JCAHO standards not enough, consumers argue

Organization says subacute federal regs still needed

Some nursing home providers, answering a recent New York survey, repeatedly said they do not need more federal mandates because they already follow strict Joint Commission standards.

Officials with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, said it’s true that the Joint Commission standards for subacute care are thorough. But they say there still is a need for federal regulations that specifically address subacute care.

"The nursing home population has changed drastically in the past two years, and you have to gear your standards to what their patient needs are and the services you can give those patients to provide the quickest rehabilitation possible," says Margaret Vanamringe, MPH, director of federal relations for the Joint Commission’s branch office in Washington, DC.

The subacute survey, published in January 1997 by the New York City-based Nursing Home Community Coalition of New York State, said consumers across the country also want federal regulations of subacute care. More than half of the consumer advocates surveyed said no current regulations should be weakened for subacute care, or the federal government should mandate new standards.

Consumer advocates gave a wide variety of opinions about subacute care. Some of these comments were:

In my opinion, subacute care should remain in hospitals. I fear unqualified and untrained nursing home staff will be required to provide care beyond their capacity to do so.

I feel the patient receives adequate care in a setting where they are comfortable, for instance, the ursing home, at a much lower cost to Medicare or insurance or Medicaid. Smaller facilities can provide a more intimate environment.

Nursing homes are not doing well with their current residents; this prospect is horrifying.

The laws are good, and we should not waive any laws. We need all the protection we can get for all frail people.

Federal regulations in home health care and hospital care have been influenced by the Joint Commission’s movement to more patient-focused standards, so the same could happen in the subacute care arena, Vanamringe suggests.

"Most of our accredited nursing homes have subacute units, so it’s a growing trend," Vanamringe says. "My feeling is that standards do need to be written for that patient population."

The Joint Commission first began surveying subacute care facilities in January 1995, when its subacute standards were implemented, says Janet Sonnenberg, RN, MS, LNHA, a long-term care and subacute care surveyor for the Joint Commission. Last year, the Joint Commission surveyed 150 subacute facilities.

Sonnenberg says some key areas in which the Joint Commission’s standards surpass state and federal mandates are as follows:

Credentialing for licensed independent practitioners: The Joint Commission requires subacute providers to undergo a specific process to verify the licensed employees’ education, experience, licenses, and any additional certifications and degrees.

"It’s a process that no state or federal agency that I know of asks," Sonnenberg states. "It far exceeds getting a copy of the doctor’s license."

Education and competency of all staff that provide subacute services: Sonnenberg says surveyors make sure providers are offering regular inservices, orientations, and evaluations for all staff.

"They must demonstrate an employee is trained and competent when they hire them and that they continue to hold regular training and competency evaluations for these individuals," she notes.

Assessment process, admissions criteria: "We want to make sure the patient is a good match for a subacute program," Sonnenberg says.

"We require that there be an assessment not only of the resident but also of the family in pre-admission, admission, and throughout their entire stay to make sure everybody is in agreement with the care plan and to make sure that they continue to make progress in the program," Sonnenberg says. "Then we require completion of all required assessments within 48 hours of admission, and the care plan must be completed within 72 hours after the assessments, so that’s on day five."

The assessments are not necessarily the same ones required for nursing homes because not all of these are necessary.

"Say you have a healthy adult who had a knee replaced and went into a subacute program," Sonnenberg explains. This patient might not need a nutritional assessment.

But it still would be important to have a social service assessment because discharge planning is a part of that. Assessments for speech therapy and occupational therapy might be omitted, but the patient still would need assessments in nursing, medical, and physical therapy, she adds.

Skilled nursing care: The Joint Commission looks at the entire staffing on subacute units in relation to which services are being delivered, Sonnenberg says.

For example, a facility might only provide subacute ventilator care. The provider’s nursing hours might be the same as for its nursing home care, but perhaps it employs one or two respiratory therapists, so this might meet the standard.

"The other thing the Joint Commission requires is 24 hours a day, seven days a week of registered nurse coverage in a subacute unit," Sonnenberg says. "They need to be there in the building and on staff."

This standard reflects fluctuations in patient populations, she adds. For example, if there are only four subacute residents, then one registered nurse might provide sufficient coverage.

Discharge criteria: Discharge planning has to start with the pre-assessment, and the resident and family need to agree with it, Sonnenberg insists.

"You can have the best discharge planning available, but if the patient and the patient’s family don’t go along with it, and if it’s not their plan, then you’ve wasted everybody’s time, and that equates to a lot of money," she says.

And money is the whole reason that the health care system is moving in the direction of more subacute units, Sonnenberg adds.

"The whole system is trying to put these people in the most cost-effective scenario, so it’s as important to get them out of that subacute program when they’re ready as it is to get them in the program," she says.