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CMS Needs to Step Up Oversight of Nation's Worst Nursing Homes, GAO Says

By Jane Norman, CQ HealthBeat Associate Editor

April 16, 2010 -- A Government Accountability Office report to be released on Monday says the nation's worst nursing homes are in some cases improving, but the government could do a better job in identifying them and tracking their deficiencies.

The report found that some homes improved and graduated from a special program designed to pinpoint the worst facilities — even though they had not been surveyed as often as required or subject to the tougher enforcement required by the government for the most poorly performing homes. Decisions to publicize the names of the worst homes and make sure owners and boards of directors know about the label "have given homes additional incentives to improve their performance," said the report.

In addition, nursing homes that graduated from the special program because they improved often failed to sustain that improvement, the GAO said.

The results would be better if the Centers for Medicare and Medicaid Services (CMS) followed a GAO recommendation to compile a list of the worst homes nationally rather than on a state-by-state basis, the GAO said. In addition, CMS guidance to states is "vague" and interpreted in different ways by different regional and state offices, the report said. Homes with similar problems with compliance receive different fines, for example.

In their reply, CMS officials agreed with five of six recommendations for improvement made by GAO and said they would consider the other one — charging the nursing homes for additional surveys required for the worst homes.

"While we are encouraged by data indicating that CMS' Special Focus Facility initiative is producing positive and enduring results, we remain concerned by those nursing homes in the program that do relapse into a pattern of serious deficiencies, and by the length of time it is taking for some nursing homes to evidence improvement," said CMS. "During any period of relapse, nursing home residents suffer."

The report on the Special Focus Facility Program, or SFF, was requested by senators Herb Kohl of Wisconsin, a Democrat, and Charles E. Grassley of Iowa, a Republican.

Some 1.4 million elderly and disabled Americans live in nursing homes and the SFF is a list of the poorest-performing homes in each state — that, for example, have been cited repeatedly for serious deficiencies such as residents with preventable pressure sores that harmed them or put them at risk of death.

State agencies are responsible for conducting inspections and investigations of violations in nursing homes, under contract with CMS. Earlier reports by the GAO found some homes to be noncompliant over a long period of time, and 12 years ago the government developed the SFF program as a way of monitoring the two worst homes in every state. Such homes are looked at twice as often and more subject to enforcement.

The program since has been expanded to 136 homes nationwide, or up to six per state, which would take in less than 1 percent of the nation's 16,000 nursing homes. GAO said the list is limited to 136 because of funding constraints. Homes on the list are more likely to be for-profit, large and operated by chains, GAO said.

Each state also has a "candidate list" of 15 homes that might make the final list, and the GAO said state officials don't always look at the highest rank on that list to pick the worst. They might consider whether the home had a new owner they believe is committed to solving quality problems.

The GAO has said in the past the 136-home list includes the worst homes in every state but not necessarily the worst homes in the nation, and has recommended moving away from the state-by-state approach. An August 2009 report estimated that 4 percent of all homes are among the very worst. The options for homes are to graduate from the list, remain on it if improvement is shown — or have participation in Medicare and Medicaid terminated.

The new report says that a "troubling" number of homes remain on the list for longer than the desired 18 months, preventing other problematic homes from being added.

GAO recommendations include telling nursing homes they are at risk of winding up on the SFF list, ensuring that states have more stringent enforcement, such as higher monetary penalties.

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