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GAO Finds Continued Problems with Oversight of Nursing Home Care

JANUARY 20, 2005 -- Despite increased oversight of nursing homes, the Government Accountability Office has found several safety issues remain, such as worsening pressure sores, untreated weight loss, and uninvestigated complaints about harm to residents.

GAO also found the results of state inspections, known as surveys, understated the extent of serious quality-of-care and fire safety problems, reflecting weaknesses in the survey methodology and inconsistent application of federal standards.

Senate Finance Chairman Charles E. Grassley, R-Iowa, one of two senators who requested the report, said "faster, sustained progress" is needed to improve nursing home safety. "A lack of oversight by [the Centers for Medicare and Medicaid Services] years ago is what led to the steady decline in nursing home quality," he said.

Millions of baby boomers heading into retirement will increase the demand for nursing home care. Residents of such facilities often require help with feeding, grooming, and other routine activities of daily life. Some residents also suffer from cognitive impairments or have chronic health care conditions such as heart disease.

Combined Medicare and Medicaid payments for nursing home services were about $65 billion in 2003, including a federal share of about $43 billion, GAO reported to Grassley and Herb Kohl, D-Wisc., the ranking minority member of the Senate Special Committee on Aging.

GAO found serious complaints by residents, family members, or staff alleging harm to residents remained uninvestigated for weeks or months, and that delays in the reporting of abuse allegations compromised the quality of available evidence, which hindered investigations.

GAO investigators also found that when serious deficiencies were identified, federal and state enforcement policies did not ensure the problems were addressed and didn't resurface. Federal mechanisms for overseeing state monitoring of nursing home quality and safety "were limited in their scope and effectiveness," GAO reported.

While CMS' nursing home data show a significant decline in the proportion of nursing homes with serious quality problems since 1999, the trend "masks two important and continuing issues: inconsistency in how states conduct surveys and understatement of serious quality problems," GAO concluded.

According to GAO, CMS generally concurred with the report's findings, noting progress has been made in many areas, such as surveys and complaint investigations, oversight activities, and citation of serious deficiencies, but that challenges remain.

Groups representing nursing homes said they generally agreed with the GAO's findings, especially the agency's conclusion that the nation's survey and enforcement system for nursing homes is consistently inconsistent, with significant variations from state to state.

"Providers have long maintained that the government cannot utilize a one-dimensional punitive approach as a means to achieving quality care," the American Health Care Association said in a statement. "Achieving sustained quality care can only be achieved with a collaborative approach based on patient outcomes rather than a punitive, highly subjective process that provides no best-practices counsel to facilities."

Larry Minnix, president and chief executive officer of the American Association of Homes and Services for the Aging, said his group is urging Congress to pass legislation "that makes common sense reforms in these processes. What we all want to achieve is a system that addresses deficient practices in a fair and equitable manner."

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