Quality Improvements in Nursing Facilities and Other Settings


Regulators should address several issues that can affect the quality of life and care in nursing facilities and other settings.

Private rooms—studies consistently show that residents strongly prefer private rooms and bathrooms, which they see as essential to dignity and any meaningful protection of privacy. In addition, private rooms and bathrooms improve security of personal belongings and infection control. Evidence also indicates less conflict between residents and less staff time spent resolving those conflicts when residents have private rooms. Most nursing facility residents have semi-private rooms (a shared room with a barrier such as a curtain to provide limited privacy).

Culture change—growing numbers of facilities are embracing culture change as a means to becoming more life-enhancing places in which to work and live. Culture change can have many meanings, but it usually includes three major elements:

  • changes in the physical characteristics of care facilities to make them more residential in scale and provide more private spaces for residents;
  • changes in the staffing model to give more training, autonomy, and career advancement opportunities to direct-care staff; and
  • changes in the service delivery model to give care recipients and their families/caregivers more control over the types and timing of the services they receive.

For example, the Green House Project and similar efforts transform nursing facilities from institutions into small, home-like settings with private rooms and bathrooms, incorporating an emphasis on resident-centered care and staff empowerment. Other efforts include moving toward household-living models, resident-directed care practices, and improved workplace cultures within existing facilities. Some assisted living facilities are using an intergenerational community model in which residents share a building or campus with staff and their families or with college students.

Bed holds—federal law requires that nursing facility residents who are temporarily absent from the facility be allowed to return to the next available bed in that facility. Medicaid coverage during a temporary absence varies from state to state, with some states providing no coverage. In those states, if the residents are unable to pay privately, they may not be able to return to their room or even to the same facility. Laws regarding such “bed holds” in other settings vary from state to state.

Video technology—video technology can facilitate frequent communication between residents in nursing facilities or supportive housing and their loved ones. Virtual visits can also help family members monitor and document a resident’s care. In 2001, Texas passed a law that protects the right of nursing facility residents to request electronic monitoring devices. The state added assisted living residences to the statute in 2003. The law requires nursing facilities and assisted living residences to provide reasonable accommodation for electronic monitoring and prohibits facilities from refusing to admit or release residents because they request monitoring.

Admitting people with criminal records—admission of people with a record of violent crimes to nursing facilities and assisted living residences has raised some concern. For example, a report by the Government Accountability Office identified about 700 registered sex offenders living in long-term services and supports (LTSS) facilities in 2005. Although these offenders may be people with disabilities, they can still put vulnerable residents at risk. Very few facilities have the staffing levels, training, and security needed to care for these residents and ensure the safety of other residents.

Emergency preparedness plans—federal law requires nursing facilities that participate in Medicare or Medicaid to have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. In addition the facility must train all employees in emergency procedures when they begin work at the facility, periodically review the procedures with existing staff, and carry out unannounced drills. Requirements for emergency preparedness in other settings vary from state to state.

Private right of action—a private right of action exists when a statute authorizes individuals aggrieved under the law to bring suit. With a private right of action, LTSS consumers can sue a provider or the government for breach of statutory or regulatory rights, duties, or responsibilities. The primary purposes of the private right of action are to obtain compensation for injuries and ensure performance of duties. A secondary purpose is to supplement traditional government regulatory enforcement with private oversight and enforcement. Some state legislatures have established a private right of action both for nursing facility and assisted living residents.

Alternative dispute resolution—residents in nursing and assisted living facilities often lack the practical ability needed to sue the facility because of cognitive impairments or limited finances. Mediation and other alternative forms of nonbinding resolution may help with some kinds of disputes, such as when a resident has problems with a roommate. However, they are inappropriate for other issues, including disputes about life, health, or safety (see Chapter 12, Personal and Legal Rights: Alternative Dispute Resolution).

Quality Improvements in Nursing Facilities and Other Settings: Policy

Promotion of privacy and home-like environments

In this policy: FederalState

The federal government and the states should encourage and provide incentives including, but not limited to, grants and loans for new, affordable models of long-term services and supports (LTSS) that emphasize resident-centered care, a home-like environment, a positive workplace culture, and opportunities for resident involvement in the community.

In states where a certificate-of-need process exists, that process should be employed to promote the development of home-like, consumer-centric nursing facilities and assisted living/residential care settings.

The federal government and the states should support the exploration of changes in staffing models to give more person- and family-centered training, autonomy, and career advancement opportunities to direct-care (frontline) staff.

Providers with existing facilities that need renovations in order to create private baths, kitchenettes, and other improvements should have incentives for making such changes.

States should require all nursing facilities and assisted living/residential care settings to maximize each resident’s dignity, independence, autonomy, and privacy.

All new or retrofitted nursing facilities and other settings should provide private living quarters, except when residents request to share rooms or apartments. States should ensure that any new facilities that are developed meet consumers’ needs and preferences.

The federal government should conduct research to develop measures of clinical, functional, and quality-of-life outcomes and to explore innovative approaches to achieving high-quality outcomes in both existing and new facilities.


In this policy: Federal

The federal government should couple new quality-related standards with financial assistance to states, through Medicaid and other sources, to improve resident services, increase monitoring and enforcement efforts, train operators and staff, and help owners retrofit homes when necessary and feasible.

Bed holds

In this policy: FederalState

The federal government and the states should require providers to hold residents’ units for them during temporary absences as long as the residents’ fees continue to be paid.

Government reimbursement programs should provide funding to hold a unit or bed for an eligible individual during a temporary absence of reasonable duration.

Video technology

In this policy: FederalState

The federal government and the states should enact laws that clearly establish the right of nursing facility and assisted living/residential care residents—or their legally recognized decision makers—to use video technology for monitoring the quality of care, for documentation of care, and for virtual visitation.

Video technology should be allowed only when protections are in place to ensure that it does not infringe on roommates’ right to privacy.

For residents who are unable to provide consent, care must be taken to balance the benefits of video technology with the need to protect the resident’s right to privacy.

Nursing facilities and supportive housing residences should be prohibited from removing or refusing to admit a resident who chooses to use such technology. Nursing facilities and assisted living/residential care providers should be required to notify residents and/or family members when video technology is being used by the facility and/or their roommate.

Preadmission screening

In this policy: FederalState

Because nursing facilities and supportive housing facilities must ensure the safety of residents, agencies that refer individuals to nursing facilities or supportive housing should be required to inform the facility when an applicant poses a potential threat to the safety of other residents.

Preadmission screenings should include questions to identify individuals who present a risk of violent behavior.

When facilities deny access to an individual who is otherwise eligible for publicly funded services on the basis of a criminal history (i.e., when a judicial sentence has been completed), the federal government and the states must provide alternative access to needed services. This should include access to services in the home or community, specialized facilities for those who present a risk of violence and need facility-based care, and enhanced family caregiver support.

Admitting parolees or violent offenders to long-term services and supports (LTSS) facilities

In this policy: FederalState

The federal government and the states should not parole or prerelease violent offenders to LTSS facilities that serve the general population.

Violent offenders who are subject to the jurisdiction of federal or state correctional agencies and who need LTSS should be served by correctional agencies in units that meet appropriate staffing and training requirements for proper care.

At the individual and systems levels, LTSS agencies and state corrections agencies should begin to plan for the release of older adult nonviolent offenders through early-release and other programs.

Emergency preparedness plans

In this policy: FederalState

Federal and state licensing standards should require that nursing facilities and assisted living/residential care facilities have well-developed, feasible, and practiced emergency plans for residents, as well as adequate numbers of well-trained staff to carry out such plans.

These plans should be prepared and reviewed annually by the local emergency management agency as well as the state regulatory agency.

Plans must include procedures for safely evacuating residents; transporting medical records, emergency medicines, and other supplies; and continuing needed care.

The standards should require that emergency plans be on file with the state.

Emergency plans should be given to family members when a client is admitted to the facility as well as annually, following state approval.

Facility administrators should be criminally liable for not properly following these plans and any emergency orders issued by federal, state, or local authorities.

State governments are responsible for ensuring that systems are in place to protect all nursing facility and assisted living/residential care residents in the event of emergencies.

These systems should ensure clear communication and points of contact in state and federal government and in LTSS facilities before, during, and after a disaster.

States should put policies and procedures in place to safely move residents from unsafe facilities or facilities that can no longer provide care.

Consumer participation in LTSS facilities’ operation

In this policy: State

All nursing facilities and large assisted living/residential care residences should be required to create a board or an advisory body to review operations. Advisory boards should include at least two independent consumer representatives.

States should enforce the family and resident rights outlined in the 1987 Nursing Home Reform Act and should require nursing facilities, assisted living residences, and board and care homes to facilitate the formation of community, resident, and family councils.

States should require nursing facilities and assisted living/residential care facilities to allow notices of council meetings to be posted, permit mailings to prospective members, provide a meeting room within the facility, and provide a contact person to respond to the council’s concerns.

Facilities should arrange for staff to attend council meetings and should allow the presence of outside representatives only upon the council’s request.

Ombudsman programs

In this policy: State

States should provide adequate funding to permit state LTSS ombudsmen to visit all facilities.

Regulatory enforcement

In this policy: State

States should have a full range of sanctions available, including (but not limited to) civil money penalties, a ban on all new admissions, monitoring of directed plans of correction, denial of Medicaid payment for new admissions, and appointment of temporary managers and receivers.

Remedies should be swiftly imposed, with harsher sanctions for recurring, serious, or widespread deficiencies.

States should ensure that licensing laws specify the conditions of care for each type of facility, including all subacute and LTSS beds in hospitals and special care units for residents with dementia.

Community involvement

In this policy: State

States should encourage facilities to involve family members and the local community in facility activities and to help residents develop and maintain relationships in the broader community. Community organizations should be encouraged to facilitate the involvement of nursing facility residents and their families as volunteers, when possible.

Private right of action

In this policy: FederalState

States should guarantee and protect the rights of residents, including their right to pursue a private right of action in court when facilities violate state laws and regulations or when the government fails to enforce such laws.

Dispute resolution

In this policy: FederalState

States should establish a resident’s right to alternative forms of dispute resolution, such as mediation, provided the states do not inhibit or discourage residents or their families from resolving disputes through other means, including the federal and state enforcement system, the ombudsman program, and the courts.

States should ensure a fair and timely hearing process for residents who wish to challenge proposed transfers or discharge decisions. The process should include the same due process protections that apply to Medicaid fair hearings.

The administrative and judicial appeals process should be streamlined to minimize a facility’s ability to avoid or delay penalties.

A facility’s use of binding arbitration and dispute resolution agreements as a condition of admission or continued stay should be prohibited.

Antidiscrimination laws

In this policy: FederalLocalState

States should enact and strictly enforce antidiscrimination and civil rights laws to protect the fundamental right of all applicants to and residents in nursing facilities and other settings to be free from discrimination.

Antidiscrimination laws should be amended to include sexual orientation and ensure the right of same-sex couples to be housed together in assisted living and residential care facilities, nursing facilities, and other LTSS settings (see Chapter 12, Personal and Legal Rights: Civil Rights, for additional policy on antidiscrimination laws).

Information confidentiality

In this policy: State

States should ensure confidentiality of residents’ information.