Julie Boggess

At one time, I was a nursing home administrator who was “on fire” about the topic of culture change in long-term care. I believed that working to de-institutionalize the institution was the reason I was guided into the industry over 30 years ago.

I was delighted to move up the chain of command from Social Service Assistant, to Director, Assistant Administrator, Executive Director and finally Chief Executive Officer. Each step of the way, I tried to make an impact, no matter how small.

I attended Pioneer Coalition conferences, and early in my tenure as CEO, wrote and received a grant to send several department directors and a board member to the national conference. I felt like I could make a difference and truly impact the culture of my community, and therefore, improve the quality of living for my residents.

It all seemed possible, doable and achievable.

But sadly, things have changed, and not for the better. I made the difficult but necessary decision to exit my leadership position in aging services. My passion for culture change became deeply buried under the weight of the ever-increasing mandates and regulations required by the federal government to operate a long-term care community. All were, we are told, to improve the quality of care of the residents.

I could not overcome the mental struggle of knowing that improved quality of life was more likely to happen with the continued focus on changing the institutional culture versus the intense demands to comply with regulations that invade a facility’s ability to be flexible, customize care and unwind the institutional culture.

Regulations that are so prescriptive that they dictate the exact steps required to comply with the regulation create nothing but an assembly line of care — which is exactly what we are supposed to be fighting against.

I find it baffling that regulations require a facility to operate a “home-like” environment, but then sends surveyors into a facility to pick apart attempts to individualize care. For example, many residents wish to have one side of their twin bed up against a wall to create an increased sense of safety, as well as assist with bed mobility. Upon notification of a surveyor that this was a form of restraint, we had to “undo” the beds that were set up this way to avoid a citation for restraints.

Then that started the tedious process to evaluate the resident, obtain consent, revise the care plan and ensure that documentation from the staff addressed the continued need of the resident.

The paternalistic approach of “we know what is best for you” will only serve to solidify the Institutional care model that seems to be the chosen and preferred method for our societal approach to caring for the frail elderly.

Another sad change is that surveys are no longer about determining substantial compliance.

Surveys are about “catching” facility errors that have nothing to do with quality of life or care. One late assessment in a sample of 30, one date label that fell off a frozen bag of corn will result in a violation.

Harassing a nurse who was 10 minutes behind schedule administering a non-critical medication versus interviewing a resident or family member about how they are being treated is how surveyor time is being spent. We have fallen way off track about the purpose of surveys.

No facility will ever be perfect, yet that seems to be the expectation. And now that expectation comes with real consequences tied to the Five-Star rating system. One over-reaching negative survey can impact a facility’s reputation, despite multiple indicators of quality such as lack of IDPH complaints, high customer satisfaction, lower staff turnover than industry benchmarks, above average staffing and high RN hours.

The federal State Operations manual is over 700 pages. Layer on top of that requirements under state licensure, Life Safety, HIPAA, Corporate Compliance … it is endless and untenable.

Small facilities that do not have a corporate office for regulatory compliance are drowning and spend precious resources on attorneys to defend themselves against rogue surveys.

A gerontology textbook written by Harry Moody and Jennifer Sasser includes the following statement: “A general rule of our legal system is that people are allowed to exercise self-determination, and people have both the right and responsibility to make their own decisions about how they will live, on what they will spend their money, and how they will spend their days. For the most part, people are free to think, speak, and do as they please without interference from our government.”

If this is so, then why can’t a nursing home resident gain 10 pounds without triggering a wave of interventions by the social worker, dietitian and physician and being forced into a weight loss diet? Why can’t a competent assisted living resident be allowed to fall in her apartment without a surveyor citing the facility for a resident rights violation? And why is someone who has always been solitary and independent with their leisure time cajoled daily to attend group activities out of fear that the facility will receive a resident dignity violation?

Our residents are the affected party in this battle, with staff on the verge of hysteria because surveyors are in the building, and administrators who only have the time to write policies and procedures rather than focus on the real activities that will improve their quality of living.

I am sad and angry that I could not find the energy to spend the last 15 years of my career doing the work of a nursing home administrator. This is not just my reality. I speak with many administrators who have already left the field, or question how much longer they can do this work.

I am now turning my efforts to educate and mentor students into the industry. I must find a way to characterize the career of a nursing home administrator in the most positive light, being both realistic and hopeful.

Regulations are needed and should serve as the foundation of quality care and service. But when things like a missing word in a policy or one missed temperature log recording or a date label that fell off a frozen bag of beans is more important than resident and family satisfaction and outcomes of care, there is a serious problem, and it is driving passionate hard-working individuals out of this industry.

The conclusion that propelled me out of this industry is that I, and my staff, were in the quest for quality and culture change alone. The government is nothing but an impediment. I thought the goal was to improve quality care, but if the real goal is to push out good people from the industry, then the government is wildly successful.

Julie Boggess started her 30-year career in aging services on the front line and served the last 15 as Chief Executive Officer at Bethesda Rehab & Senior Care in Chicago. She has been a licensed nursing home administrator since 1990. She served on the Board of Directors for LeadingAge Illinois and chaired its Nursing Facilities cabinet.  She currently is an instructor in Gerontology and Leadership in Aging Services at Northern Illinois University in DeKalb, IL.