Holding Nursing Homes Accountable
A number of congressional hearings since July 1998 have focused considerable attention on the need to improve the quality of care for the nation's 1.7 million nursing-home residents, a highly vulnerable population of elderly and disabled individuals. As we previously reported, poor quality of care at about 15% of the nation's approximately 17,000 nursing homes--an unacceptably high proportion--had repeatedly caused actual harm to residents, such as worsening pressure sores or untreated weight loss, or had placed them at risk of death or serious injury.
Significant weaknesses in federal and state nursing home oversight that we identified in a series of reports and testimonies since 1998 included (1) periodic state inspections, known as surveys, that understated the extent of serious care problems due to procedural weaknesses, (2) considerable state delays in investigating public complaints alleging harm to residents, (3) federal enforcement policies that did not ensure deficiencies were addressed and remained corrected, and (4) federal oversight of state survey activities that was limited in scope and effectiveness.
In July 1998, the Health Care Financing Administration (HCFA)--the federal agency with responsibility for managing Medicare and Medicaid and overseeing compliance with federal nursing-home quality standards--launched a series of actions intended to address many of the weaknesses we identified. Since 1998, the agency has worked to strengthen surveyors' ability to detect quality-of-care deficiencies; required states to investigate complaints alleging resident harm within 10 days; mandated immediate sanctions for nursing homes with a pattern of harming residents; and begun measuring state compliance with federal survey requirements and reviewing data on the results of state surveys to help pinpoint shortcomings in state survey activities.
State survey data indicate that the proportion of nursing homes with serious quality problems remains unacceptably high, despite a decline in such reported problems since mid-2000. Compared to the prior 18-month period, the percentage of nursing homes cited for actual harm or immediate jeopardy from July 2000 through January 2002 declined by about one-third--from 29% (about 5,000 homes) to 20% (about 3,500 homes). Consistent with this reported improvement in quality, federal comparative surveys completed during a recent 20-month period found actual harm or higher-level deficiencies in 22% of homes where state surveyors found no such deficiencies, compared to 34% in an earlier period.
Fewer discrepancies between federal and state surveys suggest that state surveyors' performance in documenting serious deficiencies has improved and that the decline in serious quality problems nationwide is potentially real. Despite this improvement, however, the magnitude of understatement of actual harm deficiencies remains a cause for concern. …