The surveyors determine the level of compliance with each of the federal requirements through the survey process. Deficiencies are issued for standards of care not met. Deficiencies are divided into resident-centered and facility-centered. A dietary food handling violation would be a facility-related deficiency. Resident-centered requirements must be met for every resident regardless of whether that resident is receiving Medicare or Medicaid reimbursement for care or any payor source. The deficiencies are reportable outcome measures applied by the surveyors to care given in the facility. The surveyors use the Scope and Severity grid in judging the seriousness of each deficiency issued to a facility. For each deficiency, the surveyor determines the level of harm to the resident or resident(s) involved and the scope of the problem within the nursing facility. The Scope and Severity matrix is an integral part of how nursing facility scores are calculated in the scoring system.

A nursing facility’s ability to survive economically is affected by an increasing variety of pressures, such as federal and state reimbursement policies, the types of services offered by the facility, and resident payment sources. Over the past decades, government regulators who pay for the care of Medicare and Medicaid residents in nursing facilities have sought ways to narrow the margin of facility profit to achieve mandated government cost savings. The nursing facility is in the business of marketing services. Marketing employs the management techniques, using a vocabulary explicitly developed for the field of marketing. Without marketing, a facility will most likely close its doors. The federal government and surveyors are among your most important customers. This section helps the reader to understand the forces leading to the intense competition among facilities. It also explains how healthcare marketing is evolving.

The Patient Protection and Affordable Care Act (PPACA) that was commonly called the Affordable Care Act (ACA), or “Obamacare”, was a U.S. federal statute signed into law by President Barack Obama on March 23, 2010. The ACA was enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce healthcare costs for individuals and the government. The law also required insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of preexisting conditions or sex. The ACA continued a trend of shifting Medicaid and Medicare spending toward greater home- and community-based services care and away from skilled nursing care reimbursement. The offerings are similar in all states, but the benefits are state-specific as it is a Medicaid outreach program.

Reimbursements from Medicare and Medicaid account for well over half of the typical nursing facility cash flow. This section discusses the Social Security Act (Medicare and Medicaid), and the Medicaid concepts such as spend down and buy-in agreements. Medicaid and Medicare were both passed as amendments to the Social Security Act. Medicare has been essentially an insurance program for recipients of Social Security benefits. Medicaid has not been insurance; as designed, it has been medical aid for persons receiving assistance (formerly referred to as “welfare”) and for comparable groups of persons defined as medically indigent. Licensed nursing facilities may apply to be certified for participation in the Medicare and/or Medicaid program voluntarily. Facilities may participate in (a) the Medicaid only program, (b) the Medicare only program, or (c) in the Medicare/Medicaid dually certified program.

The care given in the nursing facility takes place as part of the continuum of long-term care and the broader healthcare system. This section provides background on the nursing facility industry and information on several of the laws of which the administrator must be aware while operating a facility. The nursing facility is part of a continuum of caregiving. The section provides information about other providers in the healthcare field. The everyday life of the facility takes place within the rules set by Medicare and Medicaid, labor laws, occupational safety laws, the Life Safety Code, and the Americans with Disabilities Act Accessibility Guidelines for facilities. The nursing facility resident population is heavily dependent on the nursing facility staff, especially the nursing assistants. The section details some of the outside groups and organizations that may directly or indirectly impact the lives of nursing facility administrators.

Health promotion, exercise, and the need to focus on these to enhance a healthy long life are discussed. Identification of significant areas of health promotion and barriers to achieving good health are presented. Next, disease prevention along with primary, secondary, tertiary, and quaternary preventive measures are listed. Healthy People 2030, the fifth national health initiative, and its objectives are outlined along with the Patient Protection and Affordable Care Act. Exercise, its meaning, and value in modifying age-related changes are briefed. Types of exercise programs; isometric, isotonic, and aerobic and their recommended use by older adults are listed.

Room changes may present controversies for social workers for a variety of reasons. Over time, the room and the staff become familiar to the resident and the resident’s family. When rehabilitation is complete and residents remain long term, they are often reluctant to shift to another room even within the same facility because of their familiarity with the physical location and association with the staff. However, most facilities have specific areas for short- and long-term stays. The reasons for this vary, but primarily, rooms that are used for short-term stays may not have the same features as those used for long-term stays. Additional reasons for a room change can include the following: moving a resident because of a medical condition (e.g., infection or precautions) that indicates a need for isolation or more observation; moving a resident at the request of either the resident or the family; moving a resident in order to access a particular section of the facility, such as a specialized Alzheimer’s Unit; moving a resident to support a facility administrative need; and moving a resident because of a change in the status of payment.

Funeral arrangements are often difficult for people in our culture to discuss. Indeed, for many, the issue of dying and death and the process of making decisions around a person’s death are almost taboo. During the admissions process, social workers can address the topic of funeral arrangements as a general issue. The simple question “Have you, or the resident, a preference for a funeral home?” can open the door to discussions of end-of-life decisions, as well as reveal tensions over illness, loss, and dying. The social worker can assist the family with addressing funeral arrangement issues by discussing the Medicaid application where prepaid funeral arrangements can be an allowable expense. Social workers in nursing facilities are in a prime position to help residents and their families around this key advanced directive issue, and this chapter outlines the key elements of funeral arrangements and other issues related to death in the nursing facility.

The focus of all good care is to determine need. Long-term care (LTC) is not an extension of acute care—it is distinctive in its very nature. Because LTC continues for prolonged periods, it becomes enmeshed in the very fabric of people’s lives. Screening for LTC is one way in which the federal government and, in particular, a state attempts to eliminate unnecessary or premature placement of older or disabled individuals in nursing homes. There are two types of screening: those for a level of care (LOC) involving just medical need and those that address additional factors of care need, which assess issues such as mental illness, development disabilities, and intellectual disabilities. The determination of LOC addresses whether the individual’s care needs meet criteria for a stay in a nursing facility long term. This chapter provides an overview of long-term care screenings and how the Omnibus Budget Reconciliation Act (OBRA) has and continues to impact this process.

The field of health promotion has come a long way since it was initially defined as exercise, nutrition, and smoking cessation. Moreover, older adults were typically excluded from early writings on health promotion and disease prevention. They were old after all, perhaps resistant to change and without much of a future. Health promotion and aging now covers dozens of topics. Health professionals need to be careful about defining good health among older adults. Health promotion is a more proactive approach than primary prevention, which tends to imply a reaction to the prospect of disease. Directing a client’s anger or frustration into political advocacy work is a proactive, health-promoting enterprise that benefits both the individual and society. Medicare, Medicaid, and Social Security have had a tremendous impact on health. It is important, therefore, to review these legislative acts, as many people do not even understand the difference between Medicare and Medicaid.