Medicare and Medicaid:

Stronger Enforcement of Nursing Home Requirements Needed

HRD-87-113: Published: Jul 22, 1987. Publicly Released: Sep 18, 1987.

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In response to a congressional request, GAO investigated the enforcement of Medicare and Medicaid requirements for nursing homes, focusing on the: (1) extent and potential effect of repeated noncompliance; and (2) adequacy of enforcement actions taken by state and federal agencies.

GAO found that: (1) 3,372 of 8,298 certified skilled nursing facilities and 2,005 of 5,970 certified intermediate care facilities did not meet one or more of the requirements most likely to affect resident health and safety during three consecutive inspections; (2) 12 of 26 studied facilities corrected serious deficiencies which could have precluded continued participation in Medicare or Medicaid, while 3 were decertified; (3) 11 of the facilities had less serious deficiencies and continued participation in the programs without complying with requirements; and (4) in many cases, inspection officials did not follow regulations requiring facilities to justify repeated noncompliance before recertification. GAO believes that, while termination is too severe a penalty for many deficiencies, such measures as civil monetary penalties and bans on new admissions may provide effective motivation for compliance.

Matters for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: OBRA 87 strengthened enforcement provisions to help preclude terminated facilities from being readmitted to the Medicaid program with uncorrected deficiencies.

    Matter: Congress should amend title XIX of the Social Security Act to preclude nursing homes terminated from the Medicaid program from being readmitted to the program unless the state survey agency can establish that the deficiencies that led to termination have been removed, and it has reasonable assurance that they will not recur.

  2. Status: Closed - Implemented

    Comments: OBRA 87 established authority for a wide range of alternative sanctions, including civil penalties and bans on admissions.

    Matter: Congress should enact legislation such as S.1108, H.R. 2270, or H.R. 2770, to give the Department of Health and Human Services and the states additional alternatives for enforcing compliance with nursing home requirements.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: The passage of OBRA 87 established at the federal level the alternative sanctions this recommendation was aimed at utilizing.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration to encourage states to apply state licensing sanctions to nursing homes with repeat deficiencies that are not adequately justified.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Not Implemented

    Comments: HHS does not believe that requiring written justification for all repeat deficiencies would provide any meaningful incentive to maintain compliance.

    Recommendation: The Secretary of Health and Human Services should revise the repeat deficiency provisions of Medicare and Medicaid regulations to require nursing homes to justify all repeat deficiencies, including those reported at the element level or subsequently corrected.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: The Department of Health and Human Services (HHS) addressed this recommendation in regulations implementing the Omnibus Budget Reconciliation Act, but disagreed that it should require written justification for any repeat deficiency.

    Recommendation: The Secretary of Health and Human Services should revise the repeat deficiency provisions of Medicare and Medicaid regulations to limit the use of decertification to those instances where a nursing home cannot adequately justify repeat deficiencies that seriously threaten patient health and safety.

    Agency Affected: Department of Health and Human Services

 

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