Nursing Homes:

More Can Be Done to Protect Residents from Abuse

GAO-02-312: Published: Mar 1, 2002. Publicly Released: Mar 5, 2002.

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Often suffering from multiple physical and mental impairments, the 1.5 million elderly and disabled Americans living in nursing homes are a highly vulnerable population. These individuals typically require extensive help with daily living, such as such as dressing, feeding, and bathing. Many require skilled nursing or rehabilitative care. In recent years, reports of inadequate care, including malnutrition, dehydration, and other forms of neglect, have led to mounting scrutiny from state and federal authorities, which share responsibility for overseeing the nation's 17,000 nursing homes. Concerns have also been growing that some residents are abused--pushed, slapped, or beaten--by the very individuals to whom their care has been entrusted. GAO found that allegations of physical and sexual abuse of nursing home residents are not reported promptly. Local law enforcement officials said that they are seldom summoned to nursing homes to immediately investigate allegations of abuse and that few allegations are ever prosecuted. Some agencies use different policies when deciding whether to refer allegations of abuse to law enforcement. As a result, law enforcement agencies were never told of some incidents or were notified only after lengthy delays. GAO found that federal and state safeguards intended to protect nursing home residents from abuse are inadequate. No federal statute requires criminal background checks for nursing home employees. Background checks are also not required by the Centers for Medicare and Medicaid Services, which sets the standards that nursing homes must meet to participate in the Medicare and Medicaid programs. State agencies rarely recommend that sanctions be imposed on nursing homes. Although state agencies compile lists of aids who have previously abused residents, which can prevent an aide from being hired at another nursing home, GAO found that delays in making these identifications can limit the usefulness of these registries. GAO summarized this report in testimony before Congress; see GAO-02-448T.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To better protect nursing home residents, the CMS Administrator should clarify the definition of abuse and otherwise ensure that states apply that definition consistently and appropriately.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Implemented

    Comments: CMS implemented GAO's recommendation by sending a memorandum to State Survey Agency Directors, clarifying its definition of abuse and by instructing them to report suspected abuse to law enforcement authorities, and, if appropriate, to the state's Medicaid Fraud Control Unit.

    Recommendation: To better protect nursing home residents, the CMS Administrator should systematically assess state policies and practices for complying with the federal requirement to prohibit employment of individuals convicted of abusing nursing home residents and, if necessary, develop more specific guidance to ensure compliance.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: CMS pointed out that Section 307 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires the Secretary of HHS to establish a pilot program to identify efficient, effective, and economical procedures for long term care facilities or providers to conduct criminal background checks on prospective direct patient access employees. CMS is in the process of establishing the "Pilot Program For National And State Background Checks On Direct Patient Access Employees Of Long-Term Care Facilities Or Providers," and anticipates selecting up to 10 pilot states by November 2004. The purpose of this pilot is to evaluate state programs requiring background checks of all direct patient access employees working in long-term care facilities. One goal of this program is to prohibit employment of individuals convicted of crimes such as abusing nursing home residents. In 2005, CMS noted that it has not issued any additional guidance about the prohibition of employing individuals accused of abusing nursing home residents. However, it also pointed out that it clarified its definitions of abuse in December 2004, following concerns that some states were over-reporting injuries of an unknown source as abuse. CMS also said that states not participating in the pilot program requiring background checks reported these checks created a large workload. In 2006, CMS said that it had no further information to report.

    Recommendation: To better protect nursing home residents, the CMS Administrator should accelerate the agency's education campaign on reporting nursing home abuse by (1) distributing its new poster with clearly displayed complaint telephone numbers and (2) requiring state survey agencies to ensure that these numbers are prominently listed in local telephone directories.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: In 2004, CMS reported that it released a video with three segments entitled "The Importance of Being a Certified Nursing Assistant; Choosing Long-Term Care; and Living in a Nursing Home." The videos were distributed to over 16,000 nursing homes in the fall of 2003, as well as to advocates and regional offices. The poster is not yet released, but it is pending approval by the Department to display on the CMS partnership web site for viewing and downloading so that it can be printed and distributed by interested partners. In 2005, CMS reported that the posters have never been printed and that, among other things, cost appears to be a factor in the poster's production and distribution. In 2006, CMS said that it had no further information to report.

    Recommendation: To better protect nursing home residents, the Centers for Medicare and Medicaid Services (CMS) Administrator should ensure that state survey agencies immediately notify local law enforcement agencies or Medicaid Fraud Control Units when nursing homes report allegations of resident physical or sexual abuse or when the survey agency has confirmed complaints of alleged abuse.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: In 2002, CMS issued a memorandum to its regional offices and state survey agencies emphasizing its policy for preventing abuse in nursing homes and promptly reporting abuse to the appropriate authorities when it occurs. In 2004, CMS reported that it continues to hold discussions with the Department of Justice and with the Office of General Counsel about the authority and potential effectiveness of requiring state survey agencies to immediately notify local law enforcement of suspected physical and sexual abuse. In 2005, CMS noted that it does not track whether or not state survey agencies notify law enforcement agencies when abuse occurs. CMS pointed out that it is only required to report substantiated findings--not allegations. In 2006, CMS said that it had no further information to report.

    Recommendation: To better protect nursing home residents, the CMS Administrator should shorten the state survey agencies' time frames for determining whether to include findings of abuse in nurse aide registry files.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: CMS said that, because findings of abuse must be substantiated and due process to the accused must be ensured, considerable time may pass before reports to the registry are made. CMS pointed out that most of these time frames are defined in regulation. However, the regulations do not specify timeframes that states must follow in substantiating abuse. CMS agreed to review this matter when changes to the regulations are considered, but did not indicate when this would be done. In 2004, CMS reported that there has been no change in the status of this recommendation. In 2005, CMS noted that it has not set a timeframe for states to substantiate allegations of abuse, nor does it collect data on how long states typically take to do so. In 2006, CMS said that it had no further information to report.

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