Nursing Homes

Despite reforms to ensure that nursing homes comply with federal quality standards, one-fourth of all homes nationwide continue to be cited for deficiencies that either caused actual harm to residents or carried the potential for serious injury or death. Although the reforms equipped federal and state regulators with many alternatives and tools to help sustain compliance with Medicare and Medicaid standards, the way in which the states and the Health Care Financing Administration (HCFA) have applied them appears to have resulted in little headway. Repeated noncompliance carries few consequences. HCFA's recent actions, such as broadening the definition of a poorly performing facility, are a step in the right direction. However, four key problems remain. First, if the backlog of civil monetary penalties is not reduced, much of their deterrent effect will be lost. Second, weaknesses remain in the deterrent effect of termination, including the lack of a tie to poorly performing facility status for reinstated homes and the limited reasonable assurance period for monitoring terminated homes before reinstating them. Third, the states are not required to refer for sanction all homes with deficiencies that contribute to resident deaths. Fourth, the changes do not address HCFA's need to improve its management information system. HCFA's ability to improve its oversight of nursing homes will depend heavily on whether it has the information to identify and monitor the homes that pose the greatest risk of harm.

GAO noted that: (1) GAO's work showed that while the Health Care Financing Administration (HCFA) has taken steps to improve oversight of nursing home care, it has not yet realized a main goal of its enforcement process--to help ensure that homes maintain compliance with federal health care standards; (2) surveys conducted in the nation's 17,000-plus nursing homes in recent years showed that each year, more than one-fourth of the homes had deficiencies that caused actual harm to residents or placed them at risk of death or serious injury; (3) the most frequent violations causing actual harm included inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care; (4) although most homes were found to have corrected the identified deficiencies, subsequent surveys showed that problems often returned; (5) about 40 percent of the homes that had such problems in their first survey during the period GAO examined (July 1995 to October 1998) had them again in their last survey during the period; (6) sanctions initiated by HCFA against noncompliant nursing homes were never implemented in a majority of cases and generally did not ensure that the homes maintained compliance with standards; (7) GAO's review of HCFA's survey data combined with GAO's analysis of 74 homes that had a history of problems showed a common pattern; (8) HCFA would give notice to impose a sanction, the home would correct its deficiencies, HCFA would rescind the sanction, and a subsequent survey would find that problems had returned; (9) the threat of sanctions appeared to have little effect on deterring homes from falling out of compliance again because homes could continue to avoid sanctions' effect as long as they kept correcting their deficiencies; (10) HCFA has some tools to address this cycle of repeated noncompliance but has not used them effectively; (11) fines are potentially a strong deterrent because they can be applied even if a home comes back into compliance; (12) however, the usefulness of civil monetary penalties is being hampered by a backlog of administrative appeals coupled with a legal provision that prohibits collection of the penalty until the appeal is resolved; (13) the sanction is often delayed for several years; and (14) GAO also found problems with several aspects of HCFA's policies for ensuring that sufficient attention is placed on homes that have serious deficiencies or a history of recurring noncompliance as well as policies for reinstating homes that have been terminated from the Medicare and Medicaid programs.

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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