Some States’ Policies or Practices Limit the Filing of Complaints or Quick Response

Some states have practices that may limit the number of complaints that are filed and investigated. Michigan met its time frames in about one-fourth of cases. Application of Sanctions Does Not Ensure Nursing Homes Maintain Compliance

On the basis of of our analysis of nationwide survey data, we found that more than one in four nursing homes had serious and often repeated deficiencies that resulted in immediate jeopardy or actual harm to residents. While HCFA’s initiation of actions typically brought homes into at least temporary compliance, they were often ineffective in ensuring that homes maintained compliance over time with federal standards. Our review of 74 homes that states had referred to HCFA for federal enforcement action, as a result of serious or uncorrected deficiencies, showed that the threat of sanctions often helped bring the homes back into temporary compliance but provided little incentive to keep them from slipping back out of compliance. Because many homes corrected their deficiencies before the effective date of the sanction, HCFA often rescinded the sanction before it took effect. This yo-yo pattern of compliance and noncompliance could be found even among homes that were terminated from Medicare, Medicaid, or both. Within 5 months, state surveyors again identified a series of deficiencies involving harm to residents, including failure to prevent avoidable pressure sores or ensure that residents received adequate nutrition. Further HCFA Oversight and Enforcement Needed

Given these weaknesses in many states’ complaint practices and the current inadequacy of enforcement actions to maintain homes’ compliance with federal standards, one would expect HCFA to be more proactive in overseeing states and enforcing sanctions when nursing homes do not maintain compliance with its standards. HCFA, however, has exercised limited oversight or guidance of states’ complaint practices. Since July 1998, HCFA has taken or proposed several initiatives to improve nursing home oversight. The problem with terminations is twofold. Conclusions and Recommendations

As the Congress, HCFA, and the states seek to better ensure adequate quality of care for nursing home residents, our work has demonstrated that key components of complaint investigations and enforcement actions need to be strengthened to better protect the growing number of elderly and disabled Americans who rely on nursing homes for their care–one of the nation’s most vulnerable populations. Absent such improvements, many federal and state policies and practices continue to result in serious complaints—which allege harm to residents—not being investigated for weeks or months. Broadly, these recommendations call for HCFA to develop additional standards for the prompt investigation of serious complaints and strengthen its oversight of state complaint investigations; improve the effectiveness of enforcement actions, including reducing the backlog of appeals of civil monetary penalties; and strengthen policies regarding terminated homes, such as requiring reasonable assurance periods of sufficient duration and maintaining the home’s pretermination history; and develop better management information systems to integrate the results of complaint investigations, track the status and history of deficiencies, and monitor enforcement actions.
Why GAO Did This Study

Pursuant to a congressional request, GAO discussed the effectiveness of complaint and enforcement practices to protect nursing home residents, and to ensure that homes participating in Medicare and Medicaid comply with federal standards, focusing on the: (1) effectiveness of states' complaint practices in protecting residents; (2) Health Care Financing Administration's (HCFA) role in establishing standards and conducting oversight of states' complaint practices and in using information about the results of complaint investigations to ensure compliance with nursing home standards; and (3) assessment of HCFA's use of sanction authority for homes that failed to maintain compliance with these standards.

What GAO Found

GAO noted that: (1) neither complaint investigations nor enforcement practices are being used effectively to ensure adequate care for nursing home residents; (2) as a result, allegations or incidents of serious problems often go uninvestigated and uncorrected; (3) GAO's work in selected states reveals that, for serious complaints alleging harm to residents, the combination of inadequate state practices and limited HCFA guidance and oversight have often resulted in: (a) policies or practices that may limit the number of complaints filed; (b) serious complaints alleging harmful situations not being investigated promptly; and (c) incomplete reporting on nursing homes' compliance history and states' complaint investigation performance; (4) further, regarding enforcement actions, HCFA has not yet realized its main goal--to help ensure that homes maintain compliance with federal health care standards; (5) GAO found that too often there is a yo-yo pattern where homes cycle in and out of compliance; (6) more than one-fourth of the more than 17,000 nursing homes nationwide had serious deficiencies--including inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care--that caused actual harm to residents or placed them at risk of death or serious injury; (7) although most homes corrected deficiencies identified in an initial survey, 40 percent of these homes with serious deficiencies were repeat violators; (8) in most cases, sanctions initiated by HCFA never took effect; (9) the threat of sanctions appeared to have little effect on deterring homes from falling out of compliance because homes could continue to avoid the sanctions' effect as long as they kept temporarily correcting their deficiencies; and (10) HCFA has taken a number of recent actions to improve nursing home oversight in an attempt to resolve problems pointed out in earlier studies.