Overview: The Clinton Administration has made ensuring the health and safety of nursing home residents a top priority. In 1995, the Department of Health and Human Services issued the toughest nursing home regulations in the history of the Medicare and Medicaid programs. Those reforms led to measurable improvements in quality of care for nursing home residents.

After implementing those reforms and monitoring their results, the Administration developed additional steps in July 1998 to further assure that all nursing home residents receive quality care. As part of this ongoing commitment, the Health Care Financing Administration now requires states to crack down on nursing homes that repeatedly violate health and safety requirements. HCFA also has given consumers ready access to comparative information about nursing home quality and is changing the inspection process to increase its focus on preventing bedsores, malnutrition and resident abuse. HCFA also is conducting a study of nursing home staffing levels and supports the Administration on Aging’s State Long Term Care Ombudsman programs.

About 1.6 million elderly and disabled Americans receive care in nearly 17,000 nursing homes across the United States. Under the Medicare and Medicaid programs, states have the primary responsibility for conducting on-site inspections and recommending sanctions against nursing homes that violate health and safety requirements. The federal government helps fund these activities.

New actions. HCFA today announced additional steps to further strengthen state enforcement efforts to assure high-quality care in nursing homes and to give consumers more detailed information to help them choose an appropriate nursing home to meet their needs.

HCFA instructed states to impose immediate sanctions, such as fines, against nursing homes in more situations -- including any time that a nursing home is found to have caused harm to a resident on consecutive surveys. The new instructions further expand the instances when nursing homes face immediate sanctions even if they quickly correcting the problem. Nursing homes that do not fix the problems will lose their ability to receive Medicare and Medicaid payments.

To encourage the speedier imposition of penalties, states also received expanded authority to notify nursing homes when they would be denied payments for new admissions and other sanctions for failing to meet health and safety requirements. HCFA provided this increased flexibility to put additional pressure on nursing homes to meet all health and safety standards.

Nursing Home Compare, HCFA’s Internet resource for consumers, now includes more data about residents’ health status at every Medicare- and Medicaid-certified nursing home -- including data about the prevalence of bedsores, incontinence and other conditions. This new information, as well as nursing-home inspection results, is on HCFA’s consumer website -- www.medicare.gov.

Consumers now can use HCFA’s updated "Guide to Choosing a Nursing Home" to take families and friends step-by-step through the process of identifying an appropriate home for a loved one. The guide includes questions to ask, a nursing-home checklist and expanded information about recognizing, reporting and preventing abuse and neglect.

Additional Resources. As part of its strategy for continuous quality improvement in nursing homes, the Administration is adding new enforcement tools and strengthening federal oversight of nursing home health and safety standards. For Fiscal Year 2000, the President requested and secured more than $50 million in new resources to support the nursing-home initiative, including $18.1 million more for states’ Medicare survey efforts and another $15.6 million in Medicaid matching funds available to states. Other resources will support federal oversight activities and increased legal activity related to enforcement. HCFA’s Fiscal Year 1999 budget included $4 million earmarked for the initiative, and the agency reprogrammed another $4 million from other sources to support these activities.

Making state inspections more effective, less predictable. Since July 1998, HCFA has instructed states to strengthen the nursing home inspection process and to toughen enforcement against poor performers:

States now must investigate complaints alleging actual harm to residents within 10 days. HCFA established the new requirement in March. In addition, states also must continue to investigate the most serious complaints within two days, and other complaints in a timely manner. HCFA also is developing minimum standards for how states should conduct complaint investigations.

States now must conduct more frequent inspections of nursing homes with repeated serious violations without decreasing their inspections for other facilities.

HCFA has instructed states to consider the performance of other facilities in a chain of nursing homes when determining appropriate penalties against another facility in the same chain. HCFA is continuing to examine alternatives to address overall performance within chains.

HHS and the Department of Justice are working together to prosecute the most egregious non-compliance cases -- particularly those that harm residents -- under appropriate civil and criminal laws. A national steering committee is also developing better ways to share information and ensure that proper referrals and investigations take place in the most egregious cases.

State inspectors now must stagger surveys and conduct visits on weekends, early mornings and evenings, when quality, safety and staffing problems may be more likely to occur.

Nursing homes now may face fines of up to $10,000 for each serious incident that threatens residents’ health and safety. In the past, fines could only be linked to the number of days that nursing homes failed to comply with federal requirements. This new option permits penalty amounts to be more quickly determined and imposed.

Improving quality of care. HCFA is taking additional steps to improve the quality of care for all nursing home residents and to prevent bed sores, dehydration, malnutrition and abuse.

State inspectors now use new inspection protocols to detect quality problems in nursing homes using a systematic, data-driven process. The new surveys focus additional attention on preventing bedsores, malnutrition and abuse affecting nursing-home residents.

HCFA is testing and distributing new "nutrition care alerts" to guide nursing assistants and other caregivers to identify and assist residents at risk of malnutrition and dehydration. The alerts, which were developed by doctors, dieticians and consumers through the Nutrition Screening Initiative, are part of HCFA’s national education campaign to promote nutrition and hydration.

HCFA has posted best practice guidelines on the Internet to help nursing homes care for residents at risk of weight loss and dehydration. HCFA is working with the American Dietetic Association, clinicians, consumers, and nursing homes to expand this repository. The site can be reached at www.hcfa.gov/medicaid/siq/siqhmpg.htm.

HCFA is conducting a study on nursing home staffing that is expected to be completed next year. The study will consider the potential costs and benefits of establishing minimum staffing levels.

Stronger federal oversight of state inspections. HCFA also has implemented new systems to make state inspection systems stronger and more consistent in their enforcement.

HCFA this year conducted an extensive training campaign for nursing-home inspectors to help states enforce federal requirements effectively and consistently. HCFA has directly trained more than 600 federal and state survey managers, who are training their staffs.

HCFA established a new monitoring system in October 1998 to ensure comparable federal evaluations of state survey agencies, nursing home monitoring, and enforcement activities. The system will result in additional state surveyor training and improved enforcement.

HCFA is developing specific measures to evaluate states’ performance in protecting nursing-home residents. States that fail to perform adequate survey functions and fail to improve their performance could lose their funding for nursing home survey and certification activities. HCFA then will contract with other entities to perform those functions properly.

HCFA issued new instructions to states to ensure that they perform an on-site visit to verify when a nursing home has fixed any serious problem that posed a threat to the health and safety of residents.

Helping consumers make educated decisions. HCFA is committed to making relavent consumer information available to nursing-home residents, their families and caregivers. Nursing Home Compare and the new "Guide to Choosing a Nursing Home" are part of this effort. Other aspects include:

HCFA encourages states to provide appropriate alternatives to nursing-home care in home and community settings through state Medicaid programs. HCFA will include information about such options as part of education efforts about nursing home choices.

HCFA supports a strong long-term care ombudsman program to serve as advocates for residents and is working with the Administration on Aging to promote effective cooperation with the states. The ombudsman program helps residents, their families and their friends voice their concerns, and identify and correct substandard conditions and potential incidents of abuse and neglect.

HCFA has begun a national education campaign to prevent abuse and neglect in nursing homes. This effort includes a pilot poster campaign to help nursing-home workers, residents and visitors identify and report suspected incidents of abuse and neglect.

In collaboration with the Administration on Aging, HCFA has funded several demonstration projects to educate residents, family members, staff workers and others about risk and prevention strategies. In November, AoA awarded four grants totaling $450,000 for innovative projects sponsored by the National Association of Area Agencies on Aging, the National Long Term Care Ombudsman Resource Center, The National Center on Elder Abuse, and the National Policy and Resource Center on Nutrition and Aging.

Legislative proposals. In March 1999, the President signed bipartisan legislation to protect residents who are on Medicaid from being evicted inappropriately by nursing homes. Additional legislation before the 106^th Congress will provide additional assurances that nursing-home residents will receive the quality care that they deserve and expect by:

Requiring nursing homes to conduct criminal background checks of employees and establishing a national registry of workers who have been convicted of abusing residents.

Allowing more types of nursing home workers with proper training to help residents eat and drink during busy mealtimes.