Nursing Homes
More Can Be Done to Protect Residents from Abuse Gao ID: GAO-02-312 March 1, 2002Often suffering from multiple physical and mental impairments, the 1.5 million elderly and disabled Americans living in nursing homes are a highly vulnerable population. These individuals typically require extensive help with daily living, such as such as dressing, feeding, and bathing. Many require skilled nursing or rehabilitative care. In recent years, reports of inadequate care, including malnutrition, dehydration, and other forms of neglect, have led to mounting scrutiny from state and federal authorities, which share responsibility for overseeing the nation's 17,000 nursing homes. Concerns have also been growing that some residents are abused--pushed, slapped, or beaten--by the very individuals to whom their care has been entrusted. GAO found that allegations of physical and sexual abuse of nursing home residents are not reported promptly. Local law enforcement officials said that they are seldom summoned to nursing homes to immediately investigate allegations of abuse and that few allegations are ever prosecuted. Some agencies use different policies when deciding whether to refer allegations of abuse to law enforcement. As a result, law enforcement agencies were never told of some incidents or were notified only after lengthy delays. GAO found that federal and state safeguards intended to protect nursing home residents from abuse are inadequate. No federal statute requires criminal background checks for nursing home employees. Background checks are also not required by the Centers for Medicare and Medicaid Services, which sets the standards that nursing homes must meet to participate in the Medicare and Medicaid programs. State agencies rarely recommend that sanctions be imposed on nursing homes. Although state agencies compile lists of aids who have previously abused residents, which can prevent an aide from being hired at another nursing home, GAO found that delays in making these identifications can limit the usefulness of these registries. GAO summarized this report in testimony before Congress; see GAO-02-448T.
RecommendationsOur 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.
Director: Team: Phone:GAO-02-312, Nursing Homes: More Can Be Done to Protect Residents from Abuse
This is the accessible text file for GAO report number GAO-02-312
entitled 'Nursing Homes: More Can Be Done to Protect Residents from
Abuse' which was released on March 1, 2002.
This text file was formatted by the U.S. General Accounting Office
(GAO) to be accessible to users with visual impairments, as part of a
longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the
printed version. The portable document format (PDF) file is an exact
electronic replica of the printed version. We welcome your feedback.
Please E-mail your comments regarding the contents or accessibility
features of this document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
United States General Accounting Office:
GAO:
Report to Congressional Requesters:
March 2002:
Nursing Homes:
More Can Be Done to Protect Residents from Abuse:
GAO-02-312:
Contents:
Letter:
Results in Brief:
Background:
Delays in Reporting Abuse Preclude Immediate Response by Law
Enforcement or Survey Authorities:
Abusive Nursing Home Staff Difficult to Prosecute:
Measures to Safeguard Residents from Abusive Employees Are
Ineffective:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Centers for Medicare and Medicaid
Services:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Timeliness of Complaints Submitted to State Survey Agencies
in 1999 and 2000:
Table 2: Timeliness of Notifications to State Survey Agencies in 1999
and 2000:
Table 3: Cases Referred by Survey Agencies to Their Respective MFCUs
in 1999:
Table 4: Number of Homes Cited for Abuse-Related Deficiencies:
Table 5: Cases of Alleged Abuse Involving Nurse Aides:
Abbreviations:
AAHSA: American Association of Homes and Services for the Aging:
AHCA: American Health Care Association:
CMS: Centers for Medicare and Medicaid Services:
DHR: Georgia Department of Human Resources:
DOH: Pennsylvania Department of Health:
DOJ: Department of Justice:
FBI: Federal Bureau of Investigation:
HCFA: Health Care Financing Administration:
EMS: Department of Health and Human Services:
IDPH: Illinois Department of Public Health:
MFCU: Medicaid Fraud Control Unit:
RN: registered nurse:
[End of section]
United States General Accounting Office:
Washington, DC 20548:
March 1, 2002:
The Honorable John Breaux:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable Charles E. Grassley:
Ranking Minority Member:
Committee on Finance:
United States Senate:
The 1.5 million elderly and disabled individuals residing in nursing
homes are a highly vulnerable population. They often have multiple
physical and cognitive impairments that require extensive assistance
in the basic activities of daily living, such as dressing, feeding,
and bathing. Many require skilled nursing or rehabilitative care. In
recent years, increased attention has been focused on the quality of
care afforded nursing home residents. Concerns with inadequate care
involving malnutrition, dehydration, and other forms of neglect have
contributed to mounting scrutiny from state and federal authorities.
There is also growing concern that some residents are abused”pushed,
slapped, beaten, and otherwise assaulted”-by the individuals to whom
their care has been entrusted. Accordingly, the ability to both
apprehend those who have abused nursing home residents and prevent
further abuse has generated considerable interest.
While nursing homes are expected to keep residents safe from harm,
there are a variety of federal, state, and local agencies”including
law enforcement entities”-that typically play a part in investigating
instances of resident abuse. The federal government and the states
share oversight responsibility for the almost 17,000 nursing homes in
the nation. The recently renamed Centers for Medicare and Medicaid
Services (CMS), formerly the Health Care Financing Administration
(HCFA)[Footnote 1]”-within the Department of Health and Human Services
(HHS)”-is responsible for establishing standards that nursing homes
must meet to participate in the Medicare and Medicaid programs. CMS
contracts with state agencies, such as departments of health, to
conduct annual inspections”called surveys”of nursing homes to certify
that they are eligible for Medicare and Medicaid payments. These state
survey agencies are also responsible for investigating complaints they
receive about the care nursing homes provide. In some instances, state
survey agencies may notify state or local law enforcement agencies to
conduct criminal investigations involving resident abuse. Depending on
the policy of the survey agency, it may opt to involve the state's
Medicaid Fraud Control Unit (MFCU), typically an investigative
component within the state's Office of the Attorney General, or the
appropriate local police department in investigating abuse
allegations. [Footnote 2]
We have previously reported on deficiencies in the oversight of the
quality of care provided to nursing home residents, noting weaknesses
in states' complaint investigations, annual surveys, and enforcement
actions. For example, in March 1999, we reported that inadequate state
procedures and limited HCFA guidance and oversight resulted in, among
other things, extensive delays in investigating serious complaints
alleging harmful situations.[Footnote 3] Also in March 1999, we
reported that state surveys identified deficiencies that harmed
residents or placed them at risk of death or serious injury in more
than one-fourth of nursing homes nationwide.[Footnote 4] Moreover,
sanctions that HCFA initiated against a majority of these homes for
noncompliance with federal standards were often not implemented and
generally did not ensure that homes maintained compliance with
standards. More recently, in September 2000, we reported that,
although HCFA had begun requiring states to investigate complaints
alleging harm within 10 working days of their receipt, states were not
consistently meeting this time frame.[Footnote 5]
In response to your concerns with the adequacy of protections afforded
nursing home residents and the responsiveness of federal, state, and
local agencies to allegations of resident abuse, we (1) determined
whether allegations of abuse are reported promptly to local law
enforcement and state survey agencies, (2) assessed the extent to
which abusers are prosecuted and the impediments to successful
prosecutions, and (3) evaluated whether sufficient safeguards exist to
protect residents from abusive individuals.
To address these questions we limited our work to acts of alleged
physical and sexual abuse committed by nursing home employees against
nursing home residents. We did not address other forms of abuse such
as neglect or verbal abuse nor did we examine instances of nursing
home residents abusing other residents. We interviewed CMS officials
and reviewed agency policies and procedures for overseeing nursing
home care quality. We visited three states with relatively large
nursing home populations”Georgia, Illinois, and Pennsylvania. During
these visits, we interviewed state officials”including those in survey
agencies and MFCUs”who are responsible for responding to, and
investigating, allegations of abuse. We also reviewed relevant federal
laws and regulations, as well as the state laws and regulations
pertaining to these three states.
To learn more about the manner in which abuse investigations are
conducted, we judgmentally selected and reviewed files documenting
Georgia, Illinois, and Pennsylvania state survey agency investigations
of 158 physical and sexual abuse allegations, mostly from 1999 and
2000. Our findings cannot be generalized or projected. Where the files
indicated that states had cited the nursing homes for deficiencies, we
obtained subsequent surveys conducted to determine what, if any,
sanctions had been imposed. We also determined the states' policies
and procedures concerning employees with criminal backgrounds and
examined records of survey agencies' actions related to nurse aides
who had allegedly abused residents. All three states we visited had
established dedicated telephone lines exclusively devoted to reporting
complaints. We called these lines to verify that they were working
properly and to verify that complaints of physical and sexual abuse
would be accepted. We also made similar calls to other organizations
we identified in local Georgia, Illinois, and Pennsylvania telephone
books to determine whether these entities would accept complaints
regarding the abuse of nursing home residents or make referrals to
other organizations. Finally, to learn about law enforcement's role in
responding to and investigating abuse allegations, we interviewed
officials in these states who represented 19 local police departments
and 4 local prosecutors' offices. See appendix I for more detailed
information on our scope and methodology.
We conducted our work from July 2000 through February 2002, in
accordance with generally accepted government auditing standards.
Results in Brief:
Allegations of physical and sexual abuse of nursing home residents
frequently are not reported promptly. Local law enforcement officials
indicated that they are seldom summoned to nursing homes to
immediately investigate allegations of physical or sexual abuse. Some
of these officials indicated that they often receive such reports
after evidence has been compromised. Although abuse allegations should
be reported to state survey agencies immediately, they often are not.
For example, our review of state survey agencies' physical and sexual
abuse case files indicated that about 50 percent of the notifications
from nursing homes were submitted 2 or more days after the nursing
homes learned of the alleged abuse. These delays compromise the
quality of available evidence and hinder investigations. In addition,
some residents or family members may be reluctant to report abuse for
fear of retribution while others may be uncertain about where to
report abuse. Although state survey agencies in the three states we
visited had designated telephone numbers for reporting abuse, we found
it difficult to identify these numbers in the government and consumer
pages of local telephone books for some of the major and mid-size
cities in these states. However, we did find a wide variety of other
organizations that, by their name, appeared to be able to address
abuse complaints, but, in fact, had no authority to do so. Although
CMS requires nursing homes to post these numbers, it is not clear that
this ensures that residents and family members have access to this
information when it is needed. In recognition of the need to better
inform residents and family members about abuse reporting, the agency
initiated an educational campaign in 1998. The campaign included
development of a new poster with removable information cards
containing appropriate numbers for reporting abuse. Although a pilot
test was conducted, the poster has not been approved for distribution
nationwide.
Few allegations of abuse are ultimately prosecuted. The state survey
agencies we visited followed different policies when determining
whether to refer allegations of abuse to law enforcement. As a result,
law enforcement agencies were sometimes either not apprised of
incidents or received referrals only after long delays. When referrals
were made, criminal investigations and, thus, prosecutions were
sometimes hampered because witnesses to the alleged abuse were unable
or unwilling to testify. Delays in investigations, as well as in
trials, reduced the likelihood of successful prosecutions because the
memory of witnesses often deteriorated.
Safeguards to protect residents from potentially abusive individuals
are insufficient at both the federal and state level. There is no
federal statute requiring criminal background checks of nursing home
employees nor does CMS require them. Although the three states we
visited required background checks to screen potential nursing home
employees, they do not necessarily include all nursing home employees
nor are they always completed before an individual begins working.
They also focus on individuals' criminal records within the state
where they are seeking employment. Safeguards at the state level are
also insufficient. While nursing homes are responsible for protecting
residents from abuse, survey agencies in the states we visited rarely
recommended that certain sanctions”such as civil monetary penalties or
terminations from federal programs”be imposed. Twenty-six homes were
cited for deficiencies related to abuse from the 158 case files we
reviewed. The survey agencies recommended a civil monetary penalty for
1 home, while the remaining 25 nursing homes faced less punitive
sanctions such as a requirement to develop corrective action plans.
State survey agencies also play a role in preventing homes from hiring
potentially abusive caregivers through the states' nurse aide
registries. These registries, among other things, identify aides that
have previously abused residents. A finding of abuse should prevent a
home from hiring an aide. However, delays in making these
determinations can limit the usefulness of these registries as a
protective safeguard. In addition, findings of abuse for several nurse
aides could not be found in one state's Web-based registry,
compromising its protective value. As a result, aides who the state
survey agency had already determined had abused residents could have
been hired by unsuspecting nursing homes. Finally, none of the three
states we visited had a safeguard in place”similar to a nurse aide
registry”to professionally discipline those nursing home employees who
do not need certifications or licenses to perform their duties, such
as maintenance or housekeeping personnel.
We are making recommendations to the CMS administrator to facilitate
the reporting, investigation, and prevention of abuse and thus help
ensure the protection of nursing home residents. In comments on a
draft of this report, CMS generally agreed with our recommendations
and said that it is committed to protecting nursing home residents
from harm. It also elaborated on its initiatives to ensure their
safety and described steps it would take in response to our
recommendations.
Experts who have conducted studies on the issue of physical and sexual
abuse[Footnote 6] of nursing home residents have reported that it is a
serious problem with potentially devastating consequences.[Footnote 7]
Nursing home residents have suffered serious injuries or, in some
cases, have died as a result of abuse. Nursing homes are required to
protect their residents from harm by training staff to provide proper
care and by prohibiting abusive behavior.
The vast majority of nursing homes participate in the Medicare and
Medicaid programs and were projected to have received about $58.4
billion from the programs in 2001 for their care. State survey
agencies”such as Georgia's Department of Human Resources, Illinois's
Department of Public Health, and Pennsylvania's Department of Health”
perform surveys at least every 15 months to assess nursing homes'
compliance with federal and state laws and regulations. These surveys
are designed to determine whether nursing homes are complying with
Medicare and Medicaid standards. Nursing homes found to be out of
compliance are cited with deficiencies, which can result in monetary
penalties or other enforcement actions, including termination from
federal programs, depending on their severity.
In addition to periodic surveys, state survey agencies investigate
complaints of inadequate care, including allegations of physical or
sexual abuse. CMS requires that states designate a specific telephone
number for reporting complaints and that all nursing homes publicize
these numbers.
Complaints can be submitted by residents, family members, friends,
physicians, and nursing home staff.[Footnote 8] In addition, advocates
of nursing home residents, such as long-term care ombudsmen, may file
complaints.[Footnote 9] When state survey agencies receive these
complaints they are responsible for investigating all allegations,
determining if abuse occurred, and identifying appropriate corrective
actions.
CMS requires nursing home officials to notify the state survey agency
of allegations of abuse in their facilities immediately. Nursing homes
are also required to conduct their own investigations and submit their
findings in written reports to the state survey agency within 5
working days of the incident. Depending on the severity of the
circumstances, the state survey agency may visit the nursing home to
investigate the incident or wait until the nursing home submits its
report. Depending on the content of the facility's report, the survey
agency may request the home to conduct additional work or the agency
may investigate further on its own. If the agency opts not to
investigate further, it may still review the manner in which the home
conducted its investigation during the agency's next scheduled survey
of the home.
To protect residents from potentially abusive personnel, nursing homes
must adhere to federal and state requirements concerning hiring
practices. CMS's regulations require that facilities establish
policies prohibiting employment of all individuals convicted of
abusing nursing home residents. Although there is no CMS requirement
to do so, the three states we visited require nursing homes to conduct
criminal background checks on some or all prospective employees. All
nursing homes must also verify with the relevant state board of
licensing the professional credentials of the licensed personnel, such
as registered nurses (RN), they hire.
In nursing homes, the primary caregivers are nurse aides. According to
federal law, each state must maintain a registry of all individuals
who have satisfactorily completed an approved nurse aide training
[Footnote 10] and competency evaluation program in that state. Before
employing an aide, nursing homes are required to check the registry to
verify that the aide has passed a competency evaluation.[Footnote 11]
Aides whose names are not included on a state's registry may work at a
nursing home for up to 4 months to complete their training and pass a
state administered competency evaluation.
CMS requires that if a state survey agency determines that a nurse
aide is responsible for abuse, neglect, or theft of a resident's
property, this "finding" must be added to the state's nurse aide
registry. The inclusion of such a finding on a nurse aide's record
constitutes a ban on nursing home employment.[Footnote 12] As a matter
of due process, nurse aides have a right to request a hearing to rebut
the allegations against them, to be represented by an attorney, and to
appeal an unfavorable outcome. State survey agencies are not
responsible for disciplining other nursing home professionals, such as
RNs, who are suspected of abuse. Such personnel are referred to their
respective state licensing boards for review and possible disciplinary
action.
Local police departments may learn of suspected instances of resident
abuse and conduct criminal investigations. In addition, state survey
agencies may notify the state MFCU to pursue these allegations. States
were provided financial incentives to establish MFCUs as a result of
the enactment of the Medicare-Medicaid Anti-Fraud and Abuse Amendments
to the Social Security Act of 1977.[Footnote 13] Although one of their
primary missions is to investigate financial fraud and abuse in the
Medicare and Medicaid programs, MFCUs also have authority to
investigate the physical and sexual abuse of nursing home residents.
MFCUs typically learn of such allegations by receiving referrals from
state survey agencies. If, after investigating an allegation, the MFCU
decides that there is sufficient evidence to press criminal charges,
it may prosecute the case itself or refer the matter to the state's
attorney general or a local prosecutor.
Delays in Reporting Abuse Preclude Immediate Response by Law
Enforcement or Survey Authorities:
Most of the local police departments in the three states we visited
told us that they were seldom summoned to a nursing home following an
alleged instance of abuse. Several police officials indicated that,
when they were called, it was sometimes after others had begun
investigating, potentially hindering law enforcement's ability to
conduct a thorough investigation. Instead, state survey agencies were
typically notified of allegations of abuse. However, these
notifications were frequently delayed. Allegations of abuse may not be
reported immediately for a variety of factors, including reluctance to
report abuse on the part of residents, family members, nursing home
employees, and administrators. In addition, individuals who are
unaware that state survey agencies have designated special telephone
numbers as complaint intake lines may have difficulty identifying
these numbers in telephone directories, which could also result in
delays.
Police Not Immediately Notified of Abuse or Routinely Involved in
Survey Agency Investigations:
Victims of crimes ordinarily call the police to report instances of
physical and sexual abuse, but when the victim is a nursing home
resident, the police appear to be notified infrequently. Residents and
family members are not required to notify local police of abusive
incidents. Several police officials told us that, like any crime,
police should be summoned as soon as the incident is discovered.
However, police told us that when they do learn of an allegation of
abuse involving a nursing home resident, it is sometimes after another
entity, such as the state survey agency, has begun to investigate,
thus hampering law enforcement's evidence collection and limiting
their investigations. Most of the police departments also indicated
that they did not track reports of abuse allegations involving nursing
home residents and thus did not have data on the number of such
reports.
When residents and family members do report allegations of abuse, they
may complain directly to the nursing home administrator rather than
contact police. According to one long-term care ombudsman, resident
and family members do not always view the abuse as a criminal matter.
Nursing homes are usually not compelled to notify local law
enforcement when they learn of such reports. There is no federal
requirement that they contact police, although some states”including
Pennsylvania”have instituted such a requirement. According to an
Illinois state survey agency official, a similar requirement will go
into effect in that state in March 2002.
Our discussions with officials from 19 local law enforcement agencies
indicate that police are rarely called to investigate allegations of
the abuse of nursing home residents. Besides infrequent contact from
residents, family members, and nursing homes, officials from 15 of the
19 police departments we visited told us that they had little or no
contact with survey agencies. Officials from several of these
departments reported that they were unaware of the role state survey
agencies play in investigating instances of resident abuse.
Abuse Allegations Not Immediately Reported to State Survey Agencies:
Our review of 158 case files”mostly from 1999 and 2000”indicated state
survey agencies were often not promptly notified of abuse allegations.
[Footnote 14] While individuals filing complaints are not compelled to
report allegations within a prescribed time frame, nursing homes in
the states we visited are required to notify the state survey agency
of abuse allegations the day they learn of the allegation or the
following day. We found that both complaints from individuals and
notifications from nursing homes are frequently submitted to survey
agencies days, and sometimes weeks, after the abuse has taken place.
As table 1 shows, 20 of the 31 complaint cases we could assess for
promptness of submission contained allegations that were reported to
the state survey agency 2 days or more after the abuse took place.
Further, eight were reported more than 2 weeks after the alleged abuse
occurred.
Table 1: Timeliness of Complaints Submitted to State Survey Agencies
in 1999 and 2000:
State: Illinois[A];
Submitted same day or next day: 6;
Submitted two or more days later: 5;
Summary of later submissions: 2-7 days: 5;
Summary of later submissions: 8-14 days: 0;
Summary of later submissions: 15+ days: 0.
State: Georgia;
Submitted same day or next day: 2;
Submitted two or more days later: 5;
Summary of later submissions: 2-7 days: 2;
Summary of later submissions: 8-14 days: 1;
Summary of later submissions: 15+ days: 2.
State: Pennsylvania;
Submitted same day or next day: 3;
Submitted two or more days later: 10;
Summary of later submissions: 2-7 days: 4;
Summary of later submissions: 8-14 days: 0;
Summary of later submissions: 15+ days: 6.
Total:
Submitted same day or next day: 11;
Submitted two or more days later: 20;
Summary of later submissions: 2-7 days: 11;
Summary of later submissions: 8-14 days: 1;
Summary of later submissions: 15+ days: 8.
Percent:
Submitted same day or next day: 35.5;
Submitted two or more days later: 64.5.
[A] Two Illinois cases were first reported in 1998.
Source: GAO analysis of 31 state complaint files.
[End of table]
There were comparable delays in facilities' notifications of alleged
abuse to the state survey agencies. The three states we visited
require that nursing homes notify them of instances of alleged abuse
immediately”interpreted by survey agency officials in all three of the
states to mean the day the facility learns of the abuse or the next
day. As table 2 shows, however, only about half of the 111 nursing
home notifications we could assess for promptness were submitted
within the prescribed time frame.
Table 2: Timeliness of Notifications to State Survey Agencies in 1999
and 2000:
State: Illinois[A];
Submitted same day or next day: 19;
Submitted two or more days later: 18;
Summary of later submissions: 2-7 days: 14;
Summary of later submissions: 8-14 days: 3;
Summary of later submissions: 15+ days: 1.
State: Georgia;
Submitted same day or next day: 26;
Submitted two or more days later: 18;
Summary of later submissions: 2-7 days: 13;
Summary of later submissions: 8-14 days: 2;
Summary of later submissions: 15+ days: 3.
State: Pennsylvania;
Submitted same day or next day: 12;
Submitted two or more days later: 18;
Summary of later submissions: 2-7 days: 10;
Summary of later submissions: 8-14 days: 4;
Summary of later submissions: 15+ days: 4.
Total:
Submitted same day or next day: 57;
Submitted two or more days later: 54;
Summary of later submissions: 2-7 days: 37;
Summary of later submissions: 8-14 days: 9;
Summary of later submissions: 15+ days: 8.
Percent:
Submitted same day or next day: 51.4;
Submitted two or more days later: 48.6.
[A] Nine Illinois cases were first reported in 1998. Source: GAO
analysis of 111 state notifications.
[End of table]
Delays in notifying survey agencies of abuse prevent the agencies from
promptly investigating and ensuring that nursing homes are taking
appropriate steps to protect residents. Residents may remain
vulnerable to abuse until corrective action is taken.
Untimely Reporting Attributable to Multiple Factors:
Allegations of abuse of nursing home residents may not be reported
promptly for a variety of reasons. For example, a recent study found
that nursing home staff may be skeptical that abuse occurred.[Footnote
15] Residents may also be afraid to report abuse because of fear of
retribution, according to another study and two long-term care
ombudsmen we met with.[Footnote 16] According to one law enforcement
official, family members are sometimes fearful that the resident will
be asked to leave the home and are troubled by the prospect of finding
a new place for the resident to live. In addition, nursing home staff
and management do not always report abuse promptly, despite
requirements to do so. According to law enforcement and state survey
agency officials, staff fear losing their jobs or facing recrimination
from co-workers and nursing home management. Similarly, they also said
that nursing home management is sometimes reluctant to risk adverse
publicity or sanctions from the state.
We saw evidence of delayed reporting by family members, staff, and
management in our file reviews, as illustrated by the following
examples:
* A resident reported to a licensed practical nurse that she had been
raped in the nursing home. Although the nurse recorded this
information in the resident's chart, she did not notify nursing home
management. She also allegedly discouraged the resident from telling
anyone else. Two months later the resident was admitted to a hospital
for unrelated reasons and told hospital officials that she had been
raped. It was not until hospital officials notified police of the
resident's complaint that an investigation was conducted.
Investigators then discovered that the resident had also informed her
daughter of the incident, but the daughter, apparently not believing
her mother, had dismissed it. The resident later told police that she
did not report the incident to other staff at the nursing home because
she did not want to cause trouble. The case was closed because the
resident could not describe the alleged perpetrator. However, the
nurse was counseled about the need to immediately report such
incidents.
* An aide, angry with a resident for soiling his bed, threw a pitcher
of cold water on him and refused to clean him. Another aide witnessed
the incident. Instead of informing management, the witness confided in
a third employee, who reported the incident to the nursing home
administrator 5 days after the abuse took place. The abusive aide was
fired, and a finding of abuse was recorded in her nurse aide registry
file.
* One nursing home employee witnessed an aide slap a resident; two
other employees heard the incident. The aide denied the allegation,
yet the resident developed redness, swelling, and bruising around her
eye. The witnesses reported the matter to nursing home management,
which investigated the situation and suspended the aide the next day.
The aide was subsequently fired. However, the state survey agency was
not notified of the incident by the home until 11 days after the abuse
took place.
During our work we discovered that nursing home residents and family
members who are prepared to report abuse to the state survey agency
could encounter difficulty in identifying where to report a complaint
of abuse, which can further delay reporting. For example, telephone
books for Chicago and Peoria, Illinois, and Athens and Augusta,
Georgia, did not include complaint telephone numbers. Although
telephone books in Philadelphia and Pittsburgh, Pennsylvania,
contained the correct numbers for the state survey agency's offices,
they did not identify the designated complaint number, making it
difficult for an individual unfamiliar with the agency to recognize
its telephone number as an appropriate place to report suspected abuse.
Individuals who are not already familiar with the state survey
agency's role and its complaint telephone line may encounter a
confusing array of numbers both public and private in their local
telephone directory. In the three states we visited we reviewed the
government and consumer pages in nine telephone books and identified a
wide variety of organizations, which, by their names, appeared capable
of addressing complaints. However, many did not have the authority to
do so. In this review, we identified 42 entities that appeared to be
organizations where abuse could be reported and were not affiliated
with the state survey agencies. Only six of these entities represented
organizations”such as long-term care ombudsmen”that are capable of
pursuing abuse allegations. The remaining 36 entities either could not
be reached or could not accept complaints, despite having listings
such as the "Senior Helpline." Sometimes these entities attempted to
refer us to a more appropriate organization, but with mixed success.
For example, our calls in Georgia resulted in four correct referrals
to the state survey agency's designated complaint telephone line but
also led to five incorrect referrals. Five other Georgia entities
offered us no referrals.
To facilitate reporting, nursing homes are required to post the
telephone numbers of complaint lines in a prominent location within
the facility. State survey agencies are expected to verify that these
numbers are properly displayed when they conduct their annual
inspections and have the option of citing homes with deficiencies if
they fail to do so. However, deficiency data compiled by CMS do not
specifically identify the number of homes cited for failure to display
these numbers, and so it is not readily apparent how often nursing
homes do not comply with this specific requirement.
Despite its requirement that nursing homes post the complaint
telephone numbers, CMS recognized that a greater awareness of how to
report abuse was warranted and so, in 1998, it initiated an
educational campaign regarding abuse prevention and detection in
nursing homes. Because publicizing the appropriate telephone numbers
for reporting abuse is critical, a key component of the campaign was
the development of a poster to be used by nursing homes nationwide.
According to a CMS official, the poster will identify several options
for reporting abuse, including notifying nursing home management,
local law enforcement, complaint telephone numbers, and CMS.[Footnote
17] In addition to displaying these numbers, the posters will feature
removable cards-”which individuals may retain-”listing the
organizations and telephone numbers contained on the poster. A pilot
test of the poster was conducted in 1999. Based on feedback received
from the pilot test, the poster was revised, but it has not been
approved for distribution.
Abusive Nursing Home Staff Difficult to Prosecute:
Relatively few prosecutions result from allegations of physical and
sexual abuse of nursing home residents. We identified two impediments
to the successful prosecution of employees who abuse nursing home
residents. First, allegations of abuse were not always referred to
local law enforcement or MFCUs. When referrals were made it was often
days or weeks after the incident occurred, compromising the integrity
of what limited evidence might have still been available. Second, a
lack of witnesses to instances of abuse made prosecutions difficult
and convictions unlikely.
States' Policies Regarding Referrals to Law Enforcement Varied and
Limited Prosecutions:
Each of the states we visited had a different policy for referring
instances of suspected abuse to law enforcement officials. While
Illinois and Georgia both relied on their MFCUs to pursue criminal
investigations concerning resident abuse, they followed different
policies.[Footnote 18] Our review of case files in Illinois showed
that the state survey agency consistently referred all reports of
physical and sexual abuse”regardless of whether they were complaints
or incident reports”to the MFCU, which in turn determined whether to
open an investigation. As a result, the Illinois MFCU appeared to play
a substantial role in abuse investigations. On the other hand, the
Georgia survey agency evaluated each allegation and selectively
referred cases to its MFCU according to a mutually agreed upon
procedure. In accordance with this procedure, the survey agency
screened complaints and incident reports before making referrals to
its MFCU based on an assessment of the severity of the allegations or
circumstances. Survey agency officials also told us that, in making
these assessments, they considered the likelihood that reporting the
abuse to the MFCU would result in a criminal conviction.
The differences in Illinois's and Georgia's referral policies yielded
dramatically different results. While the Illinois survey agency
referred approximately 300 allegations of abuse to its MFCU in 1999,
[Footnote 19] Georgia only referred 27 allegations in the same period.
Although Illinois had more than twice as many nursing home residents
as Georgia--81,500 vs. 33,800-”the discrepancy in population size does
not account for the significant difference in the number of referrals.
Our review of the 50 Illinois cases revealed that the Illinois survey
agency referred cases to its MFCU earlier than the Georgia survey
agency. The Illinois cases were referred to the MFCU, on average, 3
days after receiving a report of abuse, while Georgia referred cases,
on average, 15 days after learning about an allegation. Illinois's
policy of routinely referring all allegations to its MFCU enables
referrals to be made more quickly than Georgia's system of evaluating
and screening all allegations prior to making selective referrals.
The state survey agencies in Illinois and Georgia referred 64 of the
cases we reviewed to the MFCUs for investigation. As indicated in
table 3, Georgia, which referred fewer cases to its MFCU, had fewer
convictions. By referring more cases to its MFCU, the Illinois survey
agency presented law enforcement with the opportunity to assess
whether an abusive act had been committed and whether it should be
criminally pursued. In addition, by referring its cases to its MFCU
sooner, on average, than Georgia, Illinois also enhanced law
enforcement's ability to conduct more timely and effective
investigations. The Georgia survey agency's screening process provided
law enforcement fewer and less timely opportunities to investigate
allegedly abusive caregivers.
Table 3: Cases Referred by Survey Agencies to Their Respective MFCUs
in 1999:
State: Illinois;
Number reviewed: 50;
Number of MFCU referrals: 50;
Number of convictions: 18.
State: Georgia;
Number reviewed: 52;
Number of MFCU referrals: 14;
Number of convictions: 3.
Source: GAO analysis of 102 case files.
[End of table]
In discussing Georgia's referral policy with survey agency and MFCU
officials, we learned that the agency substantially changed its MFCU
referral criteria in 2000, leading to an increased number of
referrals--111”-that year. This change followed a new understanding
between survey agency and MFCU officials based on the MFCU's expressed
willingness to investigate instances of abuse. Previously, the survey
agency typically did not refer instances that it considered less
serious”such as incidents involving nursing home employees slapping
residents with no reported visible injuries”to the MFCU. According to
survey agency officials, they did not refer such allegations because
they believed that these cases did not meet the referral criteria. In
their view, it was unlikely that the MFCU would consider such acts
serious enough offenses to warrant an investigation and prosecution.
Lack of Witnesses Reduce Likelihood of Successful Prosecutions:
The lack of compelling evidence often precludes prosecution of those
who have abused nursing home residents. MFCU and local law enforcement
officials indicated that nursing home residents are often unwilling or
unable to provide testimony. The state survey agency and law
enforcement officials we spoke to agreed with this determination. Our
file reviews confirmed that residents were reluctant or unable to
provide evidence against an accused abuser in 32 of the 158 cases we
reviewed, thus making it difficult to pursue a criminal investigation.
Our work also indicated that resident testimony could be limited by
mental impairments or an inability to communicate. We noted several
instances in which residents sustained unexplained black eyes,
lacerations, and fractures. However, despite the existence of serious
injuries, investigators could neither rule out accidental injuries nor
identify a perpetrator.
Prosecutions of individuals accused of abusing nursing home residents
are often weakened by the time lapse between the incident and the
trial. Law enforcement officials and prosecutors told us that the
amount of time that elapses between an incident and a trial could ruin
an otherwise successful case because witnesses do not always remember
important details about the incident. Although it is not uncommon for
the memories of witnesses in criminal cases to fade, impaired recall
is even more prevalent among nursing home residents. Our review showed
that nursing home residents may become incapable of testifying months
after they were abused. For example, in one case, a victim's roommate
witnessed the abuse and positively identified the abuser during the
investigation. However, by the time of the trial-”nearly 5 months
later”-she could no longer identify the suspect in the courtroom,
prompting the judge to dismiss the charges. Moreover, given the age
and medical condition of many nursing home residents, many might not
survive long enough to participate in a trial. One recent study of 20
sexually abused nursing home residents revealed that 11 died within 1
year of the abuse.[Footnote 20] Law enforcement officials told us
that, without testimony from either a victim or a witness, conviction
is unlikely.
Measures to Safeguard Residents from Abusive Employees Are Ineffective:
The safeguards available to states do not sufficiently protect
residents from abusive employees. CMS's requirements preclude
facilities from employing an individual convicted of abusing nursing
home residents but permit the hiring of those convicted of other
abusive acts, such as child abuse. Although some states have
established more stringent requirements, criminal background checks
typically do not identify individuals who have committed a crime in
another state. Nursing homes can be cited for deficiencies if they
fail to adequately protect residents from abuse, but these
deficiencies rarely result in the imposition of sanctions, such as
civil monetary penalties, by state survey agencies. State survey
agencies, which also oversee the operation of state nurse aide
registries, do not adequately ensure that residents will be protected
from aides who previously abused residents. Finally, states are unable
to take professional disciplinary actions against other employees,
such as security guards or housekeeping staff, who may have abused
residents but who are neither licensed nor certified to care for
residents.
CMS Employment Requirements and Background Checks Do Not Ensure
Resident Protection:
While CMS requires nursing homes to establish policies that prevent
the hiring of individuals who have been convicted of abusing nursing
home residents, this requirement does not include offenses committed
against individuals outside the nursing home setting, nor does it
specify that states conduct background checks on all prospective
employees. CMS's requirement does not preclude individuals with
similar convictions”such as assault, battery, and child abuse”from
obtaining nursing home employment.
The three states we visited all apply a broader list of offenses that
prohibit employment in a nursing home. Each state's prohibition of
employees includes those convicted of offenses such as kidnapping,
murder, assault, battery, or forgery and is not limited to offenses
against nursing home residents. However, the three states vary in
their application of these prohibitions. For example, Illinois's
prohibition does not apply to employees who are not directly involved
in providing care to residents and allows nurse aides who have been
convicted of such offenses to apply for a waiver. Waivers may be
granted if there are mitigating circumstances and allow these aides to
work in nursing homes. Pennsylvania's prohibition applies to all
nursing home employees, not just those involved in patient care.
Georgia's prohibition, enacted in 2001, also applies to all nursing
home employees, but only if they were convicted of abuse-related
crimes within the preceding 10 years.
Criminal background checks do not adequately protect residents, in
part, because, as in Illinois, they may not apply to all nursing home
employees.[Footnote 21] More importantly, the background checks that
are performed by state and local law enforcement officials in the
three states we visited are typically only statewide. Consequently,
individuals who have committed disqualifying crimes in one state may
be able to obtain employment at a nursing home in another state.
Nationwide background checks on prospective nursing home employees can
be performed by the Federal Bureau of Investigation (FBI) if nursing
homes request them. These checks could identify offenses committed
elsewhere, but not all states take advantage of this option. According
to an FBI official, 21 states have requirements that subject some
health care employees to these checks, but state requirements vary and
do not always apply to prospective nursing home employees. This
official told us that most of the requests the FBI receives on health
care personnel are from these 21 states. He told us that, of the
remaining states, only nursing homes in North Carolina and Ohio
request such background checks regularly.[Footnote 22] Of the three
states we visited, only Pennsylvania submits background check requests
to the FBI. However, these are limited to those individuals who have
lived outside the state during the 2 years prior to applying for
nursing home employment.
Two of the states we visited allow employees to report for duty before
background checks are completed. Pennsylvania[Footnote 23] and
Illinois permit new employees to report to work before criminal
background checks are completed, for up to 30 days and 3 months,
respectively. However, Georgia survey agency officials told us that
nursing homes could be cited with a deficiency if new employees assume
their duties before the nursing home receives the results of the
background checks. Georgia requires that these checks be completed
within 3 days of the request.
CMS does not require that the results of criminal background checks be
included in nurse aide registries. Of the three states we visited,
only Illinois requires that the results be reported to the state
survey agency by the nursing home.[Footnote 24] If the check reveals a
disqualifying criminal history, it will be included in the Illinois
registry. Therefore Illinois nursing homes are able to identify some
aides with disqualifying convictions before offers of employment are
made and criminal background checks are initiated. Officials in
Georgia and Pennsylvania explained that they verify the completion of
background checks for new employees, including nurse aides, as they
conduct their periodic nursing home surveys. As a result, they told us
that they do not believe that the results of these checks need to be
added to their registries.
Nursing Homes Rarely Sanctioned for Improperly Responding to Abuse:
For the states that we reviewed, sanctions were rarely imposed against
nursing homes for deficiencies associated with their handling of
instances of abuse. Deficiencies considered the most severe”those
resulting in actual harm or immediate jeopardy to resident health or
safety”could result in an immediate sanction, such as a civil monetary
penalty. Deficiencies not resulting in actual harm or immediate
jeopardy usually resulted in nursing homes being required to submit a
plan of corrective action. Nursing homes that submit corrective action
plans may also face other sanctions.
The Georgia, Illinois, and Pennsylvania survey agencies eventually
cited 26 nursing homes”from the 158 cases we reviewed”for abuse-
related deficiencies such as failing to report allegations of abuse in
a timely manner or failing to properly investigate them, as well as
inadequately screening employees for criminal backgrounds, as
indicated in table 4.
Table 4: Number of Homes Cited for Abuse-Related Deficiencies:
State: Georgia;
Number cited: 2;
Number assessed civil monetary penalties: 0.
State: Illinois;
Number cited: 7;
Number assessed civil monetary penalties: 1.
State: Pennsylvania;
Number cited: 17;
Number assessed civil monetary penalties: 0.
Total:
Number cited: 26;
Number assessed civil monetary penalties: 1.
Source: GAO analysis of 158 case files.
[End of table]
The state survey agencies rarely recommended to CMS that civil
monetary penalties be imposed against nursing homes for abuse-related
deficiencies, primarily because most of the deficiencies cited for
these 26 nursing homes were not categorized as placing residents'
health or safety in immediate jeopardy or resulting in actual harm to
residents. Only 1 of these 26 facilities”in Illinois”was assessed a
civil monetary penalty. However, the penalty was reduced on appeal.
State survey agencies did not recommend other sanctions on the 25
remaining nursing homes.
Nurse Aide Registries Do Not Ensure Resident Protection:
We found that allegedly abusive nurse aides received different
treatment depending on the state in which they worked. In addition,
when states determined that aides were abusive, there were frequent
and long delays in the inclusion of this information in their registry
files. Residents could have been exposed to abusive individuals while
their cases were pending.
Finally, we found that one state's Web-based nurse aide registry
lacked complete information on aides who had been found to be abusive.
Inconsistent Treatment of Nurse Aides Poses Risks to Nursing Home
Residents:
CMS defines abuse as the willful infliction of injury, unreasonable
confinement, intimidation, or punishment with resulting physical harm,
pain, or mental anguish. CMS officials told us that states may use
different definitions so long as they are at least as broad as the CMS
definition.[Footnote 25] While the three states we visited have
definitions that appear at least as broad as the CMS definition,
variations in the way these states interpret or apply their
definitions affect whether aides' actions are reflected in state
registries.
For example, the Georgia definition is very similar to CMS's and
defines abuse to include, among other things, the "willful infliction
of physical pain, physical injury, [or] mental anguish " Officials
there told us, however, that in order to add a finding of abuse to an
aide's registry file, they must be convinced that the aides' actions
were intentional. They are less likely to determine that an aide has
been abusive if the aide's behavior appeared to be spontaneous or the
result of a "reflex" response. Officials said they would view an
instance in which an aide struck a combative resident in retaliation
after being slapped by the resident as an unfortunate reflex response
rather than an act of abuse.
Similarly, Pennsylvania defines abuse to include, among other things,
"infliction of injury...or intimidation or punishment with resulting
physical harm, pain or mental anguish." While this definition appears
to be at least as broad as the CMS definition, Pennsylvania officials
told us that they would be unlikely to annotate an aide's registry
file to reflect a finding of abuse unless the aide caused serious
injury or obvious pain. Our review of Pennsylvania files indicated
that most of the aides that were found to have been abusive had, in
fact, clearly injured residents or caused them obvious pain. However,
these files also indicated that in several instances in which
residents were bumped or slapped and indicated that they were in pain
as the result of aides' actions, the survey agency decided not to take
action because the residents had no physical injuries. As in Georgia,
agency officials indicated that they needed to establish that the
action was intentional.
In contrast, Illinois defines abuse as "any physical...or mental
injury inflicted on a resident other than by accidental means."
Incidents like those not reported to registries in Georgia or
Pennsylvania”reflex actions and those devoid of serious injury or
obvious pain”are added to Illinois's registry. We saw 17 such cases in
Illinois in which state survey officials did find the aides to have
been abusive. We also reviewed, in both Illinois and Georgia, what
appeared to be comparable complaints in which a nursing home employee
witnessed another staff member strike a combative resident. Both
survey agencies made preliminary determinations that the employees
had, in fact, abused residents. The Illinois survey agency not only
included its determination in the aides' registry files, it also
referred the matter to its MFCU, resulting in a criminal conviction.
[Footnote 26] The Georgia survey agency reversed its initial
determination that the aide was abusive when the aide requested that
the matter be reconsidered, even though the aide did not provide new
evidence to disprove the allegation. Notes in the case file indicated
that Georgia reversed its decision because the aide's action was
reflexive. Consequently, Georgia did not annotate the aide's registry
information to reflect a finding of abuse and did not refer this
incident to its MFCU. We identified four additional instances among
the 52 Georgia cases we reviewed involving nurse aides who hit or
otherwise injured combative residents after these residents had tried,
sometimes successfully, to harm them first. None of these cases
resulted in determinations that aides were abusive. The files
indicated that officials had determined that the aides did not intend
to hurt the resident and were not abusive because the residents were
combative. Consequently, no further actions were taken.
CMS officials agreed with state survey agency officials that intent is
a key factor in assessing whether an aide abused a resident. However,
they would not necessarily find a reflex response to be unintentional.
These officials indicated that an aide who slaps a resident back could
have developed intent in an instant and thus should be considered
abusive.
Of the 158 cases of alleged physical and sexual abuse that we
reviewed, 105 involved nurse aides. States notified 41 of these aides
of their intent to annotate their registry files to reflect findings
of abuse, which would prevent them from obtaining future employment in
a nursing home. As table 5 shows, 27 of these 41 aides eventually had
their registry files annotated. Consistent with Illinois's broad
definition of abuse and the fact that officials there have not
narrowed its scope through its application, most of these aides were
from that state.
Table 5: Cases of Alleged Abuse Involving Nurse Aides:
State: Georgia;
Cases involving nurse aides: 31;
Aides notified of intent to annotate registry records: 9;
Aides with registry records annotated as of January 2002: 5.
State: Illinois;
Cases involving nurse aides: 40;
Aides notified of intent to annotate registry records: 27;
Aides with registry records annotated as of January 2002: 22.
State: Pennsylvania;
Cases involving nurse aides: 34;
Aides notified of intent to annotate registry records: 5;
Aides with registry records annotated as of January 2002: 0.
Total:
Cases involving nurse aides: 105;
Aides notified of intent to annotate registry records: 41;
Aides with registry records annotated as of January 2002: 27.
Source: GAO analysis of 158 reviewed case files and related nurse aide
registry data.
[End of table]
Delays in Annotating Record Leave Residents Vulnerable:
We found examples of delays between the time the state survey agencies
learned that a nurse aide had allegedly abused a resident to the date
of the agencies' final determinations. Our review of the 71 case files
from Illinois and Georgia involving allegedly abusive aides, and our
review of 1999 nurse aide registry records in Pennsylvania[Footnote
27] indicated that while some determinations were made in less than 2
months, a substantial number12”took 10 months or more. Three of these
12 determinations took at least 2 years. Such delays can put residents
of other nursing homes at risk. By the time state survey agencies have
determined that some aides are abusive, these aides may have already
found employment in other homes.
The process of determining whether an aide actually abused a resident
can be time-consuming. While CMS requires survey agencies to begin
their investigation of an allegedly abusive aide within two days of
learning of an allegation, it does not impose a deadline for
completing these investigations. State survey agency investigations
can be prolonged, particularly if law enforcement is involved.
Nurse aides are entitled to due process, but nursing home residents
may remain vulnerable to abuse until final determinations are made.
Once officials make an initial determination that an aide abused a
resident, the aide must be informed in writing. The notification must
also inform the aide that the agency intends to update the registry to
reflect this determination, which would prevent the aide from
obtaining future employment in a nursing home in that state. Because
of the severity of these consequences, aides are entitled to hearings.
Hearings must be requested in writing within 30 days of the
notification from the state survey agency regarding its determination
and its intent to include a finding of abuse in the registry. Hearings
may not be held for several months, and hearing officers may not
render their decisions immediately. No entry may be made in an aide's
registry record until a final determination is made that the aide was
abusive. Our analysis of nurse aide registry records from 1999
indicated that, for all aides with abuse findings recorded in their
registry files in all three states, hearings added, on average, 5 to 7
months to the determination process.
Inaccuracies in Nurse Aide Registry Web Sites May Compromise Resident
Safety:
We identified problems with the accuracy of information contained in
one state's nurse aide registry Web site that could have resulted in
the provision of inaccurate information to nursing homes screening
potential employees. Our test of the accuracy of the sites for the
three states we visited showed that, in some instances, findings of
abuse had been annotated to an aide's registry record but had not been
included in registry information posted on the Web site. For example,
four Georgia aides with final determinations of abuse did not have
such findings reflected in their files at the state's registry Web
site. Agency officials confirmed our results and consequently closed
the agency site for more than a week. However, they told us that the
problem was limited to the site and did not affect their ability to
provide correct information by telephone or fax. They also reported
that the agency's ability to provide a complete list of abusive aides
in its quarterly bulletins to nursing homes was not compromised.
Just as background checks would typically reveal only offenses
committed in the state in which an applicant seeks employment, nurse
aide registries reflect an aide's history in a particular state. In
1998, the HHS Office of Inspector General recommended that HCFA assist
in developing a national abuse registry and expand state registries to
include all nursing home employees who have abused residents or
misappropriated their property in facilities that receive federal
reimbursement.[Footnote 28] A CMS contractor is currently conducting a
feasibility study regarding the development of such a registry. The
study includes a cost-benefit analysis to assess the implications of a
centralized nurse aide registry and, to a lesser extent, the
implications of tracking all nursing home employees. The implications
of requiring other health care providers”-such as home health
agencies-”to query nurse aide registries is also under study. The
contractor is scheduled to report its findings as soon as March 2002.
Other Nursing Home Employees May Not Be Disciplined:
Although nurse aides compose the largest proportion of nursing home
employees, other employees, such as laundry aides, security guards,
and maintenance workers have also been alleged to have abused
residents. While survey agencies can prevent abusive aides from
working in nursing homes and can refer licensed personnel, such as
nurses and therapists, to state licensing boards for disciplinary
action, they have no similar recourse against other abusive employees,
who may continue to work in nursing homes. Survey agencies can,
however, cite facilities for deficiencies if appropriate actions”such
as reporting and investigating the allegations”are not taken.
Of the 158 cases of alleged physical and sexual abuse that we
reviewed, 10 suspected perpetrators were employees who were not
subject to licensing or certification requirements. None of the
facilities in these cases were cited for deficiencies. Although there
is no administrative process to enable the state to take actions
against such employees, these employees could be criminally
prosecuted. Of these 10 cases, 4 involved allegations that proved
unfounded or for which evidence was inconsistent. One of the 10
employees ultimately pled guilty in court. Three others were
investigated by law enforcement but were not prosecuted.[Footnote 29]
The remaining 2 employees were terminated by their nursing homes but
were not the subject of criminal investigations.[Footnote 30]
Conclusions:
Nursing homes are entrusted with the well-being and safety of their
residents yet considerable attention has recently been focused on the
inadequacies of care provided to many nursing home residents. Along
with receiving quality care, residents are entitled to be protected
from those who would harm them. Residents who are abused need to be
assured that their allegations will be immediately referred to the
proper authorities and investigated expeditiously. In addition, law
enforcement authorities need to ensure that abusive individuals are
prosecuted when appropriate, and survey agencies should recommend to
CMS that available administrative sanctions be imposed against known
abusers.
Our work shows that nursing home residents need both stronger and more
immediate protections. Law enforcement agencies, such as state MFCUs
or local police departments, are not involved as often or as soon as
they should be, especially when there are indications of potential
criminal activity. Additionally, determining where to report
complaints of alleged abuse can be confusing. Prompt reporting is
especially crucial given the often-limited evidence available.
CMS is taking important steps that may better protect residents. For
example, its feasibility study on the development of a national abuse
registry could lead to enhanced resident safety. However, other
efforts have fallen short. For example, an important tool could be the
agency's educational campaign using a new poster in nursing homes
nationwide to better inform residents and family members about how to
report abuse. However, the poster has been under development for more
than 3 years.
More should be done to protect nursing home residents. CMS's
requirement that nursing homes not employ individuals convicted of
abusing residents does not sufficiently prevent the hiring of
potentially abusive individuals. Those who have committed similar
offenses, such as child abuse, are eligible to work in nursing homes
unless states impose a more stringent requirement. While CMS does not
require criminal background checks, some states have instituted them.
However, they may not be required for all prospective employees and
may not identify offenses committed in other states. In addition,
CMS's definition of abuse is not sufficiently detailed to ensure that
all states report every incident that CMS would consider abusive.
Affording due process to nurse aides who have allegedly abused
residents is important and necessary. However, determinations that
nurse aides have been abusive can be time-consuming, leaving residents
at risk if these aides continue to work in nursing homes. Finally,
nurse aide registries may have incorrect information, allowing nursing
homes to hire aides previously found abusive.
Recommendations for Executive Action:
To better protect nursing home residents, we recommend that the CMS
administrator:
* Ensure that state survey agencies immediately notify local law
enforcement agencies or MFCUs when nursing homes report allegations of
resident physical or sexual abuse or when the survey agency has
confirmed complaints of alleged abuse.
* Accelerate the agency's education campaign on reporting nursing home
abuse by (1) distributing its new poster with clearly displayed
complaint telephone numbers and (2) requiring state survey agencies to
ensure that these numbers are prominently listed in local telephone
directories.
* Systematically assess state policies and practices for complying
with the federal requirement to prohibit employment of individuals
convicted of abusing nursing home residents and, if necessary, develop
more specific guidance to ensure compliance.
* Clarify the definition of abuse and otherwise ensure that states
apply that definition consistently and appropriately.
* Shorten the state survey agencies' time frames for determining
whether to include findings of abuse in nurse aide registry files.
Agency Comments and Our Evaluation:
We received comments on a draft of this report from CMS, the
Department of Justice (DOJ), the three state survey agencies we
visited (the Illinois Department of Public Health, the Georgia
Department of Human Resources, and the Pennsylvania Department of
Health), and the MFCUs in Illinois and Georgia.[Footnote 31] We also
received comments from two organizations representing the nursing home
industry”-the American Health Care Association (AHCA) and the American
Association of Homes and Services for the Aging (AAHSA).
In its comments, CMS generally agreed with our recommendations and
said that it is committed to protecting nursing home residents from
harm and explained that it is currently investigating new ways to
combat resident abuse and neglect. We have reprinted CMS's letter in
appendix II.
CMS also provided technical comments, which we have incorporated as
appropriate.
CMS agreed with our first recommendation and said it would instruct
state survey agencies to immediately notify local law enforcement
agencies or MFCUs of confirmed abuse allegations. CMS also said it
would thoroughly review this recommendation when it completes its
analysis of its Complaint Improvement Project. We believe that
immediately notifying law enforcement of suspected abuse will enhance
the safety of nursing home residents, and we urge CMS's prompt action.
In responding to our second recommendation”that CMS accelerate its
education campaign”the agency said that it is working with HHS to
release its new poster as soon as possible, but did not indicate when
it might be distributed to nursing homes. In addition, CMS agreed to
request states to prominently list telephone numbers for reporting
abuse in local telephone directories.
CMS agreed with our third recommendation and said it will review state
policies and practices and reissue guidance regarding employment
prohibitions pertaining to individuals convicted of abusing nursing
home residents. We believe that an assessment of the current
requirements, that includes an evaluation of the states'
implementation of these requirements, could have a lasting impact on
resident safety.
In addressing our fourth recommendation”to clarify the definition of
abuse and ensure that states consistently and appropriately apply this
definition”CMS explained that states can use their own established
definitions of abuse. According to CMS, the state's definitions may be
used when citing homes for deficiencies under their state licensure
program but, when performing a federal survey, CMS noted that the
federal definition must be used. CMS added that it would clarify this
distinction with the states. However, we believe that it is also of
great importance to clarify the definition of abuse that states should
apply when considering whether nurse aides have abused residents and
consequently may have this action reflected in their nurse aide
registry files.
CMS agreed to consider our fifth recommendation”to shorten the time
frames for determining whether to include findings of abuse in the
nurse aide registry. CMS acknowledged that a considerable amount of
time may elapse before reports of abuse are finalized and reported to
the nurse aide registry. CMS added this is largely attributable to
steps associated with due process. CMS pointed out that, with the
exception of the time taken by the states to substantiate abuse
allegations, all of these time frames are specified by regulation.
However, the regulations do not specify a time frame for making a
final decision once the hearing has been completed and the hearing
record has been closed. CMS said it would take our
recommendation into account when considering changes to these
regulations. We believe that reducing this time period will provide
residents with greater certainty that they will not be exposed to
abusive aides.
We received oral comments from the Coordinator of DOJ's Nursing Home
and Elder Justice Initiative. She agreed with the findings in our
report. She also added that resident abuse may be underestimated, as
studies suggest a significant number of abuse cases are never
reported. She said that, in order to respond appropriately to victims
of abuse, local law enforcement and other "first responders" such as
firefighters and paramedics, would benefit from special training. In
her view, this training should include guidance regarding how to
distinguish signs of physical abuse from other types of injuries,
advice on interviewing elderly and confused residents, and
investigative techniques and evidence preservation strategies unique
to the nursing home setting. Our work did not include an evaluation of
the training programs offered to law enforcement officials or "first
responders." In addition, she pointed out that DOJ could become
actively involved in investigating abuse allegations in certain
situations, such as those involving facilities where a pattern of
abuse has been detected and instances where nursing home managers or
employees have made false statements to state surveyors regarding
resident care. In addition to these comments, we received technical
comments from the FBI, which we incorporated as appropriate.
We received comments from all three of the state survey agencies we
visited as well as the Illinois MFCU. These agencies described
initiatives they have undertaken to increase awareness of resident
abuse and improve reporting and offered technical comments, which we
incorporated as appropriate. Although we provided our draft to the
Georgia MFCU, it did not offer any comments.
Finally, we received comments from representatives of AHCA and AAHSA.
Both organizations generally agreed with our recommendations. AHCA
representatives told us that they suspect that abuse of nursing home
residents is underreported. They said that they support providing more
training to both caregivers and law enforcement officials. They noted
that such training could discourage abusive behavior by nursing home
staff and improve law enforcement's responsiveness to instances of
resident abuse.
Our work did not include an evaluation of such training programs.
Representatives of both AHCA and AAHSA indicated that they strongly
support the establishment of a national nurse aide registry and a
national criminal background check for nursing home employees. In
addition, the AAHSA representatives said that they strongly agreed
with our recommendation to clarify the definition of abuse. They noted
that the definition of abuse has long been the subject of debate and
its clarification by CMS is in the interest of residents, as well as
nursing home management and staff. In addition to these comments, both
AHCA and AAHSA offered technical comments, which we have incorporated
as appropriate.
As agreed with your offices, unless you announce its contents earlier,
we plan no further distribution of this report until 30 days after its
issuance date. At that time, we will send copies to the CMS
administrator, interested congressional committees, and other
interested parties. We will then make copies available to others upon
request. If you or your staff have any questions about this report,
please call me at (312) 220-7600. An additional GAO contact and other
staff who made major contributions to this report are listed in
appendix III.
Signed by:
Leslie G. Aronovitz:
Director, Health Care”-Program Administration and Integrity Issues:
[End of section]
Appendix I: Scope and Methodology:
To determine the federal requirements for responding to, and
investigating allegations of, abuse of nursing home residents, we
reviewed federal laws and regulations. We interviewed officials from
the Centers for Medicare and Medicaid Services (CMS ) regarding these
requirements and also discussed their oversight of the state survey
agencies responsible for surveying nursing homes and certifying their
compliance with federal laws and regulations. We conducted our work in
three states with relatively large nursing home populations”Illinois,
Georgia, and Pennsylvania”and discussed these requirements with survey
and law enforcement officials in these states. In addition, we met
with officials from the three states' departments on aging and local
area agencies on aging because they may also receive abuse referrals
and conduct investigations. We reviewed and discussed relevant state
policies and procedures with these officials. Finally, to become
familiar with the general progression of abuse investigations, we
attended conferences and consulted with experts in the field of elder
abuse.
For each of the three states we visited, we reviewed cases involving
allegations of physical and sexual abuse.[Footnote 32] Most of these
cases were opened by Medicaid Fraud Control Units (MFCUs) or reported
to state survey officials in 1999 or 2000. We focused on the survey
agencies' and MFCUs' files. We did not review any of the allegations
investigated by the state departments on aging or local area agencies
on aging because of agency officials' concerns with confidentiality.
In total, we reviewed 158 cases to determine the circumstances and
nature of the cases, the extent to which the allegations were
investigated and prosecuted, and the timeliness of referrals and
investigations. However, our findings cannot be generalized or
projected. To assess the timeliness of reporting abuse allegations, we
used the information from our case review and compared these results
to federal and state guidelines. For cases that the state survey
agency referred to the MFCU, we calculated the number of days between
agency receipt and referral to the MFCU. We also determined the number
of convictions resulting from these referrals.
At the Illinois Department of Public Health (IDPH)”the state survey
agency”we identified and reviewed 50 cases involving physical or
sexual abuse that were reported by individuals as complaints or by
nursing homes in incident reports. All of these allegations were
referred by IDPH to its MFCU. These included all of the allegations of
physical or sexual abuse for which the MFCU had opened investigations
in 1999 and closed at the time of our review.[Footnote 33] We reviewed
the relevant files at both agencies. We also examined 1 month of
referrals that the MFCU reviewed but ultimately did not investigate.
These referrals typically involved bruises of unknown origin, old
injuries, a lack of witnesses, or instances in which the intent to
hurt a resident was questionable or unfounded.
In Georgia, we reviewed 52 abuse allegations. Of these, 14 were either
complaints or incident reports that the state Department of Human
Resources (DHR)-”in which Georgia's state survey agency is housed-”had
referred to the MFCU in 1999. These 14 cases represent all of the
allegations of physical or sexual abuse that DHR referred to the MFCU
in 1999 and for which the MFCU opened and subsequently closed an
investigation. We reviewed these 14 cases at both agencies. Because
DHR does not refer all physical and sexual abuse cases to the MFCU, we
judgmentally selected and reviewed 38 additional abuse cases that DHR
had received but had not referred to the MFCU. We chose these
additional cases from the survey agency's 1999 log of complaints,
which included 60 physical and 14 sexual abuse cases, as well as from
its 1999 log of incident reports, which included 361 physical and 47
sexual abuse cases. We selected cases based on the proportion of the
allegations that involved physical and sexual abuse, as well as
complaints and incident reports.
Because local law enforcement in Pennsylvania is assigned primary
responsibility for investigating the physical or sexual abuse of
nursing home residents, our case file selection for this state
differed from that of Illinois and Georgia. As the MFCU is typically
not involved in these cases, the files we reviewed included 56 cases
reported to Pennsylvania's state survey agency-”the Department of
Health (DOH)-”in 1999 and 2000. These cases included a mix of
complaints and incident reports as well instances of both physical and
sexual abuse.
To identify agencies that might accept reports of abuse, we obtained
several telephone books from each state, including those for large and
small metropolitan areas. We reviewed government and consumer pages to
identify complaint telephone numbers for state survey agencies, other
social service and law enforcement agencies (excluding local police
departments), and other organizations, such as long-term care
ombudsmen, that appeared to be potential places for reporting abuse of
nursing home residents. We called these numbers to verify that the
organization would accept such a complaint. We also made follow-up
calls when we were referred elsewhere.
To determine the extent of law enforcement's involvement in
investigating abuse allegations, we interviewed MFCU officials in
Illinois, Georgia, and Pennsylvania. We also spoke with
representatives from 19 police departments from these states”including
both urban and rural areas”and four prosecutors' offices. Some of
these departments and prosecutors were chosen because of their
involvement in some of the cases we reviewed.
To determine the extent to which nursing homes were sanctioned for
violations related to abuse, we identified from the files we reviewed
the nursing homes that had been cited for deficiencies related to the
abuse allegations. We then searched state Web sites to obtain surveys
pertaining to these homes from the time of the abuse allegation to the
present and reviewed the surveys to determine what, if any, sanctions
had been recommended.
To evaluate whether sufficient safeguards exist to protect residents
from abusive individuals, we reviewed federal and state laws regarding
criminal background check requirements for nursing home employees and
state nurse aide registries. We also interviewed state survey agency
officials and obtained relevant documentation.
We tested the accuracy of online nurse aide registry Web sites in each
state we visited to verify that findings of abuse had actually been
posted to the site. Survey officials in the three states provided us
with lists of nurse aides who had been found to be abusive through
their administrative processes. Using those lists, we tested the
registries to determine whether all names and information provided to
us were accurately reflected by each state's Web site. In addition, we
obtained copies of state agencies' 1999 and 2000 quarterly bulletins
that were sent to nursing homes and compared the names of nurse aides
with abuse findings listed in these bulletins to the list originally
obtained from the state agency.
In Georgia and Illinois,[Footnote 34] we reviewed lists of aides
notified by the survey agencies that their registry files would be
annotated to reflect a finding of abuse. From these lists, we
determined the number of aides requesting an administrative hearing
and the number of findings actually entered in the registries. In
Pennsylvania, we reviewed a similar list, although it only included
those aides who actually had findings of abuse annotated in the
registry. For all three states, we calculated the average length of
time between when the state notified aides of its plan to annotate the
registry to the date the agency ordered that the findings be posted.
Finally, we interviewed state agency officials about their policies
regarding professionals and other staff who abuse nursing home
residents.
[End of section]
Appendix II: Comments from the Centers for Medicare and Medicaid
Services:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: March 1, 2002:
To: Leslie G. Aronovitz :
Director, Health Care”Program Administration and Integrity Issues:
General Accounting Office:
From: [Signed by] Thomas A. Scully:
Administrator:
Centers for Medicare & Medicaid Services:
Subject: General Accounting Office (GAO) Draft Report, Nursing Homes:
More Can Be Done to Protect Residents from Abuse (GA0-02-312):
Thank you for the opportunity to review and comment on the above-
referenced draft report. The information gathered by GAO in
conjunction with information we have gathered from our own reports,
will help us make sound policy decisions about how best to protect
residents in nursing homes from abuse and neglect. This report helps
to validate some of the information we have gathered while working on
the Nursing Home Complaint Improvement Project and on a future Report
to Congress: "The Role of the Nurse Aide Registry, Impact of
Institutional Environmental Factors, and Effectiveness of Other
Sanctions in Preventing Abuse and Neglect in Nursing Homes. The
Nursing Home Complaint Improvement Project is scheduled to be
completed this fall and the Report to Congress should be released by
the end of this summer.
We are currently focusing our attention on developing solutions to
this problem and we appreciate GAO's commitment to helping us achieve
that goal. Along with beneficiary advocates, the nursing home
industry, as well as other stakeholders, we are currently
investigating the feasibility of expanding an existing program to
allow us to create policies to combat the problems of abuse and
neglect. The Centers for Medicare & Medicaid Services (CMS) remains
committed to protecting nursing homes residents from harm. Thank you
again for the opportunity to review this report.
We appreciate the effort that went into this report and the
opportunity to review and comment on the issues it raises. Our
comments on the GAO recommendations follow:
GAO Recommendation:
Ensure that state survey agencies immediately notify local law
enforcement agencies or Medicaid Fraud Control Units (MFCUs) when
nursing homes report allegations of resident physical or sexual abuse
or when the survey agency has confirmed complaints of alleged abuse.
CMS Response:
The CMS will instruct state survey agencies that they are to
immediately notify local law enforcement or MFCUs any time the survey
agency confirms a complaint of abuse. The CMS will thoroughly review
this recommendation when we evaluate all the information and
recommendations that result from our Complaint Improvement Project.
GAO Recommendation:
Accelerate its education campaign on reporting nursing home abuse by
(1) distributing its new poster with clearly displayed complaint
telephone numbers, and (2) requiring state survey agencies to ensure
that these numbers are prominently listed in local telephone
directories.
CMS Response:
We have a developed a poster that contains the phone numbers for the
state ombudsman, the state survey agency and the CMS 1-800-Medicare
number and are working with the Department to release it as soon as
possible. We will request that states ensure that the abuse contact
numbers are prominently listed in local telephone directories.
In addition, as part of our educational activities, three videos were
prepared for the nursing home industry. They are, "The Importance of
Being a Certified Nursing Assistant, Choosing Long Term Care, and
Quality Living in a Nursing Home." The videos are ready for release
pending Department clearance. The advocates and nursing home provider
groups have examined these materials and all support the use and
distribution of the products.
GAO Recommendation:
Systematically assess state policies and practices for complying with
the Federal requirement to prohibit employment of individuals
convicted of abusing nursing homes residents and, if necessary,
develop more specific guidance to ensure compliance.
CMS Response:
The CMS will review state policy and practice and reissue guidance
relating to the Federal prohibition of employment of individuals
convicted of abusing nursing home residents. In July 1999 CMS
published Task 50 ” Abuse Prohibition Review and Investigative
Procedures in the State Operations Manual ” Survey Procedures for Long-
Term Care Facilities. The objective is to determine if the facility
has developed and operationalized policies and procedures that
prohibit abuse, neglect, involuntary seclusion, and misappropriation
of property for all residents. The review includes components on the
facility's policies and procedures as contained in the Guidance to
Surveyors at 42 CFR 483.13(c), F226. As part of the protocol, state
surveyors evaluate whether the facility had screened potential
employees for a history of abuse, neglect, or mistreating residents as
defined by applicable requirements at 42 CFR 483.13(c)(1)(ii)(A) and
(B). This includes attempting to obtain information from previous
employers and/or current employers, and checking with appropriate
licensing boards and registries. Surveyors cite facility noncompliance
contained in the guidance to surveys at 42 CFR 48.13 (c) (1) (ii) and
(iii), F225 when the facility is deficient in its commitment to hiring
employees without histories of abusive behavior or in reporting and
investigating allegations of abuse. The percentage of facilities cited
for failures at F225 has steadily increased from 5.8 percent the first
quarter in 1998 to 12 percent in the last quarter in 2000.
In 1998, CMS established the Abuse and Neglect Prevention Forum (the
Forum) in an effort to raise awareness of the extent of the abuse and
neglect problem affecting the elderly and people with disabilities.
The Forum consisted of representatives from a cross-section of
Federal, state, provider, and advocacy organizations. The group
identified seven key components that can potentially reduce, detect,
and prevent abuse and neglect. Pre-employment screening of potential
staff is one of the seven key components.
In May 2001, CMS implemented an abuse and neglect detection and
prevention train-the-trainer program for representatives from each
state agency. In an October 2001 memorandum sent to the Associate
Regional Administrators of the Division of Medicaid and State
Operations and the state survey agency directors, CMS requested states
to complete training within their respective areas by March 20, 2002.
To monitor the number and type of individuals trained, we have asked
each state to complete and submit a tracking plan. We will evaluate
whether more guidance is needed to ensure the Survey Protocol and the
Abuse and Neglect Prevention Program are being followed by each state
survey agency. We will also evaluate the need to implement a policy to
assess state policies and practices for complying with the Federal
requirement to prohibit employment of individuals convicted of abusing
nursing home residents.
GAO Recommendation:
Clarify the definition of abuse and otherwise ensure that states apply
the definition consistently and appropriately.
CMS Response:
The regulatory definition of abuse is found in 42 CFR 488.301. This
definition is reinforced and reiterated in the State Operations Manual
Guidance to Surveyors in Long Term Care Facilities, and the CMS Abuse
and Neglect Training manual that serve as a basis for training state
surveyors. We want to clarify that a state can use any definition it
has established when citing deficiencies under its own state licensure
program. However, when the state is performing a Federal survey, the
Federal definition must be followed when citing deficiencies for
abuse. We will clarify this with state agencies.
GAO Recommendation:
Shorten the state survey agencies' timeframes for determining whether
to include findings of abuse in the nurse aide registry.
CMS Response:
Since the findings of abuse must be substantiated, the accused
notified in writing, and any due process for a hearing completed prior
to reporting the substantiated findings to the nurse aide registry,
considerable time may pass before reports to the registry are made.
Currently, much of the timeframes are defined in regulation. The only
part of the process not defined by regulation is the time it takes the
state to substantiate abuse. The CMS can review these timeframes when
changes to the regulations are considered.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Geraldine Redican-Bigott (312) 220-7678:
Staff Acknowledgments:
Lynn Filla-Clark, Tiffani Green, Barbara Mulliken, and Christi Turner
also made key contributions to this report.
[End of section]
Related GAO Products:
Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides
Is a Growing Concern. [hyperlink,
http://www.gao.gov/products/GAO-01-750T]. Washington, D.C.: May 17,
2001.
Nursing Homes: Success of Quality Initiatives Requires Sustained
Federal and State Commitment. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS-00-209]. Washington, D.C.:
September 28, 2000.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-197]. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-6]. Washington, D.C.: November
4, 1999.
Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies
to Better Ensure Quality Care. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS-00-27]. Washington, D.C.:
November 4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-154R]. Washington, D.C.:
August 13, 1999.
Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will
Require Continued Commitment. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS-99-155]. Washington, D.C.: June
30, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing
Homes Has Merit. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157]. Washington, D.C.: June
30, 1999.
Nursing Homes: Complaint Investigation Processes in Maryland.
[hyperlink, http://www.gao.gov/products/GAO/T-HEHS-99-146].
Washington, D.C.: June 15, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-80]. Washington, D.C.: March
22, 1999.
Nursing Homes: Stronger Complaint and Enforcement Practices Needed to
Better Ensure Adequate Care. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS-99-89]. Washington, D.C.: March
22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46]. Washington, D.C.: March
18, 1999.
California Nursing Homes: Federal and State Oversight Inadequate to
Protect Residents in Homes With Serious Care Violations. [hyperlink,
http://www.gao.gov/products/GAO/T-HEHS98-219]. Washington, D.C.: July
28, 1998.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-98-202]. Washington, D.C.: July
27, 1998.
[End of section]
Footnotes:
[1] On June 14, 2001, the Secretary of Health and Human Services
announced that the name of the Health Care Financing Administration
had been changed to the Centers for Medicare and Medicaid Services. In
this report, we will refer to HCFA where our findings apply to
operations that took place under that organizational structure and
name.
[2] MFCUs conduct investigations into criminal activity in the
Medicare and Medicaid program. In some states, MFCUs may be located in
other agencies, such as the state police, instead of the Office of the
Attorney General.
[3] U.S. General Accounting Office, Nursing Homes: Complaint
Investigation Processes Often Inadequate to Protect Residents,
[hyperlink, http://www.gao.gov/products/GAO/HEHS-99-80] (Washington,
D.C.: Mar. 22, 1999).
[4] U.S. General Accounting Office, Nursing Homes: Additional Steps
Needed to Strengthen Enforcement of Federal Quality Standards,
[hyperlink, http://www.gao.gov/products/GAO/HEHS-99-46] (Washington,
D.C.: Mar. 18, 1999).
[5] U.S. General Accounting Office, Nursing Homes: Sustained Efforts
Are Essential to Realize Potential of the Quality Initiatives,
[hyperlink, http://www.gao.gov/products/GAO/HEHS-00-197] (Washington,
D.C.: Sept. 28, 2000).
[6] CMS defines abuse as the willful infliction of injury,
unreasonable confinement, intimidation, or punishment with resulting
physical harm, pain, or mental anguish (42 C.F.R. § 488.301).
[7] Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky,
"Sexual Abuse of Nursing Home Residents," Journal of Psychosocial
Nursing, 38, no. 6, (June 2000); and Brian K. Payne and Richard
Cikovic, "An Empirical Examination of the Characteristics,
Consequences, and Causes of Elder Abuse in Nursing Homes," Journal of
Elder Abuse and Neglect (1995).
[8] The three states we visited require that certain individuals, such
as physicians, social workers, and law enforcement officers report
suspected abuse to state survey agencies.
[9] The Older Americans Act of 1965 (P.L. 89-73) established the Long-
Term Care Ombudsman program.
[10] Under certain circumstances, some individuals would be exempt
from this training, such as student nurses or nurses trained in
another country.
[11] Nursing homes in the states we visited have several means of
checking the nurse aide registries to determine whether aides are in
good standing and eligible for employment. Homes receive quarterly
bulletins listing all disqualified aides in their state. In addition,
they may obtain this information from their state survey agency's Web
site or by calling the survey agency.
[12] Nurse aides may petition the state to remove findings of neglect
after one year.
[13] P.L. 95-142.
[14] Eleven of the cases from Illinois were first reported in 1998.
[15] Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky,
"Sexual Abuse of Nursing Home Residents," Journal of Psychosocial
Nursing, 38, no. 6 (June 2000).
[16] Paul D. Hodges, "National Law Enforcement Programs to Prevent,
Detect, Investigate, and Prosecute Elder Abuse and Neglect in Health
Care Facilities," Journal of Elder Abuse and Neglect (1998).
[17] Although the same poster would be used nationwide, nursing homes
would receive posters listing any telephone numbers unique to their
state.
[18] The survey agency in Pennsylvania referred three abuse cases to
its MFCU in 1999 because, by agreement, this MFCU typically
investigates neglect matters, while local law enforcement agencies
investigate abuse. Consequently, Pennsylvania's approach does not lend
itself to a comparison with Illinois and Georgia.
[19] The MFCU did not open investigations for each of the 300
referrals it received from the state survey agency. In some instances,
the MFCU obtained insufficient information to pursue an investigation.
In other instances, it conducted preliminary work and concluded that
continuing the investigation was not warranted.
[20] Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky,
"Sexual Abuse of Nursing Home Residents," Journal of Psychosocial
Nursing, 38, no. 6 (June 2000).
[21] Illinois requires the background check on employees providing
direct care, except for licensed personnel.
[22] Under P.L. 105-277, Omnibus Consolidated and Emergency
Supplemental Appropriations Act, 1999, 112 Stat. 2681-73, nursing
homes may obtain national, fingerprint-based background checks from
the FBI for applicants for employment in positions involving direct
patient care.
[23] Under Pennsylvania law, applicants who have lived in the state
less than two years may be employed on a provisional basis for up to
90 days while their FBI background checks are being completed.
[24] A 1998 survey conducted by the Department of Health and Human
Services Office of Inspector General reported that Illinois was the
only state with this requirement (Safeguarding Long-Term Care
Residents, A-12-97-00003 (Washington, D.C.: Sept. 14, 1998).
[25] CMS officials told us that a state must follow the federal
definition of abuse when it is performing a federal survey.
[26] As a result, this aide was sentenced to 2 years probation,
directed to complete 100 hours of community service, and prohibited
from employment that would involve contact with the elderly or
disabled.
[27] Thirty-four of the Pennsylvania case files we reviewed involved
allegedly abusive nurse aides. As of January 2002, none of these aides
had findings of abuse reflected in their registry records. In order to
assess the time frames of Pennsylvania's abuse determinations, we
reviewed files of all nurse aides who had been found abusive in 1999.
[28] Department of Health and Human Services Office of Inspector
General, Safeguarding Long-Term Care Residents, A-12-97-00003
(Washington, D.C.: Sept. 14, 1998).
[29] Two of these employees were terminated. The third was a security
guard, employed by a private company, who was removed from duty at the
nursing home.
[30] These cases involved alleged physical abuse, but the residents
did not sustain apparent injuries.
[31] Because of the limited role of the Pennsylvania MFCU in abuse
cases, we did not provide it a copy of our draft, although we briefed
the MFCU officials on its contents.
[32] Our objectives were limited to allegations of physical and sexual
abuse. Thus, we omitted all cases with allegations solely of neglect.
In addition, we omitted those that were still under investigation at
the time of our review.
[33] Eleven of these cases were reported to IDPH in 1998.
[34] In Georgia, this list included letters regarding findings of
abuse, while in Illinois this list included all aides sent letters
regarding findings of abuse, neglect, or theft.
[End of section]
GAO‘s Mission:
The General Accounting Office, the investigative arm of Congress,
exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO‘s commitment to good government is reflected in its
core values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO‘s Web site [hyperlink,
http://www.gao.gov] contains abstracts and full text files of current
reports and testimony and an expanding archive of older products. The
Web site features a search engine to help you locate documents using
key words and phrases. You can print these documents in their
entirety, including charts and other graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as ’Today‘s Reports,“ on
its Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
[hyperlink, http://www.gao.gov] and select ’Subscribe to daily E-mail
alert for newly released products“ under the GAO Reports heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are
$2 each. A check or money order should be made out to the
Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are
discounted 25 percent. Orders should be sent to:
U.S. General Accounting Office: 441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov:
(202) 512-4800:
U.S. General Accounting Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
