History of Nursing Homes

In 1965 Medicare and Medicaid came into existence and along with it came federal nursing home regulation. Nursing homes that qualify and voluntarily elect Medicare and Medicaid to their facility must follow a set of guidelines put forth by federal standards. The Health Care Finance Administration that is part of the United States Department of Health and Human Services enforces these nursing home regulations. Congress authorized the first set of standards that were to be met by nursing facilities in 1967 and created classifications for the Skilled Nursing Facilities and Intermediate Care Facilities. Both in 1980 and again in 1987 these standards were updated with the most current nursing home regulations imposed under the Omnibus Budget Reconciliation Act of 1987.

OBRA 87: Omnibus Budget Reconciliation Act of 1987 (OBRA 87)
OBRA 87 requires that the facility provide each patient with care that will enable the patient "to attain or maintain the highest practicable physical, mental and psychosocial well-being."

• Quality of life for patients is the goal. The facility must allow patient choice in activities, schedules and health care decisions.
• OBRA 87 requires that SNFs and ICFs provide 24-hour licensed practical nurse care seven days a week, and have at least one RN on duty at least 8 hours per day, seven days a week. Nurse’s aides are required to undergo special training.
• OBRA 87 makes it the State's responsibility to establish, monitor and enforce state licensing and federal standards. States are required to maintain investigatory units and Ombudsman units, and to fund and staff them adequately.

OBRA 90: Omnibus Budget Reconciliation Act of 1990 (OBRA 90)
The Patient Self Determination Act covers all long-term care facilities that participate in Medicare or Medicaid. At the time of admission to a hospital or nursing home, at the time of enrollment with an HMO, Hospice, or Home Health Care Agency, the following must happen:

• The facility must provide the patient written information concerning the patient's rights under state law to participate in decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, the right to formulate advance directives.
• The facility must provide a written statement of its policy regarding implementation of these rights.
• The facility must document in its records whether the patient has executed an advance directive. Note: the facility is not required to provide advance directives to patients.
• The facility is forbidden to discriminate in the provision of medical care on the basis of whether a patient has or has not executed an advance directive.
• The facility is required to comply with all state laws regarding advance directives.
• The facility must provide for staff and community education on issues related to advance directives.

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