Summary: Description, terms, and links to these early surveys of the structure and characteristics of nursing and personal care homes.
The Master Facility Inventory (MFI) Survey was conducted by the National Center for Healthcare Statistics (NCHS) in 1963, 1967, 1969, 1971, 1973, and 1976 to count nursing and personal care homes. A more detailed survey of nursing homes was conducted in 1968. The Resident Places Survey (RPS) was conducted in by NCHS in 1963, 1964, and 1969 to obtain detailed information.
One of the problems designers of the surveys had was in defining what constituted a "nursing home". They settled on four classifications: nursing care homes, personal care with nursing homes, personal care homes, and domiciliary homes, and decided to count all facilities with 3 or more beds. The places they identified were grouped using the following categories:
- Nursing care home
- Nursing care is the primary and pre-dominant function of the facility. Facilities were counted in this category if one or more registered nurses or licensed practical nurses were employed, and 50%+ of the residents received nursing care during the week prior to the survey.
- Personal care home with nursing
- Personal care is the primary and predominant function of the facility but some nursing care is also provided. Facilities were counted in this category if either one of the following is true:
- Some but less than 50% of the residents received nursing care during the week prior to the survey and there was one or more registered professional or licensed practical nurses on the staff.
- Some of the residents received nursing care during the week prior to the survey, no registered nurses or licensed practical nurses were on the staff, but one or more of the following conditions were met:
- Medications and treatments were administered in accordance with physicians orders.
- Supervision over self-administered medications was provided.
- Three or more personal services were routinely provided.
- Personal care home
- The primary and predominant function of the facility is personal care, and no residents received nursing care during the week prior to the survey. Facilities were counted in this category, even if there were nurses on staff, if they meet either one of the following.
- Medications and treatments were administered in accordance with physicians orders, or supervision over medication which may be self-administered was provided.
- Three or more of the criterion personal services were routinely provided.
- Domiciliary care home
- The primary and predominant function of the facility is domiciliary care but has a responsibility for providing some personal care. If the criteria for a nursing care home or personal care home were not met but one or two of the criterion personal services were routinely provided, it was classified as a domiciliary care home.
The "personal care home" classification more nearly resembles what we today call "assisted living" and the "domiciliary care home" is more of a board and care home, neither of which are included in modern statistics about nursing homes. To make things even more confusing, in later reports, the term "nursing home" sometimes refers to the first two categories combined, and in other reports only homes in the first category are counted as "nursing homes" and all three of the lower categories are grouped together as "personal care and other homes".
Another problem in early surveys was making sure that all facilities had been identified and counted. The federal government provided no certification or oversight to the industry, so there was no "master list" to refer to. The surveyors relied partly on information provided by the state licensing bureaus, but the states all had different standards for licensing homes, and some of them had little or no information in their own files. For several years after the surveys were initiated, reports analyzing the data emphasized that there was no way to be sure whether facilities that appeared for the first time on a new survey were actually new nursing homes, or whether they had just been omitted from earlier reports.
The first ever national inventory of nursing homes was done in 1954. When the first survey was tabulated, it was estimated that there were about 270,000 people living in 9,000 homes classified as "nursing care home" or "personal care home with nursing". Virtually all the homes were for-profit facilities -- 86% of all nursing homes were proprietary, 10% were voluntary, and only 4% were public.
An overview of state regulations for nursing and care homes prior to the enactment of Medicare and Medicaid in 1965, and the difficulty of getting an accurate count can be seen from this excerpt from a 1968 report describing the problems of trying to inventory nursing homes in the nation.
Homes for the Aged
The major problem in the [Agency Reporting System] ARS lies in the area of homes for the aged providing personal care. This area is difficult to evaluate since the State licensure requirements vary considerably when differentiating between homes providing some kind of nursing skill and other facilities considered to be Â“boarding homes.Â” The definition of an institution as used in the [Master Facility Inventory] MFI requires that the facility provide something more than just room and board. This discrepancy between the national and State definitions leaves several facilities in a borderline area. To insure that the coverage of the MFI is complete, these borderline cases have been included, at least until they are proved to be out of scope through the MFI questionnaire.
Idaho, South Carolina, and West Virginia do not license personal care homes and have no regulatory program for those facilities defined as less than Â“skilled Â”nursing homes. With the exception of Idaho which lists seven so-called boarding homes in their files, these States exclude those facilities which provide personal and/or custodial care from their lists. The coverage gap in this type of facility is estimated as quite large, West Virginia estimates the number of such facilities in the State at approximately 500 to 600.This estimate may be too large, however, since it may include boarding homes providing nothing more than room and board. South Carolina and Idaho (with the exception of the seven facilities listed on their schedules) did not provide estimates of the number of facilities which maybe in the State.
The literature of the national voluntary organizations in the area of homes for the aged is limited in that most of the lists are published by various denominations and include only facilities which are under those particular religious auspices. If the required information about homes for the aged in these three problem States is to be obtained from these sources, a time-consuming search of these numerous publications would be involved. Even if this were done, the list would not be complete because many proprietary facilities would be missed since facilities under religious auspices are usually nonprofit.
The national listing used to evaluate the undercoverage of homes for the aged was the "Directory of Nonprofit Homes for the Aged, 1962.Â” This source is not complete in listing facilities of this type. An example of the undercoverage can be seen in West Virginia. The schedule received from this State reports an estimate of 500 to 600 personal care homes. Excluding those facilities classified as nursing homes, the directory reports only two nonprofit homes for the aged in West Virginia. This discrepancy between the State estimate and the directory is large enough to throw doubt on both the estimate and the completeness of the directory. Likewise, the directory reports three establishments each for Idaho and South Carolina. It seems unreasonable that States of this size could have as few as three facilities providing personal care for the aged, even considering that the directory lists only non- profit homes.
Included in the report submitted by SRC is the recommendation that a one-time census in these States be made to identify the personal care homes. Because of the large cost of such an undertaking, it could be justified only if there were a large number of facilities in these States. However, West Virginia is the only State providing an estimate of facilities. Since there is no complete national listing it is impossible to give a meaningful estimate of the number of facilities in Idaho and South Carolina. Therefore action on this recommendation has been deferred until more information is available.
California posed a unique problem with regard to homes for the aged. The licensure program at the State level includes only those facilities of 16 beds or more. The control of all smaller facilities is relegated to the counties. A special survey letter was sent to each county requesting a listing of homes for the aged with fewer than 16 beds. The survey resulted in the addition of more than 3,000 facilities to the MFI and the elimination of this particular coverage gap in California.
Three additional States posed problems of a lesser nature. Kansas does not license either church-owned nursing homes or personal care homes. The State estimates that approximately 17 facilities of this type exist in the State. When the Â“Directory of Nonprofit Homes for the Aged Â” was checked, no facilities falling into this category were identified. To discover these 17 facilities it may be necessary to check the many listings of religious organizations. However, these facilities might also be found in the State Board of Health files and a followup inquiry to the State could be fruitful.
Nebraska reported that its licensing program excludes fraternal homes and estimates that two facilities fall into this gap. Connecticut does not license municipal homes for the aged. Neither the two facilities estimated by Nebraska nor the three municipal facilities estimated by Connecticut were identified in the directory. For total estimations in this area it will be necessary to accept those made by the States.
From: The Agency Reporting System for Maintaining the National Inventory of Hospitals and Institutions. April 1968. 19 pp. (PHS) 1000. PB-262955. PC A03 MF A01.