oversight

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care

Published by the Government Accountability Office on 1999-03-22.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                          United States General Accounting Office

GAO                       Testimony
                          Before the Senate Special Committee on Aging




For Release on Delivery
Expected at 1:00 p.m.
Monday, March 22, 1999
                          NURSING HOMES

                          Stronger Complaint and
                          Enforcement Practices
                          Needed to Better Ensure
                          Adequate Care
                          Statement of William J. Scanlon, Director
                          Health Financing and Public Health Issues
                          Health, Education, and Human Services Division




GAO/T-HEHS-99-89
Nursing Homes: Stronger Complaint and
Enforcement Practices Needed to Better
Ensure Adequate Care
              Mr. Chairman and Members of the Committee:

              Thank you for inviting me to discuss our findings on the effectiveness of
              complaint and enforcement practices, which are an integral part of the
              federal-state process to protect nursing home residents and to ensure that
              homes participating in Medicare and Medicaid comply with federal
              standards. The nearly 1.6 million elderly and disabled residents living in
              nursing homes are among the sickest and most vulnerable populations in
              the nation. They frequently depend on extensive assistance in the basic
              activities of daily living such as dressing, grooming, feeding, and using the
              bathroom, and many require skilled nursing or rehabilitative care.

              The federal government, which will pay nearly $39 billion for nursing
              home care in 1999, plays a major role in ensuring that residents receive
              adequate quality of care. On the basis of statutory requirements, the Health
              Care Financing Administration (HCFA) defines standards that nursing
              homes must meet to participate in the Medicare and Medicaid programs
              and contracts with states to certify that homes meet these standards
              through annual inspections and complaint investigations. The federal
              government has the authority to impose sanctions, such as fines, if homes
              are found not to meet these standards.

              In hearings before this Committee last year, we reported that unacceptable
              care was a problem in many California nursing homes, including one in
              three where state surveyors found serious or potentially life threatening
              care problems. We also concluded that federal and state oversight was not
              sufficient to guarantee the safety and welfare of nursing home residents.1
              The information I am presenting today updates and expands upon the
              information presented last year with the results of our work on two
              recently completed projects conducted for this committee and several
              other requesters. In a report issued today, we examine the effectiveness of
              states’ complaint practices in protecting residents.2 In this report, we also
              assess HCFA’s role in establishing standards and conducting oversight of
              states’ complaint practices and in using information about the results of
              complaint investigations to ensure compliance with nursing home
              standards. In the second report, issued last week, we analyze national data

              1
               See California Nursing Homes: Federal and State Oversight Inadequate to Protect Residents in Homes
              With Serious Care Violations (GAO/T-HEHS-98-219, July 28, 1998) and California Nursing Homes: Care
              Problems Persist Despite Federal and State Oversight (GAO/HEHS-98-202, July 27, 1998).
              2
               See Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents
              (GAO/HEHS-99-80, Mar. 22, 1999). We examined Maryland, Michigan, and Washington as well as 11
              other states reviewed by state auditors—Iowa, Kansas, Kentucky, Louisiana, New York, North
              Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Wisconsin.



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    Nursing Homes: Stronger Complaint and
    Enforcement Practices Needed to Better
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    on the existence of serious deficiencies in nursing home compliance with
    Medicare and Medicaid standards. Further, we assess HCFA’s use of
    sanction authority for homes that failed to maintain compliance with these
    standards.3

    In brief, we found that neither complaint investigations nor enforcement
    practices are being used effectively to ensure adequate care for nursing
    home residents. As a result, allegations or incidents of serious problems,
    such as inadequate prevention of pressure sores, failure to prevent
    accidents, and failure to assess residents’ needs and provide appropriate
    care, often go uninvestigated and uncorrected. Our work in selected states
    revealed that, for serious complaints alleging harm to residents, the
    combination of inadequate state practices and limited HCFA guidance and
    oversight have often resulted in

•   policies or practices that may limit the number of complaints filed,
•   serious complaints alleging harmful situations not being investigated
    promptly, and
•   incomplete reporting on nursing homes’ compliance history and states’
    complaint investigation performance.

    Further, regarding enforcement actions, HCFA has not yet realized its main
    goal—to help ensure that homes maintain compliance with federal health
    care standards. We found that too often a yo-yo pattern develops in which
    homes cycle in and out of compliance. More than one-fourth of the more
    than 17,000 nursing homes nationwide had serious deficiencies that
    caused actual harm to residents or placed them at risk of death or serious
    injury. Although most homes corrected deficiencies identified in an initial
    survey, 40 percent of these homes with serious deficiencies were repeat
    violators. In most cases, sanctions initiated by HCFA never took effect. The
    threat of sanctions appeared to have little effect on deterring homes from
    falling out of compliance because homes could continue to avoid the
    sanctions’ effect as long as they temporarily corrected their deficiencies.

    HCFA has recently taken a number of actions to improve nursing home
    oversight in an attempt to resolve problems pointed out in earlier studies.
    These initiatives include varying the scheduling of annual surveys to
    lessen their predictability and more vigorously prosecuting egregious
    violations. We are making several additional recommendations to HCFA

    3
     See Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality
    Standards (GAO/HEHS-99-46, Mar. 18, 1999). The scope of this review included analysis of HCFA’s
    nationwide database of periodic inspections and detailed work in four states–California, Michigan,
    Pennsylvania, and Texas.



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                                 Nursing Homes: Stronger Complaint and
                                 Enforcement Practices Needed to Better
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                                 that should strengthen its standards for and oversight of states’ complaint
                                 practices and improve the deterrent effect of enforcement actions,
                                 including the use of fines and terminations. We are also recommending
                                 that HCFA improve its management information systems to more
                                 completely include complaint investigation results and to be able to more
                                 effectively identify and respond to homes with recurring problems. Last
                                 week, the Administrator generally concurred with these recommendations
                                 and announced new initiatives to address these issues.


                                 Investigations of complaints filed against nursing homes can provide a
Some States’                     valuable opportunity for determining if the health and safety of nursing
Complaint Practices              home residents are threatened. Complaint investigations are typically less
Are Limited in Their             predictable than annual surveys and can target specific areas of potential
                                 problems identified by residents, their families, concerned public, and
Ability to Protect               even the facility itself. However, we found that complaint investigation
Residents                        practices do not consistently achieve their full potential.

Some States’ Policies or         Some states have practices that may limit the number of complaints that
Practices Limit the Filing       are filed and investigated. For example, both Maryland and Michigan
of Complaints or Quick           encourage callers to submit their complaints in writing. In contrast,
                                 Washington readily accepts and acts on phone complaints without
Response                         encouraging a written follow-up. This practice would appear to contribute
                                 to Washington’s much higher volume of complaints than in either
                                 Maryland or Michigan.

                                 When a complaint is received, the state agency ascertains its potential
                                 seriousness. HCFA requires states to investigate complaints that may
                                 immediately jeopardize a resident’s health, safety, or life within 2
                                 workdays of receipt. For other serious complaints, states are permitted to
                                 establish their own categories and time frames for investigation. Some
                                 states permit relatively long periods of time to pass between the receipt of
                                 these complaints and their investigation. For example,

                             •   Michigan’s statute allows 30 days, but Michigan’s operating practice in
                                 1998 allowed 45 days;
                             •   Tennessee allows 60 days; and
                             •   Kansas allows 180 days.

                                 Other states, however, such as Maryland, Pennsylvania, and Washington,
                                 have additional priority levels that categorize other serious complaints to
                                 be investigated within shorter time frames, such as 10 workdays.



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                             Nursing Homes: Stronger Complaint and
                             Enforcement Practices Needed to Better
                             Ensure Adequate Care




Some States Assign Low       We found that some states classify few complaints in high-priority levels
Priority Levels to Serious   that would require a prompt investigation. For example, in the 1-year
Complaints                   period from July 1997 to June 1998, Maryland did not classify any
                             complaints as having the potential to immediately jeopardize residents and
                             thereby requiring a visit within 2 workdays. Maryland most frequently
                             classified complaints as not requiring a visit until the next on-site
                             inspection–which could be as long as a year or more away. Similarly,
                             Michigan categorized nearly all of its complaints between July 1997 and
                             June 1998 as not requiring a visit for 45 days or until the next annual
                             survey. In contrast, Washington determined that 9 out of 10 complaints
                             should be investigated within either 2 or 10 workdays.

                             Several states have explicit procedures or operating practices that do not
                             place serious complaints in high-priority categories for investigation. A
                             Maryland official, for example, acknowledged reducing the priority of
                             some complaints since the agency recognized that it could not meet
                             shorter time frames because of insufficient staff. Michigan gave some
                             complaints low priority if the resident was no longer at the nursing home
                             when the complaint was received—even if the resident had died or been
                             transferred to a hospital or another nursing home because of care
                             problems. For example, in one such complaint in Michigan, it was alleged
                             in July 1998 that a resident died because the home did not properly
                             manage his insulin injections or perform blood sugar tests. The state had
                             recently investigated the home and determined that previous problems
                             with treatment of diabetic residents had been corrected. However, the
                             state did not investigate the complaint until this month as part of the most
                             recent annual survey—nearly 8 months after the complaint was
                             received—and state investigators did not identify any problems with
                             treatment of diabetic residents. We question why the state agency did not
                             investigate this complaint sooner given that the resident died and the
                             home had previous deficiencies related to diabetic care. Michigan also
                             delayed investigating certain non-immediate jeopardy complaints against
                             nursing homes undergoing a federal enforcement action. Officials told us
                             that they adopted this practice to avoid potential confusion that might
                             result from having two enforcement actions pending simultaneously. This
                             practice, however, could unreasonably delay the investigation of serious
                             complaints at nursing homes already identified as violating federal
                             standards.

                             In reviewing complaints from the states visited, we identified several
                             complaints that raise questions about why they were not considered as




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                               Enforcement Practices Needed to Better
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                               involving potential immediate jeopardy and thereby requiring a visit within
                               2 workdays. Examples of these allegations include the following:

                           •   A resident was found dead with her head trapped between the mattress
                               and the side rail of the bed with her body lying on the floor. The state
                               categorized this complaint as one needing to be investigated within 45
                               days. The state investigated this complaint within 13 days and determined
                               that 11 of 24 sampled beds had similar side rail problems.
                           •   An alert resident who was placed in a nursing home for a 20-day
                               rehabilitation stay to recover from hip surgery was transferred in less than
                               3 weeks to a hospital because of an “unprecedented rapid decline [in his
                               condition].” A member of the ambulance crew transporting the resident to
                               the hospital reported that the resident “had dried . . . blood in his
                               fingernails and on his hands . . . sores all over his body . . . smelled like
                               feces . . . and (was) unable to walk or take care of himself. . .. I personally
                               feel he was not being properly cared for.” The state eventually determined
                               that the nursing home had harmed the resident, but only after categorizing
                               this complaint as not needing an investigation until the next on-site
                               inspection which was more than 4 months after receipt of the complaint.


Some States Not                Further, we found that states often did not conduct investigations within
Conducting Complaint           the time frames they assigned complaints, even though some states
Investigations in Timely       frequently placed complaints in priority categories that would increase the
                               time available to investigate them. Some of these complaints, despite
Manner                         alleging serious risk to resident health and safety, remained uninvestigated
                               for several months after the deadline for investigation. For example,
                               Maryland met its time frames for only 21 percent of complaints assigned to
                               the 10-workday category and 69 percent of complaints assigned to the
                               45-workday category. Michigan met its time frames in about one-fourth of
                               cases. Washington, which assigned most complaints to the category
                               requiring a visit within 10 workdays, met its time frames in slightly more
                               than half (55 percent) of all complaints.

                               During our visits to Maryland, Michigan, and Washington, we asked the
                               states to provide copies of all complaints in the Baltimore, Detroit, and
                               Seattle areas that had not yet been investigated and that exceeded the
                               assigned time frame. The Baltimore and Detroit metropolitan areas had
                               over 100 such complaints, and the Seattle area had 40. For example, in
                               Baltimore we identified a nursing home that had three complaints alleging
                               neglect or abuse that had not yet been investigated and had been pending
                               for at least 3 or 4 months. These allegations included a resident who was



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                           Nursing Homes: Stronger Complaint and
                           Enforcement Practices Needed to Better
                           Ensure Adequate Care




                           not fed for nearly 2 days and was hospitalized with dehydration, pressure
                           sores, and an infection; a resident whose condition deteriorated, including
                           losing 10 percent of her body weight in 2 months, and who suffered from
                           poor hygiene; and a resident who was improperly transferred and suffered
                           two fractured legs. In Detroit, a nursing home had four pending complaints
                           that had not been investigated for between 2 and 8 months and that
                           alleged neglect and abuse of residents. These allegations included a
                           resident who died after the home allegedly failed to send her to the
                           hospital promptly and who the hospital’s physician determined was
                           dehydrated and malnourished; a resident with an uncared-for cut that
                           became infected and resulted in heel amputation; an unattended resident
                           who was found outside the home with injuries from a fall; and a resident
                           who was verbally abused by a staff member.

                           Failure by states to investigate complaints promptly can delay the
                           identification of serious problems in nursing homes and postpone needed
                           corrective actions. As a result of delayed investigations, situations in
                           which residents are harmed are permitted to continue for extended
                           periods. For example, we found a complaint in Michigan alleging
                           inadequate care for pressure sores and fractures due to falls that was not
                           investigated for over 7 months. When the state did investigate, it found
                           that the nursing home had a pattern of deficiencies of inadequate care that
                           actually harmed residents.


                           On the basis of of our analysis of nationwide survey data, we found that
Application of             more than one in four nursing homes had serious and often repeated
Sanctions Does Not         deficiencies that resulted in immediate jeopardy or actual harm to
Ensure Nursing             residents. While HCFA’s initiation of actions typically brought homes into at
                           least temporary compliance, they were often ineffective in ensuring that
Homes Maintain             homes maintained compliance over time with federal standards.
Compliance
Many Nursing Homes Incur   Surveys conducted since the July 1995 implementation of stronger
Repeated Serious           enforcement tools showed that, each year, more than 4,700 homes had
Deficiencies               deficiencies that caused actual harm to residents or placed them at risk of
                           death or serious injury. The most frequent violations causing actual harm
                           included inadequate prevention of pressure sores, failure to prevent
                           accidents, and failure to assess residents’ needs and provide appropriate
                           care. Although most homes were found to have corrected the identified
                           deficiencies, subsequent surveys showed that problems often returned.
                           About 40 percent of the homes that had such problems in their first survey



                           Page 6                                                       GAO/T-HEHS-99-89
                           Nursing Homes: Stronger Complaint and
                           Enforcement Practices Needed to Better
                           Ensure Adequate Care




                           during the period we examined (July 1995 to October 1998) had them
                           again in their last survey during the period.


Sanctions Often Do Not     Our work in four states and four HCFA regions showed that HCFA-initiated
Take Effect or Result in   sanctions against noncompliant nursing homes did not take effect in a
Only Temporary             majority of cases and generally did not ensure that the homes maintained
                           compliance with standards.4 Our review of 74 homes that states had
Corrections                referred to HCFA for federal enforcement action, as a result of serious or
                           uncorrected deficiencies, showed that the threat of sanctions often helped
                           bring the homes back into temporary compliance but provided little
                           incentive to keep them from slipping back out of compliance. On the basis
                           of state recommendations, HCFA most commonly initiated three sanctions
                           for these homes: denial of payments for new admissions, civil monetary
                           penalties, and termination.5 States had referred these homes to HCFA for
                           possible sanctions an average of about three times each. Because many
                           homes corrected their deficiencies before the effective date of the
                           sanction, HCFA often rescinded the sanction before it took effect. For
                           example, sanctions did not take effect in 55 percent of cases where denial
                           of payments was recommended; 68 percent of cases of civil monetary
                           penalties; and 72 percent of cases of termination.6

                           However, the threat of sanctions only temporarily induced homes to
                           correct identified deficiencies, as many were again out of compliance by
                           the time the next inspection was conducted. Of the 74 homes we reviewed
                           that faced possible sanctions, 69 were again referred for sanctions after
                           being found out of compliance once more—some went through this
                           process as many as 6 or 7 times. For example, twice in 1995, and again in
                           1996 and 1997, Michigan cited one home for causing actual harm to
                           residents. Deficiencies included failure to prevent the development of
                           pressure sores in several residents and failure to prevent accidents, which
                           resulted in a broken arm for one resident and a broken leg for another. In

                           4
                            The four states were California, Michigan, Pennsylvania, and Texas, which—combined—account for
                           23 percent of nursing homes nationwide. The HCFA regions we reviewed included San Francisco,
                           Chicago, Philadelphia, and Dallas, which are responsible for overseeing states with 55 percent of
                           nursing homes nationwide. Within these four states, we chose a judgmental sample of 74 nursing
                           homes that had deficiencies of sufficient severity that states had referred the homes to HCFA for 241
                           separate federal enforcement actions.
                           5
                            Other sanctions, including increased state monitoring, appointment of a temporary manager to
                           oversee the home while it corrects its deficiencies, and state-directed plans of correction, have been
                           infrequently used.
                           6
                            The relatively small number of civil monetary penalties that have taken effect is a reflection of the
                           large number of fines under appeal. As appeals are settled, a higher proportion of the fines imposed
                           may take effect.



                           Page 7                                                                             GAO/T-HEHS-99-89
                        Nursing Homes: Stronger Complaint and
                        Enforcement Practices Needed to Better
                        Ensure Adequate Care




                        another example, Texas surveyors cited one nursing home for placing
                        residents in immediate jeopardy and actual harm twice in 1995—including
                        failure to prevent choking hazards, provide proper incontinent care, and
                        prevent or heal pressure sores. On the next annual survey, surveyors again
                        found quality of care deficiencies that caused harm to residents, including
                        failure to provide adequate nutrition.

                        This yo-yo pattern of compliance and noncompliance could be found even
                        among homes that were terminated from Medicare, Medicaid, or both.
                        Termination is usually thought of as the most severe sanction and is
                        generally used only as a last resort.7 Once a home is terminated, however,
                        it can generally apply for reinstatement if it corrects its deficiencies and
                        has demonstrated “reasonable assurance” that they will not recur. Of the
                        74 homes we analyzed, 13 were terminated at some point; however, the
                        pattern of noncompliance returned for 3 of 6 homes that were reinstated.
                        For example, a Texas nursing home was terminated from Medicare for a
                        number of violations that included widespread deficiencies causing actual
                        harm to residents. About 6 months after the home was terminated, it was
                        readmitted under the same ownership. Within 5 months, state surveyors
                        again identified a series of deficiencies involving harm to residents,
                        including failure to prevent avoidable pressure sores or ensure that
                        residents received adequate nutrition.


                        Given these weaknesses in many states’ complaint practices and the
Further HCFA            current inadequacy of enforcement actions to maintain homes’ compliance
Oversight and           with federal standards, one would expect HCFA to be more proactive in
Enforcement Needed      overseeing states and enforcing sanctions when nursing homes do not
                        maintain compliance with its standards. HCFA, however, has exercised
                        limited oversight or guidance of states’ complaint practices. In addition,
                        while HCFA has some tools to address the cycle of repeated noncompliance
                        among some homes, it has not used them effectively.


HCFA Oversight of       Although federal funds finance over 70 percent of complaint investigations
Complaints Is Limited   nationwide, HCFA plays a minimal role in providing states with direction or
                        oversight regarding these investigations. HCFA has left it largely to the
                        states to determine which complaints are so serious that they must be
                        investigated within the federally mandated 2 workdays. Until last week,
                        HCFA had no formal requirements for the prompt investigation of serious

                        7
                        When a home is terminated, it loses any income from Medicare and Medicaid payments, which for
                        many homes represents a substantial part of operating revenues. Residents who receive support from
                        Medicare or Medicaid must be moved to other facilities.



                        Page 8                                                                        GAO/T-HEHS-99-89
                             Nursing Homes: Stronger Complaint and
                             Enforcement Practices Needed to Better
                             Ensure Adequate Care




                             complaints that could harm residents but were not classified as potentially
                             placing residents in immediate jeopardy. Moreover, HCFA’s oversight of
                             state agencies that certify federally qualified nursing homes has not
                             focused on complaint investigations. We found that

                         •   a HCFA initiative to strengthen federal requirements for complaint
                             investigations was discontinued in 1995, and resulting guidance developed
                             for states’ optional use had not been widely adopted.
                         •   federal monitoring reviews of state nursing home inspections primarily
                             focus on the annual standard survey of nursing homes, with very few
                             conducted of complaint investigations.
                         •   since 1998, HCFA has required state agencies to develop their own
                             performance measures and quality improvement plans for their complaint
                             investigations, but for several of the states we reviewed complaint
                             processes were addressed superficially or not at all.

                             In response to our findings and concerns raised by advocates for nursing
                             home residents, HCFA announced last week several initiatives intended to
                             strengthen its standards for and oversight of states. For example, HCFA will
                             now require states to investigate complaints alleging actual harm to
                             residents within 10 workdays.


HCFA Policy Limits           Regarding enforcement actions, the manner in which some sanctions have
Enforcement Sanctions’       been implemented limits their effectiveness. For example, civil monetary
Effectiveness                penalties have a potentially strong deterrent effect because they cannot be
                             avoided simply by taking corrective action, and the longer the deficiency
                             remains, the larger the penalty can be. However, the effectiveness of civil
                             monetary penalties has been hampered by a growing backlog of appeals.
                             Nationwide, a lack of hearing examiners has created a growing backlog,
                             with over 700 cases awaiting decision as of February 1999 and some cases
                             dating back to 1996. HHS estimated that each year at least twice as many
                             appeals would be received as would be settled and has requested
                             additional funds for fiscal year 2000. This appeals backlog creates a
                             bottleneck for timely collections. As of September 1998, only 37 of the 115
                             monetary penalties imposed on the 74 homes we reviewed had been
                             collected. This backlog of appealed civil monetary penalties encourages
                             HCFA to settle appealed cases, often reducing the size of the fine, and
                             delays the imposition of the fine even if it is ultimately upheld after appeal.
                             As a result, it is not surprising that some nursing home owners routinely
                             appeal imposed penalties. For example, we found that one large Texas
                             chain appealed 62 of the 76 civil monetary penalties imposed on its



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                              nursing homes between July 1995 and April 1998. These 62 potential
                              penalties totaled $4.1 million.

                              Since July 1998, HCFA has taken or proposed several initiatives to improve
                              nursing home oversight. These initiatives include varying the scheduling of
                              annual surveys to reduce the predictability of surveyors’ visits, revising the
                              definition of a poorly performing facility to broaden the criteria for taking
                              immediate enforcement action, and prosecuting egregious violations of
                              care standards. While these are important steps, it is too early to gauge
                              their effect in resolving earlier identified problems. HCFA’s initiatives do
                              not, however, address some weaknesses identified in our most recent
                              work. For example:

                          •   HCFA  does not require states to refer homes for sanction in all cases where
                              identified deficiencies contributed to the death of a resident. We identified
                              examples where investigation of a resident’s death found that the deficient
                              practice had ceased at the time of the investigation, thus resulting in a
                              finding of actual harm. Under HCFA policy, states are not required to refer
                              homes with this level of deficiency for sanction.
                          •   The problem with terminations is twofold. First, HCFA should require that
                              nursing homes better demonstrate reasonable assurance that violations
                              will not recur before deciding to reinstate a terminated home. Second,
                              HCFA policy prevents state agencies from considering a reinstated home’s
                              prior record. This policy effectively gives the home a “clean slate” and
                              produces the disturbing outcome that termination could actually be
                              advantageous to a home with a poor compliance history.


HCFA’s Management             Finally, our work points to weaknesses in HCFA’s management information
Information Systems Are       systems that have limited its effectiveness in addressing both nursing
Inadequate                    home complaints and enforcement. HCFA reporting systems for nursing
                              homes’ compliance history and complaint investigations do not collect
                              timely, consistent, and complete information. Having full and accurate
                              information on a nursing home’s compliance and enforcement history,
                              including the results of complaint investigations, would improve HCFA’s
                              ability to identify nursing homes in need of further enforcement sanctions.
                              Further information system weaknesses pertain to the inability to centrally
                              track enforcement actions or to identify nursing homes under common
                              ownership.




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                      Nursing Homes: Stronger Complaint and
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                      As the Congress, HCFA, and the states seek to better ensure adequate
Conclusions and       quality of care for nursing home residents, our work has demonstrated
Recommendations       that key components of complaint investigations and enforcement actions
                      need to be strengthened to better protect the growing number of elderly
                      and disabled Americans who rely on nursing homes for their care–one of
                      the nation’s most vulnerable populations. Absent such improvements,
                      many federal and state policies and practices continue to result in serious
                      complaints—which allege harm to residents—not being investigated for
                      weeks or months. In addition, HCFA’s ineffective use of common
                      enforcement sanctions, such as fines, denial of payments, and termination,
                      leads to nursing homes temporarily correcting deficiencies that recur all
                      too often.

                      Our reports contain several specific recommendations to HCFA. The
                      Administrator has already concurred and has started taking steps to act on
                      them. Broadly, these recommendations call for HCFA to

                  •   develop additional standards for the prompt investigation of serious
                      complaints and strengthen its oversight of state complaint investigations;
                  •   improve the effectiveness of enforcement actions, including reducing the
                      backlog of appeals of civil monetary penalties; and strengthen policies
                      regarding terminated homes, such as requiring reasonable assurance
                      periods of sufficient duration and maintaining the home’s pretermination
                      history; and
                  •   develop better management information systems to integrate the results of
                      complaint investigations, track the status and history of deficiencies, and
                      monitor enforcement actions.


                      Mr. Chairman, this concludes my statement. I will be happy to answer any
                      questions that you or other Members of the Committee may have.




(101813)              Page 11                                                    GAO/T-HEHS-99-89
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