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Regulation of Nursing Facilities in the United States

An Analysis of Resources and Performance of State Survey Agencies

^a Health Services Management Centre, University of Birmingham, UK
^b Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco

Correspondence: Charlene Harrington, PhD, Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94188. E-mail: chas{at}itsa.ucsf.edu.

Decision Editor: Laurence G. Branch, PhD

Purpose: This study was undertaken to examine the resources, staffing, and performance of the state survey agencies that have primary responsibility for regulating nursing facilities—licensing them at a state level and certifying them for participation in Medicare and Medicaid on behalf of the Center for Medicare and Medicaid Services (CMS; formerly the Health Care Financing Administration). Design and Methods: A telephone and fax survey of survey agencies in all 50 states and the District of Columbia was used, supplemented by secondary data collected from CMS's On-Line Certification and Reporting (OSCAR) system. Results: Total state agency expenditures on nursing facility regulation in 2000 were $382.2 million, which is less than one half of 1% of the total expenditures on nursing facilities in the United States. About 3,000 full-time equivalent surveyors are employed to regulate more than 17,000 nursing facilities in the United States. Nursing facility licensing and certification dominates the work of state survey agencies, although they are responsible for regulating many other health care organizations. Spending has risen recently, but resource levels vary greatly across states, and most state agencies report significant funding shortfalls that impact on their ability to perform their regulatory function. On a range of indicators, the performance of state survey agencies varies fivefold. Some of that state variation is explained by differences in resource levels for regulation, but most is not. Implications: State survey agencies probably need more funding to fulfill their responsibilities properly, but other changes are also needed to improve their performance, including more support and oversight by CMS and more effective regulatory design.

Key Words: Nursing homes • Licensing and certification • HCFA • CMS • Long-term care

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