A major overhaul of federal rules for nursing homes, including a "patients' bill of rights" and more stringent rules for round-the-clock care, will be proposed this week by the Department of Health and Human Services.
The new rules would apply to all residents of any home receiving federal funds through Medicaid or Medicare, the vast majority of nursing homes. The plan, designed to improve the quality of care for more than a million people in 16,000 facilities, also requires that nurses' aides be given at least 80 hours of training by the home before they handle patients.
The document, which will not become final until after 90 days of public comment, also recommends requiring that trained, licensed nurses be present 24 hours a day in every nursing home.
But at the insistence of the Office of Management and Budget, it lists two less stringent alternatives to the 24-hour plan that will be considered before the HHS issues its final regulation.
The proposed regulations would also:
Require an initial assessment of a person's needs within 48 hours after entering a nursing home, a comprehensive one within 14 days, and a care plan developed, with rechecks every three months.
Spell out the rights of patients in a variety of situations -- in many cases for the first time -- to: dignity, privacy, a clean, homelike environment, a choice of activities, substitute foods if they refuse standard fare, a personally chosen "ombudsman" who could examine their records, self-administration of drugs unless a doctor disapproves, rehabilitation and social services, and protection from physical mistreatment.
The regulations, drafted after years of controversy, are based mainly on 1986 recommendations by the Institute of Medicine (IOM) of the National Academy of Sciences. It studied the issue after rules changes early in the Reagan administration were blocked by Rep. Henry A. Waxman (D-Calif.) and others as likely to reduce patient protections.
Waxman and Rep. Fortney H. (Pete) Stark Jr. (D-Calif.) have inserted in the House version of the budget reconciliation bill various new rules also based on the institute's recommendations, although they are not identical to the ones HHS will publish Tuesday in the Federal Register.
The HHS proposal, obtained by The Washington Post, estimates that the cost of carrying out the rules -- if the stringent 24-hour option is adopted -- could be as high as $100 million a year for 3,200 new licensed nurses and for upgrading 3,600 existing practical nurse positions to registered nurse slots. Industry officials, who could not be reached for comment yesterday, have expressed concern in the past about the costs.
Asked for comment, Medicare administrator William L. Roper, who drafted the rules, said, "They will include all the proposed recommendations of the Institute of Medicine -- 95 percent."
A major institute recommendation was that licensed nursing personnel be required 24 hours a day at all 16,000 homes. This is required now at 9,000 skilled nursing facilities but not at 7,000 "intermediate care" nursing homes. The HHS regulation, in what HHS called its preferred alternative for a final rule for all homes, would adopt the recommendation.
It would require that trained, licensed nurses -- either registered nurses, licensed practical nurses or licensed vocational nurses -- be present 24 hours a day in all facilities, including a registered nurse on duty at least eight hours a day seven days a week.
Under the two alternatives, intermediate facilities would not be required to have registered or licensed nurses on duty 24 hours, but only enough trained personnel to provide the care outlined in care plans.