Nursing Homes:

Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards

HEHS-99-46: Published: Mar 18, 1999. Publicly Released: Mar 18, 1999.

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Pursuant to a congressional request, GAO provided information on the enforcement of federal nursing home standards, focusing on: (1) national data on the existence of serious deficiencies in nursing home compliance with Medicare and Medicaid standards; and (2) the use of sanction authority for homes that failed to maintain compliance with the standards.

GAO noted that: (1) GAO's work showed that while the Health Care Financing Administration (HCFA) has taken steps to improve oversight of nursing home care, it has not yet realized a main goal of its enforcement process--to help ensure that homes maintain compliance with federal health care standards; (2) surveys conducted in the nation's 17,000-plus nursing homes in recent years showed that each year, more than one-fourth of the homes had deficiencies that caused actual harm to residents or placed them at risk of death or serious injury; (3) 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; (4) although most homes were found to have corrected the identified deficiencies, subsequent surveys showed that problems often returned; (5) about 40 percent of the homes that had such problems in their first survey during the period GAO examined (July 1995 to October 1998) had them again in their last survey during the period; (6) sanctions initiated by HCFA against noncompliant nursing homes were never implemented in a majority of cases and generally did not ensure that the homes maintained compliance with standards; (7) GAO's review of HCFA's survey data combined with GAO's analysis of 74 homes that had a history of problems showed a common pattern; (8) HCFA would give notice to impose a sanction, the home would correct its deficiencies, HCFA would rescind the sanction, and a subsequent survey would find that problems had returned; (9) the threat of sanctions appeared to have little effect on deterring homes from falling out of compliance again because homes could continue to avoid sanctions' effect as long as they kept correcting their deficiencies; (10) HCFA has some tools to address this cycle of repeated noncompliance but has not used them effectively; (11) fines are potentially a strong deterrent because they can be applied even if a home comes back into compliance; (12) however, the usefulness of civil monetary penalties is being hampered by a backlog of administrative appeals coupled with a legal provision that prohibits collection of the penalty until the appeal is resolved; (13) the sanction is often delayed for several years; and (14) GAO also found problems with several aspects of HCFA's policies for ensuring that sufficient attention is placed on homes that have serious deficiencies or a history of recurring noncompliance as well as policies for reinstating homes that have been terminated from the Medicare and Medicaid programs.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: Congress approved funding and full-time equivalent staffing levels for the Board in fiscal years 2000 and 2001, sufficient to double the number of staff administrative law judges (ALJ) hearing nursing home appeals from four to eight, with an appropriate increase in supporting staff. In March 2002, the backlog had reached 833 cases, but has declined since that time as more ALJs and attorneys have been hired. As of August 2003, the backlog stood at 496 cases--the lowest level in at least 5 years. The Chairwoman of the Board told GAO that the increase in funding and the resultant increase in staff have had a clear impact on reducing the board's backlog of nursing home cases.

    Recommendation: To strengthen its ability to ensure that nursing homes maintain compliance with Medicare and Medicaid quality-of-care standards, the Administrator, HCFA, should improve the effectiveness of civil monetary penalties. The Administrator should continue to take those steps necessary to shorten the delay in adjudicating appeals, including monitoring progress made in reducing the backlog of appeals.

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

  2. Status: Closed - Implemented

    Comments: HCFA has issued State Operation manual changes, effective January 2000, to address parts 2 and 3 of this recommendation. It has completed a study to address parts 1 and concluded that it is not practical to establish rules to address the problem with terminated homes continuing to receive Medicare payment beyond the termination date.

    Recommendation: To strengthen its ability to ensure that nursing homes maintain compliance with Medicare and Medicaid quality-of-care standards, the Administrator, HCFA should strengthen the use and effect of termination. The Administrator should: (1) continue Medicare and Medicaid payments beyond the termination date only if the home and state Medicaid agency are making reasonable efforts to transfer residents to other homes or alternate modes of care; (2) ensure that reasonable assurance periods associated with reinstating terminated homes are of sufficient duration to effectively demonstrate that the reason for termination has been resolved and will not recur; and (3) revise existing policies so that the pre-termination history of a home is considered in taking a subsequent enforcement action.

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

  3. Status: Closed - Implemented

    Comments: HCFA has made changes to the State Operations Manual consistent with GAO's recommendation.

    Recommendation: To strengthen its ability to ensure that nursing homes maintain compliance with Medicare and Medicaid quality-of-care standards, the Administrator, HCFA, should improve the referral process. The Administrator should revise HCFA guidance so that states refer homes to HCFA for possible sanction (such as civil monetary penalties) if they have been cited for a deficiency that contributed to a resident's death.

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

  4. Status: Closed - Implemented

    Comments: As part of the overall redesign of its information systems, CMS implemented in 10/2004, as GAO recommended, a national enforcement data system, ASPEN Enforcement Manager (AEM), to collect enhanced enforcement data, replacing an interim national enforcement system. In January 2004, the agency achieved national implementation of its new ASPEN complaint tracking system (ACTS). A scheduling system, Aspen Scheduling and Tracking (AST) was also released in 2004 but is voluntary. CMS plans to integrate these systems into a single system called QIES/CASPER in 2005. The QIES/CASPER system will also include an enhanced capability to track the status and history of nursing home deficiencies. Currently, CMS estimates that QIES will not be available until CY 2008. GAO will continue to monitor CMS's progress in fielding the new QIES/CASPER system. August 2007 Update: CMS has delayed replacement of the Online Survey, Certification, and Reporting (OSCAR) data system until 2009 as a result of funding cuts and its focus on other initiatives. August 2008 Update. CMS has not finalized replacement of the OSCAR system because of other priorities. Aug 2009 Update: CMS has implemented both ACTS and AEM and has established an interface for these systems, therefore, CMS has implemented this recommendation and we are closing it.

    Recommendation: To strengthen its ability to ensure that nursing homes maintain compliance with Medicare and Medicaid quality-of-care standards, the Administrator, HCFA, should develop better management information systems. The Administrator should enhance the Online Survey, Certification, and Reporting system or develop some other information system that can be used by the states and by HCFA to integrate the results of complaint investigations, track the status and history of deficiencies, and monitor enforcement actions.

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

 

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