testimony on nursing home neglect by michael hash
Health Care Financing Administration
U.S. Department of Health and Human Services
Before the Senate Special Committee on Aging
July 28, 1998
Senator Grassley, Senator Breaux, Committee members, thank you
for inviting us to discuss the need to strengthen assurances that
Americans in nursing homes receive high quality care and are treated
with dignity and compassion. Clearly, intolerable situations have
occurred, and our most vulnerable citizens have suffered.
As the President announced last week, we are taking strong new
steps to address what both our own Report to Congress and the
General Accounting Office investigation make clear is a serious
problem. We can and we will implement many of these new actions on
our own now. We also need Congress to give us legislative authority
for some additional provisions that will help ensure that we can
meet our obligation to protect the very vulnerable Americans who
need nursing home care. We want to work with you to make sure that
all of these important steps are taken quickly and effectively.
Since 1995, the Administration has been enforcing the toughest
nursing home regulations in the history of the Medicare and Medicaid
programs. Working with states, who have the primary responsibility
for conducting on-site inspections and recommending sanctions, we
have sharply increased the number of penalties levied on
poor-quality nursing homes. Our new Report to Congress notes
improvements in the quality of care delivered in nursing homes as a
result of these new regulations. But the report also finds a need
for further improvement by states, nursing homes, the federal
government, and others.
In our new initiative, we will:
- Work with states to improve their nursing
home inspection systems;
- Crack down on nursing homes that
repeatedly violate safety rules;
- Require criminal background checks on all
new nursing home employees;
- Focus on reducing the incidence of bed
sores, Dehydration, and malnutrition; and
- Publish nursing home quality ratings on
About 1.6 million elderly and disabled people receive care in
approximately 16,800 nursing homes across the United States. The
federal government, through the Medicare and Medicaid programs,
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 are violating health
and safety rules. Since 1995, we have had authority to levy harsher
penalties on nursing homes found out of compliance with those rules.
That authority was granted to us through the Omnibus Budget
Reconciliation Act of 1987, which reformed the way states and the
federal government oversee nursing homes and protect the health of
residents. The legislation established new standards for quality, a
set of resident rights, a new system to assess the quality of
nursing home residents? lives, and a new survey mechanism focused on
patient outcomes. The law also created new staffing requirements for
licensed nurses and new training requirements for nursing assistants
and others. And it established new, more flexible enforcement rules
and penalties to help identify and punish nursing homes that violate
the new rules. On July 1, 1995, the Clinton Administration published
new regulations implementing key provisions of the law. Under these
regulations, the number of civil monetary penalties rose from zero
in 1994 to 430 in FY 1997.
The enforcement system under these regulations focused on giving
facilities a chance to correct problems and avoid sanctions. There
are many instances in which better care has been the result.
However, even when sanctions have been imposed, facilities with
serious problems often improve only temporarily, and subsequent
surveys find residents in real danger once again.
EVIDENCE OF IMPROVEMENT
According to the new Report to Congress, there is clear evidence
that the new regulations are improving the health and safety of
nursing home residents. Specifically:
- overuse of anti-psychotics is down.
Before reforms were implemented, about 33 percent of residents
were receiving these drugs, now just 16 percent are;
- appropriate use of antidepressants is up.
Before reforms were implemented, just 12.6 percent of residents
were receiving these drugs, now 24.9 percent are;
- use of physical restraints is down, from
about 38 percent to under 15 percent;
- use of indwelling urinary catheters is
down nearly 30 percent; and
- the number of residents with hearing
problems who receive hearing aids is up 30 percent.
NEED FOR FURTHER ACTION
Despite these improvements attributable to the new regulations,
the Report to Congress makes clear that several areas require
State-run nursing home inspections are too predictable.
Inspection teams frequently appear on Monday mornings and rarely
visit on weekends or during evening hours. This allows nursing homes
to prepare for inspections.
Several states have rarely cited nursing homes for substandard
care, an indication that their inspections and enforcement may be
Nursing home residents continue to suffer unnecessarily from such
clinical problems as bed sores (decubitus ulcers), malnutrition, and
dehydration, which are easily prevented .
Residents continue to experience physical and verbal abuse,
neglect, and misappropriation of their property.
NEW ENFORCEMENT ACTIONS
Because of these continuing problems, we are adding new
enforcement tools and strengthening federal oversight of nursing
home quality and safety standards. Resource needs for these
activities are reflected in the fiscal year 1999 budget request
currently before the Congress. Our strategy includes several
administrative actions that we will implement now using our existing
authority. It also includes additional steps that require new
legislative authority from Congress.
Our administrative steps will target states with weak
inspections. As President Clinton said last week, If state
enforcement agencies don't do enough to monitor nursing home
quality, we will cut off their contracts and find someone else who
will do the job right.
We will establish tougher inspections everywhere, focus on easily
preventable problems like bed sores and malnutrition, combat
resident abuse, increase prosecution of egregious violations,
publish survey results on the Internet, and continue development of
our automated data system to better identify problems and improve
Target States with Weak Inspection Systems.
We will provide additional training and other assistance to
inspectors in states that are not adequately protecting residents.
We will enhance federal review of the surveys conducted by the
states Standard evaluation protocols will be implemented in every
state this fall.
We will ensure that state surveyors adhere to HCFA's policy to
sanction nursing homes with serious violations and prohibit
sanctions from being lifted until after an onsite visit has verified
We will terminate federal funding for nursing home surveys for
states that fail to adequately perform survey functions or fail to
improve inadequate survey systems, and instead contract with other
entities to conduct nursing home survey and certification activities
in those states.
Tougher Nursing Home Inspections.
We will impose sanctions without a grace period for second
offenses involving violations that harm residents; until now even
serious repeat offenders have been given a chance to correct
problems and avoid penalties.
We will not lift sanctions for serious violations until state
inspectors conduct an on-site visit to verify that the problem is
We will have state surveyors conduct inspections more often for
repeat offenders with serious violations, without decreasing
inspection frequency for other facilities.
We will have state surveyors stagger survey times for all
facilities, with a set amount to be done on weekends and evenings.
We will focus on nursing home chains that have a record of
noncompliance with federal rules.
Preventing Bed Sores, Dehydration, and
We will step up review of nursing homes performance in preventing
bed sores, dehydration, and malnutrition by increasing resident case
reviews in these specific areas during the survey.
We will sanction nursing homes with patterns of violations. We
will develop a repository of best practice guidelines for residents
at risk of weight loss and dehydration with the Administration on
Aging, the American Dietitians Association, clinicians, consumers,
and nursing homes.
Combating Resident Abuse.
We will have state inspectors review each nursing Home's system
to prevent, identify, and stop physical or verbal abuse, neglect,
and misappropriation of resident property.
We will share information about each nursing home's performance
in this area with residents and their families.
We will recommend that nursing homes inquire about criminal
convictions when interviewing applicants for employment.
Prosecution of Egregious Violations.
We will work with the HHS Inspector General and the Department of
Justice to ensure that state survey agencies and others refer
appropriate cases to DOJ and/or the OIG where appropriate, for
prosecution under federal civil and criminal statutes, particularly
cases that result in harm to individual patients.
We will work with the HHS Inspector General to conduct training
for and provide technical assistance to federal survey and
certification staff and HCFA contractors on how to make appropriate
referrals of such cases to the Inspector General.
Publishing Survey Results on the Internet.
We will post individual nursing home survey results and violation
records on the Internet to increase accountability and flag repeat
offenders, as well as superior performers, for both families and the
Continuing Development of Minimum Data
We will continue development of our national automated data
system for information on resident care. We began collecting
information on what is known as a Minimum Data Set in June 1998.
We will analyze this information over time to identify potential
areas of unacceptable care in nursing homes, and use it to assess
nursing home performance in such areas as avoidable bed sores, loss
of mobility, weight loss and use of restraints.
We will use these assessments to better identify nursing homes
for immediate onsite inspections, detect and correct systematic
problems early, and improve nursing home quality.
NEW LEGISLATIVE ACTIONS
In addition to the administrative steps described above, we are
asking Congress to provide needed authority for several additional
actions to help improve nursing home care and safety.
Criminal Background Checks.
We need authority to establish a national registry of nursing
home employees convicted of abusing residents and to require
criminal background checks on all newly hired personnel.
Nutrition and Hydration Therapy.
We need to able to allow more types of nursing home employees,
with proper training, to perform crucial nutrition and hydration
Nursing Home Ombudsman Program. We need Congress to reauthorize a
strong nursing home ombudsman program through the U.S.
Administration on Aging. Ombudsmen are an excellent source of
information about poor-quality nursing homes and abuse or neglect of
We need authority, as requested in our FY 1999 budget proposal,
to collect a fee from Medicare providers and suppliers requesting
participation in Medicare both for initial surveys and for
recertification surveys. Fee amounts will reflect the unit cost of a
survey and the costs incurred by both state and the federal
government to administer the program. The amounts will vary by
state, since survey costs vary by state. The fees will be credited
to our program management appropriation, with fees for initial
surveys paid by each nursing homes when it is surveyed, and fees for
recertifications deducted from payments to the nursing home.
PUBLIC VS. PRIVATE ACCREDITATION
Finally, at Congress request, we also evaluated how private
accreditation of nursing homes compares to the current system. We
secured an independent evaluation by Abt Associates to assist in
that portion of the report. The report concludes that the private
Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) survey process is not effective in protecting nursing home
residents. JCAHO surveys focuses on structure and process measures,
not on whether residents actually get appropriate care. JCAHO
surveyors repeatedly miss instances where residents suffer actual
harm because of inadequate care. In more than half of 179 cases
where both HCFA and JCAHO conducted inspections of the same nursing
homes, JCAHO failed to detect serious problems identified by HCFA.
Also, the public does not have access to JCAHO survey findings.
According to Abt Associates, granting deeming authority to JCAHO
would place nursing home residents at serious risk. While we have
concluded in this report that JCAHO's current approach to the survey
process is unacceptable, we would be willing to consider a
public/private partnership that would help us target our survey and
enforcement efforts on poor performers.
We have made some progress in addressing the deplorable
conditions and heart wrenching human consequences in America's
nursing homes, but clearly we must do more to assure that Americans
in nursing homes receive high quality care and are treated with
dignity and compassion. The parallel findings of our Report to
Congress and General Accounting Office investigation are a clear
call to action. Testimony at this hearing underscores the urgency to
act now. We must and we will address weaknesses in state survey and
enforcement activities. We will strengthen federal oversight. And we
will work with Congress to secure authority for additional steps
needed to ensure that we at HCFA meet our responsibility for
ensuring the quality of nursing home care.