Faced with a critical shortage of nursing home beds in the District of Columbia, residents who need care, and their families, "are so concerned about getting a bed they haven't focused on quality of care," said Karyn Barquin, nursing home ombudsman with the city Office on Aging.

Barquin and other experts say problem also exist with the quality of life and care in homes.

"People aren't in desperate situations the way they were years ago or the way people are in some of the unlicensed community care facilities, but the quality of care is not all it could or should be," she said.

"Licensing people inspect twice a year and make other visits to check our complaints, but there a lots of quality-of-care and quality-of-life issues that can't be touched by licensing."

The Office on Aging is the central clearing house for complaints on nursing home care.

A major problem in many nursing homes resolves around nursing aides.

"They aren't trained. They're usually paid minimum wage ($2.90 per hour). Turnover is high. Yet these are the people providing 90 percent of the care in nusing home," Barquin said.

Herbert Marschark, administrator of Mar Salle Convalescent Center, said that many District nursing homes paid more than the minimum wage.

"We pay at least 25 to 30 cents above that. But the problem is, what is the government willing to pay? Seventy-five percent of our patients are on Medicaid and the government doesn't want to pay-and certainly the taxpayer doesn't want to pay-more for care. If you want quality care, you have to pay the bill."

Barquin and othe consumer advocates such as Elma Greisel of National Citizen's Coalition for Nursing Home Reform, would like to see nursing aides trained and certified.

"Right now anyone can walk in off the street and be hired as a nursing aide regardless of background. Through training and certification you would get people more interested in this type of job-they would have to go through the process before they got the job. Perhaps certification would lead to better pay," Barquin said.

Marschark said that his home provides "continuous in-service training. We have licensed practical nurse who spends all her time doing staff training. If you want nurse's aides to go to school and be certified before they work, that's up to the city. Facilities can't be involved to that extent."

Licensing regulations for nursing homes call for in-service training but the regulatiions are vague and difficult to enforce

"If we decide to go for and changes in regulations this year, nursing aide training would be the thing we'd ask for," said Barquin.

The licensing regulations, which were last amended in 1977, are enforced by the division of licensing and certification. The division wend a team compose of a nurse, doctor, pharmacist, social worker and environmentalist to each home on an average of fourtimes a year, according to Pat McShea, branch chief of Health services for the division. An inspector for fire safety also inspects the home.

when the homes have not complied with regulations, a plan of correctionis drawn up and inspectors monitor it. Licensing reports on individualhomes are available to the public at the division of licensing and certification.

The National Capital Medical Foundation (NCMF) offers another level of review. The professional standards review organisation has been charged by the federal government with making sure Medicaid patients in health facilities are treated at the appropriate level of care. A Medicaid patient can use only a level of bed for which he or she has been certified.

The foundation does a preadmission review and regularly reviews patients in nursing homes as to level of care. Nursing home beds are divided into two levels of care, skilled and intermediate, with skilled offering a more intensive level of professional nursing care than intermediate.

Congress also has mandated that review organization like NCMF establish quality assurance programs. The organization plans to send a team including a physician, nurse, social worker, dietician and other health professionals into each home accepting Medicaid patients. The team has made five on-sight nursing home visits to date.

"We're in the pioneer stages with this project," said Pual Schlein, president of NCMF. "We're not a licensing agent; we can apply no sanctions but so far we have found the nursing homes are cooperative about suggestions we make to improve the quality of care. In the homes we've visited, we've seen many positive things: Personal appearance of the patients is good, interpersonal relationships among the staff are good; emergency equipment is average."

Barquin insisted that official oversight is not enough.

"We are never going to improve the quality of care or life in our nursing homes if the community doesn't become involved. Community groups have to become advocates, go in and spend time visiting residents and noticing conditions," she said.

The Office an Aging has established a training program for advocates and is encouraging service and volunteer organizations to involve members with nursing home advocacy.