California Nursing Homes

Overall, despite federal and state oversight, some California nursing homes are not being monitored closely enough to guarantee the safety and welfare of their residents. Unacceptable care continues to be a problem in many nursing homes. GAO found that nearly one in three California nursing homes was cited by state surveyors for serious or potentially life-threatening care problems. Moreover, GAO believes that the extent of serious care problems portrayed in federal and state data is likely to be understated. Nursing homes generally could predict when their annual on-site reviews would occur and, if inclined, could take steps to mask problems. GAO also found irregularities in homes' documentation of the care provided to their residents, such as missing pages of clinical notes needed to explain a resident's injury later observed by a physician. Finally, GAO found many cases in which California Department of Health Services surveyors did not identify serious care problems, including dramatic weight loss, failure to prevent bed sores, and poor management of incontinence. Even when the states identified serious shortcomings, the Health Care Finance Administration's (HCFA) enforcement policies have not ensured that the deficiencies are corrected and stay that way. For example, California state surveyors cited about one in 11 nursing homes in GAO's analysis--accounting for more than 17,000 resident beds--for violations in both of their last two surveys that resulted in harm to residents. Yet HCFA generally took a lenient stance toward many of these facilities. GAO recommends a less predictable schedule of inspections for all nursing homes and prompt imposition of sanctions when violations are found. GAO summarized this report in testimony before Congress; see: California Nursing Homes: Federal and State Oversight Inadequate to Protect Residents in Homes With Serious Care Violations, by William J. Scanlon, Director of Health Financing and Systems Issues, before the Senate Special Committee on Aging. GAO/T-HEHS-98-219, July 28 (16 pages).

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.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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