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Poor Quality Persists in Some Nursing Homes, GAO Says

By John Reichard, CQ HealthBeat Editor

May 4, 2007 -- A study released this week by the Government Accountability Office concludes that a "small but significant share" of nursing homes provides substandard care despite tighter oversight of the industry required by a landmark 1987 law. Federal officials must maintain their focus on quality problems to assure continuing improvement in care, the study found.

Through passage of the Omnibus Budget Reconciliation Act of 1987, Congress shifted the focus of federal oversight of nursing homes from measuring a facility's capacity to provide good care to looking at whether it actually does so.

Federal and state officials have intensified their oversight efforts since then, but widespread reports of poor quality care have continued. For example, in 1998 the Senate Special Committee on Aging held a series of hearings exposing substandard care.

The quality of treatment appears to have improved somewhat since then. The GAO found that the percentage of nursing homes with serious deficiencies—those that caused actual harm or placed residents in immediate jeopardy—fell from 28 percent in fiscal 2000 to 19 percent in fiscal 2006. But serious problems remain at one in five nursing homes, the report says.

But sharp state-to-state variations in the percentage of homes with the deficiencies raise concerns about how consistently states are assessing compliance with quality standards, the study said. For example, the study noted that in fiscal 2006 one state found only 2 percent of facilities to have serious quality deficiencies, compared with a high of almost 51 percent in another state.

The variations may reflect the difficulty of recruiting state surveyors who assess quality, the study said. Surveyors face growing workloads and are paid salaries that aren't competitive with the private sector, creating turnover problems, the GAO noted. "It can take as long as three years for a surveyor to gain sufficient knowledge, experience and confidence to perform the job well," the study said.

Inexperience among surveyors can lead to underreporting of quality deficiencies, the analysis found. In fiscal 2006, 28 percent of federal surveys conducted to check on the adequacy of state surveys found a greater number of serious deficiencies, the GAO said.

The Centers for Medicare and Medicaid Services have beefed up enforcement by adopting new penalties for quality violations, including an "immediate sanctions" policy, government auditors found. But the complex procedure involved in levying those penalties has undermined its effectiveness, according to the study. Aimed at nursing homes that repeatedly harm residents, the policy "appears to have induced only temporary compliance."

Some quality improvement efforts overseen by CMS, such as the "Quality Indicator Survey" (QIS) have languished. The program aims to improve the quality of inspections at facilities, in part by interviewing a larger number of past and current residents about quality of care. The QIS "has been in development for over eight years and resource constraints threaten the planned expansion of this methodology beyond the initial five demonstration states," the GAO said.

"CMS has taken many important steps, but "in order to guarantee that all nursing home residents receive high quality care, it is important to maintain the momentum begun by the reforms of the [1987 budget reconciliation law] and continue to focus national attention on those homes that cause actual harm to vulnerable residents," the report concluded.

At a May 2 hearing to review the report, Aging Committee Chairman Herb Kohl, D-Wis., said that the 1987 law has "without question" improved nursing home care. He said that the law has led to a sharp drop in the practice of tying patients to their beds or chairs or sedating them to keep them from wandering.

But he found the report's finding "unacceptable"—that nearly half of a group of facilities studied in 1998 and 1999 that provided poor care have made no progress since then. Kohl said he would file a request with CMS that it brief the committee every two months on steps it has taken to further improve oversight. He also said he would pursue legislation requiring background checks to better screen out workers who might have a history of criminal abuse.

A patients' advocate told the senators at the hearing that while facilities have made strides under the law, expectations surrounding its passage have gone unfulfilled. "For many residents, the quality of their day-to-day care is minimal because of inadequate nurse staffing," Alice H. Hedt, executive director of the National Citizen's Coalition for Nursing Home Reform. Lawmakers should enact policies that increase staffing levels, she said.

The American Health Care Association, which represents the nursing home industry, said in its testimony that "stable funding" of the industry is "critical" and that its link to quality "has been noted time and time again."

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