Nursing Homes

The federal government will pay an estimated $39 billion for nursing home care in 1999. Working with the states, the federal government also plays a key role in ensuring quality care at these facilities. GAO has issued three reports that focus on problems in California nursing homes as well as the enforcement and complaint investigation processes nationwide. (See GAO/HEHS-98-202, July 1998, GAO/HEHS-99-46, Mar. 1999, and GAO/HEHS-99-80, Mar. 1999.) GAO found that one-fourth of nursing homes nationwide had serious deficiencies that actually harmed residents or placed them at risk of death or injury; 40 percent of these homes had repeated deficiencies. Complaints alleging serious care problems often went uninvestigated for weeks or months. Even when serious deficiencies were found, state and federal enforcement policies were ineffective in ensuring that deficiencies were corrected and stayed that way. HCFA agreed with GAO's recommendations and has developed about 30 initiatives to strengthen federal standards, oversight, and enforcement for nursing homes. This testimony discusses (1) the overall scope of HCFA's initiatives, (2) the early experiences of initiatives for which HCFA has already issued revised guidance to the states, (3) the implications of a proposed expansion of the category of nursing homes that would face more intensive review and immediate sanctions for deficiencies, and (3) the initiatives that will require a long-term commitment for HCFA to implement.

GAO noted that: (1) HCFA has undertaken a wide array of changes in its nursing home oversight that can be summarized in three key areas: (a) strengthening the survey process to be better able to identify violations of federal standards; (b) more strictly enforcing sanctions for nursing homes that do not sustain compliance with these standards; and (c) better educating consumers and nursing home administrators regarding quality of care; (2) HCFA has provided directives to state agencies on six initiatives, but GAO found that states have only partially adopted these revised HCFA policies; (3) while in some cases the states have largely implemented these directives, in other cases the directives have not resulted in major changes in state practices because states often indicated they already had similar practices in place, considered the guidance as optional, or lacked the resources to implement certain directives; (4) furthermore, some of the directives have not had an appreciable effect on the number of homes receiving focused reviews and stricter enforcement; (5) one of the most controversial changes proposed related to the revised definition of homes that would be categorized as "poorly performing" and would subject them to immediate sanctions for deficiencies; (6) the revised definition, which HCFA plans to implement later this year, would include homes that have had deficiencies on consecutive surveys involving actual harm to at least one resident--a "G" level deficiency in HCFA's scope and severity lexicon--which previously had not been subject to immediate sanctions; (7) GAO's review of a random sample of over 100 homes that received at least one G-level deficiency found that in virtually all cases the home has a deficiency that represented a serious problem in the nursing home's care that resulted in documented actual harm to at least one resident; (8) these deficiencies most typically included failure to prevent pressure sores, failure to prevent accidents, failure to ensure adequate nutrition, and leaving dependent residents lying for hours in their bodily wastes; (9) HCFA will soon start providing quality indicator information on homes to surveyors to consider when selecting sample cases; (10) but implementation of a more rigorous sampling methodology that will better permit identifying a problem's prevalence will not take place until mid-2000; and (11) furthermore, while much of HCFA's enforcement and oversight efforts depend on complete, accurate, and timely data, GAO's previous reports highlighted many flaws with its survey and certification management information system.