A DPNA denies a home payments for new admissions  until deficiencies are corrected. Surveys were to be conducted at 6-month intervals  rather than annually. Despite the decline in the number of serious  deficiencies, the homes we reviewed generally were cited for more  deficiencies that caused harm to residents than other homes in the four  states. The deterrent effect of sanctions for  the homes was further eroded because CMS generally imposed CMPs on  the lower end of the allowable dollar range and did not exercise its  authority to use discretionary DPNAs and terminations, allowing the  homes more opportunities to escape sanctions prior to implementation. Decline in Sanctions and Deficiencies for the Homes Reviewed Is Consistent with Nationwide Trends

The number of implemented sanctions at the homes we reviewed as well  as the number of serious deficiencies cited in these homes declined across  two time periods—fiscal years 2000 through 2002 and fiscal years 2003  through 2005—consistent with nationwide trends. 2). The median per day CMP  implemented for nonimmediate jeopardy deficiencies was $500 in fiscal  years 2000 through 2002 and $350 in fiscal years 2003 through 2005,  significantly below the maximum of $3,000 per day. Many Homes Cycled In and Out of Compliance, Continuing to Harm Residents

Consistent with our earlier work, our current analysis showed that  sanctions appear to have induced homes to correct deficiencies only  temporarily because surveyors found that many of the homes we reviewed  with implemented sanctions were again out of compliance on subsequent  surveys. We found no  record that CMS imposed a sanction for 15 of the 69 double Gs, but the  data did show that CMS implemented sanctions for the remaining double  G cases. Termination Used Infrequently

Nursing homes, even those that repeatedly harm residents, are  infrequently terminated because of CMS’s concerns about access to other  sources of nursing care and the impact of moving residents. Although the homes that remained open met the deadline to correct  deficiencies before the termination would have been implemented, a  home’s ability to correct deficiencies in a specified period of time may not  be the strongest criteria upon which to determine whether a home should  remain open, because correcting deficiencies does not ensure that the  home will improve residents’ quality of care and does not prevent the  home from again falling out of compliance. Complex Immediate Sanctions Policy and Data Limitations Hamper CMS Management of Enforcement

While the goal of enforcement is to help ensure nursing home compliance  with federal quality requirements, CMS management of the process is  hampered by the complexity of its immediate sanctions policy and by its  fragmented and incomplete data systems. Finally,  CMS has taken some steps intended to improve enforcement of nursing  home quality requirements, such as developing guidance to help ensure  greater consistency across states in CMP amounts, revising its Special  Focus Facility program, and commissioning two studies to examine the  effectiveness of nursing home enforcement. It is not clear, however, the  extent to which—or when—these initiatives will address the enforcement  weaknesses we found. Such rules  may in part explain why the homes we reviewed only had 69 instances of  immediate sanctions over a 6-year period, despite being cited 444 times for  deficiencies that harmed residents. Recommendations for Executive Action

To address weaknesses that undermine the effectiveness of the immediate  sanctions policy, we recommend that the Administrator of CMS reassess  and revise the policy to ensure that it accomplishes the following three  objectives: (1) reduce the lag time between citation of a double G and the  implementation of a sanction, (2) prevent nursing homes that repeatedly  harm residents or place them in immediate jeopardy from escaping  sanctions, and (3) hold states accountable for reporting in federal data  systems serious deficiencies identified during complaint investigations so  that all complaint findings are considered in determining when immediate  sanctions are warranted. At that time, we will send copies to the Administrator of the  Centers for Medicare & Medicaid Services and appropriate congressional  committees. These homes had a  history of providing poor quality care to residents prior to 1999. CMS enforcement data and reliability issues. Range of sanctions. Immediate sanctions policy.
Why GAO Did This Study

In 1998 and 1999 reports, GAO concluded that enforcement actions, known as sanctions, were ineffective in encouraging nursing homes to maintain compliance with federal quality requirements: sanctions were often rescinded before being implemented because homes had a grace period to correct deficiencies. In response, the Centers for Medicare & Medicaid Services (CMS) began requiring immediate sanctions for homes that repeatedly harmed residents. Using CMS enforcement and deficiency data, GAO (1) analyzed federal sanctions from fiscal years 2000 through 2005 against 63 homes previously reviewed and (2) assessed CMS's overall management of enforcement. The 63 homes had a history of harming residents and were located in 4 states that account for about 22 percent of homes nationwide.

What GAO Found

From fiscal years 2000 through 2005, the number of sanctions decreased for the 63 nursing homes GAO reviewed that had a history of serious quality problems, a decline consistent with nationwide trends. While the decline may reflect improved quality or changes to enforcement policy, it may also mask survey weaknesses that understate quality problems, an issue GAO has reported on since 1998. Although the number of sanctions decreased, the homes generally were cited for more deficiencies that caused harm to residents than other homes in their states. Almost half of the homes reviewed continued to cycle in and out of compliance; 19 did so 4 times or more. These homes temporarily corrected deficiencies and, even with sanctions, were again found out of compliance on subsequent surveys. Several weaknesses appeared to undermine the effectiveness of the sanctions implemented against the homes reviewed. First, civil money penalties (CMP), which by statute are not paid while under appeal--a process that can take years--were generally imposed at the lower end of the allowable dollar range. For example, the median per day CMP ranged from $350 to $500, significantly below the maximum of $3,000 per day. Second, CMS favored the use of sanctions that give homes more time to correct deficiencies, increasing the likelihood that the sanctions would not be implemented. Thus, more than half of the denial of payment for new admissions (DPNA) that CMS imposed were the type that give homes 3 months to correct deficiencies rather than those that only give homes up to 15 days. Third, there was no record of a sanction for about 22 percent of the homes reviewed that met CMS's criteria for immediate sanctions, a problem GAO also identified in 2003; moreover, 60 percent of DPNAs imposed as immediate sanctions were not implemented until 1 to 2 months after citation of the deficiency. Finally, involuntary termination of homes from participating in the Medicare or Medicaid programs was rare because of concerns about access to other nearby homes and resident transfer trauma; 2 of the 63 homes reviewed were involuntarily terminated because of quality problems. CMS's management of enforcement is hampered by the complexity of its immediate sanctions policy and by its fragmented and incomplete data. Its policy allows some homes with the worst compliance histories to escape immediate sanctions. For example, a home cited with a serious deficiency and that has not yet corrected an earlier serious deficiency is spared an immediate sanction. Such rules may in part explain why the 63 homes reviewed only had 69 instances of immediate sanctions over a 6-year period despite being cited 444 times for deficiencies that harmed residents. Although CMS initiated development of a new enforcement data system 6 years ago, it is fragmented and has incomplete national reporting capabilities. CMS is taking additional steps to improve nursing home enforcement, such as developing guidance to encourage more consistency in CMP amounts, but it is not clear whether and when these initiatives will address the enforcement weaknesses GAO found.