GAO report on Nursing Home

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GAO Report on Nursing Homes Finds Lack of Enforcement

Volume 12 Number 79
ISSN 1091-4021
Wednesday, April 25, 2007

Lead Report: Nursing Homes

GAO Cites Problems with CMS Enforcement
Of Nursing Homes with History of Infractions

The Centers for Medicare & Medicaid Services is not effectively
carrying out "immediate sanction" enforcement mechanisms against
nursing homes with a history of harming residents, according to a
report by the Government Accountability Office issued in March but
released April 23.

"CMS's immediate sanctions policy fails to hold homes with a long
history of harming residents accountable for the poor care
provided," according to the report, Nursing Homes: Efforts to
Strengthen Federal Enforcement Have Not Deterred Some Homes from
Repeatedly Harming Residents (GAO-07-241).

The number of sanctions and serious deficiencies cited against
nursing homes declined during the five years studied, reflecting a
nationwide trend, GAO reported. The report was prepared at the
request of Senate Finance Committee ranking member Charles E.
Grassley (R-Iowa).

Yet almost half of the 63 homes reviewed "continued to cycle in
and out of compliance," causing harm to residents, GAO found. The
homes reviewed, all of which had a history of harming residents,
corrected deficiencies only temporarily, the report found. In
fact, eight of the homes cycled in and out of compliance seven or
more times.

GAO also said the deterrent effect of civil monetary penalties was
"diluted" because CMS imposed the penalties at the lower end of
the allowable range for all of the homes reviewed.

Also, the median per day penalty imposed ranged from $350 to $500
for the homes studied, far below the maximum allowable fine of
$3,000 per day. The homes do not have to pay a federally imposed
monetary penalty while they are appealing their deficiencies, a
process that can take years, GAO wrote.

CMS Generally Concurred

CMS generally concurred with GAO's recommendations but did not
always specify how it would implement the recommendations,
according to GAO. CMS also said three of the recommendations raise
resource issues while others would require additional research.

CMS is creating a system to help guide states and regional offices
in determining appropriate civil monetary penalty amounts.
However, it is expected to be optional for states, contributing to
interstate variation, GAO wrote. The system was tested in a 2006
pilot program.

The "'immediate sanctions' label is misleading because CMS's
policy requires only that homes be notified immediately of CMS's
intent to implement sanctions, not that sanctions be implemented
immediately," the report said. Homes that are able to correct
deficiencies during the grace period can escape certain sanctions,
it wrote.

In fact, CMS favored the use of sanctions that give homes more
time to correct deficiencies, so that in many cases, sanctions
were not implemented, GAO said. In general, CMS did not exercise
its discretionary authority to impose "denial of payment for new
admissions" (DPNAs) or terminations for the homes, the report
said.

"Rather, it waited until these sanctions could be imposed on a
mandatory basis, allowing the homes more opportunities to escape
sanctions prior to implementation," the report said.

Enforcement Tools Lacking

The most powerful enforcement tool, termination of the nursing
home from federal health care programs, occurs very rarely. Only
two homes were terminated involuntarily by the end of 2005, GAO
wrote.

More than half of the DPNAs imposed gave homes up to three months
to correct deficiencies, rather than those that only give homes 15
days, as is allowed. Finally, CMS did not impose a sanction for
nearly one-quarter (22 percent) of the homes reviewed that met the
agency's criteria for immediate sanctions, a problem that GAO had
identified previously.

CMS's implementation of immediate sanctions did not appear to
deter future repeat violations at the homes studied: 18 of the 27
homes with immediate sanctions had multiple instances of such
sanctions between 2000 and 2005.

GAO's findings appear similar to its reports in 1998 and 1999,
which identified significant weaknesses in government oversight
and enforcement over nursing homes. Primarily GAO found then that
sanctions imposed on nursing homes, including those that
repeatedly harmed residents, often did not take effect because the
nursing homes were given grace periods to correct deficiencies.
Thus, "homes cycled in and out of compliance, harming residents
while avoiding sanctions," GAO wrote.

As a result, CMS created a new "immediate sanctions" policy for
repeat offenders and developed of a new data system to improvement
enforcement management. Under the new policy, CMS may impose
sanctions without giving homes an opportunity to avoid them by
correcting problems--for serious deficiencies that resulted in
actual resident harm or put residents at risk of serious injury.

GAO Recommendations

GAO said management of nursing home enforcement "is hampered by
the overall complexity of its immediate sanctions policy" and by
its fragmented data systems and incomplete national reporting
capabilities.

To help improve nursing home care, GAO recommended that CMS
develop an administrative process for collecting penalties more
quickly and seek legislation to do so. The report also advised CMS
to strengthen its immediate sanctions policy, expand its oversight
of homes with a history of harming residents, and improve the
effectiveness of its enforcement data systems.

GAO recommended a reduction in the lag time between certain
citations and the implementation of the sanctions and stop
allowing repeat-offender nursing homes to escape sanctions. It
also recommended holding states accountable for reporting serious
deficiencies identified during complaint investigations.

The report is available on the Web at:
http://www.gao.gov/new.items/d07241.pdf

Source: BNA
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