University of Southern California Dissertations and Theses

Searching for an identity: A study of residential care facilities for the elderly in California

(USC Thesis Other)

Searching for an identity: A study of residential care facilities for the elderly in California

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content SEARCHING FOR AN IDENTITY:
A STUDY OF RESIDENTIAL CARE FACILITIES
FOR THE ELDERLY IN CALIFORNIA
by
Lawrence Hinman
A Thesis Presented to the
FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE IN GERONTOLOGY
August 1989
UMI Number: EP58957
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Oiss®rtatton Publishing
UMI EP58957
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106-1346
UW Il/ERSIT/ OF SOUTHERN CALIFORNIA
LEONARD DADIS SCH O O L OF GERONTOLOGy
U N ID E R Siry PARK
LOS ANGELES, CALIFORNIA 9 0 0 0 7
tkzAiJji, iM hÂ JX zYi by
Lawrence Hinman
undeA th z dUizcXofi fi l s T/iei-cA C o n m c tte e ,
a n d appAovtd by a t t Zt6 mmbeA&, has b e e n p /te -
6 m tc d to and acczpte,d by the, Vzan o i The, Leonard
Vavtô SchooZ o i GeAontoZogy, tn poAttaZ iuZitZZment
o i th e aequUAementi ioa th e degaee
Master of Science in Gerontology
Vote
THESIS C O M M IT TE E
Ü
T A B L E OF C O N T E N T S
Introduction 1
I. C hapter I 4
Major Considerations 4
Industrial Standardization: A Theoretical Review 9
Definitions 13
Conclusion 18
II. C hapter II 19
Case Study Methodology 19
Conclusion 24
III. C hapter III 26
Political Climate Surrounding RFEs 26
Sum m ary of Conflicts Between Provider and State
Philosophies 34
Conclusion 36
IV. C hapter IV 37
The Development of S tandards in Long
Term Care 37
Conclusion 42
V. C hapter V 44
Findings and Conclusions 44
Potential Policy Implications 56
Conclusions 57
INTRODUCTION
"Consum er dem and, the rising need for additional health care services,
an d the increasing dem and for quality services have caused providers of long
term care to reassess and reevaluate the type of service they provide" (WÜgig,
1988). H ealth care services, such as acute care, skilled nursing care and
interm ediate care have evolved out of consum er dem and, dem ographic shifts,
technological advancem ents and federal and state governm ent financing. The
growth of each level of health care h as been accom panied by federal and state
governm ent controls which have sought to regulate the quality of care in all
facilities (Smith, 1988).
In 1986, individuals representing one level of licensed personal care,
referred to as residential care facilities for the elderly (RFEs), were concerned
about Calftbmia’ s attem pt to add a num ber of stan d ard s an d regulations to
existing state requirem ents. A group of RFE providers decided to develop a self
regulating docum ent - som ething th a t would guide and standardize b u t not
m andate how a RFE should be operated. If the group w as successful in
completing the docum ent prior to the development of stan d ard s perhaps
California’ s law m akers (i.e., California State Senators and Assemblymen) and
consum ers would th en be able to b etter understand the perceived role RFE
providers have in the long term care industry. The docum ent could also be
used to influence how law m akers view how RFE services should be provided.
As a graduate stu d en t studying out of the University of Southern
California’ s Leonard Davis School of Gerontology, I w as a n in tern with the
California Association of Health Facilities (CAHF). The A ssociation (CAHF) is a
2
professional organization which represents over 950 long term care facilities
which provide care to elderly, convalescent, or critically ill persons including
the m entally or developmentally disabled (California Association of Health
Facilities, 1988). During m y seven m onths with CAHF, I undertook a num ber
of ta sk s which involved the analysis of various policy areas Impacting the aged.
As an intern I w as able to provide assistance to various com m ittees.
D uring the early periods of the internship, I becam e involved w ith the
residential care committee which w as developing a policy and procedure
m anual for RFEs. After attending a num ber of RFE S tandards Committee
m eetings, I found myself following the group’ s activities due to m y p ast interest
in elderly housing issues. My interest led m e to become the au th o r of the
com m ittees M anual of Policies and Procedures for Residential Care Facilities for
the Elderlv in California.
As a n integral part of the committee, I becam e increasingly interested in
the process of developing stan d ard s an d regulations. I began to recognize the
com m ittee’ s attem pt to change existing stan d ard s after considering w hat the
m anual could m ean to future RFE regulation. My involvement in putting
together the m aterials for the policy an d procedure m anual offered m e the
opportunity to study the variables th a t are considered w hen developing
stan d ard s and regulations. Furtherm ore, I w as able to use my role as an
intern to observe how changes in stan d ard s im pacted RFE providers,
legislators, consum ers and the residents them selves. This thesis will analyze
how and why the development of stan d ard s w ithin Residential Care Facilities
for the Elderly (RFEs) takes place. C hapter one will review m ajor
3
considerations which face the RFE industry as well as review theoretical
perspectives th a t pertain to the development of stan d ard s w ithin a given
industry. C hapter two will discuss the methodology by which data were
collected for this study. C hapter three will provide a n overview of p ast and
present political climate. C hapter four analyzes the process which took place
in developing RFE standards. Finally, C hapter five will present findings,
potential policy im plications and conclusions from the study.
4
CHAPTER I
In th is chapter I will look at the five prim ary reasons why RFEs have
become an increasingly im portant concern to consum ers and legislators in
California. I will also consider w hat a num ber of theorists believe cause the
development of regulations and stan d ard s within a given industry. Following a
review of concerns and theoretical considerations a clarification of the levels of
care will be outlined to ensure th a t there is a clear understanding as to how
RFEs, Skilled Nursing Facilities (SNFs), Interm ediate Care Facilities (ICFs), and
Com m unity Care Facilities (CCFs) differ.
For a num ber of years, residential care facilities for the elderly (RFEs)
have been viewed as an attractive alternative to institutional care, such as
skilled nursing care. RFEs do not care for residents who require sophisticated
health care system s or devices and they are not currently faced w ith as m any
regulations and statu tes as one would find in nursing hom es and hospitals.
This is changing, however.
1 Ü Æ A J O R CONSroERATIONS
Consumer Demand
The first m ajor area of concern involves consum er dem and for
residential care services. The num ber of residential care facilities have been
steadily growing at a rate of approxim ately 9% each year (D epartm ent of Social
Services, 1986). The elderly population which typically resides in RFEs is
growing at a m uch faster rate th a n the nations population as a whole. Even
more im portantly, the num ber of persons residing in RFEs (individuals 75 and
older) is expected to increase 62.5 percent between 1977 and the year 2000
5
(Lowy, 1980). By the year 2035, the num ber of individuals over the age of 75
is expected to increase 113 percent. W ith th is in m ind, it is th en likely th a t
the dem and for additional RFE facilities will increase as the age of the typical
RFE resident^ population expands.
Furtherm ore, residents living in RFEs are provided with m inim al services,
such as assistance with m edications, m eals three tim es a day and a variety of
activities depending on the needs of the individual resident (Health and Safety
Code, 1986). However, the large growth in dependent elderly is likely to strain
the ability of families to provide all of th e assistance th a t will be needed.
Large Versus Small RFEs
The second concern involves growing differences betw een traditionally
sm aller RFEs (6 beds) and newly constructed larger RFEs (100+ bed). A study
conducted by the A ndrus Gerontology Center revealed th a t sm all residential
care hom es are closing at a m uch faster rate th a n larger RFEs (20+ bed
facilities). In th is study, 25% of the sm all family hom es (6 residents or less)
w ent out of business before the conclusion of the study. The study found
larger hom es (20+ residents) steadily growing each year in both size and
diversity of in-house services (Stevenson, Pynoos and Goodman, 1986). Present
regulations, however, do not distinguish betw een large RFEs and sm all RFEs.
Owners and operators of large and sm all facilities are finding th a t their
response to existing state regulations an d stan d ard s differ. F urther
‘ The resident profile In RFEs vary firom facillly to facility. The average age, gender breakdown,
average Income and other distinguishing resident profile data is unknown. Legally, RFEs can only
admit individuals whom the facility has the capability to provide personal care services, such as,
transferring, bathing, dressing, eating, toileting and grooming.
6
clarification of the state and federal regulatory expectations of large and sm all
RFEs will be necessary to give providers guidance in their attem pt to serve to
the growing n u m ber of individuals requiring residential services.
Changing RFE Resident Population
The th ird concern involves th e changing m akeup of RFE resident
populations. The enactm ent of diagnosis related groups (DRGs) and short
hospital stay Medicare coverage h a s led to a trend of discharging patients out
of hospitals sicker and quicker. The federal governm ent presum ed th at
patients needing additional health care services could find m any of the needed
services in skilled nursing facilities (SNFs or nursing homes) and hom e health
care settings (McNight Medical Com m unications, Inc. 1988). Since the inception
of short-stay Medicare coverage and DRG’ s there h as been rapid development
of life-sustaining technologies w hich have kept nursing home patients in the
nursing hom e for a longer period of tim e (Smith, 1988). Diagnosis related
groups are now filling nursing hom e beds w ith num bers of increeisingly frail
and disabled patients who were once m oderately independent (i.e., they needed
assistance with taking m edications, bathing, dressing and occasionally eating).
Nursing hom es now care for a patient population of which tw o-thirds suffer
from some sort of incontinence; and m ore th a n 90 percent can not bathe,
dress or get out of bed by them selves (California Association of Health
Facilities, 1986).
Now th a t nursing hom es beds are being filled w ith patients who require
more care, there is increasing evidence th a t the m ore independent patients who
m ight have gone to SNFs are ending u p in RFEs. At the sam e time, m any of
7
the once more Independent RFE residents have aged in place an d becom e m ore
frail over time.
Increasing Health Care Related Requirements
Because RFE patient populations are becoming more nonam bulatoiy th a n
in the past, residential care facilities are now faced w ith the possibility of
providing more health care related services. (Departm ent of Social Services
Com m unity Care Licensing Division, 1986). This is reflected in legislative
proposals suggesting th a t additional services be provided in residential care
facilities to address the increasing dem and for nonlnstitutional^ health care
services. Owners and operators of RFEs are concerned th a t the focus of Senate
Bill 50 and its potential im pact on staffing ratios, reim bursem ent rates an d
departm ental assessm ent procedures will force them into delivering services
th a t they had not intended to deliver w hen they entered the RFE business.
This topic will be discussed in more detail in C hapter 3 (p. 31).
Demand for Higher Quality Services
The fifth concern involves consum er dem and for higher quality services.
Miller (1986) believes th a t RFE owners an d operators of sm aller (1-6 bed)
facilities very often fail to m eet all Scifety stan d ard s set by state an d local fire
ordinances. However, the prim ary concern surrounding the quality of care
provided in RFEs involves the belief th a t m ost RFE adm inistrators lack
adm inistrative skills which ham pers th eir facility’s ability to provide th e quality
^ In this thesis, the term "noninstitutlonal" refers to a living environment that is outside of a
nursing home or hospital setting.
8
of service th a t is expected by consumers®. State and consum er organizations
attem pting to address these problem s have found th e ta sk a difficult one.
Nonprofit, proprietary, large and sm all RFEs have voiced different perspectives
on how to assure th a t RFE adm inistrators have a m inim um level of education
a n d /o r experience. Future requirem ents regarding additional experience and
education of RFE adm inistrators continually surface during debates
surrounding th e quality of care provided in residential care facilities. Though
no d ata exist showing a correlation betw een the expertise of the RFE
adm inistrator and the quality of care provided, attem pts to improve the
operations of RFEs is closely related to state governm ent attem pts to improve
the educational backgrounds of RFE adm inistrators (Miller, 1986).
RFEs are in transition. They are the largest, m ost recent, controversial,
under-m anaged level of health care available in California. The resident
population is growing chronically ill, the types of facilitates offering RFE
services are becom ing in creasing^ diverse, and consum ers are dem anding th a t
the quality of these services improve (Miller, 1986). W ith these concerns in
m ind, it is th en understandable th a t changes in the RFE level of care are
necessary. W idespread changes to a large extent on the development of
standards. The underlying question surrounding the development of additional
® In this thesis, the term "consumer" refers to all individuals who purchase services from long
term care facilities and residential care facilities for the elderly. In most cases, consumers will be the
individuals who oversee the care that a patient or resident will receive while outside of the home
setting.
9
RFE stan d ard s are as follows:
1) W hat variables are m ost often considered w hen developing
stan d ard s and regulations; and
2) How are laws likely to be derived from so called stan d ard s
development activity?
These questions have been addressed from a broader perspective by a
num ber of authors. These theorists share their interpretations as to why
stan d ard s and regulations are developed in any industry, an d how stan d ard s
and regulations address th e needs of consum ers, providers and governm ent
agencies.
INDUSTRIAL STANDARDIZATION: A THEORETICAL OVERVIEW
A num ber of theories have been developed regarding regulatory
development and standardization. The m ajority of the literature indicates th a t
politics are alive and well and very present in the form ulation of existing
stan d ard s and regulations which govern the health care industry (Mitnick,
1980; Wilson, 1980; Phillips, 1975; Lave, 1981). Each theorist, however,
believes th a t stan d ard s are developed out of a m ixture of particular influences,
such as costs, benefits, technological advemcements, an d political pressures, aU
of which im pact the final outcom e of stan d ard s and regulations. The following
is a n overview of selected regulatory theorists who have w ritten on standards
and regulation development.
10
Developm ent of Standards for "The Public Good”
Phillips (1975) states th a t regulation and standardization are a product of
regulators^ attem pting to regulate aspects of a particular industry which are
unregulated. Phillips goes on to say th a t imperfect m arkets create tension.
For example, w hen RFEs begin to serve different types of residents the
stan d ard operations w ithin facilities will also need to change. Treating different
types of facilities as if they perform ed sim ilar functions would, over tim e, create
a n im balance in the regulations. These im perfections are those which cause
insufficient resource allocation® and ultim ately consum er and provider unrest.
He believes th a t regulations and stan d ard s are developed because of poor p a st
industry conduct. The m ost com m on approach to resolving deficiencies is to
establish m ore rules and regulations. Although these regulations and
stan d ard s are developed with financial considerations as the prim ary m otivator
of change, the im pact on the social welfare of the consum er is not know n until
after the policies and procedures are in place and enforced. Ultimately,
Phillips believes th a t regulations are seen as the prim ary reason for the failure
of a n industry to perform in the publics interest, and th a t regulation is m ore a
cause th a n a cure for m arket failure.
* Regulators refers to elected officials who make laws which govern the way a health care related
facility should operate. Regulators would include, a) Senators, b) Assemblyman, and c) departmental
agencies who oversee and enforce facility regulations.
® Resource allocation refers to the amount of state and federal dollars that are set aside for a
large number of different purposes (i.e., transportation, health care, prisons, etc.).
11
Development of Standards Through the Reduction of Com petition and
M aximization of Profits
W ilson (1980) w rites th a t the development of regulation can be viewed as
a m echanism which benefits organizations and firm s w hich seek to maximize
profits and reduce competition. A prim ary tool recently used l y organizations
in form ulating regulation is through the influence of political action com m ittees
(PACs). These PACs provide cam paign funds for federal, state or local
organizations representing a particular interest group. PAC funds are th en
distributed to politicians at the federal, state and local levels. W ilson argues
th a t interest groups tend to be able to influence politicians after they realize
th a t the reality of m aintaining a political post m eans having the necessary
funds to stay in office. Wilson believes th a t in order to develop governm ental
policies a broad based coalition m u st first be coordinated to support and
justify the new policies, especially if the policy is to regulate.
Development of Standards as a Response to Technological Advancements
Mitnick (1980) believes th a t regulation and standardization usualfy come
about after technological advancem ents have tak en place. A lterations in
industry operations usually take place after problem areas are identified and
resolved. Regulatory changes are seldom avoided after th e working
environm ent of an industry experiences modification. While he w rites th a t
constituent support is of m ajor im portance during th e legislative life of
standardization development, he goes on to say th a t regulation and stan d ard
development is influenced by the cost effectiveness of implementing proposed
changes in th e existing system . The technological changes th a t take place
12
w ithin an industry is the m ain purpose for developing new stan d ard s and
regulations.
Standard Development Through Social Influences
Lave (1981) believes th a t existing industries appear to be unable to live
with the existing regulatory developm ent ^ s te m , yet they cannot live w ithout
it. Regulatory agencies are in co nstant turm oil. For example, RFEs have been
the subject of a long debate concerning the level of care. The debate began in
1978 and continues to th is day (Health and Welfare Agency, 1986). Lave
further w rites th a t existing regulatory program s impose excessive costs to the
economy and the political process delays and fragm ents proposals u n til the end
product is ineffective and som etim es useless. Lave believes th a t the key to
developing effective stan d ard s and regulations is to follow the social regulation
model. The Social Regulation model contends th a t consum ers would like to
elim inate all m ajor ab u ses through the development of regulations and
standards. His approach to explaining standards developm ent w as based on a
wide range of criteria, such as, the level of technological advancem ent, risk
factors, benefit factors, and cost factors. Lave, in h is social regulation theory,
believes th a t all of th e stated factors have an influence in th e creation of new
stan d ard s and regulations. He does not believe th at one particular factor
influences the process any m ore th a n another factor. R ather, Lave establishes
a framework whereby a num ber of issues and concerns can potentially im pact
the development and outcome of regulations and stan d ard s in a given industry.
13
This thesis follows the social regulation development model. The
developm ent of residential care stan d ard s were developed out of consideration
for technology, risk factors, benefit factors and cost factors. This thesis will
explain the process of th e development of stan d ard s w ithin RFEs. Before a
description of the methodology, it will clarify how residential care facilities for
the elderly fit in the existing m edical and nonm edical continuum of service.
DEFINITIONS
Before a description of the differences betw een various m edical and
nonm edical services is discussed, it is im portant to recognize th a t these
definitions follow state law. These definitions do not always follow the true
picture of the type of service provided. For th is reason departm ents are
established to provide services as well as occasionally police a n in d u stiy to
assure th a t the in d ustiy is providing w hat they are licensed to provide. W ith
this in m ind, RFEs are defined as follows:
"...a group housing arrangem ent chosen voluntarily by residents over 60,
b u t also including persons u n d er 60 w ith compatible needs, who are
provided varying levels of intensity of care and supervision and personal
care based upon th e varying needs, as determ ined in order to be
adm itted and rem ain in the facility."(Health and Safety Code, S. 1569.2
p.
O utside of California, RFEs are considered Personal Care Homes, Board
and Care Homes, Sheltered Care Facilities, Domiciliary Care Homes and
Supervisory Care Homes (Newcomer and Stone, 1985). The term residential
care facility for th e elderly cam e out of a statutory m easure (SB 185) in 1985
w hich developed a new level of care out of the Com m unity Care Licensing
Division w ithin th e California D eparim ent of Social Services (DSS).
14
California h as roughly 3,500 RFEs in existence w hich house over 75,000
residents. Approximately 2,400 (70 percent) of these facilities consist of six or
fewer residents while alm ost 550 (16 percent) house over 21 residents (Miller,
1988). In 1985, th e facilities operating w ith six or fewer residents were
prim arily owned and operated by individual hom e owners who rented out
rooms of their hom es. These landlords, or operators, provided m inim al services
to elderly persons in need of shelter and assistance w ith daily activities. The
prim ary m ethod of service provision involved accessing com m unity based long
term care services.
The resident profile in RFEs vary from facility to facility. The average age,
gender breakdown, average income and other distinguishing resident profile
data is unknow n. Legally, RFEs can only adm it individuals whom the facility
h as the capability to provide personal care services, su ch as, transferring,
bathing, dressing, eating, toileting and grooming; nevertheless, facilities tend to
retain an increasingly disabled resident population in order to avoid having a
resident become placed in m ore costly skilled nursing care setting. Legislation
addressing th e need to consider additional services to retain residents in RFEs
will be discussed in C hapter III.
DIFFERENTIATION BETWEEN RFES. SNFS. ICFS AND CCFS
In order to u n d erstan d where RFEs operate along th e continuum of care it
would be helpful to first identify other levels of services w hich provide more or
less m edical and nonm edical support, su ch as, skilled nursing (SNF),
interm ediate care (IGF) and com m unity care (CCF) facilities.
15
Before reviewing th e differences betw een the continuum of services, I will
consider their sim ilarities. First, all four levels of care (SNF, ICF, RFE, CCF)
are required to provide services which allow individuals to reside in the least
restrictive setting possible. Second, each level of care is dependent on the
other to provide the designated level of service required by state law. Third,
w ithout th e provision of any one of the levels of care, patients would be forced
to utilize services which would either exceed or not satisfy th eir health care
needs. Fourth, subsections of each service level are now being developed to
b etter serve an increasingly diverse health care consum er. And finally, each
level of care is subject to m andated alterations in th eir delivery of services as
federal and state governm ents see fit. These sim ilarities expose an overall
intradependence which exists betw een the various level of care, and potential
discomfort w hich can arise out of service additions or subtractions w ithin a
given level of care.
Skilled Nursing and Interm ediate Care
In California, skilled nu rsin g facilities are characterized by 24 h o u r
skilled nursing care and supportive care to patients whose prim ary need is for
availability of skilled nursing care on an extended basis (Health and Safety
Code, S. 1250. (c)). In close com parison to skilled nursing, interm ediate care
is referred to as a health facility which provides 24 ho u r care to residents who
have a recurring need for skilled nursing supervision and need supportive care,
b u t who do not require availability of continuous skilled nursing care (Health
an d Safety Code, 1250. (d)).
16
Skilled nursing and Interm ediate care facilities typically house more
residents th a n all RFEs combined. California h as approxim ately 1,200 SNFs
and ICFs which house over 135,600 patients statew ide (California Association
of Health Facilities, 1987). Skilled nursing and interm ediate care facilities in
California house a n average of 113 patients. W ithin these facilities patients
will have a requirem ent for skilled nursing care each day. In com parison,
RFEs typically house an average of 6 residents per facility with m inim al need
for assistance w ith activities of daily living® and no skilled nursing care.
In 1986, over $517 million dollars from the general state fund and $510
million dollars from federal Medicaid and M edicare funds were used to
subsidize care provided in SNFs and ICFs. This figure is continually rising as
the dem and for health care services expands (California Legislature Analyst
Office, 1986). Conversely, RFE expenditures, com bined with other m ajor
com m unity based long term care funding sources (i.e., SSI, Title XX and Title
III funding) totaled approxim ately $120 million dollars for 1986. This
tran slates to approxim ately $47 dollars per day for skilled nursing and
interm ediate care and $18 dollars per day for RFE care (Joint’Legislative
Budget Committee, 1986).
In addition to differences in state and federal support, RFEs do not have
sim ilar stringent regulation to which SNFs and ICFs are subject. Generally
speaking, state RFE regulations and statu tes are limited to broad licensing,
service provision and local regulation requirem ents w hich are prom ulgated by
17
the D epartm ent of Social Services Com m unity Care Licensing Division (DSS-
CCLD). Skilled nursing statu tes and regulations, on th e other hand, are
lengthy and detailed guidelines w hich are m onitored by the D epartm ent of
Health Services Division of Licensing and Certification. F u rth er alterations in
both SNF and RFE levels of care, through statutory and departm ental actions,
are ongoing.
Community Care Facilities
Com m unity Care Facilities (CCFs) were the sam e as residential facilities
for the elderly prior to reform atory actions which affected Com m unity Care
Facilities in 1985. Com m unity Care facilities are now considered "a place, or
building which is m aintained an d operated to provide nonm edical residential
care, day care, or homefinding agency services for children and adults,
including, b u t not limited to, the physically handicapped, m entally im paired, or
incom petent persons" (Health and Safety Code, 1502). Com m unity Care
Facilities currently provide care which is considered one level lower on the
continuum th a n RFE care due to the em phasis on nonm edical services.
In general, RFEs do not care for residents who require 24 h o u r skilled
n ursing supervision, yet they provide closer supervision th a n would be found in
a CCF. RFEs currently house fewer patients th a n SNFs an d ICFs. They do
not operate u n d er sim ilar funding program s (Medicaid, or Medi-Cal in
California vs. SSI) and they do not have as stringent regulatory dem ands as
SNF/ICF care.
18
CONCLUSION
There are a num ber of concerns which su rro u n d the dem and, operations
and expectations of the deliveiy of residential care services. These concerns
have created a desire to develop stan d ard s prior to any requirem ents to change
the types of services which are now being offered in RFEs. A theoretical review
of why stan d ard s and regulations are developed w as provided w ith an
explanation of the differences betw een th e various levels of long term care.
Now th a t we have a clearer understanding of: 1) why there are concerns
surrounding RFEs; 2) w hat approaches have been tak en to resolve these
concerns; 3) who h as provided a rational for the development of stan d ard s and
regulations; and 4) w hat th e differences are betw een the levels of care, it is
necessary to define w hat approach h as been used in th is thesis to study the
developm ent of stan d ard s in RFEs.
19
CHAPTER H
CASE STUDY METHODOLOGY
A participant observation methodology w as used to collect the inform ation
presented in th is thesis. A n u m ber of inform ation gathering strategies could
have been used to reveal the process of stan d ard s development for RFEs.
However, after careful consideration of m y involvement in RFE activities as a
student intern, th e m ost appropriate m ethod of gathering inform ation w as
determ ined to be as a participant observer in th e RFE S tandards Committee.
As a n intern, I w as fam iliar w ith th e personal attrib u tes and styles which
committee m em bers used to their advantage in influencing committee decisions.
My involvement w ith the committee allowed m e to analyze and observe the
reasoning behind the com m ittee’s stance on specific standards. As a m em ber
of the RFE S tandards Committee and au th o r of the RFE policy and procedure
m anual, I w as allowed to use a large portion of m y eight h o u r w ork day to
review m aterials th a t outlined how stan d ard s and regulations were developed
for residential care facilities in California. Because of m y involvement in the
com m ittee’s activities and m y ability to collect data, I decided th a t such a
methodology would allow m e the opportunity to collect th e m ost accurate data
over th e shortest period of tim e.
Before identifying th e m ost appropriate m ethod of collecting the data,
available sources of inform ation needed to be tak en into consideration. One
source of data w as governm ent docum ents gathered to provide a solid
foundation from which to base the case study. These docum ents included
m em oranda, m inutes of m eetings, reports, studies, new s clippings.
20
organizational records, various lists of nam es and oiganizations, and other
w ritten m aterials. While w ritten m aterials provided both qualitative and
quantitative, historical and som etim es lengthy account of events^, participation
w ith the RFE committee w as a prim ary location for inform ation gathering.
Com m ittee Involvem ent
In addition to gathering w ritten m aterials, interaction w ith policy
form ulating bodies w as also an im portant aspect of collecting inform ation.
Policy form ulating bodies included com m ittee’s, groups of RFE providers and
legislative staff personnel. In th is case study, the policy form ulating body is a
group of individuals, providers and DSS/CCLD staff who are assem bled as a
com m ittee to develop stan d ard s for one level of service w ithin the health care
industiy: residential care facilities for the elderly (RFEs).
Interviews
O ther m ethods of gathering data, such as surveys and interviews would
not have been appropriate in th is case study. While surveys would identify the
quantitative process of stan d ard development, the objective in th is case study
is to discover the qualitative, or the how and why of stan d ard s development.
While quantitative data m ight have been useful, it is unlikely th a t a
questionnaire could explain w hich factors are considered prior to identifying
which policies and procedures will be im pacted by the com m ittees actions.
^ Minutes from hearings and other committee meetings were sometimes lengthy as were a
number of state policy and procedure manuals which were used as models for the RFE policy and
procedure manual.
21
Extensive interviews in th is case study would have been inappropriate
due to the fact th a t I attem pted to track the theoretical approach to developing
stan d ard s by observing the com m ittees interaction and decision m aking
processes. Interviews would also be inappropriate tn th is case study because
committee m em bers could not draw conclusions as to the outcome of the
stan d ard s being discussed w ithin the committee. Only the entire committee
could decide w hat constituted a conclusion or inform ation th a t would go into
the m anual. Nevertheless, personal interviews, to a limited extent, were used
during informal conversations and phone correspondence with committee
m em bers. And finally, tim e constraints were another reason why interviews
were not used.
Lim itations
One of the prim aiy lim itations concerning the use of participant
observation as a prim ary m ethod of gathering inform ation is observation bias.
W ith ongoing involvement in committee activities, th e participant observer can
tfecome less objective in h is /h e r observations (Yin, 1979). It is difficult to find
two participant observers who perceive and record th e sam e events in the sam e
way; however, if done correctly, the d ata should be similar.
One’s tendency to select out w hat one w ishes to prove h as been an
ongoing argum ent, and, in effect, the reliability of the data suffer. T hroughout
the course of th is case study, observations were m ade by recording w ritten
changes in the stan d ard s which were p art of the RFE policy and procedure
m anual. In th is case, the committee m em bers acknowledged my role as
participant observer b u t appeared uninterested in th e scope or outcome of m y
22
thesis project. Their m ain Interest focused on th eir attem pts to establish
stan d ard s through the developm ent and distribution of an RFE policy and
procedure m anual.
Advantages to Using Participant Observation
J u s t as there are disadvantages to using participant observation as a
d ata collection m ethod, there are a num ber of advantages to using th is m ethod
a s well (Yin, 1979). First, observations took place in a setting where group
interactions occur, such as convention m eeting room s, private facilities.
D epartm ent of Social Services offices, and a t tim es, w ithin th e trade
associations conference room. Overall, the interaction w as not ham pered by
the environm ental setting w here com m ittee m eetings were held.
Yin (1979) w rites th a t participant observation can be useful in identifying
emotional responses to particular developm ents throughout th e process of
gathering data. Em otional responses were not discouraged throughout th e life
of the committee. Interaction w as free flowing and open.
Participant observation also allows opinions an d values of group m em bers
to be recorded w ithin the context of th eir underlying m eanings. Too often
experim ental variables evade the underlying m eaning behind certain responses
or behaviors. In th is case study only committee conclusions were recorded
into the m easurem ent tool, the policy and procedure m an u al for RFEs. My
involvement in the group allowed m e to decipher the Intent of com m ents and
in p u t provided. While m any com m ittee m em bers w ished to revise certain
segm ents of the m anual, each individual m em ber collaboratively agreed th a t
23
the final outcom e of the project should reflect th eir overall values and beliefs
as health care providers and governm ental agencies.
Finally, m y role as participant observer provided a n opportunity to
establish a solid rapport w ith all parties involved. Each com m ittee m em ber
learned to tru st m e and confide in m e to influence the outcome to the m anual;
however, to a large extent, m y interaction with the committee an d A ssociation
staff provided an excellent neu tral position of com m unication for both providers
and association staff to interact. My rapport and neutral position w ithin the
committee w as a benefit to th e overall outcom e of th e RFE policy and
procedure m anual.
Collection of Information
The d ata base consisted of case study notes which described th e events
which took place w ithin the committee. These notes were used as the prim ary
source of inform ation w hen constructing th e conclusions of the thesis. In
addition to the case study docum ents, draft m an u al notes were used to elicit
responses to suggested changes In the delivery of services w ithin RFEs. The
case study notes were w ritten during com m ittee m eetings, after the m eetings
h ad concluded, following informal encounters w ith committee m em bers and
during phone conversations w ith com m ittee m em bers. In addition, d ata were
collected by interviewing D epartm ental contacts over the phone. And finally,
the m ost recent literature regarding RFE stan d ard s and regulations were
reviewed.
The case study notes revealed a conglom eration of specific observations
which reflected why committee m em bers believed a certain stan d ard should be
24
added or subtracted. In addition, observations were m ade regarding which
factors the com m ittee w as expected to address a suggested change to existing
standards. These how and why questions were the prim ary focus of all
observations. For example, w hen a suggestion w as m ade to add dental service
inform ation Into the policy and procedure m anual, th e committee m em ber
reasoning behind th is suggestion w as explored an d recorded using the following
categories:
1. Financial Considerations
2. C onsum er D em and
3. M arket Control
4. For the good of "Public Interest"
5. Political Pressure
6. Technological Advancem ents
These variables acted a s guidelines from w hich m y observations were
based. W hen a com m ittee m em ber attem pted to change a standard, the
factors or variables th a t were considered w hen th e com m ittees decision w as to
change a stan d ard w as th e n recorded.
CONCLUSION
A case study methodology w as used in th is thesis. As a student intern
w ith the California Association of H ealth Facilities (CAHF), I acted as
participant observer to the RFE S tandards Committee which w as in th e process
of developing a policy an d procedure m anual for RFEs. I conducted a num ber
of interviews and gathered w ritten inform ation while a m em ber of the
committee. At the sam e tim e I carefully identified w hich variables swayed the
25
com m ittee’s decision to add or delete proposed regulations and standards.
Lim itations in using participant observation as m y prim ary role while gathering
the data were considered as w as th e advantages in acting as participant
observer. The RFE S tandards Committee w as formally organized, and I becam e
au th o r of th e com m ittees RFE Policy an d Procedure M anual. My role w as
acknowledged, and the com m ittee proceeded with their plans to complete the
self-regulating docum ent.
26
CHAPTER m
POLITICAL CLIMATE SURROUNDING RFES
Before I present th e findings from th e com m ittee’s actions, I th in k it
would be im portant to first consider how the com m ittee w as formed, why the
committee w as formed, w hat political actions had tak en place in the p ast
which created concern am ongst the com m ittee m em bers, and who the m ajor
players are w ithin the RFE regulatory arena.
RFE Standards Committee Becom es Organized
Residential facility owners an d operators were continually expressing an
interest in establishing a set of criteria th a t all RFEs should adhere to prior to
consum er an d D epartm ental efforts to standardize th e industry (CAHF, 1986).
The California Com m ission on State Governm ent and Economy, better know n
as th e "Little Hoover" Commission, h ad recently com pleted one year of RFE
reform activities which created discomfort am ong providers throughout the
state, while legislative activities surrounding RFEs were on the rise as well.
Providers w ished to slow future RFE reform legislation by establishing a set of
self regulating stan d ard s th a t h ad little state regulation attached. After one
full year of shared fear and anticipation (1985-1986), it w as decided am ong
RFE owners an d operators th a t a RFE com m ittee would be established to
/develop, as th eir goal, a m echanism w hich would com m unicate a new set of
m inim um stan d ard s for RFEs.
The RFE Committee w as p u t in place to attem pt to establish RFE
stan d ard s for th e S tate of California. The com m ittee m et in July, 1986 to
27
establish tim e fram es, overall goals of the com m ittee and who should
participate as formal m em bers.
The com m ittee w as com prised of owners and operators of RFEs and
D epartm ent of Social Services Com m unity Care Licensing Division Designee’s.
M embers felt th a t th e com m ittee should consider conducting a close review of
state and federal stan d ard s for RFEs. In addition, it w as a unanim ous
decision to have in p u t from th e D epartm ent (DSS) since they, more th a n any
other agency, would be knowledgeable as to th e w eaknesses w ithin the
industry and where the committee would be of m ost benefit to the industry.
Few m em bers of th e group were interested in disregarding input from the
D epartm ent, although th eir initial concerns were focused on the possibility th a t
the D epartm ent would attem pt to standardize RFEs through using committee
suggestions as a tool for adding state RFE licensing requirem ents. However,
after considering th e necessity for objective oversight, th e com m ittee concluded
th a t all D epartm ent of Social Service Com m unity Care Licensing Division
(DSS/CCLD) input would be welcomed. The com m ittees goal w as to complete
a policy and procedure m anual for residential care facilities for the elderly by
Ju n e, 1987. The docum ent would be approved by th e committee, reviewed and
accepted by the DSS/CCLD, and distributed to RFE providers by A ugust of
1987. The docum ent would act as a policy statem ent from th e RFE industry
and the regulating departm ent (DSS/CCLD).
The RFE S tandards Committee w as interested in moving quickly to
establish som e kind of self-regulating docum ent, such as a policy and
procedure m anual. The Committee w as anxious to develop th e m anual due to
28
the political clim ate surrounding issues related to residential care facilities for
the elderly. RFE regulations, once nonexistent, were beginning to take forms
which challenged owners and operators to attentively oversee activities taking
place w ithin th eir facilities. These laws® prim arily addressed paperw ork
requirem ents, stru ctu ral com ponents of the facility, delivery of health services
and licensing requirem ents. Additions to existing RFE regulation were likely
due to the uncovering of poor RFE m anagem ent practices, low safety
standards, the possibility of RFEs providing a wider range of services and the
need to reevaluate present health care expenditures to the state (California
Commission on State Governm ent and Economy, 1988).
This chapter will provide background inform ation regarding who h a s
played a k ^ r role in changing the scope of services provided in RFEs. An
overview of the key players will clarify why the RFE S tan d ard s Committee
w ished to expedite the process of developing specific stan d ard s for RFEs. First,
I will look at how RFEs becam e a priority concern to th e California State
Legislature, and how those concerns have carried into proposed changes in
how RFEs should operate. Second, I will consider the players who have been
involved in RFE reform. I will conclude by reviewing various philosophical
differences in key players involved in RFE reform. This inform ation will clarify
why the developm ent of stan d ard s for RFEs h as been ongoing since 1983.
® Health and Safety Codes, Fire Safety Codes, and Title 22, Division 8 requirements.
29
Past and Present Development of RFE Regulation
H eated political environm ents are not new to RFE owners, operators and
representatives. The residential care reform w hich took place in 1982 led to a
broad upgrade in the delivery of com m unity care services in California. State,
consum er, provider and trade association involvement played a m ajor role in
the development of a separate licensing category for residential care facilities
for th e elderly. The prim ary players involved w ith th e development of
stan d ard s for RFEs were the Little Hoover Commission, Senator Henry Mello,
consum er advocate organizations, the California Association of Homes for the
Aged (CAH^, the California Association of Health Facilities (CAHF) an d the
D epartm ent of Social Services Com m unity Care Licensing Division (DSS/CCLD).
The Little Hoover Commission *
The Little Hoover Com m ission w as the prim ary instigator of com m unity
care reform. The Com m ission’ s interest in elim inating abuse in com m unity
care facilities dates back to 1976 w hen they first held hearings on the
organization and m anagem ent of D epartm ent of H ealth Services licensing an d
certification activities. Since 1976, the D epartm ent of Health Services licensed
com m unity care facilities as well as nursing hom es. Since then, the
responsibility h as been transferred to the D epartm ent of Social Services. The
Com m ission initiated a new investigation of conditions in nursing hom es in
1983 and found th a t poor living conditions in com m unity care facilities were
far m ore severe th a n in nursing hom es (California Commission on State
Governm ent an d Economy, 1988). Findings from th a t study prom pted the
Little Hoover Com m ission to begin a thorough investigation of the care provided
30
in com m unity care facilities. Their prim ary goal w as to establish adequate
quality controls in the over 22,000 com m unity care facilities throughout the
state. In 1983, th e Little Hoover Com m ission presented a report w hich
proposed specific action to improve the quality of services provided in
com m unity care facilities.
Senator Henry Mello
Senator Henry Mello (D - Watsonville), p ast chairm an of th e Senate Aging
and Long Term Care Committee, authored a num ber of bills containing m any
Little Hoover Com m ission recom m endations for Com m unity Care Reform.
Senator Mello’ s legislative actions eventually heightened state governm ent
aw areness of abuses occurring in com m unity care facilities. One piece of
legislation which specifically differentiated residential care facilities from
com m unity care facilities w as Mello’s Senate Bill 185 (SB 185). This bill
established specific licensing stan d ard s for residential facilities for the elderly.
It acknowledged th a t m any clients now served in th ese facilities were requiring
increased levels of supervision, and the line betw een the "social and medical"
model w as becoming less defined (Feingold, 1983). Senator Mello h a s once
again recognized the need to redefine residential care; however, his focus h as
been on requirem ents to develop a three level health care system w ithin RFEs,
as suggested by th e D epartm ent of H ealth Services. As suggested by Lave
(1981), these historical events which led to the establishm ent of a separate
licensing category cam e out of a n attem pt to elim inate poor care and abuse
which had been identified. In addition, political processes brought forward
Little Hoover recom m endations after careful consideration of costs, benefits.
31
provider capabilities (technology) an d consum er dem and to Improve RFE
services.
Department of Health Welfare Perspectives
In SB 185, Senator Mello suggested th a t the D epartm ent of H ealth and
Welfare determ ine appropriate levels of care w ithin residential care facilities for
th e elderly. The report which cam e out in Decem ber of 1986 distinguished
three prim ary levels of care. R ecom m endations which cam e out of the
D epartm ent of Health and Welfare’s RFE levels of care report were adopted into
legislation th a t w as authored by Senator Henry Mello. Senate Bill 50
suggested th a t the first level of RFE care provide basic care services and
supervision such as help w ith ADL’s, obtaining supportive services, and
rem aining aware of the resident’s w hereabouts. The second level of care would
provide personEil care services such as dressing, feeding, toileting, bathing,
transferring, and assistance w ith mobility related tasks. In addition to
personal care services, level II care would provide param edical services, su ch
as m aintenance of oxygen therapy equipm ent, assistance w ith colostomy and
catheter equipm ent and assistance w ith self-adm inistered injections. And
finally. Level III services would provide all of the services found in Level I and
II, plus the occasional a ^ is ta n c e from licensed health professionals w ith
tem porary or not serious health problem s such as tracheostom y care, dem entia
supervision and stage one decubitus ulcers (Health and Welfare Agency, 1986).
These proposed stages of care developed by H ealth and Welfare Agency
suggest severe changes in the present delivery of residential care services. The
D epartm ent h a s been reluctant to set these stringent stan d ard s for the
32
regulation of RFEs. The D epartm ent (DSS/CCLD) u n d erstan d s th a t larger
RFEs (100+ bed) have the capability to provide additional supportive services
while sm aller RFEs (6 bed) would find it m uch m ore difficult to develop
additional service system s due to lack of staffing an d financial resources. As
stated in C hapter 1, sm aller RFEs m u st rely on access to com m unity based
long term care services for personal care assistance which the facility itself
cannot offer (Goodman, Pynoos, Stevenson 1986). The D epartm ent of Social
Services CCLD (Community Care Licensing Division) is working w ith trade
associations (CAHA, CAHF) to identify the health care needs of RFE residents
while considering a variety of paym ent options available at th e state and
federal level. In th is instance, providers and D epartm ental agencies carefully
considered the cost benefit, as well as th e technological im pact th a t an
increase in services would have on th e RFE service delivery system.
Trade Association Involvem ent
Com petition for Members. Trade association involvement in RFE political
activities h a s been fragm ented prim arily because the two prim ary RFE
representatives serve different segm ents of residential care providers. For
example, the California Association of Homes for the Aged (CAHA) prim arily
represents non-profit RFEs which tend to be located on cam puses of large
continuum of care retirem ent com m unities. On the other hand, the California
Association of H ealth Facilities (CAHF) tend to represent independently owned,
for-profit RFEs which average approxim ately 90 residents per facility. Each
association has, in its m em bership, fewer th a n 100 RFEs w hich accounts for
less th a n six percent (6%) of all residential care facilities throughout the state.
33
F u rth er expansion of RFE m em bership is a concern to both associations,
especially considering the increasingly im portant role RFEs have played in long
term care since the im plem entation of SB 185, and the possible requirem ent
for these facilities to provide additional health care services. Nevertheless, the
m ajority of all RFE owner and operators (94%) rem ain outside trade association
m em bership.
Changing M embership M arket. Trade associations are attem pting to
provide additional representation to RFEs despite the fact th a t additional RFE
m em bership can potentially strain the existing focus on skilled nursing issues.
How CAHA an d CAHF respond to th is segm ent of the continuum largely
depends up o n the states decision surrounding Senator Mello’s SB 50 and the
proposed changes in the levels of care sent down by the H ealth and Welfare
D epartm ent. If RFEs provide additional health care services, su ch as Level III
services, it would be safe to assum e th a t both CAHA and CAHF would develop
strategies to encourage additional RFE owner an d operator m em bership. If
reform s are not accepted, trade associations will m ost likely m aintain th eir
p resent sta tu s as representatives of a limited n u m ber of residential care
facilities in California.
RFE Role W ithin the C ontinuum of Care. Trade association’s view RFEs
a s th e "weak link" in long term care, prim arily because of the existing lack of
quality control m easures. M andatory licensing, for example, h a s recently
(1985) come into being. Prior to 1985, a large num ber of the 22,000
com m unity care facilities (CCFs) operated w ithout a license. A ssociations can
u n d erstan d th e m onum ental ta sk of m onitoring 22,000 CCFs; however.
34
Inadequate system s to inspect operators h as been unnerving to trade
associations in th eir attem pt to assure th a t their m em bers are fulfilling state
operating requirem ents. CAHF and CAHA typically spend the m ajority of th eir
time concerned w ith skilled nursing issu es and reim bursem ent related
activities. W ith RFEs a s the sm allest segm ent of m em bership, the am ount of
time spent on RFE related issues tend to be proportional to the size of the
m em bership group.
Attempting To Control Qualitv. Trade associations fight a n ongoing uphill
battle to control the quality of services provided in RFEs prior to statutory
m andates. Only a sm all num ber of poorly ru n facilities can cause public
u n rest which, in tu rn , prom otes actions of law governing both th e "good"
facilities and the "bad" facilities. The RFE S tandards Committee attem pt to
develop a policy and procedure m anual is one example of how providers
attem pt to control the quality of care w ithin their industry. A m ore common
approach in controlling the quality of care is through the legislative process.
R epresentation before governm ent agencies will continue to exist in order to
direct changes in the system . These cheinges in th e stan d ard s should be
designed to increase the quality of service and pu n ish providers operating
below state and federal standards.
Summary of Conflicts Between Provider and State Philosophies
In lieu of the proposed levels of care, adm inistrators operating residential
facilities for the elderly have begun to question th eir roles a s service providers.
Existing regulations handed down by the D epartm ent stipulating levels of
services are limited; therefore, facilities tend to develop policies which reflect
35
the attitudes of the provider rath er th a n m irror regulations developed by the
D epartm ent (Phillips, 1975). W ith the proposed levels of care, RFE ow ners and
operators are forced to decide w hat level of care they prefer to provide.
Providers fear th a t the state will not substantially raise the
reim bursem ent rate or Supplem ental Security Income (SSI) for the provision of
additional services ju s t as they failed to do in earlier reform m easures
(Feingold, 1983). Providers believe adding services would cause operational
expenses to become excessive, th u s, forcing them to increase entry level costs
to residents. The increase in th e need for staffing also concerns providers and
im pedes provider support for adding health related services. A dm inistrators
also recognize th a t with increased health service requirem ents, a n intensified
survey process would also be needed. Residential care adm inistrators favor
increasing services w ithin th eir facilities: however. D epartm ental proposed
alterations is viewed as too health care focused (CAHF, 1987).
Consumer Involvem ent
C onsum er groups in California have ju s t begun to touch th e tip of the
political iceberg as it pertains to RFE activities. Up until 1988, consum er
advocacy groups in California have had little voice in prom oting higher
stan d ard s in the California’s 3,500 RFEs. As stated earlier, the Little Hoover
Com m ission (LHC) h as acted as the prim aiy consum er voice. Prior to LHC
involvement, little notice w as given to stan d ard s and quality of care issu es in
RFEs.
RFEs are Small Nursing Homes. RFEs rem ain under the stigm a of the
nursing hom e industry. It is not uncom m on to w itness new spaper articles
36
which refer to RFEs as nursing facilities. Public perception surrounding the
differences betw een the services provided in RFEs versus th e services provided
in SNFs did not began to change until after th e LHC held a num ber of hearing
on th e abuses th a t occur in board and care hom es. Until th is perception
between the differences in RFEs vs. SNFs is completely changed, consum er
involvement in political activities surrounding RFE stan d ard s m ay continue to
be com bined w ith broader skilled nursing facility issues. Conclusion
CONCLUSION
Consum ers, trade associations, state agencies and residential care
providers are concerned about the potential outcom es of existing political
discussion surrounding RFE regulations. These concerns prim arily center
around the goal of all health care professionals — to deliver quality services
which enable individuals to reside in the m ost nonrestrictive setting possible.
State governm ent agencies and consum er advocates approach the problem by
stressing the need for m ore stringent regulations. O perators w ithin one trade
association (CAHF) approach the problem by developing self-policing regulations
which thQT contend do not limit creativity in th e delivery of residential care
services. B ut because of th e increased attention given to RFEs in California by
the Little Hoover Commission, Senator Henry Mellow, other trade associations,
and consum er advocacy groups, providers are forced to reevaluate where
existing stan d ard s could be expanded an d modified. In the next chapter, I will
review the developm ent of regulations and stan d ard s in term s of present state,
consum er, provider and self-controlling practices.
37
CHAPTER IV
THE DEVELOPMENT OF STANDARDS IN LONG TERM CARE
The purpose of the RFE S tandards Committee w as to attem pt to speed-up
the process of developing RFE standards. In light of th is m ission, it is im portant
to u n d erstan d the various m ethods in which stan d ard s are used to enforce
residential care facilities and skilled nursing facility regulations. In his chapter
I will consider how the Com m unity Care Licensing Division, providers and
consum ers use stan d ard s to assure th a t services are being delivered according to
state requirem ents.
Quality Assurance Through State Inspection
M easuring the quality of health care related services is seldom seen as a
simple ta sk w hen considering the differing perspectives betw een regulators and
providers. For RFEs, th e Com m unity Care Licensing Division (DSS/CCLD)
attem pts to assu re quality by sending out surveyors into the facilities to review
the RFEs operations. These state inspections serve as the prim aiy m ethod of
assuring th at quality services are being delivered in RFEs. Quality indicators
used by the DSS/CCLD have derived out of state laws developed prim arily by
Senator Mello’s SB 185 and Little Hover Commission recom m endations in 1983.
These state laws serve as a guideline for surveyors during th e survey process.
State inspections closely look a t facility operating stan d ard s to determ ine the
degree of facility compliance w ith existing laws and regulations. By conducting
facility inspections existing law s can be reviewed and refined to m eet both the
consum er expectations and provider expectations. State Inspections reveal how
facilities are following the requirem ents th a t are handed down from state and
38
federal governm ents. Inspections tend to focus on paper com pliance requirem ents,
various form s of abuse and patient m istreatm ent; any situation in which a facility
is unclean, unsan itaiy , or in poor condition; and any situation in which a facility
h a s insufficient personnel or incom petent personnel on duty (Health and Safety
Code, 1569.47, (f)). W hen stan d ard s are not followed, the m ost com m on response
from surveyors is some form of financial penalty or possibly having the operators
license revoked. The penalty (ies) levied on the facility depends upon the severity
of the violation.
Peer Expectations
S tandards also act as a n evaluation tool for peer surveyors. Peer evaluation
of residentisil care facilities is less extensive th a n skilled and interm ediate care
facilities; nevertheless, peer evaluation activities reflect the expectations shared
betw een RFE providers. In some instances, peer review organizations u se the
sam e stan d ard evaluation form s to review peers a s state surveyors u se during
inspections.
Health facilities tend to review th eir peers through the peer review process.
Peer reviews m u st first be allowed by a facility adm inistrator. After th e
adm inistrator h a s agreed to go through the peer review process, one facility
adm inistrator, designated from th e peer review organization, acts a s th e peer
review surveyor. The surveyor to u rs the facility an d determ ines w hether or not
the facility is in compliance with specific standards. Typically, the facility
interested in becom ing a m em ber of a trad e association will receive notice of the
upcom ing peer review prior to m em bership approval. The facility will rem ain
39
u n d er probationary sta tu s until the peer review is com pleted and acceptance into
th e association is recom m ended by the peer review surveyor.
Facility owners an d operators are often Judged by th e perform ance of th eir
peers. It is therefore appropriate th a t all providers of health care related services
be concerned w ith th e effectiveness of th e peer review process. For example, the
m ajority of residential care facilities are not p art of the group of facilities which
receive daily coverage from the new spapers, television an d radio stations; however,
providers are often judged by the handful of facilities th a t have been found out
of compliance w ith state or federal standards. Often tim es, m edia coverage of
horrifying occurrences in these facilities leads to im m ediate legislative responses.
As Lave (1981) suggests, im m ediate responses to inequities in the delivery system
are intended to assu re th a t consum er ab u ses do not continue.
Consumer Pressure
W hen facilities do not comply w ith existing regulations, consum ers often
hear about it. C onsum er advocacy agencies, su ch as, the Bay Area Advocates for
Nursing Home Reform an d O m budsm an organizations respond to consum er
concerns and bring these concerns to the legislature and other com m unity
organizations. D ram atic depictions of long term care facility injustices m any tim es
force legislators to take the p art of m ediator betw een providers and consum ers.
This is not a n easy ta sk since m ost legislators do not have a clear understanding
of the difficulties experienced in delivering services to chronic ill elderly and
disabled individuals. Phillips (1975) believes th a t in m ost cases, consum er
pressure ultim ately provides th e driving force for change w hen frequent abuses
are found.
40
Standard Setting Through Legislation and Regulation
While the overall intent of health care legislation and regulation is to
elim inate the possibility of future wrong doings, excessive dem ands can be the
actual cause of future m ishaps (Phillips, 1975). For example, in 1986, a
consum er advocacy agency attem pted to improve the adm ission process in long
term care facilities. This consum er agency successfully lobbied to am end state
regulations which addressed th e adm ission contract by adding to th e content of
the cu rrent adm ission agreem ent. After a full year of legislative debate and
deliberation, the state adopted a new requirem ent to have existing adm ission
agreem ents include a laundry list of item s. After contracted legal organizations
h ad am ended th e old adm ission agreem ent to include th e new adm ission
agreem ent requirem ents, th e docum ent had grown from a 10 page adm issions
agreem ent to a 47 page agreem ent w hich takes approxim ately three h o u rs to
complete; th a t is, if the individual is capable of interpreting a lengthy legal
docum ent. This is one example of how quality assu ran ce m easu res can create
a stum bling block for quality rath er th a n an enhancem ent to provide better
services. RFE providers share concerns about the im pact of sim ilar quality
assurance m easures.
Avoiding th e legislative process in th e development of stan d ard s is not a n
e a ^ task. Legislators su pport or au th o r bills designed to alleviate identified
problem s in the system . Laws an d regulations provide surveying bodies, su ch as
the Com m unity Care Licensing Division, an opportunity to evaluate facility
operations. C onsum er groups prefer th is approach over nonm andated suggestions.
41
Legislation is considered as a last resort by providers to solving a problem or
developing standards. Legislation h a s been used as the prim ary m ethod of
initiating responses to stan d ard s developm ent despite th e fact th a t th e legislative
process can be tim e consum ing, controversial and costly.
In general, there have been attem pts to establish new stan d ard s an d
regulations in residential facilities for the elderly. First, the Little Hoover
Com m ission prom pted a review of existing state policies an d practices surrounding
com m unity care facilities. These efforts spurred fu rth er action by state legislators,
nam ely Senator Henry Mello, who w as able to draw a significant am ount of
consum er attention to the abuses th a t were occurring in CCFs. Eventually,
legislative actions proposing changes in th e delivery of CCF services were adopted.
C hanges in the existing delivery of RFE services were proposed after a series of
hearings brought to the forefront m ajor concerns of both providers and
consum ers. As it stands, RFEs are now given th e choice of delivering any
com bination of three levels of RFE care. Facilities are concerned th a t if changes
in the existing levels of care proposals are not m ade, RFEs m ay go b ack to
offering m eals an d shelter and perhaps some assistance with th e activities of
daily living. It is too early, however, to assess the im pact of th e levels of care
proposal.
Self Regulation; Developm ent of the Manual
Before legislators and consum ers begin to develop stan d ard s and regulations,
providers h ad a n opportunity to draw a clear set of internal expectations of how
RFEs should operate. The action tak en by th e RFE S tandards Committee
(development of the RFE Policy and Procedure M anual) w as a clear illustration of
42
a collaborative effort on the p art of the state and the provider to b etter integrate
an d clarify the existing expectations in th e delivery of residential care services.
W hat w as unique about th is process w as th a t it w as done outside of the
legislative arena. Unlike m ost standardization processes w here consum er dem and
and state funding m echanism s force reform atory acts, the RFE m an u al created
a n avenue where the provider and the adm inistrative branch h ad a n opportunity
to exert their views on w hat residential care policies should be w ithout creating
dem and for strict bureaucratic controls.
While not all self regulation comes in the form of m anuals, one can
conclude th a t self regulation is a form of establishing an internal system of
control whereby outside intervention in not included in th e im plem entation of
those regulations. The RFE Policy an d Procedure M anual acts as a guideline of
internal control for RFEs in California.
CONCLUSION
I have reviewed how stan d ard s are used by state governm ent agencies,
consum ers, legislators and providers. Though each separate group (i.e.,
consum ers and regulators) u ses the regulations and stan d ard s in different ways,
each attem pts to verify the degree to which a given facility is following state
requirem ents and standards. This chapter h a s looked at how th e various groups
use different approaches to affect the quality of care being provided in RFEs
throughout California. In dustry groups, such as the RFE S tan d ard s Committee,
can play a significant role in su ch a process. Now th a t I have considered why
th e RFE S tandards Committee is in place, and how various group use stan d ard s
and guidelines, in C hapter five, I will look at how the RFE S tan d ard s Committee
43
created th eir self-regulating docum ent an d w hat im pact the docum ent m ight have
for future efforts to self-regulate w ithin health care related industries.
44
CHAPTER V
FINDINGS AND CONCLUSIONS
In chapter one, I considered the problem issu es surrounding residential
care facilities for the elderly. In C hapter two, I reviewed w hy a case study
methodology w as used in th is thesis. Following a review of the methodology, I
looked at the political clim ate surrounding RFEs and how the political climate
im pacted the developm ent of standards. In C hapter four, I analyzed how RFE
stan d ard s are enforced through the survey process, peer review process,
consum er advocacy and m edia exposure.
C hapters one through four provided a fram ework for understanding
behind the environm ent which existed during the RFE S tan d ard s Committee
developm ent of stan d ard s for RFEs. This chapter will analyze the prim aiy
variables th a t influenced the RFE S tan d ard s Committee to develop new
stan d ard s for RFEs? W as it a cost-benefit factor which influenced their
decision, or w as existing political p ressure the deciding factor? W as the
Committee looking out for th eir share of th e m arket (residents 75 an d older) or
were they simply attem pting to improve th e existing range of services for the
good of each patient? All of these questions will be addressed in th is chapter.
Following these findings, I will discuss how the developm ent of stan d ard s for
RFEs m ay im pact future stan d ard s development for RFEs.
Final RFE Standards Com m ittee Contacts Are Made
The RFE S tandards Committee m et on two occasions in 1986 and four
occasions in 1987. In betw een the quarterly m eetings th e Committee m em bers
were sent RFE M anual revisions and other types of correspondence regarding
45
the developm ent of the RFE M anual. M onthly phone conversations and
interviews w ith each of the Committee m em bers attem pted to identify the
prim ary variables th a t are considered w hen developing stan d ard s an d
regulations. In total, I had, as a m inim um , seventeen contacts with each of
th e m em bers of the committee during the developm ent stages of the m anual.
Each contact w ith the m em bers of the com m ittee focused on th e content of the
m anual. For example, during the beginning stages of developing th e m anual, I
addressed the responsibilities w hich th e RFE Stgmdards Committee m em bers
believed were crucial to operating a n RFE. At the tim e th a t I m et, spoke or
wrote to the committee m em bers, I asked why the m em bers believed th a t a
stan d ard or m an u al procedure should be added or deleted. On every occasion,
I would receive a response w hich focussed on the variables th a t have been
considered for th is case study (i.e., financial considerations, consum er dem and,
m arket control, for the good of "public interest", political pressure, technological
advancem ents). Upon receiving clarification from the committee m em ber
regarding w hat variables h ad influenced th eir com m ents, I would record each
variable th a t w as m entioned in the response to add or delete stan d ard s or
regulations.
RFE Standard Committee Influences
Throughout th e process of developing stan d ard s for RFEs, there were a
n um ber of variables w hich im pacted th e direction of final com m ittee
conclusions. After seventeen m o n th s of observing RFE Stgmdards Committee
m em bers, historical RFE regulatory data, RFE legislative developm ents an d
provider assessm ents, it becam e apparent th a t ^ of the veiriables considered
46
m arket control, for the good of "public interest", and consum er demand) had
influenced the decisions m ade by th e RFE S tandards Committee.
The strongest su p p o rt in redefining RFE stan d ard s cam e o u t of the influence
of political decision m akers and financial im pacts, while an alm ost equal am ount
of attention w as given to the need for future im provem ents in the quality of RFE
services and the need for additional RFE beds. The desire to elim inate
com petition w as not a predom inate factor in determ ining why stan d ard s were
developed as stated in W ilson (1980) an d Phillips (1975), yet, strategies to
elim inate poor RFE providers w as a prim aiy underlying com m ittee objective.
The Integration of Influences
Each decision th a t w as m ade by the RFE S tan d ard s Committee first
considered the financial im pact a stan d ard would impose on each RFE. The RFE
committee m em bers recognized the need for expanding the types of services
offered; however, they tended to shy away from developing stan d ard s th a t would
become difficult for facilities to adhere to and state and federal governm ents to
fund.
EXAMPLE #1 D ental Hygiene
The S tandards Committee believed th a t a stan d ard procedure should be
undertaken to assure th a t each resident receives some kind of dental assistance.
As au th o r of th e m anual, I w as asked to contact the California D ental Association
mobile outreach division for assistance. I found th a t providing dental care in a
central location sim ilar to a n RFE setting would be beneficial for the dental
outreach program as well as for th e RFE residents. The program would provide
a highly accessible source of dental service for the RFE residents while maximizing
47
the n u m ber of clients seen by the dentist. A list of providers an d necessary
stan d ard s were w ritten and presented to the RFE S tandards Committee.
Initially, the committee w as in favor of accessing com m unity based dental
services for th eir residents. However, during th e deliberations each m em ber began
to reconsider their position based the following factors:
1.) Political Influences: Committee m em bers were initially concerned th a t the
state DSS/CCLD m ight strongly encourage th is program to be put in place
in all RFEs. D ental care is a necessary service and is gravely needed by
RFE residents, th u s it w as assum ed th a t th is service would m ost likely
becom e a statutory requirem ent if supported by the industry and the
DSS/CCLD. In th is argum ent, political influences were present.
2.) M arket Control: Despite the obvious need, a select num ber of ru ral facilities
m ight find access to mobile dental hygiene services difficult to obtain. The
S tandards Committee w anted to avoid creating a precedent for future growth
of state funding inequities betw een ru ral v ersus u rb a n RFE services. This
concern w as influenced by the com m ittees desire to eliminate the possibility
of fragm enting the RFE licensure category.
3.) Cost Effectiveness: Resources required by the visiting dentist would create
a n unreim bursable cost factor to an already growing laundry list of operating
expenses. In addition, liability considerations weighed heavily on the final
outcom e of the dental hygiene stan d ard s. This rationale considered the
cost-benefit factors in providing dental assistance to RFE residents.
4.) For the "Public Good": R esidents need assistance vdth regards to dental
care; therefore RFEs should be poised to respond to th is need in some way.
48
The com m ittee concluded th a t regardless of th e cost-benefit factor and
political and consum er pressure, som e kind of stan d ard w as needed to
assure th a t the residents received th e dental services needed. Here, the
"pubhc good" variable w as of prim ary concern.
In th is instance, the committee decided to adopt a stan d ard w hich
encouraged adm inistrators to inquire about the dental needs of each resident and
assure th a t appropriate services are accessed for each individual resident.
EXAMPLE #2 Supportive Services
A second example m ight help clarify the decision m aking process which took
place w ithin the stan d ard s committee; furtherm ore, th is example should clarify the
variables th a t were used to determ ine which stan d ard s and regulations would be
included in th e RFE m anual.
In th is second example, th e type of supportive services provided (i.e.,
assistance w ith taking m edications, accessing com m unity based long term care
programs® an d assistance w ith walking) in RFEs w as th e prim ary concern of the
committee. M embers of the com m ittee initially w anted to see som e kind of
uniform ity in the delivery of services related to the activities of daily living. The
committee agreed th at, as a m inim um , the following services should be included
in the m anual:
A. Physician an d Nurse Visits
B. A dm inistration of M edications
“ Community based long term care programs refer to programs outside of the RFE setting such
as Multi Purpose Senior Centers, Adult Day Care Centers, Meals on Wheels, Title III meal programs,
etc.
49
C. Food Service
D. Supportive Services
M embers of the com m ittee who were affiliated w ith the D epartm ent of Social
Services Com m unity Care Licensing Division believed th a t th e following item s
m u st be considered prior to adopting additions to existing state RFE service
requirem ents:
1.) Financial Considerations: While DSS/CCLD designee’s agreed th a t there is
a need to expand the num ber of services th a t are provided in RFEs, they
also believed th a t a n expansion of these services would require m ore state
and federal dollars to im plem ent. No one from DSS/CCLD h a d any idea as
to how m uch federal financial assistance would be needed or w here these
dollars would come from (i.e.. Supplem ental Security Income, a new
Medicaid categoiy). Additionally, th e D epartm ent w as concerned th a t no
funding increases would come out of th e Deukm ejian adm inistration
considering th e budget facing the state.
2.) M arket Control: A nother concern shared by the departm ent w as the
Im pact th a t increased supportive services m ight have on sm all RFEs (i.e.,
six bed facilities). As previously stated, sm aller RFEs found it m ore difficult
to access outside services th a n larger RFEs (Goodman et al. 1986). In the
event th e D epartm ent of Social Services encouraged a n expansion of services
provided in RFEs, sm aller RFEs w hich already experience difficulties in
providing supportive services would m ost likely find it increasingly difficult
to stay in business. In order to avoid th is potential segregation of RFE
providers, th e D epartm ent representatives recom m ended the RFE S tandards
50
Committee reconsider deletion of the supportive service standards.
3.) Political Influences: The D epartm ent recognized th e potential political
ram ifications of expanding the role of supporting service w orkers in RFEs.
They believed th a t the State Assembly and Senate would accept the
recom m endations; however. Governor Deukm ejian, for budgetary reasons,
m ight veto any significant change to the RFE levels of care. As a precursor
to the D eukm ejian adm inistrations recom m endations to m aintain the existing
RFE service, the D epartm ent representatives suggested th a t th e Committee
m aintain the existing RFE service requirem ents.
4.) For the "Public Good": D epartm ent representatives were u n su re how an
increase in supportive services m ight im pact th e quality of services provided
in RFEs. Considering the problem s th a t the D epartm ent had experienced
in identifying poor adm inistrative practices, an increase in the
responsibilities held by RFE adm inistration w as not a widely welcomed
suggestion. Ultimately, D epartm ent representatives recom m ended th a t the
m anual reflect existing requirem ents which h ad already been w ritten into
state regulations, such as physician and n u rse services, assistance with
m edications, and assistance with m eals.
M embers of the Committee who were affiliated w ith th e long term care
industry used sim ilar rational and variables to determ ine w hich supportive
services should be included in the m anual. They believed th a t an expansion in
th e area of supportive services would be a n unw ise decision considering a.)
insufficient financial resources; b.) sm aller RFEs m ight ultim ately suffer
financially; c.) political p ressu res to divert an increasingly ill patient population
51
to lower levels of care along th e continuum would not be supported by the
Governor; and d.) abuse w hich occurs in RFEs would only potentially grow in light
of existing difficulties to oversee RFE operations, th u s, the "public good" m ight
ultim ately suffer. The variables th a t were considered by industry and D epartm ent
representatives were consistently reviewed by Committee m em bers regardless of
the issue. In addition, the process which took place in identifying the dental
hygiene an d supportive service needs w as sim ilar to th e decision m aking process
surrounding each of th e following areas of the m anual:
a. G eneral Personnel Responsibilities
b. A dm issions Agreem ents
c. Fire and D isaster
d. M anaging Difficult R esidents
e. A dm inistration
Seldom did the S tandards Committee adopt a stan d ard w ithout carefully
considering each of the variables described in C hapter 2 (i.e., financial
considerations, consum er dem and, m arket control, for th e good of "public
interest", political pressure, technological advancem ents). Before 1 consider the
policy im plications of th is study, 1 wül first review each variable and how it
im pacted the RFE S tandards Committee outcom es.
Political Influences
It is not difficult to locate political influences w hich im pacted RFE S tandard
Committee outcom es. M any of these political influences cam e in th e form of
legislation w hich suggested a restructuring of th e services delivered in RFEs.
These legislative activities posed a significant th reat to th e stru ctu re of RFE
52
services provided at th e tim e of the study.
A num ber of outside actors were identified as m ajor political contributors to
the direction which the com m ittee took following certain political events (i.e.. Little
Hoover Com m ission hearings and legislative committee sessions). P ast and
present activities of the two prim aiy parties (i.e., Senator Mello an d the LHC)
caused RFE committee agendas to be altered an d modified to focus on the
prim aiy objectives of the two key players. RFE committee m em bers m ade clear
attem pts to address the developm ent of stan d ard s w ith consideration of LHC
positions and the legislative m ovem ent of Senator Mello’s Senate Bill 50.
Therefore, political Influences were p resent and strongly considered in each of the
RFE S tandards Committee conclusions.
Technological Advancement and Financial Considerations
Technological advancem ents in RFEs are ongoing. These technological
changes w hich are taking place have come about from consum er dem and as well
as from provider desires to allow residents to rem ain in RFEs for a s long as
possible. Once again, the alterations in regulations and stan d ard s did not come
about solely from technological advancem ents as Mitnick (1980) suggests. Mitnick
w as correct w hen he stated th a t stan d ard s and regulations are largely form ulated
from analysis of projected costs versus projected effectiveness of th e desired
technological advancem ent. Technological advancem ents have allowed providers
th e opportunity to care for individuals w ith additional health care needs.
A dm inistrators in the RFE S tan d ard s Committee found few legislative suggestions
unreasonable due to available health care related resources (i.e., ointm ents and
m aterials for decubitus care). However, lim itations in state augm entations for
53
these services served as the prim aiy disincentive for accepting an d endorsing
legislative recom m endations. In general, technological advancem ents and financial
considerations im pacted the decisions w hich were m ade by the RFE S tandards
Committee.
Market Control and for the Good o f "Public Interest”
As Phillips (1975) suggested, regulation w ithin a given industry does not
always establish criteria on which operators can depend. By establishing a
m inim um set of regulations which are to be used w ithin a given industiy,
providers can th en use those m inim um regulations as a fram ework for self
Improvement as they see fit. In th is case, providers decided to develop a
docum ent w hich would direct facilities in th eir day to day operations. In th is case
study, providers took it upon them selves to add stan d ard s which were not
included in existing regulations. The RFE S tan d ard s Committee attem pted to
improve on existing m inim um state requirem ents as a m easure of "internally
controlling standards". While W ilson (1980) would call th is m arket control and
elim ination of com petition, Phillips m ight argue th a t the S tandards Committee
developed a docum ent of improved stan d ard s for "the public good".
Consumer Demand
Although not openly discussed as frequently as legislation and financial
considerations, consum er dem and w as, w ithout a doubt, seriously considered prior
to the outcom e of all com m ittee decisions concerning the development to RFE
standards. RFE S tan d ard s Committee m em bers recognized th a t committee
activities could ultim ately im pact the flow of consum er dem and for RFE services.
The com m ittee’s decisions could also Im pact future funding to RFEs, and the
54
num ber of legislative activities surrounding RFE services.
C onsum ers have, an d will continue to, create dem ands u p o n industries
w hich will force providers to m ake changes to m eet the needs of its consum er
population. RFEs are no exception. C onsum ers vdll continue to dem and
accessible, affordable, quality services which should be m ade available to all
consum ers. The S tandards com m ittee recognized consum er dem ands and
attem pted to have th e RFE Policy and Procedure M anual reflect consum er
expectations. In short, consum er dem ands h ad a slight, b u t significant bearing
on th e outcom es and conclusions draw n from RFE S tandards com m ittee efforts.
Social Regulation in the Developm ent o f RFE Standards
The theoretical approach to regulatory development described by Lave (1981)
w as m ost consistent w ith the developm ent of stan d ard s and regulations found in
th is case study. As described earlier in the text, a coalition of providers and
regulators cam e together w ith th eir various expectations and levels of expertise to
resolve the issue a t hand; to improve stan d ard s found in residential care facilities
for th e elderly. The coalition responded to external factors, su ch as, public
hearings and m edia reports to develop a conceptual fram ew ork for the
developm ent of RFE standards. Feedback an d open interaction allowed coalition
m em bers to com m unicate m isunderstandings in the existing delivery of RFE
services. In addition, influential groups outside of th e coalition w itnessed a
com prom ising approach to establishing guidelines in an environm ent w hich w as
not available in th e past.
Prior to the establishm ent of th e coalition, each organization h ad little
understanding of th e objective of the other organizations in improving residential
55
care facilities in California. This th esis found th a t regulations and stan d ard s
evolved out of political activities, advances in technology, the cost-effectiveness of
RFE service proposals, interest group involvement, consum er dem ands, and
attem pts to assu re th e betterm ent of th e public good through th e elim ination of
patient and resident abuses. While Lave’ s social regulatory development theory
held tru e in m ost circum stances, he did not include one im portant factor which
influenced change in the development of regulations and standards.
Internal Industry Efforts
An industries internal desire and effort to m ake im provem ents in existing
regulations an d stan d ard s is a n elem ent w hich w as seldom discussed in the
literature. Regulations an d stan d ard s developm ent in th is case stucfy were
strongly influenced by internal industry factors. Industries are aware of legislative
and consum er attem pts to alter stan d ard s and regulations. Industries m ay
choose to act upon legislative suggestions or sim ply allow the change to occur
w ithout industry opposition or support. In the long term care industry in
Caltfomia, legislative and consum er in p u t to regulation and stan d ard s developm ent
have been ongoing. These suggested changes to existing laws have occasionally
ham pered the ability of facilities to adhere to th e p ^ ch o so cial and physical needs
of th eir patients. Legislation effecting the health care delivery system is not
always perceived as an effective approach to addressing th e need for improved
care and services delivered at all levels w ithin th e continuum of care. Industries
have th e capacity and desire to improve a product by looking internally and
externally for suggested changes. Although th is approach exposes an industries
w eaknesses, it also provides a n open avenue of com m unication betw een potential
56
future adversaries. In th is study, internal in d u stiy efforts were the prim aiy
im petus for th e developm ent of stan d ard s and regulations for RFEs in California.
POTENTIAL POLICY IMPLICATIONS
Policy and Standards Developm ent
W hich cam e first: the policy or th e standard? It is not always clear which
factor influences which. Does th e policy provide direction from w hich stan d ard s
are to be developed or do stan d ard s, or the lack of stan d ard s, create an
environm ent w hich encourages alterations to existing policies? In th is case study,
stan d ard s identified w eaknesses in existing policies, and attem pted to expand on
those existing policies by encouraging a particular direction for future RFE
political direction.
This case study does not attem pt to prove th a t stan d ard s yield a greater
influence over existing federal an d state policies, rather, th is th esis provides a n
example of how stan d ard s are developed and changed from inadequacies in
existing policies w ithout going through the process of legislative action.
Additionally, th is thesis clarifies w hich factors are considered w hen regulations
and stan d ard s are developed.
The RFE S tandards Committee seem s to have h ad a m inim al im pact on
stan d ard s an d regulations for RFEs. The RFE Policy and Procedure M anual for
RFEs h as been reviewed by consum er advocacy organizations throughout the
state. If th e m an u al is adopted by regulatory agencies a s a guide, future RFE
policy m ay be derived from th e stan d ard s th a t have been w ritten into th e m anual.
The m aterials have been distributed to RFE providers an d other organizations
wishing to have a copy of the docum ent. One organization w hich h a s not
57
considered th e content of th e m anual however is th e influential Little Hoover
Commission. The Com m ission h a s not reviewed the m aterial despite increasing
RFE activity in LHC hearings and regulatory debate. The Commission m ay
consider using th is m aterial in later years; however, th eir interest in exploring
problem s w ithin RFEs in th e future is unclear. There is however, a strong
likelihood th a t legislative and consum er advocacy agencies will pu rsu e interest
group feedback regarding a continued effort on behalf of Senator Mello to
reintroduce a levels of care bill for RFEs. These organizations wÜl inquire as to
interest group expectations and stan d ard s w ithin RFEs. And in light of the
nursing hom e trad e associations endorsem ent of the m anual, the stated
organizations would have th e m ajority of their policy form ulating w ork com pleted
in advance after receiving industry accepted policies and procedures w hich are not
included in existing RFE regulations and statu tes.
On the other hand, the S tandards Committee efforts m ay not be considered,
by state, local and consum er agencies, due to th e com m ittee stru ctu re (i.e.,
providers and adm inistrative personnel). If th is is the case, the w ork of the
com m ittee m ay have h ad only lim ited im pact on future changes in RFE stan d ard s
and regulations.
CONCLUSIONS
This thesis showed th a t stan d ard s are developed by considering a n um ber
of variables, su ch as technological advancem ent, th e needs of the public, cost-
benefit factors, consum er dem and, to m aintain a segm ent of th e m arket share and
political pressure. I analyzed how th e RFE S tandards Committee considered each
variable in the decision to add or su b tract a given stan d ard which would apply
58
to RFEs. This finding su p ports Lave’s (1981) theory th a t stan d ard s and
regulations are developed from a consideration of a n u m ber of variables.
This study also em phasized th e consistent process which took place in
coming to a conclusion regarding the development of new stan d ard s. AH
conclusions th a t cam e out of th e RFE S tandards Committee carefully looked at
how the stan d ard s would im pact outside agencies, groups, organizations and other
industries. This decision m aking process allowed the com m ittee to look m ore
carefully at how the content of th e m anual would im pact SNFs, ICFs and other
health care related services. B ecause of the w idespread considerations w hich took
place, the RFE Policy eind Procedure M anual w as able to evolve as a RFE service
specific docum ent th a t could apply to RFE service providers of all sizes^°.
If a sim ilar approach w as used by our law m akers at the state and federal
level, m any of our fragm ented health care services m ight be more integrated as
a continuum . Instead, o u r laws have created gaps betw een m any of o u r existing
health care services. C onsideration of provider expectations w as the prim ary force
in assuring th e all of the service gaps were being considered. Those services
which RFEs were unable to provide were introduced to other levels of care to
assure th a t consum ers do n o t fall into they grey area w here health care services
are not m ade available. Elim ination of a num ber of service gaps would not have
been likely h ad the RFE S tandards Committee not tak en th e tim e to carefully
identify their role as residential service providers. If m ore of our state and federal
While the entire RFE Policy and Procedure Manual would not be applicable to six-bed RFEs,
other sections of the manual, such as the Fire and Disaster, Managing the Difficult Patient and Social
Services would be beneficial to all RFEs regardless of size.
59
law m akers would consider su ch issues, one m ight find fewer gaps in our health
care system th a n is currently present.
Regardless of the outcom e of policy im plications of the RFE m anual, RFEs
will no longer continue to be overlooked as a potential outlet for the state
governm ent to reduce o u r growing long term care costs in California. F u rth er
oversight of RFE practices and service delivery philosophies could lead the state
back to the drawing board in reconsidering the stru ctu re of the levels of care
w ithin RFEs. In th is situation, providers and consum ers would th en have
eventually come together to w ork tow ard a more collaborative agreem ent w hich
details the delivery of quality residential services.
Residential facilities for th e elderly are in California to stay. Efforts to
assu re th a t quality residential service rem ain available will be increasingly
im portant as the dem and for these services rises. This thesis h as provided an
overview of the present and possible future environm ent of th a t service, and h as
attem pted to expose how, why, and w hat factors are considered w hen developing
stan d ard s for residential care facilities in California.
60
r e f e r e n c e s
California Legislative Anatyst Office. The 1986-87 budget: perspectives and
issues. Report of the legislative analvst to the loint legislative budget
committee. California Office of State Printing, Sacram ento, 1986.
California A ssociation of H ealth Facilities. L oi^ range
planning. Paper presented to CAHF Long Range Planning Committee,
Sacram ento, Caltfomia. A ugust 1986.
California Association of H ealth Facilities (1987). [Survey sum m ary conducted
by CAHF w hich assessed provider concerns and priorities for 1988].
U npublished raw data.
California Association of H ealth Facilities M em bership directory. CAHF Printing
Office. Sacram ento 1988.
California Commission on State Governm ent and Economy (1988).
U npublished m inutes from S anta Ana Little Hoover Com m ission hearing
on RFE abuse and licensing difficulties. M arch, 1988. S an ta A na City
Hall.
California H ealth and Safety Code, Section 1569.2. 1986
California H ealth and Safety Code, Section 1569.47. 1986
California H ealth and Safety Code, Section 1569. 1986
California H ealth and Safety Code, Section 1502. 1986
California H ealth and Safety Code, Section 1250. 1986
California H ealth and Safety Code, Section 1250.(c). 1986
California H ealth and Safety Code, Section 1250.(d). 1986
California H ealth and Safety Code, Section 1251. 1986
Davis, R ichard (1975) Aging: prospects an d issues, revised
Percy A ndrus Gerontology Center. Los Angeles, California.
D epartm ent of Social Services, Com m unity Care Licensing Division (1986).
[Comprehensive listing of all licensed RFEs throughout California]
U npublished raw data.
D epartm ent of Social Services, Com m unity Care Licensing Division. Inform ation
presented at an RFE T ask Force m eeting, Sacram ento, California. (June,
1986].
61
D epartm ent of Social Services, A dm inistration Division (1987) SSI/SSP paym ent
stan d ard s - lan u arv 1 through decem ber 31. 1988. Unpublished
sum m ary of SSI/SSP rates for 1988.
E ustis, N., Greenberg, J ., Patten, S. (1984) Long term care for older persons: a
policy perspective. B rooks/Cole Publishing, Monterey, California, p.86.
Feingold, R. (1983, August). Hearing on com m unity care licensing. Hearing
w as conducted in California State Capitol, Sacram ento.
Stevenson, L.M., Pynoos, J ., Goodman, C.C. (1986) Board an d care castaways:
other adults outside the long term care continuum . University of
Southern California. Los Angeles, CA.
H ealth and Welfare Agency, D epartm ent of Social Services (1986) Report to th e
legislature of a level of care system from residential care facilities for the
elderly. (Research p u rsu a n t to chapter 1127, 1985). Sacram ento, CA.
Lave, Lester B. (1981) The strategy of social regulation: decision fram eworks for
policy. The Brooking Institution. W ashington D C.
M ahan, R.C. (1983, August). Report on overview of com m unity care
workshops. Testim ony to discuss th e overall purpose of five statew ide
little hoover com m ission hearings, Sacram ento, CA.
McKnight Medical C om m unications Co. "Survey gauges im pact of diagnosis
related groups’s on nursing hom es." Today’s nursing hom e and
retirem ent housing today quarterly. A ugust 1988. p .l.
Mello, H. M onthly new sletter to senator’ s seventeenth district. Henry.
Septem ber 1985, p. 2.
Miller, F. (1986). Interview at first RFE S tan d ard s Committee Meeting.
Sacram ento. A ugust 21, 1986. D epartm ent of Social Services.
Miller, F. (1988). Statem ent to the Little Hoover Com m ission during public
hearing on com m unity residential care facilities. U npublished
m anuscripts.
Mitnick, B arry M. (1980) The political economy of regulation: creating,
designing, and removing regulatory forms. New York. Columbia
University Press.
Newcomer, R., Stone, R. (1985) Board and Care H ousing Expansion and
Im provem ent Needed. Generations. Sum m er Edition.
Phillips, Alm arin (1975) Promoting com petition in regulated m arkets. The
Brookings Institution. W ashington D C., pp. 1-12.
62
Sherwood, C.C. (1981). Model regulations: Evaluation of board an d care hom es
(Contract No. HEW 100-79-0117). Denver, CO: Denver Research Institute
and the University of Denver.
Sm ith, G.W. (1988). Setting directions to m eet dem ands. Provider for long term
care professionals. North W est W ashington, D.C. A ugust, 1988. vol.
14, no. 8.
Wilglg, Paul, Executive Vice President for th e Am erican H ealth Care Association
(1988). Opening statem ent m ade to th e California Association of Health
Facilities quarterly convention: Sacram ento, California. May 1988.
Wilson, Jam e s Q. (1980) The politics of regulation. Basic Books Inc.,
Publishers. New York.
Yin, Robert K. (1979) Case study research: design and m ethods. Sage
Publications. Beverly Hflls. vol. 5.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Psychotropic medication consumption patterns observed in residential care facilities for the elderly

PDF

Mobile health care: An alternative approach in the delivery of preventive health care to the rural elderly in Arkansas

PDF

The role of a nursing home's philosophy and culture in the rehabilitation of the residents

PDF

Nursing management of elderly patients with delirium and/or dementia

PDF

The use of modified Delphi/Nominal Group Technique to set priorities for a system of long term care for the elderly

PDF

An application of the ridge regression method to a neurological nursing care study

PDF

A descriptive analysis of health care rationing: A focus on renal disease and the elderly

PDF

Effect of physical theraphy evaluation on care planning in frail elderly receiving case management

PDF

Towards a cross-cultural comparison on measuring disability in the elderly

PDF

The use of complaints against nursing homes as an index of quality care

PDF

Impact of the Title III Meals Program as perceived by the participants of SCAMP

PDF

Programs for the secondary consumer of long-term care services

PDF

Impact of environmental stimulation of functioning of nursing home patients

PDF

A study of the effects of geriatric experience in health professional on feelings about the elderly

PDF

An analysis of how auspices and administrator preparation affect who is served by board and care homes for the elderly

PDF

What do elderly blacks know about high blood pressure as compared to elderly whites

PDF

Herpesvirus and HIV type 1 infections: A seroepidemiologic study of relationships in selected populations

PDF

An evaluation of a concept formation test for two and three year old deaf and hard of hearing pupils

PDF

A score card for evaluating the health, sanitation and safety aspects of organized camps

PDF

The American Red Cross and its activities during the world war

Asset Metadata

Creator Hinman, Lawrence (author)

Core Title Searching for an identity: A study of residential care facilities for the elderly in California

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-411769

Unique identifier UC11658364

Identifier EP58957.pdf (filename),usctheses-c37-411769 (legacy record id)

Legacy Identifier EP58957.pdf

Dmrecord 411769

Document Type Thesis

Format application/pdf (imt)

Rights Hinman, Lawrence

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA