California Nursing Homes:

Care Problems Persist Despite Federal and State Oversight

HEHS-98-202: Published: Jul 27, 1998. Publicly Released: Jul 27, 1998.

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Pursuant to a congressional request, GAO reviewed allegations that residents in California nursing homes are not receiving acceptable care, focusing on: (1) examining, through a medical record review, whether these allegations had merit and whether serious care problems currently exist; (2) reviewing the adequacy of federal and state efforts in monitoring nursing home care through annual surveys; and (3) assessing the effectiveness of federal and state efforts to enforce sustained compliance with federal nursing home requirements.

GAO noted that: (1) despite the federal and state oversight infrastructure currently in place, certain California nursing homes have not been and currently are not sufficiently monitored to guarantee the safety and welfare of their residents; (2) GAO reached this conclusion primarily using data from federal surveys and state complaint investigations conducted by California's Department of Health Services (DHS) on 1,370 California homes, supplemented with more in-depth analysis of certain homes and certain residents' care; (3) GAO found that surveyors can miss problems that affect the safety and health of nursing home residents and that even when such problems are identified, enforcement actions do not ensure that they are corrected and do not recur; (4) with regard to allegations made about avoidable deaths in 1993, GAO's expert nurses' review of the 62 resident cases sampled found that residents in 34 cases received care that was unacceptable and that sometimes endangered their health and safety; (5) in the absence of autopsy information or other additional clinical evidence, GAO cannot be conclusive about the extent to which this unacceptable care may have contributed directly to individual deaths; (6) unacceptable care continues to be a problem in many homes; (7) GAO believes that the extent of serious care problems portrayed in federal and state data is likely to be understated; (8) GAO found that homes could generally predict when their annual on-site reviews would occur and, if inclined, could take steps to mask problems otherwise observable during normal operations; (9) GAO found irregularities in the homes' documentation of the care provided to their residents; (10) in visiting homes selected by California DHS officials, GAO found multiple cases in which DHS surveyors did not identify certain serious care problems; (11) surveyors missed these care problems because federal guidance on conducting surveys does not include sampling methods that can enhance the spotting of potential problems and help establish their prevalence; (12) the Health Care Financing Administration's (HCFA) enforcement policies have not been effective in ensuring that the deficiencies are corrected and remain corrected; (13) California's DHS grants all noncompliant homes, with some exceptions, a 30- to 45-day grace period, during which they may correct the deficiencies without penalty; (14) a substantial number of California's homes that have been terminated and later reinstated have soon thereafter been cited again for serious deficiencies; and (15) the problems GAO identified are indicative of systemic survey and enforcement weaknesses.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: On January 1, 1999, HCFA issued instructions to state survey agencies directing them to begin some of their surveys on evenings and weekends, to vary the sequencing of surveys in a geographical area to avoid alerting others that the surveyors are in the area, and to vary the month in which surveys are conducted for a specific survey. However, HCFA disagreed with GAO's suggestion to segment the standard annual survey into more than one review throughout a 12-to 15-month period and, therefore, did not implement the recommendation. HCFA stated that segmenting the survey will render it ineffective and that, as the survey is designed, it functions best as a whole and cannot effectively be divided into smaller parts that can be conducted independently at different times.

    Recommendation: In order to better protect the health, safety, welfare, and rights of nursing home residents and ensure that nursing homes sustain compliance with federal requirements, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by staggering or otherwise varying the scheduling of standard surveys to effectively reduce the predictability of surveyors' visits; the variation could include segmenting the standard survey into more than one review throughout the 12- to 15-month period, which would provide more opportunities for surveyors to observe problematic homes and initiate broader reviews when warranted.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Implemented

    Comments: In response to our recommendation, CMS developed the new Quality Indicator Survey (QIS) to improve the consistency and efficiency of state surveys and provide a more reliable assessment of quality. As of August 2009, CMS has started implementing the QIS in eleven states: Connecticut, Florida, Kansas, Louisiana, Maryland, Minnesota, New Mexico, North Carolina, Ohio, Washington and West Virginia, and prioritized the remaining 39 states, District of Columbia, Puerto Rico and Virgin Islands for QIS implementation. The QIS uses an expanded sample and structured interviews with residents in a two-stage process. State surveyors are guided through the QIS process using customized software on tablet personal computers. In stage 1, a large resident sample is drawn and relevant data from on- and off-site sources is analyzed to develop a set of quality-of-care indicators, which will be compared to national benchmarks. Stage 2 systematically investigates potential quality-of-care concerns identified in stage 1 CMS concluded a five-state demonstration project of the QIS in 2007 and has since released the QIS evaluation.. Based on the QIS evaluation, CMS has identified several areas for improvement such as increasing the specificity and usability of investigative guidelines and evaluating how well the new methodology accurately identifies the areas in which there are potential quality problems. In addition, CMS articulated that future QIS development efforts should concentrate on improving survey consistency and giving supervisors more tools to assess performance of surveyor teams.

    Recommendation: In order to better protect the health, safety, welfare, and rights of nursing home residents and ensure that nursing homes sustain compliance with federal requirements, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by revising federal survey procedures to instruct surveyors to take stratified random samples of resident cases and review sufficient numbers and types of resident cases so that surveyors can better detect problems and assess their prevalence.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  3. Status: Closed - Implemented

    Comments: HCFA implemented this recommendation in two stages. In September 1998, it modified its policy to require that states refer for immediate imposition of a sanction on any nursing home with a pattern of harming a significant number of residents on successive surveys (levels H and above on HCFA's scope and severity grid). Effective December 15, 1999, HCFA expanded this policy to include deficiencies that harmed only one or a small number of residents (level G deficiencies) on two successive surveys.

    Recommendation: In order to better protect the health, safety, welfare, and rights of nursing home residents and ensure that nursing homes sustain compliance with federal requirements, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by eliminating the grace period for homes cited for repeated serious violations and impose sanctions promptly, as permitted under existing regulations.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  4. Status: Closed - Implemented

    Comments: HCFA responded to the recommendation by sending an August 20, 1998 memorandum to its regional offices and state survey agencies, strengthening its revisit policy. HCFA now requires that if a home is found to have serious violations during a survey, the home must correct all its violations and any new violations found during a revisit, until it comes into full compliance with federal standards. These homes will no longer be allowed to self-report resumed compliance.

    Recommendation: In order to better protect the health, safety, welfare, and rights of nursing home residents and ensure that nursing homes sustain compliance with federal requirements, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by requiring that for problem homes with recurring serious violations, state surveyors substantiate, by means of an on-site review, every report to HCFA of a home's resumed compliance status.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

 

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