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Background: Behavioral and psychological symptoms in dementia (BPSD) are a major concern. The French government gave a consensual definition of reinforced intermediate-term care units for BPSD within the project "Plan Alzheimer 2008/2012"., Objective: Our aim was to report one of the first experiences of this unit in France., Results: Fifty-two patients (38 females, 14 males) were included, mean age 82.07±7.84 (73-97). About 80% of patients were improved and there was a high discharge rate to home of about 30%. Night-time behaviors, aberrant motor behaviors and agitation were the most frequent symptoms., Conclusion: Our study confirms that demented elderly patients greatly benefit from a specific BPSD care unit in agreement with the objective of Plan Alzheimer 2008/2012., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objective: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home., Design: Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records., Measurements: The percent of residents by diagnostic group and antipsychotic use., Main Results: An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased., Conclusion: OBRA 87 had a significant impact on antipsychotic use in this facility.

The role of active treatment has been recognized as vital to the habilitation of persons with mental retardation; however, evaluating the provision of active treatment has been difficult. This study describes the development of the Active Treatment Client Rights checklist (ATCR), which was designed to facilitate the assessment, monitoring, and implementation of readily observable client active treatment services. This investigation provides an explanation of item content, initial reliability data (Phase I), and the results of implementation of the ATCR over a 2-year period in an ICF/MR facility with 29 living units serving nearly 500 clients (Phase II). The ATCR is highly reliable, valid, and useful in enhancing staff provision of active treatment. The most sensitive indicator of active treatment was shown to be related to frequency of functional interactions between clients and staff.

This document contains corrections to final regulations (BPD-311-F) that were published September 23, 1992 (F.R. Doc. 92-22582) (57 FR 43906). The regulations describe new limitations on the valuations of assets acquired as the result of changes in ownership occurring on or after July 18, 1984. These changes affect hospitals and skilled nursing facilities under the Medicare program, and hospitals, nursing facilities, and intermediate care facilities for the mentally retarded under the Medicaid program.

This final rule revises and clarifies the meaning of the prohibition against the use of Federal financial participation (FFP) for vocational training and educational activities in intermediate care facilities for the mentally retarded (ICFs/MR) and in psychiatric facilities or programs providing psychiatric services to individuals under age 21. It resolves issues that have been raised by the States and courts regarding the method and criteria that have been used by HCFA to determine which services are not eligible for FFP because of the educational and vocational training services exclusion.

Results of a survey of six Midwestern states demonstrated that although some state Medicaid agencies have had work incentive policies for ICF/MR residents for some time, others continue to utilize policies that are a disincentive to work. Policy changes toward employment incentives in state Medicaid agencies should improve work opportunities for workers with mental retardation at little expense to the government.

Regulations and voluntary standards within the context of organizational design and mission as well as leadership in management for quality were discussed. Rules and regulations are closely associated with the structure and mission of the organization. Altering them may require fundamental redesign of organizational structure and purpose. Likewise, alterations in organizational design can change the need for rules and regulations. In addition, standards do not automatically yield quality. Rather, they define expected levels of performance from individuals, programs, and the organization. The senior management of organizations is responsible for exercising the leadership in managing for quality.

Licensing and certification of ICFs/MR can adversely affect individuals, distort the allocation of (and waste) scarce resources, and encourage community residences to become small institutions. At a home in Northern California, used as a case study, recent interest in active treatment has emphasized good paper rather than good service or quality lives. Several recommendations were offered to encourage responsive services in line with progressive values and the wants and needs of individuals with developmental disabilities.

Contrasts between the rhetoric of quality assurance and the realities of poor quality in today's ICFs/MR were explored. Comparative studies have shown that ICFs/MR provide the poorest quality of life for persons with mental retardation. The ICF/MR operational model was described here as paper-oriented, failure-based, and insensitive to the effects of its own practices. Recommendations, including the establishment of local control, a less-direct relation between funding and rule compliance, and alternate forms of program evaluation and monitoring, were made.

In this article we have described the impetus, research, and recommendations for a new reimbursement system based on client resource use for ICFs/MR in Minnesota. Research to develop a targeted reimbursement strategy has been completed and a proposal for basing program rates on client resource use developed. Residents (N = 913) in a stratified sample of 65 facilities were assessed and staff resource use determined. Results showed that although predictors in the area of personal interaction, integration, and independence, activities of daily living, special treatment/medical complexity, and behavior accounted for a significant amount of variation in resource use, the unaccounted for variation was sufficiently large to support recommending a system that will base program rates on individual client resource use and the historical costs of individual facilities. Key design issues were also discussed.

These final regulations with comment period revise and consolidate the requirements that facilities furnishing long term care are required to meet to participate in both the Medicare and Medicaid programs. They contain revisions to our proposal of October 16, 1987 (52 FR 38582) based on comments submitted by the public. Long term care facilities include both skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) and, as of October 1, 1990, nursing facilities (NF) created by the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). Under these regulations, one set of requirements replaces the existing separate ones for SNFs participating in the Medicare program, and for SNFs and ICFs participating in the Medicare program. (After October 1, 1990, SNFs, and ICFs participating in the Medicaid program will be known as nursing facilities (NFs).) Although some essential distinctions imposed by the statute remain, these new requirements reflect common needs in SNFs and ICFs. These regulations do not apply to ICFs for the mentally retarded or persons with related conditions.

This rule amends a definition in Medicaid regulations concerning intermediate care facilities for the mentally retarded (ICF/MR) and persons with related conditions. The definition of "persons with related conditions" contained in our regulations was tied to the definition of developmental disability included in the Developmental Disabilities Assistance and Bill of Rights Act (DDABRA) as amended in 1978. The DDABRA, as amended, however, also included the mentally ill within the definition of developmental disability. The prior cross-reference in our regulations to the DDABRA definition resulted in confusion about the kind of care covered by the ICF/MR benefit. To avoid misunderstandings in the future, this rule establishes an independent Medicaid definition of persons with conditions related to mental retardation.

This rule changes the effective date of regulations issued in the Federal Register on February 2, 1989 (54 FR 5316), as amended by a rule published on July 14, 1989 (54 FR 29717), that contained new and revised requirements for long-term care facilities (skilled nursing facilities, intermediate care facilities, and effective October 1, 1990, nursing facilities) that participate in the Medicare and Medicaid programs. The effective date of January 1, 1990 is changed to October 1, 1990.

This rule would clarify policy on Federal financial participation (FFP) in State Medicaid payments to a long-term care (LTC) facility after the State agency has terminated the provider agreement or failed to renew the agreement when it expires. These amendments are necessary to establish Medicaid policy that is consistent with sound administrative practice. Clear policy will ensure uniform understanding and application by all Medicaid agencies.

These final regulations provide States options under which an intermediate care facility for the mentally retarded (ICF/MR) found to have substantial deficiencies only in physical plant and staffing (or physical plant, staffing, and other minor deficiencies) that do not pose an immediate threat to the clients' health and safety may remedy those deficiencies. The regulations provide the State Medicaid agency with options to submit written plans either to correct the necessary staff and physical plant deficiencies, and all other minor deficiencies, within 6 months of the approval date of the plan, or to reduce permanently the number of beds in certified units within 36 months of the approval date of the plan. These regulations implement section 9516 of the Consolidated Omnibus Budget Reconciliation Act of 1985 and section 4217 of the Omnibus Budget Reconciliation Act of 1987. The purpose of the correction plan provision is to promote correction of deficiencies without having to exclude ICFs/MR from the Medicaid program. The reduction plan provision is intended to move Medicaid clients out of deficient ICFs/MR into licensed or certified (as applicable) community settings while maintaining the clients' quality of life and retaining their Medicaid eligibility.

This regulation authorizes Intermediate Care Facilities For the Mentally Retarded (ICFs/MR) to negotiate revisions to their 1977 correction plans for Life Safety Code, living, dining, and therapy area deficiencies under certain circumstances. Under this regulation, HCFA is authorized to approve revised correction plans when facilities have completed at least 25 percent of their original plans and agree to phase out an increased number of beds in previously certified units not already scheduled for phase out under existing correction plans. The timetable for the phase out and the actual number of beds to be phased out will be negotiated with target figures established for each six-month period of the plan. The total time for the plan cannot exceed five years from the effective date of this rule. Facilities are still required to meet the July 18, 1982 deadline for those items in existing plans which include construction or renovation of units that will remain in use after the phase out is completed. The intent of this regulation is to stimulate an overall reduction in the number of certified beds in large residential facilities. We hope that it will forestall further expenditures of capital funds for renovation of existing facilities or construction of new units where an expanded phase out of units is feasible.

This rule sets forth expanded standards for protection of personal funds of patients in skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) that participate in the Medicare or Medicaid programs. The changes are required for SNFs by Section 21(a) of Pub. L. 95-142, the Medicare-Medcaid Anti-Fraud and Abuse Amendments of 1977, and for ICFs by Section 8(c) of Pub. L. 95-292, the End-Stage Renal Disease Amendments of 1978. The intent is to safeguard patient funds from misuse by facilities, and to assure that personal funds held by the the facilities are fully accounted for and made available to patients when they need or want them.

This final rule amends the Medicare and Medicaid regulations to require that the State survey agencies use the survey methods and procedures prescribed by HCFA and forms contained in regulations. The regulations define the principles on which Medicare and Medicaid survey methodologies are based and the required elements of a skilled nursing facility (SNF) or intermediate care facility (ICF) survey. This rule is in response to a court order.

As the number of elderly Americans continues to grow, increased attention is being focused on the field of long term care. This article discusses a variety of recent legal developments affecting providers of long term care, specifically skilled and intermediate level nursing homes. These developments include pending federal legislative initiatives, recent administrative agency decisions from the federal Health Care Financing Administration related to reimbursement and quality of care, and private sector initiatives in the development of long term care insurance. Finally, the article discusses a number of recent judicial decisions of importance to long term care providers.

This rule corrects an oversight by setting forth time limits for new issues that may be considered by an Administrative Law Judge (ALJ) during a hearing afforded a Medicaid skilled nursing facility (SNF) or intermediate care facility (ICF) because the Secretary proposes to cancel its approval under section 1910(c)(1) of the Social Security Act (the Act). This amendment is necessary because current rules do not take account of the fact that hearings under section 1910(c) of the Act (unlike Medicare hearings) may take place before the cancellation is put into effect. The purpose is to establish time limits appropriate to section 1910(c) situations.