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. This testimony summarizes a July 1998 report (GAO/HEHS-98-202).

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.