive and legislative political institutions, interest groups, and the interaction of pressure from external groups and political institutions with inspectors’ views about managers influence the activities of regulatory agencies. This dissertation was the first study to systematically examine the implementation of the OBRA 87 laws across the states and over time, and it contributes to the literature by using quantitative techniques to test various external environmental factors and internal agency factors causal hypotheses and by identifying which factors systematically influence the activities of regulatory agencies across states and over time. .....‘V“~I'L .‘..' A!‘ LIMA \llel III Copyright by LUCINDA MARIE DEASON 2000 l' fl: [TIE-33R“ ( DEDICATION To the Universal Creator, my grandmother, my mother, my children, my family, my fiancee, and my true friends . .. ”u I ~ - .. ‘-.... 3C 'L‘! ’ ' _ an .. s .5‘ l' . \._‘.'.T‘:; 5.; .L I 1:" ' .IA '31:; ”1;. 1*” .-5‘ 'ca . . ,_ . (L:.\_‘1““«.~ ‘eu. Ii") 1. L-) o-«n -—~o Ami. “W. . ‘r g . . gm“; *6 ‘ 5s. . ‘ ~u‘ A~Ol| u 't ‘L .1- K s -‘| .:'.. h‘ ‘ ‘vch ‘ ‘5 s 'l ACKNOWLEDGMENTS I would like to express my deepest appreciation to Dr. Robert C. Lowry, who guided and supported my dissertation with his invaluable suggestions and insights and taught me about regulation during my doctoral Studies. I am also grateful to Drs. Carol Weissert, Harry Perlstadt, James Granato, Kenneth Williams, Darren Davis, and Michael Mintrom for their guidance and constructive criticisms. I also want to thank the various nursing home policy experts for their help. They provided me with extremely useful information that contributed to my gaining a thorough understanding of the nursing home policy arena. I want to also express my sincere thanks to the Universal Creator. I am also deeply grateful to my grandmother Lucinda Deason, my mother Almeda White, the rest of my family that supported me, all of my true friends, and my editor, whose support and encouragement helped me through the many hard times I experienced. My most heartfelt thanks go to my son Brandon Ramsey, my daughter Kareemah Garba, and my fiancee Timothy Howell. Without their extraordinary patience, intelligence, and love, which supported me throughout the many challenges I faced as I completed the dissertation, I would never have reached my goal. I owe them a lifetime of gratitude. vi I "O. n V: l~ cu... ‘_ .. i 3123 (ll - If: \km- TABLE OF CONTENTS LIST OF ABBREVIATIONS ............................. CHAPTER 1 INTRODUCTION ........................... Introduction ................................... State Implementation of Nursing Home Laws and Regulations Prior to OBRA 87 ...................... Enactment of OBRA 87 ............................ W State Implementation of the Enforcement Provisions after OBRA 87 ................................ CHAPTER 2 HISTORY OF STATES IMPLEMENTING NURSING HOME LAWS AND REGULATIONS . . Introduction ................................... 19303 through 19403: Creation of the Nursing Home Industry 19503 through 19603: Growth in the Nursing Home Industry Multiplies Nursing Home Care Problems ................ 19703: Political Efforts to Improve Nursing Care ............ 1980s and 19903: Enactment of Legislation that Focuses on Resident Care ................................ CHAPTER 3 LITERATURE REVIEW ...................... Major Views about Regulatory Agencies .................. External Actor Theories of Regulatory Agencies ............. Interest Group Theories ............................ Executive Theories ............................... Legislative Theories .............................. Organizational Factor Theories of Regulatory Agencies ......... Scientific Management Perspective ..................... Human Relations Perspective ......................... Scientific Management and Human Relations Perspective . . Nursing Home Structural Factor Theories ................. Current Studies of States Implementing Nursing Home Laws vii 10 15 15 15 16 17 20 30 30 35 36 40 42 45 46 48 49 52 54 CHINE“ A C.- 0F 7 Intriduai 2 Slithigan's E1117 4mm Baits: 163‘s; 1093 It. Est ‘l. 1095 If. the 0' M43 Ill ()liRJ lztsn m t . Mt’ih tj Rti‘ik Par; If" \~ CHAPTER 4 A CASE STUDY OF MICHIGAN’S IMPLEMENTATION OF THE OBRA 87 ENFORCEMENT REGULATIONS . . . 58 Introduction ................................... 58 Michigan’s Experience Implementing the OBRA 87 Enforcement Regulations .......................... 59 Background ................................. 59 1987 through 1992: Passage of the OBRA 87 Regulations . . . . 70 1993 through 1994: Michigan Regulators Implement Interim Enforcement Regulations ........................ 71 1995 through 1997: Michigan Regulators Implement the OBRA 87 Final Federal Enforcement Regulations ...... 72 1998 through 1999: Problems with Implementing the OBRA 87 Final Federal Enforcement Regulations Persist . . . . 91 Interviews with Michigan Actors ...................... 98 Methodology ................................ 98 Results .................................... 100 Purposes 1 and 2: Determine the Role Each Actor Played in Improving or Hindering the Implementation of the OBRA 87 Enforcement Regulations and Examine the Perceptions of the Extent of Each Actor’s Influence on Regulators Implementing the OBRA 87 Enforcement Regulations . . . . 101 Purpose 3: Determine How the Implementation of the OBRA 87 Enforcement Regulations Can Be Improved in Michigan .............................. 121 Limitations ................................. 122 Conclusion .................................... 122 CHAPTER 5 DO EXTERNAL ENVIRONMENTAL FACTORS INFLUENCE INSPECTORS IMPLEMENTING THE OBRA 87 ENFORCEMENT REGULATIONS? ......... 124 Introduction ................................... 124 Hypotheses .................................... 125 Interest Groups ................................. 125 Executive and Legislative Political Institutions .............. 125 Nursing Home Structural Controls ..................... 126 Time Controls .................................. 127 Variables ..................................... 128 Methodology ................................... 136 Regression Diagnostics ............................ 136 Results ...................................... 139 Interest Groups ............................... 139 Executive and Legislative Political Institutions ............ 140 Nursing Home Structural Controls ................... 142 Time Controls ............................... 143 Conclusion .................................... 143 viii .fi‘flfllé DO E ” INTI} Illl’Ll RlfiGl' Intridutti- in Hmulhc‘xcs . External 1 lmcrml .1 Nursing ll .3": ILIDC C watt. .3 Vanities . Slit‘zxi.‘ i ”it 0671):“ All R:gr:\\i in [3 RNELS 5.167131 1 p'iitlsdi lat-cm] .5 X11531: i Ilmc C. ‘T liittlliti. 32‘ Comm . WTER’ COM laminar-n TWO Xijhlr \' ‘M‘erlm I” u :‘Hmm’t’md: and R1531; I Fm: 5013:: “WE . 33'?me A Table ] Iahk. 2 ID]:- 3 IN: 4 lb}: 5 T9}: 6 I.” a) CHAPTER 6 DO EXTERNAL ENVIRONMENTAL FACTORS OR INTERNAL AGENCY FACTORS INFLUENCE STATES IMPLEMENTING THE OBRA 87 ENFORCEMENT REGULATIONS? ........................... Introduction Hypotheses .................................... ................................... External Environmental Factor Hypotheses .............. Internal Agency Factor Hypotheses .................. Nursing Home Structural Controls ..................... Time Controls .................................. Variables ..................................... Methodology ................................... Overview of the Survey Results ....................... Regression Diagnostics ............................ Results OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO External Environmental Factors: External Groups and Political Institutions ........................... Internal Agency Factors: Organizational Factors .......... Nursing Home Structural Controls ................... Time Controls ............................... Limitations .................................... Conclusion .................................... CHAPTER 7 CONCLUSION AND RECOMMENDATIONS ......... Introduction Two Major Views of Public Bureaucracy Revisited ........... Comparison with the Literature ....................... Recommendations from this Dissertation to Policymakers and Public Managers ............................. Future Studies .................................. APPENDICES ...................................... APPENDIX A Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Tables ............................... Status of OBRA 87 Nursing Home Reform Regulations as of February 1998 ............. Enforcement Sanctions ..................... Scope and Severity of Deficiencies .............. OBRA 87 Sanctions Imposed .' ................ Significant Events Occurring During the Adoption and Implementation of Nursing Home Laws ...... Percentage of Nursing Home Residents Receiving Medicaid Benefits by State: For the Years 1991, 1992, 1993, 1994, 1996, 1997, and 1998/1999 . . . . Enforcement Sanctions ..................... The OBRA 87 Sanctions Imposed in Michigan: July 1, 1997 to January 6, 1998 ............. ix 147 147 148 148 148 149 149 150 157 158 159 161 161 161 163 164 164 165 168 168 168 170 171 173 175 175 175 177 178 179 180 192 194 195 I351: 9 Isflc 10 .931: ll Die 13 '—‘l I; .J. n) H ':J T451: 24 Titus Tall: 15 Tzl‘ic 1‘ If}: Table 9 Estimate of the Influence of Michigan Actors on the OBRA 87 Enforcement Regulations ........... 196 Table 10 Participants’ Perceptions of their Influence on Improving or Hindering Enforcement Regulations . . 197 Table 11 Regional Inspection Activity: July 1, 1997 to January 6, 1998 ..................... 198 Table 12 Description of the External Environmental Factors Influencing the Average Number Of Deficiencies Cited per Facility by State: Covering the Periods 1991 through 1994, 1995 through 1997, and 1991 through 1997 ......................... 199 Table 13 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Period 1991 through 1994 ..................... 202 Table 14 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity: Covering the Period 1991 through 1994 ..................... 203 Table 15 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity and Autocorrelation: Covering the Period 1991 through 1994 ........ 204 Table 16 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Period 1995 through 1997 ..................... 205 Table 17 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiences Cited per Facility by State: Correcting for Heteroscedasticity: Covering the Period 1995 through 1997 ..................... 206 Table 18 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiences Cited per Facility by State: Correcting for Heteroscedasticity and Autocorrelation: Covering the Period .................... 207 Table 19 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiences Cited per Facility by State: Covering the Period 1991 through 1997 ..................... 208 .- ‘. '-.\- I" . I Table 30 Table II Title I: TIDlC :3 lat-3c 24 Title 25 Idi‘lc If) ‘0 4J1}; C Table 20 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiences Cited per Facility by State: Correcting for Heteroscedasticity: Covering the Period 1991 through 1997 ..................... 209 Table 21 Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiences Cited per Facility by State: Correcting for Heteroscedasticity and Autocorrelation: Covering the Period 1991 through 1997 ........ 210 Table 22 Description of the External Environmental Factors and Internal Agency Factors Influencing Enforcement . . 211 Table 23 Factor Analysis Results ..................... 212 Table 24 Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspection Managers .................... 214 Table 25 Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspectors ................... 215 Table 26 Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspection Managers and Inspectors ........... 216 Table 27 Deficiency Citation Data: Average Number of Deficiences per Certified Nursing Facility by State over the Years 1991—1997 ........... 217 Table 28 Comparison of Mean, Difference of Means Test, and Kappa Statistic Results for Selected Inspection Managers’and Inspectors’ Survey Responses ...... 219 Table 29 Cochrane-Orcutt Test of Autocorrelation (1991-1994) . . 221 Table 30 Cochrane-Orcutt Test of Autocorrelation (1995-1997) . . 222 Table 31 Cochrane-Orcutt Test of Autocorrelation (1991—1997) . . 223 Table 32 Cochrane-Orcutt Test of Autocorrelation for the Manager Model Estimated (1995—1997) . . . . 224 Table 33 Cochrane-Orcutt Test of Autocorrelation for the Inspector Model Estimated (1995-1997) . . . . 225 APPENDIX B Figures 1—3 Figure 1 Annual Inspection Flow Chart as of 1997 .......... 227 Figure 2 Organizational Chart for the Department of Health and Human Services Health Care Financing Administration as of April 6, 1994 .............. 228 Figure 3 Organizational Chart for Nursing Home Regulators within the Michigan Department of Consumer and Industry Services as of 1997 ................. 229 APPENDIX C AARP and AHCA’S Percent of PAC Contributions by Political Party for the Years 1991 through 1997 . . . . 230 xi REESDIX D .'-_??E\'DlX E iEP‘ENDlX F .3.V‘FE\'DIX G , f a #71 :2. .r’? (I) ,_ ‘t" .‘_-q L r ./t :1 >4 O :-: l a CAKJKX I: 31' CI} 021 Ch (7'11 01-. ind Sit: Ir; APPENDIX D The United States Senate Special Committee on Aging: 106th Congress (1999-2001) ........ 231 APPENDIX E Structured Interview Questions ................ 232 APPENDIX F Completed Structured Interview Questions ......... 235 APPENDIX G Michigan’s Enforcement Unit’s Formal Responsibilities ....................... 254 APPENDIX H Interview Consent Form .................... 256 APPENDIX I Coding Results for Question 14 ................ 257 APPENDIX J Chow Test Comparing the Pre- and Post-Implementation Regression Models ........ 258 APPENDIX K Check for Multicollinearity (1991—1994) .......... 259 APPENDIX L Glesjer Test for Heteroscedasticity (1991—1994) ...... 260 APPENDIX M Check for Multicollinearity (1995-1997) .......... 261 APPENDIX N Glesjer Test for Heteroscedasticity (1995-1997) ...... 262 APPENDIX 0 Check for Multicollinearity (1991—1997) .......... 263 APPENDIX P Glesjer Test for Heteroscedasticity (1991-1997) ...... 264 APPENDIX Q Indices for Regression Analysis ................ 265 APPENDIX R State Nursing Home Regulators’ Questionnaire for Managers of Nursing Home Inspectors ......... 275 APPENDIX 8 State Nursing Home Regulators’ Questionnaire for Nursing Home Inspectors ................. 281 APPENDIX T Frequency Report of the State Nursing Home Regulators’ Questionnaire for Managers of Nursing Home Inspectors ................. 287 APPENDIX U Frequency Report of the State Nursing Home Regulators’ Questionnaire for Nursing Home Inspectors ....................... 293 xii .lfFB'DlX \' AP?E.\'DlX W EPENDIX X ASPEN C‘J 1X Y .‘.?PE\'DIX Z 4339“ AA .iSE'EXDIX BB h FEERINCES APPENDIX V F-Test for Testing Sets of Coefficients Comparing the Inspection Manager Model to the Inspection Manager and Inspector Model .................... 299 APPENDIX W F—Test for Testing Sets of Coefficients Comparing the Inspection Manager Model to the Inspection Manager 300 and Inspector Model .................... APPENDIX X Matrix of Correlations between the Estimated Regression Coefficients for the Manager Model . . . . 301 APPENDIX Y Glesjer Test for the Manager Model ............. 302 APPENDIX Z Matrix of Correlations between the Estimated Regression Coefficients for the Inspector Model . . . 303 APPENDIX AA Glesjer Test for the Inspector Model ............ 304 APPENDIX BB Difference of Mean Test for Deficiency Citations Assessed across the States before (1991-1994) and after (1995—1997) Implementation of the OBRA 87 Enforcement Laws ............... 305 REFERENCES ..................................... 307 xiii AAHSA AARP AHCA AHFSA AOA CBC CQIP CRP DHHS FTC GAO HCAM HCFA HEW IDDR IOM MAHSA LIST OF ABBREVIATIONS American Association of Homes and Services for the Aging American Association of Retired Persons Americans for Democratic Action American Health Care Association Association of Health Facility Survey Agencies Administration on Aging Citizens for Better Care Continuous Quality Improvement Program Collaborative Remediation Project Department of Health and Human Services Federal Trade Commission General Accounting Office Health Care Association of Michigan Health Care Financing Administration Department of Health, Education, and Welfare Informal Deficiency Dispute Resolution Institute of Medicine Licensed Practical Nurse Michigan Association of Homes and Services for the Aging xiv if)? lE‘flS \Cf‘F'il Ht". .A40 .1230 MDCH MDCIS MDPH MPHI MPRO NA OBRA 87 ONHA OSHA OSA PACE RPI Michigan Department of Community Health Michigan Department of Consumer and Industry Services Michigan Department of Public Health Michigan Public Health Institute Michigan Peer Review Organization Nursing Assistant Omnibus Budget Reconciliaton Act of 1987 Office of Nursing Home Affairs Occupational Safety and Health Administration Office of the Services for the Aging Patient Appraisal and Care Evaluation Registered Nurse Resident Protection Initiative XV lntnduction ln lit} 10"1' ’1 Kevin {HI 0 Tr: misfit} ' (hr natun 18-1312 nut p.151 it'll wmunm: are utiizzcd :1in; in {11;} if LDC iii“ R .3 .lUSI 35 'Mii Eta-9.2m, .,' .1341 if IhC L l I re» .. ’i 'm - ‘ u ll“.hv ‘ u n. I- ‘ ,,._‘ ‘r.’ 411‘ .n ‘ CHAPTER 1 INTRODUCTION Introduction In May 1975 the Commissioner of the Administration on Aging (AOA) explained the necessity for overseeing the implementation of regulations impacting the nursing home industry: Our nation has been conducting investigations, passing new laws, and issuing new regulations relative to nursing homes at a rapid rate during the past few years. All of this activity will be of little avail unless our communities are organized in such a manner that new laws and regulations are utilized to deal with the individual complaints of older people who are living in nursing homes. The individual in the nursing home is powerless. If the laws and regulations are not being applied to her or him, they might just as well not have been passed or issued (US. Department of Health, Education, and Welfare, Administration on Aging, May 1975). This statement depicts the problems that have occurred over the past thirty years with implementing regulations and laws in the nursing home policy arena. That is, despite all of the laws and regulations that have been adopted to improve the quality of care residents receive, many problems persist. Furthermore, the Institute of Medicine (IOM) conducted a study in 1986 supporting the commissioner’s View by stating that, “even with improved regulatory standards and a more effective inspection process, it is unlikely that quality of care and quality of life for residents in marginal or substandard “v- ‘ ‘MH 3 \ “j? I} 55.5 '-..n Q - - a‘ ."' ' 1:. Aid. ,A ,) H.355. 17:37.35 law q > -;. . -" '1’? I“. .45.». ' §‘ “» v I)- ,9. \ I :‘ 5nns—C. .n. us. ~ I T'”’~"~.""‘a_" 'T. ““"‘“t~H-§ L.- ‘ Q‘uv-g" . y! AL-,‘N \ ‘1: II c *‘t? . "‘8 pi! , x...‘ 1‘.\‘ 5“ t u --4.\- "to l,,.‘ . l t ‘t.:_ x . .. i "..Y' * . n. - “Wt-15¢ I 44;-u,’ . I .‘tk "s 3‘ s~l -'- . ext-"a _ -q .‘F .., : \‘\ ’0 P b " ‘3. l I a- w “ 3N1. nursing homes will improve unless compliance with the standards is effectively enforced. ”1 Hence, poor state implementation has significantly weakened the ability of the numerous laws and regulations that have been adopted to improve nursing home care. Therefore, more attention needs to be focused on the implementation of nursing home regulations and laws, not on the adoption of laws and regulations. Examining the factors influencing the implementation of regulations and laws governing the nursing home industry (not the adoption of laws and regulations) will provide an opportunity to improve nursing home care. From a conceptual standpoint, this topic can help scholars understand which factors influence states implementing laws. Various scholars have identified and studied the factors that have influenced the adoption of various policies. For instance, Brudney and Hebert (1987) show that external actors can influence state policy adoption by pursuing litigation, directly interacting with state agencies, or contacting state level politicians. Yet, some scholars’ studies indicate that industry influences state regulatory agencies’ policymaking (Huntington, 1952; Bernstein, 1955; Stigler, 1971; Pertschuk, 1982). Other researchers argue that a mixture of pro—producer and pro—consumer policies emerges from fierce competition among conflicting interest groups (Sabatier, 1975; Peltzman, 1976; Wilson, 1980). Yet few scholars have examined the factors that influence state implementation of laws and regulations adopted. For example, Pressman and Wildavsky (1984) showed that state environments and resources influence the implementation of federal policies. ‘Substandard certification means facilities do not completely comply with Medicaid and/or Medicare standards. .,J-., rt“! . 1:.» 5.14.11» 11‘ l no.1; ~ I», -11..~:1::tdll"n J! I -"#mdr.l,. \ u..:.s..151l|:li' n P " I V‘ . ' ‘ Admit: “Pu. 115;. C I 9 . . ““rlt In\‘\ A ., . at I- 1.. 5 find] .5, . ‘5 ‘1;- Scholz, et a1. (1991) showed that local political environments and interest groups systematically influenced agency activities at the county level. Furthermore, Scholz and Wei (1986) indicated that state—level organizational and political problems limit an agency’s ability to implement federal policies. Thus, the few Studies that have examined implementation at the state level Show that differences in state environments influence implementation. Policymakers and public managers in the nursing home policy arena can also gain some insight into which factors facilitate and which impede the implementation of laws and regulations. Over the past thirty years, many laws and regulations have been adopted to improve resident care in nursing homes. Yet poor care persists. However, very little attention has been focused on identifying the factors that influence implementa- tion. An examination of these factors can help to improve state implementation of nursing home laws and regulations, which could ultimately help to improve resident care. As the Commissioner of the AOA stated earlier, the care for residents will not improve until the laws that are enacted are adequately implemented (IOM, 1986). In this chapter, state implementation of nursing home laws and regulations will be discussed. Next, an overview of the nursing home reform provisions of the Omnibus Reconciliation Act of 1987 (OBRA 87) will be described. Then, state implementation of the enforcement provisions after the enactment of the OBRA 87 will be discussed. State Implementation of Nursing Home Laws and Regulations Prior to OBRA 87 The federal government initially became involved with regulating nursing homes in the 19503 after various stories, research, and testimony indicated that facilities’ services resulted in neglect, abuse, and death of residents (Mendelssohn, 1974; Butler, 3 $1 is). a; Grams vn ul 1. ~u- "‘ .;l :1 .-.,‘ \ HAUL \ d . I f: .- 41 “.“.. \II-a ‘ h; r I .5 l I.‘, .~;' 0 - .‘ CR; 1? I a .4 i‘“~s I ~, , M415 hm. .._ ¥ ° Lin. ~ .'_ l «: 1'?‘ dud“ ' lb‘~ - - ‘7‘ \ I INC, a,“ O D .r . ‘¢‘\‘ :1." u‘:\ x L; ' ”"i I'm. , “-4 «A ‘ “J K. I. v“- ‘1- .“ K'II' 1979; Butler, 1980; IOM, 1986). For example, in the late 19503 several governmental units were commissioned to study the nursing home standards established by states. In the late 19703 and early 19803 legal scholars identified similar systemic problems in their examination of the public enforcement system (Edelman, 1998). Furthermore, the Ohio Nursing Home Commission cited earlier reports from Michigan, New York, Illinois, Texas, Arkansas, and Connecticut indicating that the “ineffectiveness of regulatory agencies...has been acknowledged and reported...with depressing regularity (Ohio Nursing Home Commission, 1979). That is, the public enforcement systems’ failure to impose timely and effective sanctions against facilities led to poor care for residents. Furthermore, the Special Committee on Aging identified the following reasons for state nonenforcement: 0 enforcement meant the closure of facilities, already in short supply, with no place to put patients; 0 states had few weapons other than the threat of license revocation to bring a home into compliance; 0 the license revocation itself was of very little use because of complicated administrative or legal procedures required; 0 judges were reluctant to close a facility when the operator claimed that the deficiencies were being corrected; and 0 nursing home inspections were geared to examining the physical plant rather then assessing the quality of care. Thus, limited sanctions, fear of the impact the sanctions would have on residents, and the focus of the inspections weakened state implementation of nursing laws and ,4. ,- .; :3....‘:...-m. Thctc; . »- l. — t- ' jI‘IU-I‘ig P“r M1: Cunsrcss I: u\ 5?de {l ’I I .,. ,M ‘4" '- wading}. Th .1 2:53 in Mir: II" -_0\ _ P dug“. ' ’9 t ', 53.; A?“ .11 BL. m3? ‘3‘.) . . . ‘ ~ um: l 5< "Zfi . _ ‘L 16"” . 3 must 1 '0- x .9, "ML 1 o 1‘31,“ r L" , ¢ «‘1' ~“ ‘I P 'i at I, ., .L \ ,‘. _“l\ 3‘” ‘.. ‘5‘I regulations. Therefore, there were no effective deterrents to prevent nursing homes from providing poor care to residents. . Congress responded to residents’, residents’ families’, and various other advocacy groups’ concerns by authorizing the IOM’S Committee on Nursing Home Regulation to thoroughly study the problems with state regulatory systems and to make recommenda- tions for improvement. The committee published the results of its findings and recommendations in a report entitled, “Improving the Quality of Care in Nursing Homes,” in March 1986. In this report, the committee identified the importance of implementation for achieving high quality of care for residents by stating, “even with improved regulatory standards and a more effective inspection process, it is unlikely that quality of care and quality of life for residents in marginal or substandard nursing homes will improve unless compliance with the standards is effectively enforced. ”2 This report also identified four categories of problems with federal and state implementation activities, which included: 0 federal and state orientation and attitudes toward enforcement; 0 federal rules and procedures; 0 state variations in enforcement authority, policies, and procedures; and 0 inadequate federal and state resources committed to implementation (IOM, 1986). Federal and state resources, rules, and procedures can facilitate or impede the internal agency operations of nursing home inspection managers and inspectors implementing nursing home laws and regulations. Also, state orientations and enforcement authority 2The survey process is the nursing home inspection process and will be referred to as the inspection process throughout this dissertation. . . 1 .33 DC 13241: l“ k..li.;l¢d ‘ 1".“ ..‘ ., [H '0' ‘E‘l‘ 5 Ii.ThS‘ .1 3§\l :‘z-«o, _ ‘ . 5...; fix ‘3'”- O‘- ‘~ 3, ' _ “54.x ."‘ «K». “r '._ ‘ . .\ - : E's-21 JFK: ‘j g u I 6“]1 ‘ -- .L\ ~'*t? “V in \ I“ at} 1.. 145$». ’1‘ ' ._ ,9. . ‘2. a‘.“\‘ I. I‘M :"u; I".- A.\. . -.l (h v l 3‘ I -. d - ‘5 '-. '3‘; :4 x ‘. ‘5 . -.“ M‘, ._l a- -«~\ (N o‘_ ‘. 1“,; I h " rig-vb, 4 4 ~_ ‘1 A A; V... . “"v . ‘ ‘=_ " . s d \.. -- r s - 5. s q T‘- can be influenced by state-level actors. Hence, the state implementation problems identified by the IOM imply that various external actors and internal organizational factors influence state implementation. That is, the regulatory agencies at the state level responsible for inspecting nursing homes can be influenced by state-level actors and their agency’s internal organizational factors. Enactment of OBRA 87 In response to the IOM’s report, Congress enacted new standards of care and sanctions with the passage of the OBRA 87. More specifically, the OBRA 87 established standards for long-term care facilities, nurse aide training, survey and enforcement, physical and chemical restraints, nursing waivers, administrator qualifications, charges to resident’s funds, pre-admission screening, and resident assessment (see Table 1). Table 1 describes the nursing home provisions of the OBRA 87 and lists the status of the regulation’s adoption as February 1998. The significance of the nursing home laws outlined in the OBRA 87 was that the focus for examining nursing facilities shifted from solely assessing the facilities’ capability to provide adequate care (nursing home operations) to encompassing examining patient outcomes (patient care). One of the major changes in the enforcement provisions resulting from the OBRA 87 was an expansion of the range of sanctions that could be imposed on noncompliant facilities. Congress expanded the range of sanctions for deficiencies cited in order to ensure that facilities would achieve and maintain compliance with the new standards (General Accounting Office [GAO], 1999). The sanctions were expanded in order to create a strong incentive for nursing homes to maintain compliance with federal standards by imposing sanctions on noncompliant facilities (GAO, 1999). For instance, in the past, 6 :13"; ”,3? “mild!“ .1 7:51:an and term: strs'rs lisucxr' .2 ran l‘t‘l‘azlllt‘fi 217.27.; 6.3:;th r7 lino» R'\ {2‘} £111.73 5:7: aux; 3€"\“C' )U n- malt; '\ ii 1 ll... :hvmc 1:13: .‘l a T4356 3 I'L'tizr‘ “39 PF'\AJl\hcd1 "_ I “It: :\ {1H ‘Cn 5h" tic 3311331 “3:11 me “it: i .. IT” in I’LCU'I nu‘i'kL h.A_ "i‘d‘kw‘nixl x, ’i' i 9 cl' ‘l‘ Th: Prm. “i. T“ 1"an "Ui‘qwi. I ‘1: 3.:- 3..., d. {I}: trfhr N the only sanctions available were denial of payments for new Medicare and Medicaid residents and termination from the programs; these sanctions were rarely imposed by inspectors. However, with the passage of the OBRA 87, the new sanctions included civil monetary penalties, temporary management, denial of payments, directed in-service training, directed plan of correction, state monitoring, and termination (see Table 2). Table 2 describes the enforcement sanctions contained in the OBRA 87 and shows which sanctions were available prior to the adoption of the OBRA 87. The new sanctions are imposed on noncompliant facilities based on the scope and severity of deficiencies cited by nursing home inspectors (see Table 3). Table 3 outlines the methodology that the Health Care Financing Administration (HCFA) established for imposing the OBRA 87 enforcement sanctions on noncompliant facilities given the deficiencies that are cited by inspectors. A deficiency citation occurs when a nursing home inspector examines a facility and determines that it is not delivering care in accordance with the standards outlined in the OBRA 87. After a formal deficiency citation is reported sanctions are then assessed based on the scope and severity of the deficiency citation(s) cited by inspectors. The provisions of the OBRA 87 were supposed to become effective October 1990. However, when HCFA published its proposed enforcement regulations in 1992, various external actors submitted comments during the rulemaking process, which lengthened the time that the enforcement provisions were to become effective (see Table 1). Furthermore, the policymaking process at the state level further lengthened the implementation of the OBRA 87 enforcement provisions as interest groups and other concerned actors attempted to influence state legislators. 1h: llCH 1: still) 10 Sl‘filii H; 55:53:. HCFA JR 7:515:11 55ch n5 -l rigrmazinn 551 l 5:1“. “J. mm" It in: '55:: HCFA plated . 3.55:7; :15 ll m; 575:: ;:‘.i:5'7:'.;n 1172:. .‘-. 3“! . . -k\ a IC‘JI. *‘3 mics l '34 .u Stilts [)N.1 giliCIIa l u. ‘5. I") , .- 5; X , D 37,. . . vi: The HCFA in the Department of Health and Human Services (DHHS) was given authority to specify criteria regarding how the sanctions should be applied by states. However, HCFA did not finalize the enforcement rules for imposing sanctions on nursing homes that were not complying with state statutes until 1995 (see Table 1). Thus, state implementation of the new standards of care statutes was essentially “enforcement without teeth” from October 1, 1990 through July 1, 1995. This situation was extended when HCFA placed a moratorium, effective July 1, 1995 through January 1997 on states imposing civil monetary fines (Edelman, 1998). The HCFA imposed the moratorium on civil monetary fines in order to evaluate states’ proposed use of the sanction (Edelman, 1998). As a result of the moratorium, many civil monetary fines proposed by states were neither imposed nor collected (Edelman, 1998). That is, facilities that received citations for deficiencies did not incur sanctions for providing poor patient care to residents. Given this circumstance, it is less likely that inspectors were motivated to cite deficiencies. The HCFA was ordered to establish enforcement rules for nursing homes by the United States District Court in Ottis v. Shalala, March 22, 1994 (Michigan Department of Social Services Medical Services Administration, 1994). In this case residents filed a lawsuit to compel the state and federal governments to implement the enforcement provisions of OBRA 87. In response to the lawsuit, HCFA issued rules for implement- ing the enforcement provisions of OBRA 87 in July 1995. The criteria that HCFA established for implementation required states to match sanctions to the scope and severity of the deficiencies cited. For each deficiency citation assessed, the approach places the deficiency citation in one of twelve categories (see Table 3). Homes in substantial compliance are not subject to sanctions. However, states 8 — n. Nfl‘gql. .» p.uL:l~llb 55$. 15 It" r :71” ' - [1. ha -. f‘] ILA . 5'. l4 T‘XC“ I ' ”, and”. \1— 5‘ .fd fir high-us } I \J‘n It?“ :15 L& .‘p “ n' \ ‘ l ‘ .95‘ 3'1. , fL..'k 'v 51. ‘n . 0 Au 3 .,» ‘ ¢ \3 ”KC‘ I.“ v' . 4‘ J. 35. :5, O . ! "5 . ‘. ‘H I. ‘ f lu\, I'M t ,r‘ v- “‘ ~ . .4- “uL\, , ‘p k |b ‘4'. “ recommend sanctions for noncompliant facilities and then refer them to HCFA for sanctions to be imposed on Medicare-licensed facilities. States were granted authority to impose sanctions on Medicaid-licensed facilities and must also submit a report to HCFA of the sanctions imposed on facilities (Edelman, 1998). The states and HCFA possess authority to impose sanctions on facilities participating in both the Medicaid and Medicare programs (Federal Register, 1994). Also, for each category in the scope and severity grid, a sanction from a particular group must be imposed and sanctions from other categories can be added (see Table 3). Under HCFA’s policies, most homes are given a grace period, usually 30 to 60 days, to correct deficiencies cited. States do not refer Medicare-licensed homes to HCFA for sanction unless they fail to correct their deficiencies within the grace period granted to them. Exceptions are provided for homes with deficiencies rated J, K, or L and for homes that meet HCFA’s definition of a “poorly performing facility”—a special category of homes with repeat severe deficiencies. HCFA’s policy calls for states to immediately refer these homes for sanctions (GAO, 1999). The HCFA also gives a notice period before a sanction takes effect. The HCFA allows homes 15 to 20 days to come into compliance, and if a home meets the standards by the deadline, then the sanction does not take effect. There are two major exceptions to this policy which are: (1) civil monetary penalties can be assessed retroactively even when homes correct the problem, and (2) nursing homes with deficiencies rated J, K, or L (the most severe deficiencies) are not given a notice period. Stat: Implement.“ it Dc5ptt: C 5 551. | 5523:255trr5i5t T? I 5': 5.5m: app: :25; 35351.5.th t. 1:325:55: if thcr: :5 53:5: stat: tlctzhxf: :T:=.i':7:Zi-.fi. alto dm :t:".'.:';”:t:t5.t statcm -1‘}\l.l‘35t55: H5 55: 5:336:33; the ( .‘a’fiSZit'Q. Comm 525‘. 5.7;:5'.td:t:5 and ‘ The rem-35.5 t‘ 5:15:71- thc CM 57 a ‘ uLi‘. 55.55557 : 7 ' _‘u‘:L\ Arc n‘ “ H 57:53“ - . ‘31 and Imp.- 5.7155 :ué h ‘ rm -. ““V‘ 3th 5- ‘93} ‘ 7 . I") "5 \ trifling l“ r “I la 5'. l TL. ..3 ' ' {lift-11 1‘ t. L! 7“ ‘ 5"?“ ”4..“ us;l 'o s5; State Implementation of the Enforcement Provisions after OBRA 87 Despite Congress’ intent to improve the standards of care provided to residents problems persist. The HCFA developed a scope and severity grid to classify deficiencies and determine appropriate sanctions. The grid gave states broad discretion to choose among available remedies in particular situations and it gave states discretion to determine if there is sufficient evidence to cite deficiencies (Edelman, 1998). While some state flexibility may be necessary to accommodate variations among states, flexibility also decreases consistency. One of the main purposes of the federal enforcement system was to create uniform implementation procedures among states (IOM, 1986). However, the final rules adopted by HCFA granted states flexibility with implementing the OBRA 87 enforcement provisions at the expense of national consistency. Consequently, state regulatory agencies are exposed to political pressure from providers and various other actors (Edelman, 1998). The results of political pressures from providers and other actors continue to weaken the enforcement systems across the states based on the fact that many proposed sanctions are not imposed (see Table 4). Table 4 shows the OBRA 87 sanctions proposed and imposed for the years 1995—1996 and 1996—1997. Moreover, many nursing homes across the states, whose resident population is approximately 1.6 million elderly, continue to be noncompliant with the standards of care outlined in the OBRA 87 (Edelman, 1998; GAO, 1999). For instance, “national data on nursing home inspections for the period July 1995 to October 1998 show that the proportion of homes with the most severe deficiencies remained at uncomfortably high levels throughout this period” (GAO, 1999). Also, approximately 40 percent of the homes cited with serious deficiencies during one inspection were found to have deficiencies of equal or greater 10 —____‘ . 5 O- ; ~‘ ‘f‘ {'3‘5. 1n \d‘ A'- «fern-M ; \ Sm: Lk&a.1LI '3 37,5 1 .‘f 3! c5115. , .1 hint“ .1! . s ...“‘_H. "r.- ” 3‘ 0L an; 5; I! “:1 -'5~. ' r .3 Q “5'... 5\er" .:5“ A i .' “‘ 71": ”i: T: MC 1 ‘55 1 . L k ‘C‘i‘4’ ‘ .‘, .:iap- ~“'“-J P‘ \ ,. t, v A .I‘ w ‘ K ".2?. a“ - y 1 \ u - .‘ "2 $ -‘ . ‘ ‘ § 4 - ‘ . ; » ‘u h ‘7 ‘c .‘ . M . s - -~ _ |_ ... , ‘ “7... , \ ‘ . x “ x 1 “'A . ‘ . t-..‘ . V ~..‘ ‘ c ‘ a \_ 5" . I' I u I ‘ 55.. "\ ~4- . : - v. K 'I x u‘.‘ a. . 5 . K - ‘Ip .‘ Q \ \'~ ‘. . A “ .1 .. a; “I .“b \I"\" -....._;" .‘ . . u. -. t .- \ l A 5‘." “l K . ‘ I D severity in subsequent inspections. In 1997, states’ poor implementation of the OBRA 87 enforcement provisions resulted in 30 percent of nursing home residents suffering and/or dying from malnutrition based upon expert testimony at some US. Senate hearings (American Association of Retired Persons Bulletin, 1997). Additionally, HCFA estimates that approximately 40 percent of nursing home residents are malnourished nationally (PR Newswire, 1999). The persistence of noncompliant homes is indicative of continual problematic enforcement systems across the states, despite the implemen— tation of the OBRA 87 enforcement provisions. Thus, this dissertation will determine which external actors and organizational factors systematically influence state implemen- tation of the enforcement provision of the OBRA 87. The triangulation design was used to assess state implementation. Triangulation is a research approach that is used to increase credibility (Wholey, Joseph S., et al., 1994). Triangulation involves combining methods, data sources, and other factors for the examination of a topic under study.3 More specifically, the various approaches used to examine state implementation of the OBRA 87 enforcement provisions included the following: 0 reviewing relevant documents pertaining to state implementation of the OBRA 87 enforcement provisions (covering the 1930s through 1999); 3Triangulation of multiple and different sources of information, methods, and theories is used to strengthen data collection and analysis and is normally categorized in three different ways. One is triangulation of measurement, when evaluators use more than one method (qualitative or quantitative) to describe the unit of analysis. For example, structured questionnaires can probe for responses to match against the results of unstructured interviews or participant observation. Content analysis of documents can be compared with information from other sources. Triangulation also can be used in examining conclusions within a study, when different measurements produce the same results, patterns, or different informants give the same account. Triangulation of conclusions across studies that used different methods can also be performed. 11 o Obwmni period 1“ uhkh :51 mutant: CA3 I" 3‘ {3:15 :5 :5 mcttt P75 and 351.715.1151; tritium: Chit met: 7‘ 13"“ " ' dsx mCLJ ‘7‘}“I‘ J ~ ,..7.. arm: 5t‘rc5 t' '36: 5.5575257 If } ll 'd'ghcg ‘5‘ #55. M5 tli‘ lmp’ 0 observing participants’ activities at various meetings in Michigan (covering the period 1994 through 1999); 0 conducting a case study of implementation in Michigan in order to identify which external actors have influenced the implementation of the OBRA 87 enforcement provisions (covering the period July 1995 through 1998); 0 performing robust regression analyses using primary and secondary state level data to assess the influence that external actors and internal organizational factors exerted on states before and after the implementation of the enforce- ment provisions of the OBRA 87 (covering the period 1991 through 1997); and 0 administering a survey to inspectors and inspection managers to examine the influence that internal organizational factors exert on the implementation of the enforcement provisions of the OBRA 87 (covering the period 1995-1998). These methodologies will help to gain an in—depth understanding of the factors influencing states implementing the enforcement provisions of OBRA 87. Furthermore, these approaches will help identify which systemic factors are influencing implementa- tion. More importantly, the triangulation approach can help to rule out competing explanations for the results. Differences in the average number of deficiencies per facility across states and across time will be the dependent variable in this dissertation and will act as a proxy measure for state implementation of the enforcement provisions of the OBRA 87. A similar approach was used by Scholz and Wei (1986). Scholz and Wei (1986) used citations and penalties as a proxy for state implementation of enforcement standards in 12 ' 5 M 0-2" ’h. 1:}; .LUU Hill". A: ,. .§.n—~.nq 55.55: 5' .pxgx " 2.- rs I \ . u‘ii‘ t..- - their study which assessed the implementation for the federal Occupational Safety and Health Administration (OSHA). The deficiencies used for this dissertation are cited by state inspectors. The state inspectors assess nursing homes’ compliance with quality of care, quality of life, residents’ rights, and resident assessment and care planning regulations established by OBRA 87 (see Table 1). The state inspectors work in a team under the direction of the licensing officer. Inspections are conducted by teams of professionals, which can include registered nurses (RNs), social workers, dietitians, and sanitarians who are employed by the state to be nursing home inspectors. The licensing officer is in charge of monitoring all nursing homes in their assigned areas, scheduling inspections, reviewing results and correction plans, recommending enforcement sanctions to the enforcement unit or HCFA (depending on the level of the deficiency citation), and keeping track of information about each nursing home. Each of these areas has specific regulations that state inspection teams review to determine whether or not facilities have met the standards (Harrington, 1999). State inspection teams then submit the deficiency citation report to their respective licensing officer who then reviews the teams’ findings and determines whether or not to issue a written official statement of deficiency citation(s). The licensing officer then makes recommendations for sanctions to their enforcement unit for the sanctions that HCFA allows them to impose or the licensing officer makes recom- mendations for sanctions to HCFA for sanctions to be imposed on noncompliant facilities. The HCFA allows states to impose the directed-in-service training, directed plan of correction, and state monitoring sanctions on noncompliant facilities. However, HCFA imposes the temporary manager, denial of payments, civil monetary fines, and 13 27:1. 55:51 4 .‘h' s "‘9' “Luv I 3115-1 155: c‘YW‘AWg'j‘ b.“ n.5tnl8 .al tuna Hw-épvr'r a... ahuu¥dsu n ‘1'"Iu‘I-O, ‘ .5 a 5~-a-LLU‘A' | ‘— wu. . I‘ ’ :75.»- ‘h ' ‘¥\r-..5 3“;;I-v- .‘ \‘,.~._‘:‘L ‘5‘ WI termination sanctions on noncompliant facilities. Thus, a deficiency citation is an indirect measure of proposed and/or imposed sanctions. In conclusion, this dissertation will examine state implementation of the enforcement provisions of the OBRA 87 by providing a detailed history of state implementation in chapter 2. A literature review of the influence external actors and organizational factors exert on regulatory agencies will be provided in chapter 3. A case study of implementation of the enforcement provisions in Michigan will be discussed in chapter 4. An examination of external actors influence on state implementation of the enforcement provisions will be covered in chapter 5. Next, internal organizational and external actors influence on state implementation of the enforcement provisions will be assessed in chapter 6. Then, the conclusion and recommendations will be discussed in chapter 7. 14 \Iiilt'dUCiit lttt ‘ I .0“. .a ‘5» J u 51““- red CHAPTER 2 HISTORY OF STATES IMPLEMENTING NURSING HOME LAWS AND REGULATIONS Introduction In this chapter the history of major implementation events impacting the nursing home industry from the 1930s through 19903 will be described. The history will Show that many laws have been adopted to improve nursing home care. However, weak state implementation of the laws adopted, HCFA’s rulemaking process, and litigation impacts the quality of care that residents receive in nursing homes. Table 5 outlines the major events that have impacted state implementation of nursing home laws and regulations. The narrative will summarize the events reported in Table 5. 19305 through 1940s: Creation of the Nursing Home Industry In the 19303, few nursing homes existed and states possessed sole authority to regulate the industry. The Social Security Act was enacted in 1935. This Act created the Old Age Assistance program, which provided funds to the elderly to pay for nursing home care (see Table 5) (Dunlop, 1979). During the 19405, problems with board and care and residential homes were reported. The Senate Committee on Education and Labor conducted public hearings to hear testimony regarding problems in the board and care and residential homes. Also, 15 It: 135 5:555 "O‘IIHV ‘- tgtl.‘ “ M . ”5. y 19505 the Home C it in ‘»\n-Q . W p; 9. r. 'LN usr.‘ " vq-o Fl' \ 1". \‘ “LR-.. ”a ~A\ {7‘4“ \ I. . .. A h'l § ‘ . '14. 7‘ 7~ .- I . u, — 5. . ' - ‘. i < ‘ fi, .‘. A the Advisory Council on Social Security expressed concern about the quality of care in nursing homes (The Long-Term Care Advocates Desk Reference, 1997). 19505 through 19605: Growth in the Nursing Home Industry Multiplies Nursing Home Care Problems In the 19503, the federal government provided funding for nursing home construction and operation, which dramatically increased the supply of nursing homes. For instance, laws were also adopted that authorized the Small Business and Federal Housing Administrations to aid proprietary nursing home construction and operations. These laws helped to increase the supply of nursing in the United States. For example, in 1954, there were approximately 9,000 nursing homes that were classified accordingly: 86 percent for-profit, 10 percent not-for-profit, and 4 percent public (IOM, 1986). However, growth in the industry multiplied the problems with nursing home care. Throughout the late 19508 and 19605, several governmental units examined state implementation of nursing home standards. Most of these studies highlighted problems with the quality of nursing home care and weak state implementation of nursing home laws (see Table 5). The results of the studies from the late 1950s prompted the Senate to create the Special Committee on Aging, which was chaired by Senator Frank Moss. This committee immediately began to hold hearings on nursing home problems in 1963 and documented great variation in state nursing home standards and enforcement efforts (The Long-Term Care Advocates Desk Reference, 1997). Furthermore, various amendments were adopted to improve nursing home care resulting from the studies conducted. For instance, amendments to the Social Security Act required states to establish programs for licensing nursing homes. Two significant 16 EGG-'37.“ ~ Yr 115:: 7,555.. s 35.1 ‘ r " lu'fi'f". I .. 5.“.115-51 i“? 1.535 T5 5 \-.'_; n 5. , 1“““3 lit.“ amendments to the Social Security Act were the Medicare and Medicaid programs. These programs brought regulation of the nursing home industry by the federal government for the first time. The federal government began tying federal reimburse- ment for these programs to compliance with federal standards of care and safety (IOM, 1986; The Long-Term Care Advocates Desk Reference, 1997). In 1965, the Medicare and Medicaid programs were established. The Medicare program provided funding to beneficiaries needing convalescence in extended care facilities only after hospitalization. The Medicaid program paid for skilled nursing services. The Medicaid program was amended in 1967 and required that participating skilled nursing facilities meet certain standards (see Table 5). Over the years, the Medicaid program has become the major payor for nursing home care nationally. For instance, the Medicaid program has paid for resident care ranging from 40 percent in Delaware to 90 percent in New Mexico (see Table 6) (The Guide to the Nursing Home Industry, 1993 and 1998/99). Table 6 shows the percentage of nursing home residents receiving Medicaid benefits by state for the years 1991 through 1999. 1970s: Political Efforts to Improve Nursing Care During the 19703 mounting pressure was exerted on Congress to increase the standards for nursing homes participating in the Medicare and Medicaid programs and to improve state enforcement. For example, in 1970 and 1971 nursing home problems became the front page news with reports that a fire killed 32 residents in Ohio, a case of food poisoning in Maryland killed 36, and Congressman David Pryor reported on the floor of the House his experiences as a nursing home orderly (IOM, 1986). 17 m Spat: 3.". ‘I‘KS‘: l‘tt'il 51:25.7: 555“" 37:11: ’51 CIC Cl 3’53 It.1 19...]. :rfft:::5:nt ma 5.0.505. In 5:55: 1:5;2533115 '115 $7.515. '5 1th 5 555:5. dept .75 555.555.: ha 55:55: 5:555: "'(5 , .. .. ‘ ‘ ‘YS‘\\“\“\ ‘ r'x .‘ -.L I 17 S in. \ ”Q. 5:4." "" ' . as.) 5 r» ~Cfi‘r, 5 i. .‘w. | ‘ ‘ ‘ hi 1 , ._ I; I 'd I ,‘a ' v '“h . e .5 “’5 ‘ 0“. A. d‘._ “mg!” ‘AL\ [1} \' l I) '. \‘7, ‘7 \Ni-. / 5:5 (“:wa \ A. I _A\— ‘ The Special Committee on Aging hearings, which began in 1963, ended in 1973. During these hearings, the undersecretary of the Department of Health, Education, and Welfare (HEW) testified that 74 percent of nursing homes participating in the Medicare program were certified with deficiencies and more than 70 percent had deficiencies from 1968 to 1971. After the hearings, Senator Moss concluded that reliance on state enforcement machinery led to widespread nonenforcement of federal standards (IOM, 1986). In response to the problems occurring, 900 Social Security offices were designated as “listening posts” to receive complaints about nursing homes and to provide the public with nursing home inspection records. Additionally, President Nixon made a speech deploring conditions in nursing homes and pledged to end federal payment to substandard facilities. In a second speech President Nixon announced an 8-point plan to improve nursing home regulation. This plan included the federal government assuming 100 percent of the necessary costs of state inspection teams under the Medicaid program and the initiation of a comprehensive review of the use of facilities, standards, and practices in order to take remedial action as needed. This plan also included an initiative to centralize the Medicare and Medicaid enforcement activities (The Long-Term Care Advocates Desk Reference, 1997). President Nixon also made proposals for the following: training nursing home staff; experimental funding of state nursing home ombudsmen, and creation of the Office of Nursing Home Affairs in HEW to coordinate new enforcement efforts and to conduct a comprehensive study of federal long-term care policies. In 1972 Congress passed remnants of Nixon’s plan to improve nursing home regulation. The law provided: (1) full federal funding for state inspection and certification activities, (2) authorization for 18 —+ L‘ng-Trn‘; Ir. 1 firm {a r: 12:06:31.1 f {.112 *2}; LI“ . _‘I "‘ _ 4L1.“ ‘i‘i . n. ., 1.11) \‘td‘; U\‘ I '.-.~_ A l ’,~.o I. “tn 1 XI“? H? fl. “: rm ‘ii ”View... 3...”.1 HEW to develop a single set of standards for Medicare and Medicaid skill nursing facilities, (3) experimental funding for the state nursing home ombudsman program, and (4) funding to establish the Office of Nursing Home Affairs (ONHA) (IOM, 1986; The Long-Term Care Advocates Desk Reference, 1997). In 1974, the ONHA conducted a study and found that the extent to which nursing homes comply with federal standards of care and safety varies widely. A report generated from the study was entitled “Introductory Report.” This report called for nationwide training, credentialing, certification and licensure of all inspectors, a complete analysis of the fiscal approach of reimbursement, and training of all health professionals. This study also found that the inspection regulations only looked at whether facilities had the capacity to deliver required services; not whether adequate quality care was actually being provided to patients. In response to these findings, the ON HA developed a patient assessment instrument based on patient outcome measures. The patient assessment instrument was called the Patient Appraisal and Care Evaluation (PACE). The PACE forms and process were very complex, and were consequently published for voluntary use by nursing homes. The ONHA also became involved in overseeing substantial revisions to the skilled nursing facility standards with an interagency workgroup in 1976 (IOM, 1986). In 1978 amendments were added to the Older American’s Act for establishing the Long—term Care Ombudsman program. The amendments gave the ombudsman program statutory authority: 0 to investigate and resolve complaints; 0 to monitor the development and implementation of federal, state, and local laws, regulations, and policies; 19 —+ “" ~ ,,., v ‘1‘“. .. Yr- ‘1... m H . W A! "a v;, ‘. ‘l\‘- x ‘ . ‘ - T~\ h.-_~~ ‘ . t 0 to provide information to appropriate government agencies; 0 to provide for training volunteers and promoting the development of citizen organizations; 0 to develop procedures for appropriate access by the ombudsman to long-term care facilities and patient records; and 0 to establish measures to ensure patient confidentiality (AARP, 1991). The ombudsman program was created in order to help resolve resident problems and complaints. 1980s and 19905: Enactment of Legislation that Focuses on Resident Care The HCFA began to revise the certification procedures contained in Subpart S of the regulations (42 CFR Part 405) (IOM, 1986). After two years of work and three drafts, HCFA published its proposed new rules in 1980. The HCFA planned to shift the focus of the regulations from a paper review of facility capability to an evaluation of patients and the care they actually received (IOM, 1986). The new regulations proposed to: 0 consolidate all patient care planning requirements into a single condition, and required a patient care management system that called for interdisciplinary teams to assess patients and plan their care, 0 deemphasized the medical model by increasing the minimum time required between attending physician visits, reducing the medical director requirements, and making consultant services discretionary after one year, 0 elevated the residents’ rights standard to the status of a condition of participa- tion, and 20 I t D‘. ~o- 4'. . i:\i.l\..\_. 5 [Er-5’». .f'. 1a).: L l" ’s , _‘ nix._l| “ l u mug: .7‘ u.5 Lh" I], I ‘n 0 combined the skilled nursing facility and intermediate care facility regulations into a single set in the Code of Federal Regulations (IOM, 1986). The nursing home industry disputed HCFA’s estimates of the cost that the Subpart S regulations would impose. The Subpart S regulations stayed in limbo until the final hours of the Carter administration. The Subpart S regulations were immediately rescinded by the Reagan administration, which began a new regulatory reform effort. Therefore, HCFA established a Task Force on Regulatory Reform that reevaluated the Subpart S regulations. The task force decided to retain major elements of the Subpart S regulations, which included elevating the resident’s rights to a condition of par- ticipation; it also proposed to delete or revise many other conditions and standards or made them effective only if there were no applicable state laws (IOM, 1986). In June 1982, HCFA issued prOposed rules to change the inspection system and offered a 60—day public comment period (The Long-Term Care Advocates Desk Reference, 1997). The reaction from consumer groups, state regulators, the Congress, and providers was so strong that Secretary of Health and Human Services Richard Schweiker announced that the draft regulations would be dropped. In the summer of 1983, HCFA and Congress agreed to postpone virtually all changes in the regulations until a committee appointed by the IOM studied the issues and reported its recommendations for changes. The Senate Special Committee on Aging held hearings on HCFA’s proposed changes. Representatives Pepper, Dingell, Waxman, and Jacobs introduced legislation calling for a two-year moratorium on regulation action and a national commission on regulations (The Long-Term Care Advocates Desk Reference, 1997). A six—month moratorium on any new rule-making relating to nursing homes was imposed when an amendment was attached to the Tax Equity Bill (Section 135 of Public Law 97-248). In 21 .. l K; "11;... 'fl_\ 0.3M a net IICII to cor *u r In Iv III 3 \“I tuui 0 ho» .‘ ‘ . ‘ ‘ ~41 'F ‘ munggu J~Iu October a new Congressional amendment extended the moratorium 120 days, directing HCFA to consult with Congress and seek public review and comment on any proposed regulations (The Long-Term Care Advocates Desk Reference, 1997). In 1983 Congress resubmitted the 1982 legislative proposal, including a proposal for a study by the Academy of Sciences, IOM. In May, HCFA began contract negotiations with the IOM to conduct the study. The IOM and HCFA contract was finalized and the two—year study began. After the study was conducted, the IOM issued a report that identified the importance of enforcement to achieving high quality of care for residents in nursing homes. More specifically, the report called for major improvement in the standards of care that nursing homes must meet, the inspection process, and the government’s enforcement of standards. Fifty national organizations joined in a Campaign for Quality Care to develop consensus positions for nursing home reform based on implementation of the IOM report. Consequently, Senator Mitchell and Congressmen Dingell, Waxman, and Stark introduced sweeping nursing home reform legislation (The Long-Tenn Care Advocates Desk Reference, 1997). On December 21, 1987 Congress enacted Public Law 100-203, the OBRA 87, which included many of the recommendations from the 1986 IOM report (The Long-Term Care Advocates Desk Reference, 1997). Hence, HCFA began work on the OBRA 87 implementation through the development of new requirements. The HCFA’s rulemaking process, the public comments, and litigation have impacted the implementation of many of the provisions of the OBRA 87 (see Table 1). Table 1 shows when HCFA proposed regulations for implementing the OBRA 87 provisions and when the final regulations were published and became effective (Edelman, 1998). As of February 1998, HCFA has not published final regulations for three 22 r111 .. " \ “r" 5: DJ .~~..‘ y,” ’ f.“ I. ’- w ' n a! 1’. \ (physical and chemical restraints, administrator qualifications, and nursing waivers) of the nine provisions contained in the OBRA 87 (see Table 1).1 Furthermore, the industry association and residents filed several lawsuits pertaining to HCFA implementing the OBRA 87 provisions. For instance, in 1994, residents of Michigan nursing homes filed a lawsuit against the Secretary of the Department of Health and Human Services for not implementing the enforcement provisions of the OBRA 87 in the case Ottis er al. versus Shalala. The court ordered Michigan to implement the OBRA 87 enforcement provisions by July 15, 1994. The court also required Michigan to outline its enforcement plan by March 15, 1994 for public comment (Edelman, 1998). Furthermore, in 1995 the industry associations’ challenged the OBRA 87 in courts in Michigan and Illinois. Both suits were ultimately dismissed for lack of jurisdiction—the courts found that the nursing home plaintiffs had not exhausted required administrative avenues (The Long-Term Care Advocates Desk Reference, 1997). One of the most significant and controversial provisions of the OBRA 87 is the enforcement provisions. The enforcement provisions expanded the sanctions available to states to impose on facilities not complying with the OBRA 87 requirements (see Table 7). Table 7 shows the sanctions available to states to impose on noncompliant facilities before and after the Congress enacted the OBRA 87 nursing home reform laws in 1990. The enforcement provision outlined in the OBRA 87 was supposed to become effective October 1, 1990. The HCFA, a unit within the DHHS, was given authority to establish rules for states implementing the enforcement provisions of the OBRA 87. The HCFA issued proposed enforcement rules on April 28, 1992. After the proposed rules were ‘A detailed description of the provisions of OBRA 87 are provided in Appendix A, Table 23 1W". '1 n 61.5.5W. IOII Ctr: SL725 .1. ‘f‘tnvq If. I hit-htkOl \ I: . ‘nn‘ ,,.. _ I. t' \ r, “nuJu. an .M“ "b. published in the federal register, HCFA received over 22,000 public comments from various groups which included the American Health Care Association (AHCA), the American Association of Homes and Services for the Aging (AAHSA), members of the IOM Committee on Nursing Home Regulation, and the Association of Health Facility Survey Agencies (AHFSA) (Edelman, 1998). Each of these organizations have affiliate organizations located in each state. The AHCA is a federation of 50 state health organizations’ nursing facility administrators representing nearly 12,000 non-profit and for-profit assisted living, nursing facility, and subacute care providers that care for more than one million elderly and disabled individuals nationally. The goals of the association are: 0 to improve the standards of service and administration of member nursing homes; 0 to secure and merit public and official recognition and approval of the work of nursing homes; 0 to adopt and promote programs of education and legislation (History of the American Health Care Association, 1999; Profile of the American Health Care Association, 1999). The AAHSA represents not-for—profit long-term care organizations. Its membership consists of over 5,000 not-for-profit nursing homes, continuing care retirement communities, senior housing facilities, assisted living and community services. AAHSA serves its members by representing their concerns through interaction with Congress and federal agencies. It also provides its members with continuing education through its Professional Development Institute and publications representing current thinking in long—term care. The AAHSA’s mission is “to advance the interests of its 24 matters In. 15 MIISK I. It» . 1‘ u . an. In m.“ 5&1; 4"“ ‘9. r \\t.a.I‘_ut ‘ 7“" H .0 "i":li.§\“u L'L “In. JIJLL \iIu, LA' u u. ., . . 4A: F‘\[‘:n «.7 members through leadership, advocacy, networking, education, and other services (What is AAHSA?, 1999). The AHFSA is a not-for-profit organization that provides a forum for health care regulatory agency directors and managers to address common interests, concerns, and health care program issues. Members of the AHFSA are leaders from state survey and certification agencies that regulate nursing facilities, hospitals, medical laboratories, intermediate care facilities for the mentally retarded, home health agencies, hospice, rural health clinics, renal dialysis centers, ambulatory surgical centers, rehabilitation services, Nurse Aide training, competency and certification programs and an array of other health care services. The AHFSA member agencies are responsible for improving the quality of care and services provided by health care facilities, agencies and programs by ensuring that established standards and regulations are met. The mission of the AHFSA is to strengthen the role of its member state agencies in advocating, establishing, overseeing and coordinating health care quality standards that will assure the highest practicable quality of health care for all state and federally-regulated health care providers (Association of Health Health Facilities Survey Agencies: Monitoring the Health of a Nation Fact Sheet, 1999; Association of Health Facilities Survey Agencies Mission Statement, 1999). The purpose of the association is: 0 to advocate for information and resources so that health facility survey agencies can assure the highest practicable quality of health care; 0 to strengthen the role of health facility survey agencies with their respective states and territories, with HCFA, with advocacy organizations, and national and state health provider associations; 25 17:: RI .d'M ‘~ A“ 5 0 to provide a forum for the communication of information and the exchange of experiences among state and territorial health facility survey agencies and between such agencies and the US. Congress, HCFA, advocacy or— ganizations, and national health provider associations; 0 to improve the quality of state and territorial health facility survey programs and to coordinate these activities with related activities within the states and territories; and 0 to promote the professional development of its members (Association of Health Health Facilities Survey Agencies: Monitoring the Health of a Nation Fact Sheet, 1999; Association of Health Facilities Survey Agencies Mission Statement, 1999). The AHFSA also provides it members with information and education pertaining to long- term care. The IOM nursing home regulation committee was commissioned to study nursing home regulation and to recommend ways to improve nursing home regulation (IOM, 1986). The committee published its report of results and recommendations in 1986 in a book entitled Improving the Quality of Care in Nursing Homes. Many of the recommendations from this report were included in the OBRA 87 nursing home reform regulations (IOM, 1986). The majority of the public comments regarding the proposed enforcement rules were submitted by members of the AHCA (Edelman, 1998). The AHCA indicated in its comments that the proposed rules needed revisions that would: (1) incorporate scope and severity scales and a determination of a facility’s level of responsibility prior to deficiencies being cited; (2) add an informal dispute resolution process allowing for 26 t ‘ r) '1. I .i:;:.‘ r» . 'fi .0 TIC'VIIIM 1 Ln A. V. ’7' .n ‘\‘~Ih. *1 a. ” \ ,l ‘. :‘ l1 Q I... \\‘l~\ . :1 m ‘L‘ A. wt, 5.“ .~‘ 'fi.» ‘ § I): 5‘. I i . . -~I I “j‘ C. D a.“ >.v ‘ l timely resolution of survey and enforcement disputes short of litigation; and (3) allow pre-sanction hearings where there were no findings of immediate and serious threat to residents (Edelman, 1998). Some of the members of the IOM committee on nursing home regulation submit- ted comments pertaining to the following four issues: (1) support for the preamble language stating that providers’ interests are secondary to the needs of program beneficiaries; (2) Opposition against use of scope and severity scales for determining the existence of deficiencies; (3) opposition for the alternative dispute resolution; and (4) support for the definition of substandard quality of care and use of scope and severity scales for remedies rest on a broad and meaningful concept of resident focused and outcome oriented (Edelman, 1998). The AHFSA recommended that the rules designate states as the primary enforcement entity, rather than the Secretary, and that HCFA provide additional regulatory guidance on temporary management, monitors, and civil monetary penalties. The AHFSA also supported the scope and severity scales for determining deficiencies and for imposing remedies, but was critical of using them rigidly when they were arbitrary, not supported by field testing, and not quantitatively precise (Edelman, 1998). Finally, the AAHSA issued a news release on September 1, 1992 criticizing the proposed rules for not allowing facilities to appeal surveyor decisions, for not establishing an objective way of determining whether a deficiency exists, and for not including a dispute resolution process. The AAHSA also submitted comments to HCFA regarding the proposed enforcement rules. Each organization’s comments required HCFA to consider whether it should adjust the proposed enforcement rules that were published in April 1992. 27 . .. . . l .vik'q . t ' L n. 61 ‘- , . "\ll H. . 5 ‘ ' " b... “we On July 1, 1995 HCFA issued the final inspection and enforcement rules along with a moratorium on civil monetary fines and conducted a study to examine states proposed usage of this sanction. The enforcement provision allowed states to impose the following sanctions on noncompliant Medicaid/Medicare facilities. 0 directed plan of correction, 0 state monitoring, and 0 directed in-service training The HCFA imposed the following sanctions on noncompliant facilities: 0 termination, 0 ban on payments for new Medicare and Medicaid admissions, 0 civil fines, and 0 temporary management (The Long-Term Care Advocates Desk Reference, 1997). In 1996 HCFA held “listening sessions” for consumers, providers, and professionals to air their experiences with the new enforcement system. Retaliation against residents, families, and staff emerged as a major problem (Edelman, 1998; The Long-Term Care Advocates Desk Reference, 1997). In January 1997 HCFA lifted its moratorium on civil monetary fines and revised its policy, limiting fines to more serious noncompliance, while expanding the informal dispute resolution policy and allowing providers to challenge the scope and severity of a deficiency (Edelman, 1998; The Long— Term Care Advocates Desk Reference, 1997). Despite the OBRA 87 nursing home reform legislation, enforcement problems persist. In response to the continual enforcement problems, President Clinton announced 28 ".‘J'WHTM Knit”; t» A a 21-point plan to improve enforcement in 1998 (Edelman, 1999). This initiative attempted to improve enforcement by focusing on the following issues: strengthening enforcement, conducting criminal background checks, creating a national abuse registry, improving nutrition and hydration, and reauthorizing the nursing home ombudsman program. Additionally, Congress authorized the US. GAO to study state implementation of OBRA 87 enforcement provisions. In March 1999 the GAO issued a report entitled, “Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards” (GAO, 1999). This report contained the following recommendations to improve state enforcement: improve the effectiveness of civil monetary fines, strengthen the use and effect of termination improve the referral process, and develop a better management information system (GAO, 1999). The history of the nursing home policy arena clearly shows that poor state implementation of nursing home laws, HCFA’s rulemaking process, and litigation have impacted the capability of the numerous laws and regulations that have been adopted to improve nursing home care. 29 [‘05 , . EH”; ”t- ‘ I ‘*---I....\ I. .3 M '3‘ ~ “‘3“ Y“ i: y' .|_',V 3m: 3J0‘\ V . I 4 ‘ .1: M. - V r,‘ CHAPTER 3 LITERATURE REVIEW The literature review in this chapter will assess interest group, political executive, legislative, organizational, and nursing home structural factor theories. The literature review will also include an examination of current studies of states implementing nursing home laws. Major Views about Regulatory Agencies Two major views have dominated the study of regulatory agencies. One view argues that external actors influence agency activities. The other view asserts that internal organizational factors of regulatory agencies influence their activities. Researchers have separately tested both views. For instance, some studies have assessed the influence that external actors exert on agency activities (Truman 1951; Bernstein, 1955; Edelman, 1967; Brudney and Herbert, 1987), whereas other studies have examined the influence of internal organizational factors on agency activities (Downs, 1967; Likert, 1967; Goggin et al. , 1990; Osborne and Gaebler, 1992). The results of these studies show that external environmental factors and internal organizational factors do exert influence on agency activities, which supports the two major views about public bureaucracy . 3O \Iv 1 y. 'V’HV ‘11". ILLQHIDLI. ‘m {39"9 1 at». \u‘u U ‘7 a t: 1'. “S. .‘iuun “Ism.l 1.51.31 c\.‘. 1'. -n. 4.0%.} h § 13;» 4.4. .P_ , .‘\\_\. 3 . ,\r ‘U n '41 an I. l .1". A“. “w u; . , ‘1 ‘ .3 .. '.. ,_. 1"~ I. at .~ — . ‘» I‘r-Q b ‘ A. . ._ 'w Next, scholars began to argue that both the external actors and internal organizational factors should be jointly studied in order to further expand our understanding of how regulatory agencies are impacted by these influences. Thus, some case studies were conducted to explore how both external and internal organizational factors impact agencies (Pressman and Wildavsky, 1984; Goggin, 1987; Cohen, 1988; Wilson, 1980; Derthick, 1990). The results from these studies have helped to identify which external actors and internal organizational factors jointly influence the activities of regulatory agencies. However, the results from these studies were limited because they were based on case study results, which cannot be broadly generalized. Goggin (1987) argued that future studies should combine qualitative and quantitative techniques in order to test causal hypotheses developed from qualitative results. This dissertation will test both views. The activity that external actors and internal agency factors can influence in the nursing home policy arena is inspectors’ citation of deficiencies. Many regulatory agencies assess citations for violations or deficiencies when a firm does not comply with the law. The citations for violations and deficiencies that inspectors assess play a major role in determining the type of sanction imposed on firms. For instance, nursing homes lose profits when monetary fines are imposed that are based on the deficiency citations assessed by regulators. Thus, it is asserted that the nursing home industry association has an incentive to pressure regulators to reduce their citation activities. In contrast, nursing home residents can suffer and die from the services or products purchased from facilities not complying with the laws. The family members of the residents who received poor care, and other concerned groups, may pressure regulators and nursing homes to improve their services. Hence it is asserted that resident’s family members and 31 j” R- (I! advocacy groups will pressure regulators to increase the deficiency citations assessed on noncompliant facilities.‘ Therefore, it is argued that various actors impacted by the state inspection agencies implementing the OBRA 87 enforcement laws will attempt to influence the deficiency citations assessed. Inspectors’ deficiency citations impact the type of sanction imposed on nursing homes not complying with the OBRA 87 nursing home reform laws (see Table 12). Moreover, the results from chapter 4 show that external actors have attempted to influence inspectors’ citation for deficiencies in Michigan (see Tables 9 and 10). Various studies have supported the theory that external actors influence regulatory agencies. For instance, Brudney and Hebert (1987) showed that agencies interact with actors in their external environment in order to obtain political support. This finding was consistent with the theoretical work of Katz and Kahn (1978). Katz and Kahn (1978) argued that organizations should be viewed as open systems that must interact with significant actors in their external environment in order to survive. Some scholars have identified which external actors have the capability of influencing public organizations (Weingast and Moran, 1983; Scholz and Wei, 1986; Wood and Waterman, 1991). Scholz and Wei (1986) showed that the external actors that systematically influence citations for violations included the president, Congress, governors, state legislatures, and interest groups. Differences in the average number of deficiencies per facility across states covering the period 1991 through 1997 will be the dependent variable in this dissertation and will act as a proxy measure for state regulators implementation of the enforcement ‘Citations for violations or deficiencies can result in sanctions being imposed on noncompliant firms. The sanctions imposed can include a firm being required to change its operations, a firm being required to pay a monetary fine, or a firm losing its license to operate. 32 EI‘HSIIJI . ...I 158mm 35.0? 1?: ..;. '. f. kn}. nuA.‘ "'3‘!" ‘r‘\ ‘IN-OI n». . {‘"'~ ~— a“. .1 ‘1 f; '1,“ 3.“- ‘n .7 -‘ .. “x J I" ". V.‘ ’ t 'h (- ...~ .L. .. . —~.‘ § 5 . I n,. 5‘ ' . . . . I I I. provision of OBRA 87.2 A similar approach was used by Scholz and Wei (1986), who assessed the degree to which enforcement activities vary in response to external political actor and organizational task factor differences among states. More specifically, these scholars examined the influence of both external political actors and state regulatory agencies’ organizational task factors on the OSHA’s enforcement activities covering the years 1976 through 1983 across the states. This study used citations and penalties as the dependent variable, which was a proxy for state implementation of enforcement standards in their study. The independent variables for external political actors included measures for the president, governor, Congress, state legislature, and labor. This assumption is supported by the ADA ratings of the committee members of the Senate Special Committee on Aging and a study conducted by Weingast and Moran (1983) (see 2The deficiencies used for this dissertation are cited by state inspectors. The state inspectors assess nursing homes’ compliance with quality of care, quality of life, residents’ rights, and resident assessment and care planning regulations established by OBRA 87 (see Table 1). The state inspectors work in a team under the direction of the licensing officer. Inspections are conducted by teams of professionals, which can include RNs, social workers, dietitians, and sanitarians who are employed by the state to be nursing home inspectors. The licensing officer is in charge of monitoring all nursing homes in their assigned areas, scheduling inspections, reviewing results and correction plans, recoMending enforcement sanctions to the enforcement unit or the HCFA (depending on the level of the deficiency), and keeping track of information about each nursing home. Each of these areas has specific regulations that state inspection teams review to determine whether or not facilities have met the standards (Harrington, 1999). State inspection teams then submit the deficiency report to their respective licensing officer who then reviews the teams’ findings and determines whether or not to issue a written official statement of deficiency(ies). The licensing officer then makes recommendations for sanctions to their enforcement unit for the sanctions that the HCFA allows them to impose or the licensing officer makes recommendations for sanctions to the HCFA for sanctions to be imposed on noncompliant facilities. The HCFA allows states to impose the directed-in-service training, directed plan of correction, and state monitoring sanctions on noncompliant facilities. However, the HCFA imposes the temporary manager, denial of payments, civil monetary fines, and termination sanctions on noncompliant facilities. Thus, a deficiency is an indirect measure of proposed and/or imposed sanctions. 33 AW}. 21' 1 . . H .F . huh. t . 9., ‘ | u\.l ._. ‘ .,.ov "r Luna's. :1 3:3 I.-‘ ah. an. g “ {‘11 .LL\ ‘ Appendix C). Appendix C shows that Democratic senators received much higher ratings than Republican senators. This rating measures an individual politician’s preference for activist regulation. Furthermore, Weingast and Moran (1983) examined Congress’ influence over the FTC’s behavior and conducted some tests that provided systematic evidence that ADA scores were a meaningful index of senator’s preference over FTC activism. That is, a high ADA score corresponded to a senator’s preference for protecting consumers through activist regulation. The results of this study indicated that the enforcement actions of the OSHA systematically responded to state-level political and task differences. Moreover, they found that the state OSHA agencies, with their smaller size and greater flexibility, were more responsive than the federal OSHA agency to political and task differences. The independent variables for organizational task factors were measured indirectly and included accidents, unemployment, and income. These scholars found that OSHA’s enforcement activities were responsive to both external political actors and state regulatory agencies’ organizational task factors. This dissertation will also examine the responsiveness of state nursing home regulatory agencies to both external political actors and regulatory agencies’ internal organizational factors. The dependent variable is the average number of deficiencies per certified nursing home covering the period 1991 through 1997. The independent external political actors variable will include measures for governors, state legislatures, HCFA (federal oversight agency), and interest groups. The independent internal organizational agency factors variable is different from Scholz and Wei (1986), who were unable to obtain direct measures of internal organizational factors for OSHA and therefore used indirect measures. However, this dissertation will use direct measures of internal organizational factors, including inspection managers’ and inspectors’ monetary, social, 34 and psychological needs and inspector’s relationships with management, which are based upon the organization theory literature. External Actor Theories of Regulatory Agencies Regulatory agencies are public organizations that are required to be responsive to their clients. For instance, Brudney and Hebert (1987) assert that agencies interact with actors in their external environment in order to obtain political support. This view is consistent with the theoretical work of Katz and Kahn (1978), in which organizations are viewed as open systems that must interact with significant actors in their external environment in order to survive. Various scholars have identified which external actors have the capability of influencing public organizations. Some of the most common actors who have attempted to influence regulatory agencies include the president, Congress, governors, state legislatures, and interest groups. The external actors who have attempted to influence state nursing home regulatory agencies include interest groups representing the nursing home industry and consumers, HCFA (federal oversight agency), the governor, state legislatures, and the Long-Term Care Ombudsman program. The influence of most of these actors will be assessed in this dissertation. The Long- Term Care Ombudsman, a congressional oversight program, has also been very active in influencing state nursing home regulators. However, this program will not be included in this dissertation due to the lack of sufficient data being compiled nationally for this actor.3 In the sections that follow, I will cover the interest group, executive, 3Budget data for the Long-Term Care Ombudsman program was only available for the year 1995, which prevented me from including it in my analysis of this actor’s influence on inspectors citing deficiencies on noncompliant facilities. I wanted to argue that differences in the budget of the Long-Term Care Ombudsman program across the 35 and legislative theories that will be tested in this dissertation. After each theory is described, the related hypotheses will be stated. Interest Group Theories In the 19508 and 19605, scholars of regulatory politics argued that regulatory agencies were overly responsive or dominated by the industries they regulated (Huntington, 1952; Bernstein, 1955; Noll, 1971). However, in the 1970s, scholars indicated that regulatory agencies were dominated by the influences of conflicting interests between industry and consumers. For instance, Sabatier (1975) argued that regulatory agencies will be influenced to adopt pro-consumer policies if an organized group advocates for consumer claims. Yet, the interest group model of regulatory agencies asserts that these organizations are influenced by competing groups and that their resulting activities are a compromise to appease the competing groups (Gormley, 1982). The capture theory of regulation and an alternative model to the capture theory will be used to assess the industry and resident interest groups’ influence on state enforcement. Social scientists originally took the view that industry interest groups captured regulatory agencies. More specifically, capture theory asserted that regulated industries states and across time would impact the average number of deficiencies that inspectors cited on noncompliant facilities. One of the major roles of the ombudsman program is to resolve nursing home residents’ problems. This program has been very active across the states and across time in attempting to influence regulators and politicians and to solve nursing home residents’ problems as noted by this actor’s activities in chapters 1, 2, and 4 of this dissertation. Hence it is assumed that the larger the Long-Term Care Ombudsman program’s budget, the more resources the program would have available for hiring additional ombudsmen to solve nursing home residents’ problems, thereby decreasing inspectors’ citation of deficiencies. 36 msId a 1 ”909:" .IL‘K‘ 51‘ 45 Au“ . I’M” a ;I.,?P Jinx.» EiifiSI ‘2 . tr. :de Il‘ ’ECLxIIIp 1"— II ‘ v‘t ~1 ‘7'--. I 'I'I. l‘l .. 51.1.5“ :T‘ . 5‘ 7”,. :-.I.L~|_ wk ._ -. 9 P‘ IL 1., ‘\>JAI l“~I . , I 1’) Ft ‘_‘~\ an?“ , . . .. ‘ l‘~. "4 " F, 3‘ 'v t-‘ ‘ \ 1.. K r . . .. ‘“l“ | "i. .- I" v.“ wield a substantial amount of influence over regulatory agencies (Huntington, 1952; Bernstein; 1955; Stigler 1971; Peltzman, 1976; Becker, 1983; Berry, 1984). Conse- quently, Stigler (1971) argued that regulation was created primarily for the benefit of industry. In the 19703 and 19805, social scientists’ views about the influence of industry interest groups on regulatory agencies changed. These scholars examined consumer and industry interest groups’ influence over regulatory agencies and developed an alternative model to the capture theory. The alternative model argued that the influence of regulated industries can be balanced by the activities of consumer groups (Peltzman, 1976; Becker, 1983; Gormley, 1982; Berry, 1984; Brudney and Hebert, 1987). For example, Peltzman (1976) and Becker (1983) asserted that regulation was a mechanism for benefitting well- organized groups that supplied legislators with votes and campaign contributions. Hence, it is assumed that regulation benefits the interests groups that can provide politicians with votes and campaign contributions. In the nursing home policy arena the nursing home industry association (AHCA) and the American Association of Retired Persons (AARP) at the national level give campaign contributions to support the majority party in office based on the past contributions of each group’s PAC activity (see Appendix C). Appendix C shows the percentage of the AARP’s and the AHCA’s federal PAC contributions by political party for the years 1991 through 1997. During the period 1991 through 1994 the Democratic party was the majority party in Congress. Over this period the AARP and AHCA gave a large percentage of their PAC funds to Democratic congressional members (see Appendix C). During the period 1995 through 1997, the Republican party was the majority party in Congress. Over this period, the AARP and AHCA gave a large 37 " r” '3: ‘l 3" .lpl 1.. “A. percentage of their PAC funds to Republican congressional members (see Appendix C). This pattern indicates that both groups are attempting to influence the majority political parties in office. Given the AHCA’s and the AARP’s PAC contributions at the national level, it is assumed that this strategy is employed at the state level too. Moreover, Scholz and Wei (1986) argued that state level agencies are more responsive to local interest groups because their members can directly facilitate or impede enforcement activities. In this study, it was noted that enforcement agencies routinely met with affected groups to discuss inspection procedures, interpretations of regulations, and enforcement problems. In the nursing home policy arena the AHCA is the industry interest group and the AARP is the resident interest group. Both groups have chapters located in every state. The industry association (AHCA) and resident interest group (AARP) have met with state-level nursing home regulators to discuss various enforcement issues.4 Thus, it is argued that the AARP and AHCA have the capability to influence state nursing home regulators. State regulators implementing the enforcement provision of the OBRA 87 cite deficiencies to facilities that do not comply with the various provisions outlined in OBRA 87 (see Table 1). Once deficiencies have been formally assessed after an inspection of a nursing home is completed, then sanctions can be recommended for imposing on noncompliant facilities. The sanctions are based on the scope and severity of the deficiencies cited (see Table 3).5 The OBRA 87 enforcement provisions include 4Interviews with nursing home policy experts and actors, AARP and AHCA membership brochures, newsletters, and various issues of The Guide to the Nursing Home Industry all indicate that the AARP and AHCA have met with enforcement agencies. 5The scope of a deficiency is determined based on the number of patients affected 38 Ir ‘1'.) ~I\§ TV} rhs. ‘3; J _'J «I. sanctions that can impose civil monetary fines and prevent nursing homes from admitting new patients. These two categories of sanctions can have an adverse impact on facilities’ financial performance. Therefore, it is argued that the nursing home industry will benefit when regulators cite fewer deficiencies. Thus, this group will pressure state regulators to decrease their citation of deficiencies. Yet, when more deficiencies are cited for facilities that do not comply with OBRA 87 provisions, then nursing home residents benefit. That is, the citation of deficiencies should lead to sanctions being imposed on noncompliant facilities. Consequently, the noncompliant facility will resolve the problem and avoid future deficiencies being cited and sanctions being imposed. After the facility resolves the problem that caused it to be cited for a deficiency, it is assumed that the residents will benefit by receiving improved patient care. Therefore, it is argued that the AARP (resident interest group) benefits when more deficiencies are imposed on noncompliant facilities. Hence, the AARP will pressure state regulators to increase their citation of deficiencies. Proxy measures of interest group strength were developed given that there were no direct measures available. Scholz and Wei (1986) also created proxy measures of interest group influence. These scholars used the number of worker complaints per 1,000 industrial workers filed with the OSHA as a measure of direct activity of labor to influence enforcement. They were not able to compute a measure for business due to missing data. In this dissertation, similar measures for interest group strength were developed. More specifically, the number of nursing home beds as a percent of the (isolated, pattern, or widespread). The severity of a deficiency is determined based on whether or not various categories of harm occur, including actual or potential for death/serious injury, other actual harm, potential for more than minimal harm, or potential for minimal harm (substantial compliance) (see Table 3). 39 t f.- E; h 1.! 'L Q Li .. v '0'. All ELLEIV3 I" - .énm r '.'."*.' {1' “.1‘1' l ‘::_A_V‘L1 voting-age population in each state was used as a measure of the direct activity of the influence of the nursing home industry’s interest group. The number of AARP members as a percent of the voting-age population in each state was used as a measure of direct activity of the resident interest group influence. Executive Theories Political executives can influence regulatory agencies through their appointment powers. This assertion is supported by work conducted by various scholars (Wood and Waterman, 1991; Moe, 1985; Waterman, 1989). For example, Wood and Waterman (1991) examined seven different public agencies for responsiveness to the president and systemically found that political appointment was the most important mechanism of political control. This study also noted that changing budgets, legislation, congressional signals, and administrative reorganization were less influential on public agencies. These scholars asserted that modern presidents chose political appointees for their ability to implement the president’s plan, as well as for their expertise and campaign support. The Federal Trade Commission (FTC) was one of the agencies that Wood and Waterman (1991) included in their study. The FTC is an independent commission headed by five commissioners with its chair designated by the president. This agency regulates unfair and deceptive trade practices under the FTC and Clayton Acts of 1914. The agencies’ vague statutory mandate provides it with wide discretionary authority over what sorts of activities to pursue (Wood and Waterman, 1991). The dependent variable for this agency was the number of enforcement actions between 1977 and 1987. The results of this study showed that during the same month that President Reagan appointed James Miller III to become commission chair of the FTC, there was approximately a 50 40 percent drop in the monthly number of enforcement actions. Moreover, the average level of enforcement actions continued to decrease for the remainder of the Reagan administration. The governor is the executive at the state level. In the nursing home policy arena governors appoint agency heads to their nursing home regulatory agencies across the states. As noted by the FTC study, political appointees can have an impact on changes in the number of enforcement actions imposed on firms. Hence, it is assumed that the political appointee, in this policy arena, will enact the governors’ views by either pressuring the nursing home regulatory agencies to increase or decrease citation of deficiencies. The Republican party has a tendency to promote less regulation due to their past ties to industry as noted by the drastic reduction in enforcement actions during Reagan’s appointment of James Miller 111 to the FTC. Yet the Democratic party has a tendency to promote more regulation due to its historical ties with labor. This assumption is supported by the ADA ratings of the committee members of the Senate Special Committee on Aging and a study conducted by Weingast and Moran (1983) (see Appendix C). Appendix C shows that Democratic senators received much higher ratings than Republican senators. This rating measures an individual politician’s preference for activist regulation. Furthermore, Weingast and Moran (1983) examined Congress’ influence over the FTC’s behavior and conducted some tests that provided systematic evidence that ADA scores were a meaningful index of senator’s preference over FTC activism. That is, a high ADA score corresponded to a senator’s preference for protecting consumers through activist regulation. This assumption is also supported by the Americans for Democratic Action (ADA) ratings of the committee members of the 41 'JVI'V‘Y'Ith v' I. n... ‘. b“ .l: .v‘r‘ , . ' mu - hut _u.;..' ._ Senate Special Committee on Aging (see Appendix D) and a study conducted by Weingast and Moran (1983). Appendix D shows that Democratic senators had much higher ratings than the Republican senators. Furthermore, Weingast and Moran (1983) examined Congress’ influence over the FTC’s behavior and conducted some tests that provided systematic evidence that ADA scores were a meaningful index of senator’s preference over FTC activism. That is, a high ADA score corresponded to a senator’s preference for protecting consumers through activist regulation. Legislative Theories There are two major views about congressional influence over regulatory agencies: the bureaucratic and congressional dominance approaches. The bureaucratic view argues that regulatory agencies operate independent of congressional influence (Anderson, 1975; Rourke, 1976; Wilson, 1980). This perspective cites several factors that prevent Congress from controlling regulatory agencies, including: 0 agencies control the flow of information from their policy area; 0 access to clientele fosters agency-clientele alliances to protect the agency from Congress; and 0 the high cost of passing new legislation to redirect agency policy, limits congressional action in only the most important cases (Weingast and Moran, 1983). Thus, according to the bureaucratic approach the aforementioned factors insulate regulatory agencies from congressional influence and allow these agencies to pursue their own goals as opposed to the public purposes for which they were established. 42 The congressional dominance approach argues that agencies are directly tied to the legislature or specific committees within the legislature and are therefore influenced by Congress (Lowi, 1979; Weingast, 1981; Becker, 1982). The congressional domin- ance approach assumes that Congress possesses the authority to reward or sanction regulatory agencies. That is, rewards are provided to agencies that pursue the policies of interest to the current congressional committee members. Yet agencies that do not pursue the congressional committees’ policy interests are sanctioned. The congressional incentive system is based upon Congress’ authority over agencies, including: 0 Congress can give budgetary rewards to agencies; 0 Congress can impose sanctions through its powers of oversight and appropria- tions; and 0 Congress can control who gets appointed and reappointed to regulatory agencies (Weingast and Moran, 1983)." Therefore, Congress’ appointment and appropriations powers provide it with the ability to influence regulatory agencies. State legislatures also have similar authority over state 6Many observers have noted that the congressional constituency regularly exercises veto over nominations. See Cary (1967), Kohlmeier (1969), and N01] (1971). Even Katzmann (1980, chap. 9), who argues that the confirmation hearings are perfunctory, reports how the Senate subcommittee virtually dictated FTC appointments in the 19703. The last argument has important implications for recent claims that new policy directions are linked to changes in the nature of the types of experts comprising agency manage- ment (Heclo, 1978; Levine, 1981). Their observation is again consistent with both views. According to the traditional view, this is evidence of agency discretion since we can associate policy change with different types of managers. On the other hand, if Congress controls who gets appointed to agencies, then it controls which experts gain influence and control of agency management. Veto power over appointments implies that the only changes in agency management we observe are those preferred by Congress, and thus new and different managers are the means but not the cause of agency policy change. 43 )ry agencies. Hence it is assumed that state legislatures also reward and sanction gulatory agencies. Weingast and Moran (1983) conducted a study of the FTC to test the bureaucratic ngressional dominance approaches. In this study these scholars attempted to regulatory agency behavior. The independent variables used in this study were Ividual senators’ liberal support scores (ADA rating), senate subcommittee ADA senate subcommittee chairman ADA rating, house subcommittee ADA rating, :ubcommittee chair ADA rating, and agency budget appropriations.7 Weingast Iran (1983) found that the higher the ADA rating, the greater the support for FTC n. These scholars gathered data covering the period 1964 through 1976 to assess Itionship between Congress and the FTC. The dependent variable was derived ISCS falling under the Fair Credit Reporting Act, cases falling under the fur, wool, .tiles statutes, and cases falling under the Robinson-Patman Act. Their results that the Senate was more important than the House, the Senate subcommittee and r have a greater impact than the full Senate, and the Senate yields a dramatic shift ive caseloads. Therefore, they concluded that the FTC was remarkably sensitive ges in the composition of its oversight subcommittee and changes in its budget. In the nursing home policy arena it is argued that changes in the number of icy citations will be influenced by the majority party of the state legislature. That publican-controlled legislatures will support industry interest groups and 1e Americans for Democratic Action rating represents the percentage of votes on :he individual member voted in favor of a special interest group’s position on a I set of issues of particular concern to that group. Furthermore, Weingast and (1983) showed that a high ADA rating corresponded with a senator’s preference tecting consumers through activist regulation. 44 ' : -:: E'. t, a. 3" 3:. 33 J5. a? s" 'n‘ 3': E ’5 i! D I". '-"a E as I: 5 I: I”: i? a: Democratic-controlled legislatures will support consumer interest groups. The ADA ratings of the members of the Senate Special Committee on Aging affirrn this assumption (see Appendix D). Appendix D shows the ADA ratings of the members of the Special Committee on Aging for the 106th Congress. The ADA ratings measure an individual members’ preference for protecting consumers through activist regulation. These ratings show that Democratic senators received substantially higher ADA ratings as compared to the Republic senators. Furthermore, Scholz et al. (1991) showed that state legislatures with a higher percentage of Democrats had significantly more enforcement actions imposed on noncompliant firms. Thus, it is assumed that states with a unified Republican legislature will have fewer deficiencies being cited as compared to states with a unified Democratic legislature. It is not clear how regulatory agencies are affected when the party of the governor differs from the majority party of both houses in state legislatures. Moreover, it is not clear how regulatory agencies are impacted when the party of the governor is Democrat or Republican and one house of the state legislature is controlled by Democratic party and the other house is controlled by the Republican party (split). It is also assumed that interest groups influence legislators to pressure state regulatory agencies to adjust their enforcement actions. That is, the AARP (resident mtere$t group) will influence legislators to pressure state nursing home regulatory agencies to increase citation of deficiencies on noncompliant facilities and vice versa for the industry interest group. Organizational Factor Theories of Regulatory Agencies Two perspectives have dominated social scientists’ understanding of organizations. One perspective is the scientific management approach and the other perspective is the 45 human relations approach. The scientific management approach views organizations as a mechanical system whose goal is to minimize inputs (resources) and maximize outputs (production of goods and services). The human relations approach argues that the organizations’ goals are to satisfy the monetary, social, and psychological needs of its members, as well as to minimize inputs and maximize outputs. This dissertation will assess both perspectives. In the sections that follow, the scientific management perspective and human relations perspective will be described. Then, both perspectives will be compared and the hypotheses to be tested will be stated. Scientific Management Perspective In the 19303 and 19405, administrative theorists argued that the correct organiza- tional structure could be derived from scientific principles (Taylor, 1923; Gulick, 1937; Fayol, 1949). Frederick Taylor (1923) developed the concept “scientific management,” which was a management approach that focused on designing detailed measurements of time and motion to discover how the worker might become more efficient. Although Taylor developed the concept of “scientific management,” Henri Fayol and Luther Gulick expanded this concept for practitioners to apply to their organizations. For instance, Fayol (1949) outlined fourteen different principles of management, which included clear chains of command, responsibility, remuneration, and incentives. Gulick (1937) coined the acronym “POSDCORB” to denote planning, organizing, staffing, directing, coordinating, reporting, and budgeting. The work of the early scholars who developed the scientific management perspective influenced scholars and practitioners thereafter. 46 As a result of the scientific management perspective, scholars began to view structure as being of utmost importance to achieving organizational efficiency. Consequently, scientific management principles began to be applied by scholars and practitioners in both the public and private sectors (Denhardt, 1991). For example, Taylor and Gulick were often asked to address issues of public sector management with the goal of creating an efficient and productive governmental bureaucracy (Brehm and Gates, 1999). Also, White ( 1926) supported the scientific management perspective by arguing that “the objective of public administration is the most efficient utilization of resources at the disposal of officials and employees.” However, Simon (1957) attacked the scientific management view that ad- ministration could be guided by scientific laws. He asserted that instead of deriving a “correct” organizational structure from pseudoscientific principles, an organization’s structure should be matched with the unique needs of the organization (Cohen, 1988). Gibson (1978) supported Simon’s view by stating the following: If one views organization structure as the buffer between the public agency and its environment, then the nature of that buffer influences the sources and types of information getting into the agency, the agency’s ability to respond to external political influences, and ultimately, that agency’s ability to accomplish its goals (Bozeman and Straussman, 1990). As a result of the scientific management perspective, public managers have been manipulating their organization’s structure to help them accomplish the mission of their agencies. That is, structure determines who works with whom and therefore can influence managers’ relationships with staff. Structure can also influence the agency’s accomplishment of its goals (Bozeman and Straussman, 1980; Shortell and Kaluzny, 1997). 47 Human Relations Perspective Some skeptics of the scientific management approach began to assess whether subordinates’ preferences influenced the organization’s ability to accomplishment its goals. Chester Barnard was one of these skeptics and spawned the development of the human relations perspective. Barnard (1938) wrote a book entitled The Functions of the Executive, in which he described organizations as cooperative arrangements between management and subordinates. More specifically, Barnard (1938) argued that all supervisory power in organizations was cooperative because subordinates had to accept the authority of supervisors as legitimate. As a result of Bamard’s (1938) work, scholars of management science began to examine the relationship between employee morale, preferences, productivity, and efficiency. For example, a group of researchers from Harvard at the Hawthorne Works of the Western Electric Company conducted a study to measure the relationship between working conditions (such as lighting, temperature, and humidity) and worker productivi- ty. These researchers systematically adjusted the lighting, temperature, and humidity of certain groups. The results of their experiments indicated that regardless of changes in environmental conditions the productivity of the experimental group tended to increase. These researchers observed that the experimental group was responding to the fact that they had been singled out to receive special attention, not to changes in their working conditions. Thus, these researchers concluded that organizational goals included the production of goods and services, as well as satisfying the monetary, social, and psychological needs of its members. Therefore, various studies were conducted to assess the relationship between workers’ needs and productivity. 48 Scientific Management and Human Relations Perspective Many of the studies conducted to assess the relationship between employees’ needs and productivity indicated that changes in management structure could lead to important differences in productivity. That is, a management structure that fulfills the organization’s goals and employees’ needs tended to be more productive than structures that were designed to solely fulfill the organizations’ goals. For example, Likert (1967) rigorously tested four management structures that were based on the scientific management approach and the human relations approach. The management structures he assessed ranged from exploitative authoritative, benevolent authoritative, consultative, and participative. The exploitative and benevolent authoritative structures were based upon the scientific management perspective. The consultative and participative structures were based upon the human relations perspective. Likert (1967) found that the consultative and participative structures systematically resulted in high productivity and the exploitative and benevolent authoritative structures systematically resulted in low productivity. More specifically, the consultative and participative structures were characterized by: 0 supportive relationships between management and subordinates; 0 group decision making; 0 favorable attitudes towards superiors; 0 high confidence and trust; 0 excellent communication; 0 high peer group loyalty; 0 low absence and turnover; 0 high earnings; and 49 0 high performance goals. However, exploitative and benevolent authoritative structures were characterized by: 0 High pressure via tight work standards, personnel limitations, tight bud- gets—imposed; 0 unfavorable attitudes towards superiors; 0 little confidence and trust; 0 poor communication; 0 low levels of influence; 0 low levels of cooperative motivation; 0 low performance goals; 0 restriction of output; and 0 high absence and turnover. The results systematically showed that the human relations approach (consultative and participative structures) increased productivity. Likert (1967) concluded that structure based upon the human relations perspective increases productivity. Moreover, Likert (1967) demonstrated that consultative and participative management structures resulted in higher productivity, lower costs, favorable attitudes, and excellent labor relations. Therefore, organizational appraisals should be based on some examination of the interaction of the employee with the organization (Miller, 1991). Hence, in this dissertation the internal organizational factors that will be examined are relations between inspection managers and inspectors’ and inspection managers’ and inspectors’ monetary, social, and psychological needs. These factors will help to determine whether or not enforcement actions (productivity) are influenced by the aforementioned factors. 50 In the nursing home policy arena, the goal of regulators is to cite deficiencies and impose sanctions on facilities that do not comply with the OBRA 87. However, history has shown that there are problems with enforcement systems across the states, which have prevented regulators from accomplishing their organizational goals. For instance, some inspectors in Michigan stated that they received pressure from management not to cite deficiencies, they did not have adequate time to complete inspections, and they were intimidated by attorneys representing nursing homes as they conducted inspections (GAO, 1999).8 Given these factors, it is assumed that inspectors’ productivity decreased. In the nursing home policy arena, the goal of regulators is to cite deficiencies and impose sanctions on facilities that do not comply with the OBRA 87 enforcement laws. However, history has shown that there are problems with enforcement systems across the states, which have prevented regulators from accomplishing their organizational goals. For instance, some inspectors in Michigan stated that they were pressured by manage- ment not to cite deficiencies, they did not have adequate time to complete inspections, and they were intimidated by attorneys representing nursing homes as they conducted inspections (GAO, 1999).9 Furthermore, it is assumed that external groups and political institutions will systematically exert pressure on managers and inspectors assessing deficiency citations, 8This information is based upon information obtained during meetings with the regulators, interest groups, and aging professionals. Also, in the March 1999 GAO report, it was noted that inspectors in Michigan did not want to cite deficiencies that would result in a facility being sanctioned for being out of compliance with OBRA 87. 9This information is based upon information obtained during meetings with the regulators, interest groups, and aging professionals. Also, in the March 1999 GAO report, it was noted that inspectors in Michigan did not want to cite deficiencies that would result in a facility being sanctioned for being out of compliance with the OBRA 87 nursing home reform laws. 51 and thereby interact with their views about the working relationships and their working conditions. The internal agency factors that will be examined are: inspectors’ views about managers, managers’ views about inspectors, and inspectors’ working conditions. 1° Thus, it is argued that satisfactory working conditions and inspectors’ positive views about their working relationships with managers in states that support regulation should result in increases in deficiency citations being assessed on noncompliant nursing homes. It is also argued that unsatisfactory working conditions and inspectors’ negative views about their working relationships with managers in states that do not support regulation should result in decreases in deficiency citations being assessed on noncompliant nursing homes. Lastly it is argued that deficiencies will change when there are either satisfactory or unsatisfactory working conditions and when inspectors or managers have positive or negative views about their working relationships in states that support or do not support regulation. Given the organizational theory literature, it is assumed that inspectors’ relations with inspection managers and fulfillment of inspectors’ and inspection manager’s monetary, social, and psychological needs will influence the deficiency citations assessed. Nursing Home Structural Factors Theories In addition to interest groups and executive and legislative political institutions, nursing home characteristics can influence the number of deficiencies cited by inspectors. Harrington, et al. (1999) argued that facility-level characteristics are important. These 10A manager variable for working conditions was not created because the alpha was .50, which was not close to the recommended .70 by Nunally (1978), thereby suggesting that this index was not reliable. 52 ghohrs coI Iati‘tit) char homes. H. measure of mm of l air-m res); Iacihzzcs u guilty of hIL‘CI (In the {fierce} Cited. H mid} 1m “Ii-‘5“ c; 3?th a I. scholars collected state-level data covering the period 1991 through 1997 describing facility characteristics that influence the quality of care that residents receive in nursing homes. Harrington, et al. (1999) included resident groups and family groups as a measure of facility characteristics. Resident groups and family groups are organized groups of residents or residents’ family members that meet regularly to discuss issues about residents’ care, treatment, and quality of life. Harrington, et al. asserted that facilities with organized resident groups or organized family groups could have higher quality of care as compared to facilities without these groups. It is then assumed that higher quality of care should result in fewer deficiencies being cited. Thus, the higher the percentage of resident groups or family groups, the fewer the number of deficiencies cited. However, one of the officials interviewed in connection with the Michigan case study in chapter 4 suggested that resident groups work with facilities to resolve problems, which can decrease the number of deficiencies cited; while family groups tend to form after a major problem has been identified and pressure regulators and inspectors to cite deficiencies.11 Therefore, it is assumed that the higher the percentage of family groups, the greater the number of deficiencies cited by inspectors and the higher the percentage of resident groups the lower the number of deficiencies cited. Nursing home structural characteristics can also influence the average number of deficiencies cited. Spector and Takada (1991) conducted a study assessing the predictors of resident outcomes in nursing homes. In this study, these scholars modeled both resident characteristics and facility characteristics as predictors of the health outcomes of 2,500 resident in 80 nursing homes in Rhode Island. They defined structure as a “This information is based on an interview with a nursing home expert with over 20 years of experience in this area. 53 facility’s capacity to provide high-quality care. The structural variables in their study included nursing staff ratios, staff turnover, operating costs, number of beds, and for- profit or not-for—profit status. The results of this study showed that facility structure was a predictor of residents’ health outcomes. Current Studies of States Implementing Nursing Home Laws Some recent studies examined the enforcement systems of several states (GAO, 1999; Edelman, 1998; Hawes 1996; and Edelman, 1999). The GAO (1999), Edelman (1998), and Edelman (1999) studies examined state implementation of the enforcement provisions of the OBRA 87 and found that HCFA had problems implementing the enforcement provisions of the OBRA 87. For instance, in the Edelman (1998) study it was asserted that state enforcement has begun to resemble the system that Congress criticized and redesigned with the passage of the OBRA 87 nursing home reform laws. Edelman (1998) also indicated that there were three principal reasons for problems with state implementation of the enforcement provisions of the OBRA 87: 1. Reductions in federal spending resulted in a lack of sufficient funds to enforce public standards at the federal and state levels. 2. The HCFA has moved away from a regulatory orientation to a collaborative corporate model of quality improvement. 3. The HCFA has succumbed to the pressure and demands of the nursing home industry to decrease regulatory oversight (Edelman, 1998). Edelman (1998) suggested that HCFA implement the enforcement rules according to the terms outlined by Congress in the OBRA 87. 54 MOI: 55mm succ of the OBR resident ca “thing's mums discussion refrains} [111351.312 Moreover, Edehnan (1998) indicated that the state of Washington inspection system successfully implemented the OBRA 87 enforcement laws. Prior to the enactment of the OBRA 87, the state of Washington had successfully implemented laws to improve resident care in nursing homes. For example, Edelman (1998) notes that the state of Washington uses a variety of state law mechanisms; it devotes a considerable amount of resources to quality improvement activities; it involves all interested parties in its discussion and processes, which creates widespread support; and it has a close working relationship with HCFA regional office, which helps them improve the performance of nursing homes and their inspection agency (Edelman, 1998). Also, the state of Washington’s inspection system works because there is consensus among state officials, the ombudsman program, and other advocates for residents, the nursing home industry, and HCFA regional office (Edelman, 1998). According to Edelman (1998) all concerned parties respect the work of the other parties. The GAO (1999) study identified problems with state inspection agencies and HCFA and published its recommendations to improve enforcement. In its report to Congress and HCFA, the GAO (1999) stated that “the enforcement system we observed still sends signals to noncompliant facilities that a pattern of repeated noncompliance carries few consequences.” They further noted the following: 0 the deterrent effect of civil monetary penalties will be lost if the backlog of these sanctions is not reduced, 0 the deterrent effect of termination is weakened when terminated facilities are reinstated into the Medicare and Medicaid programs without a reasonable assurance period for monitoring them, 55 The GAO The I: Iit 0 The HCFA’s rules do not require states to refer for sanction all homes with deficiencies that contribute to residents’ deaths, and 0 The HCFA’s ability to improve oversight of nursing homes depends heavily on whether it has the information to identify and monitor homes posing the greatest risk of harm. The GAO submitted the following recommendations to Congress and HCFA: 0 improve the effectiveness of civil monetary penalties, 0 strengthen the use and effect of termination, 0 improve the referral process, and 0 develop a better management information systems. The findings and recommendations submitted by the GAO (1999) and the Edelman (1998) to improve state implementation of OBRA 87 enforcement provisions identified some of the factors influencing enforcement and some methods for strengthening state enforcement systems. The Edelman (1999) study assessed President Clinton’s 21-point Nursing Home Initiative to improve the quality of care that residents receive. This initiative was announced a week before the Senate Special Committee on Aging hearing entitled “Betrayal: The Quality of Care in California Nursing Homes.” This hearing was conducted to address malnutrition and dehydration in California facilities and the lenient enforcement system that permits most facilities an opportunity to correct deficiencies, without sanctions being imposted. The four major components of the President’s initiative were: 0 stagger survey schedules, 0 increase the sample size for nutrition, dehydration, and pressure sores, 56 0 eIin tmt ' ch L’NI} federal stand the 08% S MMam& Hates (th mTat-xtent. he “Edie; of [he OBI 0 eliminate the grace period for homes with repeated serious violations and impose remedies promptly, 0 define HCFA’s revisit policy and ensure compliance. Lastly, Hawes (1996) conducted a study assessing the history and impact of the federal standards in the OBRA 87. In this study, Hawes (1996) argues that the effect of the OBRA 87 reforms have been impressive. Hawes (1996) notes that several studies found a reduction in the use of physical restraints and psychotropic drugs. Moreover, Hawes (1996) indicates that studies have found improved resident outcomes after implementation of the OBRA 87 laws. Therefore, Hawes arges that any adjustments to the Medicaid law must recognize the improvements resulting from the implementation of the OBRA 87 laws. 57 CHAPTER 4 A CASE STUDY OF MICHIGAN’S IMPLEMENTATION OF THE OBRA 87 ENFORCEMENT REGULATIONS Introduction In this chapter an assessment of the influence of various actors over Michigan’s regulators will be conducted in order to determine which actors have facilitated or impeded regulators implementing the OBRA 87 enforcement regulations.‘ The following topics will be described and analyzed in the remainder of this chapter: 0 Michigan’s experience implementing the OBRA 87 enforcement regulations 0 Background 0 1987 through 1992: Passage of the OBRA 87 regulations 0 1993 through 1994: Michigan regulators implement interim enforcement regulations 0 1995 through 1997: Michigan regulators implement the OBRA 87 final federal enforcement regulations 0 1998 through 1999: Problems with implementing the OBRA 87 final federal enforcement regulations persist ‘Various actors have tried to facilitate or impede regulators citing deficiencies on facilities that do not comply with the OBRA 87 quality of care, quality of life, residents’ rights, and resident assessment and care planning standards outlined in the OBRA 87 regulations. 58 o In El 0 Met ' lmt Michigan's I Bat‘igrnwzj As a on Consum trims are I Whed IEJ it) 15 [I]: ‘II C'V'LICS, 3.“ Interviews with Michigan actors Methodology and limitations 0 Interview results Conclusion Michigan’s Experience Implementing the OBRA 87 Enforcement Regulations Background As of June 1997, Michigan had 52,271 residents living in 458 facilities (Focusing on Consumer and Industry Services, 1997). Approximately 74 percent of the nursing homes are for-profit firms, 17 percent are not-for-profit firms, and 9 percent are publicly owned (Edelman, 1998). Approximately 68 inspectors examine nursing homes every 12 to 15 months to determine if they are complying with state statutes, the public health codes, and federal regulations. The nursing home industry in Michigan employs approximately 59,000 full-time and part-time employees. Also, employment in long-term care has increased 12 percent since 1986 and the business cycle has had little effect on the growth in health care services employment (Orme, 1997). The industry generates $3.1 billion to the Michigan economy and $223 million in general fund tax revenues (Orme, 1997). Furthermore, it is projected that employment in this industry will continue to increase in the future due to increases in the aged population and increases in demand for nursing home services. The growth in the nursing home industry in Michigan increases the workload of inspection managers and inspectors. Most nursing homes have a full inspection about once a year, which is called a standard inspection. Federal law requires Medicare- licensed and Medicaid-licensed facilities to be inspected at least once every 15 months 59 (see Appendix B, Figure l, which shows the inspection process in Michigan). In addition to routine annual inspections, the Michigan Department of Consumer and Industry Services (MDCIS) investigates complaints about nursing homes. When inspectors investigate complaints, these are called complaint inspections. By law, the MDCIS must begin investigation of complaints within 15 days of receiving a complaint, and must respond to the complainant in writing within 30 days. According to the ombudsman program these timelines are rarely met. However, according to a manager in the MDCIS, these timelines are currently being met (CBC, 1997). Some of the actors that can directly or indirectly impact Michigan’s regulators implementing the OBRA 87 enforcement regulations include HCFA, the governor’s office, state senators and representatives, the courts, the media, the CBC (Michigan’s Long-Term Care Ombudsperson), the AARP, the HCAM, and the MAHSA. The HCFA is a federal agency located in the DHHS (see Appendix B, Figure 2, which shows HCFA’s organizational chart). This agency was given authority to oversee states implementing the OBRA 87 enforcement regulations and to specify the criteria for states to cite deficiencies and impose sanctions on noncompliant facilities. For instance, HCFA immediately imposed a moratorium on states collecting civil monetary fines (a new sanction created by the OBRA 87 enforcement regulations) after the OBRA 87 final federal enforcement regulations became effective July 1, 1995. That is, states could propose civil monetary fines for facilities that were cited with serious and nonserious deficiencies, but none of the penalties for serious and nonserious deficiencies could be 60 collected until During the e\ SlillllllCl' of 1‘. establish 3 pr to Edelman t‘. states cited t undeniting ( HCFA awe; included MI Edelman. l‘ 1997. It al described M circumstance that could h. 33‘? States I directed it... collected until HCFA analyzed states’ proposed use of the sanction (Edelman, 1998).2 During the evaluation period, HCFA established two outside monitoring groups in the summer of 1995 to help evaluate states’ proposed usage of civil monetary fines and to establish a process for evaluating state deficiency reports (Edelman, 1998). According to Edelman (1998) HCFA solely focused on the number and category of deficiencies that states cited on inspection reports. However, HCFA ignored the problem of states’ underciting deficiencies and imposing too few sanctions (Edelman, 1998). That is, HCFA appeared to identify states that cited more deficiencies than the norm, which included Michigan, and advised the outliers to revise their enforcement systems (Edelman, 1998). The HCFA lifted the moratorium on civil monetary fines in January 1997. It also revised its federal guidance in the State Operations Manual, which described who had the authority to impose the enforcement sanctions and under what circumstances the enforcement sanctions could be proposed and imposed.3 The sanctions that could be imposed on noncompliant facilities are described in Table 2. The HCFA gave states the authority to impose the directed plan of correction, state monitor, and directed in-service training sanctions. The HCFA also gave state Medicaid agencies the 2The HCFA classified nonserious deficiencies for those deficiencies falling into the categories designated by letters ranging from “A” through “C” on Table 3. The HCFA classified serious deficiencies for those deficiencies falling into the categories designated by letters “D” through “J.” The HCFA allowed states to collect civil monetary fines from those facilities whose deficiencies were classified as serious deficiencies. 3The State Operations Manual specifies the HCFA’s interpretation of the OBRA 87 provisions and contains policies and procedures that states must employ as they implement the OBRA 87 provisions, which include the enforcement regulations. Further- more, this manual is updated regularly as the HCFA reinterprets the OBRA 87 provisions. 61 authority to irnpose the termination sanction.“ However, HCFA retained the authority to impose the denial of payment for all new Medicare and/or Medicaid admissions, the denial of payment for all Medicare and/or Medicaid admissions, civil monetary fines, temporary management, and termination.’ Therefore it is argued that HCFA’s authority over states implementing the enforcement provisions can have a direct impact on the average number of deficiency citations. The governor has the authority to appoint the top managers to the MDCIS (see Appendix B, Figure 3, which shows the organizational chart for the MDCIS). This agency is responsible for inspecting nursing homes, issuing official statements of deficiencies, and recommending that sanctions be imposed on noncompliant facilities. The managers’ authority over the MDCIS provides them with the ability to influence the number of deficiency citations that inspectors cite on noncompliant facilities. For example, in July 1996, the political appointees of the MDCIS conducted a series of summit meetings with providers, HCFA Regional and Central office staff, state officials, and resident advocates to discuss inspection and enforcement issues. The summit meetings resulted in the development of the Resident Protection Initiative (RPI). The RPI was a series of initiatives that included: “The state Medicaid agencies are responsible for paying nursing homes that have Medicaid residents. Table 6 shows the percentage of nursing home residents who pay for their care via the Medicaid program. 5The state Medicaid agency has authority to impose sanctions on facilities that are certified by Medicaid only without making recommendations to the HCFA. Further- more, the federal government has the authority to qualify nursing homes to receive payment from the Medicaid and Medicare programs. The states have authority to give nursing homes a license to operate. 62 0 establishing a distinct enforcement unit in May 1997 to oversee and coordinate enforcement activities; 0 integrating the complaint scheduling system with the standard inspection scheduling system (June 1997); 0 establishing an Early Intervention Program; 0 establishing a Pilot Collaborative Remediation Project in conjunction with the Michigan Public Health Institute (MPHI); and 0 establishing an Informal Deficiency Dispute Resolution (IDDR) process administered by the (Michigan Peer Review Organization (MPRO).6 The RPI were designed to address enforcement and inspection issues that can directly or indirectly impact the number of deficiencies that inspectors assessed on noncompliant facilities (MDCIS, 1997). For instance, the IDDR could decrease the number of deficiencies cited by inspectors through the decisions rendered from this initiative.7 The HCFA required that all states institute the IDDR process, which gives nursing homes the right to appeal deficiency citations assessed from inspections. The facility has the opportunity to dispute the finding and offer new or additional information that can lead to a change in the deficiency level or result in the deficiency being deleted from the inspection report. That is, if the inspectors’ deficiency citations are found to be valid through the IDDR then the number of deficiencies cited is not affected. However, if the 6The details of each of the Resident Protection Initiative are discussed later in this chapter in the section entitled, “Michigan Employs Changes to Its Implementation of the OBRA 87 Final Federal Enforcement Regulations.” 7The definition of a poor performer is a facility that had a citation for substandard quality of care or immediate jeopardy in the current inspection and in two or more of the last three years. All other facilities are labeled historically compliant, regardless of the mom and severity of their deficiencies. 63 inspectors’ deficiency citations are not found to be valid through the IDDR then the number of deficiencies are decreased. Thus, the political appointees can influence the number of deficiencies cited by inspectors. State senators and representatives have the authority to pass legislation to implement the provisions of the OBRA 87 and to recommend budget appropriations for the MDCIS (nursing home inspection agency) which can indirectly impact the number of deficiencies that inspectors cite on noncompliant facilities. For instance, in October 1998, Representative Thomas Kelly (Democrat from Wayne County) proposed creating a nonpartisan taskforce in the House of Representatives to examine conditions in Michigan’s nursing homes. The proposed taskforce could be given authority to propose legislation that could help inspectors cite deficiencies on noncompliant facilities. However, Representative Kelly plans to create a taskforce were delayed until after the November 1998 election (Capitol Capsule, 1998). Representative Kelly was not successful in his efforts to create a bipartisan taskforce. However, the Michigan House of Representatives Democratic Caucus created the House Democratic Task Force on Nursing Home Reform and, with residents and nursing homes, assessed the challenges confronting Michigan’s nursing home industry (Nursing Home Reform: Interim Recommendations, 2000). The Speaker of the Michigan House of Representatives, Representative Perricone, created a bipartisan Long-Term Care Workgroup, which consisted of Senators Alma Wheeler-Smith (Democrat) and Joel Gougeon (republican); representatives Sandy Caul (Republican) and Marc Shulman (Republican); James K. Haveman, Director of the MDCH; Lynn Alexander, Director of the OSA; Carol Isaacs, Deputy Director of the MDCH; and Robert Smedes, Deputy Director of the MDCH. This workgroup focused 64 on financing long—term care, integrating the service delivery system, and enhancing the quality of life for individuals requiring long-term care. State senators and representatives can also increase or decrease the MDCIS’ annual budget appropriations, which can provide funds for additional inspectors. In 1998, the Michigan House Appropriations subcommittee on the MDCIS approved a budget provision adding 8 inspectors to the staff of 60 (Gongwer, 1998). The additional inspection staff provided the MDCIS with the resources to inspect the complaints received by nursing home residents and families and to cite deficiencies on noncompliant facilities. Thus, if the annual budget appropriations are increased or decreased for additional inspectors, then this can also have a direct impact on the average number of deficiency citations assessed. That is, an increase/decrease in inspectors should result in more/fewer noncompliant facilities being cited deficiencies. The nursing home industry and consumers can take a regulatory agency to court when they can provide evidence that the agency is not complying with the OBRA 87 enforcement provision. For example, some residents in Michigan’s nursing homes sued the state and HCFA for not implementing the enforcement provisions of the OBRA 87. On March 22, 1994 a memorandum opinion and order issued by Honorable Judge Benjamin F. Gibson, United States District Court, Western District of Michigan, Southern division, required the State of Michigan to implement the OBRA 87 enforcement provisions. The outcome of this court order gave regulators the authority to implement the OBRA 87 enforcement sanctions on facilities. It is assumed that the motivation of inspectors to cite deficiencies on facilities increased when they could see that sanctions were being imposed for the deficiencies they identified. 65 Furthermore, in September 1996, the Michigan Court of Appeals accepted a facility’s challenge to a civil fine that had been imposed by the state in the case Heritage Manor, Inc. v. the Department of Social Services. The facility successfully argued that the fine was invalid because the state had promulgated the enforcement system authorizing fines through a Medicaid bulletin, as opposed to state legislation or rulemaking. The court of appeals recognized that the state had issued the bulletin pursuant to the court order in the case Ottis v. Shalala, yet the court held that the state could not enforce the policy bulletin because the bulletin had not been promulgated pursuant to the state’s administrative procedure act (Edelman, 1998). The results of this court order could have demoralized inspectors and decreased their motivation to identify deficiencies because the OBRA 87 enforcement sanctions could not be imposed for the deficiencies that inspectors cited on noncompliant facilities. Thus, the courts’ decisions regarding the OBRA 87 enforcement regulations can impact inspectors’ motivation to cite deficiencies on noncompliant facilities. Therefore, it is assumed that the number of deficiencies cited by inspectors can be indirectly impacted by the courts’ decisions. The media can indirectly influence the deficiency citations. According to Dye and Ziegler (1989) the media exerts strong influence over people’s cognition and comprehen- sion. That is, the media generates awareness and increases the information levels of its audience. The media also has the capability of making issues salient. If the media in Michigan makes the public aware of the problems with the MDCIS implementing the enforcement provisions of the OBRA 87, then this can lead people to pressure legislators and the MDCIS to resolve the problems. For instance, in October 1996, the Detroit Free Press ran a series of articles criticizing the majority of nursing homes in Michigan for 66 providing substandard care and criticizing the regulators for not collecting the OBRA 87 civil monetary fines imposed on noncompliant facilities (Young, 1996). This series kept Michigan’s citizens aware of the problems with nursing homes and regulators implementing the OBRA 87 provisions. Thus, it is argued that when implementation problems are kept in the public eye, this can lead the public to pressure inspectors to increase their citation of deficiencies on noncompliant facilities. Hence, the media can have an indirect impact on the average number of deficiencies cited. The CBC (Michigan’s Long-Term Care Ombudsman), is a government program that provides services to long-term care facility residents, residents’ families, and other interested parties. As the CBC resolves residents’ problems related to the OBRA 87 patient care and enforcement standards and participates in meetings with long—term care regulators, nursing home inspectors should find fewer problems in facilities. For example, the CBC participated in the MDCIS’ OBRA enforcement workgroup, which helped create the plans for implementing Michigan’s final enforcement system. This implementation plan for the enforcement system specified the process for inspectors to use during inspections and could facilitate or impede inspectors’ citation of deficiencies on noncompliant facilities.8 That is, if the implementation plan was too complex and cumbersome, then this could impede inspectors’ citation of deficiencies. However, if the implementation plan was simple, then this could facilitate inspectors’ ability to cite deficiencies. Hence, it is argued that the CBC can have a direct impact on deficiency citations assessed. 8The HCFA established the inspection protocol that states use for examining nursing homes. 67 The AARP is a nonprofit organization that promotes the concerns of the elderly. The AARP focuses a lot of its advocacy activities at the state and local levels of government. This organization is also interested in improving the quality of care the elderly receive in nursing homes. For example, in Michigan, the AARP joined a coalition called the Michigan Campaign for Quality Care. Some of the goals of this coalition included improving the standards of care in nursing homes, strengthening and increasing the frequency of state monitoring of facilities, and creating more effective sanctions for poor care (Michigan Protection and Advocacy Services, 1998). If the activities of this coalition translate into increasing the frequency of state monitoring of facilities, then this could lead to inspectors identifying more problems in nursing homes and citing deficiency citations. For instance, in California the AARP spearheaded efforts to bring together nursing home stakeholders to achieve a bipartisan effort. This effort resulted in state legislators vowing to reshape ineffective regulation (PR Newswire, 1996). The AARP was also critical of the state of Texas’ weakened enforcement legislation and made nursing home reform its key legislative priority. The AARP efforts helped create a political climate in Texas that was favorable to stronger state legislation (Edelman, 1998). Therefore it is argued that the AARP can have an indirect impact on the deficiency citations assessed. The HCAM represents primarily the for-profit nursing homes and is a state affiliate of the national AHCA in Michigan. The HCAM promotes the interests of its members by becoming actively involved with governmental regulatory agencies committees and workgroups. For instance, the HCAM ensures that its staff are appointed to those committees responsible for the preliminary work on draft legislation, proposed regulations, and reimbursement program development (HCAM’s membership 68 brochure, 1994). The HCAM’s active involvement with the governor, state legislature, the MDCIS and its various committees and workgroups can result in changes in inspectors’ deficiency citations. For example, the HCAM participated in the OBRA enforcement workgroup, which helped design Michigan’s enforcement system that resulted from the OBRA 87 final federal enforcement regulations. A long-term care expert provided written testimony to Mary Fehrenbach, Legal Affairs Coordinator of the Michigan Department of Community Health (MDCH), arguing that the HCAM demanded and won the following measures or actions as a result of its participation in the OBRA enforcement workgroup: 0 reduced numbers of deficiency citations, 0 state consultation rather than the imposition of sanctions, 0 extensive restrictions on the use of civil monetary fines, 0 repeated chances to correct deficiencies before action is ever taken, 0 multiple appeal opportunities, 0 reduced monitoring, and 0 withholding information from the public about poor nursing home perform- ance. Thus its asserted that the HCAM can have a direct impact on deficiency citations assessed. The MAHSA is a state affiliate of the national AAHSA for the Aging. The MAHSA primarily represents the not-for-profit facilities and promotes the common interest of its members through leadership, advocacy, and education (MAHSA, 1992). The MAHSA’s active involvement with the governor, state legislature, the courts, and the MDCIS can influence inspectors’ decisions to assess deficiency citations. For 69 instance, on October 18, 1995, the MAHSA filed a lawsuit against the federal DHHS to prevent the implementation of the OBRA 87 (MAHSA, 1995). The MAHSA complained that the number of facilities found to provide substandard care increased from 6 percent to more than 60 percent following the implementation of the new enforcement regulations on July 1, 1995 (Edelman, 1998). On May 20, 1996, the federal court dismissed the MAHSA’s complaint for lack of subject matter jurisdiction (Edelman, 1998). Therefore, it is argued that the MAHSA can have an indirect impact on deficiency citations assessed. 1987 through 1992: Passage of the OBRA 87 Regulations Various members of Congress and resident advocates that supported the passage of the OBRA 87 nursing home reform legislation will be identified and the provisions of this legislation will be discussed in this section. On December 22, 1987, Public Law 100—203, the OBRA 87 nursing home reform legislation, was signed into law (Nursing Home Reform Law: The Basics, 1993). The OBRA 87 was sponsored by Senator George Mitchell (Democrat-Maine) and Representatives John Dingell (Democrat- Michigan), Henry Waxman (Democrat-California), and Pete Stark (Democrat-California) (Nursing Home Reform Law: The Basics, 1993). This law resulted from two decades of consumer advocacy by residents, family members, ombudspersons, and other advocates (Nursing Home Reform Law: The Basics, 1993). The OBRA 87 nursing home reform legislation contained various provisions for improving patient care and sustaining nursing homes’ compliance with the provisions’ standards. The patient care provisions included quality of care, quality of life, residents’ rights, and resident assessment and care planning standards (see Table 1). The OBRA 87 also included an enforcement provision that expanded the range of sanctions that could 7O be imposed on facilities cited with deficiencies for being out of compliance with the patient care provisions’ standards (see Table 2). The HCFA was given authority to specify how states will implement the enforcement regulations and to oversee states implementing the regulations. Congress planned for the enforcement provision’s sanctions to become effective October 1, 1990. However, HCFA did not publish its proposed enforcement regulations until April 28, 1992 (see Table 1). As Michigan’s regulators awaited HCFA’s promulgating the OBRA 87 enforce- ment regulations, nursing home residents filed a lawsuit against the state and HCFA on June 11, 1992 (Ottis v. Shalala, 1992). That is, nursing home residents in Michigan became frustrated with HCFA’s lengthy rule-making process and sued the state and HCFA to compel them to implement the enforcement provision of the OBRA 87 nursing home reform law (Ottis v. Shalala, 1992). In this lawsuit the residents alleged that the federal and state govermnents did not implement the enforcement provision’s sanctions against noncompliant nursing homes required by the OBRA 87. I 993 through 1994: Michigan Regulators Implement Interim Enforcement Regulations The lawsuit compelling Michigan regulators to implement the OBRA 87 enforcement regulations and Michigan’s initial experience with imposing the enforcement sanctions will be covered in this section. On March 22, 1994, a memorandum opinion and order was issued by Honorable Judge Benjamin F. Gibson, United States District Court, Western District of Michigan, Southern division, requiring the State of Michigan to implement the OBRA 87 enforcement regulations. In this order, the court also developed a timetable for the state to establish an enforcement system through an amendment to the state Medicaid plan. The timetable required the state’s enforcement 71 plan to be in place by July 15, 1994 (Edelman, 1998). Michigan responded to the court order and established an interim enforcement plan on July 1, 1994 through its Medicaid bulletin (Medical Services Administration Bulletin, 1994). The interim enforcement regulations were enacted pending the adoption of the final federal enforcement regulations by HCFA. The enforcement regulations allowed the state regulators to impose fines and other sanctions against nursing homes not complying with the OBRA 87 patient care provisions. During the implementation of the interim enforcement regulations the state began imposing civil monetary fines on noncompliant facilities. For instance, Michigan regulators assessed civil monetary fines against twenty-nine facilities, totaling $432,350. Fourteen of the twenty—nine facilities paid the early payment amount totaling $175,175.50. Fourteen of the twenty-nine facilities appealed. One facility filed for bankruptcy (Edelman, 1998). I 995 through 1997: Michigan Regulators Implement the OBRA 87 Final Federal Enforcement Regulations In this section various events will be covered that describe Michigan’s experience with implementing the OBRA 87 final federal enforcement regulations. More specifically, this section will show how HCFA, the HCAM, the Long-Term Care Ombudsman, the MAHSA, and the courts influenced Michigan’s regulators implementing the OBRA 87 enforcement regulations (CBC Bulletin, 1995). Michigan’s interim enforcement regulations expired on July, 1, 1995. HCFA published the final federal enforcement regulations on November 10, 1994. The final federal enforcement regulations became effective on July 1, 1995. When the new 72 enforcement regulations first became effective, HCFA immediately imposed a moratorium on the collection of some civil monetary fines, which was an OBRA 87 enforcement sanction. That is, states could propose that HCFA impose civil monetary fines on noncompliant facilities, but none of the penalties for less serious deficiencies would be collected until HCFA determined how states could use the sanction (Edelman, 1998). In the period during which HCFA imposed a moratorium on civil monetary fines, it also evaluated state deficiency reports (Edelman, 1998). While HCFA evaluated how states could use civil monetary fines, Michigan commissioned an OBRA enforcement workgroup in January 1995. The purpose of the workgroup was to develop, implement, and support an enforcement system that would: 0 promote continuous provision of quality care for all long-term care residents; 0 protect the health, welfare, rights, and choices of long-term care residents, as defined by law and regulation, without infringing upon the rights of residents; and 0 promptly remedy noncompliance through effective application of appropriate regulatory remedies (Kerzak, 1995). The OBRA enforcement workgroup provided an opportunity for concerned groups and advocates to participate in the formulation of an enforcement plan that was consistent with the final federal enforcement regulations. The OBRA enforcement workgroup consisted of members representing the HCAM (for-profit nursing home industry association), the MAHSA (not-for—profit nursing home industry association), the CBC (state Long-Term Care Ombudsman), various state agencies, and other concerned actors. The HCAM and the CBC were very vocal during the workgroup meetings and helped draft the OBRA 87 enforcement system. 73 The workgroup met regularly and helped to specify Michigan’s plan to implement the OBRA 87 final federal enforcement regulations that became effective on September 30, 1995 (Medical Services Administration Bulletin, 1995). Michigan began implementing the OBRA 87 final federal enforcement regulations, as interpreted by the workgroup, and proposed that HCFA impose civil monetary fines on some of its noncompliant facilities. More specifically, Michigan recommended to HCFA that civil monetary fines be imposed on nine facilities totaling $206,700 between August 1995 and July 1996 (Edelman, 1998). Five of the nine facilities paid the reduced “early payment amount” totaling $106,957.50 (Edelman, 1998). Over the period August 1996 and May 1997, Michigan regulators recommended to HCFA that civil monetary fines be imposed on seven facilities, totaling $68,300. Two of the seven facilities paid the “early payment amount” totaling $4,062.50. The Detroit Free Press, a major newspaper in Michigan, criticized the state’s inability to collect civil monetary fines imposed on noncompliant facilities (Edelman, 1998). More specifically, the Detroit Free Press reported in October 1996 that only four of the forty-two facilities had paid the fines that were imposed against them (Young, 1996). Moreover, in 1995 Governor Engler’s political appointees (Kathy Wilbur and Ron Basso) instituted a Medicaid program called the Continuous Quality Improvement Program (CQIP), which was developed to improve services provided to residents in Michigan nursing homes (Garba, 1995). The CQIP program was developed by a team of professionals from various sectors of Michigan’s long-term care arena, including the HCAM, the MAHSA, the Michigan League for Nurses, the Michigan Department of Public Health, the Michigan Department of Social Services, the CBC (Long-Term Care Ombudsman program), the County Medical Care Facilities, and the OSA (Garba, 1995). 74 Under this program, nursing homes developed the CQIP teams, made up of residents, family, staff, governing board, and community members to assess needs, plan and implement improvement strategies, and evaluate results (Garba, 1995). Early in 1995 the CQIP participation became standard practice for nursing homes receiving Medicaid reimbursement (Garba, 1995). The $25 million CQIP program provided approximately 75 percent of Michigan’s 458 nursing homes with extra funds to improve the services they provided to residents (Young, 1999). If the CQIP helped to improve the services facilities provide to residents, then it is assumed that fewer deficiencies would be cited. Thus, it is asserted that the top managers of the MDCIS can have a direct impact on the average number of deficiencies cited per certified nursing home. In July 1995, HCFA began examining state deficiency reports during the period it placed a moratorium on states imposing civil monetary fines. More specifically, HCFA received copies of all inspection forms, which listed deficiencies cited from the states as they were completed (Edelman, 1998). Staff from HCFA Central Office and Regional Offices and from various states met in Baltimore in teams to evaluate samples of the surveys that states submitted. The teams examined the data that showed which states were citing deficiencies and recommending remedies and which were not (Edelman, 1998). According to Edelman (1998) HCFA solely focused on the high-end outlier states that cited more deficiencies than the norm. However, HCFA ignored the problem of states underciting deficiencies and imposing too few sanctions (Edelman, 1998). Edelman (1998) also noted that the teams generally agreed with the findings reported on the state deficiency reports that were submitted to HCFA for examination during the moratorium period. Furthermore, it was generally known in the nursing home 75 community of states, providers, and resident advocates that HCFA was closely looking at Michigan’s performance (Edelman, 1998). In response to HCFA’s memorandum clarifying score and severity, Michigan’s regulators suspended annual inspections for a two-week period, commencing October 1995, in order to analyze all inspectors’ classification of deficiencies that were cited during the first three months of implementing the federal enforcement regulations. Michigan regulators initiated the review of deficiencies cited after receiving a call from HCFA’s central office reporting problems with sc0pe/severity assignments, documen- tation, and citations being incorrectly assigned (Thomas, 1995). The HCFA sent the states its policy clarification and Michigan reevaluated the scope and severity clas- sifications of deficiencies cited since July 1995 (Thomas, 1995). During the review Michigan also compared the deficiency level with the nation’s deficiency level. It should be noted that no other state reevaluated its initial inspections under the new inspection process, yet all states received HCFA’s policy clarifications (Thomas, 1995). After the review, the MDCIS reclassified the scope and severity of deficiencies cited for the inspections conducted during the first few months of their implementing the OBRA 87 final federal enforcement regulations. For instance, the MDCIS reclassified its level “P” deficiencies, which are widespread in scope (see Table 3). Initially 22.1 percent of Michigan’s deficiencies were cited at level “F.” However, after the review the amount was reduced to 9.4 percent (Edelman, 1998). The post-review adjustments placed Michigan below the national average. With regard to severity of deficiencies, Michigan also adjusted its classification of deficiencies. For example, the MDCIS decreased level 3 deficiencies (severity category “other actual harm”) from 25 percent to 21.8 percent while increasing level 1 deficiencies (severity category “potential for 76 minimal harm”; placing facilities in substantial compliance) from 17.6 percent to 21.1 percent (see Table 3). The change in the scope and severity classifications of deficiency citations helped to place more of Michigan’s nursing homes in substantial compliance with the OBRA 87 patient care standards. That is, in July 1995 61 percent of Michigan’s nursing homes were classified as substandard (Bauer, 1999). However, after pressure from HCFA, Michigan reclassified the scope and severity of deficiencies and only 7 percent of facilities were classified as providing substandard quality of care as defined by HCFA (Bauer, 1999). The state ombudsperson wrote to the state about its plan to reclassify its deficiency citations (Tumham, 1995). The ombudsperson was concerned about HCFA’s plans to examine states with the highest deficiency citation levels and requested that Michigan not reduce its deficiency citation level (Edelman, 1998). More specifically, the ombudsperson wrote the following: HCFA’s apparent failure to examine Michigan’s citations not issued, citation in those boxes which do not carry substandard quality of care implications, or citations in those boxes which do not carry substantial remedial sanctions is indicative of its primary concern to answer industry complaints rather than to serve resident interests or even to develop a balanced survey and complaint investigation process. We strongly urge the Bureau not to make the same mistakes in its evaluation of its own work product (Tumham, 1995). The ombudsperson also suggested that they evaluate whether the inspectors had sufficient time to determine the appropriate scope and severity levels and to consult inspectors’ notes before any citation is reduced for the lack of adequate documentation (Tumham, 1995). The HCAM was also displeased with Michigan inspectors implementing the OBRA 87 final federal enforcement regulations. The HCAM voiced its complaints by 77 mailing a letter, dated October 10, 1995, to James Haveman, Acting Director of the Department of Community Health, requesting a meeting (Edelman, 1998). James Haveman agreed to meet with the HCAM. During the meeting, the HCAM shared the results of a study it paid a consultant from Ohio to conduct of the first 24 inspections performed under the new enforcement system. This study criticized the scope and severity of assignments made by Michigan inspectors and noted that the average number of deficiencies cited per inspection had steadily increased since July 1, 1995. The HCAM then provided Haveman with its recommendations for improving the state’s management of the inspection process, which included: 0 retraining inspection staff 0 providing a realistic, objective, and timely informal dispute resolution process, 0 implementing a total quality management system to monitor inspector training and implementation, and 0 reviewing the department’s punitive approach to regulation. The HCAM also admonished its members to pressure regulators and inspection managers to change the way they implemented the OBRA 87 enforcement regulations. For instance in the September 8, 1995 issue of the HCAM newsletter, Nursing Home Pulse, an article entitled, “HCAM’s Response to Enforcement” documented the HCAM’s complaints with Michigan’s implementation of the final federal enforcement regulations. More specifically, the HCAM stated: ...HCAM’s staff and leadership are fully aware of the Department of Public Health’s implementation of the enforcement rules and the current and future impact on members homes. The initial survey citation rate for inspections completed after July 1 reflects Michigan’s aggressive regulatory practices that have historically been twice the national average. HCAM will do everything in our power to rectify this unrealistic and unattainable expectation for perfection in any setting. 78 ...Why is Michigan’s citation rate for inspectors twice the national average? Michigan’s outlier status has been true since the OBRA was implemented in 1990. Neither HCFA nor MDPH seem to know the answer. However, the answer is simple and obvious: Michigan MDPH inspectors have been told by HCFA central office and reinforced by HCFA regional office in inspection enforcement training to aggressively cite deficiencies and to categorize them at the highest level of scope and severity. ...the OBRA 87 legislation and each of its revisions were developed by a group of professional client advocates who believed that more and more regulations would ultimately lead to higher quality of care. This federal legislation specified an unrealistic level of care to attain or maintain the “highest practicable physical, mental and psycho-social well-being” possible. In addition, HCFA has implemented this unrealistic federal law by publishing even more unrealistic guidelines and rules culminating with the most recent enforcement regulations effective July 1, 1995. The HCAM listed its plan to change the OBRA 87, which is outlined below: 0 we will mount a grass roots education and information advocacy initiative to garner the legislative votes to change the law into a more reasonable approach to ensuring quality, 0 we will develop guidelines for implementing the current law until the federal law can be changed, 0 the HCAM leadership will explore all other legal, political, public relations, and administrative options available to change the federal law and the state interpretation of the federal law. In order to implement their plan, the HCAM admonished its members to: 0 be prepared to aggressively demand your right to be actively involved with the inspection team’s findings throughout the inspection process so that the necessary documentation can be provided for an accurate representation of CHIC , 79 0 challenge each and every citation with appropriate documentation as each citation can lead to subsequent definitions of “poor performer,” out of substantial compliance, or providing “substantial quality of care.” 0 provide the Department of Public Health with a detailed report on the way the inspection was conducted and any deviations from the acceptable professional inspector practices, 0 provide the HCAM with your assessment of the inspection process and any suggested changes to the process (Edelman, 1998). Michigan’s inspectors were also frustrated with implementing the OBRA 87 enforcement regulations and sent a memorandum to their managers voicing their questions and concerns. On September 17, 1997 a group of Michigan’s inspectors sent a memorandum to their managers seeking answers to some concerns and questions they had about factors that have impeded them from performing their job (Woodard, 1997). A summary of the concerns and questions contained in the inspectors’ memorandum is listed below: 0 Inspectors wanted to know if division management possessed a copy of a “Black Book” that was compiled by Tendercare Corporation, which contained information about inspectors.9 9I‘he Tendercare Corporation submitted a document to the MDCIS stating that they were unhappy with the inspection process. This document also indicated the names of inSpectors whom they felt were not performing their jobs correctly. This information was obtained from an enforcement expert in Michigan. 80 Inspectors wanted to know if Tendercare Corporation was behind the attorneys who were making copies of all documents in the Saginaw office in order to show inconsistencies in inspectors’ documentation of deficiencies cited.‘O Inspectors wanted to know if the conclusions that the attorneys made about the inspectors would be used in inspectors’ performance evaluations and disciplinary actions. Inspectors wanted to know why inspectors were removed from conducting inspections and suspended for more than two months based on allegations when there was no substantiation to the charges. Inspectors wanted to know how to conduct an adequate inspection given that they were required to process excessive paperwork, which decreased their time for inspecting facilities. Inspectors wanted to know how they could conduct full Phase I and Phase II inspections when there was a lack of sufficient inspection staff, which meant they were not able to carry out all of the inspection protocols required by the OBRA 87. Inspectors wanted to know who received priority as their customer, the nursing home or vulnerable elderly residents, given that the MDCIS stated that facilities are the inspectors’ customers. “The attorneys who were making copies in the Saginaw office were hired by AHCA. The: AHCA had a law firm in Washington, DC obtain copies of every inspection con- ducted, in order to determine if they had sufficient evidence to pursue a lawsuit. After examining the inspection reports, the law firm concluded that they did not have adequate evidence for a lawsuit. This information was obtained from an enforcement expert in Michigan. 81 0 Inspectors wanted to know what the MDCIS’ plan was to fix their computers, which were needed for completing their reports in a manner that was acceptable to management. ' Lastly, inspectors wanted to know how they would be protected from harassment and not embarrass the MDCIS when they were subpoenaed by the court since they were not consulted when their deficiency findings reported on form 2567L were changed or eliminated without consulting them. The inspectors gave management until October 1, 1997 to respond. In addition to directing the states to adjust their implementation of the enforce- ment regulations, HCFA urged states to streamline their inspection process in order to reduce costs. In the fall of 1995, HCFA region V Office sent a memorandum to state Medicare managers recommending ways to reduce the costs of conducting inspections. More specifically, HCFA region V office listed the following recommendations for reducing costs: 0 using a smaller survey team augmented by facility staff to assist in completing the survey; ' reducing the resident sample by 50%; 0 eliminating inspection sections in the areas of environmental quality as- sessment, dietary, and closed record review, unless they are determined to be necessary during the tour; and 0 allowing the ombudsperson staff to conduct environmental quality assessment (Edelman, 1998). In response to HCFA’s request, Michigan regulators began reviewing techniques for reducing the costs associated with conducting inspections. 82 In November 1995, the MDPH established an Ad Hoc Survey Committee to con- sider HCFA’s cost-saving suggestions. In January 1996 a document entitled, “Improving the Long-Term Care Survey Process, Hope for the Future” was circulated that suggested ways for creating an efficient and cost-effective government. This document proposed that the state reduce its sample by 50%, reduce the inspection team size and the duration of inspections in facilities with good histories; and limit follow-up inspections with facilities with deficiencies that were classified as having “other actual harm” and classified as having “actual harm occurred or potential for death/serious injury” (see Table 3) (Edelman, 1998, GAO, 1999). This document also proposed that states should permit facilities to attest to their compliance if their deficiencies were classified as level G and below (see Table 3). That is, facilities could send the state regulators a letter attesting to their compliance with the OBRA 87 provisions without the inspectors revisiting the facility. The ad hoc survey committee met for five consecutive days in February 1996. The committee produced a final report entitled, “The Streamlined Survey Protocol.” This report recommended changes to many of the inspection tasks. For example, the report proposed reducing the sample size of residents that inspectors use for assessing facility compliance with the OBRA 87 provisions. The HCFA Central and Regional offices examined the state’s proposal to change the survey protocol and recommended that Michigan implement it (Edelman, 1998). In March 1996 Michigan began allowing facilities to report that they had come into compliance, without a follow-up inspection, 83 when the original deficiencies were at severity level G or below and were not classified as providing substandard quality care (see Table 3).“ On April 1, 1996, Michigan implemented the Streamlined Survey Process that its ad hoc committee had recommended. The ad hoc committee’s recommendations included reducing the sample size of residents for inspections, only conducting a medication pass observation based on identified concerns (rather than as a routine part of each inspection), and allowing facilities to provide written attestation to compliance with the OBRA 87 provisions when they were cited for deficiencies classified as level “G” or below on the sanction grid (see Table 3). Michigan evaluated this new process and found that on-site inspection time increased an average of 9.96 hours; yet the total inspection time was reduced by 5.41 hours. They also noted that citations levels decreased and that there was a decline in findings of substandard quality of care. Michigan concluded that the new inspection protocol was effective (Edelman, 1998). The streamlined survey process remained in effect until October 6, 1997 (Wheeler, 1997).‘2 Michigan also saved additional funds with its early retirement program. That is, Michigan’s Governor gave state employees an option to retire early. In early 1997, 22 state inspectors accepted the state’s offer to take early retirement (Muskegon Chronicle, 1997). “Severity Levels are defined as follows: categories A, B, and C are classifications for deficiencies that have a potential for minimal harm (substantial compliance); categories D, E, and F are classifications for deficiencies that have a potential for more than minimal harm; categories G, H, and I are classifications for deficiencies where actual harm has occurred; and categories J, K, and L are classifications for deficiencies where there has been actual or there is a potential for death/serious injury (see Table 3). ”Letter from Walt Wheeler III, Director, Bureau of Health Systems, dated October 2, 1997 stating that State Agency will “return to the standard survey process as outlined in the State Operations Manual, Transmittal 274, Appendix P” and suspend the State Agency Modified Survey Protocol implemented April 1, 1996, effective October 6, 1997 . 84 In July 1996, Michigan began a series of summit meetings of providers, HCFA Regional and Central Office staff, state officials, and residents’ advocates to discuss inspection and enforcement issues. The summit meetings were initiated because HCAM was unhappy with the way that inspectors were implementing the OBRA 87 enforcement law. The HCAM felt that the deficiency citations being assessed were too severe and that Michigan had a higher deficiency citation rate as compared to other states. This information was obtained from an enforcement expert in Michigan. Resident advocates participated in the summit meetings, but were concerned about how participants addressed nursing home enforcement issues. For instance, the state ombudsperson addressed a letter to the state dated October 24, 1996 identifying three primary concerns of the resident advocates: (1) the need for consensus about the scope and seriousness of nursing home problems in Michigan; (2) whether it was appropriate to use nonremedial sanctions and under what circumstances should they be imposed; and (3) whether the inspection and enforcement systems needed to be redesigned to more accurately identify and respond to quality of care and quality of life problems experienced by nursing home residents (Edelman, 1998). Despite the resident advocates’ concerns, the enforcement summit workgroups instituted a series of nonremedial sanctions for imposing on noncompliant facilities. The enforcement surrunit workgroup also created plans to implement separate enforcement protocols for poorly performing and historically compliant facilities (Edelman, l998).‘3 ”The HCFA created the protocols for the poorly performing facilities and historically compliant facilities. The definition of poor performer is a facility that had a citation for substandard quality of care or immediate jeopardy in the current inspection or in two or more of the last three years. All other facilities are labeled historically compliant, regardless of the scope and severity of their deficiencies. 85 More specifically, poorly performing facilities were not given an opportunity to correct deficiencies before civil monetary fines were imposed. However, historically compliant facilities were given an opportunity to correct deficiencies without civil monetary fines being imposed (Edelman, 1998). Additionally, as a result of the 1996-1997 enforcement summit workgroup meetings, Michigan regulators implemented a series of initiatives that the workgroup created to address inspection and enforcement issues. These initiative included: 0 establishing a distinct enforcement unit in May 1997 to oversee and coordinate enforcement activities; 0 integrating the complaint scheduling system with the standard inspection scheduling system (June 1997); 0 establishing an Early Intervention Program; . establishing a Pilot Collaborative Remediation Project in conjunction with the MPH]; and 0 establishing an IDDR process administered by the Michigan Peer Review Organization. The distinct enforcement unit, one of the initiatives recommended by the 1996—1997 enforcement summit workgroup, was created to oversee and coordinate nursing home enforcement actions in May 1997 (see Appendix G).‘“ Appendix G outlines the specific responsibilities of the enforcement unit. In general, the enforcement unit was given authority to impose nonserious sanctions (directed plan of correction, l“The HCFA requires that all states create an enforcement unit (Department of Consumer and Industry Services agenda for a meeting to discuss the Resident Protection Initiative dated June 12, 1997). 86 directed in-service training, and state monitor) on noncompliant facilities based on the licensing officer’s recommendations. However, the enforcement unit must propose that HCFA impose serious sanctions (denial of payment for new Medicare and/or Medicaid admissions, denial of payment for all Medicare and/or Medicaid admissions, temporary manager, civil monetary fines, and termination) on noncompliant facilities.‘5 The Early Intervention Program was another initiative recommended by the surmnit workgroup and was implemented in November 1997. This is a computer—based program that assesses nursing homes’ current and past performance measures in order to determine which will receive early intervention from the MPHI. The primary goal of the Early Intervention Program is to take remedial action before the state is required by HCFA time frames. The facilities that are greater than 1 standard deviation from the average would trigger early intervention (MDCIS, 1999). Based on this methodology, Edelman (1998) showed that an average of 9.7 percent of facilities were subjected to the early intervention. Therefore, approximately 90.3 percent or more of Michigan’s facilities with deficiency citations would be given an opportunity to correct deficiencies before any enforcement is imposed. The MDCIS and the MDCH also contracted with the MPHI, a not-for-profit think tank, to examine the opportunities to improve compliance with federal and state regulations through increased collaboration.‘6 The goal of the Collaborative Remedia- tion Project (CRP) is “to assist, through the provision of collaborative remediation ”The State Medicaid Agency also has authority to impose the sanction of ter- mination. In Medicaid only facilities the state can impose all of the OBRA 87 enforcement regulations’ sanctions without the HCFA’s approval. 16The Department of Public Health in Michigan was changed to the Department of Community Health by Governor Engler. 87 services, long—term care providers to further enhance their commitment to provide quality resident care and services and achieve and maintain compliance with licensure and certification requirements (MPHI, 1997).” The MPHI trains independent consultants to serve long-term care facilities that are referred by the MDCIS or self referral. The consultants can serve as temporary managers, administrative advisors, clinical advisors, consultants, or trainers. The CRP is also responsible for the following: 0 implementing short-term enforcement actions such as directed plans of correction and directed in-service training; 0 facilitating communication between facilities/remediator and state inspection agency personnel; and 0 assisting in providing joint collaborative training for consumers, providers, regulators, and remediators. The CRP is funded with civil monetary fines collected by the state since July 1995 and with the fee-for-service charged to facilities, which are allowable costs for the purposes of Medicaid reimbursement. In November 1997 the IDDR (an initiative required by HCFA) was instituted through a contractual arrangement (Edelman, 1998). The MDCIS signed a contract with the MPRO to establish a panel of trained professionals to review deficiencies that facilities dispute in a timely manner. Every state is required to have an IDDR process per Federal Regulation 42 CFR 455.331 (MDCIS, 1997). This regulation requires state inspection agencies to offer nursing homes an informal opportunity to dispute cited deficiencies upon receipt of the formal HCFA Citation Form. More specifically, HCFA created the IDDR and requires that providers be offered a single IDDR opportunity to dispute deficiency citations at the time of the notice of citations; that the process must 88 not delay formal sanctions; that failure to complete the IDDR in a timely fashion will not postpone official sanctions; that a provider must be notified of the results in writing; and that face-to—face meetings are possible, but not required (MDCIS, 1997). Under this process facilities are given two opportunities to use the IDDR. The IDDR opportunity provided during an inspection and before HCFA Citation Form 2567 is issued is called a “Level 1” IDDR (MDCIS, 1997). The IDDR opportunity that follows the delivery of HCFA Citation Form 2567 is called a “Level 2” IDDR (MDCIS, 1997). The state ombudsperson responded to Michigan’s regulators implementing the summit workgroup’s initiatives in a letter dated June 11, 1997. In this letter the ombudsperson noted that she supported establishing an enforcement unit, improving the state data system, and focusing attention on the 40—50 facilities identified as poor performers. However, she expressed grave concern for residents living in the remaining 400 facilities whose deficiencies would be processed by the untested Collaborative Remediation Project. The ombudsperson also mentioned a number of other issues that the state had not addressed, including: 0 systemic underrating of severity and scope of deficiencies; 0 vacancies in inspector and supervisory positions; 0 the need for inspections to be more frequent, less predictable, and more flexible; 0 the need for inspectors to give more credibility to the comments of residents and families; and 0 the need for more inspections to be held on nights, holidays, and weekends (Edelman, 1998). 89 It appears that changes in Michigan’s implementation of the OBRA 87 enforcement regulations have resulted in fewer deficiencies being cited. Yet, the average citations per inspection in Michigan over the period 1995 through 1999 indicate that more deficiencies are cited in Michigan than in the region or in the nation (Rector, 1999). Another enforcement expert concurred with the ombudsperson and argued that the nursing home industry association (HCAM) exerted undue influence during the summit workgroup meetings and won the following: 0 reduced numbers of citations for deficiencies, 0 state regulators employing consultation rather than proposing and imposing sanctions, 0 extensive restrictions on use of fines, 0 repeated chances to correct deficiencies before action is ever taken, and 0 multiple appeal opportunities. This advocate also stated that Michigan’s enforcement system exhibits the state’s support for the nursing home industry. Furthermore, HCFA lifted the moratorium on civil monetary fines in January 1997. It also revised its federal guidance in the State Operations Manual, which describes who has the authority to impose the enforcement sanctions and under what circumstances the enforcement sanctions could be proposed and imposed.‘7 The sanctions that could be imposed on noncompliant facilities are described in Table 2. ”The State Operations Manual specifies the HCFA’s interpretation of the OBRA 87 provisions and contains policies and procedures that states must employ as they implement the OBRA 87 provisions which include the enforcement regulations. Furthermore, this manual is updated regularly as the HCFA reinterprets the OBRA 87 provisions. 90 HCFA gave states the authority to impose the directed plan of correction, state monitor, and directed in-service training sanctions. The HCFA also gave state Medicaid agencies the authority to impose the termination sanction.‘8 However, HCFA retained the authority to impose the denial of payment for all new Medicare and/or Medicaid admissions, the denial of payment for all Medicare and/or Medicaid admissions, civil monetary fines, temporary management, and termination. I 998 through 1999: Problems with Implementing the OBRA 87 Final Federal Enforce- ment Regulations Persist In this section the MDCIS problems with implementing the OBRA 87 enforcement regulations will be described, the US. GAO’s assessment of Michigan’s experience with implementing the OBRA 87 final federal enforcement regulations will be discussed, and a nursing home tragedy resulting from poor care and Michigan’s inspection process will be covered. Although the OBRA 87 final federal enforcement regulations were enacted on July 1, 1995, the MDCIS was prevented from implementing them. More specifically, Heritage Manor, Inc. was cited and assessed civil monetary fines in July 1995 for providing poor care to residents. In 1996 the Heritage Manor nursing home appealed the regulators’ decision to impose civil monetary fines to the State Court of Appeals (Heritage Manor, Inc. v. Department of Social Services, 1996). In this lawsuit the Heritage Manor, Inc. argued that Michigan did not promulgate statutes to implement the ”The state Medicaid agencies are responsible for paying nursing homes who have Medicaid residents. Table 6 shows the percentage of nursing home residents who pay for their care via the Medicaid program. 91 OBRA 87 enforcement regulations, rather they enacted the enforcement regulations through their state Medicaid bulletin. The State Court of Appeals found in favor of Heritage Manor, Inc. in December 1997 (Edelman, 1998). In response to the lawsuit, the MDCIS began the process to promulgate statutes to implement the OBRA 87 enforcement regulations. Carol L. Isaacs, Director of Health Legislation and Policy Development, scheduled a public hearing on July 14, 1998 to discuss the proposed administrative rules that would establish Michigan statutes for the OBRA 87 final federal enforcement regulations. Various actors attended the hearings or expressed concerns with Michigan’s proposed enforcement statutes. Some of the actors included the Michigan Protection and Advocacy organization, a HCFA inspector, and a long-term care expert. For instance, in 1998, Elizabeth W. Bauer, executive director of the Michigan Protection and Advocacy Services, Inc., submitted testimony to Mary Fehrenbach, legal affairs coordinator for the MDCH, that the proposed enforcement system was designed to protect providers from sanctions (Bauer, 1999). She also identified the following problems with the current state and federal enforcement plans: 0 the systems were designed to minimize the findings of substandard care and abuse, 0 the inspectors used threats of imposing sanctions as opposed to actually imposing sanctions when they found violations of the OBRA 87 standards, and 0 the sanctions imposed were often ineffective in ensuring long—term improve- ment in the quality of care resident receive. Moreover, Ms. Bauer reported that a situation occurred where Michigan regulators reclassified many nursing homes delivering substandard care. More specifically, she noted that 61 percent of Michigan’s nursing homes were found to be 92 delivering substandard care in July 1995, which was the first month of implementing the OBRA 87 enforcement sanctions. However, after pressure from the industry, pressure from HCFA, and after calling all the inspectors from the field for a two-week retraining and evaluation period, only 7 percent of the homes were classified as substandard. These allegations could indicate that inspectors were motivated to cite fewer deficiencies in order to reduce their workloads. Moreover, Elizabeth Bauer’s allegations were shared by HCFA’s inspectors. The HCFA regional offices participate in approximately 5 percent of state inspection of facilities as a part of their monitoring responsibilities (GAO, 1999). A summary report of a July 15—18, 1997 survey, completed by a HCFA Region VII inspector revealed that they had considerable concern with the conduct of Michigan’s inspections (Edelman, 1998). The federal inspectors noted that Michigan uses its own inspection process as opposed to the federally prescribed process.‘9 More importantly, the regional office reported that inspectors were reluctant to cite deficiencies based on the following observation: ...the teams’ hesitancy at times was in part related to the sense of apprehension of potential for substandard quality of care. A team wide sense of evading any potential substandard quality of care was very apparent to the regional office inspector. While problems with obvious substandard-quality of care did surface before the end of the inspection ”Michigan’s failure to use the federal survey process should have prompted an additional response from the HCFA, since states do not have authority to revise the inspection protocol that the HCFA promulgates. The State of California had more than $4.5 million disallowed because it refused to use the federal inspection protocol. See Decision in the Appeal of the California Department of Health Services, HHS Departmental Appeals Board, Appellate Division, Doc. No. A—94-77, Dec. No. 1490 (Aug. 12, 1994). A chief in the MDCIS noted that the inspection process used was the streamlined system approved by the HCFA. The streamlined inspection process remained in effect until October 6, 1997. 93 these we 1998). Ihe federal inst Which are listed ° inspec ° inspec quality inspec ' inSpee lday deficit- impel“ classiifi these were addressed with an almost grave sense of concern (Edelman, 1998). The federal inspectors also identified a number of concerns with Michigan inspectors, which are listed below: 0 inspectors’ caution with citing too many deficiencies, 0 inspectors’ inability to figure out what to do if a determination of substandard quality of care is made (he noted this appeared to be looked at unfavorably by inspectors’ supervisors), 0 inspectors’ concern about completing a lengthy Citation Form‘in the allowed 1-day period (hastily prepared citation forms could lead to more informal deficiency dispute resolutions), 0 inspectors’ concern for facility administration being fired if a facility was classified as providing substandard quality of care, and 0 inspectors’ fear of retribution and punitive measures for classifying a facility as providing substandard quality of care (Edelman, 1998). Furthermore, a long-term care expert who participated in the OBRA enforcement workgroup, which helped establish the new system, was displeased with Michigan’s proposed enforcement system. This expert provided written testimony to Mary Fehrenbach, Legal Affairs Coordinator of the MDCH. In this expert’s written testimony it was argued that the nursing home representatives (HCAM) demanded and won the following measures or actions: 0 reduced numbers of citations, 0 state consultation rather than sanctions, 0 extensive restrictions on the use of civil monetary fines, 94 Mt Conducted ICEJUIJIIOn' SESlCm (\f h“‘IIICS in Ctit'erjng . MDCIII‘InS mlClTed C ‘EV‘E‘V in. cnSUre SQ Client to ‘ HCFA‘S Tl 0 repeated chances to correct deficiencies before action is ever taken, 0 multiple appeal opportunities, 0 reduced monitoring, and 0 withholding information from the public about poor nursing home perform- ance. Moreover, in March 1999 the US. GAO published its findings from a study it conducted to assess state implementation of the OBRA 87 final federal enforcement regulations (GAO, 1999). The GAO was given authority to review the enforcement system of several states, which included Michigan. The GAO reviewed 18 nursing homes in Michigan that received 81 percent of the enforcement sanctions from HCFA covering the period July through November 1998 (GAO, 1999). The enforcement sanctions consisted of both standard and complaint inspections where the state had referred cases to HCFA regional office for sanctions. Some of the goals of the GAO’s review included: 1) determining the extent to which HCFA’s actions were sufficient to ensure sanctions were applied in a timely and effective manner, and 2) examining the extent to which adequate management information systems existed to support and oversee HCFA’s revised initiatives to strengthen the enforcement process. The GAO found problems with Michigan’s and other states’ enforcement process. For instance, the GAO found that there were a few cases in Michigan where deficiencies contributing to resident deaths were not referred to HCFA for immediate sanction. Overall, the GAO recommended that the following actions be taken to strengthen the enforcement process: 95 0 improve the effectiveness of civil monetary penalties by shortening the delay in adjudicating appeals, including monitoring progress made in reducing the backlog of appeals. 0 strengthen the use and effect of termination, 0 improve the referral process so that states can refer facilities to HCFA for sanctions when they are cited a deficiency that contributed to a resident’s death, 0 develop a better management information system that can be used by both the states and HCFA to integrate the results of complaint investigations, track the status and history of deficiencies, and monitor enforcement actions. Michigan provided a lengthy response to the GAO’s findings. For instance one response regarded a high citation of deficiencies for pressure sores. Michigan regulators responded to this issue by stating: Michigan held a state-wide inspector/provider training conference on the prevention, recognition, and treatment of pressure sores in the Spring of 1998. Since that conference, the citation rate for pressure sore deficien- cies has been significantly reduced. It went from the second highest cited deficiency in 1997 to the sixth highest in 1998. However, it is not clear if the facilities improved their practices for preventing or treating pressure sores or if the inspectors felt pressured to cite fewer pressure sore deficiencies. The MDCIS inspectors have cited deficiencies on noncompliant facilities, before and after the passage of the OBRA 87, yet the quality of care provided to residents remains questionable despite the state implementing the OBRA 87 enforcement regulations and the Resident Protection Initiative. For instance, in November 1999, the Clara Barton nursing home boiler exploded, killing 5 people and injuring 32, including 96 residents and employees of the facility (Mickle, 1999). This facility had a history of noncompliance since 1993 as noted below: 0 In February 1993 39 patients were removed after the facility could not meet the licensure requirements. 0 In 1994 and 1995 annual inspections showed that serious violations were cited at Clara Barton. 0 In February 1996, the state threatened to stop Medicaid payments to Clara Barton, but cleared them after a revisit showed improvements. 0 In 1997 the state inspectors classified Clara Barton as much worse than the norm. 0 In October 1998, the state inspectors cited 29 deficiencies, which were more than 3 times the state average and 6 times the national average (Mickle, 1999). However, it should be noted that to date there is no evidence showing that the boiler explosion was the fault of the facility or was it related to the history of poor-quality care. In summary, individuals representing nursing home residents, facilities, inspectors, and HCFA have influenced Michigan’s regulators implementing the OBRA 87 enforcement regulations. That is, representatives for nursing home residents argued that the nursing home industry overwhelmingly influenced the implementation of the new enforcement system. Yet the nursing home industry representatives believed that the goals of the OBRA 87 provisions were unrealistic and that nursing homes could not attain the standards established. Ten inspectors in Michigan noted that their supervisors were pandering to facilities by eliminating citations and assigning insufficient staff to perform inspections. Lastly, HCFA’s inspectors monitored an inspection and indicated that 97 during an inspection in Western Michigan the inspectors exhibited a sense of evading any potential substandard quality of care deficiencies. Interviews with Michigan Actors Methodology In-person structured interviews were conducted with various actors in Michigan, which gathered their perceptions of enforcement in Michigan over the period July 1995 through 1998. The perceptions reported were obtained from structured interviews conducted between November 1998 and May 1999 with 10 respondents in Michigan. Structured interviews were employed in order to facilitate coding the responses for comparison between the respondents’ perceptions and the document review. The structured in—person interviews also allowed for asking sensitive questions about which actors influenced the implementation of the OBRA 87 enforcement regulations (O’Sullivan and Rassel, 1995). More importantly, the structured interviews helped to identify who influenced the implementation of the OBRA 87 enforcement regulations, to determine the role each actor played in influencing the implementation of the OBRA 87 enforcement regulations, and to determine if each actor facilitated or impeded the implementation of the OBRA 87 enforcement regulations. The unit of analysis in this case study is the individual actors in Michigan who have attempted to influence implementation of the enforcement regulations. Respondents included representatives from the Michigan House of Representatives’ Democratic Health Policy Staff, managers from the MDCIS, the CBC (the Long-Term Care Ombudsman), the AARP, the Michigan Protection and Advocacy Services, a nursing home policy expert, and a consumer. 98 Perceived influence was measured by asking respondents to answer a set of questions about eleven actors in order to assess their individual impact on the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix E, which lists all of the interview questions). The eleven actors that the interview questions pertained to were HCFA, the Governor and his appointees, state senators, state representatives, the courts, the media, the MDCIS, the CBC (Long-Term Care Ombudsman in Michigan), the AARP, the HCAM, and the MAHSA. These actors were selected because they were directly or indirectly impacted by the OBRA 87 enforcement regulations. The perceptual approach was used to help determine how influential various participants are perceived to be by major actors in the nursing home policy arena. This method relies on interviews with knowledgeable observers to determine how influential various participants in the policy-making process are perceived to be by other participants. This approach relies on unambiguous questions and a simple coding scheme and has been used widely by social scientists. It has also been used by political scientists testing conflicting perspectives of business groups influence versus consumer groups’ influence on regulatory agencies (Gormley, 1982; Friedman, 1978), and it has been used to evaluate citizen participation programs (Cole, 1974; Sewell and Phillips, 1979). The major advantage of the perceptual approach is that it provides a comprehen- sive overview of influence. The major disadvantage of this approach is that is relies on personal judgments, which can be incorrect. These problems were partially addressed through the usage of closed-ended structured questions and interviews with diverse respondents. However, two open-ended questions were included in order to: (1) determine the role each actor played in influencing the implementation of the enforcement 99 regulations, and (2) determine how the implementation of the enforcement regulations can be improved in Michigan. The responses to the closed-ended and open-ended questions are listed in Appendix F, which shows each respondent’s answer to the structured-interview questions. Results The purpose of this exploratory case study was threefold: (1) to determine the role each actor has played in improving or hindering the implementation of the OBRA 87 enforcement regulations, (2) to examine the perceptions of the extent of each actor’s influence on regulators implementing the OBRA 87 enforcement regulations, and (3) to determine how the implementation of the OBRA 87 enforcement regulations can be improved in Michigan.20 The threefold purpose of this exploratory case study and the results will be described in the remainder of this chapter. The results will be based on the interviewees’ responses and the document review.“ 20Various actors have tried to facilitate or impede regulators citing deficiencies on facilities that do not comply with the OBRA 87 quality of care, quality of life, residents’ rights, and resident assessment and care planning standards outlined in the OBRA 87 regulations (see Table l). 2‘The document review consisted of compiling information from various sources which included the Michigan Department of Consumer and Industry Services, the Detroit Free Press newspaper, the Muskegon Chronicle newspaper, the HCAM’s newsletter, Nursing Home Pulse (nursing home trade association), the CBC’s literature (Michigan’s Long-Term Care Ombudsman), various OBRA 87 workgroup meetings, and other sources that are noted in the narrative. 100 Purposes 1 and 2: Determine the Role Each Actor Played in Improving or Hindering the Implementation of the OBRA 87 Enforcement Regulations and Examine the Perceptions of the Extent of Each Actor’s Influence on Regulators Implementing the OBRA 87 Enforcement Regulations All of the aforementioned actors were perceived to influence inspectors in Michigan based on the interviewees’ responses and the document review (see Appendix F). The interviewees’ perceptions regarding their roles in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, some of the activities that these actors employed that directly or indirectly influenced inspectors included monitoring legislation; providing formal feedback to legislators, regulators, and other concerned actors about enforcement; meeting with concerned actors to adjust enforcement of the OBRA 87; litigating; reporting problems with nursing homes; and creating an awards program for nursing homes that improved services they provided to residents (see Appendix F, question 3a). The respondents also perceived their joint estimated influence on Michigan regulators implementing the OBRA 87 enforcement regulations to be a mean score of 5.8 (see Table 9). Table 9 shows the respondents’ perception of the external actors influence relative to the other actors influence on the regulators implementing the OBRA 87 enforcement regulations. The standard deviation of the respondents’ estimate of their influence on the implementation of the OBRA 87 enforcement regulations was 2.6, indicating that the responses varied (see Table 9). The responses ranged from a rating of 2 to 10 (see Table 9).22 The responses are consistent with the respondent’s 22A rating of “l” signifies a very low impact, while a rating of “10” signifies a very high impact. 101 perceptions of the role they played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 3a). Moreover, the results of the respondents’ perceptions show that the respondents activities improved implementation of the OBRA 87 enforcement regulations (see Table 10). Table 10 shows the respondents’ perception of the external actors’ influence on improving or hindering regulators implementing the OBRA 87 enforcement regulations in Michigan. The results in Table 10 indicate that all 9 respondents perceived their influence to improve implementation of the enforcement regulations (see Table 10). The results of the document review and the interviewees’ perceptions about the influence of HCFA, the governor, the state senators, the state house of representatives, the MDCIS, the courts, the media, the CBC, the AARP, the HCAM, and the MAHSA over Michigan’s regulators implementing the OBRA 87 enforcement regulations will be described and discussed next. Also, the results regarding the respondents’ perceptions of the role each actor played in improving or hindering the implementation of the enforcement regulations and their perceptions about the extent of each actors’ influence on inspectors’ implementing the enforcement regulations will be reported by actor. Given the results of the interviewees’ perceptions and the document review, it is argued that all of the actors exerted some influence over Michigan regulators implement- ing the OBRA 87 enforcement regulations. It is also concluded that all of the actors viewed their activities as improving implementation of the enforcement regulations. HCFA—The interviewees’ perceptions regarding HCFA’s role in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, some respondents indicated that HCFA’s role included setting enforcement policies; overseeing state enforcement, and issuing regulations. However, other 102 respondents stated that HCFA did practically nothing and played a negative role in Michigan because they allowed the nursing home industry association (HCAM) to negotiate the state’s OBRA 87 enforcement plan without listening to consumers. The respondents also perceived the influence of HCFA on Michigan regulators implementing the OBRA 87 enforcement regulations to be above average as compared to the other actors in Michigan (see Table 9). The HCFA’s estimated influence mean score was 6.8 as compared to the 5.8 mean score for the other actors in Michigan (see Table 9). Moreover, the results of the respondents’ perceptions show that HCFA’s activities improved and hindered Michigan’s regulators implementing the OBRA 87 enforcement regulations (see Table 10). The results in Table 10 indicate that 4 respondents perceived HCFA to improve implementation of the enforcement regulations, 2 respondents perceived HCFA to hinder implementation of the enforcement regulations, and 3 respondents perceived HCFA to improve and hinder implementation of the enforcement regulations. The standard deviation of the respondents’ estimate of HCFA’s influence on the implementation of the OBRA 87 enforcement regulations was 2.0, indicating that the responses varied (see Table 9). The responses ranged from a rating of 3.5 to 9 (see Table 9). The responses are consistent with the respondents’ perceptions of the role HCFA played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 4a). The document review results are also mixed regarding HCFA’s influence on Michigan’s regulators implementing the OBRA 87 enforcement regulations. For instance, the document review shows that HCFA pressured Michigan regulators into reclassifying and decreasing its citation of deficiencies, and HCFA urged Michigan to streamline its inspection process in order to reduce the costs associated with conducting 103 inspections. However, HCFA criticized Michigan’s inspectors, who were observed showing fear of citing deficiencies that could result in facilities being classified as substandard. Given the results of the interviewees’ perceptions and the document review, it is argued that HCFA exerts a substantial amount of influence over Michigan regulators implementing the OBRA 87 enforcement regulations. The HCFA’s influence has both improved and hindered implementation of the OBRA 87 enforcement regulations in Michigan over the period July 1995 through 1998. That is, HCFA pressured Michigan’s regulators into decreasing the number of citations for deficiencies and later criticized them for fearing to cite deficiencies on noncompliant facilities. Thus, it is concluded that HCFA both facilitates and impedes implementation of the OBRA 87 enforcement regulations in Michigan. The MDCIS—The interviewees’ perceptions about the MDCIS’s role in influencing the implementation of the OBRA 87 enforcement regulations are mixed. For example, some respondents stated that the MDCIS tried to effectively implement the OBRA 87 enforcement regulations by being responsive to HCFA, the CBC, and other actors by trying to actualize the intent of the OBRA 87, and using the appropriate remedy at the right time. Yet other respondents stated that the MDCIS played a negative role. More specifically, these respondents argued that the MDCIS played a limited and negative role. That is, the MDCIS attempted to avoid implementing the parts of the OBRA 87 that were distasteful to the nursing home industry, failed to promulgate regulations consistent with the OBRA 87, did not listen to the problems occurring in facilities, did not invite consumers to its meetings with other actors who were impacted by the enforcement 104 regulations, and used subtle budget appropriations threats to pressure the ombudsperson into going along with industry’s desires. Furthermore, some interviewees viewed the MDCIS as improving the implemen- tation of the OBRA 87 enforcement regulations in Michigan while others viewed them as hindering the implementation of the regulations (see Table 10). The results in Table 10 indicate that 2 respondents perceived the MDCIS to improve the implementation of the enforcement regulations, 4 respondents perceived the MDCIS to hinder implemen- tation of the enforcement regulations, and 2 respondents perceived the MDCIS to hinder and improve implementation of the enforcement regulations. Also, the MDCIS received an above average rating for exerting influence over the implementation of the OBRA 87 enforcement regulations as compared to the other external actors in Michigan (see Table 9): the MDCIS’ estimated influence mean score was 6.1 as compared to the 5.8 mean score for the other actors in Michigan (see Table 9). The standard deviation of the respondents’ estimate of the MDCIS’ influence on regulators implementing the OBRA 87 enforcement regulations was 3.1. The responses ranged from a rating of 1 to 9 (see Table 9). These results are consistent with the respondents’ perceptions of the role that the MDCIS played in the implementation of the OBRA 87 enforcement regulations (see Appendix F, question 5a). The document review showed that the MDCIS attempted to implement the OBRA 87 enforcement regulations in a manner that was acceptable to HCFA, the nursing home industry (HCAM), and consumer advocates. For example, the document review revealed 'that the MDCIS instituted the “Resident Protection Initiative,” which consisted of 105 initiatives that were designed to benefit residents and the nursing home industry.23 That is, the “Early Intervention Program” was developed in order to help inspectors identify poorly performing facilities early and to facilitate intervention by the MPHI, which would ultimately lead to improving services for residents if the facility corrected the deficiencies cited. Yet the IDDR was designed to allow nursing homes an opportunity to appeal deficiency citations through a peer review process that can decrease the deficiencies cited. Therefore, the MDCIS has both improved and hindered implemen- tation of the OBRA 87 enforcement regulations in Michigan. Thus, it is argued that the MDCIS exerted a significant amount of influence over Michigan’s regulators implement- ing the OBRA 87 enforcement regulations. The Governor and His Appointees—The interviewees’ perceptions regarding the role of the governor and his appointees in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, some respondents stated that the Governor was not doing all he could do given his authority. Moreover, it was noted that regulations have not been promulgated since December 1997, which would have given the state legal authority to implement the OBRA 87 enforcement regulations. Furthermore, another respondent noted that the governor and his appointees have played a destructive role in ensuring that the OBRA 87 enforcement regulations were not implemented. However, other respondents perceived the governor and his staff as being supportive of creating initiatives that were designed to work with the industry and 23The details of each of the Resident Protection Initiatives are discussed in this chapter in the section entitled, “Michigan Employs Changes to Its Implementation of the OBRA 87 Final Federal Regulations.” 106 residents in order to improve conditions in nursing homes. The governor’s appointees and staff invited major long-term care actors to become members of their taskforces and workgroups. The groups who became participants on these taskforces and workgroups included the CBC, the HCAM, the MAHSA, and other major long-term care actors. The goal of these taskforces and workgroups was to develop ideas for improving implementation of the OBRA 87 enforcement regulations and to develop initiatives to reward nursing homes who were complying with the OBRA 87 nursing home regulations. Some of the initiatives created and implemented by the governors’ appointees, the MDCIS staff, and the OBRA 87 taskforces and workgroups were the governor’s Quality Care Award and the Resident Protection Initiative. The Resident Protection Initiative was a series of initiatives and implementation plans to address inspection and enforce- ment issues and the Governor’s Quality Care Award was a program that rewarded funds to nursing homes who improved the services they provided residents.“ The respondents also rated the governor and his appointees as exerting the most influence over the implementation of the OBRA 87 enforcement regulations as compared to other actors in Michigan (see Table 9). The mean score for the estimated influence of the governor and his appointees was 7.2 as compared to the 5.8 mean score for other actors in Michigan (see Table 9). Moreover, the majority of the respondents stated that the activities of the governor and his appointees hindered the implementation of the OBRA 87 enforcement regulations (see Table 10). The results in Table 10 indicate that l respondent perceived the governor and his appointees to improve implementation of the 2“The details of the Resident Protection Initiatives are provided in this chapter in the Section entitled, “Michigan Employs Changes to Its Implementation of the OBRA 87 Final Federal Enforcement Regulations.” 107 enforcement regulations, 7 respondents perceived the governor and his appointees to hinder implementation of the enforcement regulations, and l respondent stated that the governor and his appointees neither improved nor hindered the implementation of the enforcement regulations. The standard deviation of the respondents’ estimate of the influence of the governor and his appointees on the implementation of the OBRA 87 enforcement regulations was 3.1, indicating that the responses varied. The responses ranged from a rating of 2 to 10 (see Appendix F, question 10c and Table 9). These results are consistent with the respondents’ perceptions of the role that the governor and his appointees played in the implementation of the OBRA 87 enforcement regulations (see Appendix F, question 10a). The document review is consistent with the interview results and shows that the governor and his appointees influenced the implementation of the OBRA 87 enforcement regulations and engaged in activities that benefitted industry and consumers. Thus it is concluded that the governor and his appointees were very influential and their activities hindered and improved the implementation of the OBRA 87 enforcement regulations in Michigan. State Senators—The interviewees’ perceptions regarding the role of the state senators in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For instance, a few respondents noted that state senators have played a role in the enforcement of the OBRA 87 in Michigan. These respondents stated that senators have directly intervened and requested that the MDCIS and providers fix problems in nursing homes, a senator worked with an advocacy group in Southfield, Michigan, and a senator introduced a nursing home staffing bill on the floor. However, most respondents stated that senators have not been involved in the implementation of the 108 OBRA 87 enforcement regulations, because the Republican governor and the Republican- controlled senate wanted to deregulate the nursing home industry. Moreover, one respondent stated that senators have been lobbied by the HCAM and were pressured to support the industry. Furthermore, the respondents perceived the influence of state senators on Michigan regulators implementing the OBRA 87 enforcement regulations to be below average as compared to the other actors (see Table 9). Table 9 shows that the state senators’ estimated influence mean score was 4.9 as compared to the 5.8 mean score for other actors in Michigan (see Table 9). Overall, the respondents viewed state senators as both hindering and improving the implementation of the OBRA 87 enforcement regulations (see Table 10). The results in Table 10 indicate that 2 respondents perceived the state senators to improve the implementation of the enforcement regulations, 3 respondents perceived the state senators to hinder implementation of the enforcement regulations, 3 respondents stated either that they did not know or that the state senators neither hindered nor improved the implementation (see Appendix F, question 11b). The standard deviation of the respondents’ estimate of the influence of state senators on the implementation of the OBRA 87 enforcement regulations was 2.8, indicating that the responses are mixed. The responses ranged from a rating of 1 to 9.5 (see Appendix F, question 11c). These results are not consistent with the respondents’ perceptions of the role that the state senators played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 11a). The document review showed that state senators attempted to influence the irnplementation of the OBRA 87 enforcement regulations in Michigan by holding hearings. More specifically, the Michigan Senate Special Committee on Aging held 109 hearings regarding weaknesses in the enforcement system. However, the results of these hearings did not result in the Senate changing the enforcement system. Thus, it is concluded that state senators exerted limited influence over regulators implementing the OBRA 87 enforcement regulations in Michigan. State Representatives—The interviewees’ perceptions regarding the state representatives’ role in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, half of the respondents noted that the state representatives have taken very little if any action to influence the implementation of the enforcement regulations. They argued that party politics limited the house’s ability to take actions to impact the implementation of the OBRA 87 enforcement regulations. Also, a respondent stated that some representatives have sided with the nursing home industry. Yet the other half of the respondents argued that the state representatives introduced quite a few good bills to create laws consistent with the OBRA 87 enforcement regulations and to improve conditions in nursing homes. These respondents also stated that representatives have called the MDCIS when a facility was in trouble, they appropriated funds for hiring additional nursing home inspection staff, and they required the MDCIS to have nursing home inspections on evenings and weekends. The respondents also gave the state representatives an above-average score for exerting influence over the regulators implementing the OBRA 87 enforcement regulations (see Table 9). Table 9 results show that the state representatives’ estimated influence mean score was 5.7 as compared to the 5.8 mean score for all of the other actors in Michigan (see Table 9). Furthermore, the respondents perceived that the influence of the state representatives has helped to improve the implementation of the 110 OBRA 87 enforcement regulations in Michigan (see Table 10). The results in Table 10 indicate that 5 respondents perceived the state representatives to improve the implemen- tation of the enforcement regulations, 2 respondents perceived the state representatives to hinder the implementation of the enforcement regulations, and l respondent stated either that they did not know or that the state representatives neither hindered nor improved the implementation. The standard deviation of the respondents’ estimate of the influence of state representatives on the implementation of the OBRA 87 enforcement regulations was 2.9, indicating that the responses varied. The responses ranged from a rating of l to 9.5 (see Appendix F, question 11c1). These results are consistent with the respondents’ perception of the role the state representatives played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question llal). The document review showed that in 1998 the Michigan House Appropriations subcommittee on the MDCIS approved a budget provision that added 8 inspectors to the staff of 60 who inspect most of Michigan’s 458 nursing homes approximately every 15 months.25 The document review also showed that Representative Thomas Kelly (Democrat from Wayne County) proposed to create a nonpartisan taskforce to examine conditions in Michigan’s nursing homes after the elections in November 1998. Based on the document review and the interview responses it is concluded that the state representatives exerted some influence over the implementation of the OBRA 87 25Federal law requires that Medicare—certified and Medicaid-certified nursing homes be inspected at least once every 15 months, with a statewide average of all 450 homes 01' nor more than 12 months between inspections. The few nursing homes that do not Participate in Medicare or Medicaid are inspected only once every 2 years to determine cOtnpliance with Michigan standards. 111 enforcement regulations and that their activities helped to improve the implementation of the enforcement regulations. The Courts—The interviewees’ perceptions regarding the role of the courts in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, some respondents stated that the courts have played a positive role in influencing implementation of the OBRA 87 enforcement regulations when there has been demonstrated negligence by nursing homes. Another respondent stated that the courts found in favor of residents in the Ottis v. Shalala case (Ottis v. Shalala, 1992). In this lawsuit residents sued the Secretary of Health and Human Services and the State of Michigan for not issuing the OBRA 87 enforcement regulations. The residents won and the court directed the State of Michigan to promulgate enforcement regulations that were compliant with the OBRA 87 legislation. However, other respondents stated that the courts have prevented the implemen- tation of the OBRA 87 enforcement regulations by invalidating the rule-making process that was used to create the state standards that would replicate the OBRA 87 enforcement regulations, thereby preventing implementation of the OBRA 87 enforcement regulations in Michigan. That is, the courts prevented the state from implementing the enforcement regulations that were established as a result of the Ottis v. Shalala case. The case that later prevented the state from implementing the enforcement regulations after the Ottis v- Shalala was the case Heritage Manor, Inc. v. Department of Social Services (Heritage Manor, Inc. v. Department of Social Services, 1996). This case was initiated after Heritage Manor nursing home was cited and fined by the inspectors for providing poor care to residents. The Heritage Manor nursing home appealed the regulator’s decision 112 to impose civil monetary fines to the State Court of Appeals. They argued that Michigan did not promulgate statutes to implement the OBRA 87 enforcement regulations, but rather enacted the enforcement regulations through their state bulletin. The State Court of Appeals found in favor of Heritage Manor. The outcome of the Heritage Manor case left nursing home inspectors and residents feeling powerless. Moreover, the respondents gave the courts an above-average score for exerting influence on the regulators implementing the OBRA 87 enforcement regulations as compared to the other actors in Michigan (see Table 9). The results in Table 9 show that the courts’ estimated influence mean score was 5.7 as compared to the 5.8 mean score for other actors in Michigan (see Table 9). Also, most of the respondents perceived that the courts’ influence hindered the implementation of the OBRA 87 enforcement regulations in Michigan (see Table 10). The results in Table 10 indicate that 2 respondents perceived the courts as improving the implementation of the enforcement regulations, 5 respondents perceived the courts as hindering the implementation of the enforcement regulations, 2 respondents perceived the courts as hindering and improving the implementation of the enforcement regulations, and 1 respondent stated either that he/ she did not know or that the courts neither hindered nor improved the implementation (see Table 10). The standard deviation of the respondents’ estimate of the influence of the courts on the implementation of the OBRA 87 enforcement regulations was 3.0, indicating that the responses varied. The responses ranged from a rating of 2 to 10 (see Appendix F, question 12c). These results are consistent with the respondents’ perceptions of the role that the courts played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 12a). 113 The document review revealed similar information as the interview responses. The regulators’ inability to impose the OBRA 87 enforcement regulations as a result of the court’s decision could have demoralized the inspectors and decreased their motivation to cite deficiencies. Thus, it is concluded that the influence of the courts over the implementation of the OBRA 87 enforcement regulations is significant and can facilitate or hinder the inspectors’ ability to impose sanctions on noncompliant facilities that provide substandard care to residents. The Media—The interviewees’ perceptions regarding the role of the media in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For instance, a majority of respondents noted that the media has educated and informed the public about nursing home issues in Michigan. However, one respondent stated that media attention has played no role in shaping state policy or having an influence on the implementation of the OBRA 87 enforcement regulations in Michigan. Another respondent stated that the Detroit Free Press has an advocate for residents and this advocate believes nursing homes in Michigan are bad. Moreover, the respondents gave the media an average score for exerting influence over the implementation of the OBRA 87 enforcement regulations as compared to the other actors in Michigan (see Table 9). The results in Table 9 show that the media’s estimated influence mean score was 5.6 as compared to the 5.8 mean score for all of the other actors in Michigan. Yet most of the respondents perceived that the media has helped to improve the implementation of the OBRA 87 enforcement regulations in Michigan (see Table 10). The results in Table 10 indicate that 6 respondents perceived the media to iinprove the implementation of the enforcement regulations, 2 respondents perceived the media to hinder implementation of the enforcement regulations, and 1 114 respondent stated either that they did not know or that the media neither hindered nor improved the implementation. The standard deviation of the respondents’ estimate of the influence of the media on the implementation of the OBRA 87 enforcement regulations was 3.0 indicating that the responses were mixed. The responses ranged from a rating of 1 to 9.5 (see Appendix F, question 13c). These results are not consistent with the respondents’ perceptions of the role the media played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 13a). The document review revealed the same information as the interview responses. The stories reported by the media helped to keep Michigan’s citizens aware of the problems with nursing homes and the problems that occurred with regulators implement- ing the OBRA 87 enforcement regulations. As the OBRA 87 enforcement regulation problems and nursing home problems were kept in the public eye, it is argued that this caused the concerned public to pressure regulators to increase their citation of deficiencies on noncompliant facilities. Thus it is concluded that the media has influenced and improved the implementation of the OBRA 87 enforcement regulations in Michigan. The CBC—The interviewees’ perceptions about the role of the CBC in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For instance, many respondents stated that the CBC helped to identify enforcement policies that provided quick results, resolved resident complaints, and made the public aware of their long-term care options. Yet some respondents argued that the CBC’s activities were not effective in influencing regulators implementing the OBRA 87 enforcement regulations because the CBC was a “toothless tiger” that possessed little or very limited influence. 115 The CBC’s estimated influence mean score was 5.6 as compared to the 5.8 mean score for all of the other actors in Michigan (see Table 9). Additionally, all of the respondents who were aware of the CBC stated that the CBC’s activities improved the implementation of the OBRA 87 enforcement regulations in Michigan (see Table 10). The results in Table 10 show that 5 respondents perceived the CBC’s influence to improve implementation of the enforcement regulations, and 1 stated either that they did not know or that the CBC neither hindered nor improved the implementation. The standard deviation of the respondents’ estimate of influence of the CBC on the implementation of the enforcement regulations was 3.2, indicating that the responses varied. The responses ranged from a rating of l to 9 (see Table 9). These results are consistent with the respondents’ perceptions of the role that the CBC played in the implementation of the OBRA 87 enforcement regulations (see Appendix F, question 6a). These results are consistent with the respondents’ perceptions of the role the CBC played in the implementation of the OBRA 87 enforcement regulations. The document review also shows that the CBC was very active in trying to influence Michigan regulators implementing the OBRA 87 enforcement regulations. However, the CBC was not very successful in getting the regulators to implement its recommendations. Thus, it is concluded that the CBC attempted to improve the implementation of the OBRA 87 enforcement regulations, but the CBC’s influence was limited by the activities of the more influential actors in Michigan. The AARP—The interviewees’ perceptions regarding the AARP’s role in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan converge. For instance, most of the respondents noted that the AARP has not played a 116 role in enforcement. Yet a few respondents stated that the AARP has played a larger or limited role in enforcement. Furthermore, the AARP’s estimated influence mean score was 1.9 as compared to the mean score of 5.8 for other actors in Michigan (see Table 9). The interviewees perceived that the AARP’s influence both improved and hindered the implementation of the OBRA 87 enforcement regulations in Michigan (see Table 10). That is, 1 respondent perceived the AARP as improving the implementation of the enforcement regulations, 1 respondent perceived the CBC as hindering the implementation of the enforcement regulations, and 6 respondents stated either that they did not know or that the AARP neither hindered nor improved the implementation (See Appendix F, question 7b). The standard deviation of the respondents’ estimate of the influence of the AARP on the implementation of the OBRA 87 enforcement regulations was 1.6, indicating that the responses converged. The responses ranged from a rating of l to 5, where most of the ratings were 1 (see Table 9 and Appendix F, question 7c). These results are consistent with the respondents’ perceptions of the role that the AARP played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 7a). The document review also showed that the AARP was not influential over Michigan’s regulators implementing the OBRA 87 enforcement. More specifically, the document review only showed that the AARP joined the Michigan Campaign for Quality Care in order to help create more effective sanctions for poor care. The document review also revealed that the AARP was very active and influential over regulators implementing the OBRA 87 enforcement regulations in Texas and California. Thus, it is asserted that the AARP has played a very small role in influencing the implementation of the OBRA 87 enforcement regulations in Michigan. 117 The HCAM—The interviewees’ perceptions regarding the role of the HCAM in influencing inspectors implementing the OBRA 87 enforcement regulations in Michigan are mixed. For example, a majority of the respondents agreed that the HCAM has played a significant role in influencing Michigan regulators implementing the OBRA 87 enforcement regulations. These respondents argued that the HCAM played a significant role in preventing enforcement action from occurring by litigating, making recommen- dations to the regulators, and writing Michigan’s enforcement policies, accepting the Resident Protection Initiative developed by the HCAM and the participants of the MDCIS’s summit meetings, helping their members cooperate with regulators, and encouraging their members to attend joint training with nursing home inspectors. The HCAM received an above-average rating for influencing the implementation of the enforcement regulations as compared to the other actors in Michigan (see Table 9). That is, the HCAM’s estimated influence mean score was 6.6 as compared to the 5.8 mean score for other actors in Michigan (see Table 9). However, most of the respondents viewed the HCAM’s activities as hindering the implementation of the OBRA 87 enforcement regulations (see Table 10). The results in Table 10 indicate that 1 respondent perceived the HCAM to improve the implementation of the enforcement regulations, 6 respondents perceived the HCAM to hinder the implementation of the enforcement regulations, and 2 respondents stated either that they did not know or that the HCAM neither hindered nor improved the implementation. Thus, it is argued that the HCAM was very influential in hindering the implementation of the OBRA 87 enforcement regulations in Michigan. The standard deviation of the respondents’ estimate of the influence of the HCAM on the implementation of the OBRA 87 enforcement regulations was 2.5, indicating that the responses varied (see Table 9). The 118 responses ranged from a rating of 2 to 8 (see Table 9 and Appendix F, question 8c). These results are not consistent with the respondents’ perceptions of the role that the HCAM played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 8a). The document review showed that the HCAM was very successful in influencing Michigan regulators implementing the OBRA 87 enforcement regulations in Michigan. For example, the HCAM demanded and won the following measures and actions: 0 reduced numbers of citations, ' state consultation rather than sanctions, 0 extensive restrictions on the use of civil monetary fines, 0 repeated chances to correct deficiencies before action is ever taken, 0 multiple appeal opportunities, 0 reduced monitoring, and 0 withholding information from the public about poor nursing home perfor- mance. Hence, it is argued that the HCAM was very influential in getting regulators to implement the OBRA 87 enforcement regulations in a manner that was acceptable to them. The MAHSA—The interviewees’ perceptions regarding the role of the MAHSA in influencing inspectors implementing the OBRA 87 enforcement regulations converge. For example, most respondents stated that the MAHSA played a role in influencing the implementation of the OBRA 87 enforcement regulations in Michigan. However, some respondents argued that the MAHSA followed the HCAM’s lead and sided with the HCAM to prevent enforcement actions from occurring, whereas another respondent 119 stated that the MAHSA was supportive of the state’s enforcement regulations. Furthermore, the MAHSA received a below-average rating for its success in influencing the implementation of the enforcement regulations (see Table 9): the MAHSA’s estimated influence mean score was 5.5 as compared to the 5.8 mean score for other actors in Michigan (see Table 9). However, the majority of the interviewees perceived that the activities of the MAHSA hindered the implementation of the OBRA 87 enforcement regulations (see Table 10). Table 10 results indicate that 1 respondent perceived the MAHSA to improve the implementation of the enforcement regulations, 5 respondents perceived the MAHSA to hinder implementation of the enforcement regulations, 2 respondent stated either that they did not know or that the MAHSA neither hindered nor improved the implementation. The standard deviation of the respondents’ estimate of the influence of HCFA on the implementation of the OBRA 87 enforcement regulations was 1.5, indicating that the responses were similar. The responses ranged from 3.5 to 8 (see Appendix F, question 9c and Table 9). These results are consistent with the respondents’ perceptions of the role that the MAHSA played in the implementation of the OBRA 87 enforcement regulations in Michigan (see Appendix F, question 9a). The document review showed that the MAHSA was a member of the OBRA 87 enforcement workgroup, which helped develop the interim enforcement system in Michigan. However, the MAHSA was not as active as the CBC nor the HCAM in their efforts to influence Michigan regulators implementing the OBRA 87 enforcement regulations. Hence, it is concluded that the MAHSA was not very influential over Michigan’s regulators implementing the OBRA 87 enforcement regulations. In summary, the nursing home inspectors implementing the OBRA 87 enforce- ment regulations are influenced by various external actors in Michigan. This finding is 120 consistent with the work of Katz and Kahn (1978) and Brudney and Hebert (1987). That is, the nursing home regulators do interact with actors in their external environment. More specifically, the regulators have worked with and been influenced by all of the actors examined, in varying degrees, as they implemented the OBRA 87 enforcement regulations. Purpose 3: Determine How the Implementation of the OBRA 87 Enforcement Regulations Can Be Improved in Michigan The perceptions of the respondents regarding the implementation of the OBRA 87 enforcement regulations fell into 4 categories (see Appendix I). Twenty-seven responses were provided from 9 respondents (see Appendix I, which shows the percentage of responses for each category of recommendations to improve enforcement in Michigan). Forty—one percent of the responses were related to adjusting implemen- tation of the OBRA 87 enforcement regulations; 30 percent were related to adjusting resources to help inspectors perform their job or improving inspections; 19 percent of the responses were related to changing the attitudes of the leadership of HCFA, the MDCIS, or the state Medicaid agency; and 11 percent of the responses were related to improving nursing home operations (see Appendix I). The suggestions include increasing the number of inspectors, changing the MDCIS’s attitude toward protecting residents and not the nursing home industry, and giving clear legal authority to impose a wide variety of remedies. These results indicate that approximately 71 percent of the respondents believed that adjustments in implementing the OBRA 87 enforcement regulations and resources 121 to help inspectors perform their job or improve inspections could improve enforcement in Michigan. Limitations The major limitation of this study was getting actors to agree to be interviewed. Approximately fifteen people declined to be interviewed. Initially, there were plans to interview representatives from all of the groups examined in this chapter. However, some groups declined to be interviewed, which limited the responses received. Conclusion All of the actors examined in this chapter have attempted to influence inspectors implementing the OBRA 87 enforcement regulations in Michigan. Some actors have acted in ways that improved implementation of the enforcement regulations while others have attempted to hinder or weaken the enforcement regulations. For instance, the governor and his appointees were perceived to be the most influential participants who have hindered the implementation of the enforcement regulations. For example, some respondents stated that the Governor was not doing all that he could do given his authority. The HCFA issued changes to the state’s enforcement system through its state operations manual that brought about adjustments in Michigan’s enforcement system. For example, some respondents indicated that HCFA’s role included setting enforcement policies, overseeing state enforcement, and issuing regulations. The CBC, the HCAM, and the MAHSA were very active in various enforcement committees and were engaged in other activities that helped to create Michigan’s enforcement system. For instance, a facility successfully challenged a civil fine that had been imposed by the state in the 122 case Heritage Manor, Inc. v. Michigan Department of Social Services (Heritage Manor, Inc. v. Department of Social Services, 1996). The facility argued that the fines were invalid because the state had promulgated the enforcement system authorizing civil fines through a bulletin, rather than through state legislation or rulemaking. This case also showed the courts’ involvement in Michigan’s implementation of the OBRA 87 enforcement regulations. This case prevented Michigan from imposing fines until it promulgated the OBRA 87 enforcement regulations through state legislation or rulemaking. The Governor’s Office created a CQIP to motivate nursing homes to make improvements in their services through a combination of Medicaid reimbursement incentives and public recognition. Michigan’s Senate Special Committee on Aging conducted hearings regarding weaknesses in the enforcement system (Bryant, 1999). Also, Representative Thomas Kelly (Democrat representing Wayne County) discussed plans to create a taskforce to examine nursing home conditions in Michigan (Capitol Capsule, 1998). Lastly, the Detroit Free Press has consistently printed news articles describing and criticizing Michigan’s enforcement system. For example, in October 1996, the Detroit Free Press ran a five day special report entitled, “Who Cares? Inside Michigan’s Nursing Homes” (Young 1996). Hence it is concluded that nursing home inspectors are influenced by various actors in their external environment. More irnportantly, these actors can help improve or hinder implementation of the OBRA 87 enforcement regulations, by becoming politically involved, attending regulators policy development meetings, litigating, and engaging in various other activities. Thus, it is concluded that the external environments of state regulators can influence their ability to implement federal legislation. 123 CHAPTER 5 DO EXTERNAL ENVIRONMENTAL FACTORS INFLUENCE INSPECTORS IMPLEMENTING THE OBRA 87 ENFORCEMENT REGULATIONS? Introduction In this chapter, an analysis will be conducted to determine whether external environmental factors systemically influence states implementing the OBRA 87 enforcement laws. The results of the history of states implementing nursing home laws and regulations in chapter 2 indicated that external environmental factors influence regulatory agencies, the literature review in chapter 3 showed that external environmental factors can influence regulatory agencies, and the findings of the case study in chapter 4 identified various external environmental factors that were perceived to influence inspectors in the state of Michigan implementing the OBRA 87 enforcement laws. Many of the external environmental factors discussed in chapters 2, 3, and 4 will be tested to determine if they systematically influenced inspectors implementing the OBRA 87 en- forcement law across states and time.‘ In the sections that follow, the hypotheses to be tested will be discussed and the variables included in the regression models will be de- fined and described; next the methodology employed and the regression diagnostics will \ ‘The state of Nebraska was not included in the regression models estimated because it has a Umcameral legislature. 124 be discussed; then the regression results will be analyzed; and finally the conclusion will synthesize the results. Hypotheses The external actors that have attempted to influence state nursing home inspection agencies include the nursing home industry association, the AARP, HCFA (federal oversight agency), the governor, state legislatures, the Long-Term Care Ombudsman program, resident groups, and family groups. The influence of governors, state senators, state representatives, the nursing home industry association, the AARP, resident groups, and family groups will be assessed in this chapter. The Long-Term Care Ombudsman, a congressional oversight program, has also been very active in influencing state nursing inspection agencies. However, this program will not be included in this dissertation due to the lack of sufficient data being compiled nationally for this actor. A detailed discussion of the theories that I am testing can be found in chapter 3. The hypotheses to be tested are listed below: Interest Groups Hypothesis 1: It is expected that an increase in industry strength will cause a decrease in deficiency citations. Hypothesis 2: It is expected that an increase in resident strength will cause an increase in deficiency citations. Executive and Legislative Political Institutions Hypothesis 3a: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of both houses in the legislature is Democrat, as compared to when the party of the governor 125 is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3b: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of both houses in the legislature is Republican, as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3c: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of the both houses of the legislature is split (differs), as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3d: It is expected that deficiency citations will increase when the party of the governor is Republican and the majority party of both houses of the legislature is Democrat, as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3e: It is expected that deficiency citations will increase when the party of the governor is Republican and the majority party of both houses of the legislature is split (differs), as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Nursing Home Structural Controls Hypothesis 4: It is expected that an increase in the RN nursing hours will cause a decrease in deficiency citations. Hypothesis 5: It is expected that an increase in the LPN nursing hours will cause a decrease in deficiency citations. Hypothesis 6: It is expected that an increase in the NA nursing hours will cause a decrease in deficiency citations. Hypothesis 7: It is expected that an increase in resident groups will cause a decrease in deficiency citations. Hypothesis 8: It is expected that an increase in family groups will cause a decrease in deficiency citations. 126 Time Con Ad other event assessed. events have influence Sl HCFA W35 standards tl citations as. facility requ 01 [he OBR rtgttlations resident ret'i issued the f” 19959 HCF‘ Openllng Ct 1‘s it is “5!qu I Could have in citations in l’ Time Controls Additionally, control variables for time were included in order to determine if other events and factors not accounted for in the model influenced the deficiency citations assessed. In 1990 the OBRA 87 nursing home reform laws were enacted. Various events have occurred after the enactment of the OBRA 87 nursing home laws that could influence state inspection agencies responsible for assessing deficiency citations. The HCFA was given authority to develop the final regulations, which determined the standards that nursing homes had to comply with in order to avoid having deficiency citations assessed. For instance, HCFA issued final regulations for the long-term care facility requirements and the nurse aide training and competency evaluation provisions of the OBRA 87 laws on April 1, 1992 (see Table 1). In 1993, HCFA issued final regulations for the charges to residents’ funds and pre-admission screening/annual resident review provisions of the OBRA 87 laws (see Table 1). On July 1, 1995, HCFA issued the final regulations for the survey and enforcement regulations (see Table 1). In 1995, HCFA urged states to streamline their inspection process in order to reduce operating costs, and some states streamlined their processes in 1995 and 1996. Thus, it is argued that as states implemented the OBRA 87 laws, other events occured that could have influenced the deficiency citations assessed. It is also argued that deficiency citations in 1997 are a function of deficiency citations in 1996, 1995, 1994, 1993, 1992, and 1991. Therefore, a lag of the dependent variable was also included in this analysis. The lag variable will help to assess if there are some factors that have not been accounted for in the models estimated. Given that this chapter only assesses the external environmental factors and does not examine the internal agency factors it is assumed that 127 there are other factors that are not accounted for in this model. Hence, the following hypotheses will be tested: Hypothesis 9: It is expected that there will be a change in the average number of deficiencies cited per facility after the implementation of the OBRA 87 enforcement regulations in 1995. Hypothesis 10: It is expected that there will be a trend within each subperiod. Variables The dependent variable is a proxy for enforcement, which is the average number of deficiencies cited per facility by state for the years 1991 through 1997. A similar approach was used by Scholz and Wei (1986), who assessed the degree to which enforcement activities vary in response to external political actor and organizational task factor differences among states. More specifically, these scholars examined the influence of both external political actors and state regulatory agencies’ organizational task factors on the OSHA’s enforcement activities covering the years 1976 through 1983 across the states. This study used citations for violations and penalties as the dependent variable, which was a proxy for state implementation of enforcement standards in their study. Moreover, Spector and Takada (1991) used deficiency citations as a measure of regulatory effectiveness in a study they conducted. In this study, Spector and Takada (1991) examined various data to assess the impact of process and structural factors on nursing home residents’ health outcomes in 80 nursing homes in Rhode Island. They argued that the receipt of a severe deficiency citation would result in changes of a facility’s structure or process that should lead to observing measurable effects on residents’ health outcomes. The results of their study showed that their measure of regulatory effectiveness did systematically influence nursing home residents’ health 128 outcomes in the state of Rhode Island. Hence, deficiency citations were used as the dependent variable in this chapter. Deficiency citations are a significant input into state enforcement systems that help to determine the sanctions that can be imposed on facilities not complying with the OBRA 87 resident care, resident rights, quality of life, and resident assessment and care planning provisions. The deficiencies used for this dissertation are cited by state inspectors. The state inspectors assess nursing homes’ compliance with quality of care, quality of life, residents’ rights, and resident assessment and care planning regulations established by the provisions of the OBRA 87 nursing home reform laws (see Table 1). The state inspectors work in a team under the direction of the licensing officer. Inspections are conducted by teams of professionals, which can include RNs, social workers, dietitians, pharmacists, and sanitarians who are employed by the state to be nursing home inspectors. The licensing officer is in charge of monitoring all nursing homes in their assigned areas, scheduling inspections, reviewing results and plans of correction, recommending enforcement sanctions to the enforcement unit or HCFA (depending on the level of the deficiency), and keeping track of information about each nursing home (CBC, 1997). Each of these areas has specific regulations, which state inspection teams review to determine whether or not facilities have complied with the OBRA 87 nursing home reform laws (Harrington, 1999). State inspection teams then submit a deficiency report to their respective licensing officer, who then reviews the teams’ findings and determines whether or not to issue a written official statement of deficiency(ies). The licensing officer then makes recommendations to their enforcement unit for the sanctions that HCFA allows them to impose, or the licensing officer makes r6commendations to HCFA for sanctions to be imposed on noncompliant facilities. 129 HCFA allows states to impose the directed-in-service training, directed plan of correction, and temporary manager sanctions on noncompliant facilities. However, HCFA imposes the temporary manager, denial of payments, civil monetary fines, and termination sanctions on noncompliant facilities. Prior to the implementation of the enforcement laws (1991 through 1994), the mean for deficiency citations was 8.1, the standard deviation was 4.1, and the data ranged from 1.6 to 19.3 (see Table 12). After the implementation of the enforcement laws (1995 through 1997), the mean for deficiency citations was 5.2, the standard deviation was 2.6, and the data ranged from 1.5 to 15 (see Table 12). A difference of mean test was conducted and indicated that the mean for deficiency citations before the implementation of the OBRA 87 enforcement laws was different from those after implementation (1995—1997) (see Appendix BB). The drop in the mean for deficiency citations after the implementation of the OBRA 87 enforcement laws may indicate that interest groups, executive and legislative political institutions, nursing home structural controls, and the enactment of various provisions of the OBRA 87 laws have systemati- cally influenced the activities of inspection agencies across the states. Overall, the mean for deficiency citations was 6.8, the standard deviation was 2.6, and the data ranged from 1.5 to 19.3 over the period 1991 through 1997 (see Table 12). The independent variables are measures for the external environmental factors that can influence inspectors implementing the enforcement laws across states and time. The external environmental factor variables include measures for interest groups, executive and legislative political institutions, nursing home structural controls, and time controls. The interest group variables consist of measures for assessing the influence that resident and industry advocates exert on the average number of deficiency 130 citations a advocate 1- chapters 1. det'eltiped created pre Worker cor activity of business. d Strength We ‘Or the V011 nursing 1101 a PelCem ( “will of 111161851 g” 87 enforcel The val‘iabteS It both hougc, specifically citations assessed per facility. The resident advocate is the AARP and the industry advocate is the AHCA (nursing home for-profit trade association). Both groups have chapters located in every state. Proxy measures for interest group strength were developed because there were no direct measures available. Scholz and Wei (1986) also created proxy measures of interest group influence. These scholars used the number of worker complaints per 1,000 industrial workers filed with OSHA as a measure of direct activity of labor to influence enforcement. They were not able to compute a measure for business, due to missing data. In this chapter, similar measures for interest group strength were developed. More specifically, the number of nursing home beds adjusted for the voting age population in each state was used as a measure of direct activity of the nursing home industry’s interest group influence.2 The number of AARP members as a percent of the voting age population in each state was used as a measure of direct activity of the resident interest group influence. Tables 12 summarizes data for the interest group variables before, after, and throughout the implementation of the OBRA 87 enforcement law, respectively. The executive and legislative political institution measures include dummy variables representing the political party of the governor and the party of the majority in both houses of state legislatures for the years 1991 through 1997 (see Table 12). More specifically, the following dummy variables were included in the regression model: 2The number of nursing home facilities was initially used in the numerator as a measure of industry strength. However, this variable was correlated with some of the other independent variables and did not move in the expected direction. Therefore, the number of nursing home beds was used in the numerator to assess industry strength. This measure was not highly correlated with some of the other independent variables and moved in the expected direction. 131 Table before lCSch‘ 0 Republican Governor and unified Republican legislature, 0 Republican Governor and unified Democratic legislature, 0 Republican Governor and a split legislature, 0 Democratic Governor and unified Democratic legislature,3 0 Democratic Governor and unified Republican legislature, and 0 Democratic Governor and a split legislature. Table 12 summarizes data for the executive and legislative political institution variables before, after, and throughout the implementation of the OBRA 87 enforcement law, respectively. Harrington et al. (1999) also argued that facility—level characteristics are important. These scholars collected state—level data covering the period 1991 through 1997 describing facility characteristics that could influence the quality of care residents receive in nursing homes. Harrington et al. (1999) included resident groups and family groups as a measure of nursing home structure. A resident group is an organized group of residents that meets regularly to discuss and offer suggestions about policies and procedures affecting residents’ care, treatment, and quality of life, and for any other purpose (Harrington et al., 1999). A family group is an organized group of residents’ family members that meet regularly to discuss and offer suggestions about policies and procedures affecting residents’ care, treatment, and quality of life, and for any other purpose (Harrington et al., 1999). Resident groups are required by the OBRA 87 nursing home reform laws, and family groups are required by some states (CBC, 1999). k 3This category was the comparison dummy variable and was not included in the regression models estimated. 132 Th licensed p groups. In resident d; NA hours measured GrOUp vc; state. Pr RN hours mnSL‘d In the LPN I rang“ in ‘esldem d Table 12. de‘i‘allOn the mm” devian-On 13). The nursing home structural variables used in this chapter are RN hours, licensed practical nurse (LPN) hours, nursing assistant (NA) hours, facility resident groups, and facility family groups. The RN hours were measured as RN hours per resident day. The LPN hours were measured as the LPN hours per resident day.“ The NA hours were measured as the NA hours per resident day.5 Resident Group was measured as the percent certified nursing facilities with resident groups by state. Family Group was measured as the percent certified nursing facilities with family groups by state. Prior to the implementation of the OBRA 87 enforcement laws, the mean for the RN hours was .5 hours per resident day, the standard deviation was .2, and the data ranged from .2 to 1.3 over the period 1991 through 1994 (see Table 12). The mean for the LPN hours was .6 hours per resident day, the standard deviation was .2, and the data ranged from .3 to 1.2 (see Table 12). The mean for the NA hours was 2.1 hours per resident day, the standard deviation was .2, and the data ranged from 1.6 to 3.1 (see Table 12). The mean for resident group variable was 93.3 percent, the standard deviation was 5.2, and the data ranged from 67.6 to 100 percent (see Table 12). Also, the mean for family group variable during this period was 45.4 percent, the standard deviation was 13.2, and the data ranged from 19.2 percent to 81.2 percent (see Table 12). After the implementation of the OBRA 87 enforcement laws, the mean for the RN hours was .7 hours per resident day, the standard deviation was .2, and the data ranged 4LPN hours includes licensed vocational nursing staff hours. “The NA hours includes nurse aide and nurse assistant hours. 133 from .3 ti the data r; Standard 1 mean for I and the d although I Alaska di, states shot the family 13. and thT any famil} I California. WaShingto: lam”)... gnu. The enf‘I‘Cemen “I‘lllemcma "allabl’c’s Clo impunamly Some facllll; State laws. that milk: 1 hr ,IIIIC re {0 n» “Itch... ”in Is. I from .3 to 1.7. The mean for the LPN hours was .7, the standard deviation was .2, and the data ranged from .3 to 1.1 (see Table 12). The mean for the NA hours was 2.1, the standard deviation was .2, and the data ranged from 1.6 to 3.0 (see Table 12). The mean for the resident group variable was 90.5 percent, the standard deviation was 10.8, and the data ranged from 0 to 100 percent (see Table 12). It should be noted that although the OBRA 87 laws require nursing homes to have resident groups, the state of Alaska did not have any resident groups in 1997. It should also be noted that many states showed a downward trend in the percent of resident groups. Also, the mean for the family group variable during this period was 44.4 percent, the standard deviation was 13, and the data ranged from 0 to 75.7 percent. Also, the state of Alaska did not have any family groups in 1997 (see Table 12). Furthermore, the states of Alaska, Arizona, California, Colorado, Florida, Iowa, Idaho, Indiana, Minnesota, Mississippi, Nevada, Washington, West Virginia, and Wyoming exhibited a downward trend in the percent of family groups. The mean for the RN hours increased after the implementation of the OBRA 87 enforcement laws. The means for the NA hours remained the same before and after implementation. However, the mean for the LPN hours, resident and family group variables decreased after the implementation of the OBRA 87 enforcement laws. More importantly, the decrease in the resident group and family groups variables indicates that some facilities were not complying with the OBRA 87 nursing home reform laws and state laws. For instance, the data range dropped to a minimum of zero, which shows that some facilities did not have resident and family groups. The OBRA 87 nursing home reform laws require facilities to have resident groups. Moreover, the State of Michigan requires that facilities have family groups. 134 OI deviation (see Table the data r: standard ( mean for and the da gTOUp vari the (1813 r; TiI Other men 1997, Dui of the OB} the comml the ‘mPIen Where 199:. to amount deficiencyc and ““er I} 1993, 1994 summarlzes Overall, the mean for RN hours was .6 hours per resident day, the standard deviation was .2, and the data ranged from .2 to 1.7 for the period 1991 through 1997 (see Table 12). The mean for the LPN hours was .6, the standard deviation was .2, and the data ranged from .3 to 1.2 (see Table 12). The mean for the NA hours was 2.1, the standard deviation was .2, and the data ranged from 1.6 to 3.1 (see Table 12). The mean for the resident group variable was 92.1 percent, the standard deviation was 8.2, and the data ranged from 0 to 100 percent (see Table 12). Also, the mean for the family group variable during this period was 44.9 percent, the standard deviation was 13.1, and the data ranged from 0 to 81.2 percent (see Table 12). Time control variables were included in the regression model to account for other events influencing the deficiency citations assessed over the period 1991 through 1997. Dummy variables were created to represent the period before the implementation of the OBRA 87 enforcement law for the years 1992, 1993, and 1994, where 1991 was the comparison year. Dummy variables were also created to represent the period after the implementation of the OBRA 87 enforcement laws for the years 1996 and 1997, where 1995 was the comparison year. A lag of the dependent variable was also created to account for factors not included in the models estimated that systematically influence deficiency citations. Lastly, dummy variables were created to represent the period before and after the implementation of the OBRA 87 enforcement laws for the years 1992, 1993, 1994, 1995, 1996, and 1997 where 1991 was the comparison year. Table 12 summarizes the data for the time variables. 135 Methodo Re period 19 is to iden‘ assessing 87 IlUISlIl': enforceme facilities. 51'516m an number (It relationsh;; Enforce” Where i “31 The eanM for the Peri “991 throu “tenth en, RegreSSlm] The . of the 08R I ll Methodology Regression analyses were performed on annual state-level panel data over the period 1991 through 1997 using STATA statistical software. The goal of this chapter is to identify which external environmental factors systematically influenced inspectors assessing deficiency citations on facilities not complying with the provisions of the OBRA 87 nursing home reform laws. The deficiency citations that inspectors assess help the enforcement unit and HCFA to determine which sanctions should be imposed on facilities. Therefore, deficiency citations are a significant input into the enforcement system and various external environmental factors have attempted to influence the number of deficiency citations. The following model was used to examine the causal relationship between deficiency citations and state-level external environmental factors: Enforcement,t = C + Interest Groups,_, + executive and legislative political institutions“ + nursing home structural controlsiJ + time controls, + 6a.: where i represents the states and t the year. The enforcement law became effective July 1, 1995. Regression models were estimated for the periods before (1991 through 1994), after (1995 through 1997), and throughout (1991 through 1997) the implementation of the OBRA 87 enforcement laws to assess the external environmental factors that systematically influenced deficiency citations. Regression Diagnostics The original regression model estimated for the period prior to the implementation 0f the OBRA 87 enforcement laws (1991 through 1994) exhibited multicollinearity, heteroscedasticity, and autocorrelation (see Table 13). The matrix of correlations between the estimated regression coefficients indicated that there may be multicollinearity 136 ,,_....... . betvtee WCIC II The G Of hClt hetero: COITCCI ICEI'CSS the In} Tables (see T COI’rela for am, 01 the ( and am ESTER] peernn‘ ‘7: lids ,_ L ”thud . H”We ’ ‘ regre“In 7:31 . ‘v . r ifnce ‘r‘L'lh : r [ELh at n . I631. 83‘ ”35v lib IHTO‘. enllIQn‘ Igtt between some of the variables (see Appendix K). No corrections for multicollinearity were made because theory suggests that these variables should be included in the model. The Glesjer test for detecting heteroscedasticity was performed to test for the presence of heteroscedasticity (see Appendix L). The results of the Glesjer test indicated that heteroscedasticity was present (see Appendix L). A robust regression model was run to correct for heteroscedasticity (see Table 14).“ The standard errors of the robust regression model were smaller than the original regression model thereby indicating that the robust regression model coefficients were more efficient than the original model (see Tables 13 and 14). The Cochrane-Orcutt procedure was used to test for autocorrelation (see Table 29). The results of the Cochrane-Orcutt procedure indicate that auto- correlation is present. A lag of the dependent variable was added to the model to correct for autocorrelation (see Table 15). The original regression model estimated for the period after the implementation of the OBRA 87 enforcement laws (1995 through 1997) also exhibited heteroscedasticity and autocorrelation (see Table 16). The matrix of correlations between the estimated regression coefficients indicated that there was not any significant multicollinearity between the variables (see Appendix M). The Glesjer test for heteroscedasticity was performed in order to test for heteroscedasticity (see Appendix N). The results of the “Under ideal conditions, ordinary least squares performs better than other regression methods. However, under certain nonideal conditions, ordinary least squares breaks down. Yet, robust regression is designed to perform well under a broader range of conditions than ordinary least squares. Robust regression is a technique for weighing outliers, which lessens their influence. The Huber iteration technique was used for the robust regression analyses performed. The Huber technique is an iteratively reweighted least squares procedure. On each iteration, robust regression estimates regression parameters, calculates the residuals, and downweights cases with large residuals. The process repeats until weights no longer show much change (Hamilton, 1992; Hamilton, 1993). 137 Glesjer order tti procedu results ( of the (1 Table l tation 0' linearity Correlati Pussibili OI. N0 Variable: ‘n Order indicate“. COTTeci f. Was USCG Cog-mam depend-en ~11. U01], Of 0 353633 if It Glesjer test indicated that heteroscedasticity was present. Robust regression was run in order to correct for the heteroscedasticity present (see Table 17). The Cochrane-Orcutt procedure was used to test for the presence of autocorrelation (see Table 30). The results of the Cochrane—Orcutt procedure indicate that autocorrelation is present. A lag of the dependent variable was included in the model to correct for autocorrelation (see Table 18). The original regression model estimated for the period throughout the implemen- tation of the OBRA 87 enforcement laws (1991 through 1997) also exhibited multicol- linearity, heteroscedasticity, and autocorrelation (see Table 19). The matrix of correlations between the estimated regression coefficients indicated that there was a possibility of multicollinearity between some of the variables in the model (see Appendix 0). No corrections for multicollinearity were made because theory suggests that these variables be included in the model. The Glesjer test for heteroscedasticity was performed in order to test for heteroscedasticity (see Appendix P). The results of the Glesjer test indicated that heteroscedasticity was present. Robust regression was run in order to correct for the heteroscedasticity present (see Table 20). The Cochrane-Orcutt procedure was used to test for the presence of autocorrelation (see Table 31). The results of the Cochrane-Orcutt procedure indicate that autocorrelation is present. A lag of the dependent variable was included in the model to correct for autocorrelation (see Table 21). The Chow test was used to determine if the pre-implementation, post-implementa- tion, or overall model should be used. More specifically, the Chow test will help to assess if the pre—implementation and post-implementation models are different functions. The results of the Chow test indicate that the pre-implementation and post-implementation 138 Results Interest functions are different (see Appendix J). Therefore, the pre-implementation (1991-1994 and the post-implementation (1995—1997) models will be used to test the hypotheses. Results Interest Groups Hypothesis 1: It is expected that an increase in industry strength will cause a decrease in deficiency citations. Hypothesis 2: It is expected that an increase in resident strength will cause an increase in deficiency citations. Hypotheses 1 and 2 were not supported by the regression results (see Tables 15 and 18). The results of the pre- and post-implementation models show that the nursing home industry association and the AARP interest groups had no systematic influence on deficiency citations (see Tables 15 and 18). However, the coefficients for the AARP interest group variable and the nursing home industry association variable did not move in the hypothesized direction (see Tables 15 and 18). An examination of the correlation between the AARP variable and other variables included in the model did not show evidence of multicollinearity (see Appendices K, M, and O). This result may indicate that the AARP acts in a manner similar to resident groups. That is, the AARP may 'work with facilities to resolve resident problems before inspections occurs, thereby decreasing the deficiency citations assessed on nursing homes. Additionally, the nursing home industry association variable did not move in the hypothesized direction (see Table 18). Future research should be conducted to examine these findings. 139 litettttit "Ff-1h— O l\ 11) paI the gov 19g 11y] 18) The n p0I‘liCal in' 513163 WhCr EuvernOr ar 9 . StallstjCaHy f gCIVernUr a n, Executive and Legislative Political Institutions Hypothesis 3a: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of both houses in the legislature is Democrat, as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3b: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of both houses in the legislature is Republican, as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3c: It is expected that deficiency citations will increase when the party of the governor is Democrat and the majority party of the both houses of the legislature is split (differs), as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3d: It is expected that deficiency citations will increase when the party of the governor is Republican and the majority party of both houses of the legislature is Democrat, as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypothesis 3e: It is expected that deficiency citations will increase when the party of the governor is Republican and the majority party of both houses of the legislature is split (differs), as compared to when the party of the governor is Republican and the majority party of both houses of the state legislature is Republican. Hypotheses 3c and 3d were supported by the regression results (see Tables 15 and 18). The results of the pre-implementation model show that the executive and legislative political institutions at the state level systematically influenced deficiency citations in states where there is a Democratic governor and a split legislature and a Republican governor and a unified Democratic legislature as compared to states with a Republican governor and a unified Republican legislature (see Table 15). These results were statistically significant at the .05 level and .10 level (see Table 15). The democratic governor and unified Democrat legislature variable was not statistically significant. This 140 result I COl'lSCI‘ Democ («fl—J_J~_A.-._.._ Band On fOr [he [ “"65 “h. Slates th ”Elke, [ht result might be due to a Southern regional effect. That is, southern Democrats are more conservative than Democrats from other regions of the country. The states that had a Democratic governor and unified Democratic legislature were: Alabama 1994, 1995 Arkansas 1995 Arizona 1992, 1993, 1994 Florida 1992, 1993 Georgia 1992, 1993, 1994, 1995, 1996, 1997 Hawaii 1992, 1993, 1994, 1995, 1996, 1997 Kentucky 1992, 1993, 1994, 1995, 1996, 1997 Louisiana 1993, 1994, 1995, 1996, 1997 Maryland 1992, 1993, 1994, 1995, 1996, 1997 Mississippi 1992 Missouri 1994, 1995, 1996, 1997 Nevada 1992, 1993 New Jersey 1992, 1993, 1994 New Mexico 1992, 1993, 1994, 1995 North Carolina 1994, 1995 Oklahoma 1992, 1993, 1994, 1995 Oregon 1992, 1993, 1994, 1995 Pennsylvania 1994, 1995 Rhode Island 1992, 1993, 1994, 1995 Tennessee 1992, 1993, 1994, 1995 Texas 1992, 1993, 1994, 1995 Virginia 1992, 1993, 1994 Washington 1994, 1995 West Virginia 1992, 1993, 1994, 1995, 1996, 1997 Based on the data, it can be argued that the Southern regional effect influenced the results for the Democratic governor and unified Democratic legislature variable in the model estimated. The post-implementation model indicated that deficiency citations increased in states where there was a Democratic governor and a split legislature as compared to states where there was a Republican governor and a unified Republican legislature (see Table 18). This result was statistically significant at the .10 level (see Table 18). Hence, the results suggest that deficiency citations are systematically influenced by 141 executivt impleme only stat deficienc a split leg Nursing I H; (“d H} ca “5 Cal “5 (let Hy det N o] and 13). T grOUDS Cdu SIatistjCa”V Nlin “Era .- 3 8141113” executive and legislative political institutions across the states before and after the implementation of the OBRA 87 enforcement laws. Furthermore, the results show that only states with a Democratic governor and a split legislature systematically caused deficiency citations to increase as compared to states with a Republican govemore and a split legislature after the implementation of the OBRA 87 enforcement laws. Nursing Home Structural Controls Hypothesis 4: It is expected that an increase in the RN nursing hours will cause a decrease in deficiency citations. Hypothesis 5: It is expected that an increase in the LPN nursing hours will cause a decrease in deficiency citations. Hypothesis 6: It is expected that an increase in the NA nursing hours will cause a decrease in deficiency citations. Hypothesis 7: It is expected that an increase in resident groups will cause a decrease in deficiency citations. Hypothesis 8: It is expected that an increase in family groups will cause a decrease in deficiency citations. None of the hypotheses were supported by the regression results (see Tables 15 and 18). The pre-implementation results show that increases in the percentage of resident groups caused an increase in deficiency citations (see Table 15). This result was statistically significant at the .05 level (see Table 15). None of the post-implementation model nursing home structural control variables were statistically significant (see Table 18). 142 Time Cl 18). Th as Cllmf accounte 15 and I and the I The resu; decrease 10 states “Ssmiated the citatic iml-‘i’Clltm 15) The accounted IntreaSe. COnc'uSiU Var af’e’ imp}. Implcmema Time Controls Hypothesis 9: It is expected that there will be a change in deficiency citations after the implementation of the OBRA 87 enforcement regulations in 1995. Hypothesis 10: It is expected that there will be a trend within each subperiod. Hypotheses 9 and 10 were supported by the regression results (see Tables 15 and 18). The results of the post—implementation model show that events occurring in 1996 as compared to 1995 caused a decrease in deficiency citations and the events not accounted for in the model estimated caused deficiency citations to increase (see Tables 15 and 18). The results for the year 1996 were statistically significant at the .10 level and the lag variable was statistically significant at the .01 level (see Tables 15 and 18). The results for the year 1996 indicate that there was an event that caused a systematic decrease in the deficiency citations across the states. The HCFA issued a memorandum to states in late 1995 indicating that their inspection agencies should reduce the costs associated with conducting inspections. This event could have caused states to decrease the citation of deficiencies because they would have fewer resources for conducting inspections. However, the lag variable caused deficiency citations to increase (see Table 15). The result for the lag variable suggests that some significant factors were not accounted for in the regression model estimated that caused deficiency citations to increase. Conclusion Various external environmental factors influenced deficiency citations before and after implementation of the OBRA 87 enforcement laws. During the pre- and post- implementation period the following factors systematically influenced deficiency citations: 143 Violallti 0 states with a Democratic governor and a split legislature and a Republican governor and unified Democratic legislature caused an increase in deficiency citations as compared to states with a Republican governor and a unified Republican legislature, 0 an increase in resident groups caused an increase in deficiency citations, 0 events in 1996 caused an increase in deficiency citations as compared to events in 1995, and 0 factors not accounted for in the model estimated caused an increase in deficiency citations. The Scholz and Wei (1986) study indicated that the following factors influenced violations citations: 0 Democratic presidents caused an increase in violation citations, 0 Congressional members who frequently vote for prolabor positions in Congress caused an increase in violation citations, 0 Democratic governors as compared to Republican governors caused an increase in violation citations, 0 High percentage of Democrats in the state legislature caused an increase in violation citations, and 0 Labor interest groups at the state level caused an increase in the violation citations. In comparison to the Scholz and Wei (1986) study, the governor and state legislature results were somewhat similar. However, this chapter showed that nursing home structural controls also influenced deficiency citations. 144 11 87 enfor cited for potential the imple state imp nursing } despite [h In GAO‘S f“ and the p, were Imp] deficiency of the OE deficiency 80““: factli group requ SFSIEmaU-Ca Add “1 POlitica] lHflUenCed d unified RCpL. Moreover, the GAO (1999) conducted a study of states implementing the OBRA 87 enforcement laws and found that one-fourth of all homes nationwide continue to be cited for deficiency citations that either caused actual harm to residents or carried the potential for death or serious injury. They noted that this pattern did not change with the implementation of the OBRA 87 enforcement laws in July 1995. They concluded that state implementation of the OBRA 87 enforcement laws sends signals to noncompliant nursing homes that a pattern of repeated noncompliance carries few consequences, despite the addition of various sanctions to help promote sustained compliance. In comparison to the GAO (1999) study, the results of this chapter support the GAO’s findings as noted by a substantial decrease in the mean for deficiency citations and the percentage of resident and family groups after the OBRA 87 enforcement laws were implemented. For example, the resident group variable systematically influenced deficiency citations prior to implementation, yet in the period after the implementation of the OBRA 87 enforcement laws, the resident group variable had no impact on deficiency citations after implementation (see Tables 15 and 18). This also shows that some facilities are not complying with the OBRA 87 nursing home reform laws resident group requirement. Therefore, it is concluded that external environmental factors do systematically influence regulatory agencies. Additionally, the models showed that two of the categories for the combination of political parties for the governor and the majority party of the state legislatures influenced deficiency citations as compared to states with a Republican governor and a unified Republican legislature. The states with a Democratic governor and a unified Democratic legislature did not assess more deficiency citations as compared to states with a Republican governor and a unified Republican legislature. This result occurred because 145 many states with a Democratic governor and a unified Democratic legislature were located in the Southern region of the United States. The Democrats in the Southern region of the United States are more conservative than the Democrats across the country. Lastly, the models showed that resident groups influenced deficiency citations assessed across the states before the implementation of the OBRA 87 enforcement laws; yet, after implementation, resident groups were no longer influential. 146 CHAPTER 6 DO EXTERNAL ENVIRONMENTAL FACTORS OR INTERNAL AGENCY FACTORS INFLUENCE STATES IMPLEMENTING THE OBRA 87 ENFORCEMENT REGULATIONS? Introduction In this chapter an analysis will be conducted to determine whether external environmental factors or internal agency factors systematically influence states implementing the OBRA 87 enforcement regulations. This analysis will cover the period 1995 through 1997. The results of the history of states implementing nursing home laws and regulations in chapter 2 indicated that internal agency factors can influence regulatory agencies. Furthermore, the case study in chapter 4 shows that external groups and political institutions influence some of the internal agency factors faced by inspectors, thereby causing deficiency citations to change. lastly, the literature review in chapter 3 showed that internal agency factors influence regulatory agencies. A survey was administered in August 1998 to assess the impact that external environmental factors and internal agency factors have on states implementing the OBRA 87 enforcement regulations (see Appendices R and S). Indices were developed to measure the perceptions of nursing home inspection managers and inspectors about the external environmental factors and internal agency factors that influenced their implementing the OBRA 87 enforcement laws over the period 1995 through 1997. In 147 the sections that follow, the hypotheses to be tested will be discussed, the variables included in the regression models will be defined and described, and the methodology employed will be discussed. Then, the overview of the survey results will be described, the regression diagnostics will be discussed, the regression results will be analyzed, the limitations will be listed, and finally the conclusion will synthesize the results. Hypotheses A detailed discussion about the theories that I am testing can be found in chapter 3. The hypotheses to be tested are listed below: External Environmental Factor Hypotheses Hypothesis 1: It is expected that pressure from external groups and political institutions will influence inspection managers and cause deficiency citations to change. Hypothesis 2: It is expected that pressure from external groups and political institutions will influence inspectors and cause deficiency citations to change. Internal Agency Factor Hypotheses Hypothesis 3: It is expected that pressure from external groups and political institutions will influence inspectors and their internal working conditions, thereby causing a change in deficiency citations assessed. Hypothesis 4: It is expected that pressure from external groups and political institutions will influence managers and their views about inspectors, thereby causing a change in deficiency citations assessed. Hypothesis 5: It is expected that pressure from external groups and political institutions will influence inspectors and their views about managers, thereby causing a change in deficiency citations assessed. 148 Nursing Home Structural Controls Hypothesis 6: It is expected that an increase in the RN nursing hours will cause a decrease in deficiency citations. Hypothesis 7: It is expected that an increase in the LPN nursing hours will cause a decrease in deficiency citations. Hypothesis 8: It is expected that an increase in the NA nursing hours will cause a decrease in deficiency citations. Time Controls Additionally, control variables for time were included in order to determine if events not accounted for in the models estimated caused the number of deficiency citations to change across the states and to account for time trends. For instance, one of the events that was not included in the model was states implementing a streamlined inspections to cut costs at the urging of HCFA. This reduction in costs led to fewer inspection resources and, therefore, fewer facilities were cited for not complying with the OBRA 87 enforcement laws (Edelman, 1998). A lag of the dependent variable was also included in this analysis. The lag variable will help to assess if there are other factors “that systematically influence deficiency citations that are not accounted for in the models estimated. This chapter assesses only the external environmental factors and the internal agency factors that can impact deficiency citations, therefore it is assumed that there are some other factors that are not accounted for in this model. Hence, the following hypotheses will be tested: Hypothesis 9: It is expected that there will be events occurring after the implementation of the OBRA 87 enforcement regulations in 1995 that will influence deficiency citations. Hypothesis 10: It is expected that other factors not accounted for in the models estimated will influence deficiency citations. 149 Variables The dependent variable is a proxy for enforcement, which is the average number of deficiencies cited per facility by state for the years 1995 through 1997. Table 22 summarizes the data for the deficiency variable. A similar approach was used by Scholz and Wei (1986), who assessed the degree to which enforcement activities vary in response to external political actor and organizational task factor differences between states. More specifically, these scholars examined the influence of both external political actors and state regulatory agencies’ organizational task factors on the Occupational Safety and Health Administration’s enforcement activities covering the years 1976 through 1983 across the states. This study used citations and penalties as the dependent variable, which was a proxy for state implementation of enforcement standards in their study. Moreover, Spector and Takada (1991) used deficiency citations as a measure of regulatory effectiveness in a study they conducted. In this study, Spector and Takada (1991) examined various data to assess the impact of process and structural factors on the health outcomes of nursing home residents in 80 nursing homes in Rhode Island. They argued that the receipt of a citation would result in changes of a facility’s structure or process that should lead to observing measurable effects on residents’ health outcomes. The results of their study showed that their measure of regulatory effectiveness did systematically influence the health outcomes of nursing home residents in the state of Rhode Island. Hence, deficiency citations was used as a measure of regulatory effectiveness in this chapter. Deficiency citations are a significant input into state enforcement systems that help to determine the sanctions that can be imposed on facilities not complying with the 150 OBRA 87 resident care, resident rights, quality of life, and resident assessment and care planning provisions. The deficiencies used for this chapter are cited by state inspectors. The state inspectors assess nursing homes’ compliance with quality of care, quality of life, residents’ rights, and resident assessment and care planning regulations established by OBRA 87 (see Table 1). The state inspectors work in a team under the direction of the licensing officer. Inspections are conducted by teams of professionals, which can include RN 5, social workers, dietitians, and sanitarians who are employed by the state to be nursing home inspectors. The licensing officer is in charge of monitoring all nursing homes in their assigned areas, scheduling inspections, reviewing results and plans of correction, recommending enforcement sanctions to the enforcement unit or HCFA (depending on the level of the deficiency), and keeping track of information about each nursing home (CBC, 1997). Each of these areas has specific regulations, which state inspection teams review to determine whether or not facilities have complied with the OBRA 87 enforcement laws (Harrington, 1999). State inspection teams then submit a deficiency report to their respective licensing officer, who then reviews the teams’ findings and determines whether or not to issue a written official statement of deficiency(ies). The licensing officer then makes recommendations to their enforcement unit for the sanctions that HCFA allows them to impose or the licensing officer makes recommendations to HCFA for sanctions to be imposed on noncompliant facilities. The HCFA allows states to impose the directed-in—service training, directed plan of correction, and temporary manager sanctions on noncompliant facilities. However, HCFA imposes the temporary manager, denial of payments, civil monetary fines, and termination sanctions on noncompliant facilities. 151 Exploratory factor analyses were performed in order to confirm that the indices were measuring various internal agency factor constructs (see Table 23).1 I used SPSS- X to generate a series of factor loadings for each index and the factor loading with the highest eigenvalue was selected. No rotations were performed on the factor loadings. The Cronbach’s alpha test was performed on each index in order to test for reliability (see Table 23). Nunnally’s (1978) rule of thumb asserts that alpha should be at least .70 for a scale to demonstrate internal consistency. Five of the six indices created met this criteria (see Table 23). Although the inspectors’ working conditions index had an alpha of .60, it was included in the regression models estimated because it was substantively important and very close to .70 (see Table 23). The managers’ working conditions index had an alpha of .50 and was not included in the regression models estimated (see Table 23). The eigenvalue is a measure used to help validate indices. Eigenvalues represent the proportion of variance accounted for by each factor. Eigenvalues greater than 1 indicate that items within an index strongly intercorrelate (Spector, 1992). All of the indices created had eigenvalues with values greater than 1 (see Table 23). The independent variables are variables created from indices based on the survey responses. A survey was administered in August 1998 to assess the impact that external environmental factors and internal agency factors have on states implementing the OBRA ‘Factor analysis originated with the work of Spearman (1904). Factor analysis is concerned with finding a small number of common factors that linearly reconstruct the original variable. Exploratory factor analysis is a good technique for studying the dimensionality of a scale, either a unidimensional or multidimensional one. Two major questions must be addressed with a factor analysis: (1) the number of factors that best represent the items, and (2) the interpretation of the factors. Although factor analysis is a mathematical procedure, the answer to these two questions falls in the realm of subjective judgment as much as in the realm of statistical decision rules. 152 87 enforcement regulations. Indices were developed to measure the perceptions of nursing home inspection managers and inspectors about the external environmental factors and internal agency factors that influenced their implementing the OBRA 87 enforcement laws over the period 1995 through 1997. Variables were created from the indices to measure the external environmental factors and internal agency factors that can influence managers and inspectors implementing the OBRA 87 enforcement laws across states over the period 1995 through 1997. Surveys were administered to one nursing home inspector and one inspection manager in forty—nine states in August 1998 (see Appendices R and S).2 The response rate was 66% for managers and 60% for inspectors.3 Only 23 states were used because some questions were not answered by the managers and inspectors who responded. The surveys asked the respondents about the influence that external environmental factors and internal agency factors exerted on enforcement covering the period 1995 through 1998.“ The director of each state agency selected the inspector and inspection manager for participation in this study. It is assumed that the inspection manager and inspector selected by the directors represented the inspection employees in each state. Although 2The states that responded to the inspection managers’ questionnaire are AL, CA, CO, FL, HI, ID, IL, IN, IA, KS, LA, ME, MD, MI, MS, MT, NE, NV, NH, NJ, NM, NY, NC, OK, RI, SC, SD, TX, UT, VT, VA, WA, and WV. The states that responded to the inspectors’ questionnaire are AL, CA, CO, FL, HI, ID, IL, IN, IA, KS, LA, ME, MD, MT, NE, NV, NH, NJ, NY, NC, ND, OK, RI, SC, TX, UT, VT, VA, WA, and WV. 3The responses for the state of Nebraska were not included because it has a unicameral legislature. “Although the responses from the inspection managers and inspectors cover the period 1995 through 1998, the analyses will be based on regression models estimated for the period 1995 through 1997 because data were not available for some of the other variables in 1998. 153 the process for selecting participants could result in selection bias, the responses reported show that the respondents were not afraid to provide negative responses about their agencies, which indicates that there should not be any significant systemic bias (see Appendices T and U).5 Indices were created based on several surveys that were tested for validity and reliability (see Appendix Q and Table 23). The indices for this study were created because none of the previously developed indices adequately addressed the issues pertinent to this study. The interaction terms for the external environmental factors and internal agency factors include measures for external groups and political institutions influence on inspection managers’ views about inspectors, external groups and political institutions influence on inspectors’ views about managers, external groups and political institutions influence on the working conditions of inspectors, nursing home structural controls, and time controls. The external group variables were created from an index that consists of items that assessed the managers’ and inspectors’ views regarding the pressure that governors, state senators, state representatives, HCFA, the nursing home industry association, the AARP, resident groups, and family groups exerted on inspection managers and inspectors assessing deficiency citations (see Appendix Q, which describes the indices that were used to create variables).“ The managers and inspectors were asked a set of questions about the frequency that the nursing home industry association, the AARP, resident groups, and family groups “It should also be noted that some respondents did not respond to various items asked on the questionnaire administered. “The AARP question was erroneously left out of the inspectors’ questionnaire, therefore this group was not included in the pressure group and political institutions index for inspectors. 154 attempted to encourage to them to cite or not cite a deficiency (see Appendix Q). The managers and inspectors were also asked a set of questions regarding receiving pressure from the governor, state senator, state representative, and HCFA to increase or decrease their enforcement efforts. The kappa-statistic measure of interrater agreement, the difference of mean t-test, and a comparison of means were used to determine if separate indices should be created for managers and inspectors (see Table 28). The kappa statistic of interrater agreement indicated that there was not much agreement between the managers’ and inspectors’ ratings regarding external groups’ and political institutions’ pressure and their working relationships (see Table 28). The kappa-statistic measure of agreement is scaled to be 0 when the amount of agreement is what would be expected to be observed by chance, and 1 when there is perfect agreement (Stata Reference Manual, Release 6, 1999). For intermediate values, Landis and Koch (1977) suggest the following interpretations: below 0.0: poor 0.00—0.20: slight 0.21-0.40: fair 0.41-0.60: moderate 0.61—0.80: substantial 0.81-1.00: almost perfect Some of the difference of mean t-test results indicated that the responses of managers and inspectors differed. Also, a comparison of the means for manager and inspector indicated that their responses were different. Therefore, separate indices were created for inspection managers and inspectors. The indices for the managers and inspectors were tested for validity and reliability (see Table 23). 155 The internal agency factors variables were also created from indices based on the survey responses. These variables were measured as interaction terms between external environmental factors and internal agency factors because theory did not suggest how the internal agency factors would influence the deficiency citations assessed. For example, it is not clear if deficiency citations will increase or decrease when inspectors and managers have satisfactory working conditions or satisfactory views about their relationships with each other. Therefore, interaction terms were created. The goal of this dissertation was to measure the separate variables for the internal agency factors; however, the limitations of theory led to using interaction terms. These variables measured the influence that external groups and political institutions exert on inspectors, which thereby influence their working conditions; the influence that external groups and political institutions exert on managers, which influence their views about inspectors; and the influence that external groups and political institutions exert on inspectors, which influence their views about managers (see Table 22). Table 22 summarizes the data for the external environmental factor and internal agency factor variables. All of the indices developed were based on a 5-point Likert scale (see Appendices T and U). The internal organizational factors that will be assessed are based on indices that were tested for validity and reliability (see Table 23). Managers’ views about inspectors index consists of items related to discussions about important things, willingness to share information, trust and confidence, and inspectors’ morale (see Table 23). The inspectors’ views about management index consists of items related to discussions about important things, sharing information, trust and confidence, problems, working conditions, boss’s own success, training, cooperation, improvements, and superior’s trust (see Table 23). The inspectors’ working conditions index consists of items related to 156 conditions concrning their job that can be improved, pay, and pressure on the job (see Table 23). The managers’ working conditions index consists of items related to pay, pressure on the job, job being unpleasant, and job satisfaction (see Table 23). Variables were created from the indices using SPSS-X. Time control variables were included in the regression model to account for events that occurred over the period 1995 through 1997. Dummy variables were created to represent the period during the implementation of the OBRA 87 enforcement law for the years 1995, 1996, and 1997, where 1995 was the comparison year. A lag of the dependent variable was created to account for factors not included in the model estimated. Table 22 summarizes the data for the time control variables. Methodology Variables were created for the indices using SPSS-X statistical software. Regression analyses were performed on annual state-level panel data over the period 1995 through 1997 using STATA statistical software. The values for the indices are the same for each year because the survey was attempting to assess the experiences of the inspection managers and inspectors during the first three years of states implementing the OBRA 87 enforcement laws. The goal of this chapter is to determine if external environmental factors or internal agency factors influenced deficiency citations as states implemented the OBRA 87 enforcement regulations that became effective July 1, 1995. The following model was used to examine the causal relationship between deficiency citations, external environmental factors, and internal agency factors: Enforcement“ = C + External Groups’ and Political Institutions’ Pressure, + External Groups’ and Political Institutions’ Pressure x Inspection Managers’ Views 157 about Inspectorsm + External Groups’ and Political Institutions’ Pressure X Inspec- tors’ Views about Managers” + External Groups’ and Political lnstitutions’ Pressure X Working Conditions of Inspectors” + Nursing Home Structural Controls“ + Time Controlsl + em where i represents the states and t the year. Regression models were estimated for the period 1995 through 1997. Overview of the Survey Results In this section some demographic information about the inspection managers and inspectors who responded to the survey will be provided. Also interesting survey results for the inspection managers and inspectors implementing the OBRA 87 enforcement laws will be discussed. All of the respondents were civil servants and the majority of respondents for the inspection managers survey were managers (see Appendix T). Approximately eighty-two percent of the respondents had 5 or more years experience on the job (see Appendix T). Moreover, eighty-two percent of the respondents indicated that they interacted with three or more organizations to implement the OBRA 87 enforcement laws (see Appendix T). Furthermore, seventy-two percent of the managers stated that training resources were good or fairly good (see Appendix T). However, approximately 60 percent of the managers indicated that the number of nursing home inspectors in their agency was inadequate and not improving, or inadequate and getting better (see Appendix T). Additionally, forty-eight percent of the respondents indicated that the budget they were appropriated to inspect nursing homes was inadequate and not improving, or inadequate and getting better (see Appendix T). Approximately seventy percent of the respondents indicated that employee turnover ranged from average to very 158 high (see Appendix T). These respondents also indicated that approximately thirty-six percent of their inspectors’ morale was low and sixty-seven percent indicated that they agreed or strongly agreed that there was too much pressure on the job. Lastly, all of the managers indicated that there were some conditions concerning their jobs that could be improved. All of the inspectors were civil servants and seventy percent of them were RNs (see Appendix U). Approximately seventy-seven percent of these respondents had 5 or more years of experience in their current position. All of the respondents have received training (see Appendix U). Moreover, approximately forty-seven percent indicated that they were not ordinarily involved or not involved in decisions related to their job (see Appendix U). Fifty-three percent of the respondents indicated that they were not paid fairly compared with other employees (see Appendix U). Furthermore, fifty percent of the inspectors stated that there was too much pressure on the job (see Appendix U). N inety-seven percent of the respondents indicated that there were some conditions concerning their jobs that could be improved (see Appendix U). Lastly, thirty-three percent of the inspectors stated that their morale was low or very low (see Appendix U). Regression Diagnostics Three regression models were estimated for inspection managers, inspectors, and a combination of inspection managers and inspectors (see Tables 24, 25, and 26). An F-test for testing sets of coefficients was performed in order to determine which model should be used to test the hypotheses (see Appendices V and W). The F-test results indicated that the combined regression model estimated for inspection managers and inspectors did not improve the model as compared to a separate model for inspection 159 managers and inspectors (see Appendices V and W). Furthermore, the annual inspection flow chart shows that there are different steps in the inspection process (see Figure 1). The inspectors play a role in some steps of the inspection process, and managers play a different role in other steps in the inspection process (see Figure 1). Therefore, the separate models estimating the managers’ and inspectors’ external environmental factors and internal agency factors will be used in the results section of this chapter. The matrix of correlations between the estimated regression coefficients for the manager model indicated that there was not any significant multicollinearity between the variables (see Appendix X). The Glesjer test was performed to test for the presence of heteroscedasticity. The results indicate that heteroscedasticity was present (see Appendix Y). A robust regression model was run to correct for heteroscedasticity (see Table 24). The standard errors of the robust regression model coefficients were more efficient than the original model. The Cochrane-Orcutt procedure to test for the presence of autocorrelation was performed (see Table 32). The results of the Cochrane-Orcutt test indicated that autocorrelation was present. Thus, a lag of the dependent variable was added to the model to correct for autocorrelation (see Table 24). The matrix of correlations between the estimated regression coefficients for the inspector model indicates that there may be some multicollinearity between some of the variables (see Appendix Z). No corrections for multicollinearity were made because theory suggests that they should be included in the model. The Glesjer test was performed to check for the presence of heteroscedasticity (see Appendix AA). A robust regression model was run to correct for heteroscedasticity (see Table 25). The standard error of the robust regression model were more efficient than the original model. The Cochrane-Orcutt test for autocorrelation was performed (see Table 33). The results of 160 the Cochrane-Orcutt test indicate that autocorrelation was present. Therefore, a lag of the dependent variable was created to correct for autocorrelation (see Table 25). Results External Environmental Factors: External Groups and Political Institutions Hypothesis 1: It is expected that pressure from external groups and political institutions will influence inspection managers and cause deficiency citations to change. Hypothesis 2: It is expected that pressure from external groups and political institutions will influence inspectors and cause deficiency citations to change. Hypothesis 1 was supported (see Table 24). The regression results show that external groups and political institutions systematically cause deficiency citations across the states to decrease (see Table 24). The external groups and political institutions variable for managers was statistically significant at the .05 level (see Table 24). This finding suggests that managers assessing deficiency citations were systematically influenced by external groups and political institutions across the states over the period 1995 through 1997. Internal Agency Factors: Organizational Factors Hypothesis 3: It is expected that pressure from external groups and political institutions will influence inspectors and their internal working conditions, thereby causing a change in deficiency citations assessed. Hypothesis 4: It is expected that pressure from external groups and political institutions will influence managers and their views about inspectors, thereby causing a change in deficiency citations assessed. Hypothesis 5: It is expected that pressure from external groups and political institutions will influence inspectors and their views about managers, thereby causing a change in deficiency citations assessed. 161 Hypothesis 5 was supported (see Table 25). The influence of external groups and political institutions on inspectors, which influences their views about managers variable was statistically significant at the .10 level (see Table 25). This finding indicates that external groups and political institutions influence inspectors, which also influences their views about managers, resulting in a systematic increase in deficiency citations assessed across the states. The matrix of correlation between regression coefficients indicated that there was a strong negative correlation between the external groups and political institutions exerting pressure on inspectors, which influences their working conditions, and external groups and political institutions exerting pressure on inspectors, which influences their views about managers variable (see Appendix Z). The correlation between these variables indicates that multicollinearity may be present. Some of the consequences of multicollinearity are a high R2 value but few significant t ratios, difficulty in assessing the individual contributions of explanatory variables to the explained sum of square, and wrong signs for regression coefficients (Gujarati, 1992). High correlation between the external groups and political institutions pressuring inspectors, which influences their working conditions, and external groups and political institutions pressuring inspectors, which influences their views about managers variables, indicates that multicollinearity is present. This may also suggest that some of the other interaction terms should be statistically significant. Despite the presence of multicollin- earity, both variables were included in the model estimated because theory suggests that they be addressed. All of the other internal agency variables were statistically insignificant. 162 Nursing Home Structural Controls Hypothesis 6: It is expected that an increase in the RN nursing hours will cause a decrease in deficiency citations. Hypothesis 7: It is expected that an increase in the LPN nursing hours will cause a decrease in deficiency citations. Hypothesis 8: It is expected that an increase in the NA nursing hours will cause a decrease in deficiency citations. None of the hypotheses were supported by the regression results (see Table 24). However, the regression results for the LPN hours were statistically significant at the .05 level (see Table 24). The LPN hours variables moved in a counterintuitive direction. This result indicates that an increase in LPN hours systematically caused an increase in deficiency citations across the states (see Tables 24 and 25). However, an enforcement expert stated that the findings for the LPN hours result from these nurses not providing direct patient care to nursing home residents.7 That is, in many facilities, RNs and LPNs are responsible for taking doctors’ orders and distributing medication throughout the day. 7An enforcement manager with the MDCIS reported this information. 163 Time Controls Hypothesis 9: It is expected that there will be events occurring after the implementation of the OBRA 87 enforcement regulations in 1995 that will influence deficiency citations. Hypothesis 10: It is expected that other factors not accounted for in the models estimated will influence deficiency citations. Hypothesis 10 was supported by the regression results (see Tables 24 and 25). The results of the lag of the dependent variable were statistically significant at the .01 level (see Tables 24 and 25). These results indicate that there are some other factors that have not been accounted for in the model estimated. Future studies should be conducted to identify the factors that have not been accounted for in the model estimated. Limitations There were various limitations with the methodology that was used to assess the views of managers and inspectors about the factors influencing them as they implemented the OBRA 87 enforcement laws. For instance, the survey asked respondents to assess the factors influencing their implementing the OBRA 87 enforcement laws over the period 1995 through 1998. However, data were not available for the deficiency citations for the year 1998, therefore the analysis is limited to 1997. Moreover, the findings are limited due to the fact that only one inspector and one manager per state was selected to complete the questionnaires. Furthermore, the values for the manager and inspector indices are the same for each year. It is argued that managers’ and inspectors’ views about implementing the OBRA 87 enforcement laws did not change significantly over the period 1995 through 1998. Also, the alpha level for the managers’ working conditions index was .50, which was low for the recommended .70 level (Nunally, 1978). 164 Therefore, this index was not used to create a variable to account for managers’ working _ conditions. Lastly, the frequency reports for the inspection managers and inspectors show that a large percent of the respondents believed that there were conditions concerning their jobs that could be improved and that there was too much pressure on their jobs. Future studies should assess what conditions concerning managers’ and inspectors’ jobs could be improved and why there is too much pressure on the job. Conclusion This chapter showed that external environmental factors and internal agency factors influence managers and inspectors implementing the OBRA 87 enforcement laws. More specifically, external groups and political institutions in states that do not support regulation systematically pressured managers and inspectors, and external groups and political institutions pressured inspectors and influenced their working conditions, causing deficiency citations to decrease across the states over the period 1995 through 1997. Furthermore, external groups and political institutions pressured inspectors and influenced their views about managers, which caused deficiency citations to increase across the states. The Scholz and Wei (1986) study indicated that agency task factors influenced enforcement. The agency task factors that they assessed were inspectors’ decisions to employ enforcement resources on firms with high accident rates and the general economic conditions faced by states. Both of these factors influenced enforcement. In comparison to the Scholz and Wei (1986) study, this chapter examined internal agency factors and found that these factors also influence enforcement. Furthermore, the GAO (1999) conducted a study of states implementing the OBRA 87 enforcement laws. This study’s results indicated that state enforcement 165 systems send signals to noncompliant nursing homes that a pattern of repeated violations carries few consequences. They concluded that states should improve the effectiveness of civil monetary penalties, improve the referral process to HCFA for sanctions to be imposed, and HCFA should improve their management information system. In comparison to the GAO study, this chapter assessed the external environmental factors and internal agency factors that have impacted enforcement. Spector and Takada (1991) examined the impact that the receipt of a severe federal citation had on the health outcomes of residents in nursing homes in Rhode Island. Their results indicated that the citation of serious deficiencies was associated with a reduced risk of decline of about 30 percent (Spector and Takada, 1991). This chapter complements the Spector and Takada (1991) study by showing that external environmen— tal factors and internal agency factors influence states implementing the OBRA 87 enforcement laws. In sum, it is concluded that external environmental factors interact with internal agency factors and influence states implementing the OBRA 87 enforcement laws. One of the goals of this chapter was to examine the influence of internal agency factors on the activities of nursing home inspector. However, the variables were measured as interaction terms between pressure from external groups and political institutions and internal agency factors because theory did not suggest how the internal agency factors would influence the deficiency citations assessed. The results of this chapter contribute to the literature by showing that pressure from external groups and political institutions influences inspectors and has a systematic impact on deficiency citations assessed across the states. Furthermore, this study was innovative because the survey results from inspectors and managers were one of the first 166 to systematically examine the factors influencing implementation of the OBRA 87 enforcement laws. 167 CHAPTER 7 CONCLUSION AND RECOMMENDATIONS Introduction In this chapter the implications from the results from the case study of Michigan in chapter 4, the external environmental factors tests in chapter 5, and the external environmental factors and internal agency factors tests in chapter 6 will be discussed and compared to the literature. In the sections that follow the two major views of the public agencies will be examined, a comparison of the literature will be conducted, recommen- dations from other studies will be described, and recommendations from this dissertation will be discussed. Lastly, future studies will be discussed. Two Major Views of Public Bureaucracy Revisited The goal of this dissertation was to examine the two major views of bureaucracy. One view emphasized the influence of external actors on agency activities. The other view emphasized the influence of internal organizational factors on agency activities. This dissertation assessed both views and found that external actors and internal agency factors influence regulatory agencies inspecting nursing homes across the United States. For instance, in chapter 4 the case study results show that the external actors that influenced Michigan implementation of the OBRA 87 enforcement laws included HCFA, the MDCIS, the governor, state senators, state representatives, the courts, the media, the 168 Long-Term Care Ombudsperson, the nursing home industry, the AARP, resident groups, and family groups. In chapter 5, the regression results indicate that interest groups and political institutions at the state level systematically influenced states implementing the OBRA 87 enforcement laws. Lastly, the regression results in chapter 6 suggest that external groups and political institutions influenced inspection managers and inspectors, and the working conditions of inspectors thereby systematically caused deficiency citations to decrease in states that did not support regulation. Also the results in chapter 6 indicate that external groups and political institutions influence inspectors’ views about managers in states that support regulation and systematically caused deficiency citations to increase. More specifically, the case study of Michigan in chapter 4 indicated that interest groups, state-level political institutions, the Long-Term Care Ombudsman program, the courts, and the media influence the state inspection agencies that implemented the OBRA 87 enforcement laws over the period 1995 through 1998. The systematic assessment of the influence of external environmental factors on states implementing the OBRA 87 enforcement laws covering the period 1991 through 1997 in chapter 5 also shows that the AARP (resident interest group), state—level political institutions, and nursing home structural factors influenced inspection agencies implementing the OBRA 87 enforcement laws across the United States. lastly, the systematic assessment of the external environmental factors and internal agency factors in chapter 6 indicate that external groups and political institutions pressure inspectors and managers, and external groups and political institutions exert pressure on inspectors, thereby influencing their views about managers and their working conditions. Therefore, it is argued that scholars 169 assessing the behavior of regulatory agencies should include measures for external environmental factors and internal agency factors in their studies. Comparison with the Literature In comparison to the Scholz and Wei (1986) study, this dissertation identified the systematic external environmental factors and the internal agency factors that influence the behavior of state regulatory agencies across the states and over time. The Scholz and Wei (1986) study identified the state-level political factors and agency task factors that systematically influenced the behavior of regulatory agencies across the states and over time. Both studies show that state-level factors systematically influence the behavior of regulatory agencies. This dissertation supplemented the findings from the GAO’s (1999) study, which examined the additional steps needed to improve and strengthen state implementation of the OBRA 87 enforcement laws. The GAO (1999) study cited problems with state inspection agencies and HCFA implementation of the OBRA 87 enforcement laws. The following are some of the problems they noted: forty percent of homes with severe deficiencies were repeat violators; the manner in which sanctions are implemented hampers their effectiveness; appeals backlogs hamper the deterrent effect of civil monetary fines; some procedures limit the ability to impose immediate sanctions; HCFA’s initiatives leave problem areas unresolved; the management information systems limited ability to support key HCFA initiatives; and HCFA was unable to identify homes under common ownership. This dissertation supplemented the GAO’s (1999) results by identifying which external environmental factors and internal state inspection agency 170 factors have systematically influenced states implementing the OBRA 87 enforcement laws. This dissertation utilized the data provided by the Harrington et al. (1999) study to create measures for the dependent variable and the nursing home structural factors. The Harrington et al. (1999) study, which provided descriptive data on nursing facilities, staffing, residents, and facility deficiency citations for the period 1991 through 1997, was an invaluable source of data that facilitated the analysis of the nursing home structural factors impact on deficiency citations assessed to noncompliant facilities across the United States. Spector and Takada (1991) examined the impact that the receipt of a severe federal citation had on the health outcomes of nursing home residents in Rhode Island. Their results indicated that the citation of serious deficiencies was associated with a reduced risk of decline of about 30 percent (Spector and Takada, 1991). This dissertation complements the Spector and Takada (1991) study by showing that external environmental factors and internal agency factors influence states implementing the OBRA 87 enforcement laws. Recommendations from this Dissertation to Policymakers and Public Managers Unlike the studies conducted by the GAO (1999) and Edelman (1998) assessing the implementation of the OBRA 87 enforcement provisions, this study examined the external environmental factors and the internal agency factors influencing inspection managers and inspectors implementing the OBRA 87 enforcement laws across the United States. Therefore, the recommendations of this dissertation for improving state enforcement will complement the recommendations proposed by the GAO (1999) and 171 Edelman (1998). This study recommends that policymakers, HCFA, and public managers perform the following: collect comparable resident complaint and budget data from the Long-Term Care Ombudsman programs across the states annually, assess the pressure exerted on inspection managers and licensing officers, assess the inspectors’ views about their work relationships with managers and licensing officers, assess the pressure that external groups and political institutions exert on inspectors, which influences their working conditions, examine states that have no deficiencies and high resident complaint data, examine the roles of the RN and the LPN to ensure that they provide direct patient care (see results sections in chapters 5 and 6), examine the relationships of state inspection agencies with HCFA regional office that oversees their activities, institute quality improvement teams consisting of inspectors to help nursing homes improve the care provided to residents, teach nursing homes how to meet and sustain compliance with the OBRA 87 nursing home reform laws, and reexamine the IDDR process, which creates a backlog and slows down the ability to impose sanctions on noncompliant facilities. All of the aforementioned recommendations can help to improve state implementation of the OBRA 87 nursing home reform laws. More importantly, these recommendations can help to improve state inspection systems and resident care despite the external 172 environmental factors and internal agency factors influencing the behavior of nursing home inspection agencies. Future Studies This dissertation identified some of the systemic external environmental factors and internal agency factors that influenced states implementing the OBRA 87 enforcement laws. Future studies should assess how much pressure inspection managers receive from external environmental factors and, the influence of inspectors’ relationships with managers on deficiency citations assessed to noncompliant nursing homes. Future studies should also examine the influence of resident characteristics on deficiency citations assessed to noncompliant nursing homes. 173 APPENDICES 174 APPENDIX A Tables Table 1. Status of OBRA 87 Nursing Home Reform Regulations as of February 1998 l OBRA 87 Nursing . Final , Fina] i Home Reform - Proposed Regulations Regulations . Provisions Regulations Published Effective . I Long-Term Care Standards for facility operations, 9/26/91 4/1/92 I Facility Require- residents’ rights, quality of care I ments and quality of life standards, 2 l staffing, administration, and physi- ' I cal environment. I Nurse Aide Train- Regulations for state oversight and 9/26/91 4/1/92 1 ing and Competen- evaluation of training and testing I cy Evaluation programs, curriculum, instructors’ I ' qualifications, and nurse aide I registries. I Survey and En- Regulations for state and federal 4/28/92 11/10/94 7/1/95 forcement Regula- inspections of nursing homes, tions investigations of abuse and ne- glect, and enforcement action in the event facilities do not meet the standards. Physical and Chem- Requires facilities to conduct 2/5/92 ical Restraints assessments and try alternatives before using restraints, and assure maximum resident function if restraints are used. Nursing Waivers Regulations governing state ap- 2/5/92 proval of facility requests to waive the licensed nurse staffing require- ments, and federal oversight of state approval. Waivers permit nursing homes to operate without professional nursing staff at any given time. Administrator Regulations establishing qualifica- 2/5/92 Qualifications tions for administrators. 175 Table 1 (cont’d). OBRA 87, Nursing Final :7, A Final . . .j Heme-RefOrm I_ ; - , _ PropOSed Regulations , Regulations L“ . Provisions. Description 7 Regulations Published Effective f I Charges to Resi- First required by the 1977 Medi- 11/12/92 10/1/93 I dents’ Funds care-Medicaid Fraud and Abuse | Amendments. OBRA 87 again I I required the HCFA to define what I I should be covered under Medicaid I I and thus not be billed to residents’ funds. I I Pre-Admission State screening of persons with 11/30/92 1/29/93 I Screening/ serious mental illness or mental I Annual Resident retardation to determine need for I Review nursing home care and specialized I services. Resident Assess- Minimum information facility staff 12/28/92 12/23/97 3/23/98 ment Instrument must know about each resident in order to provide care. Sources: Nursing Home Reform, September 1993. Long-Term Care Advocates ’ Desk Reference, The National Long-Term Care Ombudsman Resource Center, May 1994 with updated sections as of February 1998. Improving the Quality of Care in Nursing Homes, Committee on Nursing Home Regulation, Institute of Medicine, 1986. 176 Nursing Home Reform Law The Basics, National Citizens’ Coalition for Table 2. Enforcement Sanctions ‘ , In Place Before Added or ExpandedI ’ COBRA. 87 , Under OBRAi37-j’i? I Civil Monetary Penalties Penalties ranging from i $50 to $10,000. I I I Temporary Management The nursing home accepts ! a substitute manager I appointed by the state E with the authority to hire, ' terminate, and reassign I staff; obligate funds; and I alter facility procedures as I appropriate. I I I I I I | I I I H Denial of Payments Medicare and/or Medicaid payments can be denied for all covered residents X X or for newly admitted residents. Directed in-service Train- The nursing home is ing required to provide train- ing to staff on a specific X issue identified as a prob- 'l lem in the survey. I Directed Plan of Correc- The facility would be tion required to take action I within specified time I frames according to a I plan of correction devel- I oped by the HCFA, the I state, or the temporary I manager. I I I II State Monitoring An on-site state monitor can be placed in the nursing home to help ensure that the home I achieves and maintains compliance. eligible to receive Medi- care and Medicaid pay- X ments for beneficiaries residing in the facility. | Termination The provider is no longer I I I Source: GAO; “Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards”; GAO/HEHS-99-46 177 Table 3. Scope and Severity of Deficiencies “ ~ . ' -' Scope f VSanction‘ ‘ 1' Z Category Isolated V . Pattern: , , Widespread . . .Required _ Optional- Actual or poten- Group 3 Group 1 or 2 . tial for J K I death/serious I injury” ' Other actual Group 2 Group 1c G H harm Potential for Group 1 for Group 2 for . more than mini- D E categories D and categories D I ma] harm B; group 2 for and B; group 1 ' category F for category F Potential for None None minimal harm (substantial A B compliance) = §===I Source: GAO, “Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards,” March 1999. 2‘Group 1: sanctions are directed plan of correction, directed in-service training, and/ or state monitoring. Group 2: sanctions are denial of payment for new admissions or all individuals and/or civil monetary penalties of $50 to $3,000 per day of noncompliance. Group 3: sanctions are temporary management, termination, and/or civil monetary penalties of $3,050 to $10,000 per day of noncompliance. bThis category is referred to in regulations as “immediate jeopardy.” cSanctions for category I also include option for temporary management. The letters in the “isolated,” “pattern,” and “widespread” categories show the severity of the deficiencies, where “A” is a problem with the potential for minimal harm and is The letter “L” indicates that there is a facility problem that is widespread and many residents have actually been harmed or have the potential for being an isolated incident. banned. 178 Table 4. OBRA 87 Sanctions Imposed 1995—1996} - f 1996—1997 ' II Remedies Proposed Imposed . Proposed ' ‘ Imposed State Monitoring 2,022 128 1,873 50 I Directed Plan of Correction 2,895 36 2,423 31 I Temporary Management 18 l 15 5 I Denial of Payment for New Ad- 6,486 266 7,803 189 I missmns Denial of Payment for All Resn- 89 1 57 O I dents Directed In-Service Training 4,057 140 4,362 123 “ Civil Money Penalty 4,883 250 4,057 275 HCFA-Approved Alternative State Remedy 102 18 154 2 Transfer of Residents/ Closure Facility 1 O O 0 Transfer of Residents l 0 l 0 Termination 8,624 60 8,252 14 Source: Edelman, Tobi. 1998. Law Letter. “What Happened to Enforcement?” Nursing Home 179 Table 5. Significant Events Occurring During the Adoption and Implementation of Nursing Home Laws _ er , 1 9308 Event * Few privately owned homes and some not-for-profit facilities existed in the United States. States possessed sole authority to regulate the nursing home industry. 1935 Passage of the Social Security Act of 1935, which created Old Age Assistance programs. The Old Age Assistance program allowed the elderly to use funds from this program to pay for private boarding homes and opened opportunities for small proprietary ventures. However, this legislation prohibited payment for I persons in public institutions to discourage states from using the poorhouse system I as a means for dealing with problems of aged dependency. This legislation also assigned states the responsibility for establishing their own standards and payments methods. 1945 Inadequacies in the quality of care provided in many board and care/residential homes were brought to the attention of the public in hearings by the Senate .I Committee on Education and Labor. 1948 The Advisory Council on Social Security expressed concern about the quality of care in nursing homes. 1950 In 1950 amendments to the Social Security Act authorized payments to beneficiaries in public institutions and enabled direct payments to health care providers. The 1950 amendments to the Social Security Act also required that participating states establish programs for licensing nursing homes. 1952 A survey by the US. Public Health Service and the Commission on Chronic Illness found a serious shortage in the number of “skilled” care facilities. President Truman’s Commission on the Health Needs of the Nation recommended that existing small, independent nursing homes be replaced by “larger” homes located near hospitals and supervised and operated by hospitals. 1954 Dramatic growth occurred in the supply of facilities. For example, in 1954 there were approximately 9,000 nursing homes, which could be classified accordingly: 86 percent for-profit, 10 percent not-for-profit, and 4 percent public. The Hill-Burton Act was amended to provide funds to not-for-profit firms to construct nursing homes. 1956 The Senate Committee on Labor and Public Welfare published “Recom- mendations of the Commission on Chronic Illness on the Care of the Long-Term Facilities,” Studies of the Aged and Aging. This report described the continual deterioration of the quality of care in nursing homes due to inadequate financing. In response to this report, funding was increased for the following: 0 amendments to the Old Age Assistance Act created a new matching program I. for medical services to public assistance recipients, which included nursing home services; and 0 the Small Business Administration instituted a loan program for proprietary nursing homes. 180 Table 5 (cont’d). Year. : . ‘ I ' ‘ ‘ . Event)" 1955 throughout Several governmental units were commissioned to study the nursing home 1959 standards established by states. 1958 and 1959 Legislation was enacted authorizing the Small Business and Federal Housing Administrations to aid proprietary nursing home construction and operation. "1959 Congress established a mortgage insurance program for nursing homes: Section 232 of the Housing Act. . A special Senate Subcommittee on Problems of the Aged and Aging was I established in 1959. This subcommittee reported that only a few nursing homes were of high quality. Most facilities were substandard, had poorly trained or untrained staff, and provided few services. The subcommittee also concluded that due to the shortage of nursing home beds, many states had not fully enforced the existing regulations because they feared that strict enforcement would lead to closure of the majority of the facilities. 1960 The Social Security Act Amendments of 1960 (Kerr-Mill Act), established a new program of Medical Assistance for the Aged. In 1965 it was estimated that approximately 300,000 individuals were beneficiaries of the Kerr-Mills program. “The Condition of American Nursing Homes,” a study of the Subcommittee of Problems of the Aged and Aging of the Senate Committee on Labor and Public Welfare, found severe problems in nursing homes. The report highlighted inadequate regulations and poor enforcement. It recommended minimum standards for all facilities serving public assistance recipients. It reported inadequate financing for nursing home care. 1961 The results of the studies from the period 1955 through 1959 prompted the Senate to create the Special Committee on Aging chaired by Senator Frank Moss. This committee began to conduct hearings on nursing home problems in 1963 and documented great variation in state nursing home standards and enforcement efforts. 1965 On July 30, 1965 President Johnson signed the Social Security Amendments for the Medicare and Medicaid programs. The Medicare program provided funding to beneficiaries needing convalescence in extended care facilities only after hospitalization. The Medicaid program paid for skill nursing services. The Medicare and Medicaid programs brought nursing home regulation by the federal government for the first time. The federal government began tying H federal reimbursement to compliance with federal standards of care and safety. 1967 The 1967 Social Security Act Amendments (Moss Amendments) required that skill nursing facilities receiving payments under a state plan meet certain standards. Interim rules were published in 1969 and 1970. Some of the amendments to the Medicaid program included the following: 0 developing standards and regulations to be applied uniformly by the states; 0 creating a statutory definition of a skilled nursing facility; and 0 specifying standards for participating nursing homes. 181 Table 5 (cont’d). Year I . 1. Event Senator Edward Kennedy submitted a proposed amendment requiring states to establish programs for licensing nursing home administrators. l 969 States were required to establish regular programs of medical review whereby the care provided in nursing homes would be periodically evaluated. 1967 through 1 973 During the 19703, pressure was being exerted on Congress to increase the standards for nursing homes participating in the Medicare and Medicaid programs I and to improve state enforcement. The Moss committee began a series of hearings in 1969 that lasted until 1973, while the Department of Health, Education, and Welfare (HEW) and the US. General Accounting Office (GAO) examined state enforcement. Considerable controversy regarding regulations for nursing services was aired at the Moss hearings. Most testimony expressed the idea that requirements were too low and that there was a nursing shortage. 1970 through In 1970 and 1971 nursing home problems became the front page news with 1971 reports that a fire killed 32 residents in Ohio, a case of food poisoning in Maryland killed 36, and Congressman David Pryor reported on the floor of the House his experiences as a nursing home orderly. 1971 The undersecretary of HEW testified at a Moss committee hearing in 1971 that 74 ‘ percent of nursing homes participating in the Medicare program were certified with deficiencies, and more than 70 percent had deficiencies from 1968-1971. Senator Moss concluded that reliance on state enforcement machinery led to widespread nonenforcement of federal standards. The secretary of HEW told the White House Conference on Aging that 39 states had not been complying with federal requirements. Ii President Nixon made a major speech deploring conditions in nursing homes and pledged to end federal payments to substandard facilities. In a second speech, two months later, Nixon announced an 8-point plan to improve nursing home regulation. This plan included the federal government assuming 100 percent of the necessary costs of state inspection teams under the Medicaid program and the initiation of a comprehensive review of the use of facilities, standards, and practices in order to take remedial action as needed. This plan also included an initiative to centralize the Medicare and Medicaid enforcement activities. President Nixon also made proposals for the following: training nursing home staff; experimental funding of state nursing home ombudsmen; and creation of the Office of Nursing Home Affairs in HEW to coordinate new enforcement efforts and to conduct a comprehensive study of federal long-term care policies. Nine hundred Social Security offices were designated as “listening posts” to receive complaints about nursing homes and to provide the public with nursing home inspection records. 182 Table 5 (cont’d). 1972 Congress passed remnants of Nixon’s plan to improve nursing home regulation, which resulted in changes to the Social Security, Medicare, and Medicaid programs. The final regulations were promulgated in January 1974. The law provided: (1) full federal funding for state inspection and certification activities, (2) authorization for HEW to deve10p a single set of standards for Medicare and ‘ Medicaid skilled nursing facilities, (3) experimental funding for the state nursing home ombudsmen program, and (4) funding to establish the Office of Nursing Home Affairs (ONHA). I I I I Amendments to the Social Security Act, Public Law 92-603 combined extended I care facilities and skilled nursing homes into a single facility type—skilled nursing I facilities eligible for reimbursement under Title 18 (Medicare) and Title 19 I (Medicaid). The law required each state to establish a single state inspection I agency for both programs. I Congress directed the establishment of unified standards and regulations so that certification for participation under Medicare and Medicaid was to be obtained by demonstrating compliance with federal requirements. Section 249A gave the Secretary, rather than the states, final authority to determine the eligibility of skilled nursing facilities participating in Medicare and Medicaid. Section 249 authorized states to develop “reasonable cost-related reimbursement systems,” as determined in accordance with methods and standards that would be developed by the states but approved and verified by the Secretary. 1973 HEW published a “Patient Classification for Long Term Care: User’s Manual,” documenting the history and need for patient assessment and care management. The Subpart S regulations for Survey and Certification were published by HCFA. H LI>l974 The Special Committee on Aging published reports documenting the reasons for variation in state enforcement efforts in 1974 which included the following: ' enforcement meant the closure of facilities, already in short supply, leaving no place to put displaced residents; 0 states had few weapons other than the threat of license revocation to bring a home into compliance; 0 license revocation was useless due to the protracted administrative or legal procedures required; 0 judges were reluctant to close a facility when the operator claimed that deficiencies were being corrected; and 0 nursing home inspections were focused on operations and not patient care. Regulations to implement the new (1972) combined extended care facilities and skilled nursing homes classification into one category were issued October 1974. 183 Table 5 (cont’d). “Nursing Home Care in the United States: Failure in Public Policy,” was released in November 1974 by the Subcommittee on Long-Term Care of the Special Committee on Aging, US. Senate. Six reports were released. The Office of Nursing Home Affairs initiated a Long-Term Care Improvement Campaign, which included a survey of nearly 300 nursing homes, which was Phase I of the campaign. The ONHA conducted a study and found that the extent to which nursing homes complying with federal standards of care and safety varies widely. This study also found that the inspection regulations only looked at whether facilities had the capacity to deliver required services; not whether adequate quality care was actually being provided to patients. The ONHA developed a patient assessment instrument based on outcome measures, called the Patient Appraisal and Care Evaluation (PACE). The PACE forms and process was too complex, so the PACE was published for voluntary use by nursing homes. The ONHA was later called the Office of Long-Term Care. The Office of Long— Terrn Care, whose authority was later granted to the Health Care Financing Administration (HCFA) was established to oversee state implementation of the standards set forth for nursing homes participating in the Medicare and Medicaid programs. The ONHA released its first “Introductory Report,” to the Long-Term Care Facility Improvement Study. This report called for a total review of the inspection/certification system, stating, “there must be a shift from the facility’s capability to provide services to the patients and residents to assessing the services actually being provided to them.” The study called for nationwide training, credentialing, certification and licensure of all inspectors, a complete analysis of the fiscal approach of reimbursement, and training of all health professionals at all levels. 1975 Class-action filed. Smith v. O’Halloren, (Now Smith v. Bowen). Suite filed against a nursing home and the federal and Colorado state governments. Complaint is that the federal enforcement system fails to ensure that residents are receiving their Medicaid entitlement to optimal medical and psychosocial care in a safe, sanitary, rehabilitatively supportive, accessible and personalized environment and in a context of full civil liberties. In 1978, the plaintiffs dismissed the State of Colorado as a defendant and the state intervened and became one of the plaintiffs.) The trial was conducted in 1982. In 1983 the court ruled against the plaintiffs. The decision was reversed by the Court of Appeals in 1984. 1975 through The Senate Special Committee on Aging issued a series of reports entitled, 1976 “Nursing Home Care in the United States: Failure in Public Policy.” 1976 Phase II of the Long-Term Care Improvement Campaign was announced. This phase included the Patient Assessment/Care Evaluation (PACE) program. The PACE program was authorized to develop an inspection and certification process that was based on the quality of care provided rather than only the capability of facilities to provide care. 184 Table 5 (cont’d). [ Year” 8 Event . _ 1978 Amendments were added to the Older American’s Act for establishment of the Long-Term Care Ombudsmen program. The amendments gave the ombudsman program statutory authority: 0 to investigate and resolve complaints; 0 to monitor the development and implementation of federal, state, and local laws, regulations and policies 0 to provide information to appropriate government public agencies; 0 to provide for training volunteers and promoting the development of citizen organizations; 0 to develop procedures for appropriate access by the ombudsman to long-term care facilities and patient records; and 0 to establish measures to ensure patient confidentiality. 1980 The Boren Amendment was enacted, which required that state Medicaid nursing home reimbursement rates be “reasonable and adequate” to meet the costs that must be incurred by efficiently and economically operated facilities in order to provide care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards. This law restricted states’ freedom in setting Medicaid reimbursement rates and gave facilities a tool for pressuring state to increase the rates. HCFA released “Proposed Subpart S Revisions,” which was followed by a series of public hearings. HCFA published its proposed Conditions of Participation for nursing homes in the Federal Register, July 14, 1980. The proposal included a patient care/assessment management system. The public comment period ended October 14, 1980. HCFA then held hearings on proposed regulations in August and September. 1981 In January 1981, the Secretary of HHS, Patricia Harris, signed new regulations which elevated residents’ rights to a condition of participation for nursing homes. The regulations were rescinded January 21, 1981. promotion of revisions to Subpart S regulations. 1982 HCFA pulled back proposed Subpart S regulations, based on public opposition, but announced that it would proceed with proposed changes to the survey and certification program. m In June HCFA issued proposed regulations to change the survey system, offering ll HCFA established a “Task Force on Regulatory Reform,” which included a 60—day public comment period. The Senate Special Committee on Aging held hearings on the proposed changes. J calling for a two-year moratorium on regulatory action and a national commission on regulations. “Fa Representatives Pepper, Dingell, Waxman and Jacobs introduced legislation I 185 Table 5 (cont’d). I Year Event A six-month moratorium on any new rule-making relating to nursing homes was imposed when an amendment was attached to the Tax Equity Bill (Section 135 of Public Law 97-248). In October a new Congressional amendment extended the moratorium 120 days, directing HCFA to consult with Congress and seek public review and comment on proposed regulations. 1983 Congress resubmitted the 1982 legislative proposal, including a proposal for a study by the Academy of Sciences, Institute of Medicine (IOM). In May, HCFA began contract negotiations with IOM to conduct the study. The Subcommittee of Health and the Environment of the Committee on Energy and Commerce held a hearing on the proposal. The Institute of Medicine and HCFA contract was finalized and a two-year study began. The committee issued a report that identified the importance of enforcement to achieving high quality of care for residents. 1984 In Smith v. Bowen, the Tenth Circuit Court ruled that HHS has failed to carry out its duty to ensure that “nursing facilities receiving federal Medicaid funds are actually providing high-quality medical care,” and ordered HHS to take remedial action. 1985 HCFA proposed a new inspection process focused more on the care residents actually receive than on paper documentation. A new direction highlighted interviews with residents and direct observations of their condition during the inspection process. 1986 The Institute of Medicine issued its report, Improving the Quality of Care in Nursing Homes. The report called for major improvements in the standards of care nursing homes must meet, the inspection process, and the government’s enforcement of standards. mfl== HCFA recommended action to implement the report, including revisions in the Conditions of Participation and changes in the inspection system. 1987 Fifty national organizations joined in a Campaign for Quality Care to develop consensus positions for nursing home reform based on implementation of the IOM report. Senator Mitchell and Congressmen Dingell, Waxman, and Stark introduced sweeping nursing home reform legislation. HCFA issued two sets of proposed regulations: (1) Conditions of Participation (published in the Federal Register, October 16, 1987) and (2) Survey and Certification Procedures (published in the Federal Register November 18, 1987). On December 21, 1987 Congress enacted Public Law 100-203, The Omnibus Budget Reconciliation Act of 1987, which included Title C: Nursing Home Reform 42 U.S.C. 395i-3, 1396r. This legislation included many of the recommendations from the 1986 IOM report. 186 Table 5 (cont’d). In response to public opposition, HCFA withdrew its proposed regulations on Survey and Certification, but continued its proposed changes in the Conditions of Participation. HCFA began work on OBRA 87 implementation through development of new requirements. 1988 HCFA published a final rule on Survey Procedure, June 17, 1988 changing Medicare and Medicaid regulations to require that the state inspection agencies use the survey methods and procedures prescribed by HCFA and the forms contained in the regulations. The rule was in response to a court order in Smith v. Bowen, February 18, 1988. The rule included the new survey focus on outcomes of patient care and services through resident interviews and observation. Congress enacted technical amendments to the 1987 Nursing Home Reform Law. In December 1988 the first edition of HCFA’s “Medicare/Medicaid Nursing Home Information,” reports was released. These reports excerpted information from state inspections. Consumers and ombudsmen were not satisfied with the quality of the reports. 1989 HCFA published Long-Term Care Facility Requirements—final regulations with comment period to revise and consolidate the requirements that facilities furnishing long-term care are required to participate in both Medicare and Medicaid programs. The regulations contained revisions to the HCFA October 16, 1987 proposal based on comments submitted by the public. The regulations were to become effective August 1, 1989. Congress enacted amendments to OBRA 87 in December 1989, which included a directive to HCFA to delay implementation of the February 2, 1989 rule until October 1, 1990. HCFA published a new survey protocol in the State Operations Manual, Transmittal Number 232, September 1989 to be effective October 1, 1990. Congress enacted technical amendments to the 1987 Nursing Home Reform Law. Congressman Claude Pepper (D-Florida), a long-time champion for nursing home reform died. 19905 The Senate Subcommittee on Aging commissioned the GAO to assess the ombudsmen program. The GAO examined the usage of the ombudsmen program, barriers the ombudsmen encountered in gaining access to residents, and the impact of the program. The study found variations in the number of complaints reported, the ombudsmen did not have access to residents who were unable to provide written consent for an investigation, and the program could not be adequately examined for its impact due to failure of the Administration on Aging to collect the information necessary to evaluate the programs. 187 Table 5 (cont’d). [- Year . 1991 Event “I In March, after being under a preliminary injunction since January 11, in the Valdivia v. California DHHS lawsuit, California and HCFA reached agreement stipulating that California would implement the nursing home reform law, although consumers’ analysis was that HCFA capitulated to California demands. NCCNHR requested for the HHS Inspector General to review this agreement and was turned down. In June 1991, the Senate Special Committee on Aging conducted a hearing to review the agreement. Senator John Heinz (R-Pennsylvania), long-time advocate for nursing home reform, died April 4, 1991. On May 13, the American Health Care Association (AHCA) (the nursing home industry national trade association) filed a lawsuit against the DHHS over its process of approving state Medicaid plans. AHCA argued that the government lacked independent federal review procedures required by law to determine whether state reimbursement rates adequately covered nursing homes’ costs associated with OBRA 87 compliance. AHCA had previously filed two petitions with HCFA seeking the same ends. HCFA rejected the first and did not respond to the second. On June 20, a federal court ruled that AHCA had no legal standing to bring the suit. The judge ruled that AHCA had not demonstrated that it or any of its members had been harmed by DHHS’ alleged failure to collect enough data. The Food and Drug Administration set up a toll-free hotline to handle reports of deaths caused by physical restraints. On June 18, a federal appeals court upheld the process the HCFA used in issuing new nursing home requirements in 1989. Ruling in Gray Panthers Advocacy Committee v. Sullivan, the US. District Court of Appeals for DC. also refused to invalidate the requirements for social and dietary services, which plaintiffs argued were not as strong as those in place before the Nursing Home Reform amendments were enacted. The panel rejected consumers’ argument that OBRA 87 required HCFA to publish interpretive regulations for all nursing home requirements and to solicit public comments through the Federal Register. On September 26, HCFA published long-awaited final regulation on nurse aide training and competency evaluation and issued the “final final” version of its “Requirements for Long-Term Care Facilities.” The Requirements replaced the “final” regulations, which HCFA issued February 2, 1989 and became effective October 1, 1990. These regulations specify responsibilities for quality of care, quality of life, residents rights, environmental safety, and administration. Both regulations became effective April 1, 1992. On December 4, HCFA released a new draft of the Interpretive Guidelines and Survey Procedures for comment. 188 Table 5 (cont’d). ‘- Year 1 Event On February 5, HCFA issues proposed Omnibus Nursing Home Requirements. The public was given until April 6 to submit comments on proposals for regulating the use of physical and chemical restraints, evaluating nursing facilities requests for waivers of nurse staffing requirements, and setting basic federal qualifications for nursing home administrators. On June 19, the Food and Drug Administration proposed limited improvements in regulation of physical restraints. The proposed regulations impose a less rigorous definition of restraints than HCFA enforces in nursing homes. On August 28, HCFA issued the proposed regulations for inspections and enforcement. Controversial issues included “scope and severity” for determining deficiencies and the use of “conflict resolution” procedures in the inspection I process. The public comment period, which ended October 27, generated over 22,000 comments. On December 28, HCFA published proposed rules on the Resident Assessment Instrument. The public comments period ended February 26, 1993. 1993 DHHS Office of Inspector General issues report, “State Progress in Carrying Out the Nursing Home Survey Reforms.” Congressional committee action defeated proposed amendments that would permit a waiver of the 1987 federal nursing home reform law. Also dropped were amendments emerging from the Nursing Facility Assistance Act of 1993, sponsored by Representative Ralph Hall (D-Texas) and supported by the nursing home industry. 1994 In March, residents of Michigan nursing homes filed a lawsuit against the secretary of the Department of Health and Human Services for not implementing the enforcement provisions of OBRA 87 in the case Ottis et al. versus Donna Shalala. The court ordered Michigan to implement OBRA 87 Enforcement provisions by July 15, 1994. The court also required Michigan to outline its enforcement plan by March 15, 1994, for public comment. In November, HCFA published the final rule on survey and enforcement in the Federal Register. 1995 On July 1, implementation of the final survey and enforcement rule begins, despite a 90-day moratorium on civil monetary fines. The industry associations’ challenges to the OBRA 87 are filed in courts in Michigan and Illinois. Both suites are ultimately dismissed for lack of jurisdiction—the courts found that the nursing home plaintiffs had not exhausted required administrative avenues. Congress passed a budget that significantly weakens OBRA 87 and closely matches industry proposals for undermining the reform law’s quality standards. In December, President Clinton vetoed the budget bill and cited inadequate quality and income protection for nursing home residents. 189 Table 5 (cont’d). Year 1 996 Event I I HCFA holds “Listening Sessions” for consumers, providers, and professionals to I air their experiences with the new enforcement system. Retaliation against residents, families, and staff emerges as a major problem. In December, following a front page story in the New York Times highlighting consumer concerns, HCFA stops plans to narrow the federal inspection process. 1997 The Federal Balanced Budget Act of 1997 repealed the Boren Amendment, giving states greater freedom in setting nursing home payment rates. The repeal threatens a weakening of the law’s quality standards and deep cuts undermine quality and services. The House of Representatives Special Committee on Aging commissioned the GAO to study the implementation of OBRA enforcement provisions. In January, HCFA lifts the moratorium on civil monetary fines and revises its policy, limiting fines to more serious noncompliance, while expanding the informal dispute resolution policy and allowing providers to challenge the scope and severity of a deficiency. South Dakota is denied a waiver for an industry initiated inspection alternative challenged by advocates. HCFA Administrator Bruce Vladeck says the agency will not waive any rule “which alters in any way the inspection, certification, or enforcement process.” 1998 President Clinton announces a 21-point nursing home initiative to improve enforcement. This initiative will attempt to improve the quality of nursing home care by focusing on the following: strengthening enforcement; conducting criminal background checks; creating a national abuse registry; improving nutrition and hydration; and reauthorizing the nursing home ombudsmen program in the Older Americans Act. 1 999 GAO submitted its report entitled, “Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards.” This report contained the following recommendations to improve state implementation: 0 improve the effectiveness of civil monetary penalties; 0 strengthen the use and effect of termination; 0 improve the referral process; and 0 develop a better management information system 190 Table 5 (cont’d). A major new initiative to fight widespread malnutrition and related problems in nursing homes was launched today by the Nutrition Screening Initiative and a broad coalition of health care groups with the support of the US. Senate Special Committee on Aging and HCFA. The initiative is based on a new educational tool—Nutrition Care Alerts—designed to help front-line caregivers identify and address the most common nutrition-related problems. A multi-disciplinary team of nutrition, aging, and long-term care experts created the Alerts in direct response to findings last year of widespread nutrition problems in the nation’s long—term care facilities. HCFA has agreed to help pilot test the Care Alerts to ensure maximum effectiveness in the field. - _ ‘- - Sources: The Long-Term Care Advocates’ Desk Reference, published by the National Long-Term Care Ombudsman Resource Center, revised February 1998. Improving the Quality of Care in Nursing Homes, Committee on Nursing Home Regulation, Institute of Medicine, National Academy Press, Washington, DC. 1986. Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards, US. General Accounting Office, GAO/HEHS-99-46, March 1999. “Major Initiative Launched to Fight Malnutrition and Related Problems in Nursing Homes,” PRNewswire, August 5, 1999. “President Clinton’s Nursing Home Initiative and its Implementation, ” Nursing Home Law Letter, Issue Number 4, January 7, 1999. “What Happened to Enforcement?, ” Nursing Home Law Letter, Issues Number 1 and 2, February 13, 1998. “What Happened to Enforcement?, ” Nursing Home Law Letter, Issues Number 3 October 16, 1998. “Repeal of the Boren Amendment: Implications for Quality of Care in Nursing Homes,” New Federalism, The Urban Institute, Series A, Number A-30, December 1998. 191 Table 6. Percentage of Nursing Home Residents Receiving Medicaid Benefits by State: For the Years 1991, 1992, 1993, 1994, 1996, 1997, and 1998/1999 f State - 1991 ' 1992 1993 1994 1996 1997 1998/1999 Alabama 67 65 72 73 70 74 N/A Alaska 81 80 8O 80 89 70 67 Arkansas 80 80 80 80 75.6 76 73 Arizona“ 60 50 50 60 50 50 80 California" 67 67 62 68 66 65 65 Colorado 66 NA 65 65 83.5 60 60 Connecticut 64 64 66.9 70 70 70 N/A Delaware N/A 45 40 40 60 60 60 Florida 60 65 64 64 65 65 64 Georgia 78 80 80 80 80 80 81 Hawaii N IA 73 73 N/A 81.5 81 78 Idaho 62 62 62 62 62 60 63 Illinois 62 63 60 62 63 61 61 Indiana 60 70 67 N/A 68 68 69 Iowa 50 47. 1 N/A 50 50 52 52 Kansas 50 50 50 50 50 54 52 Kentucky 75 76 74 80 78 N/A N/A Louisiana 87.4 87.6 N/A N/A 87 84 89 Maine 78 76 76 82 84 63 63 “ Maryland 63 67.4 67.4 68 68 67 67 II Massachusetts 75 75 75 75 72 72 72 Michigan 70 65 69 69 70 70 70 Minnesota“ N/A 69.9 N/A 70 66 67 67 Mississippi 82 82 86 78 85 85 85 Missouri 51 47 58 58 57 57 66 Montana 62 62 N/A 63 62 62 60 Nevada N/A 65 68 62 67 64 67 192 Table 6 (cont’d). - , ; State 1991 1992 w 1993 ' [1997 1998/1999 New Hampshire 60 69.7 70 65 75 62 62 I New Jersey 70 N/A 68 85 69.9 69.9 70 I New Mexico 70 70 70 72 90 90 90 New York 79.9 83 83 82 80 80 80 I North Carolina 70 74 73 74 77 77 77 I North Dakota 55 55 54 57 57 54 55 I Ohio 70 74.7 70 7o 70 71.5 71 I Oklahoma 68.5 67.4 70 65 68 69.5 70 I Oregon 47 47 58 60 60 64 63 I Pennsylvania N/A 55 N/A N/A 60 63 66 I Rhode Island 72.4 75 75 80 75 75 75 I South Carolina 74 73 73 76 74.1 73.3 72 I South Dakota 54 57 N/A 65 56.5 57 62 I Tennessee 75 73 N/A N/A 76 78.5 78 I Texas 70 70 70 70 71.8 71.2 72 I Utah 75 66.2 66.2 65 7o 65 58 I Vermont 65.2 67 70.1 70 73 71 67 I Virginia 65 68.7 69 70 70 7o 70 "Washington 66 67 N/A 68 68 67 69 lLWest Virginia 71 71 73 73 76 78 76 lLWisconsin 65 70 65 65 65 66 N/A "Wyoming 63 63 59 66 64.2 60 63 I Source: HCIA Inc.‘ and Arthur Andersen CO. Note 1: * denotes that the state does not utilize the Medicaid program, but cre— ated some other health care program to provide funds to pay for the care of the indigent elderly. Note 2: Data were not available for the year 1995. 193 Table 7. Enforcement Sanctions Civil Monetary Penalties Description Penalties ranging from $50 to $10,000. In Place~_. _ Added or I _ Before- ”Expanded UnderII ‘ 7 ..033437 -.OBRA.37=W X Temporary Management The nursing home accepts a substitute manager appointed by the state with the authority to hire, terminate, and reassign staff; obligate funds; and alter facility procedures as appropriate. Denial of Payments Medicare and/or Medicaid payments can be denied for all covered residents or for newly admitted residents. Directed in-service Training The nursing home is required to provide training to staff on a specific issue identified as a problem in the survey. Directed Plan of Correction The facility would be required to take action within specified time frames according to a plan of correction developed by HCFA, the state, or the temporary manager. State Monitoring An on-site state monitor can be placed in the nursing home to help ensure that the home achieves and maintains compliance. Termination The provider is no longer eligible to receive Medicare and Medicaid payments for beneficiaries residing in the facility. Source: GAO; “Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards”; GAO/HEHS-99-46 194 Table 8. The OBRA 87 Sanctions Imposed in Michigan: July 1, 1997 to January 6, 1998 . . . . ' Hoposedfrom Proposed frOm I Remedies . Standard . a .f Complaint . < ~ . . . . 4 Inspections - ' Inspections . _ State Monitoring 395 131 14 Directed Plan of Correction 745 95 10 Temporary Manager 3 0 0 Denial of Payment for New 2,276 699 25 Admissions Denial of Payment for All 9 1 0 Residents Directed In-Service Training 1,256 366 65 Civil Monetary Penalty 925 300 65 HCFA-Approved Alternative 63 8 0 State Remedy Transfer of 0 0 0 Residents/Closure Facility Transfer of Residents 0 0 0 Termination 2,485 666 0 Source: The HCFA’s On-Line Survey, Certification, and Reporting System. 195 Table 9. Estimate of the Influence of Michigan Actors on the OBRA 87 Enforcement Regulations ' Standard- ’ - . 'f Respondent 5 I 1* V I": = . . I" » DeviatiOn American Association of Retired Persons 8 1.9 1.6 1.0—5.0 Courts 10 5.7 3.0 2.0—10.0 Governor and Governor’s Appointees 9 7.2 3.1 3.5—9.0 Health Care Association of Michigan 9 6.6 2.5 2.0—8.0 Health Care Financing Administration 9 6.8 2.0 3.5—9.0 Long-Term Care Ombudsman 6 5.6 3.2 1.0—9.0 Media 9 5.6 3.0 1.0—9.5 II Michigan Association of Homes and 8 5.5 1.5 3.5-8.0 Services for the Aging Michigan Department of Consumer and 8 6.1 3.1 1.0-9.0 Industry Services Other Actors in Michigan 9 State Representatives 8 State Senators 8 II Note: Entries are mean estimates of the perception of participants’ impact on the OBRA 87 enforcement regulations. A rating of “1” signifies a very low impact, while a rating of “10” signifies a very high impact. 196 Table 10. Participants’ Perceptions of their Influence on Improving or Hindering Enforcement Regulations Hinder and Do Not Participant f Hinder Improve Know/Neither» Participants’ Organization 9 O 0 0 (n = 9) Health Care Financing 4 2 3 0 Administration (11 = 9) Michigan Department of 2 4 2 O IIConsumer and Industry Services (11 = 8) Long-Term Care Ombudsman 5 O O 1 (n = 6) American Association of 1 1 O 6 lRetired Persons (11 = 8) Health Care Association of 1 6 O 2 Michigan (11 = 9) Michigan Association of 1 5 O 2 Homes and Services for the “Aged (11 = 8) Governor and Governor’s 1 7 0 l Appointees State Senators (n = 8) 2 3 O 3 State Representatives (n = 8) 5 2 O l Courts (n = 10) 2 5 2 1 6 2 0 l I Media (11 = 9) ‘7 Note: Scores reported reflect frequency of participants selecting a response for the fol- lowing question for each participant listed above: In your view, did (participant) hinder or improve enforcement? Two new response categories were created because some respondents selected hinder and improve, and some respondents stated neither/do not know. 197 Table 11. Regional Inspection Activity: July 1, 1997 to January 6, 1998 .- Inspection Activity Summ' j ary " _Istandard Insocc’tion. complaint. Inspection Inspections Completed 4,399 10,254 Facilities in Substantial Compliance 1,408 (32.1%) 8,902 (86.8%) *Facilities with Substandard 2,991 (67.9%) 1,352 (13.2) Compliance Total immediate remedies proposed 27 48 Total with opportunity to correct 2,991 1,331 Facilities with substandard quality 161 106 of care Dispute Resolution Reviewed 403 154 Facilities verified on revisits in 3,570 979 substantial compliance Note: *Facilities with substandard compliance is classified in this category when any deficiency in 42 CFR 483.13, Resident Behavior and Facility Practices, 42 CFR 483.15 Quality of Life, or 42 CFR 483.25 Quality of Care that constitutes immediate jeopardy to resident health or safety, or a pattern of or widespread actual harm that is not immediate jeopardy; or, a widespread potential for more than minimal harm that is not immediate jeopardy, with no actual harm. 198 Table 12. Description of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Periods 1991 through 1994, 1995 through 1997, and 1991 through 1997 n . Minimum, ‘ Dependent Variable: Deficiencies 1991—1994 8.1 4.1 1.6 19.3 196 1995-1997 5.2 2.6 1.5 15 147 1991—1997 6.8 3.8 1.5 19.3 343 Independent Variables: Interest Groups AARP 1991—1994 .2 .03 1 .3 196 1995-1997 .2 .04 .09 .3 147 1991—1997 .2 .03 l .3 343 Nursing Home Industry 1991—1994 .009 .003 .0001 .02 196 1995-1997 .009 .003 .002 .02 147 1991—1997 .009 .003 .0001 .02 343 Executive and Legislative Political . Institutions ‘ Republican Governor and Unified Republican Legislature 1991-1994 .1 .3 0 1 196 1995—1997 .2 .4 0 l 147 1991-1997 .1 .4 0 1 343 Republican Governor and Unified Democratic Legislature 1991-1994 .2 .4» 0 l 196 1995-1997 .2 .4 0 1 147 1991—1997 .2 .4 o 1 343 11 Republican Governor and Split Legislature 1991—1994 .1 .3 0 l 1964 1995—1997 .1 .3 o 1 147 ll 1991-1997 .1 .3 0 1 343 J] 199 Table 12 (cont’d). . ~' Minimum' Maximum - . ' Democratic Governor and Unified Democratic Legislature 1991—1994 .4 .5 0 1 196 1995—1997 .2 .4 0 1 147 1991—1997 .3 .5 0 1 343 Democratic Governor and Unified Republican Legislature H 1991—1994 .1 .2 o 1 196 II 1995—1997 .1 .3 0 1 147 II 1991-1997 .1 _ .3 0 1 343 Democratic Governor and Split ll Legislature 1991—1994 .1 .4 0 1 196 l| 1995-1997 .1 .3 0 1 147 1991-1997 .1 .3 0 1 343 Nursing Home Structural Controls [I RN Hours 1991—1994 .5 .2 .2 1.3 196 ll 1995-1997 .7 .2 .3 1.7 147 1991—1997 .6 .2 .2 1.7 343 LPN/LVN Hours It 1991-1994 .6 .2 .3 1.2 196 I 1995—1997 .7 .2 .3 1.1 147 1991-1997 .6 .2 .3 1.2 343 Nursing Assistant Hours 1991—1994 2.1 .2 1.6 3.1 196 fl 1995—1997 2.1 .2 1.6 3.0 147 1991-1997 2.1 .2 1.6 3.1 343 Resident Group 1991-1994 93.3 5.2 67.6 100 196 1995—1997 90.5 10.8 o 100 147 1991—1997 92.1 8.2 0 100 343 ll 200 Table 12 (cont’d). _ 7 , Mean SD. Minimum Maximum n i Family Group I 1991-1994 45.4 13.2 19.2 81.2 196 1995—1997 44.4 13.0 0 75.7 147 1991-1997 44.9 13.1 0 81.2 343 Time Controls 1991—1994 1991 .3 .4 0 l 196 1992 .3 .4 0 1 196 1993 .3 .4 0 l 196 1994 .3 .4 0 1 [I 1995—1997 1995 .3 .5 0 1 I 1996 .3 .5 0 1 1997 .3 .5 0 1 1991-1997 1991 .1 .4 0 l 1991 .1 .4 0 l 1991 .l .4 O 1 1991 .1 .4 0 l 1991 .l .4 0 1 1991 .1 .4 0 1 1991 .l .4 0 l Lag of the dependent variable 1991-1994 8.4 4.2 1.6 19.3 1995-1997 5.9 3.0 1.5 18.4 1991-1997 7.1 3.9 1.5 19.3 Sources: The Guide to the Nursing Home Industry, 1991, 1992, I993, I994, I996, 1997, and 1998/99; Reforming the Health Care System State Profiles, 1990, I991, 1993, 1994, 1995, 1996, and 1997; Nursing Facilities, Stafiing, Residents, and Facilities Deficiencies, 1991 through 1997; The World Almanac and Book of Facts, 1991, 1992, 1993, 1994, I995, 1996, and 1997. 201 Table 13. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Period 1991 through 1994 f Coefficient" ‘ ,3 t-value , I E! Deficiencies g Interest Groups I AARP -72 -.7 10.1 ' Nursing Home Industry 3295 -2.9*** 114.0 1' Executive and Legislative Political Institutions 1 Democratic Governor and Unified Democratic -.3 -.3 1.0 ' Legislature : Democratic Governor and Unified Republican 2.1 1.5 1.3 1 Legislature ' Democratic Governor and Split Legislature .5 .5 1.1 : Republican Governor and Unified Democratic .3 .3 1.0 5 Legislature Republican Governor and Split Legislature 1.3 1.0 1.3 Nursing Home Structural Controls RN Hours ~.5 -.2 2.0 LPN/LVN Hours 4.2 2.2** 1.9 Nursing Assistant Hours -1.7 -1.2 1.4 Resident Group -. 1 -1 .9* .1 Family Group .01 .2 .03 Time Controls 1992 -.6 -.8 .8 1993 -.9 -1.2 .8 1994 —l.7 -1.9** .9 Intercept Term 25 3.7*** 6.7 N = 196; R2 = .21 *statistically significant at p < .10 (two-tailed test); ”significant at p < .05 (two-tailed test); ***significant at p < .01 (two—tailed test) Sources: The Guide to the Nursing Home Industry, 1991, I992, 1993, and 1994; Reforming the Health Care System State Profiles, 1990, I991, 1993, and 1994; Nursing Facilities, Staffing, Residents, and Facilities Deficiencies, 1991 through 1997 Note 1: Regression results were estimated using panel data for 49 states for the period 1991 through 1994. Note 2: Data for the AARP were not available for 1991; therefore, 1990 was used as an estimate for 1991. 202 Table 14. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity: Covering the Period 1991 through 1994 .. ; -m _7 Deficiencies 1 H Interest Groups : ' AARP -16.4 -1.8* 9.0 1 Nursing Home Industry -l49.3 -1.5 101.6 1 Executive and Legislative Political Institutions i Democratic Governor and Unified Democratic -.3 -.4 .9 ' Legislature L Democratic Governor and Unified Republican 2.9 2.4** 1.2 , Legislature 1 Democratic Governor and Split Legislature 1.0 1.0 1.0 I Republican Governor and Unified Democratic .4 .4 .9 ’ Legislature Republican Governor and Split Legislature 1.4 1.2 1.2 . Nursing Home Structural Controls : RN Hours .6 .3 1.8 LPN/LVN Hours 2.2 1.3 1.7 L Nursing Assistant Hours -1.2 -.9 1.3 : Resident Group - . 3 -5. 1*** . 1 1 Family Group .04 1.6* .02 Time Controls ! 1992 -1.5 -2.2** .7 l 1993 -1.6 -2.4** .7 i 1994 -2.2 -2.9*** j Intercept Term 40 6.6*** 6.0 ! N = 196; R2 = .21 , *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test) Sources: The Guide to the Nursing Home Industry, 1991, 1992, 1993, and 1994; Reforming the Health Care System State Profiles, 1990, 1991, 1993, and 1994; Nursing Facilities, Stafi‘ing, Residents, and Facilities Deficiencies, 1991 through 1997 Note 1: Robust regression was run to correct for heteroscedasticity. The results were estimated using panel data for 49 states for the period 1991 through 1994. Note 2: Data for the AARP were not available for 1991; therefore, 1990 was used as an estimate for 1991. 203 Table 15. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity and Autocorrelation: Covering the Period 1991 through 1994 Coefficient I t—value . m Deficiencies i If Interest Groups ’ AARP -25 -.4 6.3 1 Nursing Home Industry -100.4 -1.5 68.8 : Executive and Legislative Political Institutions ! Democratic Governor and Unified Democratic .9 1.6 .6 ' Legislature [ Democratic Governor and Unified Republican -.04 -.05 .8 I Legislature Democratic Governor and Split Legislature 1.4 2.1** .7 .| Republican Governor and Unified Democratic 1.3 2.0“ .6 i Legislature 1 Republican Governor and Split Legislature .8 1.1 8 I Nursing Home Structural Controls l RN Hours -.7 -.5 1.3 i LPN/LVN Hours -.3 -.3 1.1 i Nursing Assistant Hours -l.0 -1.2 .9 i Resident Group . 1 2 .O** .04 a Family Group -.02 -1.1 .02 Time Controls II 1993 .6 1.5 .4 1994 .7 1.5 .5 Lag of the dependent variable 21 .0*** .04 Intercept Term -4.0 -.9 4.3 N = 147; R2 = .76 *statistically significant at p < .10 (two-tailed test); ”significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test) The Guide to the Nursing Home Industry, 1991, 1992, I 993, and 1994; Reforming the Health Care System State Profiles, 1990, I991, 1993, and 1994; Nursing Facilities, Stafiing, Residents, Robust regression was run to correct for heteroscedasticity and a lag of the dependent variable was included in the model to correct for autocorrelation. The results were estimated using panel Sources: and Facilities Deficiencies, 1991 through 1997 Note I: data for 49 states for the period 1991 through 1994. Note 2: Data for the AARP were not available for 1991; therefore, 1990 was used as an estimate for 1991. 204 Table 16. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Period 1995 through 1997 ---m Deficiencies Interest Groups AARP -4.9 -.8 6.5 Nursing Home Industry -96.9 -1.2 79.9 I Executive and Legislative Political Institutions I Democratic Governor and Unified Democratic -.4 -.7 .6 I Legislature I Democratic Governor and Unified Republican -.7 -.8 .9 I Legislature :I Democratic Governor and Split Legislature 1.6 2.3** .7 I Republican Governor and Unified Democratic .3 .5 .6 I Legislature Republican Governor and Split Legislature 1.0 1.4 .7 I Nursing Home Structural Controls I RN Hours 2.8 2.1** 1.4 I LPN/LVN Hours 4.0 3.2*** 1.3 I Nursing Assistant Hours —1 .1 -1.2 1.0 I Resident Group .01 .5 .03 I Family Group -.002 -.1 .02 I Time Controls I 1996 -1.2 -2.5*** I 1997 -1.6 -2.6*** .6 Intercept Term 4.3 1.1 4.1 I N = 147; R2 = .28 *statistically significant at p < .10 (two—tailed test); “significant at p < .05 (two—tailed test); ***significant at p < .01 (two-tailed test) Sources: Note 1 : The Guide to the Nursing Home Industry, 1996 and 1997; Reforming the Health Care System State Profiles, 1995, I 996, and I 997; Nursing Facilities, Staffing, Residents, and Facilities Deficiencies, 199] through 1997 Regression results were estimated using panel data for 49 states for the period 1995 through 1997. 205 Table 17. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity: Covering the Period 1995 through 1997 Deficiencies Interest Groups AARP -8.6 -1.4 6.0 Nursing Home Industry 47.4 .6 74.6 I Executive and Legislative Political Institutions I Democratic Governor and Unified Democratic .1 .1 .6 Legislature I Democratic Governor and Unified Republican .04 .05 .8 I Legislature Democratic Governor and Split Legislature 2.0 3.0*** .7 Republican Governor and Unified Democratic .6 .5 Legislature Republican Governor and Split Legislature .3 .4 .6 Nursing Home Structural Controls RN Hours 3.7 2.9*** 1.3 LPN/LVN Hours 4.0 3.4*** 1.2 Nursing Assistant Hours -1.0 -1.1 .9 Resident Group .01 .5 .02 Family Group .002 .1 .02 Time Controls 1996 -1.1 -2.3** .5 II 1997 -1.3 -2.3** .6 Intercept Term 2.2 .6 3.8 N = 147; R2 = .28 *statistically significant at p < .10 (two-tailed test); “significant at p < .05 (two-tailed test); ***significant at p < .01 (two—tailed test) Sources: Note 1: The Guide to the Nursing Home Industry, 1996 and 1997; Reforming the Health Care System State Profiles, 1995, I 996, and 1997; Nursing Facilities, Stafi‘ing, Residents, and Facilities Deficiencies, 1991 through 1997 Robust regression was run to correct for heteroscedasticity. The results were estimated using panel data for 49 states for the period 1995 through 1997. 206 Table 18. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity and Autocorrelation: Covering the Period 1995 through 1997 - _7 Coefficient . - . t-value “I Deficiencies I II Interest Groups I If AARP .5 .2 2.8 I II Nursing Home Industry 24.11 .7 34.9 I H Executive and Legislative Political Institutions I Democratic Governor and Unified Democratic -.2 -.8 .3 I Legislature I Democratic Governor and Unified Republican .2 .4 .4 I Legislature I Democratic Governor and Split Legislature 1.8* .3 I Republican Governor and Unified Democratic -.4 -1.5 Legislature Ir Republican Governor and Split Legislature .3 1.0 Nursing Home Structural Controls RN Hours -.9 -1.6 LPN/LVN Hours .4 .6 Nursing Assistant Hours .3 .6 Resident Group -.01 -1 .1 Family Group .001 .2 Time Controls 1996 -.4 -1.7* 1997 1.4 Lag of the dependent variable 26.6*** ll Intercept Term .9 .5 N = 147; R2 = .78 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test) Sources: Note 1: The Guide to the Nursing Home Industry, I 996 and 1997; Reforming the Health Care System State Profiles, 1995, 1996, and 1997; Nursing Facilities, Stafiing, Residents, and Facilities Deficiencies, 1991 through 1997 Robust regression was run to correct for heteroscedascity; the family group variable was dropped to correct for multicollinearity; and a lag of the dependent variable was added to the model to correct for autocorrelation. The results were estimated using panel data for 49 states for the period 1995 through 1997. 207 Table 19. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State: Covering the Period 1991 through 1997 Deficiencies I Interest Groups AARP -6.2 -.9 6.8 Nursing Home Industry -245.5 -3.3*** 74.4 ==Ir-= Executive and Legislative Political Institutions Democratic Governor and Unified Democratic -.4 -.7 .6 Legislature Democratic Governor and Unified Republican .6 .7 .8 Legislature fl Democratic Governor and Split Legislature .7 1.1 [ Republican Governor and Unified Democratic .2 .3 Legislature Republican Governor and Split Legislature .9 1.2 l Nursing Home Structural Controls RN Hours 1.1 .9 II LPN/LVN Hours I 4.6 38*“ Nursing Assistant Hours -1.8 -2.0** I Resident Group -.01 -.2 Family Group -.002 -.1 I Time Controls 1992 -.7 -1.1 l 1993 -1.0 -1.4 1994 -1.9 -2.7*** 1995 -3.4 -4.8*** 1996 —4.4 -6.0*** 1997 -4.6 -5.5*** Intercept Term 13.1 3.5*** N = 343; R2 = .29 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test) Sources: The Guide to the Nursing Home Industry, 1991, I992, I993, 1994, 1996, and 1997; Reforming the Health Care System State Profiles, I 990, 1991, I 993, 1994, I 995, 1996, and 1997; Nursing Facilities, Stafiing, Residents, and Facilities Deficiencies, 1991 through 1997 Note: Regression results were estimated using panel data for 49 states for the period 1991 through 1997. 208 Table 20. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity: Covering the Period 1991 through 1997 Coefficient Deficiencies Interest Groups II AARP -10.0 -1.7* 5.9 || Nursing Home Industry -46.9 -.7 64.5 JI Executive and Legislative Political Institutions Democratic Governor and Unified Democratic -.4 -.8 .5 Legislature I Democratic Governor and Unified Republican 1.2 1.7* .7 I Legislature Democratic Governor and Split Legislature 1.2 2.1** .6 Republican Governor and Unified Democratic .3 .6 Legislature Republican Governor and Split Legislature .5 .8 .6 Nursing Home Structural Controls RN Hours 2.7 2.5*** 1.1 LPN/LVN Hours 5.3 5.1*** 1.0 Nursing Assistant Hours -1.7 -2.2** Resident Group .001 .04 Family Group .01 .8 Time Controls 1992 -1.2 -2.1** 1993 -1.8 -3.1*** 1994 —2.6 —4.1*** 1995 -3.6 -5.8*** 1996 -4.6 -7.3*** 1997 -4.8 -6.7*** Intercept Term 8.9 2.7*** N = 343; R2 = .30 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test) Sources: The Guide to the Nursing Home Industry, 1991, I992, 1993, 1994, 1996, and 1997; Reforming Note: the Health Care System State Profiles, 1990, I991, I993, I994, 1995, 1996, 1997; Nursing Facilities, Stafi‘ing, Residents, and Facilities Deficiencies, 1991 through 1997 Robust regression was run to correct for heteroscedasticity. The results were estimated using panel data for 49 states for the period 1991 through 1997. 209 Table 21. Estimated Model of the External Environmental Factors Influencing the Average Number of Deficiencies Cited per Facility by State Correcting for Heteroscedasticity and Autocorrelation: Covering the Period 1991 through 1997 Coefficient t-value S.E. Deficiencies I Interest Groups I AARP 1.4 .5 2.9 P Nursing Home Industry -12.1 -.4 33.4 4 Executive and Legislative Political Institutions 1 Democratic Governor and Unified Democratic -.02 -.l .3 i Legislature 1 Democratic Governor and Unified Republican -.01 -.01 .4 . Legislature 1 Democratic Governor and Split Legislature .6 2.1" .3 1 Republican Governor and Unified Democratic -.l -.3 .3 ' , Legislature ! Republican Governor and Split Legislature .3 .9 .3 ll Nursing Home Structural Controls RN Hours -1.0 -1.7* .6 LPN/LVN Hours -.1 -.1 Nursing Assistant Hours .2 .6 .4 Resident Group -.01 -.6 .01 Family Group -.004 -.5 .01 Time Controls 1993 .5 1.9* 3 1994 .6 2.2“ 3 1995 .l .5 .3 1996 -.1 -.4 3 l 1997 .6 1.7* 4 Lag of the dependent variable .9 37.0*** .02 ! Intercept Term .8 .5 1.7 l N = 294; R2 = .85; *statistically significant at p < .10 (two-tailed test); "significant at p < .05 (two- tailed test); ***significant at p < .01 (two—tailed test) Sources: Note: The Guide to the Nursing Home Industry, 1991, 1992, I 993, I994, 1996, and 1997; Reforming the Health Care System State Profiles, 1990, I991, 1993, I 994, I 995, 1996, and 1997; Nursing Facilities, Staffing, Residents, and Facilities Deficiencies, 1991 through I 997 Robust regression was run to correct for heteroscedascity; the family group variable was dropped to correct for multicollinearity; and a lag of the dependent variable was added to the model to correct for autocorrelation. The results were estimated using panel data for 49 states for the period 1991 through 1997. 210 Table 22. Description of the External Environmental Factors and Internal Agency Factors Influencing Enforcement { T Minimum Maximum Dependent Variable: Deficiencies 5.2 2 .6 1 .5 15 69 Independent Variables: External Environmental Factors External Groups and Political -.1 .7 -.84074 1.77442 Ii Institutions Pressuring Inspection Managers External Groups and Political .01 1.1 -.95349 3.62666 Institutions Pressuring Inspectors Internal Agency Factors Working Conditions for Inspectors .1 .9 -1.83995 1.80363 Inspectors’ Views about Managers .1 .9 -2.03954 1.44461 I Managers’ Views about Inspectors -.1 1.1 -1.44454 1.79058 Interactions between External Factors and Internal Agency Factors External Groups and Political Institutions -.1 .7 -1.49132 1.086602 Pressuring Managers and Influencing Fl Their Views about Inspectors External Groups and Political Institutions -.1 1.2 -3.118178 3.736605 Pressuring Inspectors and Influencing Their Views about Managers External Groups and Political Institutions -.3 .8 -1.545098 2.051873 Pressuring Inspectors and Influencing Their Working Conditions Nursing Home Structural Controls fl RN hours .7 .2 .3 1.7 H LPN hours .7 .2 .3 1.1 NA hours 2.1 .2 1.6 3 Time Controls '1 1995 .33 .5 o 1.0 1996 .33 .5 0 1.0 1997 .33 .5 0 1.0 Lag of the Dependent Variable 5.9 3.0 1.5 18.4 211 Table 23. Factor Analysis Results _— . . % of Var. Eigenvalue Explained . External Environmental Factors Indices ' I External Groups and Political Institutions 3.6 39.5% .70 32 ‘ Pressuring Managers Index I Governor .73 ‘ Senators .77 i Representatives .87 ‘ I HCFA .51 ! Nursing Home Industry Association .57 i AARP .84 ' Resident Groups .48 Family Groups .39 External Groups and Political Institutions 3.3 41.0% .80 26 Pressuring Inspectors Index Governor .83 1 Senator .69 Representatives .90 } HCFA .64 Nursing Home Industry Association .28 Resident Groups .19 Family Groups .74 Internal Agency Factors Indices Inspectors’ Working Conditions Index 1.6 53.8% .60 29 Conditions concerning their job .65 Pay .85 Pressure on the job .68 Managers’ Working Conditions Index 1.7 34.6% .50 31 Pay .77 Pressure on the job .59 Job unpleasant .67 ll Job satisfaction .30 212 Table 23 (cont’d). . I. Factor % of Var. j Loadings Eigenvalue Explained Alpha n Manager’s Views about Inspectors Index 2.2 55.8% .70 32 Discussion about important things .75 Sharing information .63 Trust and confidence .83 Inspectors’ morale .76 Inspectors’ Views about Management Index 4.3 42.8% .81 27 Discussion about important things .78 lESharing information .81 ll Trust and confidence .71 ll Problems .43 Working conditions .49 Boss’s own success .58 Training .67 Cooperation .61 Improvements .49 Superior’s trust .82 II 213 Table 24. Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspection Managers l Deficiencies I [Independent Variables: External Environmental Factors External Groups and Political Institutions Pressuring Managers -.4 -2.0** .2 Interaction Terms for External Environmental Factors and Internal Agency Factors External Groups and Political Institutions Pressuring Managers -.3 -1.5 .2 and Influencing Their Views about Inspectors Nursing Home Structural Controls RN hours .9 1.3 7 ll LPN hours 1.8 2.1** .9 "i NA hours -.4 -.8 .5 Time Controls 1996 -.3 -1.2 .3 1997 .1 .3 .3 Lag of the Dependent Variable .7 15.4*** .05 Intercept Term -.1 —.1 1.1 n = 69; R2 = .85 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test). Sources: Nursing Facilities, Staffing, Residents, and Facilities Deficiencies, I 991 through 1997. Surveys administered to nursing home inspection managers covering the period 1995 through 1998. Note I: The figures are estimated regression results from survey data for 23 states covering the period 1995 through 1997. Note 2: The working conditions index for managers was not used to create a variable because it was not very close to the .70 alpha level recommended by Nunally (1978). Therefore, a variable was not created to account for the pressure that external groups and political institutions exert on managers, which could influence their working conditions. 214 Table 25. Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspectors ' i , Coefficient Dependent Variable: Deficiencies External Environmental Factors External Groups and Political Institutions Pressuring Inspectors -.2 -1.6 .1 Interaction of External Environmental Factors and Internal Agency Factors External Groups and Political Institutions Pressuring Inspectors .3 1.7* .2 Independent Variables: and Influencing Their Views about Managers ’ External Groups and Political Institutions Pressuring Inspectors -.4 -1.5 .2 and Influencing Their Working Conditions ll Nursing Home Structural Controls ll RN Hours .1 .1 .7 LPN Hours/LVN hours 1.2 1.6 .8 Nursing Assistant Hours -.7 -1.3 .5 Time Controls 1996 -.2 -.6 .3 1997 .3 .9 .4 Lag of the Dependent Variable .8 16.3*** .04 "Intercept Term 1.2 1.0 1.2 n = 69; R2 = .83 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test). Sources: Nursing Facilities, Stafling, Residents, and Facilities Deficiencies, 1991 through 1997. Surveys administered to nursing home inspectors covering the period 1995 through 1998. Note I: The figures are estimated regression results from survey data for 23 states covering the period 1995 through 1997. Note 2: The working conditions index for inspectors was used to create a variable because its alpha was .63, which was very close to the .70 level recommended by Nunally (1978). Therefore, a variable was created to account for the pressure that external groups and political institutions exert on inspectors, which can influence their working conditions. 215 Table 26. Estimated Model of the External Environmental Factors and Internal Agency Factors Influencing Inspection Managers and Inspectors . ‘" f ' 7mm: S.E., ! Dependent Variable: Deficiencies ——T_ ! Independent Variables: External Environmental Factors External Groups and Political Institutions Pressuring Managers -.3 -1.5 .2 : External Groups and Political Institutions Pressuring Inspectors —.1 -.5 .2 ! Interaction of External Environmental Factors with Internal ‘ Agency Factors External Groups and Political Institutions Pressuring Managers -.3 -1.5 .2 and Influencing Their Views about Inspectors External Groups and Political Institutions Pressuring Inspectors .1 .4 .2 and Influencing Their Views about Managers External Groups and Political Institutions Pressuring Inspectors .02 .1 .3 ‘ and Influencing Their Working Conditions I Nursing Home Structural Controls ‘ RN Hours .9 1.3 .7 I LPN Hours/LVN hours 1.7 1.7* 1.0 J Nursing Assistant Hours -.5 -.9 .5 Time Controls 1996 -.3 -l.l .3 1997 .1 .3 .4 Lag of the Dependent Variable .7 l4.6*** .1 Intercept Term .2 .1 1.3 n = 69; R2 = .85 *statistically significant at p < .10 (two-tailed test); **significant at p < .05 (two-tailed test); ***significant at p < .01 (two-tailed test). Sources: Nursing Facilities, Staffing, Residents, and Facilities Deficiencies, 1991 through 1997. Surveys administered to nursing home inspectors covering the period 1995 through 1998. Note 1: The figures are estimated regression results from survey responses from inspectors and managers from 23 states covering the period 1995 through 1998. Note 2: The working conditions index for inspectors was included in the model estimated even though the alpha level was .63 and not .7 as recommended by Nunnally (1978) because this factor has substantive significance and was very close to .7. The working conditions index for managers was not included in the model estimated because it was not very close to the .7 alpha level recommended by Nunally (1978). 216 Table 27. Deficiency Citation Data: Average Number of Deficiencies per Certified Nursing Home Facility by State over the Years 1991-1997 ’ State 1991 1992 1993 1994 1995 1996 1997 1 AL 9.7 6.8 5.4 7.4 6.7 6.4 6.1 AK 12.7 6.1 10.8 4.3 3.2 2.2 3.6 AR 13.4 10.5 7.6 7.5 8.1 8.2 7.5 A2 7.1 5.5 3.6 7.1 7.1 5.7 5.1 CA 14.2 16.2 17.8 16.2 11.7 10.7 10.7 co 13.7 11.7 6.9 2.5 2.4 2.6 2.3 CT 7.6 4.8 5.6 3.7 2.3 1.5 2.1 DE 11.2 5.8 6.3 7.2 6.6 9.5 7.3 FL 7.7 6.3 5.7 6.8 7.0 6.1 6.4 GA 9.8 7.5 5.7 6.1 5.0 3.3 2.6 HI 4.3 15.3 18.1 18.4 9.7 4.8 6.6 }11) 13.0 12.1 10.9 8.5 6.1 6.3 7.1 IL 9.5 8.1 8.2 8.5 7.9 6.2 6.0 IN 7.0 5.8 7.3 7.7 7.4 6.5 6.8 IA 5.5 5.4 4.8 4.0 3.8 4.0 4.8 KS 13.4 13.0 8.9 6.8 6.5 6.2 5.5 KY 4.0 5.3 4.2 3.1 4.1 2.3 3.2 LA 17.4 11.8 11.7 7.8 6.3 4.7 4.2 MB 3.7 2.9 3.6 4.5 4.0 2.4 2.7 MD 5.0 3.7 2.7 4.0 4.1 2.6 2.2 MA 4.2 3.2 5.7 4.7 4.6 3.2 2.6 MI 16.0 16.8 16.1 13.3 13.6 9.8 8.6 MN 5.2 5.3 7.4 6.8 5.3 2.9 2.7 Ms 10.7 11.6 10.6 10.8 8.0 4.8 3.9 MO 10.6 9.0 7.9 4.8 4.1 4.2 3.6 MT 8.6 10.5 10.3 9.6 7.2 5.7 3.5 Nv 19.0 18.8 19.2 17.2 15.0 12.7 14.3 217 Table 27 (cont’d). State 1991 1992 1995 1996 1997 NJ 7.0 6.7 4.4 3.8 4.0 2.6 2.4 NM 10.0 9.0 6.2 4.7 3.7 1.7 1.8 NY 2.8 3.1 2.4 2.5 3.1 2.7 2.2 ll NC 6.8 6.5 5.9 5.8 4.8 4.0 3.4 ND 5.9 5.7 6.5 6.2 4.8 6.6 7.9 OH 6.6 3.8 7.4 7.3 6.6 4.8 4.0 OK 3.8 5.1 4.9 4.6 4.7 4.0 4.2 OR 11.6 13.1 7.6 5.9 5.6 5.2 4.7 PA 7.1 6.3 6.1 5.4 3.8 3.1 3.2 R1 7.8 4.6 5.5 4.4 3.6 2.9 3.4 sc 4.9 8.8 9.5 6.4 5.2 7.3 7.9 II SD 8.6 5.5 5.4 4.4 4.5 4.3 3.3 II TN 6.5 9.8 8.6 7.6 7.2 5.9 2.6 TX 12.2 10.5 8.6 7.9 5.9 4.1 4.2 UT 10.8 12.3 8.9 5.2 5.0 4.4 3.2 II VT 8.0 5.5 7.9 7.1 7.2 2.1 1.8 VA 1.6 2.2 4.2 3.6 3.4 3.8 3.1 WA 10.4 9.7 9.5 8.1 7.3 7.5 8.4 wv 19.3 17.1 15.4 8.3 6.5 4.6 5.7 M 5.2 4.0 4.5 3.6 3.4 3.0 3.5 I wv 12.0 10.8 15.6 14.4 7.2 3.1 6.3 n US 8.8 8.2 7.9 7.2 6.1 5.1 4.9 n 218 Table 28. Comparison of Mean, Difference of Means Test, and Kappa Statistic Results for Selected Inspection Managers’ and Inspectors’ Survey Responses Q". E‘ 5’ “on ' Were you encouraged by Managers!“ ; : - * '~ . Inspectors’-t . . 1 Difference-of - ‘ r Mean (t =) representatives of the nursing home Managers '62 industry association to not cite facilities .85 .0218 .15 at any point during July 1, 1995 through the present? Inspectors '52 Were you encouraged by Managers .62 representatives of the AARP to cite n/a n/a n/a facilities at any point during the period July 1, 1995 through the present? Inspectors na Were you encouraged by nursing home Managers .59 residents groups to cite facilities at any 23 1251 76 point during the period July 1, 1995 ' ° ' through the present? Inspectors ’45 Were you encouraged by nursing home Managers .72 family groups to cite facilities at any 40 1158 84 point during the period July 1, 1995 ' ' ' through the present? Inspectors '62 Did you receive pressure from the governor in your state to adjust your Managers '12 enforcement of nursing home standards -2. 16** .1016 1.05 during the period July 1, 1995 through Inspectors .33 the present? To what extent do you behave so that Managers 334 nursing home inspectors feel free to 13 328 2 65*" discuss important things about their ' ' ' jobs with their immediate supervisor? Inspectors 3'11 The extent to which I have confidence and trust in my nursing home Managers '25 inspectors, or to what extent do your 0.00 .2483 1.73 superiors have confidence and trust in Inspectors .35 you? What would you say that the morale of your nursing home inspectors over the Managers -44 period July 1, 1995 through the present 2 05” _ 00062 - 09 was? or What would you say that your ' ° ' morale at work during the period July Inspectors , 33 1, 1995 through the present was? The extent to which you willingly share information with nursing home Managers '94 inspectors, or the extent to which 2.17** -.0390 —.42 superiors willingly share information Inspectors .93 with subordinates. Statistic ' 5 ' ‘ 219 Table 28 (cont’d). _ _ Question Did you receive pressure from any Managers! ; 1 . Inspectors ‘ ' through the present? senators in your state to adjust your Managers 2'94 enforcement of nursing home standards -2.08** .2160 1.77** during the period July 1, 1995 through Inspectors 2 93 the present? ' Did you receive pressure from any representatives in your state to adjust Managers 2'44 your enforcement of nursing home -1.22 .305 2.15" 1 standards during the period July 1, I 1 t 3.17 1995 through the present? nspec ors i Did you receive pressure from the M 94 HCFA to adjust your enforcement of anagers ' nursing home standards during the 1.08 .3186 226*” period July 1, 1995 through the Inspectors 93 present? ' I’m paid fairly compared with other Managers 2.94 employees, .1 l .2657 2.47“” Inspectors 2.93 There is too much pressure on my job. Managers 2.44 -2.21** -.0546 -.49 Inspectors 3.17 1 There are some conditions concerning Managers 2.66 1 my job that could be improved. I t 2 66 =46 --0606 --34 1 nspec ors . Did you resolve nursing home resident M l 13 problems with the assistance of the anagers ' 1 Long-Term Care Ombudsman at any 2.59 .1450 1.17 1 point during the period July 1, 1995 Inspectors .79 1 1 1 *statistically significant at p < .10; "significant at p < .05; ***significant at p < .01 220 Table 29. Cochrane-Orcutt Test of Autocorrelation (1991—1994) Source SS df MS Number of obs = 98 Model 253.756594 ""1 253.756594 F( 1, 96) 203.26 Residual 119.850477 96 1.24844247 Prob > F = 0.0000 Total 373.607071 "'97 3.85161929 R-squared = 0.6792 Adj R-squared = 0.6759 Root MSE = 1.1173 resid Coef. Std. Err t P> 1t: [95% Conf. Interval] """"""" 1 2;}e's'+m.8058847 .056526 14.257 0.000 .6936814 .9180879 cons L_1;1219988 .4708953 2.383 0.019 .1872782 2.056718 221 Table 30. Cochrane-Orcutt Test of Autocorrelation (1995-1997) Source SS df MS Number of obs = 147 Model 148.36057 ""1 148.36057 F( 1, 145) = 181.18 Residual 118.733177 145 .818849495 Prob > F = 0.0000 Total 267.039747 "1'46 1.82940923 R-squared = 0.5555 Adj R-squared = 0.5524 Root MSE = .9049 resid Coef. ----- Sid-Err t P> 1t: [95% Conf. Interval] lagres "3673027”.0421461 13.460 0.000 .4840026 .6506028 _cons 1.740074 .2642659 6.585 0.000 1.217763 2.262385 222 Table 31. Cochrane-Orcutt Test of Autocorrelation (1991-1997) Source SS df MS Number of obs = 245 Model 2599.788 ""1 2599.788 F( 1, 243) . Residual .239501911 243 .000985605 Prob > F = 0.0000 Total 2600.0275 "244 10.6558504 R-squared = 0.9999 Adj R-squared = 0.9999 Root MSE = .03139 resid THE-30.81: ---- Std. Err in P> 1t: [95% Conf. Interval] lagres 1.0005 .000616 1624.118 0.000 .9992862 1.001713 _cons .0002573 .004665 0.055 0.956 -.0089318 .0094464 223 Table 32. Cochrane-Orcutt Test of Autocorrelation for the Manager Model Estimated (1995—1997) Source SS df MS Model 163.177134 1 163.177134 Residual 42.441822] 44 .9645 86867 Total 205.618956 45 4.56931014 resid Coef. Std. Err t lagres 1.076332 .0827537 13.006 cons -.9252522 .4675224 -1.979 Number of obs = 46 -_-_ F( 1, 44) = 169.17 Prob > F - 0.0000 -_-- R-Squared 0.7936 Adj R-squared 0.7889 Root MSE = .98213 P> 1t: [95% Conf. Interval] 0.000 .9095528 1.243111 .0054 -1 .867482 .0169772 224 Table 33. Cochrane-Orcutt Test of Autocorrelation for the Inspector Model Estimated (1995-1997) Source SS df MS Number of obs = 46 Model 145.318049 ""1 145318049 F( 1, 44) = 199.18 Residual 32.1021552 44 .729594437 Prob > F = 0.0000 Total 177.420204 "45 3.9426712 R-Squared = 0.8191 Adj R-squared = 0.8149 Root MSE = .85416 resid "-663. ----- Std. Err t P> 1t] [95% Conf. Interval] lagres "T406727”.0741677 14.113 0.000 .8972522 1.196202. _cons -.7662243 .4178405 -1.834 .0073 -1.608327 .0758779 225 APPENDIX B Figures 1-3 226 Figure I. Annual Inspection Flow Chart as of 1997 Licensing Officer Can Receive Concerns About Nursing Facilities Passes on information to inspection team. Inspection Team Goes into Home Posts notices on all nursing home entrance ways. Informs Long-Term Care Ombudsman that inspection is starting. Inspection Team Inspects Home Talks with residents individually. Talks with resident council as a group. Talks with family members. Reviews resident charts, environment, activities, meals, medication passes, etc. i Exit Conference Inspectors orally list inspection findings, including deficiencies that may be cited and concerns that may not be cited. Residents and nursing home staff can ask questions to clarify survey findings. i Inspection Team Returns to Office Inspection Team pools their information and submits final list of facility deficiencies. ‘1 Licensing Officer Reviews Team Findings Licensing Officer issues written official Statement of Deficiencies. Written copy sent to nursing home. 1 Statement of Deficiencies Nursing home posts Statement of Deficiencies in prominent place in home. 1 Plan of Correction Nursing home may begin to drafi Plan of Correction to send to Licensing Officer. 227 h .8825 bacon -. 8825 D gm 24:50 Q may—(gab EPA¢835 lumflmmmm m0 mug—hung m0 ”mu—umo 8825 8825 mzopémmo ‘1 ¢O9>5< E<-UO~E no 3535: 8825 8825 5:20.52 hzm—ELOAHZ—n many—Exam >¢<—U.mmzmm a: hO HOE—ho mmU—hho 4:20—95 >UEOL no Danny—2m m0 HOE—ho .8825 8825 mzo_FUSOA— no... mZO-ij—z szOthU 8825 Q wZO—hémmo KO... m_m>.._9—Zth—OAEO 88525834. bnnoo 5M5— PZHESEH AO~E 228 Figure 3. Organizational Chart for Nursing Home Regulators Within The Michigan Department of Consumer & Industry Services as of 1997 Michigan Department of Consumer & Industry Services Director Deputy Director 1 | Bureau of Health Services l Chief 1 Division of Health Facility Licensing & Certification Director Field Services Section Chief ‘ Field Services Section Chief 1 - 1 Team A Team B Team C Licensing Officer Licensing Officer Licensing Officer Team D Team E Team F Team G Licensing Officer Licensing Officer Licensing Officer Licensing Officer I Intake Unit for Complaints I 1 I Inspectors, Inspection Monitors, Team Leaders | and Complaint Investigators 229 APPENDIX C AARP and AHCA’S Percent of PAC Contributions by Political Party for the Years 1991 through 1997 t 2 Party . . 91/92 .I ; 193/949 ‘ 95/96 ~ . , '97 ' f *AARP PAC Contributions Republican I 24% 19% I 83% 62% Democrat I 76% 81% I 17% 38% 1 AHCA PAC Contributions 1 Republican I 33% 36% I 55% 52% II Democrat I 67% 64% I 45% 48% Source: Almanac of Federal PACs: 1996-1997. *Note: The AARP does not have its own PAC. It is a member of the Magazine Pub- lishers of America (MPA) PAC. MPA’S 220 members are magazine publishing companies, including house organs of major membership organizations and trade associations. 230 The United States Senate Special Committee on Aging: APPENDIX D 106th Congress (1999—2001) _ _ _— Committee Members '0' . Party Affiliation/State Charles E. Grassley (Chair) Republican/Iowa 15 30 20 15 Evan Bayh Democrat/Indiana n/a n/a n/a n/a John B. Breaux Democrat/Louisiana 30 60 40 55 Richard H. Bryan Democrat/Nevada 70 80 60 75 Jim Bunning Republican/Kentucky 10 10 10 5 Conrad Burns Republican/Montana 5 5 20 0 Susan M. Collins Republican/Maine n/a n/a n/a n/a Larry E. Craig Republican/Idaho 5 0 5 0 Michael B. Enzi Republican/Wyoming n/a n/a n/a n/a Russell D. Feingold Democrat/Wisconsin n/a n/a 100 100 Chuck Hagel Republican/Nebraska n/a n/a n/a n/a Tim Hutchinson Republican/Arkansas n/a n/a 13 10 James M. Jeffords Republican/Vermont 65 65 60 85 Herb Kohl Democrat/Wisconsin 90 95 95 90 1 Blanche Lambert Lincoln Democrat/Arkansas n/a n/a 65 60 Jack Reed Democrat/Rhode Island 95 90 90 85 Harry M. Reid Democrat/Nevada 65 80 60 85 Rick Santorum Republican/Pennsylvania ‘ 15 20 20 15 Richard C. Shelby Republican/Alabama 35 30 35 30 Ronald Wyden Democrat/Oregon 85 95 95 80 Source: Congressional Quarterly ’s Congressional Stafl Directory, Summer 1999. Directory of Congressional Voting Scores and Interest Group Ratings, Second Edition, Volumes I and 11. Note: The ADA ratings represent the percentage of votes on which the individual member voted in favor of a special interest group’s position on a selected set of issues of particular concern to that group. That is, the ADA rating is a measure of an individual member’s support for protecting consumers through activist regulation. 231 APPENDIX E Structured Interview Questions Group/Organization Representing Section I: Professional Backgrgound 1. 2. What is your professional position? How many years have you been in your current position? Section II: Perceptions of External Influences on Enforcement of the OBRA ’87 3a. 3b. 3c. 4a. 4b. 4c. 5a. 5b. 5c. 6a. 6b. What role has your organization played in the enforcement of the OBRA ’87 in Michigan? In your View, did your organization improve or hinder enforcement? What is your estimate of your organization’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Health Care Financing Administration (HCFA) played in the enforcement of the OBRA ’87 in Michigan? In your View, did the HCFA improve or hinder enforcement? What is your estimate of the HCFA’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Michigan Department of Consumer and Industry Services (MDCIS) played in the enforcement of the OBRA ’87 in Michigan? In your view, did the MDCIS improve or hinder enforcement? What is your estimate of the MDCIS’S influence on the enforcement of OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Long-term Care Ombudsman/Citizens for Better Care (CBC) played in the enforcement of the OBRA ’87 in Michigan? In your View, did the CBC improve or hinder enforcement? 232 6c. 73. 7b. 7c. 8a. 8b. 8c. 9a. 9b. 9c. 10a. 10b. 10c. 11a. 11b. 11c. What is your estimate of the CBC’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the American Association or Retired Persons (AARP) played in the enforcement of the OBRA ’87 in Michigan? In your View, did the AARP improve or hinder enforcement? What is your estimate of the AARP’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Health Care Association of Michigan (HCAM) played in the enforcement of the OBRA ’87 in Michigan? In your View, did the HCAM improve or hinder enforcement? What is your estimate of the HCAM’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Michigan Association of Homes and services for the Aged (MAHSA) played in the enforcement of the OBRA ’87 in Michigan? In your View, did the MAHSA improve or hinder enforcement? What is your estimate of the MAHSA’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the Governor played in the enforcement of the OBRA ’87 in Michigan? In your View, did Governor improve or hinder enforcement? What is your estimate of the Governor’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? What role has any state senators and/or representatives played in the enforcement of the OBRA ’87 in Michigan? In your View, did these senators and/or representatives improve or hinder enforcement? What is your estimate of the state senators’ or representatives’ influence on the 233 12a. 12b. 12c. 13a. 13b. 13c. 14. enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the courts played in the enforcement of the OBRA ’87 in Michigan? In your View, did courts improve or hinder enforcement? What is your estimate of the courts’ influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? What role has the media played in the enforcement of the OBRA ’87 in Michigan? In your View, did media improve or hinder enforcement? What is your estimate of the media’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? In your View, what can be done to improve enforcement in Michigan? 234 APPENDIX F Completed Structured Interview Questions Section 1: Professional Backggound What organization do you represent? (n = 10) 1a. 1b. Citizens for Better Care Michigan House of Representatives’ Democratic Health Policy Staff American Association of Retired Persons Michigan Department of Consumer and Industry Services Michigan Department of Consumer and Industry Services Citizens for Better Care Citizens for Better Care Michigan Protection & Advocacy Services Consumer Nursing Home Policy Expert What is your professional position? (n = 10) Local Long-Term Care Ombudsman Policy Analyst Advocacy Representative State Long-term Care Ombudsman Deputy Director under the Bureau of Health Systems, Governor’s Appointee Director of the Michigan Department of Consumer and Industry Services, Governor’s Appointee State Assistant Long-term Care Ombudsman Lawyer & Advocate for Protecting the elderly Enforcement Expert Consumer of Long-term Care How many years have you been in your current position? (n = 9) 10 years 5 years 2 years 2.5 years 2.5 years 15 years 19 years 14 years 4 or 5 years 235 Section II: Perceptimrs of External Influences on Enforcement of the OBRA ’87 What role has your organization played in the enforcement of the OBRA ’87 in Michigan? (I! = 8) 3a. Provided formal feedback to the HCFA, the MDCIS, families, media, the GAO, legislators, and researchers. Added new inspection staff. Planned to work with the MDCIS, nursing home administrators, the CBC, residents and families in order to look out for residents. Monitored legislation that enhanced the office of the Long-Term Care Ombudsman. Other members have volunteered to be ombudsman volunteer. 90% of the nursing home industry, the CBC, providers, the MAHSA, the HCAM stated we had big problems living under the OBRA 87 with the new parameters established in July 1995. Also the state had higher than average citations as compared to other states citations; CBC didn’t know what to do. So the MDCIS, pulled together a summit meeting with the AAA, Medicaid, the HCFA in Chicago and Baltimore. They learned about the OBRA 87 and talked to folks who helped implement it. . They then saw a need for a long-term care workgroup which included representatives from the associations, the CBC, medical directors, and county nursing home administrators. The goal of this workgroup was to look at the enforcement system in Michigan. If the group couldn’t come to resolutions, then she could have staff implement them and She gave the workgroup a tirneline. The Free Press wasn’t willing to work with anyone else. Recommendations were sent to staff for hammering out. The HCFA & Michigan databases were combined. 236 They established an enforcement unit to answer provider questions; helped ease common problems and problems unique because of federal intervention. One of the lead staff helped to establish enforcement positions for the agency, analyzed enforcement preposals, and participated in meetings about enforcement policy. They wanted better communication between survey teams and those being surveyed. So they had a collaborative remediation agency which involved hiring someone to serve as a consultant. They worked with the MPHI and used them as the consultant (collaborative remediation agency). Once they organized the federal and state level nursing home data they created an audit system which identified problem facilities (this was a new trigger system and audit system) which included the following information: 0 history, 0 prior audits, and 0 complaints. This system allowed them to identify homes in trouble immediately so that they could: 0 get on-site training, and/or 0 institute a temporary manager. This system was better than fines. They have used the MPHI a lot and this has resulted in 80% compliance; it worked. . There were a few complaints and threats to sue. Some facilities have volunteered to get help. Their desire is to come up with a system with a good mix of tools to improve enforcement. This system is way ahead of the White House Initiative; for instance, the Resident Protection Initiative. Temporary managers stay with facilities for 6 months in order to bring about systemic change. 237 Yet they must keep a close eye. Staffing can make a difference to the operations of the facilities. They have been very progressive. With regard to appealing citations; we are one of the highest states; our cites are still high. There were a high number of appeals and no good practices came out of this. So they created the Michigan Peer Review Organization (MPRO) which is a third party and the appellant has to agree that what the MPRO says is gospel. Initially the MPRO had a backlog to deal with and they only had 2 staff members; now they have 5 staff members on board. Initially they were upholding what the survey team found; it is currently running 50/50 and has been an objective system. Appeals are important to enforcement and are now down to 20 days. Another piece is that the MDCIS called back the workgroup. The workgroup agreed to having the surveyors (inspectors) and providers (facilities) work together. So the surveyors and providers are currently receiving joint training, for instance, they have attended courses on bed sore care together. They also plan to take the 10 highest citations introduced and use the best practices in the joint training sessions, and the HCFA attends the joint training sessions. The CBC is the major advocacy group for residents. Providers, Medicaid, the HCFA, & everyone is a part of the process. Became involved in enforcement in 1998 in Michigan and worked closely with the MDCIS on enforcement issues. Helped residents sue the HCFA to get the regulations published, provided comments to the HCFA on proposed regulations. Played a three-tiered role: 1. interacted with the HCFA on oversight policymaking to state, 2. interacted with state regulatory bodies, and 3. tried to actualize enforcement that serves residents. 238 3b. 3c. 43. Tried to be a catalyst to assure enforcement was implemented in a way that protects residents. As a consumer, reported different things she saw. In your view, did your organization improve or hinder enforcement? (n = 9) Improved Improved; for example increased budget asked for $800,000 but got $40,000 or the Ombudsman program. Improved Improved, citations don’t back it up, training cuts both ways. Facilities have recognized that maybe they had problems that needed to be addressed. 10% of facilities are problematic. Minuscule improvements Improved Improved, helped improved things that have gone right; wouldn’t have gone right without their involvement. Improved Improved What is your estimate of your organization’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (n = 9) 3 or 4 7 or 8 6 10 because the HCFA let’s them be creative; the CBC and the providers are somewhat happy. \OUI-DsUtN What role has the Health Care Financing Administration (HCFA) played in the enforcement of the OBRA ’87 in Michigan? (11 = 9) Provided guidance through policy papers and directing the state’s actions. Oversight of the state departments. Representatives are available to answer questions; for example they made themselves available when it came to misuse of medicine; also some members felt the HCFA was responsive, but may not be as fast responding. The HCFA plays an important role; and they have a good relationship with the HCFA. 239 4b. The HCFA was firm on enforcement, but let Michigan do its own thing; but oversaw if we wandered too far. The HCFA is eliminating the date certain and moving it back; allowing more time to work with the facility; and this requires cooperation from the facility. A very limited role. Set and initiated enforcement policies. Instructed, persuaded, and determined state policies and actions. Issued sanctions. HCFA issued regulations, created the State Operations Manual outlining the enforcement regulations, and required states to follow the manual. Practically nothing. Ambivalent feelings. Negative role because they have allowed the industry and state to negotiate the state enforcement plan without listening to consumers. Thus they have done poorly with regard to consumer interests. High expectations about the level of care; they are good at documenting problems; Not good at taking enforcement actions. In your view, did HCFA improve or hinder enforcement? (n = 9) In the beginning during 1995 and 1996 the HCFA hindered enforcement by stopping fines and reinterpreting the regulations. There’s room for improvement. Improved Improved enforcement because it gives leeway to get involved; such as the Resident Protection Initiative. Hindered enforcement in a number of respects and improved in modest respect. Hindered based on actions of the central and regional offices. For instance they have not understood and taken into consideration the full opportunities available to improve services. Have been slow in responding to events. Don’t have enough hands on tools or experience to have the authority they have. Little of both; hindered and improved, the HCFA’S reliance on building enforcement around decertification hinders good outcomes that could come out of enforcement. Beginning to improve Hindered and improved; hindered at the central level in terms of enforcement policies. What is your estimate of the HCFA’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? (11 = 9) 6 or 7 6 7 10; allowed Michigan flexibility and the HCFA gave approval. 7 240 Sa. 8 9 4 or 5 3 or 4 with regard to influence on policy decisions. What role has the Michigan Department of Consumer and Industry Services (MDCIS) played in the enforcement of the OBRA ’87 in Michigan? (n=7) 0 MDCIS under scrutiny and pressure from family groups, Long-Term Care ombudsman and surveyors tried to effectively enforce the OBRA 87. However, oftentimes the bureaucracy prevented real change from happening. 0 Decreased role; inspectors have been cut back and number of inspectors and inspections. A very limited role. Played 3 leading role in trying to actualize the OBRA 87 and has been responsive to the HCFA, the CBC, and others. Has been creative and at other times stuck in the status quo. 0 Played many roles in the last 3 years such as: reacted at times, tried to appear strong and do the right thing, tried to avoid some parts of enforcement that they or the industry found distasteful and acquiesced to the industry’s concerns, yet acted in a strong firm way; by using the appropriate enforcement remedy at the right time, almost a schizophrenic role with multiple personalities, would be firm sometimes and other times say we don’t believe in civil penalties, yet homes responded when fines are involved. For example, ban on admissions have a financial impact so the industry said we don’t want civil penalties (fines) and the MDCIS dropped them as quick as could. They dropped the ball that led to the Heritage lawsuit by failing to promulgate regulations which left a gaping hole in the enforcement process in Michigan; left too many holes without real enforcement potential. 0 Not playing that great of a role because the higher ups were not listening to what the problems really were; they need more hands on by the Director and his assistant. 0 An entirely negative role; created a summit group in 1997 and in early 1998 created a taskforce of state, the HCFA, and industry, but did not include consumers; and the CBC reports were registered. The only proposals discussed were industry’s (no real consensus was reached; but said it was a consensus; applying pressure to the CBC with budget funding reductions if they did not go along with industry’s desires and the states efforts were not subtle. 241 5b. 5c. 63. In your view, did the MDCIS improve or hinder enforcement? (n = 8) Hindered There’s room for improvement; governor should make budget recommendation for the MDCIS. Hindered Hindered in a number of respects and improved in a few respects. Improved Hindered and improved Hindered Hindered What is your estimate of the MDCIS’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? 0! = 8) 5 5 9 9 9 8 3 1 on implementing the intent of law. What role has the Long-term Care Ombudsman/Citizens for Better Care (CBC) played in the enforcement of the OBRA ’87 in Michigan? m=o Good job; trying hardest but have limited resources and staff; good mission. Legislatively, they have made sure that their office was funded and have information for people to contact them. They are not very effective in influencing enforcement because of the way they are set up, that is, they are a “toothless tiger”. From 6/ 97; the CBC played a significant role in the way enforcement operates in Michigan, such as: - political influence, - has Strong relationship with Alison Young from the Detroit Free Press, — has made the MDCIS aware of what they should be doing, and - resolved resident complaints to help reduce citations. A very significant role. Currently people are more aware because of the CBC. The CBC makes people aware of options. Played strong role in identifying enforcement policies that would provide quick actions. Little influence on enforcement 242 6b. 7a. 7b. In your view, did the CBC improved or hindered enforcement? m=o 0 Improved Improved Improved Improved Improved Neither What is your estimate of the CBC’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (11 = 6) 9 8 5 3 8 1 for impact What role has the American Association or Retired Persons (AARP) played in the enforcement of the OBRA ’87 in Michigan? (11 = 8) 0 None None really None, never been at the table None None Have not played a significant role A lot as far as the elderly are concerned Virtually none In your view, did the AARP improve or hinder enforcement? n = 8) Don’t Know Seemed to move slow; have not participated Not applicable Neither Lack of presence has hindered it No sense of this Improved because provided information Neither A 243 7c. 8a. 8b. What is your estimate of the AARP’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (n =3) l—nlJtl—tl—tl—tl—Al—I What role has the Health Care Association of Michigan (HCAM) played in the enforcement of the OBRA ’87 in Michigan? (n = 9) Played an active Significant role in trying to prevent enforcement action from taking place. Put forth a good face; wish they could have done more in the past Not applicable Have played a positive role in enforcement; they saw a buy-in by The HCAM to the Resident Protection Initiative, although they didn’t agree with everything, but accepted the general concept. Have helped their members c00perate with regulators. Have been positive toward joint training and encouraged their facilities. A significant negative role. Gleefully supported litigation that has made certain enforcement illegal. Through themselves or their members they have made extensive recommendations to the MDCIS and other regulators that have diminished enforcement efforts. They waged a consistent campaign against enforcement that has taken away resources. Urged members to file lots of (Informal Deficiency Dispute Resolution) IDDR thereby taking away resources from enforcement. Persuaded the MDCIS’ director to eliminate civil monetary penalties and to create a more collaborative enforcement system. They have interfered, opposed, and fought to avoid consequences for bad care; have protected their members well; especially members who are poor performers They are on the internet and have provided misleading information to consumers. They write Michigan’s enforcement policies. In your view, did the HCAM improve or hinder enforcement? (n = 9) 0 Hindered 0 Not sure 0 Not applicable 0 Improved 244 8c. 9a. 9b. Hindered Hindered Hindered Hindered Hindered; policies hinder enforcement What is your estimate of the HCAM’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? (n = 9) 7 5 Not applicable 5 8 8 7 or 8 2 10 impact on enforcement policies, the fought the implementation of OBRA. They found members to fight enforcement policies. What role has the Michigan Association of Homes and services for the Aged (MAHSA) played in the enforcement of the OBRA ’87 in Michigan? (n Played an active significant role in trying to prevent enforcement action from taking place. Not familiar with them Not applicable Marlon Lundgreen met with the MDCIS regularly. They have played a significant role and were a part of the initial long-term care workgroup. A significant role. They were supportive of the MDCH’s enforcement regulations. They have almost disappeared. However they sat in on the summit meetings. They did not join in with the HCAM. Have followed the HCAM’S lead Takes similar positions to the HCAM, the MAHSA was involved in the suit to block the OBRA implementation in 1995. In your view, did the MAHSA improve or hinder enforcement? (n = 8) Hindered Don’t know Not applicable Improved Hindered Hindered because of lack of presence on the side of residents. 245 9c. 10a. Hindered Hindered What is your estimate of the MAHSA’S influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? (n = 8) 8 Don’t know Not applicable 5 6 6 3 or 4; could have had incredible influence if they would have come out on assuring that there’s consequences for bad care; they really served the HCAM’S agenda 4 or 5 What role has the Governor played in the enforcement of the OBRA ’87 in Michigan? (n = 9) Behind the scenes and was actively involved. He’s not doing all he could do given his authority; could have recommended more inspectors and more funding instead of spending on other priorities. He’s played a very active role as far as decreasing enforcement of theOBRA 87. Met with the Governor’s office on the Resident Protection Initiative and they were in favor of this program and supports the MDCIS’ activity. The Governor’s office came up with the Governor’s Quality Care Award which was an opportunity to recognize good facilities. This was a great success, there were 50 winners and they had a great outpouring from the facilities and had a gala affair. This award will continue. Also the CBC, the HCAM, and the MAHSA were involved in setting the criteria and helped judge the nominees. Has played a very significant role. The state doesn’t have the legal authority to do enforcement since 12/97; thus, they went through the MDCH’s rule process and asked that emergency regulations be promulgated and were asked 3 or 4 times. Kathy Wilbur tried to bring folks together through their taskforces and workgroups. Overall, provided folks with an opportunity to provide input; tried to come up with something that was consistent with the administration’s philosophy. None Have to say, they played a destructive role in ensuring that the OBRA 87 regulations were followed; same as the MDCIS. 246 10b. 10c. 11a. In your view, did Governor improve or hinder enforcement? (n = 9) Hindered; anti regulatory and pro business Hindered Hindered Improved Hindered Hindered because not responsive to Heritage Manor case. Hindered Neither Hindered What is your estimate of the Governor’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? (I1 = 9) 6 or 7 3 9 10 8 9 Not sure 2 10 for hindering enforcement What role have any state senators played in the enforcement of the OBRA! in Michigan? (n = 9) No senators were involved in any of the enforcement; didn’t hold hearings. Minority of the senators have proposed legislation and been interested; but a majority have stopped the process by holding bills in committee. Senators have been apprehensive because Republicans control the senate and the Republican Governor who wants to deregulate the nursing home industry. They have engaged the subject with much caution. Silent role, no real action or legislation to improve nursing home staffing no debate about the regulations; they have been lobbied by the HCAM and pushed to support the industry. Parochial role (have not heard) Very little if any. Have directly intervened with the MDCIS or providers and said you need to fix these problems. Also supported an increase in the number of inspectors. Worked with a Southfield group (a program in Southfield visiting nursing homes) appeared at these meetings; gave them a listening ear; tried to bring a bill to the floor. Hindered. 247 11b. In your view, did these senators improve or hinder enforcement? (n = 8) Not sure Hindered Hindered Not applicable No effect Improved Improved Hindered 11c. What is your estimate of the state senators’ influence on the enforcement of the OBRA 87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (11 = 8) 0 Not sure Utah—kph Ur Don’t know llal. What role have any state representatives played in the enforcement of the OBRA ’87 in Michigan? (n = 8) 0 House was active in asking questions and dealing with budget issues that affected enforcement. Directly asking for appropriate enforcement; that is, residents asked for help from representatives and received help. 0 The caucus has introduced quite a few good bills, but they were passed up to the Senate and sat there; was not sure if they were playing a political game or if the governor was protecting nursing home administrators. They take no action, there are no champions for enforcement. There’s potential in the house to get heavily involved; yet the support is not overwhelming; party politics limits the house’s ability. 0 They call the MDCIS when a facility is in trouble or if a provider complains about enforcement. Very little if any. 0 Representatives played the same role as senators; but have more frequently sided with nursing homes. 0 There was interference on the house side; most recently by adding more surveyors and appropriating more money for surveyors; and by requiring on- site weekend and evening site visits. 248 llbl. In your view, did these representatives improve or hinder enforcement? llcl. 12a. (11 .-.- 3) Improved Improved Hindered Improved because they focused attention and provided staffing to regulators. No effect Improved Improved somewhat Hindered What is your estimate of the state representatives’ influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (n = 8) 3 7 or 8 9.5 7 1 6 6 Don’t know What role have the courts played in the enforcement of the OBRA ’87 in Michigan? (11 There has been an abundance of lawsuits and basically the courts have prevented enforcement by invalidating the rulemaking process that resulted in weakened enforcement. Not familiar with the courts The courts have played a role when there’s demonstrated negligence. For instance the Attorney General’s office has had a very active role by seeking prosecution of nursing homes. A couple of cases, Heritage Manor challenged the state’s ability to implement the enforcement regulations of the OBRA 87 and there was a negative outcome for enforcement. While in the Venoy case there was a positive outcome and this went through the bankruptcy court. A significant role. Courts have sided with the industry in all litigation. Heritage decision was a negative decision by the court; this was another barrier to getting enforcement action for problem homes. Heritage was cited for poor care appealed all civil monetary fines cited; state issued a plan but not according to the APA and the home contended that they avoided the APA. They prevailed and won; the State court of appeals was the highest court. The home was sued for no assurance that residents are protected when hospitalized; thus they were fined $450/day and it had an incredible impact; 249 12b. 12c. 13a. and the loss of this case led folks to wonder if there was enforcement power in Michigan; this case was very distractful leaving regulators feeling powerless and ultimately leaving resident powerless. 0 Hard to answer; some decisions have been positive and others have been negative. Positive example is when a group of nursing home residents filed suit against state and court ruled in favor of residents (Ottis v. Shalala). Negative example is the MAHSA filed a lawsuit against the federal government and they failed the courts threw out the case and this was positive for the residents. In your view, did courts improve or hinder enforcement? (n = 10) Hindered Not familiar with the courts Improved; the courts could function as a check and balance; more rulings supporting the OBRA 87 would function as a deterrence itself. Improved and hindered Improved Hindered Hindered Hindered Hindered and improved Hindered due to lack of knowledge of those making decisions. Hindered and improved What is your estimate of the courts’ influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “1” signifies a very low impact and a rating “10” signifies a very high impact? (11 = 10) 0 3 Not familiar with the courts 10 NNQOOO-hfl or3 What role has the media played in the enforcement of the OBRA ’87 in Michigan? (n = 9) 0 The media has focused on the failure to implement a true enforcement system. 0 Brings the issue to the public and also sensationalize. 0 Detroit Free Press has done an excellent series in the last 3 years; they have helped to create an interest in nursing homes. 250 13b. 13c. The media believe they have helped or improved enforcement. The Free Press has an advocate who has determined the nursing homes in Michigan are bad. The Free Press used the trigger data, but they are currently working on a consumer guide. The electronic media has provided objective reporting. They have made a consistent effort to Show the salience of enforcement. Trying to report both systemic enforcement issues and individual things. Policymakers are very sensitive to how things will be reported in the media. They basically educated and informed the public and helped made it a public lssue. A great role reporting, but can’t say reporting is for all cities in Michigan. Detroit Free Press played a strong role and wrote about enforcement issues. Played a strong positive role in identifying the problems but no role in shaping state policy and focused on Southeast Michigan. But media attention did not make a difference. In your view, did media improve or hinder enforcement? (11 = 9) Improved Hinders by pitting the HCAM against other actors Improved Hindered enforcement, have made it a very antagonistic relationship where there is no middle ground. Improved Improved by reporting events and creating an opportunity for public discourse. Improved Improved Neither, efforts were good but had no impact on enforcement What is your estimate of the media’s influence on the enforcement of the OBRA ’87 in Michigan, where a rating of “l” signifies a very low impact and a rating “10” signifies a very high impact? (n = 9) 7 or 8 6 9.5 1 4 6 7 or 8 8 1 very low impact on policy created but their effort was very high yet problems Still exist. 251 14. In your view, what can be done to improve enforcement in Michigan? (n = 9) Ideas put forth in the White House Initiative need to be enacted by the HCFA. More oversight by the HCFA through stronger laws with regards to managers and monitors. More surveyors and better surveyor training. The taskforce is a good step in the right direction because it is bipartisanand this helps the legislative process run smoother; and we need to put more funding into advocacy services and nursing home inspectors. 4 Things: 1) Need legislation that gives enforcement agencies more teeth. 2) Need a health care ombudsman, although the LTC ombudsman is good. 3) Need a set of Standards that are consistent across the board to allow customers to compare nursing homes side by side. 4) Need an independent review because enforcement is connected to the state funding; so the problem is that their budget can be cut. Whereas the Attorney General’s office is independent and independence should be granted to the Ombudsman and the enforcement agency; giving these offices more authority to be a little more aggressive in nursing home regulation. Continue to move forward with the Resident Protection Initiative. It is critical when they reconvene the new nursing home taskforce to look at what issues we need to look at next. Additional training with the providers and surveyors continues to open the lines of communication with all of the stakeholders. Also continue flexibility with the HCFA. Also change the federal laws because according to federal law we would have 40% of facilities categorized as poor performers. Also we should go to the facilities on a more frequent basis. There needs to be a legislative reform at the state level and Strong leadership from the HCFA. A change in the attitude at the MDCIS and get back to the idea of protecting residents and not nursing homes. There needs to be more tools and more willingness to use the tools, instead of protecting nursing homes. There needs to be more resources devoted to analyzing survey data and developing remedies, sanctions, and plans of correction. There needs to be clear legal authority to impose a wide variety of remedies including forcing the sale of particular facilities when current owners can not meet nursing home standards. The Medicaid agency needs to see responsibilities as more than just paying for services; they have a responsibility to use money to protect residents in danger and to directly improve services. Providers need to take responsibility for poor services in their facilities and others and to work harder to correct it. 252 Enforcement needs to be individualized by the home. The problem is the home and the home’s operator. Need to find remedies like bans on admissions, temporary managers, and maybe other points of leverage while protecting residents and assuring they receive quality care in the homes. The state needs to determine earlier on the operator’s commitment and capability to achieve compliance with standards. When the home is not committed or capable the state needs to find a way to get someone in there to operate the home and find a way of taking that operator out of their position of control and decisionmaking. They need to get all involved parties under one roof; that is, legislators, senators, the MDCIS, surveyors, family councils need to be interacting with people who are experiencing problems. Surveyors should Visit the facilities in the middle of the night 24 hours a day schedule should exist because they can’t correct problems until they see the problems. Train the operators of nursing homes. Be sensitive to the staff at the bottom who are working with the elderly. Need more training and to increase staff salaries. Registered Nurses spend a lot of time writing reports for the Medicare and Medicaid programs, they need to provide more patient care. It’s scary in nursing homes. Minor amendments; if they followed the law instead of finding ways around it. The HCFA allows nursing homes 3 to 6 months to fix problems and never cites high enough to warrant real punishment. There is a big gap between intent and implementation. It would be nice if state government was more supportive of improving nursing home operations. 253 APPENDIX G Michigan’s Enforcement Unit’s Formal Responsibilities The responsibilities of the Michigan’s enforcement unit are listed below: 0 Review requests for enforcement action from Licensing Officers and Division Directors; assess consistency with policies and documentation; make enforcement recommendations to the Division Chief and Bureau Director. 0 Monitor reports regarding non-compliance with enforcement actions and develop appropriate responses to violations. 0 Assure that legally required documents are prepared and served to support enforcement actions and obtain expert analysis when needed in the enforcement process. 0 Arrange for informal and formal hearings necessary to provide due process related to enforcement actions. 0 Represent the Bureau in discussions with health facilities and organizations that are the subject of Specific compliance actions. 0 Develop and monitor the Bureau Enforcement Data System for tracking and evaluation of enforcement actions, including the development of reports, as needed. 0 Process and track enforcement actions in process and provide information to interested persons on the status of enforcement actions, the modification of enforcement actions, settlements and alternative resolutions. 0 Obtain Department of Attorney General approval of enforcement forms and documentation where required. Coordinate Bureau enforcement activities with the Office of Legal and Legislative Affairs, the Michigan Department of 254 Attorney General and the HCFA. Assure that the Department of Attorney General is informed and involved as necessary to defend the position of the Bureau. 0 Provide enforcement training and information to other Bureau programs and interested organizations. Develop training materials and presentations on enforcement and documentation. 0 Process Bureau responses to litigation, including answers to interrogatories and subpoenas, including arranging for staff involvement in litigation when required as witnesses.‘ 1Michigan’s Department Of Consumer & Industry Services meeting notes regarding the Resident Protection Initiative, dated June 12, 1997. 255 APPENDIX H Interview Consent Form I am a researcher from the Political Science Department at Michigan State University. The goal of this interview is to assess the implementation of nursing home standards outlined in the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87). Specifically, I am interested in determining which groups/organizations have influenced enforcement of the OBRA ’87 covering the period July 1, 1995 through the present. In order to conduct this study, I need to gather some information from you. I estimate that this interview will take approximately 45 minutes to complete. I want to make it clear that this interview is voluntary and if you do not want to answer any question asked, just let me know, and we will go on to the next question. Also, we can stop the interview at anytime you desire. Your identity will remain confidential and the data obtained from this interview will be reported in aggregate form which will not allow anyone to identify your individual answers. Your consent to this interview is given by Signing below: Interviewee: Date With your approval, during the interview, I plan to take notes and tape record our interview. I will store the tapes and notes in a locked file cabinet in my office. These notes and tapes will be destroyed after I have completed my analyses. Please check one of the boxes below to indicate which format you prefer for the interview: 1:] I will allow note taking and tape recording. 1:] I will only allow note taking 256 APPENDIX I Coding Results for Question 14 Category _ ' I __ Description. . _ m A Adjust implementation of the OBRA 87 enforcement 41% regulations B Adjust resources to help inspectors perform their job or 30% improve inspections C Change the attitudes of the leadership of the HCFA, the 19% MDCIS, or the state Medicaid agency D Issues related to improving nursing home operations 11% Note: Nine respondents provided 27 responses for improving enforcement in Michigan. 257 APPENDIX J Chow Test Comparing the Pre- and Post-Implementation Regression Models RSS = residual sum of squares k = number of parameters 11 = number of observations m = number of restrictions = k9597 + k0194 - k9197 RSS9197 = 2616 “9197 = 294 k9197 = 19 RSS9194 = 1751 n9194 = 147 k9194 = 16 RSS9597 = 631 n9597 = 147 F = IRssgm-(RSS9597+RSS9194)I/m (RSS9597 + RSS9194)/n9194 '1' “9597'2k F =18 =2.0 .1 Critical F05, 13,262 = 1.8 (note: the degrees of freedom used were based on 12,200 because 13,262 was not reported in the F table). Therefore, the null hypothesis is rejected and it can be concluded that the pre- and post- implementation functions are different. 258 correlate, _coef APPENDIX K Check for Multicollinearity (1991—1994) resgrp fangrp dd dr ds rs rd resgrp 1.0000 famgrp -0.3935 1.0000 dd 0.1553 -0.0196 1.0000 dr 0.0713 -0.ll46 0.5127 1.0000 ds 0.0541 -0.0414 0.6644 0.4586 1.0000 rs -0.0781 0.1663 0.5256 0.3545 0.4791 1.0000 rd 0.0719 -0.0688 0.7070 0.4694 0.6266 0.4999 1.000 y92 0.0716 -0.1363 0.0015 0.0591 -0.0182 -0.0060 -0.0219 y93 0.1133 -0. 1436 -0.0251 0.0160 -0.0445 -.0448 -0.0282 y94 0.0057 -0.2062 -0. 1487 -0.0041 —0.0870 -0.1686 -0.0521 mhours 0.2298 0.1218 0.2803 -0.0130 0.1437 0.1298 0.2386 lpnhours 0.2648 -0. 1602 -0. 1282 —0.0703 -0. 1090 -0.0746 -0. 1069 nahours -0. 1577 0.1017 0.1480 0.0989 0.1143 0.0534 -0.0268 indpow -0.0743 0.4200 0.0904 0.0105 -0.0220 0.0224 -0. 1208 aarpow -0.2526 —0.0411 -0. 1237 -0.0967 -0. 1245 -0.1197 -0.0305 _cons -0.7976 0.1115 —0.3077 -0.1283 -0. 1503 -0.0312 -0.1284 y92 y93 y94 mhours lpnhours nahours indpow y92 1.0000 ------ y93 0.5037 1.0000 y94 0.4525 0.4815 1.0000 mhours -0.0238 -0.0131 -0.3862 1.0000 lpnhours 0.0160 -0.0282 -0.0847 0.0031 1 .0000 nahours 0.0445 —0.0981 -0.0630 -0.2118 -0.1965 1.0000 indpow -0.0359 -0. l 135 -0.2448 0.1956 0.1349 0.3019 1.0000 aarpow -0.0403 —0.0436 0. 1040 -0.2445 -0.0276 0.0696 -0.3836 _cons -0. 1034 -0.0542 0.0963 -0.2618 -0. 3058 -0. 3301 -0.2428 aarpow cons aarpow 1.000 ----- _cons 0.0726 1 .0000 259 APPENDIX L Glesjer Test for Heteroscedasticity (1991-1994) reg absres resgrp famgrp mhours lpnhours nahours indpow aarpow Source SS MS Number of obs 196 Model 532.700075 "'7 76.1000107 F( 7, 188) 99.86 Residual 143.272446 188 .762087476 Prob > F 0.0000 Total 675.97252 "1'95 3.46652574 R-squared 0.7880 Adj R-squared 0.7802 Root MSE .87298 abres "Ci-18f“ Sid. Err t P) It} [95% Conf. Interval] resgrpq -.1004615 0145116 -6.923 0.000 -.1290879 071835 famgrp -.0036258 .0057406 -0.632 0.528 -.01495 .0076984 mhours -.9643201 .3885188 -2.482 0.014 -1.730737 -. 1979036 lpnhours 3.767482 .4391659 8.579 0.000 2.901156 4.633808 nahours -1.797878 .3191011 -5 .634 0.000 -2.427357 -1 . 168399 indpow -359.4897 24.55111 -14.643 0.000 407.9207 -311.0586 aarpow -4.629732 2.264801 -2.044 0.042 -9.09742 -. 1620445 _cons 23.41278 1.418514 16.505 0.000 20.61453 26.21103 260 correlate, _coef APPENDIX M Check for Multicollinearity (1995-1997) resgrp fangrp dd dr ds rs rd resgrp 1.0000 famgrp -0.4885 1.0000 dd 0.1265 -0.0109 1.0000 dr 0.2587 -0.0051 0.3689 1.0000 ds 0.0091 -0.0082 0.3984 0.3297 1.0000 rs 0.0637 -0.0239 0.4386 0.2889 0.3253 1.0000 rd 0.0375 -0.0328 0.4781 0.3344 0.3924 0.4429 1.0000 y96 0.0704 -0.0282 0.2394 0.1521 0.1243 0.1374 0.0918 y97 0.1188 -0. 1277 0.0901 0.0949 0.1895 -0.0233 -0.0803 mhours 0.2160 0.1796 0.2543 0.0134 -0.1080 0.1141 0.0813 lpnhours 0.2112 -0.0880 -0.0936 0.0581 -0.1436 0.0857 -0.0447 nahours 0.1017 0.1419 0.1084 0.1071 0.2129 0.1476 0.0749 indpow -0.2406 0.5013 0.1594 0.1383 0.2395 0.0248 0.0201 aarpow —O. 1686 0.0299 0.0338 -0.0562 0.2257 0.0455 0.0488 _cons -0.5518 -0.1148 -0.2954 -0.2926 -0.1215 02356 01517 y96 y97 rn hours lpnhours nahours indpow aarpow y96 1.0000 y97 0.4908 1.0000 mhours -0.0865 -0.2999 1 .0000 lpnhours 0.0032 -0. 1431 0.0626 1.000 nahours 0.0352 -0.0099 —0.1132 0.0959 1.000 indpow 0.0044 —0.0283 0.2585 0.0730 0.3442 1.000 aarpow —0.0570 -0.4572 -0.0730 0. 1827 0.0286 -0. 1972 1.000 _cons -0. 1032 0.1135 -0.3608 -0.4209 -0.6880 -0.3551 -0. 1517 _cons _conSI 1.0000 “- 261 APPENDIX N Glesjer Test for Heteroscedasticity (1995—1997) reg absres resgrp famgrp mhours lpnhours nahours indpow aarpow Source SS Model 151.555673 Residual l 15.538074 - Total 267.093747 "mthiéé """"" E: 52?. """""""" """TEEQEE"70338727 """""" famgrp -.0088323 mhours 2.580536 lpnhours 3.941756 nahours -1 .7 80301 indpow - 1 38 .453 aarpow -7.676264 _cons 4.484065 139 146 MS Number of obs = 147 7 21.6508104 F( 7, 139) = 26.05 .831209169 Prob > F = 0.0000 1 .82940923 R-squared 0.5674 Adj R-squared = 0.5456 Root MSE = .91171 Std. Err t P> III [95% Conf. Interval] - 0099046 3 .420 0.001 0.142915 .0534578 .0077413 -1.141 0.256 -.0241382 .0064736 .4816146 5.358 0.000 1.628298 3.532774 .4811085 8.193 0.000 2.990519 4.892993 .3833872 -4.644 0.000 -2.538325 -1.022276 30.25414 4576 0.000 -l98.2708 -78.63523 2.186507 -3.511 0.001 -ll.99938 -3.353151 1.474555 3 .041 0.003 1.568607 7.399524 262 correlate, _coef APPENDIX 0 Check for Multicollinearity (1991—1997) resgrp fangrp dd dr ds rs rd resgrp 1.0000 famgrp -0.4693 1 .0000 dd 0.1390 0.0190 1.0000 dr 0.2159 -0.0920 0.4461 1.0000 ds 0.0831 —0.0408 0.5546 0.3987 1.0000 rs -0.0099 0.0640 0.4861 0.3188 0.4192 1.0000 rd 0.0743 -0.0571 0.6126 0.4037 0.5147 0.4724 1.0000 y92 0.0706 -0. 1054 -0.0008 0.0439 -0.0139 0.0051 -0.0158 y93 0.0737 —0. l 133 -0.0246 0.0132 —0.0364 -0.0291 -0.0261 y94 -0.0011 -0.1704 -0.1181 0.0059 0.0399 —0.1175 -0.0204 y95 0.0244 -0. 1552 -0.1034 0.0102 -0.0339 -0.1 141 -0.0241 y96 0.0845 -0. 1708 0.0561 0.1125 0.0650 —0.0074 0.0568 y97 0.1594 -0.2332 -0.0254 0.0951 0.0748 -0.0790 -0.0558 mhours 0.1891 0.1699 0.2468 —0.0184 0.0235 0.1096 0.1549 lpnhours 0.1610 -0.1010 -0.1048 -0.0092 -0.1116 -0.0051 -0.0821 nahours -0.0023 0.1225 0.1787 0.0863 0.1669 0.0961 0.0257 indpow -0. 1920 0.4719 0.1595 0.0612 0.0886 0.0253 -0.0473 aarpow -0.2336 0.0756 -0.0113 -0. 1006 -0.1776 -0.0429 0.0021 _cons -0.6090 -0.0270 -0.3392 -0.23 13 -O. 1675 -0. 1337 -0. 1515 y92 y93 y94 y95 y96 y97 mhours y92 1.0000 y93 0.5013 1.0000 y94 0.4686 0.4902 1 .000 y95 0.4759 0.4900 0.5638 1.000 y96 0.4675 0.4778 0.5551 0.5522 1.000 y97 0.4213 0.4423 0.5440 0.5220 0.5734 1.000 mhours —0.0199 —0.0238 -0.3193 -0.2981 -0.3463 -0.4421 1.000 lpnhours 0.0152 -0.0408 -0.0931 -0.0493 -0.0418 -0.1038 0.0144 nahours 0.0360 -0.0768 0.0774 -0.0345 0.0043 -0.0278 —0. 1438 indpow -0.0382 —0.1030 0.2129 -0.1893 -0.1753 -0.1668 0.2561 aarpow -0.0205 -0.0324 0.0243 0.0737 0.0167 —0.2816 -0.1125 _cons -0. 1237 -0 . 3076 0.0966 0.0208 -0.0308 0.0701 -0.2791 lpnhours nahours indpow aarpow _cons lpnhours 1.000 nahours —0.0467 1.000 indpow 0.1 179 0.3429 1.000 aarpow 0.1272 0.0645 -0. 1869 1.000 _cons -0.3190 -0.5949 -0.3184 -0. 1372 1.000 263 APPENDIX P Glesjer Test for Heteroscedasticity (1991-1997) reg absres resgrp famgrp mhours lpnhours nahours indpow aarpow Source SS Model 7 1 6 . 926344 Residual 723. 122474 Total 1440.04882 abres I resgrp. famgrp mhours lpnhours nahours indpow aarpow cons _-—--—---—--- .0143355 -.0252771 -3. 162953 3.868497 -1.930187 -348.8778 -7.318597 14.27841 335 342 MS Number of obs 343 7 102.418049 F( 7, 335) 47.45 2.15857455 Prob > F 0.0000 4.21066906 R-squared 0.4978 Adj R-squared 0.4874 Root MSE 1.4692 Std. Err t P> III [95% Conf. Interval] 0124431 1.152 0.250 -.010141 .0388119 .0076478 -3.305 0.001 -.0403209 -.0102334 .44325 -7.136 0.000 -4.034857 -2.291049 .525465 7.362 0.000 2.83487 4.902123 .3951919 -4.884 0.000 2.707557 -1.152817 31.1338 -11.206 0.000 -410.1202 -287.6354 2.70988 -2.701 0.007 -12.64912 -1.988071 1.520398 9.391 0.000 11.28768 17.26914 264 APPENDIX Q Indices for Regression Analysis External Environmental Factor Indices External Groups and Political Institutions Index for Inspection Managers Item 1. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period July 1, 1995 through the present? (n=33) Category Freguency/ Percent * yes, frequently 4 (12.1%) * yes, occasionally 12 (36.4%) * no 17 (51.5%) Item 2. Were you encouraged by representatives of the American Association or Retired Persons to cite facilities at any point during the period July 1, 1995 through the present? (n=33) Category Freqfiuency/ Percent * yes, frequently 2 (6.1%) * yes, occasionally 3 (9.1%) * no 28 (84.8%) Item 3. Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present? (n=33) Category Frequency/Percent * yes, frequently 4 (12.1%) * yes, occasionally 11 (33.3%) * no 18 (54.5%) Item 4. Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present? (n=33) Category Frequency/Percent * yes, frequently 4 (12.1%) * yes, occasionally 14 (42.4%) * no 15 (45.5%) 265 Item 5. Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Fretmencv/ Percent * yes, to increase enforcement efforts 2 (6.1%) * yes, to decrease enforcement efforts 31 (93.9%) Item 6. Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Frequency/Percent * yes, to increase enforcement efforts 1 (3%) * yes, to decrease enforcement efforts 3 (9.1%) * no 29 (87.9%) Item 7. Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Categog Frequency/ Percent * yes, to increase enforcement efforts 2 (6.1%) * yes, to decrease enforcement efforts 5 (15.2%) * no 26 (78.8%) Item 8. Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Frequency/Percent * yes, to increase enforcement efforts 9 (27.3%) * yes, to decrease enforcement efforts 3 (9.1 %) * no 19 (57.6%) * both to increase and decrease enforcement efforts 2 (6.1%) 266 External Groups and Political Institutions Index for Inspectors Item 1. Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Frequency/Percent * yes, to decrease enforcement efforts 4 (13.3%) * no 24 (80%) * missing data 2 (6.7%) Item 2. Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Freauencv/ Percent * yes, to decrease enforcement efforts 2 (6.7%) * no 25 (83.3%) * missing data 3 (10%) Item 3. Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Categog Freguency/ Percent * yes, to increase enforcement efforts 2 (6.7%) * yes, to decrease enforcement efforts 2 (6.7%) * no 24 (80%) * missing data 2 (6.7%) Item 4. Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Freg uency/ Percent * yes, to increase enforcement efforts 8 (26.7%) * yes, to decrease enforcement efforts 2 (6.7%) * no 17 (56.7%) * both, to increase and decrease enforcement efforts 1 (3.3%) * missing data 2 (6.7%) 267 Item 5. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period 7/1/95 through the present? (n =30) Category Freguency/ Percent * yes, frequently 3 (10%) * yes, occasionally 10 (33.3%) * no 17 (56.7%) Item 6. Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present? (n=30) Category Freguency/ Percent * yes, frequently 1 (3.3%) * yes, occasionally 12 (40%) * no 17 (56.7 %) Item 7. Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present? (n=30) Category Freg uency/ Percent * yes, frequently 1 (3.3%) * yes, occasionally 13 (43.3%) * no 16 (53.3%) Item 8. Did you resolve nursing home resident problems with the assistance of the Long- Term Care Ombudsman at any point during the period July 1, 1995 through the present? (n=30) Category Frequency/ Percent * yes, frequently 1 (3.3%) * yes, occasionally 22 (73.3%) * no 7 (23.3%) 268 Internal Agency Factor Indices Working Conditions Index for Managers Item 1. I’m paid fairly compared with other employees (n=33) ' Category Frequency/Percent * agree 13 (39.4%) * undecided 3 (9.1%) * disagree 12 (36.4%) * strongly disagree 5 (15.2%) Item 2. There is too much pressure on my job (n=33) Category Frequencv/ Percent strongly agree 6 (18.2%) * agree 16 (48.5%) * undecided 6 (18.2%) * disagree 5 (15.2%) Item 3. There are some conditions concerning my job that could be improved (n =33) Category Freguency/ Percent * strongly agree 13 (39.4%) * agree 20 (60.6%) Item 4. I consider my job rather unpleasant (n=33) Category Freguengy/Percent * strongly agree 3 (9.1%) * agree 1 (3 %) * undecided 5 (15.2 %) * disagree 18 (54.5 %) * strongly disagree 6 (18.2 %) Item 5. I am satisfied with my job for the time being (n=33) Category Freguency/ Percent * strongly agree 3 (9.1%) * agree 21 (63.6%) * undecided 4 (12.1%) * disagree 4 (12.1%) * strongly disagree 1 (3 %) 269 Working Conditions Index for Inspectors Item 1. I’m paid fairly compared with other employees (n=30) Category Frequency/Percent * strongly agree 1 (3.3%) * agree 11 (36.7%) * undecided 2 (6.7%) * disagree 7 (23.3%) * strongly disagree 9 (30%) Item 2. There is too much pressure on my job (n=30) Category Frguency/Percent * strongly agree 1 (3.3%) * agree 14 (46.7%) * undecided 2 (6.7%) * disagree 13 (43.3%) Item 3. There are some conditions concerning my job that could be improved (n=30) Category Freguengy/ Percent * strongly agree 11 (36.7%) * agree 18 (60%) * disagree 1 (3.3%) Inspectors ’ Views about Relationships with Management Index Item 1. Management is doing its best to give us good working conditions (11 =30) Category * **** strongly agree agree undecided disagree missing data 270 Freguency/ Percent 7 (23.3 %) 10 (33.3%) 4 (13.3%) 8 (26.7%) 1 (3.3%) Item 2. My boss is too interested in his own success to care about the needs of employees (n=30) Category Frequency/Percent * strongly agree 3 (10%) * agree 2 (6.7%) * undecided 2 (6.7%) * disagree 11 (36.7 %) * strongly disagree 10 (33.3 %) * missing data 2 (6.7%) Item 3. My boss sees to it that employees are properly trained for their jobs (n=30) ‘ Category Frequency/ Percent * strongly agree 8 (26.7 %) * agree 14 (46.7%) * undecided 2 (6.7%) * disagree 3 (10%) * strongly disagree 2 (6.7%) * missing data 1 (3.3%) Item 4. Management sees to it that there is cooperation between departments (n=30) Category Freguency/ Percent * strongly agree 1 (3.3%) * agree 19 (63.3%) * undecided 5 (16.7%) * disagree 2 (6.7%) * strongly disagree 1 (3.3%) * missing data 2 (6.7%) Item 5. Management encourages us to make suggestions for improvements here (n=30) Category Freguency/ Percent * strongly agree 6 (20%) * agree 14 (46.7%) * undecided 2 (6.7%) * disagree 3 (10%) * strongly disagree 3 (10%) * missing data 2 (6.7%) 271 Item 6. To what extent do your superiors have confidence and trust in you (n=30) Category Frequency/ Percent * have condescending confidence and trust; such as master has in servant 5 ( 16.7%) * substantial but not complete confidence and trust; still wishes to keep control of decisions 15 (50%) * complete confidence and trust in all matters 9 (30%) * missing data 1 (3.3%) Item 7. To what extent do you have confidence and trust in your superiors (n =30) Category Frequency/ Percent * have no confidence and trust in subordinates 2 (6.7%) * substantial but not complete confidence and trust; still wishes to keep control of decisions 14 (46.7 %) complete confidence and trust in all matters 11 (36.7 %) * don’t know 1 (3.3%) * missing data 2 (6.7%) Item 8. To what extent do your superiors behave so that subordinates feel free to discuss important things about their jobs with their immediate superior (n = 30) Category Freguency/ Percent * subordinates feel completely free to discuss things about the job with their superior 10 (33.3 %) * subordinates feel rather free to discuss things about the job with their superior 12 (40%) * subordinates do not feel very free to discuss things about the job with their superior 7 (23.3%) * missing data 1 (3.3%) 272 Item 9. The extent to which superiors willingly share information with subordinates (n =30) Category Freguency/ Percent * superiors provide minimum of information 1 (3.3%) * superiors give subordinates only information superior feels they need 9 (30%) * superiors give information needed and answers most questions 10 (33.3 %) * superiors seek to give subordinates all relevant information and all information they want 9 (30%) * missing data 1 (3.3%) Item 10. How well does your immediate superior know and understand problems faced by subordinates (n=30) Category Freguency/ Percent * knows and understand problems faced by subordinates 9 (30%) * knows and understands problems of subordinates quite well 12 (40%) * has some knowledge and understanding of problems of subordinates 7 (23.3%) don’t know 1 (3.3%) * missing data 1 (3.3%) Managers ’ Views about Relationships with Inspectors Index Item 1. To what extent do you behave so that nursing home inspectors feel free to discuss important things about their jobs with their immediate superior (n=33) Category Freguency/ Percent * subordinates feel completely free to discuss things about the job with their superior 13 (39.4 %) * subordinates feel rather free to discuss things about the job with their superior 19 (57.6 %) * subordinates do not feel very free to discuss things about the job with their superior 1 (3 %) 273 Item 2. The extent to which you willingly share information with nursing home inspectors (n = 33) Category Frequency/Percent * give information needed and answers most questions 7 (21.2%) * give subordinates all relevant information they want 26 (78.8%) Item 3. The extent to which I have confidence and trust in my nursing home inspectors (n =33) Category Freqfiuencyl Percent * have condescending confidence and trust; such as master has in servant 1 (3 %) * substantial but not complete confidence and trust; still wishes to keep control of decisions 19 (57.6%) * complete confidence and trust in all matters 13 (39.4%) Item 4. Would you say that the morale of your nursing home inspectors over the period 7/1/95 through the present was (n=33) Category Freguency/ Percent * very high 3 (9.1%) * high 2 (6.1%) * normal 16 (48.5%) * low 12 (36.4%) 274 APPENDIX R State Nursing Home Regulators’ Questionnaire for Managers of Nursing Home Inspectors The goal of this questionnaire is to assess the organizational factors that impact the implementation of the nursing home standards outlined in the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87). In 1987 Congress passed OBRA ’87 which contained laws that required State nursing home regulators to change the way they examined nursing homes. This questionnaire is to be answered by a state employee who manages nursing home inspectors. Your cooperation in completing this questionnaire will help nursing home regulators, policymakers and researchers understand the factors influencing the implementation of OBRA ’87 nursing home standards covering the period July 1, 1995 through the present. Your completion of this survey is strictly voluntary and your responses are confidential. You may choose not to answer any particular question or not complete the survey. Also, once the information is gathered from all of the respondents, the data will be reported in aggregate form which will not allow anyone to identify your individual answers. An identification code was used to help identify completed questionnaires. This code will be eliminated before the data are analyzed. This questionnaire will take approximately 20 minutes to complete. Your responses will serve as your consent agreement if you choose to complete this questionnaire. Write your name and address on the last page of this questionnaire, if you are interested in obtaining a copy of the results from this study. Section I: Background 1. What is your professional position (Circle your answer)? Director Assistant Director Manager Assistant Manager Chief Other (please specify): radiance Were you hired as a political appointee or a civil servant? (Circle your answer) a. political appointee b. civil servant c. other (please specify): How many years have you been in this position? (Circle your answer)? less than one year one to two years three to five years five to ten years more than ten years 999579» What is the highest level of education you completed? (Circle your answer) a. high school diploma b. associate’s degree c. bachelor’s degree (I. graduate degree e other (please specify): 275 5. l have a membership in the following organizations outside of my full-time employment: (Circle your answer) a. membership in no outside organizations b. active only in community organizations c. membership in at least one professional organization d. membership in two professional organizations e. membership in more than two professional organizations Section II: Adeguacy of Resources 6. Approximately how many nursing home inspectors do you currently employ (Write your answer in the space provided)? 7. Do you feel that the number of nursing home inspectors in your agency were sufficient to examine the nursing homes in your state during the period 7/1/95 through the present (Circle the most accurate answer)? a. inadequate and not improving b. inadequate, but getting better c. adequate d. more than adequate e. completely adequate 8. What is your estimation of the adequacy of the resources provided to assist you in training your nursing home inspectors for the period 7/1/95 through the present (Circle the most appropriate answer) a. training resources provided are excellent b. training resources provided are very good c. training resources provided are good (1. training resources provided are only fairly good 9. The budget you were appropriated to inspect nursing homes for the period 7/1/95 through the present has been (Circle the most appropriate answer) inadequate and not improving inadequate, but getting better adequate more than adequate completely adequate sup-99'.» 10. What professions do you hire to fill your nursing home inspector vacancies? (Circle all that apply) a. Registered Nurse (2 year degree) b. Registered Nurse (4 year degree) c. Social Worker d. Dietitian e. Sanitarian f. other (please specify): 276 11. Which statement most accurately reflects the amount of employee turnover you experienced with your nursing home inspectors during the period 7/1/95 through the present (Circle the most accurate answer)? a. very high b. high c. average (1. low e. very low 12. The extent to which you have been given management training (Circle your answer) a. have received no management training of any kind I desire b. have received some management training and kind I desire c. have received quite a bit of management training and kind I desire d. have received a great deal of management training and kind I desire Sectiorl III: External Influences on Nursing Home Insp_ec_tion Management 13. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period 7/1/95 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally 0. no 14. Were you encouraged by representatives of the American Association or Retired Persons to cite facilities at any point during the period 7/1/95 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no 15. Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no 16. Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no 17. Did you resolve nursing home resident problems with the assistance of the Long-term Care Ombudsman at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no (Note: Enforcement refers to changing the number of inspections, strictly applying nursing home standards, and changing the number of severe penalties assessed for Questions 18 through 21) 277 18. 19. 20. 21. 22. Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts e. no Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts c. no Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts e. no Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts 0. no The number of organizations that we must interact with in order to implement OBRA ’87 enforcement since July 1, 1995 is: (Circle your answer) a. only one organization b. two organizations 0. three to five organizations d. five to ten organizations c. more than ten organizations SectiorflV: Managemen ’5 Views About Their Nursing Home Insation Staff 23. 24. To what extent do you behave so that nursing home inspectors feel free to discuss important things about their jobs with their immediate superior (Circle your answer) subordinates feel completely free to discuss things about the job with their superior subordinates feel rather free to discuss things about the job with their superior subordinates do not feel very free to discuss things about the job with their superior subordinates do not feel at all free to discuss things about the job with their superior don’t know tho-99‘!» The extent to which you willingly share information with nursing home inspectors (Circle your answer) a. provide minimum of information b. give subordinates only information superior feels they need c. give information needed and answers most questions (1. give subordinates all relevant information they want 278 25. 26. The extent to which I have confidence and trust in my nursing home inspectors (Circle your answer) Pei-PUP have no confidence and trust in subordinates have condescending confidence and trust; such as master has in servant substantial but not complete confidence and trust; still wishes to keep control of decisions complete confidence and trust in all matters don’t know Would you say that the morale of your nursing home inspectors over the period 7/1/95 through the present was (Circle the most accurate answer): a. paper very high high normal low very low Section V: Management’s Views About Their WorI_(_ 27. I’m paid fairly compared with other employees (Circle your answer) 28. 29. 30. 31. 99.9.69 strongly agree agree undecided disagree strongly disagree There is too much pressure on my job (Circle your answer) 9995‘.” strongly agree agree undecided disagree strongly disagree There are some conditions concerning my job that could be improved (Circle your answer) sun-90‘s» strongly agree agree undecided disagree strongly disagree I consider my job rather unpleasant (Circle your answer) .9997.” strongly agree agree undecided disagree strongly disagree I am satisfied with my job for the time being (Circle your answer) tin-99's» strongly agree agree undecided disagree strongly disagree 279 32. Is there anything else you would like to tell me about your experiences with inspecting nursing homes during the period 7/1/95 through the present? (Write your answer in the space provided) Thank you for completing this questionnaire. If you need to contact me for any reason, I can be reached at (517) 355-8151, intemet: Ramseylu@pilot.msu.edu, or mail: Lucinda M. Deason, Ph.D. Candidate, MPA Michigan State University Department of Political Science 303 S. Kedzie Hall East Lansing, MI 48824 280 APPENDIX S State Nursing Home Regulators’ Questionnaire for Nursing Home Inspectors I results from this study. i - The goal of this questionnaire is to assess the organizational factors that impact the implementation of the nursing home standards outlined in the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87). In 1987 Congress passed OBRA ’87 which contained laws that required state nursing home regulators to change the way they examined nursing homes. This questionnaire is to be answered by a state employee who inspects nursing homes and is not a manager or supervisor. Your cooperation in completing this questionnaire will help nursing home regulators, policymakers and researchers understand the factors influencing the implementation of OBRA ’87 nursing home standards covering the period July 1, 1995 through the present. Your completion of this survey is strictly voluntary and your responses are confidential. You may choose not to answer any particular question or not complete the survey. Also, once the information is gathered from all of the respondents, the data will be reported in aggregate form which will not allow anyone to identify your individual answers. An identification code was used to help identify completed questionnaires. This code will be eliminated before the data are analyzed. This questionnaire will take approximately 20 minutes to complete. Your responses will serve as your consent agreement if you choose to complete this questionnaire. Write your name and address on the last page of this questionnaire, if you are interested in obtaining a copy of the Section I: Background 1. What is your professional background? (Circle your answer) a. Registered Nurse b. Social Worker c. Dietitian d. Sanitarian e. other (please specify): Were you hired as a political appointee or a civil servant? (Circle your answer) a. political appointee b. civil servant c. other (please specify): How many years have you been in this position? (Circle your answer) a. less than one year b. one to two years c. three to five years (1. five to ten years e. more than ten years 281 4. What is the highest level of education you completed? (Circle your answer) high school diploma associate's degree bachelor’s degree graduate degree other (please specify): 90.09:? 5. I have a membership in the following organizations outside of my full-time employment: a. membership in no outside organizations active only in community organizations membership in at least one professional organization membership in two professional organizations membership in more than two professional organizations papa Section 11: Nursing Home Inspector’s Views Aborflactors RtLated to Performing Their Job 6. Your estimation of the amount of cooperative teamwork that occurs during nursing home inspections is: (Circle your answer) there is a very substantial amount there is a moderate amount there is relatively little there is none don’t know tin-99‘s» 7. To what extent is technical and professional knowledge used in your decision to cite nursing homes? (Circle your answer) a. frequently b. occasionally c. rarely (1. never e. don’t know 8. To what extent are you involved in decisions related to your work? (Circle your answer) not at all never involved in decisions; occasionally consulted usually are consulted but ordinarily not involved in decision making are involved fully in all decisions related to their work don’t know sip-Perl» 9. Extent to which you have been given the kind training you require to perform your job? (Circle your answer) have received no training of any kind have received some training have received adequate training have received quite a bit of training have received a great deal of training 9999'.» 10. I’m paid fairly compared with other employees (Circle your answer) a. strongly agree b. agree c. undecided d. disagree e. strongly disagree 282 11. There is too much pressure on my job (Circle your answer) a strongly agree b agree 0. undecided (I disagree e strongly disagree 12. There are some conditions concerning my job that could be improved (Circle your answer) a. strongly agree b. agree c. undecided d. disagree e. strongly disagree 13. I consider my job rather unpleasant (Circle your answer) a. strongly agree b. agree c. undecided (1. disagree e. strongly disagree 14. I am satisfied with my job for the time being (Circle your answer) a. strongly agree b. agree c. undecided (1. disagree e. strongly disagree 15. Would you say that your morale at work during the period July 1, 1995 through the present was (Circle the most accurate answer): a. very high b. high c. normal d. low e. very low Sectign III: External Influences on Nursing Home Insp£c_tion Staff 16. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period 7/1/95 through the present? (Circle your answer) a. yes, frequently b. yes, occasionally c. no 17. Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no 283 18. Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no 19. Did you resolve nursing home resident problems with the assistance of the Long-term Care Ombudsman at any point during the period July 1, 1995 through the present (Circle your answer)? a. yes, frequently b. yes, occasionally e. no (Note: Enforcement refers to changing the number of inspections, strictly applying nursing home standards, and changing the number of severe penalties assessed for Questions 20 through 23) 20. Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts c. no 21. Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts e. no 22. Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts e. no 23. Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (Circle your answer) a. yes, to increase enforcement efforts b. yes, to decrease enforcement efforts e. no Section IV: Nursing Home Inspector’s Views About Their Managers and Supgrvisors 24. To what extent do your superiors have confidence and trust in you (Circle your answer) a. have no confidence and trust in subordinates b. have condescending confidence and trust; such as master has in servant c. substantial but not complete confidence and trust; still wishes to keep control of decisions (1. complete confidence and trust in all matters e don’t know 25. To what extent do you have confidence and trust in your superiors (Circle your answer) a. have no confidence and trust in subordinates b. have condescending confidence and trust; such as master has in servant c. substantial but not complete confidence and trust; still wishes to keep control of decisions (I. complete confidence and trust in all matters e don’t know 284 26. 27. 28. 29. 30. 31. 32. To what extent do your superiors behave so that subordinates feel free to discuss important things about their jobs with their immediate superior (Circle your answer) a. papa- subordinates feel completely free to discuss things about the job with their superior subordinates feel rather free to discuss things about the job with their superior subordinates do not feel very free to discuss things about the job with their superior subordinates do not feel at all free to discuss things about the job with their superior don’t know The extent to which superiors willingly share information with subordinates (Circle your answer) a. b. c. d superiors provide minimum of information superiors give subordinates only information superior feels they need superiors give information needed and answers most questions superiors seek to give subordinates all relevant information and all information they want How well does your immediate superior know and understand problems faced by subordinates (Circle your answer) .999ch knows and understand problems faced by subordinates knows and understands problems of subordinates quite well has some knowledge and understanding of problems of subordinates has no knowledge of understanding of problems of subordinates don’t know Management is doing its best to give us good working conditions (Circle your answer) a. strongly agree b. agree c. undecided d. disagree e. Strongly disagree My boss is too interested in his own success to care about the needs of employees (Circle your answer) a. strongly agree b. agree c. undecided d. disagree e. strongly disagree My boss sees that employees are pr0perly trained for their jobs (Circle your answer) 99.0w? strongly agree agree undecided disagree strongly disagree Management sees to it that there is cooperation between departments (Circle your answer) 99.96:? strongly agree agree undecided disagree strongly disagree 285 33. 34. 35. 36. 37. Management encourages us to make suggestions for improvements here (Circle your answer) a. paper strongly agree agree undecided disagree strongly disagree Changes are made here with little regard for the welfare of employees (Circle your answer) tie-90's» strongly agree agree undecided disagree strongly disagree Management fails to give clear—cut orders and instructions (Circle your answer) 99.9w» strongly agree agree undecided disagree strongly disagree Management has a poor way of handling employee complaints here (Circle your answer) 9999‘s» strongly agree agree undecided disagree strongly disagree Is there anything else you would like to tell me about your experiences with inspecting nursing homes during the period 7/1/95 through the present? (Write your answer in the space provided) Thank you for completing this questionnaire. If you need to contact me for any reason, I can be reached at (517) 355-8151, internet: Ramseylu@pilot.msu.edu, or mail: Lucinda M. Deason, Ph.D. Candidate, MPA Michigan State University Department of Political Science 303 S. Kedzie Hall East Lansing, MI 48824 286 APPENDIX T Frequency Report of the State Nursing Home Regulators’ Questionnaire for Managers of Nursing Home Inspectors Section I: Background 1. What is your professional position (n=33) Category F reqnencleercefl * Director 5 (15.2%) * Assistant Director 1 (3 %) * Manager 14 (42.4 %) * Chief 3 (9.1 %) * Other 10 (30.3%) 2. Were you hired as a political appointee or a civil servant? (n=33) Catggog Fre_quency/ Percent * civil servant 33 (100%) 3. How many years have you been in this position? (n=33) Category Fre_quency/Percent * less than one year 3 (9.1%) * one to two years 3 (9.1%) * three to five years 6 (18.2%) * five to ten years 11 (33.3%) * more than ten years 10 (30.3 %) 4. What is the highest level of education you completed? (n=33) Categog Frmuency/Percent * associate’s degree 1 (3 %) * bachelor’s degree 16 (48.5%) * graduate degree 14 (42.4%) * other 2 (6.1%) 5. I have a membership in the following organizations outside of my full-time employment: (n=30) Category Frguency/ Percent * membership in no outside organizations 4 (12.1%) * active only in community organizations 11 (33.3%) * membership in at least one professional organization 8 (24.2%) membership in two professional organizations 5 (15.2 %) membership in more than two professional organizations 4 (12.1%) * missing data 1 (3 %) 287 Section II: Adeqnncy of Resources 6. Approximately how many nursing home inspectors do you currently employ? (n=33) Category Freguency/Percent * 5 1 (3%) * 6 2 (6.1%) * 8 1 (3%) * 10 3 (9.1%) * 12 1 (3%) * 13 3 (9.1%) * l8 1 (3%) * 20 3 (9.1%) * 21 l (3%) * 22 1 (3%) * 24 1 (3%) * 25 1 (3%) * 28 1 (3%) * 30 1 (3%) * 31 2 (6.1%) * 35 ' 1 (3%) * 36 2 (6.1%) * 50 1 (3%) * 90 1 (3%) * 92 1 (3%) * 100 2 (6.1%) * 200 1 (3%) * missing 1 (3%) Do you feel that the number of nursing home inspectors in your agency were sufficient to examine the nursing homes in your state during the period 7/1/95 through the present (n=33) Catggory Frequency/Percent * inadequate and not improving 6 (18.2%) * inadequate, but getting better 14 (42.4%) * adequate 12 (36.4%) * completely adequate 1 (3 %) What is your estimation of the adequacy of the resources provided to assist you in training your nursing home inspectors for the period 7/1/95 through the present (n=33) Category Frequency/Percent * training resources provided are excellent 3 (9.1%) * training resources provided are very good 6 (18.2%) * training resources provided are good 13 (39.4%) * training resources provided are only fairly good 11 (33.3%) The budget you were appropriated to inspect nursing homes for the period 7/1/95 through the present has been (n=33) Category Frequency/Percent * inadequate and not improving 8 (24.2%) * inadequate, but getting better 8 (24.2%) * adequate 14 (42.4%) * missing 3 (9.1%) 288 10. What professions do you hire to fill your nursing home inspector vacancies? (n=33) Category Fregueney * Registered Nurse (2 year degree) 24 "‘ Registered Nurse (4 year degree) 31 * Social Worker 22 * Dietitian 27 * Sanitarian 17 * Other 17 11. Which statement most accurately reflects the amount of employee turnover you experienced with your nursing home inspectors during the period 7/1/95 through the present (n=33) Category Frequency/Percent * very high 2 (6.1%) * high 6 (18.2%) * average 15 (45.5%) * low 7 (21.2%) * very low 3 (9.1%) 12. The extent to which you have been given management training (n=33) Category Freguency * have received no management training of any kind I desire I (3 %) * have received some management training and kind I desire 20 (60.6%) * have received quite a bit of management training and kind I desire 10 (30.3%) * have received a great deal of management training and kind I desire 2 (6.1%) Section HI: External Influences on Nursing Home InsMion Management 13. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period 7/1/95 through the present (n=33) Category Frgueney/Percent * yes, frequently 4 (12.1%) * yes, occasionally 12 (36.4%) * no 17 (51.5%) 14. Were you encouraged by representatives of the American Association or Retired Persons to cite facilities at any point during the period 7/1/95 through the present (n=33) Category Freguency/Percent "' yes, frequently 2 (6.1%) * yes, occasionally 3 (9.1%) * no 28 (84.8%) 15. Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present (n=33) Category Freguency/Percent * yes, frequently 4 (12.1%) * yes, occasionally 11 (33.3%) * no 18 (54.5%) 289 16. l7. l8. 19. 20. 21. 22. Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present (n=33) Category Frgnency/Percenr * yes, frequently 4 (12.1%) * yes, occasionally 14 (42.4 %) * no 15 (45.5 %) Did you resolve nursing home resident problems with the assistance of the Long-term Care Ombudsman at any point during the period July 1, 1995 through the present (n=33) Category Freqnency/Percenr * yes, frequently 7 (21.2%) * yes, occasionally 23 (69.7%) * no 3 (9.1%) Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Freqnency/Percer_1_t_ * yes, to increase enforcement efforts 2 (6.1%) * yes, to decrease enforcement efforts 31 (93.9%) Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Frguency/Percent * yes, to increase enforcement efforts 1 (3 %) * yes, to decrease enforcement efforts 3 (9.1%) * no 29 (87.9%) Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Frguency/Percent * yes, to increase enforcement efforts 2 (6.1%) * yes, to decrease enforcement efforts 5 (15.2%) * no 26 (78.8%) Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=33) Category Freqrflcy/Percenr * yes, to increase enforcement efforts 9 (27.3 %) * yes, to decrease enforcement efforts 3 (9.1%) * no 19 (57.6 %) * both to increase and decrease enforcement efforts 2 (6.1%) The number of organizations that we must interact with in order to implement OBRA ’87 enforcement since July 1, 1995 is: (n=33) Categou Freguency/Percent * only one organization 1 (3 %) * two organizations 4 (12.1%) * three to five organizations 12 (36.4%) * five to ten organizations 9 (27.3%) * more than ten organizations 2 (6.1%) * missing data 5 (15.2%) 290 Section IV: Managemen ’s Views Abent Their Nursing Home Insnection Staff 23. To what extent do you behave so that nursing home inspectors feel free to discuss important things about their jobs with their immediate superior (n=33) Category Freguency/Percent * subordinates feel completely free to discuss things about the job with their superior 13 (39.4%) * subordinates feel rather free to discuss things about the job with their superior 19 (57.6%) * subordinates do not feel very free to discuss things about the job with their superior l (3 %) 24. The extent to which you willingly share information with nursing home inspectors (n=33) Category Frequency/Percent * give information needed and answers most questions 7 (21 .2%) * give subordinates all relevant information they want 26 (78.8%) 25. The extent to which I have confidence and trust in my nursing home inspectors (n=33) Category Freguency/Percent * have condescending confidence and trust; such as master has in servant 1 (3 %) * substantial but not complete confidence and trust; still wishes to keep control of decisions 19 (57.6%) * complete confidence and trust in all matters 13 (39.4%) 26. Would you say that the morale of your nursing home inspectors over the period 7/1/95 through the present was ~ (n=33) Category Frequency/Percent * very high 3 (9.1%) * high 2 (6.1%) * normal 16 (48.5 %) * low 12 (36.4%) Section V: Management’s Views About Their Work 27. I’m paid fairly compared with other employees (n=33) Category Fregueney/Percent * agree 13 (39.4%) * undecided 3 (9.1%) * disagree 12 (36.4%) * strongly disagree 5 (15.2%) 28. There is too much pressure on my job (n=33) Category Frguency/Percent * strongly agree 6 (18.2%) * agree 16 (48.5 %) * undecided 6 (18.2%) * disagree 5 (15.2%) 291 29. There are some conditions concerning my job that could be improved (n=33) Categog Frenlflrcy/Percgn * strongly agree 13 (39.4%) * agree 20 (60.6%) 30. I consider my job rather unpleasant (n=33) Category Frequency/Percenr * strongly agree 3 (9.1%) * agree 1 (3 %) * undecided 5 (15.2%) * disagree 18 (54.5 %) * Strongly disagree 6 (18.2%) 31. I am satisfied with my job for the time being (n=33) Category Frguency/Percent * strongly agree 3 (9.1%) * agree 21 (63.6%) * undecided 4 (12.1%) * disagree 4 (12.1%) * strongly disagree 1 (3 %) 292 APPENDIX U Frequency Report of the State Nursing Home Regulators’ Questionnaire Section I: Background for Nursing Home Inspectors I. What is your professional background? (n=30) Category registered nurse social worker dietitian sanitarian other ***** Freg uency/ Percent 21 (70%) 2 (6.7%) 3 (10%) 3 (10%) l (3.3%) 2. Were you hired as a political appointee or a civil servant? (n=30) Category * civil servant 3. How many years have you been in this position? (n=30) Category less than one year one to two years three to five years five to ten years more than ten years ***** 4. What is the highest level of education you completed? (n=30) Category * associate’s degree * bachelor’s degree * graduate degree * other Frguency/Percent 30 (100 %) Freqnency/Percen_t 1 (3.3%) 3 (10%) 7 (23.3%) 7 (23.3%) 12 (40%) Frguency/Percent 5 (16.7 %) 12 (40%) 9 (30%) 4 (13.3%) 5. I have a membership in the following organizations outside of my full-time employment: (n=30) Category * membership in no outside organizations **** organizations active only in community organizations membership in at least one professional organization membership in two professional organizations membership in more than two professional * membership in both professional and community organizations * missing data EMueney/Percent 4 (13.3 %) 7 (23.3%) 9 (30%) 1 (3.3%) 6 (20%) 2 (6.7%) l (3.3%) Section II: Nursing Home Inspector’s Views About Factors Related to Performing Their Job 6. Your estimation of the amount of cooperative teamwork that occurs during nursing home inspections is: (n=30) Category * there is a very substantial amount * there is a moderate amount 293 firearm—ween: 24 (80%) 6 (20%) 10. ll. 12. 13. To what extent is technical and professional knowledge used in your decision to cite nursing homes? (n=30) Categog Frequency/Percent * frequently 28 (93.3%) * occasionally 2 (6.7%) To what extent are you involved in decisions related to your work? (n=30) Category F reqnency/Percem * not at all 2 (6.7%) * never involved in decisions; occasionally consulted 2 (6.7%) * usually are consulted but ordinarily not involved in decision making 10 (33.3%) * are involved fully in all decisions related to their work 15 (50%) * missing data 1 (3.3%) Extent to which you have been given the kind training you require to perform your job? (n=30) Category Freguency/Percent * have received some training 5 ( 16.7 %) * have received adequate training 6 (20%) * have received quite a bit of training 13 (43.3 %) * have received a great deal of training 6 (20%) I’m paid fairly compared with other employees (n=30) Category Frguency/Percent * strongly agree 1 (3.3%) * agree 11 (36.7%) * undecided 2 (6.7%) * disagree 7 (23.3%) * strongly disagree 9 (30%) There is too much pressure on my job (n=30) Category Freguency/Percent * strongly agree 1 (3.3%) * agree 14 (46.7 %) * undecided 2 (6.7%) * disagree 13 (43.3 %) There are some conditions concerning my job that could be improved (n=30) Category Frguency/Percent * strongly agree 11 (36.7 %) * agree 18 (60%) * disagree 1 (3.3%) I consider my job rather unpleasant (n=30) Category Freguency/Percent * undecided 1 (3.3%) "' disagree 20 (66.7 %) * strongly disagree 9 (30%) 294 14. 15. I am satisfied with my job for the time being (n=30) Category Frennencv/Percent "' strongly agree 8 (26.7 %) * agree 18 (60%) * undecided 3 (10%) * disagree 1 (3.3%) Would you say that your morale at work during the period July 1, 1995 through the present was (n=30) Category Frguency/Percent * very high 3 (10%) * high 4 (13.3 %) * normal 13 (43.3 %) * low 7 (23.3%) * very low 3 (10%) Sectinn III: External Influences on Nursing Home InsMon Staff l6. I7. 18. 19. 20. Were you encouraged by representatives of the nursing home industry association to not cite facilities at any point during the period 7/1/95 through the present? (n=30) Category Freanengr/Percenr * yes, frequently 3 (10%) * yes, occasionally 10 (33.3%) * no 17 (56.7%) Were you encouraged by nursing home resident groups to cite facilities at any point during the period July 1, 1995 through the present? (n=30) Categou Freqnency/Percem * yes, frequently 1 (3.3%) * yes, occasionally 12 (40%) * no 17 (56.7 %) Were you encouraged by nursing home family groups to cite facilities at any point during the period July 1, 1995 through the present? (n=30) Category Freqnency/Percenr * yes, frequently 1 (3.3%) * yes, occasionally 13 (43.3 %) * no 16 (53.3 %) Did you resolve nursing home resident problems with the assistance of the Long-term Care Ombudsman at any point during the period July 1, 1995 through the present? (n=30) Category Frequency/Percent * yes, frequently 1 (3.3%) * yes, occasionally 22 (73.3%) * no 7 (23.3%) Did you receive pressure from the Governor in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Frequency/Percenr * yes, to decrease enforcement efforts 4 (13.3%) * no 24 (80%) * missing data 2 (6.7%) 295 21. Did you receive pressure from any senators in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Frguency/Percent * yes, to decrease enforcement efforts 2 (6.7%) * no 25 (83.3 %) * missing data 3 (10%) 22. Did you receive pressure from any representatives in your state to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category F re_quency/Percent * yes, to increase enforcement efforts 2 (6.7%) * yes, to decrease enforcement efforts 2 (6.7%) * no 24 (80%) * missing data 2 (6.7%) 23. Did you receive pressure from the Health Care Financing Administration to adjust your enforcement of nursing home standards during the period July 1, 1995 through the present? (n=30) Category Frequency/Percent * yes, to increase enforcement efforts 8 (26.7 %) * yes, to decrease enforcement efforts 2 (6.7%) * no 17 (56.7 %) * both, to increase and decrease enforcement efforts 1 (3.3%) * missing data - 2 (6.7%) Section IV: Nursing Home Inspector’s Views About Their Managers and Sumrvisors 24. To what extent do your superiors have confidence and trust in you (n=30) Categog Freguency/Percent * have condescending confidence and trust; such as master has in servant 5 (16.7%) * substantial but not complete confidence and trust; still wishes to keep control of decisions 15 (50%) complete confidence and trust in all matters 9 (30 %) missing data 1 (3.3%) 25. To what extent do you have confidence and trust in your superiors (n=30) Category Freguency/Percent * have no confidence and trust in subordinates 2 (6.7%) * substantial but not complete confidence and trust; still wishes to keep control of decisions 14 (46.7%) complete confidence and trust in all matters 11 (36.7%) don’t know 1 (3.3%) missing data 2 (6.7%) 296 26. 27. 28. 29. 30. To what extent do your superiors behave so that subordinates feel free to discuss important things about their jobs with their immediate superior (n=30) Categog * subordinates feel completely free to discuss things about the job with their superior * subordinates feel rather free to discuss things about the job with their superior * subordinates do not feel very free to discuss things about the job with their superior * missing data Frequency/Percent 10 (33.3 %) 12 (40%) 7 (23.3%) 1 (3.3%) The extent to which superiors willingly Share information with subordinates (n=30) Category * superiors provide minimum of information * superiors give subordinates only information superior feels they need * superiors give information needed and answers most questions * superiors seek to give subordinates all relevant information and all information they want * missing data Frequency/Percent 1 (3.3%) 9 (30%) 10 (33.3%) 9 (30%) 1 (3.3%) How well does your immediate superior know and understand problems faced by subordinates (n=30) Category * knows and understand problems faced by subordinates * knows and understands problems of subordinates quite well * has some knowledge and understanding of problems of subordinates * don’t know * missing data Frgueney/Percent 9 (30%) 12 (40%) 7 (23.3 %) l (3.3%) l (3.3%) Management is doing its best to give us good working conditions (n=30) Category * strongly agree * agree * undecided * disagree * missing data Freguency/Percent 7 (23 .3 %) 10 (33.3%) 4 (13.3%) 8 (26.7%) 1 (3.3%) My boss is too interested in his own success to care about the needs of employees (n=30) Category * strongly agree agree undecided disagree strongly disagree missing data ***** 297 Freguency/Percent 3 (10%) 2 (6.7%) 2 (6.7%) 11 (36.7%) 10 (33.3%) 2 (6.7%) 31. 32. 33. 34. 35. 36. My boss sees that employees are properly trained for their jobs (n=30) Category ****** strongly agree agree undecided disagree strongly disagree missing data F requency/ Perce4nt_ 8 (26.7%) 14 (46.7%) 2 (6.7%) 3 (10%) 2 (6.7%) 1 (3.3%) Management sees to it that there is cooperation between departments (n=30) Category ****** strongly agree agree undecided disagree strongly disagree missing data Frequency/Percent 1 (3.3%) 19 (63.3%) 5 (16.7%) 2 (6.7%) 1 (3.3%) 2 (6.7%) Management encourages us to make suggestions for improvements here (n=30) Qagmn: * ***** strongly agree agree undecided disagree strongly disagree missing data Frguency/Percent 6 (20%) 14 (46.7%) 2 (6.7%) 3 (10%) 3 (10%) 2 (6.7%) Changes are made here with little regard for the welfare of employees (n=30) Category **** agree undecided disagree strongly disagree flyuency/Pcrcent 6 (20 %) 6 (20%) 13 (43.3%) 5 (16.7%) Management fails to give clear-cut orders and instructions (n=30) Category **‘I-I-‘l- strongly agree agree undecided disagree strongly disagree Fremcy/Percen; 1 (3.3%) 5 (16.7%) 4 (13.3%) 16 (53.3%) 4 (13.3%) Management has a poor way of handling employee complaints here (n=30) Category ***** strongly agree agree undecided disagree strongly disagree 298 Ehammgflknfln 4033%) 5 (16.7%) 7 (23.3%) 9 (30%) 5 (16.7%) APPENDIX V F-Test for Testing Sets of Coefficients Comparing the Inspection Manager Model to the Inspection Manager and Inspector Model PH", = lRSS-kH) - RSS(k)l/H [RSS(k)/(n-k) RSS(12) = 154 k = 12 n = 69 RSS(9) = 167 k = 9 n = 69 H = 3 Test F357 = 1.6 Critical F357 = 2.76 at the 0.5 level (note: the degrees of freedom used were based on 3, 60 because 3, 57 was not reported in the F table). Therefore, do not reject the null hypothesis and it can be concluded that including the additional coefficients did not significantly improve the model. 299 APPENDIX W F-Test for Testing Sets of Coefficients Comparing the Inspection Manager Model to the Inspection Manager and Inspector Model F11", = lRSS-kH) - RSS(k)l/H [RSS(k)/(n-k) RSS(12) = 154. k = 12 n = 69 RSS(IO) = 170 k = 10 n = 69 H = 2 Test F357 = 2.96 Critical F357 = 3.15 at the 0.5 level (note: the degrees of freedom used were based on 2, 60 because 2, 57 was not reported in the F table). Therefore, do not reject the null hypothesis and it can be concluded that including the additional coefficients did not Significantly improve the model. 300 APPENDIX X Matrix of Correlations between the Estimated Regression Coefficients correlate, _coef for the Manager Model exmgr exmgtir mhours lpnhours nahours y96 y97 exmgr 1.0000 exmgtir -0. 1288 1 .0000 mhours -0.0132 -0.1134 1.0000 lpnhours -0.2810 0.4915 -0.2057 1.0000 nahours -0.0012 -0.2608 -0.0836 -0. 1898 1.0000 y96 -0.0471 0.0560 -0.1409 0.1100 -0.0137 1.0000 y97 -0.0815 0.0868 -0.2338 0.1579 -0.0538 0.5570 1.0000 ylag 0.1784 -0.1004 -0.2157 -0.2176 0.0784 -0.2206 0.4773 _cons 0.0868 0.1066 -0.0929 -0.1300 -0.8422 -0.0254 0.1337 J ylag _cons ylag 1.0000 _cons -0.2640 1 .0000 301 APPENDIX Y Glesjer Test for the Manager Model reg absres exmgr exmgtir mhours lpnhours nahours ylag Source SS df MS Number of obs = 696 ""Mbde'l 235.818175_"-6 39.3030292 F( 6, 62) = 34.66 Residual 70.3054877 62 1.13395948 Prob > F 0.0000 ---- Total 306.123663 “-6.8 4.50181857 R-squared = 0.7703 Adj R—squared = 0.7481 Root MSE = 1.0649 abres .6621? ----- Sid-E-r-r- t P> ItI [95% Conf. Interval] exmgr "71397026 1946221 -7.178 0.000 -1.78607 -1.007982 exmgtir .0349538 .2236719 0.156 0.876 -.4121599 .4820675 mhours 3.343784 .7164252 4.667 0.000 1.911671 4.775898 lpnhours 8.260551 . 8929488 9.251 0.000 6.475572 10.04553 nahours -1 .305108 .5605176 -2.328 0.023 -2.425566 -. 1846488 ylag .0095562 .010329 0.925 0.358 -.01 10912 .0302035 -cons -.4118987 1.265208 -0.326 0.746 -2.941014 2.117216 302 correlate, _coef for the Inspector Model APPENDIX Z Matrix of Correlations between the Estimated Regression Coefficients echinsp exirrngt exinsp mhours lpnhours nahours echinsp 1.0000 -------- exirrngt -0.7067 1 .0000 exinsp 0.2466 -0.4231 1 .0000 mhours 0.1816 -0.1428 0.1286 1.0000 lpnhours 0.0965 -0.0081 0.3844 -0.1106 1.0000 nahours -0.0185 -0.0366 0.1646 -0.1032 -0.0135 1.0000 y96 0.0163 0.0359 0.0274 -0.1277 0.1076 0.0027 y97 0.0388 0.0715 0.0332 -0.2101 0.1552 -0.0317 ylag -0. 1858 -0.0273 -0. 1811 -0.2565 -0.2712 0.0372 _cons 0.0277 0.0685 -0.2737 -0.0941 —0.2641 -0.8513 y97 ylag cons y97 1.0000 ---- ylag -0.4860 1.0000 cons 0.1237 -0.2178 1.000 303 1.0000 0.5585 -0.2270 —0.0312 APPENDIX AA Glesjer Test for the Inspector Model reg absres Source SS Model 219246751 Residual 83.3696376 Total 302.616388 — abres Coef. - -exinsp -.939773 exirmgt .6071368 echinsp -.5603736 rnhours 2.444814 lpnhours 4.991495 nahours -1 .959769 ylag .032684 -cons 2.721618 _F----------—-------—-_- exinsp exirmgt echinsp mhours lpnhours nahours ylag 304 MS Number of obs = 69 ”tr—"313209644- F( 7, 61) 22.92 61 1.36671537 Prob > F 0.0000 68 4.450241- R-squared = 0.7245 Adj R-squared = 0.6929 Root MSE = 1.1691 Std. Err t P> ItI [95% Conf. Interval] — .1710211 5495 0.000 -1.28l751 45977952- .1903994 3.189 0.002 .2264097 .987864 .281019 -1994 0.051 -1.122306 .0015586 .8019197 3.049 0.003 .8412764 4.048351 .9261121 5.390 0.000 3.139619 6.84337 .6035512 -3247 0.002 -3.166644 -.7528935 .0119357 2.738 0.008 .008817 .056551 1.438075 1.893 0.063 -. 1539909 5.597288 APPENDIX BB Difference of Mean Test for Deficiency Citations Assessed across the States before (1991-1994) and after (1995—1997) Implementation of the OBRA 87 Enforcement Laws Variable I Obs Mean Std. Dev. 79194 """""" T 150 8.362667 4.131002 --- y9597 I 150 5.156667 2.539022 Tiff-f.- ------- T 150 3.206 3.349171 Ho: diff = 0 (paired data) t = 11.72 with 149 d.f. 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