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 licensed homes. Review of Records for 1993 Deaths Uncovered Serious Care Problems

Our work indicates that 34 residents—more than half of our sample of 62 of California’s nursing home residents who died in 1993—received unacceptable care. In certain of those cases, the unacceptable care endangered residents’ health and safety; however, without an autopsy that establishes the cause of death, we cannot be conclusive about whether the unacceptable care directly led to any individual’s death. Predictability of Surveys, Questionable Records, and Survey Limitations Hinder Efforts to Identify Care Problems

The deficiencies that state surveyors identified and documented only partially capture the extent of care problems in California’s homes, for several reasons. However, a subsequent HCFA-conducted poll of nursing home resident advocates in most states and a 1998 nine-state study by the National State Auditors Association found that predictable timing of inspections continues to be a problem. HCFA’s Enforcement Policies Ineffective in Bringing Homes With Serious, Repeated Violations Into Sustained Compliance

We also examined the efforts of the state and HCFA to ensure that the homes cited for serious deficiencies were correcting their problems and sustaining compliance with federal requirements over time. However, HCFA enforcement policies have led to relatively few federal disciplinary actions taken against these homes in California. Since July 1995, when the federal enforcement scheme established in OBRA 87 took effect, 59 California nursing homes have been cited for immediate jeopardy deficiencies and about 25 have been designated poor performers. HCFA policy permits granting a grace period to this group of noncompliant homes, regardless of their past performance. Between July 1995 and May 1998, California’s DHS gave about 98 percent of noncompliant homes a grace period to correct deficiencies. For the few California homes that have had federal sanctions imposed, HCFA has been less than vigilant. Eleven have been reinstated under the same ownership they had before termination. In a number of cases, this responsibility has not been met in California. Together, these factors can mask significant care problems from the view of federal and state regulators. In summary, we are recommending that HCFA revise its guidance to states in order to reduce the predictability of on-site reviews, possibly by staggering the schedule or segmenting the survey into two or more reviews; revise methods for sampling resident cases to better identify the potential for and prevalence of care problems; and, for those homes with a history of serious and repeated deficiencies, eliminate the offer of a grace period for resuming compliance and substantiate all of the home’s reports of resumed compliance with an on-site review. However, we also believe that continued vigilance by the Congress is needed to ensure that the promised changes in federal and state oversight of nursing home care are implemented. Additional copies are $2 each.
Why GAO Did This Study

GAO discussed its findings on nursing home care in California, focusing on: (1) care problems identified in recent state and federal quality reviews that California conducted in the last 2 or 3 years; (2) obstacles to federal and state efforts to identify care problems; and (3) implementation of federal enforcement policies to ensure that homes correct problems identified and then sustain compliance with federal requirements.

What GAO Found

GAO noted that: (1) despite the presence of a considerable federal and state oversight infrastructure, a significant number of California nursing homes were not and currently are not sufficiently monitored to guarantee the safety and welfare of nursing home residents; (2) GAO came to this conclusion by using information from California's Department of Health Services (DHS) reviews of nursing home care covering 95 percent of the state's nursing homes, and Health Care Financing Administration (HCFA) data on federal enforcement actions taken; (3) looking back at medical record information from 1993, GAO found that, of 62 resident cases sampled, residents in 34 cases received care that was unacceptable; (4) however, in the absence of autopsy information that establishes the cause of death, GAO cannot be conclusive about whether this unacceptable care may have contributed directly to individual deaths; (5) as for the extent of care problems currently, between July 1995 and February 1998, California surveyors cited 407 homes for care violations they classified as serious under federal or state deficiency categories; (6) moreover, GAO believes that the extent of current serious care problems portrayed in the federal and state data is likely to be understated; (7) the predictable timing of on-site reviews, the questionable accuracy and completeness of medical records, and the limited number of residents' care reviewed by surveyors in each home have each likely shielded some problems from surveyor scrutiny; (8) even when the state identifies serious deficiencies, HCFA enforcement policies have not been effective in ensuring that the deficiencies are corrected and remain corrected; (9) California's DHS, consistent with HCFA's guidance on imposing sanctions, grants 98 percent of noncompliant homes a 30- to 45-day grace period to correct deficiencies without penalty, regardless of their past performance; (10) only the few homes that qualify as posing the greatest danger are not provided such a grace period; (11) in addition, only 16 of the roughly 1,400 California homes participating in Medicare and Medicaid have been terminated from participation, most of them have been reinstated quickly, and many have had subsequent compliance problems; and (12) recognizing shortcomings in enforcement, California officials told GAO that they launched a pilot program in July 1998 intended to target for increased vigilance certain of the state's nursing homes with the worst compliance records.