-- ; I REPORT TO THE CONGRESS Problems In Providing Proper Care To Medicaid ‘And Medicare Patients In Skilled Nursing Homes B-764037f3j! P Department of Health, Education, and Welfare BY THE COMPTROLLER GENERAL OF THE UNITED STATES . COMPTROLLER GENERAL 0; 1 HE CNiTED STATES WASHINGTON DC 20548 B- 164031( 3) To the President of the Senate and the Speaker of the House of Representatives This 1s our report on problems m providing proper care to Medicaid and Medicare patients m skilled nursmg homes. These programs are admmlstered at the Federal level by the Social and Rehabllltatlon Service (Medicaid) and the Social Security Admmlstratlon (Medlcare), Department of Health, Ed- ucation, and Welfare. Our review was made pursuant to the Budget and Accountmg Act, 1921 (31 U.S C. 53), and the Accounting and Auditing Act of 1950 (31 U.S.C. 67) Copies of this report are being sent to the Darector, Office of Management and Budget, and to the Seqetary of Health, Educa- tlon, and Welfare. Comptroller General of the Unxted States - 50TH ANNIVERSARY 1921- 1971 COMPTROLLER GENERAL ‘S PROBLEMSIN PROVIDING PROPERCARE TO MEDICAID REPORT TO THE CONGRESS AND MEDICARE PATIENTS IN SKILLED NURSING HOMES Department of Health, Education, and Welfare B-164031(3) DIGEST ---m-e WHY THE REVIEW WAS MADE America's "age 65 and over" population has Increased from 9 million in 1940 to 20 million in 1970. As persons become older their need for care lncreasesp and, for those requiring more intensive care, this means in- stitutional care in hospitals or nursing homes. Nursing-home care 1s generally classlfled as: Skilled nursing care (Medicaid) and extended care IMedicare)--Periodic medical and dally nursing care without hospltal- ization. Intermediate care--Care over and above that classified as room and board but less than skilled care. Supervised care--Prtmanly room and board with some supervision. Because the cost of such care has increased beyond the financial capa- bility of State and local governments, Federal financial assistance has been made available through the Medicaid and Medicare programs adminis- tered by the Department of Health, Education, and Welfare (HEW). For example, under these two programs the Federal Government expended in 1969 about $1 billion for skilled nursing care and extended care--pn- marily for the elderly. The Congress 1s interested in answers to questions about skilled nurs- ing homes, such as: --Are skilled nursing homes provldlng proper care to patients? --Are patients being provided with levels of care more intensive than needed? The States of Michigan, New York, and Oklahoma have about 1,200 nursing homes certified as skilled In 1969 these States expended $336 million of Federal, State, and local funds to care for Medicaid patients ln these homes, about half of the expenditures represented the Federal share. Tear -- Sheet MAY28,1971 t- The General Accountlng Office Y GAO) vlslted 90 nursing homes (30 ln each State) having 5,581 Medlcald patients and examined into whether the homes were adhering to the requirements established by HEW for par- tlclpatlon ln the Medlcald program as skilled nursing homes. For those homes which also served Medlcare patients, GAO examined into whether the homes were adhering also to Medicare requirements. GAO examined also into whether tt appeared that a less lntenslve level of care would sattsfactorlly meet the patients' needs. FINDINGSANDCONCLUSIONS Many of the skilled nursing homes GAO visited may not have provided proper care and treatment for their Medicaid and Medicare patients. (See p 9.) Many patients in the nursing homes GAO visited may not have needed skilled care and should have been provided with less lntenslve--and less costly--care (See p. 25 ) Care and treatment gqzvento n.urs%q-home patcents Many nursing homes partlclpatlng in the Medicaid program--and in some cases the Medicare program--were not adhering to Federal requirements for participation As a result, the health and safety of the patients may have been Jeopardized, since the homes' providing proper skllled- nursing-home care 1s directly related to their meeting established re- quirements for skilled nursing homes. This problem resulted primarily from weaknesses ln State procedures for certifying ellglblllty of nursing homes and from ineffective State and HKWenforcement of Federal re ulrements which include State licensing * requirements (See pp. 9 to !4*) Following are examples of deficiencies by nursing homes in meeting re- quirements for partlclpatlon ln the Medicaid and Medicare programs found by GAO --Patients were not receiving required attention by physlclans. HEW requires that Medicaid and Medicare patients ln skilled nursing homes be seen by physicians at least once every 30 days. Neverthe- less, 47 of the 90 homes were not complying with this requirement. I Of the 47 homes, 12 were approved also for Medicare --Patients were not receiving required nursing attention. Of the 90 nursing homes vlslted, 16 did not have a full-time registered nurse ln charge of nursing service, 27 did not have a quallfled?nurse in charge of each B-hour shift, and 20 did not meet State licensing re- quirements for nurse-patient ratios. In total, 48 homes accounted 2 i for the 63 nursing deflclencles. Eight of the 48 homes were ap- proved also for Medicare. a --Many nursing homes did not have complete fire protection programs. Of the 90 homes vlslted, 44 did not comply with HEWregulations which require that simulated fire drills be held at least three times a year for each 8-hour shift in each home participating in the Medicaid and Medicare programs. Seven of the 44 homes were ap- proved also for Medicare LeveZ of care needed by nwwmg-home patzents Patients have been placed ln skilled nursing homes even though their needs are for less intensive and less costly care which should be provided ln other facllltles, however, alternative facllltles in which less intensive levels of care could be provided were limited. This not only could result ln unnecessary costs but also--and perhaps more important--could make unnecessary demands on professional care avall- able for patients who are in need of such care. GAObelieves that the primary cause of this problem 1s that HEWhas not developed a yardstick o,r cntena for measuring the need for skilled care under the Medicaid program. In the absence of such criteria, each State follows its own procedures for determining the need for skllled- nursing-home care. (See pp. 25 to 37 ) The Social Security Admlnlstratton has developed criteria defining skilled nursing care under the Medicare program. In the absence of Medicaid criteria, the State of Mlchlgan--to assist those persons who normally evaluate patient needs--has expllcltly de- fined the medical and nursing-care characterlstlcs that it believes that patients should have to qualify for skilled-nursing-home care, In Michigan--the only one of the three States ln GAO's review that had developed such critena-- the State's evaluators accompanied GAO to selected nursing homes and, at GAO's request, evaluated patient needs. The evaluators concluded that, of the 378 patients whose needs were evaluated, 297, or about 79 percent, did not require skllled-nurslng- home care. (See p. 28.) GAO could not have similar evaluations made ln New York and Oklahoma since these States had not developed such criteria The evaluators ad- vised GAO, however, that lf, ln a limited test, the medical and nursing-care characterlstlcs of New York and Oklahoma patients were Tear Sheet measured against the Michigan cr-rterla, a similar hrgh percentage (71 and 85 percent, respectively) of the patients would not require skilled care. (See pp 26 and 34 ) Further, recent reviews of patlent needs by professional health teams of voluntary areawide health planning agencies In 10 counties in New York, using crlterla established by the agencies' staffs, showed that 25 to 35 percent of the patlents in skilled nursing homes did not re- quire the level of care provided In those homes. (See p. 30.) GAO did not Judge the reasonableness of any criteria, Including Mlchl- gan's, because of the medical expertise and Judgments involved GAO IS of the opinion that criten a developed by HEWwould help plnpolnt more precisely the extent to which skilled or less costly nursing care 1s needed and, as a result, l~mlted human resources could be allocated to meet more effectively the most critIca nursing-care needs. Under the exlstlng, unreallstlc procedures, decisIonmakers often are confronted with two choices--skilled nursing care or no care at all. RECOiWdENDATIONS OR SUGGESTIONS The Secretary of HEW should instruct the Social and RehabtlitatIon Ser- vice and the HEWAudit Agency to continue and increase their monitoring of States' adherence to HEW'S requirements for nursing homes' partlcipa- bon In the MedIcaId program as skllled nursing homes (See p. 22 ) The Secretary of HEW, to assist the States in determlnlng whether Medl- cald patients are In need of skilled care, should Issue crltena set- ting forth the medlcal and nursing care required for patients to be classified as being in need of skilled-nursing-home care. GAO suggests that conslderatlon be given to the experience with the criteria already developed for the Medicare program. (See p. 36.) The Secretary of HEWshould instruct the Social and RehabIlltatlon Ser- vice and the HEWAudit Agency to continue and Increase their monitoring to ensure that States are following exlstlng HEWMedicaid regulations relating to the admlsslon of patients to skilled nursing homes and are periodically determining whether patients admitted to skilled nursing homes are still in need of skalled care. (See p. 36.) AGENCY ACTIONSANDUNRESOLVED ISSUES HEW stated --That the Social and Rehabllltation Service had implemented a new I monitoring and liaison program In each regional office that re- quired the regional offices to maintain closer relationshIps with State agencies It required also that regional officials make more frequent vlslts and make deta7led revlews of State MedIcaid 4 operations, which should aid in the reduction of such deflclencles as those discussed in this report. (See p 22.) --That the Social and Rehabilitation Service planned to issue, within 6 months, guidelines to assist the States in evaluating a patient's need for skilled nursing care and services under the Medicaid pro- gram and that, where applicable, these guIdelines would consider areas of common interest, as outlined in criteria developed for the Medicare program. (See p. 37.) The actions taken or promised by HEW should strengthen administration of the Medicaid and Medicare programs. In view of the substantial Federal and State expenditures under these programs, prompt attention should be given to the rmplementatron of the promised admlnlstratlve actions. MATTERS FORCOA'SIDER4T'IoN BY THECONGRESS This report contains no recommendations requiring legislative action by the Congress. It does contain lnformatlon on weaknesses In HEW's admln- tstratlon of MedIcaid and Medicare programs for nursing homes, sugges- tions for their correction or improvement, and corrective actions taken or promised by HEW. This lnformatlon should be of assistance to commit- tees and individual members of the Congress in connection with their leglslatlve and oversight responslbllltles relating to the Medicaid and Medicare programs. Tear Sheet 5 Contents Page DIGEST 1 CHAPTER 1 INTRODUCTION 6 MedIcaid nursing homes 7 Other nursing or related care for el- derly 7 Medicaid programs in States reviewed 8 2 ARE SKILLED NURSING HOMESPROVIDING PROPER CARE TO PATIENTS? 9 Inadequate nursing services 10 Lack of required physician visits 12 Absence of social and dietary services 12 Deficrencies in meeting requirements re- latlng to patient safety 14 Factors contributing to nursing-home de- ficlencies 16 Recent HEW actions 21 Conclusions 21 Recommendation to the Secretary of Health, Education, and Welfare 22 Agency comments and actions 22 3 ARE PATIENTS BEING PROVIDED WITH LEVELS OF CARE MORE INTENSIVE THAN NEEDED? 25 Michigan 27 New York 30 Oklahoma 32 Evaluation of patient needs using Michi- gan's criteraa 34 Recent HEW actions 35 Conclusions 36 Recommendations to the Secretary of Health, Education, and Welfare 36 Agency comments and actions 37 4 SCOPE OF REVIEW 38 APPENDIX Page I Nursing homes not fully in compliance with Medicaid requrrements including State lx- tensing requirements 41 II Letter dated March 23, 1971, from the As- sistant Secretary, Comptroller, Department of Health, Education, and Welfare, to the General Accounting Office 42 III Principal officials of the Department of Health, Education, and Welfare having re- sponslbillty for the matters discussed in this report 49 ABBREVIATIONS GAO General Accounting Office HEW Department of Health, Education, and Welfare SRS Social and Rehabllltation Service SSA Social Security Administration COMPTROLLER GENERAL'S PROBLEMSIN PROVIDINGPROPERCARE TO MEDICAID REPORT TO THECONGRESS AND MEDICARE PATIENTSIN SKILLEDNURSING HOMES Department of Health, Education, and Welfare B-164031(3) DIGEST _--e-m WHYTHEREVIEWWASMADE America's "age 65 and over" population has increased from 9 mllllon In 1940 to 20 million in 1970 As persons become older their need for care increases, and, for those requiring more intensive care, this means in- stltutlonal care in hospitals or nursing homes Nursing-home care 1s generally classlfled as: Skilled nursing care (MedIcaid) and extended care (Medicare)--Perlodlc medical and dally nursing care wlthout hospltal- ization Intermediate care--Care over and above that classified as room and board but less than skilled care. Supervised care--Pnmanly room and board with some supervision Because the cost of such care has lnc.reased beyond the financial capa- bility of State and local governments, Federal financial assistance has been made avallable through the Medicaid and Medicare programs adminis- tered by the Department of Health, Education, and Welfare (HEW). For example, under these two programs the Federal Government expended in 1969 about $1 billion for skilled nursing care and extended care--prl- marlly for the elderly. The Congress 1s interested in answers to questions about skilled nurs- ing homes, such as* --Are skilled nursing homes providing proper care to patients? --Are patients being provided with levels of care more intensive than needed? The States of Michigan, New York, and Oklahoma have about 1,200 nursing homes certified as skilled. In 1969 these States expended $336 million of Federal, State, and local funds to care for Medicaid patients in these homes, about half of the expenditures represented the Federal share The General Accounting Offlce (GAO) vlslted 90 nurs-rng homes (30 in each State) having 5,581 MedIcaId patients and examined into whether the homes were adhering to the requirements established by HEW for par- tlclpatlon in the MedicaId program as skilled nursing homes. For those homes which also served Medicare patients, GAO examined into whether the homes were adhering also to Medicare requirements. GAO examined also Into whether it appeared that a less lntenslve level of care would satisfactorily meet the patients' needs. FINDINGSAND CONCLUSIONS Many of the skilled nursing homes GAO vlslted may not have provided proper care and treatment for their Medicaid and Medicare patients. (See p 9 ) Many patients in the nursing homes GAO visited may not have needed skilled care and should have been provided with less tntenslve--and less costly--care. (See p 25 > dare and treatment pven to nurswq-home pa-bents Many nursing homes partlclpatlng in the Medicaid program--and in some cases the Medicare program--were not adhering to Federal requirements for participation. As a result, the health and safety of the patients may have been Jeopardized, since the homes' provldlng proper skllled- nursing-home care 7s directly related to their meeting established re- qulrements for skilled nursing homes. This problem resulted primarily from weaknesses in State procedures for certifying elIglblllty of nursing homes and from Ineffective State and HEWenforcement of Federal re uirements which include State llcenslng requirements. (See pp. 9 to g4.1 Following are examples of deflclencIes by nursing homes In meeting re- quirements for participation in the Medicaid and Medicare programs found by GAO --Patients were not receiving required attention by physlclans. HEW requires that Medicaid and Medicare patients in skilled nursing homes be seen by physicians at least once every 30 days. Neverthe- less, 47 of the 90 homes were not complying with this requirement. Of the 47 homes, 12 were approved also for Medicare --Patients were not recelvlng required nursing attention, Of the 90 nursing homes vlslted, 16 did not have a full-time registered nurse in charge of nursing service, 27 did not have a quallf-red nurse in charge of each 8-hour shift, and 20 did not meet State llcenslng re- quirements for nurse-patient ratios. In total, 48 homes accounted 2 for the 63 nursing deflclencles, Eight of the 48 homes were ap- proved also for Medicare. --Many nursing homes did not have complete fire protection programs. Of the 90 homes visIted, 44 did not comply with HEW regulations which require that simulated fire drills be held at least three times a year for each 8-hour shift In each home participating in the Medlcatd and Medicare programs Seven of the 44 homes were ap- proved also for Medlcare Leve2 of cure needed by nurswq-home pcrtzents Patients have been placed In skllled nursing homes even though their needs are for less lntenslve and less costly care which should be provided In other facllItles, however, alternative facllltles in which less intensive levels of care could be provided were lImIted This not only could result in unnecessary costs but also--and perhaps more important--could make unnecessary demands on professional care avall- able for patients who are in need of such care GAO believes that the primary cause of this problem 1s that HEWhas not developed a yardstick or criteria for measuring the need for skilled care under the Medicaid program In the absence of such crlterla, each State follows its own procedures for determining the need for skllled- nursing-home care. (See pp. 25 to 37.) The Social Security AdminIstration has developed criteria defining skilled nursing care under the Medicare program. In the absence of MedicaId criteria, the State of Michigan--to assist those persons who normally evaluate patlent needs--has explicitly de- fIned the medical and nursing-care characterlstlcs that It believes that patients should have to qualify for skilled-nursing-home care. In Michigan--the only one of the three States In GAO's review that had developed such cntena-- the State's evaluators accompanied GAO to selected nursing homes and, at GAO's request, evaluated patient needs The evaluators concluded that, of the 378 patients whose needs were evaluated, 297, or about 79 percent, did not require skilled-nursing- home care (See p. 28 ) GAO could not have slmllar evaluations made In New York and Oklahoma since these States had not developed such crltena The evaluators ad- vised GAO, however, that if, in a limited test, the medical and nursing-care characteristics of New York and Oklahoma patients were measured against the Mlchlgan criteria , a similar high percentage (71 and 85 percent, respectively) of the patients would not require skilled care. (See pp. 26 and 34.) Further, recent reviews of patient needs by professional health teams of voluntary areawlde health planning agencies in 10 counties in New York, using criteria establlshed by the agencies' staffs, showed that 25 to 35 percent of the patients in skilled nursln homes did not re- quire the level of care provided in those homes. aSee p. 30.) GAO did not Judge the reasonableness of any criteria, including Michi- gan's, because of the medlcal expertise and Judgments involved. GAO IS of the opln~on that criteria developed by HEWwould help plnpolnt more precisely the extent to which skllled or less costly nursing care 1s needed and, as a result, limited human resources could be allocated to meet more effectively the most critical nursing-care needs. Under the existing, unrealistic procedures, declslonmakers often are confronted with two choices--skilled nursing care or no care at all. RECOWENDATIONS ORSUGGESTIONS The Secretary of HEWshould instruct the Social and Rehabllltation Ser- vice and the HEWAudit Agency to continue and Increase their monitoring of States' adherence to HEW's requirements for nursing homes' partlclpa- tlon in the MedicaId program as skilled nursing homes. (See p. 22 ) The Secretary of HEW, to assist the States In determining whether Medl- cald patients are In need of skilled care, should Issue crltena set- ting forth the medical and nursing care required for patients to be classlfled as being in need of skilled-nurstng-home care. GAO suggests that consideration be given to the experience with the criteria already developed for the Medicare program. (See p. 36.) The Secretary of HEWshould instruct the Social and Rehabllitatlon Ser- vice and the HEWAudit Agency to continue and Increase their monitoring to ensure that States are following existing HEWMedicaid regulations relating to the admission of patients to skilled nursing homes and are periodically determining whether patients admitted to skilled nursing homes are still In need of skilled care. (See p. 36.) AGENCY ACTIONSAND UNRESOLVED ISSUES HEWstated. --That the Social and Rehabllltatlon Service had implemented a new monitoring and liaison program In each regional office that re- quired the regional offices to maintain closer relationships with State agencies. It required also that regIona offlclals make more frequent visits and make detailed reviews of State Medicaid 4 operations, which should aid in the reduction of such deflclencles as those discussed in this report. (See p. 22.) --That the Social and Rehabilitation Service planned to issue, within 6 months, guidelines to assist the States in evaluating a patient's need for skilled nursing care and services under the Medicaid pro- gram and that, where applicable, these guldellnes would consider areas of common interest, as outllned in crlterla developed for the Medicare program (See p. 37 ) The actions taken or promised by HEW should strengthen admlnlstratlon of the Medlcald and Medicare programs. In view of the substantial Federal and State expenditures under these programs, prompt attention should be given to the implementation of the promised admlnlstratlve actiohs. MATTERS FORCOh'SIDERATIOil' BY THECONGRESS This report contains no recommendations requiring legislative action by the Congress. It does contain information on weaknesses in HEW's admln- lstratlon of Medicaid and Medicare programs for nursing homes, sugges- tions for their correction or improvement, and corrective actions taken or promised by HEW. This information should be of assistance to comet- tees and lndlvldual members of the Congress in connection with their leglslatlve and oversight responslbllitles relating to the Medicaid and Medicare programs. 5 CHAPTER1 INTRODUCTION Medicaid, authorized in July 1965 as title XIX of the Social Security Act (42 U.S.C. 13961, is a grant-in-aid pro- gram in which the Federal Government participates in costs incurred by the States in providing medical care to welfare recipients and other persons who are unable to pay for such care. Medicaid is administered at the Federal level by the Social and Rehabilitation Service (SRS) of the Department of Health, Education, and Welfare. Authority to approve grants for State Medicaid programs has been further delegated to the regional commissioners of the SRSwho administer field activities through 10 HEWregional offices. Under the Social Security Act, the States have the pri- mary responsibility for their Medicaid programs. A State's program is described in its plan which, after approval by a regional commissioner, provides the basis for Federal grants to the State. The regional commissioner is responsible for determining whether a State is operating its program in ac- cordance with its approved plan, Federal requirements in supplement D of HEW's Handbook of Public Assistance Adminis- tration, and SRSprogram regulations. State Medicaid programs are required to provide inpa- tient hospital services, outpatient hospital services, lab- oratory and X-ray services, skilled-nursing-home care, and physician services. Additional items, such as dental care and prescribed drugs, may be included if a State so chooses. Depending on a State's per capita income, the Federal Government pays from 50 to 83 percent of the costs for Med- icaid services. For calendar year 1969, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, and the 41 States then having Medicaid programs spent about $4.3 bil- lion, of which about $2.2 billion, or about 50 percent, rep- resented the Federal share. 6 In our examination of HEW's administration of the skilled-nursing-home segment of the Medicaid program, we sought answers to two questions: --Are skilled nursing homes providing proper care to pa- tients? --Are patients being provided with levels of care more intensive than needed? Where nursing homes provided care also under the Medi- care program--authorized in July 1965 as title XVIII of the Social Security Act (42 U.S.C. 1395)--we ascertained whether Medicare requirements had been met. Our review was made at 90 selected nursing homes, 30 each in Michigan, New York, and Oklahoma. MEDICAIDNURSINGHOMES Nursing homes are generally defined as medical facLli- ties which provide convalescent or inpatient care to pa- tients who do not require hospital care but who are in need of certain medical care and services that cannot be pro- vided in the patients' homes or in intermediate-care, resi- dential, or custodial facilities. To participate in the Med- icaid program, nursing homes must meet State licensing re- quirements and Federal requirements. Skilled-nursing-home care is prosed to all eligible patients; however, about 80 percent of the patients being provided with such care are over 65 years of age. During calendar year 1969, Medicaid payments for nursing-home care totaled about $1.2 billion, or 27 percent of all Medicaid costs. HEW paid about half of these costs. OTHERNURSINGOR RELATEDCAREFORELDERLY Medicare --administered by the Social Security Adminis- tration (SSA) of HEW--authorizes skilled nursing care to be provided In extended-care facilities to persons 65 years of age or older after they no longer need the intensive care available in hospitals. Depending on their financial cir- cumstances, Medicare patients may be eligible for services-- including skilled nursing care--also under the Medicaid 7 program. Patients eligible under both programs, however, must first exhaust their Medicare benefits. During calendar year 1969, payments for extended care totaled about $317 mil- lion. A type of related care available to individuals is in- termediate care. Authorized in 1967 under title XI of the Social Security Act (42 U.S.C. 132Oa), the intermediate-care program provides Federal funds for care of eligible individ- uals not in need of skilled nursing care but in need of more intensive care than that provided in residential facilities. The intermediate care was designed as an alternative to skilled care and is not part of the Medicaid and Medicare programs. The major users of intermediate care also are the elderly. MEDICAIDPROGRAMS IN STATESREVIEWED The State Departments of Social Services are respon- sible for administering Medicaid programs in Michigan and New York and the State Department of Public Welfare is re- sponsible in Oklahoma. Responsibility for certifying that nursing homes meet the Federal requirements for participa- tion in the Medicaid program has been delegated to the State Departments of Health. In Michigan and New York the health departments have responsibility also for determining the level-of-care needs of patients butt in Oklahoma the State Department of Public Welfare has kept this responsibility. Information on Medicaid and nursing-home programs in these States follows. State Mxhlgan New York Oklahoma Total HEX?Regional Office Chicago, Ill New York, N Y Dallas, Tex (covers six (covers two (covers five States) States, Puerto States) Rxp, and the V1rgx.n Islands) Medacald programs Started Ott 1966 May 1966 Jan. 1966 1969 expenditures Amount (millions) $205 swp; $72 $1,311 Federal share (millions) $102 $50 $669 Skilled nursrng care 1969 expenditures Amount (millrons) $100 $199 $37 $336 Percent of total Pled- scald expenditures 49 19 51 26 Skxlled nursing homes Nxnnber 211 614 388 1,213 Available beds 21,000 49,000 23,000 93,000 CHAPTER2 ARE SKILLED NURSING HOMESPROVIDING PROPERCARE TO PATIENTS? Many nursmg homes participating in the MedIcaId pro- gram--and in some cases the Medicare program--were not ad- hering to Federal requirements for participation. As a re- suit, the health and safety of the patients may have been jeopardized, since proper skilled-nursing-home care &"di- rectly related to meeting established requfrements for skilled nursing homes. The nonadherence to requirements re- sulted primarily from weaknesses In State procedures for certifying ellglbility of homes and from ineffectlve State and HEW enforcement of Federal requirements. To participate in the Medicaid and Medicare programs as providers of skilled nursing care, nursing homes must meet and maintain Federal requirements which incorporate the in- dividual State's licensing requirements. The requLrementss< " are designed to ensure that nursing homes are capable of providing skilled care and relate to such things as physical structure, nursing-staff qualifications, food preparation, physlclan services, and drug controls. Our review at 90 nursing homes in Michigan, New York, and Oklahoma during the period October 1969 to April 1970 showed that numerous homes were not adhering to Medicaid re- quirements (including State licensing requirements). Since 33 of the homes were also participating in the Medicare pro- gram, we ascertained whether Medicare requirements had been met. The most significant deficiencies that we noted are discussed below, and all deficiencies that we noted are listed in appendix I.1 1These deficiencies in each State should not be compared be- cause of differing licensing requirements. IN-ADEQUATENURSING SERVICES HEW--under the skilled-nursing-care portion of its Med- icard and Medicare programs --requires that nursing services be provided under the direction of a registered nurse and supervnsed 24 hours a day by a registered nurse or a li- tensed practical nurse and that nursing-home staffs be com- posed of sufficient nursmg and auxiliary employees to pro- vide adequate services for patients at all times. Praor to our review, HEW had not specified the number of nurses m relation to patients (nurse-patient ratio) that a skilled nursing home must have to be eligible under Medl- cald or Medicare, but on April 29, 1970, HEW issued regula- tions requirrng SRS to establish nurse-patient ratios for Medicaid. Prior to our review, Michigan, New York, and Oklahoma had established nurse-patient ratios as part of their licensing requirements. As summarized below, we found 63 nursing-service defl- ciencies in 48 of the 90 nursing homes providing services to Medicaid patients in Michigan, New York, and Oklahoma. Eight of the homes in which these deficiences existed also were Medicare providers. Number of deficiencies Deficiency Michigan New York Oklahoma Total No full-time regis- tered nurse in charge of nursing service 1 5 10 16 Qualified nurse not in charge of each 8-hour shift 5 22 27 State nurse-patient ratio not met -10 -10 - -20 Total deficiencies &g 15 32 63 Total homes having deficiencies 12 10 In a letter dated March 23, 1971, from the Assistant Secretary, Comptroller, HEW (see app. II), commenting on a draft of this report, SSA expressed concern that our report implied that the absence of a nurse-patient ratio for Medi- care was inherently bad and would attenuate the quality of care rendered. SSA stated that under the Medicare program the adequacy of nursing services was determined on the basis of the Judgment of a survey team as It viewed the needs of a particular facility and the placing and composi- tion of Its patient load. Also an individualized determina- tion was made on the basis of the type of care furnished, the needs of the patients, and other related factors. SSA commented further that this view--which It consid- ered the most desirable approach to ensurmg the quality of nursing care rendered to Medicare patients--was shared by the American Nursing Association and by the Public Health Service, HEW, SSA stated also that there were some inherent dangers in the use of arithmetic ratios, including the pos- sibility that the minimum ratios established might gain ac- ceptance as the maximum ratios by providers and surveying agencies. The nurse-patient ratios in Mxhigan, New York, and Oklahoma were established by these States as licensing re- quirements and thus--in these States--became Medicare and Medicaid requirements. It is not our intention to imply that these ratios --or any other ratios--are good or bad, We note, however, that the establishment of nurse-patient ratios was recommended by an SRS task force on skilled nurs- ing homes in August 1969. The task force reported that it had received many rec- ommendations to assist States by developing some type of formula, standard, or ratio in the determination of the proper sizes and kinds of staff necessary to give quality ' care under the Medicaid program. The task force stated that the terms "adequate" and "sufficient" nursing service as contained in the Federal regulations "are difficult terms to deal with and must be clarified and defined." The task force recommended that pertinent agencies of HEW--including SSA--combine their efforts to establish a standard or ratio for inclusion in Federal regulations. As stated on page 10, regulations issued by HEW in April 1970 require SRS to carry out this recommendation; by April 1971 SRS had not issued implementing regulations. 11 LACK OF REQUIRED PHYSICIAN VISITS HI37 requires that a Medicaid or Medicare patient In a skilled nursing home be seen by a physiclan lnitlally and at least once every 30 days, to evaluate the patient's im- mediate and long-term needs , prescribe a planned program of medical care, and plan for continuing care and/or discharge. We found that in 47 of the 90 nursing homes In Michi- gan, New York, and Oklahoma physician visits were not al- ways made every 30 days. For example, physician visits were made regularly in only 18 of the 30 nursing homes we visited in Michigan, physician visits in the remaining 12 homes were made irregularly ranging from 35 to 210 days apart. Of the 47 homes, 12 were certified also to provide Medicare services. In his letter the Assistant Secretary, Comptroller, pointed out that, although the requirement for physlclan visits at least once every 30 days was, to some extent, be- yond the control of a facility, State agencies were working closely with facllltles to have them take whatever steps were necessary to ensure that these requisite vlslts were berng made. ABSENCEOF SOCIAL AND DIETARY SERVICES Social services HEW requires that nursing homes partlclpatlng in the Medicaid and Medicare programs recognize and seek help in solving social and emotional problems related to patients' illnesses, to their response to treatments, and to their ad- Justment to care in the facilities. Officials of 26 of the 90 nursing homes we visited ad- vised us that no one had been designated in their homes to identify social or emotional problems of patients. (Of the 26 homes, five were Medicare homes.) The importance of at- tentlon to such problems is illustrated by the following re- marks from a June 29, 1970, HEW task force report on Medlc- aid and related programs. 12 *'Some 30 to 35 percent of all reclplent-patients In nursing homes have no lmmedlate relatives, and except for the welfare agency visit, most of them have no contact with the world outside the institution. No one outslde the lnstltutron 1s concerned with whether or not their needs are being met. The agency 1s out of personal touch with the patient and may be unaware of changes In his condltaon that might indicate changes In the care which he needs ***.I' The task force report stated that the social content of the Medicaid and Medicare regulations were not adequate and rec- ommended that: "Each skilled nursing home should be required to include on Its staff (or have the part-time ser- vices of) a capable person to develop and direct a plan or program lndlvldually tailored to the psycho-social needs of each resident. This staff person would have responslblllty for marshalling communrty and lnstltutlonal resources to serve the needs and interests of residents. The reg- ulatlons should set forth.the nature and pur- pose of such a program rather than prescribe a standardized set of procedures.11 We believe that adherence to such a procedure would correct the condltlons found during our review. Dietary services HEW requires also that professional consultations be available rn Medicaid and Medicare provider facllltles to ensure that nutrltlonal standards are good and that the dietary needs of patients are met. Offlclals of 19 of the 90 nursing homes we visited said that they were not avall- lng themselves of such consultations. None of the 19 homes served Medicare patients. 13 DEFICIENCIES IN MEETING RXQUIPEMFNTS RELATING TO PATIENT SAFETY To ensure that Medicaid and Medicare patients will be properly cared for in case of emergency, HEW requires that nursing homes adhere to certain laws and regulations relat- lng to patlent safety. We found that numerous nursxng homes were deflclent in meeting safety regulations relating to fire drills, emergency electrical service, and nurses' call systems. Fire drills With respect to fire safety, HEW requires--among other things-- that simulated frre drills be held for each 8-hour shift at least three times a year in all nursing homes partlclpatlng In the Medicaid and Medicare programs. In Michigan, New York, and Oklahoma, we found that, of the 90 nursing homes we vlslted, 44 (seven of which also were Medicare provrders) were not complying with the re- quirement for simulated fire drills, as follows: Number of fire drills In the 1 Z-month period Number of preceding deficient homes our visit 27 2 7 1 &Q - Emergency electrical service HEW requires that nursrng homes have emergency elec- trical service. This requirement for both the Medicaid and Medicare programs can be waived by the States if (1) the requirement will result in unreasonable hardship on the home and (2) the waiver will not adversely affect the health and safety of patients. Although Michigan, New York, and Oklahoma had not waived this requirement for any of the 90 homes we vlslted, 52 did not have adequate emergency electrical service. Of the 52 homes, 10 were also certified to serve Medicare pataents. Nurses' call system HEW requires that Medicaid and Medicare nursing homes have systems that regaster calls at the nurses' station, from each patient bed, each patient toilet room, and each bathtub or shower. This requirement, like the requrrement for emergency electrical service, can be waived; but Michi- gan, New York, and Oklahoma had not waived it for any of the 90 homes we vrsited. We found deficiencies in 43 of the homes (of which eight were also Medicare providers). Of these 43 homes, 11 had no system and 32 had incomplete sys- tems. In his letter, the Assistant Secretary, Comptroller, stated that State agencies had been encouraging facilltles lackrng emergency electrical service and nurses' call sys- tems to install them. HEW expressed the view that, when facilities simply lacked the funds to do so immedrately but otherwise were in compliance with the requirements and rendered acceptable levels of care, rt was preferable to allow them to remarn In the program as they tried to im- prove. This concept, he stated, would be true in any case in which correction of a deficiency would require a very large expenditure in relation to the resources of the fa- c111ty. 15 FACTORS CONTRIBUTING TO NTJRSING-HOMEDEFICIENCIES The primary causes of nursing-home deficiencies were --weaknesses in State procedures for certifying eligi- blllty of nursing homes and --ineffective State and HEW enforcement of Federal re- quirements. Federal requirements Prior to January 1, 1969, eligibility of a nursing home to participate in the Medicaid program was based on certification by (1) SSA that the nursing home met the re- quirements for participation as an extended-care facility in the Medicare program or (2) an appropriate State agency that the nursing home met the Medicaid requirements pre- scribed in supplement D of HEW's Handbook of Public Assis- tance Administration and SRS's program regulations. Effec- tive Janvary 1, 1969, only those nursing homes meeting Medlcald reqvlrements were ellglble to participate in the Medicaid program. In June 1969 HEW published in the Federal Register in- terim, but blndlng, regulations settzng forth Medicaid re- quirements in more detail and clearly showing that Federal payments would not be allowed to nursing homes not meeting the requirements. States, however, were permitted to con- tinue payments for 6 months to such homes, provided: --That the deficiencies did not jeopardize the health and safety of patients and that written justifica- tions demonstrating this were on file. --That the deficiencies could be corrected in 6 months and that the homes provided plans for so doing. States could continue payments for an additional 6 months to homes having deficiencies, provided that the deficiencies were different than those for the prior period. The final regulations, published on April 29, 1970, were generally 16 the same as the interim regulations except that the second 6-month extension was also permissible if there had been substantial progress and effort made In correcting the prior-period deficlencles. Michigan enforcement of Federal requirements In 1968 the Michigan State Department of Public Health sent questionnaires to all State-licensed nursing homes and, on the basis of these questionnaires and wrthout site vlslts, certified nursrng homes as eligible to participate In the Medicaid program if they agreed to comply with the Federal requirements for partlcipatlon by January 1, 1969, Offl- coals of the State health department advised us that many of the homes certified through this process should not have been certified because they did not meet the requirements for participation in the program, These officials advised us also that they knew that these homes did not meet the re- quirements. Our review of State inspection reports for 1968 and 1969 for the 30 homes we visited in Michigan verified that the State health department had been aware of nursing-home defrclencles. For these 30 homes, State inspectors had found 75 deficiencies similar to those which we found. For example, in 11 of these 30 homes they found deflclencles In nursing-care services and In 11 homes they found no emer- gency electrical service. Officials of the State health department informed us that no action had been taken by them to enforce compliance with Federal requirements until January 1970, because re- vised State licensing standards for nursing homes--which in- corporated the Federal requirements--had not been approved by the State until August 1969 and because the health de- partment had allowed the homes a few months to implement the revised standards. Thus Federal payments were made through December 1969 to skilled nursing homes that may not have met Federal requirements. After we informed State officials of the deflclencles we had found In our visits to nursing homes, they visited 17 two of the homes and stopped Medicard payments to one home. As of September 1970, they started action to stop payments to the second home, In September 1970 State officials informed us that, as a result of deficiencies found during State inspectrons of nursing homes, the State, after January 1970, had stopped Medicaid payments to five homes and had started actlons to stop payments to seven other homes. The officials sard, however, that State laws permitting appeals by nursing homes prevented the State from always adhering to the HEW require- ment limiting the period of extension for homes not meeting requirements to 6 months or 1 year. HEW regional officials responsible for Federal adminis- tration of the Medicaid program in Mrchigan informed us that they had not reviewed the skilled nursing care program in Michigan because of a lack of manpower. After we advised them of our findings, however, they said that they would work with Michigan officials to ensure compliance wrth HEW requirements. New York enforcement of Federal requirements The State of New York determined that nursing homes in the State--except privately owned nursing homes In New York City--met HEW requirements as of January 1, 1969, on the basis that they were licensed by the State. New York City made this determination for the privately owned homes in the city. Since the program was started In May 1966, mini- mum Federal requirements for skilled nursing homes have been incorporated into the State and city licensing requirements. Cur review of State inspection reports for 1969 and 1970 showed the State health department had become aware that many homes, though licensed, were not adhering to the Federal requirements, For 22 of the 30 homes included in our review, State inspectors had reported 22 deficlencles similar to those we had found. State health department officials told us that, begin- ning early in 1966, they had identified, had docwnented, and 18 were quite concerned about srgniflcant devlatlons from New York State licensing requirements, as well as from Federal standards for program participation, among a substantial nwnber of marginal nursing homes. They stated that from February 1, 1966, approximately 160 such facllltles had closed, most of them voluntarily under the pressure of the department's appllcatlon of State and Federal standards. Certain of these facalitles were closed only after admlnls- tratlve hearings. The offlclals informed us that there had been serious and continuing-- and, in some geographical areas, critical-- shortages of suitable alternative facllltles and services for the care of chronrcally ill patients. They stated that it did not seem reasonable or practicable to take arbitrary and strong actions against some of these nursing homes at times when the only alternatlve had been to "dump" patients in the street. They stated also that It was not only these shortages that influenced decisions on such matters but also the avallabllrty of a reasonable balance between facilltles and services. They said that, lacking such balance, It was drfflcult to make arbitrary decisions regarding any one level of care that would not have untoward effects on other levels, In August 1970 a State offlclal informed us that New York had not implemented the HEW requirements--by stopping payments or giving 6-month provlslonal certlflcations--but that State agencies were then notifying facilltles of the requirements, drafting provider agreements, and establishing policies and procedures for rmplementatlon. Thus Federal payments were made to skilled nursing homes through at least August 1970 without State implementation of Federal require- ments. State officials subsequently informed us that as of January 1, 1971, all ellgrble skilled nursing homes had been sent provider agreements and that the enforcement program was under way. In dlscusslng our flndrngs with State officials in June 1970, they informed us that they had closed one home and that they planned to take enforcement action against another because of the numerous deflcrencies, some of them se-rlous, In both facilltles. 19 HEW reglonal offlcrals Informed us that no review had been made by reglonal staff of the skllled nursrng home program in New York due to the lack of sufficient staff. Oklahoma enforcement of Federal requirements Before and after January 1, 1969, the State Department of Health considered nursing homes to be eligible for the Medrcald program If they were licensed by the State and met Its required nurse-patient ratio. The State, however, did not start enforcxng MedIcaId requirements until May 1970. State lnspectlon reports showed no evidence that the inspectors had been aware of deflclencles In meeting Medi- caid requirements apparently because the requirements had been omitted from the State's licensing standards. A de- partment of health offlclal Informed us that the Medicaid requirements-- Including provlslons for stopping payments and for 6-month provlslonal certifications--were not incor- porated in State standards until May 1970 because the State had not been aware that the absence of these requirements was resulting In inadequate lnspectxons. The offlclal said that it had taken a few months to Implement the revised standards and that actual enforcement had not started until July 1970. Thus Federal payments were made to skilled nursing homes to July 1970, before State enforcement of Federal requirements. After being informed of our findings in May 1970, State Department of Public Welfare officials suspended payments to six of the 30 nursing homes included in our review. These homes had a total of 69 deficlencles. Subsequently, two of the homes were closed and one was reclassified as a board-and-room faclllty. Payments were resumed for the re- maining three homes after reglstered nurses were hired as directors of nursing. HEW reglonal offlclals informed us that they had made no In-depth review of the Oklahoma skilled nursing care program from 1967 due to a lack of sufficient staff, 20 RECENT HEW ACTIONS On November 25, 1969, the HEW Audit Agency inltlated a multlstate audit of nursing homes particrpatlng In the Med- scald program. The audit was to include a review of the procedures and controls established by the States for in- specting and licensing nursing homes. At the time our field work was completed, the HEW Audit Agency had issued three reports as a result of this audit, two of which pointed out problems similar to those noted during our review. As shown by our review, some nursing homes may not be meeting both Medicaid and Medicare requirements, evidencing the need for close coordlnatron among the separate HEW of- fices admlnlsterlng the programs. HEW also has recognized this need, and on August 11, 1970, SRS pointed out, In a memorandum to State agencies, that: It** rt may be assumed that the title XVIII [Medl- carej decisions are coordinated with the title XIX [Medicaid] actions; but, we have learned from expe- rience that this 1s not always the case." The memorandum provides that SSA advise a State when a Medicare facility has been certified or recertified, when significant deflclencles have been found during the Medlcare certification survey, and when termination actions have been taken. The States are requested to provide information to SSA on violations found in their surveys of Medicaid facill- ties. The exchange of information, if carried out, will provide added assurance that deficiencies applicable to both Medicaid and Medrcare are known to the separate groups re- sponsible for administering these programs. CONCLUSIONS There is a direct relationship between HEW requirements for skllled nursing homes and the provlslon of proper care. Deflclencles In meeting these requirements should be a clear warning that patient health and safety may be in Jeopardy and that many homes , particularly those having inadequate nursing service and those involving infrequent physicians' 21 Vlslts, are not capable of provrding the level of skilled nursing care that patients require. There is an obvrous need for vrgorous enforcement of these requirements. To set an example, HEW may find it nec- essary to take strong measures--encourage States to stop payments to those nursing homes that persistently fall to meet requirements and to obtain refunds from States for the Federal share of payments made to those homes that did not meet requirements. As evidenced by the States' actions in stopping payments to homes that we found had deflclencles, it seems likely that improper payments have been made to many ineligible homes because of States' delays in enforcing HEW requirements. The States had the responsibility for ensuring that the homes were complying with the requirements, and HEW should have been aware --through Its monstorlng efforts--that the States were not enforcing compliance. RECOMMENDATIONTO THE SECRETARY OF HEALTH, EDUCATION, AND WELFARE We recommend that the Secretary of HEW, to help ensure that patients receive proper care, instruct SRS and the HEW Audit Agency to continue and increase their monitoring of States' adherence to HEW's requirements for nursang homes' participation in the Medicaid program as skilled nursing homes. AGENCYCOMMENTSAND ACTIONS The Assistant Secretary, Comptroller, agreed wrth our recommendation for continued and increased monitoring by SRS and the HEW Audit Agency of States' adherence to Medicaid requrrements for skilled nursing homes. For Medicaid, SRS has implemented a new monitoring and liaison program with the State agencies under which primary responsibrlity for revrewlng State programs has been given to the HEW regional offices to facilitate monitoring actlvl- ties and to promote faster corrective actions. The new pro- gram requires that the regional offices maintain closer re- lationshlps with State agencies. It requires also that 22 regional officials make more frequent visits and make de- tailed reviews of State operations. HEW stated that SRS in- tended to specifically follow up on the corrective actions initiated in Michigan, New York, and Oklahoma. With regard to the HEW Audit Agency's efforts, HEW stated that Medicaid nursing home programs in 27 States had been audited or had been in the process of being audited dur- ing fiscal year 1970 and that nursing home programs in an- other 17 States were scheduled for audit in fiscal year 1971. HEW stated also that during these audits determinations had been, and would continue to be, made as to whether patients received the proper level of care and whether payments were made only for the level of care authorized.1 For Medicare, HEW stated that the fiscal year 1971 plans of the Audit Agency called for greater audit emphasis on the operational aspects of the program. In addition, HEW in- formed us that, as the Medicare program had progressed, SSA had become increasingly aware of the pattern of deficiencies, nationally, in extended-care facilities and had been empha- sizing the importance of upgrading deficient facilities. HEW stated also that, although particular attention had been devoted more recently to fire and safety requirements (Including fire drills), State agencies were working to fos- ter upgrading in all areas. With respect to the 33 nursing homes we visited that had participated in the Medicare pro- gram, HEW stated that four of these homes had voluntarily withdrawn from the program and that SSA planned to have the remaining 29 homes resurveyed. HEW stated also that SSA planned to have the State agencies work with these homes to have the homes improved, giving particular attention to the deficiencies noted by us. The actions taken or promised by HEW should strengthen administration of the Medicaid and Medicare programs. 1 As of January 1971 the Audit Agency had issued 15 reports as a result of its review. Reviews in nine States pointed out problems similar to those noted during our review. 23 Conslderlng the substantial Federal and State expenditures under the programs, prompt attention should be given to the implementation of those admxnlstratlve actions promised. 24 CHAPTER 3 ARE PATIENTS BEING PROVIDED WITH LEVELS OF CARE MORE INTENSIVE THAN NEEDED? Many Medicaid patients in skilled nursing homes may not need skilled-nursing-l care. Patients have been placed In skilled nursing homes even though their need may be for less intensive and less costly care that is available in other facilltles, What does this mean? It means that not only do unnecessary costs result but also, and perhaps more important, unnecessary demands are made on professional care available for other patients who are in need of such care. We believe that the primary cause of tlnls problem is that HEW has not developed a yardstick or criteria for measuring the need for skilled care. In the absence of such criteria, each State has its own criteria for measuring the need for skilled care, SRS 'has not Issued any explicit guidance to the States on how to decide that a patient needs skllled-nursing-home care, except that admlssion to a skilled nursing 'home must be based on a physician's recommendation, HEW requires that, after admission, p eriodic reevaluations be made of whether a patientneedsto remain in the home, Since there is no explicit guidance, however, the States develop their own procedures for judging the need for skilled care, Because of the medical knowledge and judgment involved, we have not suggested acceptable criteria for judging whether patients are in need of skilled-nursing-home care under MedicaId. SSA has developed explicit criteria for de- fining skilled nursing care under the Medicare program, In the absence of Medicaid criteria, the State of Michigan--to assist those persons w'ho normally evaluate patient needs-- has explicitly defined the medical and nursing-care charac- teristics it believes patients should have to qualify for skilled nursrng care. For example, they must need potent and dangerous Injectable medications on a regular basis; restorative procedures, suc'h as bowel and bladder training; or tube feeding. 25 To determlne the effects of not having uniform Medic- aid criteria, we examined into the procedures followed by Michigan, New York, and Oklahoma in determining the needs of patients for skilled-nursrng-home care, In Michigan-- the only one of the three States that had developed ex- plicit criteria for determining patient needs--State and county medical personnel who normally evaluate patient needs accompanied us to 15 of the 30 homes reviewed for com- pliance with Medicaid requirements for participation, (See ch. 2.) At our request, these personnel made determinations as to the level of care needed by 378 patients by reviews of patients ' medical records; discussions with nursing person- nel; and observations of the patients, if considered neces- sary, They concluded that about 297 (79 percent) of the 378 patients whose needs were evaluated did not require skilled care as defined in Michigan's criteria. We could not have similar evaluations made in New York and Oklahoma, since these States had not developed such criteria; however, as discussed on page 30, recent studies in New York showed that about 25 to 35 percent of the pa- tients in skilled nursing homes were inappropriately placed, In addition, in a limited test, we were advised by the eval- uators that, if the medical and nursing-care characteristics required by New York and Oklahoma patients were measured against the Michigan criteria, a similar high percentage of patients probably would not require skilled-nursing-home care. 26 MICHIGNA In the five counties we visited, either State or county public health nurses or medical-social caseworkers (evaluators) decided whether patients should be admitted to skilled nursing homes, Subsequently, three of the counties began requiring physicians' recommendations. But two of the counties --one of which had over 50 percent of the State's skilled nursing homes--continued to rely on recom- mendations by nonphysicians. State health department officials informed us that they did not believe that the procedures violated HEW re- quirements for a physician's recommendation, because public health nurses and medical-social caseworkers (1) were pro- vided with a physician's physical examination report, (2) were supervised by physicians, and (3) were instructed to consult with physicians when consldered necessary. The of- ficials stated that, although the Michigan criteria were applied by nonphysicians, they had been developed by physi- cians. In our opinion, however, supervisory physicians, to provide added assurance that they concur in the evaluators1 recommendations, should record their approvals. The officials also said that the evaluators often rec- ognize that patients are not in need of skllled-nurslng- home care but place the patients in skilled nursing homes because beds in alternative facilities providing less in- tensive care are not available. The State's subsequent reevaluations of patient level- of-care needs have verified that evaluators recognized that a large number of patients in skilled nursing homes were not In need of skllled-nursing-home care. Prior to and during our review, reevaluations were made by public health nurses and medical-social caseworkers; however, provision has now been made by the State for supplementary annual ob- servations and evaluations by physicians. On the basis of visits to 126 skilled nursing homes during the period Jan- uary through July 1970, the evaluators concluded that, of 6,159 Medicaid patients whose needs were evaluated, 3,353, or about 54 percent, were in need of a level of care less than skilled-nursing-home care. 27 State offlclals advlsed us that 73 addltlonal nursing homes had refused to allow the State to evaluate the needs of their patlents,because the homes were afraid the State might reduce the payments for patients determined to be not In need of skilled care. In Michigan, the Medrcaid rate for skilled nursing care 1s $2.23 a day more than for lnterme- dlate care. In September 1970 State officials advised US that action was pending to stop payments to those homes that did not permit reevaluations of patient needs but that, because of the nonavarlablllty of alternate facilities, no actlon was currently planned against homes that permrtted reevaluations even though some patients in these homes did not require skllled nursing care. This shortage of alternatlve facilltles probably will continue for some time, because (1) from January 1, 1969, through February 18, 1970, beds in skilled nursing homes increased from about 12,000 to 21,000--almost double--and beds avaalable for lower levels of care decreased from about 11,000 to 7,000--about one third and (2) beds in skilled nursing homes were expected to increase by an esti- mated 8,000 in 1970, while beds In intermediate-care facil- rtles were expected to Increase at a more gradual rate. Evaluators determine the levels of care needed by pa- tients on the basis of crlterla established by the State Department of Public Health on July 22, 1969. These crite- ria are explicit as to the medical and nursing-care needs required for patients to be classlfled as needing skllled- nursing-home care. On the basis of these criteria, State and county medi- cal personnel evaluated the needs of 378 patients rn 15 homes we visited and concluded that 297 patients, or 79 per- cent, were not In need of skilled-nursing-home care. The public health nurses and a medical-social caseworker making evaluatrons for us said that, in their opinion, the July 22, 1969, crlterla were too restrictive and that they preferred the crateraa used prior to July 1969. At our re- quest, they applied the less restrictive criteria to patients in 14 of the 15 homes vlsited and concluded that, of the 360 patients whose needs were evaluated, 151, or about 42 per- cent, did not require skllled-nursing-home care. 28 The State's evaluation of patients' needs for skilled- nursing-home care and the evaluations made at our request showed that, for a large percentage (42 to 79 percent) of the patients, less intensive levels of care would have been adequate; however, alternative facilities were not avail- able. If intermediate-care homes were available and if half of the about 14,000 Medicaid patients in skilled nurs- ing homes could be placed in intermediate-care homes, sav- ings of about $5.7 million annually would be realized by the State and the Federal Government, because intermediate care is less costly than skilled care. HEW regional officials informed us that they believed that uniform national criteria are needed to ensure that patients in skilled nursing homes are those in need of skilled nursing care. 29 NEW YORK Except for those admitted to privately owned nursing homes in New York City, patients are admltted to skilled nursrng homes on the recommendation of their physicians. Physicians acting for the State Department of Health evalu- ate patients before their stays in the home have exceeded 100 days, to determlne therr need for continued skllled- nursing-home care. Subsequently, at least annually, physr- clans reevaluate these needs. For privately owned homes In New York City, physicians of the City Department of Social Services evaluate the rec- ommendations for admission to skilled nursing homes by the patients' attending physicians. These physrcians also eval- uate the patients' needs before they have been 1n a home 100 days. Subsequently, they reevaluate the patients' needs when determined necessary by the City Department of Social Services. The State and the city, however, have not established any written criterion defining the medical and nursing care required for patients to be classified as needing skilled- nursing-home care. Patients' physical and mental conditions are shown on evaluation forms, but no lnstructlons are pro- vided as to how this rnformatlon is to be used in determln- ing whether patients need skilled-nursing-home care. As a result, evaluators (physicians) establish their own criteria. Department of Health officials informed us that several voluntary areawide health planning agencies in New York had developed rather detailed definitions of nursing homes and of the needs of patients for care in such homes and that professional health teams using these deflnltions sn care- fully designed studies had recently examined into the suit- abzllty of patients' placement in nursing homes in 10 coun- ties. According to these officials, the studies showed that 25 to 35 percent of such patients could have been cared for more suitably, and often at less cost, in some other facilities. Department of Health officials informed us also that, because there was a shortage of alternative facilities in which to place patients, they would not be able to enforce a well-defined criterion for determining which patients 30 need skxlled care. They said that an intermedrate-care pro- gram only recently had been introduced In New York and that there were about 12,000 beds available In intermediate-care facilxtres compared with about 54,000 beds in skilled nurs- ing homes, They said also that there was a serious shortage of beds in skilled nursing homes, which was rapidly being reduced, and a much more serious shortage of beds in Intermediate-care facilities. They informed us that the shortage of beds in intermedlate-care facilities would not be elrminated for several years, HEWregional officials informed us that the difficulty of establishing adequate national criteria was at least partly responsible for the absence of such criteria at the State level. 31 oTaAHoMA The Oklahoma Department of Public Welfare requires that a patient be examined by a physician and that a medical- social summary be prepared by a social worker before a de- termination can be made as to whether a patient is eligible for admIssion to a skilled nursing home. This determina- tion is made by three medical-social analysts who are not physicians but who work under the supervision of a physi- cian. Prior to our review, a physician seldom recommended the level of care required for a patient, because the phys- ical examination form did not specifically require such a recommendation from the physician. As a result of our re- view, the Department changed the form to require a physi- cian's recommendation. In addition to evaluating the condition of each pa- tient initially, the social analysts reevaluate the condi- tion of each patient annually as to continued need for skilled 'care. During 1969 the analysts made about 16,000 reevaluations and concluded that only 401 patients, or 2.5 percent, did not need skilled-nursing-home care. Both the initial and subsequent evaluations of skllled- nursing-home-care needs of patients are made on the basis of the State's general criteria which require only that eligible persons be: "*-k3c bedfast, chairfast, or require the assistance of another person to walk, or must by reason of other health problems as recommended by the at- tending physician require constant skilled nurs- ing supervision." Oklahoma does not have an intermediate-care program to provide for patients needing less than skilled care. A Department of Public Welfare official informed us that the department would not establish such a program unless forced to do so by the Federal Government. He said that, if intermediate care were provided in Oklahoma, rates al- lowed probably would be equivalent to current rates for care provided q,n skilled homes and that rates for skilled care, if more strbctly defined, would be higher. 32 HEWregional officials informed us that HEN standards for determining the level of care required by patients were needed but that they should be developed at the national level. 33 EVALUATION OF PATIENT NEEDS USING MICHIGAN'S CRITERIA -- In vlsrts to eight New York nursing homes and sxx Okla- homa homes, we obtained consrderable documented medrcal in- formation on the conditions of 120 patients in New York and 86 patients in Oklahoma. We asked medical personnel who evaluated the needs of Michigan patients for us to evaluate the needs of these New York and Oklahoma patients, using the July 22, 1969, criteria developed by Michigan State De- partment of Public Health physicians. A physicran also participated in these evaluations. We noted that the ap- placation of uniform criteria resulted In similar high per- centages of patients in New York and Oklahoma who may not have been In need of skilled care, as summarized below. Patients believed not in need of Number of skilled-nursing- patients home care State evaluated ---- Number Percent --- Michigan 378 297 79 New York 120 85 71 Oklahoma 86 73 85 As noted prevaously, we did not Judge the reasonable- ness of criteria for evaluating the needs of patlents--in- eluding Mlchlganls-- because of the medical expertise and Judgment Involved. We believe, however, that the wide range in results-- 25 to 71 percent for New York and 2.5 to 85 percent for Oklahoma, depending on the criteria used-- provndes evidence of the need for uniform criteria. The Assistant Secretary, Comptroller, advised us that Oklahoma, in replying to our draft report, had stated that, although the State had no crlticlsm of our obJectives, it felt that the true test of Its skilled-nursing-home pro- gram was whether the State had observed the provisions in its approved State plan rather than criteria established by another State. 34 In evaluating patients' needs in Oklahoma under Mrchi- ganls criteria, it was not our intentron to imply that Michigan's criteria for skilled-nursing-home care be adopted and applied by Oklahoma but it was our intention simply to point out the latitude of determinations resulting from the diversity of criteria being followed by the States in determinlng the medical and nursing-care requirements for patients to be classified as being in need of skilled- nursing-home care. RECENT HEW ACTIONS As discussed in chapter 2, HEW regional offices and the HEW Audit Agency had not made reviews of the skllled- nursing-home programs of the States included 1n our review. The multistate audit of nursing homes participating in the Medicaid program initiated by HEW on November 25, 1969, however, is aimed at ensuring that skilled-nursing-home care is provided only when such care is required. The audit provides for determining whether patients are receiving the proper level of care and whether payments are made only for the level of care authorized. This au- dit, which was partially completed at the time of our re- view, should, when completed, provide guidance in overcoming the problems found during our review. As noted in the foot- note on page 23, as of January 1971 the Audit Agency had is- sued 15 reports on Its audits of Medicaid nursing-home pro- grams, of which nine reports pointed out problems similar to those found during our review. 35 CONCLUSIONS The absence of unrform criteria settrng forth the ex- pllcit medlcal and nursing-care needs of patients under Med- icaid has permitted limited financial resources to be used for the development of skilled-care facilities, although a more critical need seems to be for alternative facllltles sn which less intensive and less costly care can be provided, Perhaps more important, the effectiveness of limited human resources, such as physicians and registered nurses, is dr- minished when they are required for provrdlng skilled care for patients not in need of such care. HEW's development of uniform criteria should in no way impinge on the professional expertise and Judgment of physl- clans. On the contrary, physicians should be directly in- volved in the development and appllcatron of such criteria. In our opinion, the use of such criteria would pinpoint more precisely the extent to which skilled or less costly nursing care is needed and, as a result, limited human resources could be allocated to meet more effectively the most critical nursing-care needs. Under the exrsting, unreallstrc proce- dures, decisionmakers often are confronted with only two choices-- skilled care or no care at all. RECOMMENDATIONSTO THE SECRETARY OF HEALTH, EDUCATION, AND WELFARE We recommend that the Secretary of HEW, to assist the States in determining whether Medicaid patients are in need of skilled care, issue criteria setting forth the medical and nursing care required for patients to be classified as being in need of skilled-nursing-home care. We suggest that consideration be given to the experience with the criteria already developed for the Medicare program. We recommend also that the Secretary of HEW Instruct SRS and the HEW Audit Agency to contrnue and increase their monitoring to ensure that States are following existing HEW MedicaId regulations relating to the admissIon of patients to skilled nursing homes and are periodically determining whether patients admitted to skilled nursing homes are still in need of skilled care. 36 AGENCY COMMENTSAND ACTIONS With regard to our recommendation that HEW issue crite- ria setting forth the medical and nursing care required for patients to be classified as in need of skilled-nursing-home care, the Assistant Secretary, Comptroller, stated that SRS was planning to issue, within 6 months, guidelines for the States to follow, which would clarify and be more specific in evaluating a patient's need for skilled nursing care and other services under the Medicaid program. He stated also that, where applicable, these guidelines would consider ar- eas of common interest, as outlined in the criteria devel- oped for the Medicare program. With regard to our recommendation for continued and in- creased monitoring by SRS and the HEX Audit Agency to ensure that the proper level of care is provided, HRW stated that monitoring programs were being increased, which would aid in the reduction of deficiencies discussed in this and other of our reports. In addition, HEW informed us, with respect to Medicare, that action had been taken to educate employees of facilities on the use of the utilization renew mechanism which ensures that the proper level of care is provided and that procedures had been tightened to prevent payments for improper levels of care. The actions taken or promised by HEW should strengthen administration of the Medicaid and Medicare programs. In view of the substantial Federal and State expenditures un- der these programs, prompt attention should be given to the implementation of the promised administrative actions. 37 CHAPTER 4 SCOPE OF REVIEW We examined into the practices of the States of Michi- gan, New York, and Oklahoma in (1) certifying homes as meeting requirements for participation as skilled nursing homes under Medicaid and (2) determining whether individual patients in skilled nursing homes were in need of the level of care provided. For those homes that were found to be deficient in meeting Medicaid requirements for participa- tion, we ascertained whether the homes were serving Medi- care patients and whether Medicare requirements were being met. Our selection of States was based on the significance of Federal fvnds expended for skilled nursing homes both in amount and in relation to total Medicaid expenditures in the States. In selecting 90 nursing homes (30 in each State), we attempted to make our sample representative of the homes in each State. Our examination into the need for the level of care provided was directed primarily toward determining the ef- fects of not having explicit HEW Medicaid criteria. We did not establish acceptable criteria for measuring level-of- care needs because of the medical expertise and judgments involved nor did we Judge the reasonableness of criteria established by the States. Our review was made at HEW headquarters in Washington, D.C., and at its regional offices in Chicago, Illinois; New York, N.Y.; and Dallas, Texas, Our review was made also In each State at the responsible State and county offices and at skilled nursing homes in various counties. As part of our review, we examined into the basic leg- islation authorizing the Medicaid program and the pertinent HEW regulations implementing the program. We also examined pertinent records and documents at State and county offices and at nursing homes. We also discussed with HEW, State, county, and nursing home officials matters relative to the administration of the program, 35 APPENDIXES 39 APPENDIXI NURSING HOMES NOT FULLY IN COMPLIANCE WITH MEDICAID REQUIREMENTS INCLUDING STATE LICENSING REQUIREMENTS Medzcaid homes having deflcrencles (note a> Medicare New homes Requirement Mlch York m Total (note b) Emergency electrical service 13 10 29 52 10 Adequate nursing staff (number and qualifications) 12 13 23 48 8 Physicran vlslts every 30 days 12 8 27 47 12 Fire drills three times a year 17 5 22 44 7 Complete nurses' call system 11 13 19 43 Rxamlnatlon room 11 10 17 38 9 Designated social worker 11 4 11 26 5 Record of current health examlna- tlons for staff members on file 6 11 10 27 9 Cubicle lsolatlon curtains 16 12 28 8 Adequate patient room accommoda- trons 2 19 2 23 9 Qualified consultant dletrtlan 14 19 Written polrcy for patient care : i 6 14 -2 Adequate torlet facllltles 15 15 5 Transfer agreement with nearby hospital 1 3 10 14 Adequate day-dlnrng area 6 5 11 -4 Elevator 3 13 -2 18 5 Wrltten nursing-care plan for each patient 1 4 4 9 1 Nurses ' station 3 5 2 10 Posted dzsaster plan 5 4 9 ; Quallfled admlnrstratlon 6 6 3 Emergency drug kit -4 1 6 Adequate bathing facilities 1 t 7 -3 Written narcotics record maintained _ 1 3 4 -zm Total 141 175 gig &gg aComparlsons of deflclencles In each state should not be made, because of dlfferlng licensing requirements. b Homes, Included rn total,whlch also served Medicare patients and which did not meet Medicare requrrements. 41 APPENDIXII DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE WASHINGTON. D C 20201 OFFICE OF THE SECREl ARY MAR23 1971 Mr John D Heller Assistant Director, Crvll Division United States General Accounting Office Washington, D.C 20548 Dear Mr Heller The Secretary has asked me to respond to the draft report on the GAO review of Violations of Medicaid and Medicare Standards for Skilled Nursing Homes and Questionable Need for Skilled Nursing Home Care Enclosed are the Department's comments on the flndings and recommendations in your report. We appreciate this opportunity to comment prior to issuance of the flnal report We also appreciate your continuing interest in helping us improve Medicare and Medicaid administration. Sincerely yours, Assistant Secretary, Comptroller Enclosure 42 APPENDIX II VIOLATIONS OF MEDICAID AND MEDICARE STANDARDS FOR SKILLED NURS'INGHOMES AND QUESTIONABLENEED FOR SKILLED NURSING HOMECARE The draft audit report presents a picture of various vlolatlons of MedicaId and Medicare standards for skilled nursliig hoqes In Mlchlgan, New York, and Oklahoma as bell as the questlonable need of skIlled nursing home care for certain lndl\lduals Its recommendations are generally consistent. with findings of the Social and Rehabllltatlon Service (SRS) and the Social Securl'c> Admlqlstratlon (SSA) on these points The Medicaid and Medicare programs are constantly working zowards upgrading the quality of care and services rendered by partlclpatlng providers of services Towards this goal, we have lnstltuted several programs deslgned to evaluate the operational effectiveness of Mealcald and Medicare State agencies and to assure that partlclpatlng facllltles are cooperating to the fullest extent of their resources In Improving their operations Coordlnatlon between MedIcaid and Medlcare program polrc1es and guldcllnes, to the fullest extent feasible, 1s highly desirable and 1s being undertaken [See GAO note. 1 The first recommendation (page 39 of the draft report) recommerds that the Secretary of mW instruct the Social and Rehabllltatlon Service and HEW Audit Agency to continue and increase their monl- toring of States' adherence to Its Medicaid requirements for skllled nursing homes SRS has implemented a new monltorlng and llalson program with the State agencies by each of the SRS Reglonal Offlces along with assistance from the Vashlngton Central Office Under this new program, primary respon- slblllty for reviewing the State program has been given to the Reglonal @fflces in order to facilitate monltorlng actlvltles and promote faster corrective actions The scope of the new program reqtlres a closer relationship with the State agencies along with more frequent vlslts and detailed reviews of State operations The lnltlal monltorlng reviews hvlll tend to be more comprehensive in the beglnnzng phases but will later develop into more lntenslve revlebs of troublesone areas such as noted In this report Concerning the deflclency corrtiented on In this recommendation, SRS ~111, of course give specldl follow-up revlew of the corrective aLtlons GAO note: The deleted comments pertain to matters discussed in the draft report but omltted from this fuxal report. 43 APPENDIXII lnltlated by the States While SRS plans contlnulng monltorlng programs In these three States, as well as in the other 49 JWLS- dlctlons, they also have these three States scheduled for lnten- slfled program reviews during FY 1971 We also agree with the recommendatlo? that the audit effort expended by JBW In this area should continue and increase With regard to MedIcaid, the GAO report did note that the agency had 'I lnltlated a multi-State audit of nursing homes partlclpatlng in the Medicaid program " During FY 1970, nursing home programs were audited, or audits were In progress, sn 27 States An addltlonal 17 States are scheduled for audit In FY 1971 Determinations have been and will continue to be made during these audits as to whether reclplents received the proper level of care and whether payments were made only for the level of care authorized We would also like to point out the review efforts of the Medrcare program by the Audit Agency and SSA The FY 1971 plans of the Audit Agency for Medicare call for greater audit emphasis on the operatlonal aspects of this program This 1s a contlnulng effort away from the earliest audits which were directed In the maln, towards verlfyzng the admlnlstratlve costs claimed by rnter- medlarles and State agencies The Audit Agency has reviewed most of the State agencies responsible for the examining and certifying of extended care facllltles SSA In conJunctlon with the Public Health Service, perforps prograrr reviews of each State agency partlclpatzng lr the Medicare program under Section 1864 SSA, and the ten health insurance regional offices conduct comprehensive reviews of State operations During these reviews, Federal surveyors do direct surveys of a sample of providers to deter- mine, among other quality controls, the effectiveness of the State review capabllltles of State surveyors and their adherence to Federal guldellnes The SSA has a valldatlon program which, among other functions, measures whether partlclpatlng facllltles are rendering quality services It also has a program integrity operation which evaluates consumer complaints against lndlvldual facllltles where there IS a llkellhood that fraud IS Involved SSA has also instituted measures to Improve the quality of State agency professional employees The third In a series of tralnlrg programs for State agency survey personnel IS being held at Tulane Unlverslty and slmllar institutes are being started In three other unlversltzes About 300 surveyors will receive this training In 1971, and it 1s planned that all surveyors will ultlmatell have the opportunity of atterdzng such training at various SSA sponsored institutes throughout the country SSA has also been working closely with Federal and State merit system offlclals to upgrade and augment staffing wlthln State Medicare agencies 44 APPENDIX II As the Medlcare program has progressed, SSA has become lncreaslngly aware of the pattern of deflclencles nationally In Ertended Care Facllltles and has been emphaslzlng the Importance of upgrading deficient facxlltles Whxle particular attention has been devoted more recently to fire and safety requlrewents (lncludlng fire drills mentioned rn the audit report), State agencies are working to foster upgrading In all areas [See GAO note on p. 43.1 45 APPENDIX II [See GAO note on p, 43.1 The third recormnendatlon (page 56 of the draft report) recommends that the Secretary issue crlterza settzng forth the medical and nursing care required for persons to be classlfled as in need of skilled nursing home care and that conslderatron be given to the experience wzth the crlterla already developed for the Medicare program SRS currently has such guzdellnes In draft form which w~l.1 clarify and be more speclflc for the States to evaluate a recipient's need for skllled nursing care and services Where applicable, these guidelines considered areas of common Interest as outlined In the criteria developed for the Medicare program SRS plans to have these guldellnes wlthln the next SIX months The fourth recommendation (page 56 of the draft report? recommends that the Secretary of HEW instruct the Social and Rehabllltatlon Ser~zce and the HEWAudit Agency to continue and increase their monltorlng to assure that States are following existing HEW regulations relating to the admlsslon of persons to skilled nursing homes and perlodlcally effectively determining whether persons admitted to skilled nursing homes are still zn need of such care As noted above, monltorlng programs are being increased which will aid in the reduction of defl- clenc+es found in this and other GAO reports 46 In addltlon to our comments on the reeommendatlons we hdve the fo .lowlng comments concerning various aspects of the report 1 Nurse-Patient Rdtlos (pdge 21) - SSA 1s concerned that the draft lmplles that the absence of nurse-patlent ratlo for Medicare 1s inherently bad and would attentuate the quality of care rendered Under title XVIII the adequacy of nursjng bervlces 1s carefully determlned based on the :Ldgment of the sLr\ey team as It views the needs of a particular faclllty and the placing and composltlon of its patient load An lndlvl- dualized determination 1s made based on type of care furnlshed, the needs of the patients, and other related factors SSA's view that this 1s the most desirable approach to assuring the quality of nursing care rendered to Medicare patients 1s shared by the American Nursing Assoclatlon and the Public Health Service, DHEW There are some inherent dangers in the use of arithmetic ratios, rncludlng the posslblllty that the mlnlmum ratios established may gain acceptance as the maximum by pro- vlders and surveying agencies Physlclan Vlslts (page 22)l- Medicare regulations, 20 CFR 405 1123, require a physrclan vlslt at least once every 30 days This condltlon of partlclpatlon has been incorporated by reference in the Medicaid regulations It should be noted that this requirement 1s to some extent beyond the control of . a facility However, our State agencies are working closely _ with facllltles to have them take whatever steps are necessary to insure that these requisite visits are being made Emergency Electrical Service (page 26)land Nurse Call System (page 27) - With respect to the lack of emergency electrical service and nurse call systems, State agencies have been encouraging facllltles lacking these items to Install them However, when facllltles simply lack the funds to do so lmmedlately, but are otherwise In compliance with the r'equlrements and render an acceptable level of care, we feel It 1s preferable to allow them to remain in the program as they try to improve Thrs concept, of course, would be true In any case where correction of a deflclency would require a very large expenditure In relation to the resources of the faclllty . Level of Care (page 40)&- One of the methods built into the law to ensure that Medicare patients admitted to nursing homes require skllled nursing care 1s btlllzatlon review Admittedly, this 1s not perfect, but actlon has been taken to educate facllltles and there 1s evidence of Improvement Also, lntermedlarles have been tightening up their procedures to prevent payment for custodial care 1GAO note: The page numbers referred to In these com- ments are applicable to GAO's draft report. 47 APPENDIX II Some Federal crxterla defining "level of care" in terms of patterns of skllled nursxng care and skilled care profiles have started a trend among "nursing homes" oriented more to custodial care to withdraw from Medicare and to realign so as to create distinct parts with different levels of care Because of our concern with regard to the speclflc facllltles visited by the auditor, we have asked the three regional offices Involved to request that the State agencies re-survey 29 of these facllltles that remain in the Medicare program (Four of them have voluntarily wlth- drawn) The State agencies will work with these facllxtles to improve, and particular attention will be given to the deflclencles noted by the auditors As requested by GAO, we furnished copies of their draft report to the responsible State agencies in Oklahoma, New York and Michigan for their review and comment The State of Mlchlgan did not submit a formal reply, but indicated they had no objections to the report Formal comments were received from Oklahoma and New York, copies of which are attached ) While these two States have raised various obJections to parts of GAO's report, these objections were not of a nature to affect our declslons on the actions we are taking on GAO's recommendations . 1 Attachment 1GAO note: These attachments have been considered in prep- aration of our final report and are not in- cluded as appendixes to the report. 48 APPENDIXIII PRINCIPAL OFFICIALS OF THE DEPARTMENT OF HEALTH, EDUCATION,ANDWELFARE HAVINGRESPONSIBILITYFOR THE MATTERS DlSCUSSEDIN THIS REPORT Tenure of office From To SECRETARY OF HEALTH, EDUCATION, ANDWELFARE: Elliot L. Richardson June 1970 Present Robert H. Finch Jan. 1969 June 1970 Wilbur J. Cohen %Y 1968 Jan. 1969 John W. Gardner Aug. 1965 May 1968 ADMINISTRATOR,SOCIALANDREHA- BILITATION SERVICE: John D. Twiname Mar. 1970 Present Mary E. Switzer Aug. 1967 Mar. 1970 COMMISSIONER, MEDICALSERVICES ADMINISTRATION: Howard N. Newman Feb. 1970 Present Thomas Laughlin, Jr. (acting) Sept. 1969 Feb. 1970 Dr. Francis L. Land Nov. 1966 Sept. 1969 COMMISSIONEROF SOCIAL SECURITY: Robert M. Ball Apr. 1962 Present DIRECTOR,BUREAUOF HWTH IN- SURANCE: Thomas M. Tierney Apr. 1967 Present Arthur E. Hess July 1965 Apr. 1967 U S GAO Wesh, D C 49
Problems in Providing Proper Care to Medicaid and Medicare Patients in Skilled Nursing Homes
Published by the Government Accountability Office on 1971-05-28.
Below is a raw (and likely hideous) rendition of the original report. (PDF)