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Once Again GAO Finds Nursing Home
Enforcement Weak and Ineffective


On April 23, 2007, the U.S. Government Accountability Office (GAO) issued a highly critical report on the federal nursing home enforcement system: Nursing Homes—Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents (GAO-07-241).

The report is the latest in a decade–long series of reports that have criticized the federal government’s enforcement of the landmark 1987 Nursing Home Reform Act. It analyzed federal sanctions from fiscal years 2000 through 2005 against 63 nursing homes in four states, including California, that have a history of harming residents.

Some key findings are:

  • Substandard nursing homes repeatedly cycle in and out of compliance while causing harm to residents;
  • The Centers for Medicare & Medicaid Services (CMS) favored the use of sanctions that give nursing homes more time to correct deficiencies, increasing the likelihood that the sanctions would not be implemented;
  • CMS generally imposes civil money penalties at the lower end of the allowable range; its fines are usually not collected until years after issued, if at all;
  • There was no record of a sanction for about 22 percent of nursing homes that met CMS’s criteria for immediate sanctions;
  • CMS enforcement actions are hampered by its fragmented, incomplete data;
  • Involuntary termination of nursing homes from Medicare and Medicaid is rare.

Sadly, none of these problems are new, despite many federal initiatives purportedly aimed at improving enforcement. The report raises serious questions about the integrity of the federal enforcement system.

The report describes a nationwide decline in the proportion of nursing homes cited for serious deficiencies. This is a serious concern in California, where the percentage of nursing homes cited for serious deficiencies dropped steeply from 24 percent in 2000 to 8 percent in 2005. Connecticut, by comparison, cited 44 percent of nursing homes for serious deficiencies in 2005. Rather than representing better care, earlier GAO reports and a recent report by the California State Auditor found that California survey officials often understate serious harm to residents. As a result, few remedies are imposed. These practices reward abuse and neglect.

In an appendix to the report, the California Department of Health Services blamed federal officials for the decline in citations of serious deficiencies in California during the review period. It said CMS directed it not to issue serious deficiencies unless a resident was harmed in a manner that included a "permanent outcome." By way of example, DHS reported that CMS overruled its efforts to issue serious deficiencies when residents suffered a fractured pelvis and dehydration requiring acute hospital stays.

The GAO made several recommendations to improve enforcement. CMS rejected its recommendation that it give greater scrutiny to more nursing homes with a long history of serious violations, citing budget problems as an excuse.

Click here to download the GAO report.

Click here to read the April 22, 2007 New York Times article on the GAO report. (pdf)