Title
Scope of practice
Education
Annual mean salary [2]
Certified nurses aids
Work under the supervision of a nurse and provide assistance to patients with daily living tasks
In addition to a high school diploma or GED, completion of a 6–12-week CNA certificate program at a community college or medical facility
$26,020
Licensed practical nurse
Provide the patient care on a very personal level. They usually report directly to physicians and RNs, and are usually responsible for taking vitals and monitoring in-and-out volumes, treating common conditions like pressure sores, and preparing or performing several procedures such as dressing wounds, bathing and dressing, and giving enemas. In some, but not all, states LPNs and LVNs may administer prescribed medicines or start IV fluids
Required to pass a licensing examination, known as the NCLEX-PN, after completing a State-approved practical nursing program. A high school diploma or its equivalent usually is required for entry
$42,910
Registered nurse
Work directly with patients and their families. They are the primary point of contact between the patient and the world of health care, both at the bedside and in outpatient settings. RNs perform frequent patient evaluations, including monitoring and tracking vital signs, performing procedures such as IV placement, phlebotomy, and administering medications. Because the RN has much more regular contact with patients than physicians, the RN is usually first to notice problems or raise concerns about patient progress
The three major educational paths to registered nursing are a bachelor’s degree, an associate degree, and a diploma from an approved nursing program. Nurses most commonly enter the occupation by completing an associate degree or bachelor’s degree program. Individuals then must complete a national licensing examination in order to obtain a nursing license
$62,010
Registered Nurse Assessment Coordinator (RNAC)
The Registered Nurse Assessment Coordinator (RNAC) will assist the Director of Nursing (DON) with ensuring that documentation in the center meets Federal State and Certification guidelines. The RNAC will coordinate RAI process assuring the accuracy timeliness and completeness of the MDS RAPS and Interdisciplinary Care Plan. The Registered Nurse Assessment Coordinator (RNAC) conducts the nursing process—Assessment Planning Implementation and Evaluation—under the state’s Nurse Practice Act for Registered Nurse Licensure
$80,190
Director of Nursing (DON)
The Director of Nursing has the responsibility of overseeing the standards of nursing practices for the organization’s nursing services. The DON participates with other members of Nursing Services and Administration in the development of patient care programs, policies and procedures to meet all requirements including ethical and legal concerns
$107,200
Social worker
Assist people by helping them cope with issues in their everyday lives, deal with their relationships, and solve personal and family problems
All States and the District of Columbia have licensing, certification, or registration requirements regarding social work practice and the use of professional titles. Although standards for licensing vary by State, a growing number of States are placing greater emphasis on communications skills, professional ethics, and sensitivity to cultural diversity issues. Most States require 2 years (3,000 h) of supervised clinical experience for licensure of clinical social workers
$52,520
Dietitian
Plan food and nutrition programs, supervise meal preparation, and oversee the serving of meals. They prevent and treat illnesses by promoting healthy eating habits and recommending dietary modifications. They perform nutrition screenings for their clients and offer advice on diet-related concerns such as weight loss and cholesterol reduction
At least a bachelor’s degree. Licensure, certification, or registration requirements vary by State
$56,300
Physical therapist
Physical therapists provide a variety of medical services to help individuals who have been injured or physically affected by illness to recover or improve function. A physical therapist must be able to evaluate a patient’s condition and devise a customized physical rehabilitation and treatment plan to enhance strength, flexibility, range of motion, motor control, and reduce any pain, discomfort and swelling the patient is experiencing
Graduate from a physical therapist educational program with a master’s or doctoral degree
$87,250
Occupational therapist
Occupational therapists help patients improve their ability to perform tasks in living and working environments. They work with individuals who suffer from a mentally, physically, developmentally, or emotionally disabling condition. Occupational therapists use treatments to develop, recover, or maintain the daily living and work skills of their patients. The therapist helps clients not only to improve their basic motor functions and reasoning abilities, but also to compensate for permanent loss of function. The goal is to help clients have independent, productive, and satisfying lives
A master’s degree or higher in occupational therapy is the minimum requirement for entry into the field
$77,890
Recreational therapist
Recreational therapists devise programs in art, music, dance, sports, games, and crafts for individuals with disabilities or illnesses. These activities help to prevent or to alleviate physical, mental, and social problems
Bachelor’s degree with some additional training is usually required for this field
$45,520
Attending primary care physician
Responsibility for initial patient care and support discharges and transfers. Also make periodic, pertinent on-site visits to patients and insure adequate ongoing coverage (see Chap. “The Role of Practitioners and the Medical Director”)
In addition to 4 years of medical school most nursing home attending physicians complete a primary residency, which is typically 1–3 years. Some go on to complete a geriatric fellowship as well.
$188,440
Medical director
Roles and responsibilities of the medical director in the nursing home can be divided into four areas: physician leadership, patient care–clinical leadership, quality of care, and education. Nursing facilities are required to have a medical director as outlined in OBRA 87 (see Chap. “The Role of Practitioners and the Medical Director”)
Currently Maryland is the only State that requires Medical Directors to be a Certified Medical Director (CMD) in Long Term Care or have similar training. CMD was established by the American Medical Directors Association to professionalize the field of medical direction
$90.60 per houra
Nurse practitioner
Advanced practice nurses who provide high-quality health care services similar to those of a doctor. NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling (see Chap. Nurse Practitioners, Clinical Nurse Specialists and Physician Assistants)
The entry-level training for NPs is a graduate degree. At this time, NPs complete a master’s or doctoral degree program. This means that NPs earn a bachelor’s degree in nursing (4 years of education), then their graduate NP degree (2–4 years of education)
$95,070
Consultant pharmacists
Focuses on reviewing and managing the medication regimens of patients, particularly those in institutional settings such as nursing homes. Consultant pharmacists ensure their patients’ medications are appropriate, effective, as safe as possible and used correctly; and identify, resolve, and prevent medication-related problems that may interfere with the goals of therapy
The Doctorate of Pharmacy (Pharm.D.) is the only professional Pharmacy degree, and the 5-year Bachelors of Science in Pharmacy is being phased out as a professional degree. Since this program traditionally follows 2 years of pre-pharmacy education, students typically take 6 years of post-secondary education to obtain their Pharm.D
$107,220
Nursing home administers
Responsibility as the managing officer of the facility to plan, organize, direct, and control the day-to-day functions of a facility and to maintain the facility’s compliance with applicable laws, rules, and regulations
The administrator shall be vested with adequate authority to comply with the laws, rules, and regulations relating to the management of the facility
Typically requirement of a certificate program of about 120 h is required before sitting for a licensing examination. Most are required to have completed a bachelor degree program as well as preceptor training as a NHA
$97,870
Regulations: OBRA 87
Prior to 1987 nursing facility care was characterized by the prevalent use of physical restraints, inappropriate use of psychotropic medication, overuse of urinary catheters, and a high occurrence of urinary incontinence, pressure ulcers, weight loss, and behavioral problems. Because of widespread poor quality of care in nursing facilities, Congress requested that the Institute of Medicine (IOM) study how to improve the quality of care in the nation’s Medicaid and Medicare certified nursing facilities. In its 1986 report, Improving the Quality of Care in Nursing Homes, the IOM expert panel recommended:
A stronger Federal role in improving quality.
Revisions in performance standards and the inspection, i.e., survey process.
Better training of staff.
Improved assessment of resident needs.
And a dynamic and improved regulatory process [3].
The Omnibus Reconciliation Act of 1987 (OBRA) contained the Nursing Home Reform Act , which was written by federal legislators in response to these recommendations proposed by the IOM. The “Campaign for Quality Care” was organized by the National Citizens’ Coalition for Nursing Home Reform in order to both implement the IOM recommendations and to support these Federal reforms. National organizations representing consumers, nursing facilities (both for profit and nonprofit) and health care professionals including AMDA-The Society for Post-Acute and Long-Term Care Medicine , as well as the American Geriatrics Society , have worked and continue to work together to create consensus positions on major nursing facility issues.
Under OBRA 1987, surveyors of nursing facilities have shifted focus from the nursing facility to resident outcomes. The quality of life and the quality of care of each resident now became the two basic areas for review. Under quality of life, the concept of the living environment maintaining or improving the residents’ “well-being” was now the major focus. In addition to physical and mental health, well-being includes the resident’s functional status, dignity, self-esteem, relationships, physical appearance as well as their social and spiritual needs.
The changes that OBRA incorporated into the care of residents are noteworthy with the most important provisions being:
Emphasis on resident quality of life as well as the quality of care.
A resident assessment process leading to development of an individualized care plan.
New expectations that each resident’s ability to walk, bathe, and perform other activities of daily living will be maintained or improved unless an underlying medical condition precludes it.
The right to be free of unnecessary and inappropriate physical and chemical restraints.
The right to choose a personal physician and to access their medical records.
The right to organize and participate in a resident or family council.
The right to return to the nursing facility after a hospital stay or have an overnight visit with family and friends.
The right to safely maintain personal funds with the nursing facility.
The right to remain in the nursing facility unless non-payment, dangerous resident behavior, or a significant change in the resident’s medical condition.
Prohibitions on asking family members to pay for Medicare and Medicaid services.
Uniform certification standards for Medicare and Medicaid homes.
75-h of training for paraprofessional staff.
New opportunities for residents with mental retardation or mental illness to access services inside and outside the nursing facility.
New penalties for certified nursing facilities that fail to meet minimum federal standards.
Under OBRA, state surveyors no longer spend their time exclusively with staff or with review of facility records. Conversations with residents and families are now an important part of the survey process. Observations of resident dining and medication administration are other focal points of the survey. Since OBRA has been implemented, it has indeed changed the care and lives of residents of nursing facilities across the USA. Significant improvements have occurred in the comprehensiveness of care planning, antipsychotic drug use has declined by 28–36 %, and physical restraints reduced by 40 %.
Nursing Facility Regulations
The Resident Assessment Instrument (RAI) provides a comprehensive assessment of each resident’s functional capabilities and helps the nursing facility staff identify each resident’s health problems. Care Area Assessments (CAAs) , previously called Resident Assessment Protocols (RAPs) are a major part of this process and provide the foundation upon which a resident’s individual care plan is developed by the interdisciplinary team. Use of the Minimum Data Set (MDS) is part of the federally mandated tool for clinical assessment of each resident and usually “triggers” several CAAs. MDS assessments are required to be completed on admission to the nursing facility and updated quarterly and annually, as well as when there is a significant change in condition (worsened or improved). These assessments focus on many areas including: tasks of daily living (basic ADL s), mobility, cognition, continence, mood, behaviors, nutritional status, vision and communication, recreational activities, psychosocial well-being, pain, falls, and injuries.
Once the MDS information is entered into a computer database by the MDS coordinator, it is then transmitted from the nursing facility to the state database. From the state database, it is then sent to the national database at the Centers for Medicare and Medicaid Services (CMS) . The information in the MDS determines the resident’s Resource Utilization Group (RUG) that in term determines the per diem rate paid to the facility for the resident’s stay under Medicare Part A, i.e., skilled care. The MDS data also determines each facility’s quality measures (QM) report, several of which are publicly reported and routinely used by surveyors during the pre-survey and survey process (Table 2).
Table 2
Uses of MDS data
• Payment Resource Utilization Groups (RUGs) Facility Prospective Payment System (PPS) |
• Care planning Resident assessment protocols (Resident assessment instrument) |
• Quality measures Quality improvement activities Available to state surveyors Available for posting at the Medicare “nursing home compare” website |
MDS 3.0 version and the Quality Indicator Survey (QIS) process are gradually being introduced to many states (Table 3). Specifics of the MDS 3.0 can be obtained at the Centers for Medicare and Medicaid Services website at: http://www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp
Table 3
MDS 3.0: goals, changes and anticipated results
Goal of MDS 3.0 | MDS 3.0 changes | Anticipated results |
|---|---|---|
Improving the: Reliability Accuracy Usefulness Length Staff satisfaction and perception of clinical utility | Introduce advances in assessment measures: Increase the clinical relevance of items Improve accuracy and validity Increase the resident’s voice by introducing more resident interview items Briefer assessment periods for clinical items | Improve identification of resident needs Enhance resident-focused care planning Enhance communication among providers |
CMS Reference
Regulations: State Operations Manual (SOM)
The State Operations Manual (SOM) sets out survey investigative protocols and interpretive guidelines to provide guidance to state surveyors. These serve to clarify and explain the intent of the Federal regulations. Furthermore, these protocols and guidelines direct the surveyor’s attention when preparing for the survey, conducting the survey, and evaluating the survey findings. The survey is conducted to determine whether a citation of non-compliance is appropriate. Deficiencies are based on a violation of the state and/or federal regulations, as supported by surveyor observations of the nursing facilities’ staff performance and care practices. Chart review, interview of staff, residents, family, and possibly practitioners and the facility medical director are also the basis for surveyor evaluations. The Interpretive Guidelines include three parts: survey tag number; wording of the regulation; and guidance to surveyors, including additional survey procedures and probes if warranted.
The regulations emphasize the need for continuous, rather than annual cyclical compliance. The enforcement process mandates that policies and procedures are established to remedy deficient practices and to ensure that correction is lasting. Facilities must take the initiative and responsibility for continuously monitoring their own performance to sustain compliance. Measures to meet the requirements for an acceptable plan of correction in response to survey deficiencies emphasize the need to achieve and maintain compliance. A second requirement is that all survey deficiencies will be addressed promptly. A third requirement is that all residents will receive the care and services they need to attain their highest practicable level of functioning.
Quality Initiative: Medicare Five Star Program
With three million older Americans admitted to nursing facilities each year of which, 1.5 million stay long enough to consider the nursing facility their main residence, it should come as no surprise that nursing facilities are strictly surveyed in order to assure appropriate care. Despite this, one in five nursing facilities nationwide was cited for deficiencies that caused actual harm or immediate jeopardy to their residents [4].
Some major concerns of quality that were identified by facility medical directors include the following: telephone conversations, transitional care, falls and hip fractures, warfarin usage, pressure ulcers, inappropriate medications, pain control, urinary incontinence, weight loss and exercise of residents [5]. The CMS “Nursing Home Compare” website publically reviews the survey deficiencies received by nursing facilities but does not reflect the entire inspection report (form HCFA-2567). The complete survey inspection report and the nursing facility’s subsequent plan of correction to address the deficiencies are available either from the State survey agency or from the nursing facility itself that can be accessed by the resident and family member.
The Department of Health and Human Services (DHHS) has a national Nursing Home Quality Initiative for improving nursing facility care. A critical part of this initiative is CMS’s public posting of the quality measures for every nursing facility, also known as “report cards” [4]. These report cards can be used by consumers to make better-informed decisions and motivate providers to improve care; but there is concern that these nursing home report cards fail to adjust for risk differences in resident populations of various long-term care facilities [5]. The CMS quality initiative continues to redirect focus on the care needs of frail elders who reside in nursing facilities. Under CMS, the Nursing Home Quality Initiative has also expanded and refined its measures in order to improve resident outcomes and care effectiveness, e.g., reducing the occurrence of pressure ulcers and avoiding potentially preventable hospital admissions. The CMS quality measures are divided between those focused on the short-term (SNF) and long stay residents. These quality measures include the following [6]:
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