Medicare Compliance & Reimbursement

Weak oversight, recurring understatements and poor compliance continue to plague nursing homes.

Nursing home oversight standards have increased, but not enough to eradicate many important quality and safety issues.

A recent report from the Government Accountability Office outlines several critical flaws in nursing home standards and care that have been recurring since 1998. Senate Finance Committee Chairman Sen. Charles E. Grassley (R-IA) and Sen. Herb Kohl (D-WI), Special Committee on Aging ranking member, requested the report.

Nursing homes fail to meet the grade in five key areas related to annual Centers for Medicare & Medicaid Services' state agency surveys and investigations, the GAO finds:

• A "small but unacceptable portion" of nursing homes repeatedly harm their residents. Such harm includes worsening pressure sores, failure to treat avoidable weight loss and putting residents at risk of death or serious injury. Many states cited confusion about the definition of "actual harm" in response to the report, notes the GAO.

• State inspections (surveys) frequently understate serious quality-of-care problems and fire safety issues. These recurring understatements reflect weaknesses in survey methodology and an inconsistent application of federal standards, the GAO suggests.

• Many states repeatedly fail to report allegations and investigate residents' and family members' serious complaints for weeks or even months, the report charges. Such delays not only hinder investigations but also compromise the quality of available evidence, says the GAO.

• Federal and state enforcement policies fail to ensure that homes adequately address and correct deficiencies that surveyors identify successfully.

• Federal mechanisms that oversee state monitoring of nursing home quality and safety have limited scope and effectiveness.

CMS oversees homes' compliance with federal nursing home standards and has set many improvement and evaluation initiatives into motion since 1998, when the GAO previously reported quality and safety weaknesses among nursing homes. The GAO evaluates the progress CMS has made since 1998 in addressing those quality and safety weaknesses in the report. The new report reviews trends in nursing home survey results, evaluates the success of CMS' improvement initiatives, and identifies challenges that threaten continuing progress in ensuring residents' quality and safety.

Declining Trends And Oversight Failures Aren't The Only Challenges

Serious surveyor oversights continue to undercut CMS' efforts to improve nursing home quality and safety. Trends from 1999 through January 2005 show that the number of nursing homes with serious quality problems has declined from roughly 29 percent to 16 percent. But inconsistencies in the way states conduct surveys, coupled with understated quality problems, undermine this success--as well as CMS' improvement initiatives, the report points out.

For example, the proportion of nursing homes with serious deficiencies varies widely--as much as 6 percent to 54 percent--from state to state. In addition, discrepancies between federal and state surveys of the same homes during 2002 to 2004 increased from 22 percent to 28 percent despite an overall decline of 17 percent during 1999 to 2004. Federal surveys of California, Florida, New York, Ohio and Texas in particular, which together account for nearly 30 percent of the nation's nursing homes, reveal that state surveyors comparatively overlooked 8 percent to 33 percent of the serious deficiencies that the federal surveyors found, the GAO points out.

CMS has already addressed several survey and oversight shortcomings, the GAO acknowledges. The agency has taken steps to strengthen oversight by assessing state survey activities and revamping survey methodology. Additional CMS initiatives have increased states' completion of complaint investigations by 45 percent and successfully identified 20 percent more fire safety deficiencies. Plus, sanctions on repeat violators aim to improve quality and safety compliance.

But CMS has yet to get survey consistency initiatives off the starting block, notes the GAO. Other existing CMS initiatives, such as the Nursing Home Compare Web site, which provides information about nursing homes' quality-of-care to consumers, have "shortcomings impairing their effectiveness" or have failed to target specific problems the GAO and CMS identified in previous assessments, according to the report.

CMS must continue its attention and commitment to improving nursing home oversight; this is essential to maintain the momentum the agency's accomplishments have built in nursing home quality and safety to date, says the GAO.

But several key health and safety challenges continue to stand in the way of progress, the GAO notes. To improve nursing home quality and safety, CMS, states and nursing homes all must overcome critical obstacles. For instance, CMS is phasing in requirements for homes to improve fire safety by installing automatic sprinklers--but the cost to retrofit older homes with automatic sprinklers could be prohibitive. In addition, inadequate compensation for registered nurses and competition from hospitals and other providers affect states' abilities to hire and retain qualified surveyors to foster consistent surveys. Increased oversight, new initiatives and provider growth also put a strain on state survey agencies' workloads.

Industry Experts Agree On Flaws But Criticize Report

CMS concurs with most of the GAO's findings in a comment letter about the report. But while the agency remains concerned about understatement, it does not agree with the GAO's assessment that the problem is getting worse. "We also remain concerned about possible understatement or omission of serious deficiencies by state survey agencies," says CMS Administrator Mark McClellan. "But we do not believe that the trend of fewer deficiencies in nursing homes is due to this problem." In addition, CMS notes that it is increasing its focus on states whose survey performance is not up to par.

The American Association of Homes and Services for the Aging agrees that the nursing home survey and certification process is highly inconsistent, adding that it is supporting federal legislation that would make common sense reforms in these processes. AAHSA also supports a fire-safety bill that sets timetables and designates funding for outfitting all homes with automatic sprinkler systems.

The American Health Care Association also supports the GAO's findings but maintains that the Nursing Home Quality Initiative offers more credible, measurable clinical outcome data. "[A]nalyzing subjective citation data from a bureaucratic system that the government's own watchdog group calls 'inconsistent' does little to benefit our frail, elderly and disabled citizens in long-term care," AHCA asserts in a Jan. 19 statement.

In a recent statement, Grassley vows to "keep after CMS" to improve oversight. "If state surveyors are missing serious deficiencies in the quality of care, then CMS has not yet achieved the necessary level of improvement in its oversight of that process, period," notes Grassley. "So CMS needs to make high-quality care for nursing home residents a consistent, high priority and get the job done once and for all."

To view the full GAO report, go to www.gao.gov/cgi-bin/getrpt?GAO-06-117.