Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016
Introduction
Genworth Financial. (2017). Annual Median Cost of Long Term Care in the Nation, 2016. Available at: https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.html.
Centers for Medicare & Medicaid Services. National Health Expenditures Accounts, Historical Data. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
Institute of Medicine (IOM), Committee on Nursing Home Regulation (1986). Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press, 1-44.
U.S. General Accounting Office (US GAO, 1987). Report to the Chairman, Subcommittee on Health and Long-Term Care, Select Committee on Aging, House of Representatives. Medicare and Medicaid: Stronger Enforcement of Nursing Home Requirements Needed. Washington, DC: US GAO.
Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987), Subtitle C: Nursing Home Reform, 42 U.S.C. § 1396r (2012).
Wiener, J.M., Freiman, M.P. and Brown, D. (2007). Nursing Home Quality: Twenty Years after the Omnibus Budget Reconciliation Act of 1987. Report prepared by RTI International. Washington, DC: Kaiser Family Foundation.
Morris, J., et al. (1990). Designing the National Resident Assessment Instrument for Nursing Homes. The Gerontologist. 30 (3):293-307.
Wells, J. and Harrington, C. (2013). Implementation of Affordable Care Act Provisions to Improve Nursing Home Transparency, Care Quality, and Abuse Prevention. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. https://www.kff.org/medicaid/report/implementation-of-affordable-care-act-provisions-to-improve-nursing-home-transparency-care-quality-and-abuse-prevention/
81 Fed. Reg. 68688-68872 (October 4, 2016), available at https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities
Boccuti, C. Casillas, G., Neuman, T. (2015). Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State. (Washington, DC: Kaiser Family Foundation), Available at: https://www.kff.org/report-section/reading-the-stars-nursing-home-quality-star-ratings-nationally-and-by-state-issue-brief/
Abt Associates. Further Improvements to the Nursing Home Compare Five-Star Quality Rating System. March 3, 2016. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf
U.S. Centers for Medicare and Medicaid Services. (2014). Nursing Home Data Compendium 2013. Baltimore, MD: CMS. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/nursinghomedatacompendium_508.pdf
Facility Characteristics
Centers for Medicare and Medicaid Services (CMS). (2016). Nursing home data compendium 2015 edition. Baltimore, MD: CMS. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/index.html
Harrington, C., Mullan, J. and Carrillo, H. (2004). State Nursing Home Enforcement Systems. J. of Health Politics, Policy, and Law. 29 (1): 43-73.
Grabowski, D. and Angelelli, J.J. (2004). The Relationship of Medicaid Payment Rates, Bed Constraint Policies, and Risk-Adjusted Pressure Ulcers. Health Services Research. 39 (4):793-812.
Grabowski and Angelelli 2004.
Grabowski, D. (2001). Medicaid Reimbursement and the Quality of Nursing Home Care. Journal of Health Economics. 20:549-569.
Grabowski, D.C. and Castle, N.G. (2004). Nursing Homes with Persistent High and Low Quality. Medical Care Research and Review. 61 (1): 89-115.
Mor, V., J. Zinn, J. Angelelli, J.M. Teno, and S.C. Miller. (2004). Driven to Tiers: Socioeconomic Factors and Racial Disparities in the Quality of Nursing Home Care. Milbank Quarterly. 82(2): 227-56.
Comondore, V.R, Devereaux, P.J., Zhou, Q. et al. (2009). Quality of Care in For-Profit and Not-For Profit Nursing Homes: Systematic Review and Meta-analysis. British Medical Journal. Aug 4; 339.
Hillmer, M.P., W.P. Wodchis, S.S. Gill, G.M. Anderson, and P.A. Rochon, 2005. Nursing Home Profit Status and Quality of Care: Is There Any Evidence of an Association? Medical Care Research and Review. 62 (2):139-166.
Harrington, C., Olney, B, Carrillo, H., and Kang, T. 2012. Nurse Staffing and Deficiencies in the Largest for-Profit Chains and Chains Owned by Private Equity Companies. Health Services Research, 47 (1), Part I: 106-128.
Harrington, C., Mullan, J. and Carrillo, H. (2004). State Nursing Home Enforcement Systems. J. of Health Politics, Policy, and Law. 29 (1): 43-73.
Hamann, D.J. (2014) Does empowering resident families or nursing home employees in decision making improve service quality? J. of Applied Gerontology. 33:603-23.
Resident Characteristics
Medicare Payment Advisory Commission (MedPac). (2014). Report to Congress: Medicare Payment Policy. Skilled Nursing Facility Services, Chapter 8. Washington, DC: MedPac, March, 185-208.
Borza T, Engedal K, Bergh S, Barca ML, Benth JŠ, Selbæk G. (2015). The course of depressive symptoms as measured by the Cornell scale for depression in dementia over 74 months in 1158 nursing home residents. J Affect Disord. 2015 Apr 1;175:209-16.
Chiu, Y., Bero, L., Hessol, N. Lexchin, J. and Harrington, C. (2015). A Review of Clinical Outcomes Associated with Antipsychotic Medication Use in Nursing Home Residents. Health Policy. In press.
Gastmans, C., Milisen, K. (2006). Use of physical restraint in nursing homes: clinical‐ethical considerations. J Medical Ethics, 32(3): 148–152.
Centers for Medicare & Medicaid Services, Center for Medicaid and State Operations/Survey and Certification Group. (2008). Memorandum: Release of Report: “Freedom from Unnecessary Physical Restraints: Two Decades of National Progress in Nursing Home Care.” Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter09-11.pdf
Castle, N. (1998) Physical Restraints in Nursing Homes: A Review of the Literature Since the Nursing Home Reform Act of 1987. Medical Care Research and Review, 55(2): 139-70.
Staffing Levels
Institute of Medicine (IOM), Page, A., Eds. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy of Sciences, IOM.
Bostick, J.E., Rantz, M.J., Flesner, M.K. & Riggs, J.C. (2006). Systematic Review of Studies of Staffing and Quality in Nursing Homes. J. American Medical Directors Association. 7 (6):366-76.
Castle, N., (2008). Nursing home caregiver staffing levels and quality of care: A literature review. Journal of Applied Gerontology, 27: 375-405.
Dellefield, M.E., Castle, N.G., McGilton, K.S., and Spilsbury, K. (2015). The Relationship Between Registered Nurses and Nursing Home Quality: An Integrative Review (2008-2014). Nursing Economics$. 33 (2):95-116.
Schnelle, J.F., Simmons S.F., Harrington, C., Cadogan, M., Garcia, E., and Bates-Jensen, B. (2004). Relationship of Nursing Home Staffing to Quality of Care? Health Services Research. 39 (2):225-250.
Spilsbury, K., Hewitt, C., Stirk, L. & Bowman, C. (2011). The Relationship Between Nurse Staffing and Quality of Care in Nursing Homes: A Systematic Review. International Journal Nursing Studies, 48(6), 732–750.
U.S. Centers for Medicare and Medicaid Services, Prepared by Abt Associates. (2001). Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final. Volumes I-III., MD: CMS.
Bowblis, J.R. (2011). Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes. Health Services Research, 46(5): 1495-516.
Harrington, C., Swan, J.H., and Carrillo, H. (2007). Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities. Health Services Research, 42: 1105-1129.
Mukamel, D.B., Weimer, D.L., Harrington, C., Spector, W.D., Ladd, H., and Li, Y. (2012). The Effect of State Rregulatory Stringency on Nursing Home Quality. Health Services Research, 47(5):1791-813.
Park, J., & Stearns, S.C. (2009). Effects of State Minimum Staffing Standards on Nursing Home Staffing and Quality of Care. Health Services Research, 44(1), 56–78.
Institute of Medicine (IOM), Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. (1996). Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Washington, DC: National Academy Press.
Institute of Medicine (IOM), Wunderlich, G.S. and Kohler, P., Eds. 2001. Improving the Quality of Long-Term Care. Washington, DC: National Academy of Sciences, IOM.
Institute of Medicine (IOM), Page, A., Eds. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy of Sciences, IOM.
Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., et al. (2000). Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the United States. The Gerontologist. 40 (1): 5-16.
U.S. Centers for Medicare and Medicaid Services, Prepared by Abt Associates. (2001). Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. Report to Congress: Phase II Final. Volumes I-III., MD: CMS.
Edelman, T. (2014). Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned. Washington, CD: Center for Medicare Advocacy. http://www.medicareadvocacy.org/staffing-deficiencies-in-nursing-facilities-rarely-cited-seldom-sanctioned/
Schnelle, J.F., Simmons S.F., Harrington, C., Cadogan, M., Garcia, E., and Bates-Jensen, B. (2004). Relationship of Nursing Home Staffing to Quality of Care? Health Services Research. 39 (2):225-250.
Harrington, C. (2005). Nurse Staffing in Nursing Homes in the United States. Part II. J. of Gerontological Nursing. 31 (3): 9-15.
Facility Deficiencies
U.S. Centers for Medicare and Medicaid Services (CMS). (2015a). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 133, 02-06-15. Baltimore, MD. Accessed June 24, 2015. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
U.S. Centers for Medicare and Medicaid Services (CMS). (2015a). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 133, 02-06-15. Baltimore, MD. Accessed June 24, 2015. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
U.S. Centers for Medicare and Medicaid Services (CMS). (2015b). State operations manual. Chapter 7. Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities. Accessed June 24, 2015. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf
Discussion
Genworth Financial. (2017). Annual Median Cost of Long Term Care in the Nation, 2016. Available at: https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.html.
Jacobson, G., T. Neuman, and M. Musumeci. (2017). What Could a Medicaid Per Capita Cap Mean for Low-Income People on Medicare? (Washington, DC: Kaiser Family Foundation). https://www.kff.org/medicare/issue-brief/what-could-a-medicaid-per-capita-cap-mean-for-low-income-people-on-medicare/
Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., et al. (2000). Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the United States. The Gerontologist. 40 (1): 5-16.
Grabowski, D. (2001). Medicaid Reimbursement and the Quality of Nursing Home Care. Journal of Health Economics. 20:549-569.
Grabowski, D. and Angelelli, J.J. (2004). The Relationship of Medicaid Payment Rates, Bed Constraint Policies, and Risk-Adjusted Pressure Ulcers. Health Services Research. 39 (4):793-812.
Grabowski, D.C. and Castle, N.G. (2004). Nursing Homes with Persistent High and Low Quality. Medical Care Research and Review. 61 (1): 89-115.
Harrington, C., Swan, J.H., and Carrillo, H. (2007). Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities. Health Services Research, 42: 1105-1129.
Appendix
U.S. Centers for Medicare and Medicaid Services (CMS). (2015a). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 133, 02-06-15. Baltimore, MD. Accessed June 24, 2015. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
U.S. Centers for Medicare and Medicaid Services. (2014). Nursing Home Data Compendium 2013. Baltimore, MD: CMS. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/nursinghomedatacompendium_508.pdf
Centers for Medicare and Medicaid Services. (2015). Medicare nursing home compare. http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1 See website data on www.Medicare.data.gov
U.S. General Accounting Office (US GAO) (1988). Report to the Chairman, Subcommittee on Health and Long-Term Care, Select Committee on Aging, House of Representatives. Medicare: Improved Patient Outcome Analysis Could Enhance Quality Assessment. Washington, DC: US GAO.
U.S. General Accounting Office (US GAO) (1999a). Report to the Special Committee on Aging, U.S. Senate. Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards. Report No. US GAO/HEHS-99-46. Washington, DC: US GAO.
U.S. General Accounting Office. (1999). Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-99-80. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (1999). Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-00-6. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (1999). Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes Has Merit. Report to the Special Committee on Aging, U.S. Senate. GAO/HEHS-99-157. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (US GAO) (2000). Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-00-197. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (US GAO) (2004). Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight. Report to Congressional Requesters, U.S.Senate. US GAO/HEHS-03-561. Washington, DC: U.S. General Accounting Office.
U.S. Government Accountability Office (GAO) (2007). Nursing Home Reform: Continued Attention is Needed to Improve Quality of Care in Small but Significant Share of Homes. GAO-07-794T, Washington, DC: GAO, May 2, 2007.
U.S. Government Accountability Office (GAO) (2009). Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weakness. GAO-08-517, Washington, DC: GAO, May 9, 2009.
U.S. Government Accountability Office (GAO) (2009). Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC: GAO, February 13, 2009.
U.S. General Accounting Office (US GAO) (1988). Report to the Chairman, Subcommittee on Health and Long-Term Care, Select Committee on Aging, House of Representatives. Medicare: Improved Patient Outcome Analysis Could Enhance Quality Assessment. Washington, DC: US GAO.
U.S. Centers for Medicare and Medicaid Services (CMS). (2015). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 133, 02-06-15. Baltimore, MD. Accessed June 24, 2015. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
U.S. Centers for Medicare and Medicaid Services (CMS). (2015). Review and Status of Nursing Home Survey: Summary of Traditional and Quality Indicator Survey (QIS) Findings and Issues. Accessed June 24, 2015.
Harrington, C., Mullan, J. and Carrillo, H. (2004). State Nursing Home Enforcement Systems. J. of Health Politics, Policy, and Law. 29 (1): 43-73.
U.S. General Accounting Office (US GAO) (1999). Report to the Special Committee on Aging, U.S. Senate. Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards. Report No. US GAO/HEHS-99-46. Washington, DC: US GAO.
U.S. General Accounting Office. (1999). Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-99-80. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (1999). Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-00-6. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (1999). Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes Has Merit. Report to the Special Committee on Aging, U.S. Senate. GAO/HEHS-99-157. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (US GAO) (2000). Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-00-197. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (US GAO) (2004). Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight. Report to Congressional Requesters, U.S. Senate. US GAO/HEHS-03-561. Washington, DC: U.S. General Accounting Office.
U.S. Government Accountability Office (GAO) (2007). Nursing Home Reform: Continued Attention is Needed to Improve Quality of Care in Small but Significant Share of Homes. GAO-07-794T, Washington, DC: GAO, May 2, 2007.
U.S. Government Accountability Office (GAO) (2009). Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weakness. GAO-08-517, Washington, DC: GAO, May 9, 2009.
U.S. Government Accountability Office (GAO) (2009). Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC: GAO, February 13, 2009.
U.S. Office of the Inspector General, Department of Health and Human Services (USOIG). (2004). Nursing Home Deficiency Trends and Survey and Certification Process Consistency. OEI-02-01-00600. Washington, DC: Inspector General.
U.S. Office of the Inspector General (US OIG). (2013). Medicare nursing home resident hospitalization rates merit additional monitoring. OEI-06-11-00040. November. Washington, DC: OIG.
U.S. Office of the Inspector General, Department of Health and Human Services (USOIG). (2004). Nursing Home Deficiency Trends and Survey and Certification Process Consistency. OEI-02-01-00600. Washington, DC: Inspector General.
U.S. General Accounting Office. (1999b). Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-99-80. Washington, DC: U.S. General Accounting Office.
U.S. Government Accountability Office (GAO) (2007). Nursing Home Reform: Continued Attention is Needed to Improve Quality of Care in Small but Significant Share of Homes. GAO-07-794T, Washington, DC: GAO, May 2, 2007.
U.S. Government Accountability Office (GAO) (2009). Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weakness. GAO-08-517, Washington, DC: GAO, May 9, 2009.
U.S. Government Accountability Office (GAO) (2009). Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC: GAO, February 13, 2009.
U.S. Office of the Inspector General (US OIG). (2013). Medicare nursing home resident hospitalization rates merit additional monitoring. OEI-06-11-00040. November. Washington, DC: OIG.
U.S. Office of the Inspector General (US OIG). (2014). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. OEI-06-11-00370. February. Washington, DC: OIG.
Walshe, K. and Harrington, C. (2002). The Regulation of Nursing Facilities in the US: An Analysis of the Resources and Performance of State Survey Agencies. The Gerontologist. 42 (4):475-486.
U.S. General Accounting Office. (US GAO) (2000). Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. Report to the Special Committee on Aging, U.S. Senate. US GAO/HEHS-00-197. Washington, DC: U.S. General Accounting Office.
U.S. General Accounting Office. (US GAO) (2004). Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight. Report to Congressional Requesters, U.S.Senate. US GAO/HEHS-03-561. Washington, DC: U.S. General Accounting Office.
Morris, J., et al. (1990). Designing the National Resident Assessment Instrument for Nursing Homes. The Gerontologist. 30 (3):293-307.
U.S. Centers for Medicare and Medicaid Services. (2014). MDS quality measures/indicator report. MDS 2.0. http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MDSPubQIandResRep/qmreport.html Accessed January 3, 2015.
Saliba, D., Jones, M., Streim, J., Ouslander, J., Berlowitz, D. and Buchanan, J. (2012). Overview of Significant Changes in the Minimum Data Set for Nursing Homes Version 3.0. J. American Medical Directors Association, 13 (7):595-601.
U.S. Centers for Medicare and Medicaid Services (CMS). (2012). Minimum data set 3.0 RAI manual. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
Medicare Payment Advisory Commission (MedPac). (2014). Report to Congress: Medicare Payment Policy. Skilled Nursing Facility Services, Chapter 8. Washington, DC: MedPac, March, 185-208.
Fries, B.E. and Cooney, L. (1985). Resources Utilization Groups: A Patient Classification System for Long-term Care. Health Care Financing Review. 23 (2):110-122.
Fries, B.E., Schneider, D., Foley, W., and Dowling, M. (1989). Case-mix Classification of Medicare Residents in Skilled Nursing Facilities. Medical Care. 9:843-858.
Fries, B.E., Schneider, D., Foley, W., Gavazzi, M., Burke, R., and Cornelius, E. (1994). Refining a Case-mix Measure for Nursing Homes: Resources Utilization Groups (RUGS-III). Medical Care. 32 (7):666-685.
Centers for Medicare and Medicaid Services (CMS). (2014). CMS announces two Medicare quality improvement initiatives. October 6, 2014. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-10-06.html.
U.S. Centers for Medicare and Medicaid Services (CMS). (2015). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 133, 02-06-15. Baltimore, MD. Accessed June 24, 2015. http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
U.S. Centers for Medicare and Medicaid Services (CMS). (2015). State operations manual. Chapter 7. Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities. Accessed June 24, 2015. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c07.pdf