Oversight Is a Shared Federal and State Responsibility

The states and the federal government share responsibility for oversight of the quality of care in the nation’s 17,000 nursing homes. Many Nursing Homes Had Deficiencies That Harmed Residents

National data on nursing home surveys for July 1995 to October 1998 showed that the proportion of homes with the most severe deficiencies remained at uncomfortably high levels throughout this period. Furthermore, about 40 percent of the homes found to have serious deficiencies in a survey early in the period were found to have deficiencies of equal or greater severity in a subsequent survey late in the period. One-Fourth of All Homes Had Deficiencies in the Highest Severity Categories

Compliance with nursing home standards of care continued to be a problem during the entire 3-year period we examined. In the two highest severity categories, common deficiencies included inadequate attention to prevent pressure sores, failure to provide supervision or assistance devices to prevent accidents, and failure to assess residents’ needs or provide necessary care. In other words, during the 3-year period, 4 of 10 homes that were found by the base survey to have caused actual or potential death or serious injury or other actual harm to residents had deficiencies (possibly different deficiencies) that were just as severe—or worse—in the most recent inspection. Sanctions Do Not Ensure Nursing Homes Maintain Compliance

To determine the role sanctions play in bringing about a greater degree of compliance, we focused on a sample of 74 homes that had been referred for sanctions. The case histories of these homes showed that sanctions helped bring the homes back into temporary compliance but provided little incentive to keep them from slipping back out of compliance. Many homes corrected their deficiencies after being notified that a sanction would be imposed. In these cases, HCFA rescinded the sanction. Civil monetary penalties, a sanction with strong potential deterrent effect, were hampered by a growing backlog of appeals. Another group of homes that can largely avoid the threat of immediate sanction even though they exhibited a pattern of recurring and serious noncompliance are those that have been terminated from Medicare and subsequently readmitted. Two other aspects of HCFA’s use of termination also limit its effectiveness. The home’s surveys did not document major problems. Recommendations to the Administrator of HCFA

To strengthen its ability to ensure that nursing homes maintain compliance with Medicare and Medicaid quality-of-care standards, we recommend that the Administrator of HCFA take the following actions: Improve the effectiveness of civil monetary penalties. The Administrator should (1) continue Medicare and Medicaid payments beyond the termination date only if the home and state Medicaid agency are making reasonable efforts to transfer residents to other homes or alternate modes of care, (2) ensure that reasonable assurance periods associated with reinstating terminated homes are of sufficient duration to effectively demonstrate that the reason for termination has been resolved and will not recur, and (3) revise existing policies so that the pre-termination history of a home is considered in taking a subsequent enforcement action. However, we did not find that the enforcement process was working as effectively as it should, even for these homes.
Why GAO Did This Study

Pursuant to a congressional request, GAO provided information on the enforcement of federal nursing home standards, focusing on: (1) national data on the existence of serious deficiencies in nursing home compliance with Medicare and Medicaid standards; and (2) the use of sanction authority for homes that failed to maintain compliance with the standards.

What GAO Found

GAO noted that: (1) GAO's work showed that while the Health Care Financing Administration (HCFA) has taken steps to improve oversight of nursing home care, it has not yet realized a main goal of its enforcement process--to help ensure that homes maintain compliance with federal health care standards; (2) surveys conducted in the nation's 17,000-plus nursing homes in recent years showed that each year, more than one-fourth of the homes had deficiencies that caused actual harm to residents or placed them at risk of death or serious injury; (3) the most frequent violations causing actual harm included inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care; (4) although most homes were found to have corrected the identified deficiencies, subsequent surveys showed that problems often returned; (5) about 40 percent of the homes that had such problems in their first survey during the period GAO examined (July 1995 to October 1998) had them again in their last survey during the period; (6) sanctions initiated by HCFA against noncompliant nursing homes were never implemented in a majority of cases and generally did not ensure that the homes maintained compliance with standards; (7) GAO's review of HCFA's survey data combined with GAO's analysis of 74 homes that had a history of problems showed a common pattern; (8) HCFA would give notice to impose a sanction, the home would correct its deficiencies, HCFA would rescind the sanction, and a subsequent survey would find that problems had returned; (9) the threat of sanctions appeared to have little effect on deterring homes from falling out of compliance again because homes could continue to avoid sanctions' effect as long as they kept correcting their deficiencies; (10) HCFA has some tools to address this cycle of repeated noncompliance but has not used them effectively; (11) fines are potentially a strong deterrent because they can be applied even if a home comes back into compliance; (12) however, the usefulness of civil monetary penalties is being hampered by a backlog of administrative appeals coupled with a legal provision that prohibits collection of the penalty until the appeal is resolved; (13) the sanction is often delayed for several years; and (14) GAO also found problems with several aspects of HCFA's policies for ensuring that sufficient attention is placed on homes that have serious deficiencies or a history of recurring noncompliance as well as policies for reinstating homes that have been terminated from the Medicare and Medicaid programs.