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 has given consumers ready access to comparative information about nursing home quality and changed the inspection process to detect and prevent bedsores, malnutrition and abuse. HCFA has completed the first part of a major study on the appropriateness and feasibility of minimum staffing levels for nursing homes. HCFA also works in collaboration with the Administration on Aging and its Long Term Care Ombudsman Program. And in September 2000, HCFA launched a national awareness campaign to help certified nursing assistants protect residents at risk of unintended weight loss and dehydration.

A new report to Congress contains early evidence of improvements under the 1998 initiative, including a further decline in restraint use and an increase in off-hour inspections by state surveyors. The results also emphasize the continued need to improve state enforcement efforts and quality of care for nursing home residents. Next year, HCFA will conduct a more detailed analysis on quality of care under the 1998 initiative.

About 1.6 million elderly and disabled Americans receive care in nearly 17,000 nursing homes in 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.

Quality of care report. In September 2000, HCFA issued a preliminary report that looks at the impact of the President's 1998 nursing home initiative. The report showed that HCFA and the states have successfully implemented many parts of the initiative, but more work remains to be done. A follow-up report is expected in 2001.

Additional Resources. As part of its strategy for continuous quality improvement in nursing homes, the Administration has added new enforcement tools and strengthened federal oversight of nursing home health and safety standards. To support these initiatives, HCFA's budget for survey and certification - including state inspections - increased from $158 million in fiscal year 1997 to $210 million in fiscal year 2000. Resources also increased for federal oversight and increased legal activity related to enforcement. For fiscal year 2001, the President has requested a 6.5 percent funding increase over fiscal year 2000 to extend and expand the initiative's progress, including additional resources for state inspections and for legal activity. The President also has proposed a $1 billion grant program to help states explore innovative ways to raise staffing levels.

Medicare reimbursements. While Medicare accounts for a small portion of revenue at most nursing homes, HCFA has taken steps to ensure Medicare nursing homes are paid adequately for caring for these beneficiaries. As a result of recent laws and other changes, Medicare's payments to skilled nursing facilities will rise nearly 20 percent starting Oct. 1. In addition, the President has proposed other changes in this year's budget to further boost Medicare spending on nursing homes by an additional $1.6 billion over the next five years.

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.

• HCFA is conducting a national awareness campaign to ensure nursing-home residents receive adequate nutrition and fluids. This month, HCFA sent new tools and materials to nearly 17,000 nursing homes nationwide to help front-line caregivers prevent and treat unintended weight loss and dehydration among residents. The campaign's partners include medical professionals, resident advocates and industry trade groups.
  
  
• State inspectors now use new inspection protocols to detect quality problems in nursing homes. The new surveys focus additional attention on preventing bedsores, malnutrition and abuse affecting nursing-home residents.
  
  
• HCFA this summer completed the first phase of a groundbreaking study that established a clear relationship between staffing levels and quality of care. The next phase will consider the costs and feasibility of establishing national minimum staffing levels for nursing homes, and will analyze whether there should be different staffing levels depending on the severity of illness experienced by a nursing home's residents. Based on the research, HCFA expects to develop a proposal for national standards in 2002.
  
  
• 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.
  

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 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 - even if the home quickly correct the problem. Nursing homes that do not fix the problems will lose their ability to receive Medicare and Medicaid payments.
  
  
• HCFA now requires states to investigate complaints alleging actual harm to residents within 10 days. In addition, states also must continue to investigate the most serious complaints within two days, and other complaints in a timely manner. HCFA is monitoring states' implementation of this requirement. HCFA also is developing minimum standards for how states should conduct complaint investigations.
  
  
• 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. Off-hour inspections rose from less than 1 percent in early 1998 to about 10 percent currently.
  
  
• States now must conduct more frequent inspections of nursing homes with repeated serious violations without decreasing their inspections for other facilities. More than 25 percent of these special-focus facilities improved significantly enough to achieve consistent compliance. Another 10 percent lost their Medicare and Medicaid funding.
  
  
• 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 preparing further instructions to require states to impose immediate sanctions for new health and safety violations in chains with patterns of such problems.
  
  
• 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.
  
  
• 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.
  
  
• The President has proposed legislation to require nursing homes to pay fines immediately except when this would jeopardize residents' health and safety. Currently, nursing homes can delay paying a fine for years while they appeal the penalty.
  
  
• The Department of Health and Human Services has devoted substantial additional resources to the Office of General Counsel and the Departmental Appeals Board to handle increased sanctions against nursing homes and to speed the appeals process.
  

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 issued specific measures to evaluate each state's performance in inspecting nursing homes, including both annual inspections and responses to complaints. States that fail to perform adequately and fail to improve could lose their funding for nursing home inspection activities.
  
  
• HCFA established a new monitoring system in October 1998 to promote 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 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 relevant 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:

• Nursing Home Compare, HCFA's Internet resource for consumers, includes data about staffing levels and the prevalence of bedsores, incontinence and other conditions at every Medicare- and Medicaid-certified nursing home. This information, as well as nursing-home inspection results, is available through 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.
  
  
• The Administration on Aging's Long Term Care Ombudsman Program advocates for the interests of residents. Working with residents, their families and friends, ombudsmen voice concerns and identify and correct substandard conditions and potential 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.
  
  
• 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.
  
  
• In collaboration with the Administration on Aging, HCFA has funded demonstration projects involving four national aging organizations to educate residents, family members, staff workers and others about risk and prevention strategies.