Nursing Homes

Federal and state practices for investigating complaints about nursing home care are often not as effective as they should be. GAO found many problems in the 14 states it reviewed, including procedures or practices that may limit the filing of complaints, understatement of the seriousness of complaints, and failure to investigate serious complaints promptly. Complaints alleging that nursing home residents were being harmed have gone uninvestigated for weeks or months. During that time, residents may have remained vulnerable to abuse, neglect (which can lead to serious problems like malnutrition and dehydration), preventable accidents, and medication errors. Although the federal government finances more than 70 percent of complaint investigations nationwide, the Health Care Financing Administration (HCFA) plays a minimal role in providing states with direction and oversight regarding these investigations. HCFA has left it largely to the states to decide which complaints put residents in immediate jeopardy and should be investigated immediately. More generally, HCFA's oversight of state agencies that certify federally qualified nursing homes has not focused on complaint investigations. GAO recommends (1) stronger federal requirements for states to promptly investigate serious complaints alleging situations that may harm residents but are not classified as posing an immediate threat, (2) more federal monitoring of states' efforts to respond to complaints, and (3) better tracking of the substantial findings of complaint investigations. GAO summarized this report and the preceding one in testimony before Congress; see: Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care, by William J. Scanlon, Director of Health Financing and Public Health Issues, before the Senate Special Committee on Aging. GAO/T-HEHS-99-89, Mar. 22 (10 pages).

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.

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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