Regulators Target Worst Nursing Homes in Nation

Federal and state officials are targeting the nation’s worst nursing homes for repeat inspections and tough sanctions for violations, including a possible ban on new admissions under the Medicare and Medicaid programs, a top federal regulator said Tuesday.

The government will start with a list of more than 100 of the worst homes, identified from state inspection reports and complaints from patients and their families, said Michael Hash, deputy administrator of the Health Care Financing Administration.

The special enforcement effort will be expanded in the next fiscal year to cover a broader category of “poor performers,” which could contain as many as 15% of the nation’s 17,000 nursing homes, Hash said in an interview after testifying before the Senate Special Committee on Aging.

Nursing homes with repeated violations that threaten patient health and safety will be punished “certainly and swiftly,” he told the committee on its second and final day of hearings on California nursing homes.

The committee members were dismayed to hear the details of a report by the General Accounting Office that 407 of California’s 1,370 nursing homes had been cited by state inspectors for “having serious or potentially life-threatening care problems.” The GAO reviewed federal and state data on surveys and complaints from 1995 until this year.

“We’re talking about abuse, about people who have not been given decent care,” said Sen. John B. Breaux (R-La.), the committee’s ranking Democrat. “We’re talking actual harm to a patient.”

Breaux became irritated after Dr. Dennis Stone, representing the California Assn. of Health Facilities, accused the GAO of “using data that may be misleading.”

The “care of the aged is an extremely complex process,” said Stone, noting that half the patients in state nursing homes have dementia or mental illness. About 40% to 50% of them need help with the basic activities of daily living, including dressing, bathing and eating, he said.

Breaux, however, accused Stone of not responding directly to the GAO criticisms of nursing home performance. “You must think I’m an idiot or I have not been [at the hearings] for two days,” Breaux said. “You’re trying to talk about something else.”

And committee members remained skeptical about the plan outlined by Hash, recalling that Congress passed a law in 1987 calling for increased quality in nursing home care and stricter enforcement. Despite a decade of rules aimed at carrying out that legislation, problems remain.

California was portrayed in the GAO report and during testimony as a state where inspectors frequently find problems in nursing home care, but where little action is taken to ensure that they are corrected.

The state ranks second in the nation in the number of deficiencies noted on a typical inspection report, said Charlene Harrington, a professor in the School of Nursing at UC San Francisco.

California is “good on identification [of problems], not good on enforcement,” said William J. Scanlon, director of the health financing division for the GAO, the investigative arm of Congress.

The GAO report found that 122 nursing homes in California--facilities with a total of 17,000 beds--had been cited in the last two annual inspections for “conditions causing actual harm or conditions that put residents in immediate jeopardy or caused death.” The repeated violations included “problems with infection control, pressure sore treatment and bladder continence care,” according to the report, which was titled, “California Nursing Homes: Care Problems Persist Despite Federal and State Oversight.”

Although the 122 troubled homes were cited again and again, in 75% of the cases no sanctions were imposed.

The typical pattern is that state inspectors find a problem and file a deficiency report. The nursing home has up to 45 days to prepare a plan of correction, which the state usually accepts, and nothing happens until the following year’s inspection, various witnesses indicated.

The state carries out inspections with funds supplied by the federal government, and there is typically not enough money for inspections more than once a year. The final responsibility for imposing fines and other punishments rests with the federal government.

California’s Department of Health Services began a new policy this month, promising to undertake inspections twice a year in the two worst homes in each of the state’s 16 regulatory districts.

Hash said the federal government’s accelerated enforcement will use a similar technique, with inspections every six months at nursing homes where violations have placed patients in immediate jeopardy or at threat of serious harm. A violation constituting immediate jeopardy might include an incident in which a resident wandered out of a home and onto the street, or in which a home had a water heater with the temperature set at a level that might scald patients. A threat of serious harm could include a patient who was strapped down with restraints without justification, or a patient with severe bedsores.

Nursing homes with repeated serious violations will no longer be given a grace period to correct the problem. Instead, Hash said, the government will move to impose immediate sanctions, such as fines or the appointment of an outsider as a temporary manager with power to hire and fire personnel.

The toughest sanction would include a ban on new admissions. That would deprive the nursing home of money for treating any additional patients under Medicare, which pays for those over 65 and the disabled, and Medicaid, which pays for the poor. The federal government paid U.S. nursing homes $28 billion in 1997 under those two programs.

Industry witnesses told the committee that they support a crackdown on bad performers. “We need to focus on making poor nursing home providers become good ones,” said Paul R. Willging, executive vice president of the American Health Care Assn. “And those facilities that will not comply should simply be shut down.”

It is “imperative we find ways to get rid of the bad apples,” said Sheldon L. Goldberg, president of the American Assn. of Homes and Services for the Aging, which represents nonprofit facilities.

Sen. Charles E. Grassley (R-Iowa), the committee chairman, pledged at the conclusion of the hearings that he will keep pressure on the federal government to enforce the regulations mandating quality care. “We want action now, not a year from now,” he said. “There are simply too many mothers, fathers, husbands and wives suffering in California nursing homes.”