In this  regulatory framework, states (1) license nursing homes to do business in  the state, (2) certify to the federal government, by conducting reviews of  nursing homes, that homes are eligible for Medicare and Medicaid  payment, and (3) investigate complaints about care provided in the homes. In addition to the requirement that states establish a complaint  investigation process, HCFA requires that states investigate the most  serious complaints that allege situations immediately jeopardizing the  health or safety of residents within 2 workdays, but leaves the timing,  scope, duration, and conduct of other complaint investigations to the  discretion of the state survey agency. Nevertheless, some states we reviewed have procedures or  practices that may limit the number of complaints. Maryland did not identify a single complaint as potentially  representing immediate jeopardy. Many of these  complaints alleged potential resident abuse by staff; resident neglect,  including malnutrition and dehydration; preventable accidents; medication  errors; and understaffing. Furthermore, delayed investigations can prolong, for  extended periods, situations in which residents are harmed. HCFA’s Complaint Investigation Standards Are Minimal, and Its Oversight of States’ Complaint Practices Is Weak

Although HCFA funds, on average, 71 percent of state agencies’ complaint  investigation costs, HCFA has established minimal standards for  investigating complaints and has conducted little monitoring of states’  complaint practices. Previous HCFA Efforts to Strengthen Federal Standards for Nursing Home Complaint Investigations Were Abandoned

Between 1993 and 1995, a HCFA task force worked to develop formal  complaint guidance for states and a complaint investigation manual to help  state investigators. This optional guidance has not been widely used. However, these  federal monitoring surveys are largely intended to focus on annual surveys  rather than on complaint investigations, and few federal monitoring  surveys are conducted of complaint investigations. In our report on California nursing homes, we determined that the results  of complaint inspections are often cited as state, not federal, deficiencies. The combination of inadequate state practices and limited HCFA guidance  and oversight have too often resulted in extensive delays in investigating  serious complaints alleging harmful situations, a lack of careful review of  states’ policies and practices, and incomplete reporting on nursing homes’  compliance history and states’ complaint investigation performance. These include a new interim requirement that states should investigate complaints  alleging actual harm to residents within 10 workdays, and a complaint  improvement project with the intention of developing additional  minimum standards for complaint investigations; increased federal oversight of complaints, including allowing HCFA  regional offices to conduct additional monitoring surveys based upon  complaints and new state agency performance measures relating to  complaints; and improved reporting on complaint information, including a review of the  form states use to report complaint information to HCFA, further  direction to states requiring that complaint findings be included in the  federal as well as state database in a timely manner, and a review of  potential long-term improvements in the federal data system. (continued)
Summary of allegation(s)
No hot water for several weeks or months at a time, so resident was not bathed or cleaned  properly. Poor care and service; quality of care in home has declined. Nothing to do in nursing home. A recorded menu will provide information on how to obtain  these lists.
Why GAO Did This Study

Pursuant to a congressional request, GAO provided information on how states implement the federal requirement that establishes a process for nursing home complaint investigations, focusing on the: (1) effectiveness of state complaint investigation practices as a component of the system to ensure sustained compliance with federal nursing home quality-of-care standards; and (2) Health Care Financing Administration's (HCFA) role in establishing standards and conducting oversight of states' complaint investigation practices and in using information about the results of complaint investigations to ensure compliance with nursing home standards.

What GAO Found

GAO noted that: (1) federal and states' practices for investigating complaints about care provided in nursing homes are often not as effective as they should be; (2) among many of the 14 states GAO examined, GAO found numerous problems, including: (a) procedures or practices that may limit the filing of complaints; (b) understatement of the seriousness of complaints; and (c) failure to investigate serious complaints promptly; (3) serious complaints alleging that nursing home residents are being harmed can remain uninvestigated for weeks or months; (4) such delays can prolong situations in which residents may be subject to abuse, neglect resulting in serious care problems like malnutrition and dehydration, preventable accidents, and medication errors; (5) although federal funds finance over 70 percent of complaint investigations nationwide, HCFA plays a minimal role in providing states with direction and oversight regarding these investigations; (6) HCFA has left it largely to the states to decide which complaints potentially place residents in immediate jeopardy and must be investigated within the federally mandated 2 workdays; (7) if a serious complaint that could harm residents is not classified as potentially placing residents in immediate jeopardy, there is no formal requirement for prompt investigation; (8) more generally, HCFA's oversight of state agencies that certify federally qualified nursing homes has not focused on complaint investigations; and (9) GAO found that: (a) a HCFA initiative to strengthen federal requirements for complaint investigations was discontinued in 1995, and resulting guidance developed for states' optional use has not been widely adopted; (b) federal reviews of state nursing home inspections are primarily intended to focus on the annual surveys of nursing homes, and very few reviews are conducted of complaint investigations; (c) since 1998, HCFA has required state agencies to develop their own performance measures and quality improvement plans for their complaint investigations, but for several of the 14 states GAO reviewed, such assessments addressed complaint processes superficially or not at all; and (d) HCFA reporting systems for nursing homes' compliance history and complaint investigations do not collect timely, consistent, and complete information.