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Testimony of
RACHEL BLOCK, DEPUTY DIRECTOR
CENTER FOR MEDICAID & STATE OPERATIONS
HEALTH CARE FINANCING ADMINISTRATION
on
IMPROVING OVERSIGHT AND
QUALITY OF NURSING HOME CARE
before the
SENATE SPECIAL COMMITTEE ON AGING
June 30, 1999
Chairman Grassley, Senator Breaux, distinguished committee
members, thank you for inviting me to discuss our efforts
to improve oversight and quality of care for America's 1.6
million nursing home residents. I would also like to thank
the General Accounting Office (GAO) for its continued involvement
and evaluation.
Last July, President Clinton announced a major initiative
to increase protections for vulnerable nursing home residents
and crack down on problem providers. Since then, we have
worked diligently with your Committee, the GAO, States,
providers, advocates, residents and their families to implement
and build upon the initiative's many essential provisions.
This hearing comes at an opportune time as we are, in effect,
moving into a second phase of the initiative. We have spent
the last 12 months primarily designing and implementing
the initiative by establishing new policies, clarifying
rules and getting guidance out to States on how they should
proceed. We are now increasing efforts to monitor how States
are acting on specific provisions and determine where we
need to take further action to ensure effective implementation.
Some lessons are already becoming clear.
- Many States have not begun investigating consumer complaints
within 10 days.
- Some States have been unable to begin conducting surveys
on evenings and weekends, often because of existing labor
agreements.
- More needs to be done to ensure that the initiative
is implemented evenly across the country.
We are taking steps to make sure providers and State survey
agencies in all parts of the country receive uniform instructions
on how to proceed. And some State legislatures are addressing
resource and other issues that may be barriers to success.
We greatly appreciate the interest and assistance of this
Committee in our initiative. We know you appreciate the
challenge of implementing its 30 distinct, often complicated,
and interrelated provisions. The task requires dozens of
agencies and thousands of individuals across the country
to literally and substantially change the way they conduct
the business of protecting vulnerable nursing home residents.
There is much left to do, but we are committed to taking
all these and any additional actions that will help build
upon our efforts. By continuing to work with you, the GAO,
States, advocates and providers, we will together put an
end to the intolerable situations that have caused this
most vulnerable population to needlessly suffer.
BACKGROUND
Protecting nursing home residents is a priority for this
Administration and our agency. We are committed to working
with States, which have the primary responsibility for conducting
inspections and protecting resident safety. Some 1.6 million
elderly and disabled Americans receive care in approximately
16,800 nursing homes across the United States. Through the
Medicare and Medicaid programs, the federal government provides
funding to the States to conduct on-site inspections of
nursing homes participating in Medicare and Medicaid and
to recommend sanctions against those homes that violate
health and safety rules.
In July 1995 the Clinton Administration implemented the
toughest nursing home regulations ever, and they brought
about marked improvements. However, both we and the GAO
found that many nursing homes were not meeting the requirements,
and that many States were not sufficiently monitoring and
penalizing facilities that failed to provide adequate care
and protection.
Therefore, in July 1998, President Clinton announced a
broad and aggressive initiative to improve State inspections
and enforcement, and crack down on problem providers. We
have provided monthly reports to the Special Committee on
Aging and the GAO on our progress with this initiative.
To strengthen enforcement, we have:
- expanded the definition of facilities subject to immediate
enforcement action without an opportunity to correct problems
before sanctions are imposed. The guidance to States made
clear that such "grace periods" should only be for violations
that do not cause actual harm to residents at facilities
that do not have a history of recurring problems;
- identified facilities with the worst compliance records
in each State, and each State has chosen two of these
"special focus facilities" for frequent inspection and
intense monitoring, and monthly status reports. Through
closer scrutiny and immediate sanctions, we are working
to prevent "yo-yo" compliance, in which problems are fixed
only temporarily and are cited again in subsequent surveys;
- provided comprehensive training and guidance to States
on enforcement, use of quality indicators in surveys,
medication review during surveys, and prevention of pressures
sores, dehydration, weight loss, and abuse;
- instructed States to stagger surveys and conduct a set
amount on weekends, early mornings and evenings, when
quality and safety and staffing problems often occur,
and so facilities can no longer predict inspections;
- instructed States to look at an entire chain's performance
when serious problems are identified in any facility that
is part of a chain, begun developing further guidelines
for sanctioning facilities within problem chains, and
begun collecting State contingency plan data in case of
chain financial problems;
- required State surveyors to revisit facilities to confirm
in person that violations have been corrected before lifting
sanctions; and
- instructed State surveyors to investigate consumer complaints
within 10 days;
- developed new regulations to enable States to impose
civil money penalties for each serious incident and supplement
current rules that link penalties only to the number of
days that a facility was out of compliance with regulations;
- begun working with the Department of Justice to improve
referral of egregious cases where residents have been
harmed for potential prosecution; and
- met with the Department's Departmental Appeals Board
to discuss increased work load due to the nursing home
initiative.
To follow through on the new requirements that have been
placed on State survey agencies, we have established a new
monitoring system for evaluating State survey teams' adherence
to Federally mandated procedures and policies using a standardized
assessment tool.
We also are now beginning to use quality indicators in
conjunction with the Minimum Data Set that facilities maintain
for each resident. These quality indicators furnish continuous
data about the quality of care in each facility. That will
allow State surveyors to focus on possible problems during
inspections, and it will help nursing homes identify areas
that need improvement.
We are beginning to get information from this new monitoring
system, and will soon be getting data based on the quality
indicators. We will use this new information to work with
States to strengthen any weaknesses in their enforcement
activities. However, we also have made clear that States
will lose federal funding if they fail to adequately perform
surveys and protect residents. We can and we will contract
with other entities, if necessary, to make sure those functions
are performed properly.
Consumer Focus
Our initiative also includes efforts to increase nursing
home accountability by making information on each facility's
care and safety record available to residents, their families,
care givers, and advocates. We have:
- created a new Internet site, Nursing Home Compare, at
www.medicare.gov, which allows consumers to compare
survey results and safety records when choosing a nursing
home, and which has so far received approximately 1,387,191
page views since Nursing Home Compare went live September
30, 1998;
- posted best practice guidelines at cms.hhs.gov/medicaid/siq/siqhmpg.htm
on how to care for residents at risk of weight loss and
dehydration;
- begun pilot testing a wide range of initiatives to detect
and prevent bed sores, dehydration, and malnutrition in
ten states. We worked with outside experts to develop
a systematic, data driven process to identify problems
and provide focus for in-depth on-site assessments. We
are taking interim steps this year, and expect to complete
the new system by the end of 2000;
- worked with the American Dietetic Association, clinicians,
consumers and nursing homes to share best practices for
preventing these problems. And we will begin a national
campaign to educate consumers and nursing home staff about
the risks of malnutrition and dehydration and nursing
home residents' rights to quality care this year; and
- begun a study on nursing home staffing that will consider
the costs and benefits of establishing minimum staffing
levels, and is expected to be completed by early next
year.
We expect in the near future to:
- implement a new survey protocol we developed with a
national abuse and neglect forum for evaluating nursing
homes' abuse and neglect prevention processes;
- publish new survey procedures on clearer guidance on
key quality of life/quality of care issues including nutrition,
hydration, and pressure sores effective early July 1999;
and
- publish new survey procedures for evaluating the use
of effective drugs.
In addition, we will continue to develop and expand our
consumer information to increase awareness regarding nursing
home issues. We are now conducting a national consumer education
campaign on preventing and detecting abuse. It features
a visually compelling poster for public display, and is
currently being pilot tested in 10 States. We also are planning
national campaigns to educate residents, families, nursing
homes and the public at large about the risks of malnutrition
and dehydration, nursing home residents' rights to quality
care, and the prevention of resident abuse and neglect.
Complaint Investigations
A key addition to our initiative includes provisions designed
to address problems with State survey agency response to
complaints. These provisions include:
- requiring all State survey agencies to investigate any
complaint alleging harm to a resident within 10 working
days;
- reiterating to States that complaints alleging immediate
jeopardy to residents must be investigated within two
days;
- stressing to States that they must enter complaint information
into our data system promptly;
- developing additional standards, including maximum time
frames, for the prompt investigation of serious complaints
alleging non-immediate jeopardy harm to residents and
for complaints deferred until the next survey;
- strengthening federal oversight of complaint investigations
by incorporating complaint responsiveness and complaint
data as performance measures; and
- requiring that substantiated results of complaint investigations
be included in Federal data systems or accessible by Federal
officials.
As mentioned above, many States are having difficulty meeting
the new requirement to investigate consumer complaints alleging
actual harm to residents within 10 days. The primary reason
cited is a lack of resources to carry out the work. This
is troubling, as your Committee and the GAO have documented
serious lapses in State investigation of complaints regarding
truly intolerable situations. We are working with the States
to assess whether additional resources are needed and to
make sure they understand the requirements and are receiving
consistent guidance.
Some States are allocating additional resources of their
own to meet the 10 day requirement. Maryland, for example,
plans to almost double the number of surveyors. Florida
also has enacted legislation to increase nursing home oversight
staff and funding. And some States were already meeting
or exceeding the requirement. Others, however, indicate
that their State legislatures are not likely to provide
addditional funding.
We have provided States with an additional $8 million for
fiscal 1999 to help comply with this and other nursing home
initiative provisions. The President has requested an additional
$60.1 million in his fiscal 2000 budget for nursing home
enforcement efforts, which will help States comply with
the mandate. However, it is clear that States must also
recognize the importance of these efforts in their own allocation
of resources.
Staggered Surveys
Another important provision in the initiative requires
States to conduct standard surveys during "off" hours. This
is already widely implemented, and surveyors report that
their appearance at 5:00 a.m. or on Saturday has indeed
caught staff off guard. One State agency projects that the
total number of problems found in these off-hours inspections
will be about 10 percent higher than in previous inspections.
However, as with consumer complaints, not all States are
successfully implementing the new requirement to stagger
surveys and conduct some on nights and weekends in order
to end the predictability that had minimized survey effectiveness.
In some States there are labor issues where existing contracts
preclude evening and weekend work assignments.
We intend to monitor this situation closely, and to work
with States to help them comply. But, again, we must reiterate
that States will lose federal funding if they fail to adequately
perform surveys and protect residents. We can and we will
contract with other entities, if necessary, to make sure
all functions are performed properly.
Improving Consistency
To ensure more consistent success across the country, we
are strengthening communication with our Regional Offices
and make sure that providers and State survey agencies in
all parts of the country receive uniform instructions on
how to proceed. We are conducting cross-regional surveys
to identify and address inconsistencies in survey findings
among Regions. And we have three workgroups of staff from
our Central and Regional Offices collaborating to address
specific problems areas.
One workgroup has found that inconsistencies in the survey
process are largely due to a need for more training on both
the State and Federal level. It also proposed systems for
tracking enforcement results and reports that could be used
to provide feedback on the State Agency's Survey Performance.
It developed several recommendations to address inconsistencies
in the enforcement process. And it is working to evaluate
and provide guidance on efforts to minimize trauma to residents
when they must relocate due to facility closures.
A second workgroup is collecting data to evaluate the budgetary
and resource impact of initiative provisions such as staggered
surveys, special focus facilities, and use of new quality
of care information and enhanced survey protocols. They
also have recommended system changes that are needed to
monitor and evaluate initiative activities.
And a third workgroup has developed strategies to develop
better coordination with the State survey agencies and Administration
on Aging ombudsmen. For example, they have recommended more
interaction, through regular conference calls and face to
face meetings, to discuss current and future goals. The
have also recommended convening a Leadership Conference
with key partners to develop more effective ways of combining
our resources to achieve success.
CONCLUSION
We are continuing to push for full implementation of our
nursing home initiative. Solid progress is being made, and
nursing homes clearly have received the message that we
are serious about protecting vulnerable nursing home residents.
We are committed to ensuring that the initiative is fully
implemented, and to evaluating its impact and making any
necessary adjustments or additions. We look forward to continuing
to work with you, the GAO, providers, advocates, nursing
home residents and families as we proceed. And, I am happy
to answer your questions.
