As part of this role, DHS (1) licenses nursing homes to do business in California; (2) certifies to the federal government, by conducting reviews of nursing homes, that the homes are eligible for Medicare and Medicaid payment; and (3) investigates complaints about care provided in the licensed homes. Serious Care Problems Found in Many Nursing Homes Reviewed

The work of our expert nurses indicates that some of California’s nursing home residents who died in 1993 received unacceptable care that, in certain cases, endangered their health and safety. Their deaths were alleged to have been caused by unacceptable nursing home care. State’s Quality Reviews Show Substantial Care Problems Occurring Today

DHS surveyors identified a substantial number of homes with serious care problems through their annual standard surveys of nursing homes and through ad hoc complaint investigations. Surveys’ Predictable Timing Likely Conceals Additional Care Problems

The extent of care problems is likely to be masked because of the predictability of homes’ standard surveys. Studies of nursing home quality cite questionable accuracy of resident medical records as a problem. 8 for examples of such problems in home A.) 9.) In the background to its final regulations, HCFA stated that its system of requirements implementing OBRA 87 reforms “was built on the assumption that all requirements must be met and enforced” and that its enforcement actions will encourage “sustained compliance.” In addition, HCFA noted that “our goal is to promote facility compliance by ensuring that all deficient providers are appropriately sanctioned.” However, our data suggest that current enforcement efforts in California are not reaching the stated goal to ensure that all requirements are met and deficient providers are appropriately sanctioned, and also may not fulfill the OBRA 87 promise to protect the health, safety, welfare, and rights of residents. In the recent past, California’s terminated homes have rarely closed for good. In a number of cases, this responsibility has not been met in California. In addition, DHS surveyors may overlook significant findings because the federal survey protocol they follow does not rely on an adequate sample for detecting potential problems and their prevalence. Federal policies allowing a grace period to correct deficiencies and to accept a home’s report of compliance without an on-site review can be useful policies, given resource constraints, when applied to homes with less serious problems. Recommendations

In order to better protect the health, safety, welfare, and rights of nursing home residents and ensure that nursing homes sustain compliance with federal requirements, we recommend that the HCFA Administrator revise federal guidance and ensure state agency compliance through taking the following actions:
Stagger or otherwise vary the scheduling of standard surveys to effectively reduce the predictability of surveyors’ visits; the variation could include segmenting the standard survey into more than one review throughout the 12- to 15-month period, which would provide more opportunities for surveyors to observe problematic homes and initiate broader reviews when warranted. We believe that basing a conclusion about the predictability of the annual survey primarily on analysis of OSCAR data is problematic, given weaknesses we identified in the classification of surveys entered into the database. DHS officials generally agreed with our findings and recommendations. More specifically, we assessed (1) whether, as alleged, residents who died in 1993 from certain causes had received unacceptable care that could have endangered their health and safety, and whether serious care problems currently exist; (2) the adequacy of federal and state efforts in monitoring nursing home care through annual surveys; and (3) the effectiveness of federal and state efforts to enforce sustained compliance with federal nursing home requirements. Comments From the Health Care Financing Administration

Comments From California’s Department of Health Services

The first copy of each GAO report and testimony is free.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed allegations that residents in California nursing homes are not receiving acceptable care, focusing on: (1) examining, through a medical record review, whether these allegations had merit and whether serious care problems currently exist; (2) reviewing the adequacy of federal and state efforts in monitoring nursing home care through annual surveys; and (3) assessing the effectiveness of federal and state efforts to enforce sustained compliance with federal nursing home requirements.

What GAO Found

GAO noted that: (1) despite the federal and state oversight infrastructure currently in place, certain California nursing homes have not been and currently are not sufficiently monitored to guarantee the safety and welfare of their residents; (2) GAO reached this conclusion primarily using data from federal surveys and state complaint investigations conducted by California's Department of Health Services (DHS) on 1,370 California homes, supplemented with more in-depth analysis of certain homes and certain residents' care; (3) GAO found that surveyors can miss problems that affect the safety and health of nursing home residents and that even when such problems are identified, enforcement actions do not ensure that they are corrected and do not recur; (4) with regard to allegations made about avoidable deaths in 1993, GAO's expert nurses' review of the 62 resident cases sampled found that residents in 34 cases received care that was unacceptable and that sometimes endangered their health and safety; (5) in the absence of autopsy information or other additional clinical evidence, GAO cannot be conclusive about the extent to which this unacceptable care may have contributed directly to individual deaths; (6) unacceptable care continues to be a problem in many homes; (7) GAO believes that the extent of serious care problems portrayed in federal and state data is likely to be understated; (8) GAO found that homes could generally predict when their annual on-site reviews would occur and, if inclined, could take steps to mask problems otherwise observable during normal operations; (9) GAO found irregularities in the homes' documentation of the care provided to their residents; (10) in visiting homes selected by California DHS officials, GAO found multiple cases in which DHS surveyors did not identify certain serious care problems; (11) surveyors missed these care problems because federal guidance on conducting surveys does not include sampling methods that can enhance the spotting of potential problems and help establish their prevalence; (12) the Health Care Financing Administration's (HCFA) enforcement policies have not been effective in ensuring that the deficiencies are corrected and remain corrected; (13) California's DHS grants all noncompliant homes, with some exceptions, a 30- to 45-day grace period, during which they may correct the deficiencies without penalty; (14) a substantial number of California's homes that have been terminated and later reinstated have soon thereafter been cited again for serious deficiencies; and (15) the problems GAO identified are indicative of systemic survey and enforcement weaknesses.