| Department of Health and Human Services |
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|
| OFFICE OF |
| INSPECTOR GENERAL |
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|
| Quality of Care in Nursing Homes: |
| An Overview |
|
|
| JUNE GIBBS BROWN |
| I n s p e c t o r G e n e r a l |
|
|
| MARCH 1999 |
| OEI-02-99-00060 |
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| OFFICE OF INSPECTOR GENERAL |
|
|
| The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to |
| protect the integrity of the Department of Health and Human Services programs as well as the |
| health and welfare of beneficiaries served by them. This statutory mission is carried out through a |
| nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The |
| Inspector General informs the Secretary of program and management problems and recommends |
| legislative, regulatory, and operational approaches to correct them. |
|
|
| Office of Evaluation and Inspections |
|
|
| The Office of Evaluation and Inspections (OEI) is one of several components of the Office of |
| Inspector General. It conducts short-term management and program evaluations (called |
| inspections) that focus on issues of concern to the Department, the Congress, and the public. The |
| inspection reports provide findings and recommendations on the efficiency, vulnerability, and |
| effectiveness of departmental programs. |
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| OEI's New York regional office prepared this report under the direction of John I. Molnar, |
| Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General. Principal |
| OEI staff included: |
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| REGION |
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| HEADQUARTERS |
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|
| Demetra Arapakos |
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|
| Susan Burbach |
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| To obtain copies of this report, please call the New York Regional Office at 212-264-2000. |
| Reports are also available on the World Wide Web at our home page address: |
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| http://www.dhhs.gov/progorg/oei |
|
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| E X E C U T I V E S U M M A R Y |
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|
| PURPOSE |
|
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| To describe general conditions in nursing homes and assess the overall capacity of systems |
| designed to monitor and improve quality of care. |
|
|
| This report is based primarily on recent studies conducted by the Office of Inspector |
| General (OIG) on quality of care in nursing homes. It draws additionally upon work |
| completed by the General Accounting Office (GAO), the Health Care Financing |
| Administration (HCFA), and others. The report summarizes steps taken recently and now |
| underway to address weaknesses in the system. It also provides a long term program of |
| action and research needed to assure nursing home care meets government standards for |
| quality of care. |
|
|
| BACKGROUND |
|
|
| While some studies indicate that changes in law and regulations may have had a positive |
| effect on improving the environment and overall health care of nursing home patients, |
| recent reports by HCFA and GAO have raised serious concerns about patient care and well- |
| being. The Senate Special Committee on Aging held hearings in the summer of 1998 on |
| these reports. At the same time, the OIG undertook a series of studies aimed at assessing |
| the quality of care in nursing homes. |
|
|
| Various systems are in place to monitor and promote quality of care in nursing homes. |
| These include the State survey and certification system, the State Long Term Care |
| Ombudsman Program, State resident abuse safeguards, law enforcement, and legislative |
| reforms established by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). |
|
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| We used multiple methods for this report. They consist of an analysis of national nursing |
| home program data, a review of written program procedures, structured telephone |
| interviews, an examination of nursing home survey results availability, a literature review, |
| and an analysis of nursing home legislation. |
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|
| FINDINGS |
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| Serious Quality of Care Problems Persist in Nursing Homes |
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| An analysis of currently available program data reveals that problems with quality of care |
| continue to exist in nursing homes. First, according to survey and certification data, 13 of |
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| 25 “quality of care” deficiencies have increased in recent years. They include a lack of |
| supervision to prevent accidents, improper care for pressure sores, and lack of proper care |
| for activities of daily living. At the same time, ombudsman complaints have been steadily |
| increasing since 1989 and complaints about resident care, such as pressure sores and |
| hygiene, have been particularly prevalent. Since 1995, the OIG has excluded 668 nursing |
| home workers from participation in the Medicare/Medicaid programs as a result of a |
| conviction related to patient abuse or neglect. On a related note, approximately one percent |
| or more of nursing home residents have had an experience serious enough to register an |
| abuse complaint. Lastly, survey and certification data, as well as discussions with survey |
| and certification staff and ombudsmen, reveal that some nursing homes are chronically |
| substandard. |
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| Experienced officials with inside information based on onsite visits to nursing homes, |
| including State survey directors, surveyors, ombudsmen, and State Aging Unit Directors, |
| express some reservations about relying exclusively on program data to gauge conditions in |
| nursing homes. Nevertheless, they confirm that problems persist in nursing homes, such as |
| malnutrition, abuse, pressure sores, and over-medication. The problems they identify are |
| similar to the problems highlighted in their program reporting systems. |
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| Evidence Suggests Inadequate Levels of Nursing Home Staff Contribute to Quality |
| of Care Problems |
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| In all 10 sample States, survey and certification staff, State and local ombudsmen, as well as |
| State Aging Unit Directors identify inadequate staffing levels as one of the major problems |
| in nursing homes. Most believe these staffing shortages lead to chronic quality of care |
| problems, such as failure to adequately treat and prevent pressure sores. |
|
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| The type and extent of survey deficiencies and Ombudsman program complaints also |
| suggest that nursing home staffing levels are inadequate. Common personal care problems |
| such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate |
| to provide the level of care needed to avoid these problems. Furthermore, specific |
| complaints about nursing home staff are some of the most common types of Ombudsman |
| program complaints in 1997. |
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| Survey and Certification Agencies are Following Required Standard Protocols but |
| Weaknesses in the Survey System Itself Limit Their Effectiveness |
|
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| State survey and certification agencies monitor nursing home care with timely and standard |
| surveys, complaint procedures, and other State procedures. However, the survey and |
| certification system has several weaknesses, such as the predictability of surveys. Although |
| all States use unannounced surveys, State directors and surveyors believe that nursing |
| homes can anticipate their survey date and modify their procedures to avoid being cited for |
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| deficiencies. The system is also limited by weak enforcement, including inadequate follow- |
| up and common inaction on abuse complaints. State directors and surveyors believe that |
| the current process allows deficient facilities too many opportunities to avoid enforcement |
| action. Lastly, survey and certification agencies have some staffing constraints and do not |
| always effectively coordinate with ombudsmen. |
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| While the Ombudsman Program is Well Designed, Inadequate Resources Limit Its |
| Capacity |
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| The Ombudsman program has several functions to promote and monitor quality of care in |
| nursing homes, including identifying and resolving complaints, making regular visits to |
| nursing homes, and engaging in a variety of different advocacy activities. While lacking |
| enforcement and regulatory oversight, ombudsmen act as independent advocates and work |
| solely on behalf of residents to ensure they have a voice in their own care. However, the |
| Ombudsman program is limited by inadequate resources, including inadequate staffing. |
| Only 1 of 10 States in our sample had a paid ombudsman to bed ratio higher than the |
| standard suggested by the Institute of Medicine. This lack of adequate staffing is |
| particularly evident in the limited extent to which ombudsmen make regular nursing homes |
| visits. The program is further constrained by the lack of a common standard for complaint |
| response and resolution, inconsistent advocacy efforts, a lack of support, and limited |
| collaboration with surveyors. |
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| State Systems to Safeguard Nursing Home Residents from Abuse are Inconsistent |
| and Unreliable |
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| Based on findings from a recent OIG audit, “Safeguarding Long Term Care Residents,” A- |
| 12-97-0003, it appears that some weaknesses exist in State efforts to safeguard nursing |
| home residents from abuse. This audit revealed great diversity in the way States |
| systematically identify, report, and investigate suspected abuse, and it found that there was |
| no assurance that individuals who posed a risk of abuse were systematically identified and |
| barred from nursing home employment. Additionally, a more in-depth audit of Maryland |
| examined eight nursing homes in the State and found that five percent of employees in those |
| homes had criminal records. |
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| Public Awareness and Access to Nursing Home Survey Results is Limited |
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| Public awareness of nursing home survey results is limited and these results are not always |
| readily available. Two-thirds of 155 families interviewed in eight sample cities did not |
| know that the results of Federal and State nursing home inspections are available on |
| request. Additionally, half were unaware such inspections are required, and only 15 had |
| ever requested a copy of survey results. Of the 11 who obtained a copy, 6 said the results |
| were not based on the most recent survey. Furthermore, when staff from the OIG visited |
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| the 32 sampled nursing homes, most did not fully meet the requirements for making survey |
| results available. The HCFA has established a more easily accessible version of nursing |
| home survey results with an internet site entitled Nursing Home Compare which appears |
| promising. |
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| New Initiatives Based on Law Enforcement Approaches are Being Considered |
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| Initiatives that use the False Claims Act and other law enforcement approaches as a way to |
| strengthen nursing homes are relatively new. National task forces comprised of |
| representatives from the Department of Justice, HCFA, OIG, and others are being formed |
| at the local, State, and national levels. These groups will examine the full range of |
| enforcement issues and develop corresponding action plans for each. By targeting key |
| strategic areas and coordinating among the various agencies responsible for nursing home |
| enforcement, these initiatives appear promising. However, it is too soon to determine their |
| full impact. |
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| Nursing Home Reforms Established by OBRA 1987 Have Not Been Systematically |
| Assessed |
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| The nursing home reforms created by OBRA 1987 impacted both nursing home systems |
| and nursing home care. The OBRA 1987 mandated that residents be given certain rights |
| and services and also added several administrative standards that nursing homes are |
| required to meet. It further changed enforcement and survey procedures. While it has now |
| been more than a decade later since this legislation was passed, there has been no systematic |
| assessment of its extensive agenda and no methodical evaluation of whether the reforms it |
| intended are actually working. While some studies have attributed positive changes to |
| OBRA 1987, the lack of a systematic review makes it difficult to determine if this major |
| legislation has been successful in improving nursing home care. |
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| AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME |
| CARE |
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| Since OBRA 1987 was first passed, real improvements have been made in nursing home |
| care. More recently, considerable attention has been paid to addressing persisting concerns |
| about nursing home conditions and systems. In particular, we commend the Health Care |
| Financing Administration (HCFA) for its extensive nursing home initiative since it addresses |
| many of these persisting problems. This initiative includes many individual action items |
| which should result in positive changes. Additionally, the Administration on Aging (AoA) |
| has been taking steps to enhance the Ombudsman program, including improving the |
| program reporting system and conducting annual training of ombudsman staff. |
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| The problems we describe in this report will require continuing attention, possibly for |
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| several years. The broad outline of an effective strategy would include actions to: |
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| enhance the survey and certification process; |
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| strengthen the Ombudsman program with increased resources; |
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| improve nursing home staffing levels; and, |
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| improve coordination between State survey agencies and ombudsmen. |
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| We also believe that further evaluation and progress measurement would make an important |
| contribution to efforts to advance nursing home care. We specifically suggest: |
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| a systematic assessment of OBRA 1987 and |
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| the creation of a periodic report card on conditions in nursing homes. |
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| We have incorporated action items from HCFA’s nursing home initiative, AoA’s |
| ombudsman activities, recommendations for additional steps to be taken, current OIG work, |
| and areas requiring further evaluation into one comprehensive, long term agenda to |
| continue improvements in nursing home care. This agenda consists of a three stage |
| approach of immediate action, research and evaluation, and continued progress |
| measurement. The full agenda can be found on page 28. |
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| AGENCY COMMENTS |
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| This report is based primarily on a series of recent studies conducted by the Office of |
| Inspector General on nursing home care. They are: |
|
|
| Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331; |
|
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| Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330; |
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| Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350; |
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| Long Term Care Ombudsman Program: Overall Capacity, OEI-02-98-00351; |
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| Public Access to Nursing Home Survey and Certification Results, OEI-06-98- |
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| 00280; and |
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| Safeguarding Long Term Care Residents, A-12-97-0003. |
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| We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning |
| and Evaluation on the above reports. We made modifications in each report to respond to |
| the comments received and to reflect the actions already being taken to improve nursing |
| home conditions. This overview report also incorporates many of these modifications. We |
| encourage everyone to read the individual reports and the comments we received on them. |
| The comments are included in each report. |
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| T A B L E O F O F C O N T E N T S |
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| EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 |
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| INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 |
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| FINDINGS |
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| Serious Quality of Care Problems Persist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 |
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| PAGE |
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| Nursing Home Staffing is Inadequate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 |
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| Survey and Certification Follows Protocols but Limited by System Weaknesses . . . . . . . 22 |
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| Ombudsman Program Well Designed but Lacks Adequate Resources . . . . . . . . . . . . . . . 23 |
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| State Resident Abuse Safeguards Inconsistent and Unreliable . . . . . . . . . . . . . . . . . . . . . 25 |
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| Awareness and Access to Survey Results Limited |
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| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 |
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| New Law Enforcement Initiatives Being Considered . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 |
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| OBRA 1987 Lacks Systematic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 |
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| AN AGENDA FOR CONTINUING IMPROVEMENT IN NURSING HOME CARE . . . . . 28 |
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| Immediate Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 |
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| Research and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 |
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| Progress Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 |
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| AGENCY COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 |
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| I N T R O D U C T I O N |
|
|
| PURPOSE |
|
|
| To describe general conditions in nursing homes and assess the overall capacity of systems |
| designed to monitor and improve quality of care. |
|
|
| This report is based primarily on recent studies conducted by the Office of Inspector |
| General (OIG) on quality of care in nursing homes. It additionally draws upon work |
| completed by the General Accounting Office (GAO), the Health Care Financing |
| Administration (HCFA), and others. The report summarizes steps recently taken and now |
| underway to address weaknesses in the system. It also provides a long term program of |
| action and research needed to assure nursing home care meets government standards for |
| quality of care. |
|
|
| BACKGROUND |
|
|
| While some studies indicate that changes in law and regulations may have had a positive |
| effect on improving the environment and overall health care of nursing home residents, |
| recent reports by HCFA and GAO have raised serious concerns about residents’ care and |
| well-being. The Senate Special Committee on Aging held hearings in the summer of 1998 |
| on these results. The OIG subsequently undertook a series of studies aimed at assessing |
| the quality of care in nursing homes. This report looks at both the general state of nursing |
| home care as well as the systems designed to oversee that care. |
|
|
| Generally, a nursing home is a residential facility offering daily living assistance to |
| individuals who are physically or mentally unable to live independently. Residents are |
| provided rooms, meals, assistance with daily living, and in most cases, some medical |
| treatment. In 1989 Medicare paid $2.8 billion to nursing homes, an amount totaling 4.7 |
| percent of the Medicare budget. In 1996 this amount had increased to $10.6 billion, |
| totaling 9 percent of the Medicare budget. Medicaid expenditures for nursing homes in |
| 1996 totaled $24.3 billion. |
|
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| In 1986, the Institute of Medicine conducted a study on nursing home regulations and |
| reported prevalent problems regarding the quality of care for nursing home residents, as |
| well as the need for stronger Federal regulations. Just one year later, GAO reported that |
| over one third of nursing homes were operating below Federal minimum standards. These |
| reports, along with widespread concern regarding nursing home conditions, persuaded |
| Congress to pass the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). As a part |
| of OBRA 1987, Congress passed the comprehensive Nursing Home Reform Act (PL 100- |
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| 203). These actions expanded requirements that nursing facilities had to comply with in |
| order to obtain Medicare certification. The Nursing Home Reform Act also strengthened |
| the rights to nursing home residents, such as the right to be free of physical or mental abuse, |
| and the right to be free from chemical and physical restraints. It additionally altered the |
| enforcement of Federal standards for nursing home care. |
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| Medicare Nursing Home Requirements |
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| The Health Care Financing Administration (HCFA) has the responsibility to act as a |
| “prudent purchaser” by ensuring that nursing homes participating in Medicare and/or |
| Medicaid meet certain requirements for quality environment and services. These |
| requirements are found at 42 Code of Federal Regulations (CFR) Part 483, Subpart B. The |
| Nursing Home Reform Act added to these requirements by introducing an increased focus |
| on the quality of life and care, the importance of the individual resident, the need to help |
| residents reach the “highest practicable level” of functioning, and the requirement that |
| residents be interviewed and assessed. |
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| Nursing homes must “conduct standardized, reproducible assessments of each resident’s |
| functional capacity...” within 14 days of admission. Additionally, periodic assessments must |
| occur throughout the duration of a patient’s stay in order to continually address their |
| fluctuating needs. With the Nursing Home Reform Act, HCFA developed the Minimum |
| Data Set (MDS) which is comprised of core elements and common definitions used in |
| conducting resident assessments. The Minimum Data Set collects data through resident |
| assessment measures, with subsequent progress or decline documented in electronic format. |
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| The Nursing Home Reform Act additionally established new enforcement provisions, which |
| were enacted when the State Operations Manual (SOM) became effective on July 1, 1995. |
| The HCFA had several process goals during the implementation of these new provisions: |
| promoting consistency through extensive training; linking appropriate remedies to |
| deficiencies; and avoiding unnecessary procedures. Congress recognized that one |
| enforcement response would not be appropriate for all deficiencies. It therefore established |
| enforcement policies that gave HCFA the license to impose a variety of corrective measures |
| for noncompliant facilities. These include: temporary management; denial of payment for |
| new admissions; civil money penalties; termination of the facility; and State monitoring of |
| the facility. States are responsible for establishing their own remedy guidelines. |
|
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| Following the implementation of the State Operations Manual, HCFA also imposed a |
| number of administrative changes on enforcement procedures . In June 1995, HCFA |
| enacted a temporary moratorium on the collection of certain lower-level money penalties |
| (CMPs). This moratorium preceded HCFA’s decision to alter the State Operations Manual |
| in December of 1996. “Civil monetary penalties are now limited to situations of immediate |
| jeopardy or to nursing facilities that are poor performers or have serious deficiencies that |
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| are not corrected at the time of a revisit.” Additional changes by HCFA redefined the scope |
| of deficiencies, permitted States to avoid revisits in facilities that have lower level |
| deficiencies, and established new terms to define facilities that are not in substantial |
| compliance. |
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| Nursing Home Systems |
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| All nursing homes participating in Medicare and/or Medicaid |
| Survey and Certification. |
| must be certified in meeting certain Federal requirements. The Nursing Home Reform Act |
| defines the State survey and certification process for determining nursing home compliance |
| with these Federal standards. The HCFA is responsible for certifying Medicare and dually- |
| eligible facilities, while States are responsible for Medicaid only facilities. Nursing home |
| certification is achieved through routine surveys, and HCFA contracts with States to |
| perform such surveys for Medicare and dually-eligible nursing homes, in addition to those |
| they perform for Medicaid nursing homes. |
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| State surveys determine the compliance or noncompliance of nursing homes. When a |
| nursing home fails to meet a specific requirement, surveyors give it a deficiency or citation. |
| Generally, there are 20 principles that are considered in the citation of deficiencies on the |
| HCFA-2567. Surveyors also provide the reasons justifying any resulting enforcement |
| action and the record on which to defend that action in the appeals process. State survey |
| teams generally consist of multi-disciplinary professionals and must include a registered |
| professional nurse. Other professionals who may be on the survey team include social |
| workers, therapists, dieticians, pharmacists, administrators, and physicians. |
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| Each State is also required to maintain written procedures and adequate staff to investigate |
| complaints of violations at nursing homes. States must review all allegations of resident |
| neglect and abuse, and misappropriation of resident property. All allegations, regardless of |
| source, must be reviewed in a timely manner. If an allegation is found to have occurred, the |
| State must notify, in writing, the individuals implicated and the administrator of the nursing |
| home where the incident transpired. |
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| A new survey and certification process was implemented in 1995. All nursing facilities are |
| now subject to an unannounced standard survey “no later than 15 months after the date of |
| the previous standard survey.” Since the Statewide average interval between standard |
| surveys “must be 12 months or less,” this creates a Federal standard survey window |
| between 9 and 15 months. Each standard survey includes a stratified case mix of nursing |
| home residents, and measures their medical, nursing and rehabilitative care, dietary and |
| nutrition services, activities, social participation, sanitation, infection control, and physical |
| environment. Written plans of care are reviewed to determine their adequacy and an audit |
| of residents’ assessments are conducted to determine the accuracy of such assessments. |
| There is also a review of facility compliance with residents’ rights. |
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| In addition to regular surveys, States also conduct “special” and “extended” surveys. |
| Special surveys may be conducted within two months of any change in ownership, |
| administration, management, or director of nursing to determine if the change is having an |
| effect on the quality of care in the nursing home. Extended surveys are performed |
| immediately or within two weeks after the standard survey completion, on those nursing |
| homes found to have provided substandard quality of care. The survey team reviews the |
| policies and procedures that produced the substandard care, expands the size of the sample |
| of resident’s assessments, reviews staffing, in-service training, and if necessary, contracts |
| with consultants. |
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| Within two months of the State survey, HCFA conducts validation surveys on a |
| representative sample of nursing homes in each State utilizing the same survey procedure as |
| the State agency. Recently, some HCFA regional offices have chosen to conduct these |
| validation surveys simultaneously with the State. The HCFA must survey at least five |
| percent of the number of facilities surveyed by the State each year, and this number must |
| never be less than five surveys a year. |
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| In order to improve the survey process, the State Agency Quality Improvement Program |
| (SAQIP) was developed to establish a process for State agencies and HCFA regional offices |
| to work together to develop the State’s individual quality improvement plans (IQIPs). The |
| regional office will assist the State by providing training, technical assistance, and support |
| as necessary and appropriate. These individual plans are tailored to the specific needs and |
| circumstances of each State, and are revised and improved based on changing needs. The |
| SAQIP is designed to promote quality and ongoing improvement in survey and certification |
| activities, and applies to all aspects of the survey and certification process. |
|
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| The HCFA’s Online Survey Certification and Reporting System (OSCAR) came online in |
| October 1991. The HCFA uses OSCAR in its survey of Medicare and Medicaid providers |
| to monitor State agency and provider performance. The OSCAR contains data for the |
| current and 3 previous surveys. Some of the data is overwritten as new information is |
| entered (e.g. number of beds, address, and employment information), but deficiency data |
| remains and is tracked historically. The HCFA recently began tracking the scope and |
| severity of deficiencies historically as well. Part of the OSCAR data is self-reported |
| information by the nursing homes about the facility and its’ patients. The remaining data is |
| information generated by the surveyors and is based on deficiencies. The Federal |
| regulations detailing survey requirements are classified into 17 major categories. The |
| specific survey requirements within these categories were consolidated from 325 individual |
| items to 185 items on July 1, 1995. |
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| Ombudsman Program. In response to growing concerns about poor quality care in |
| nursing homes and to protect the interests of residents, the State Long Term Care |
| Ombudsman program was established in 1978 in the Older Americans Act. The |
| ombudsmen advocate on behalf of residents of all long term care facilities, including nursing |
|
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| Quality of Care in Nursing Homes: An Overview |
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| 10 |
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| homes, to ensure residents have a strong voice in their own treatment and care. |
|
|
| The Ombudsman Program operates in all fifty States, the District of Columbia, and Puerto |
|
|
| Rico, and in hundreds of local communities, and uses both paid and volunteer staff. The |
|
|
| program receives funding from Federal, State and local levels, and is overseen by the |
|
|
| Administration on Aging (AoA). Most State ombudsmen operate within the State Unit on |
|
|
| Aging, some of which are independent while others are part of a larger State umbrella |
|
|
| agency. The remaining State Ombudsman programs are contracted out and administered by |
|
|
| an entity separate from the State Unit on Aging. These programs are operated by non- |
|
|
| profit organizations, legal services agencies, or by freestanding Ombudsman program |
|
|
| agencies. |
|
|
| State Ombudsman programs have multiple functions that are mandated by law, many of |
|
|
| which are closely tied to ensuring quality care for long term care residents. They include: |
|
|
| C |
| C |
| C |
| C |
| C |
|
|
| identifying, investigating, and resolving complaints; |
|
|
| protecting the legal rights of patients; |
|
|
| advocating for systemic change; |
|
|
| providing information and consultation to residents and their families; and |
|
|
| publicizing issues of importance to residents |
|
|
| States have recently started to collect and report data under a new system. In FY 1995, |
|
|
| States began to systematically collect and report data under the National Ombudsman |
|
|
| Reporting System (NORS). Prior to NORS, States reported data to AoA, which was of |
|
|
| limited use due to the lack of common definitions for key data elements. The NORS was |
|
|
| created in response to earlier recommendations made by the General Accounting Office and |
|
|
| the Office of Inspector General, and was developed by the ombudsmen themselves. It |
|
|
| includes more specific data elements than were reported before NORS. For example, it |
|
|
| separates complaints by type, distinguishes between complaints and complainants, counts |
|
|
| unresolved complaints, and reports program funding streams. Twenty-nine States reported |
|
|
| under NORS in 1995 and all States did so annually beginning in 1996. |
|
|
| Resident abuse safeguards. Federal regulations require States to establish a registry of |
|
|
| nurse aides that includes information on any aide found guilty of abuse or neglect. |
|
|
| Regulations also mandate that nursing homes not employ individuals who have been found |
|
|
| guilty of abusing or neglecting nursing home residents. States are additionally required to |
|
|
| provide criminal information to the OIG national database, which is then used to publish a |
|
|
| monthly exclusion list. However, there is no Federal requirement to conduct criminal |
|
|
| background checks of all current or prospective employees of Medicare and/or Medicaid |
|
|
| participating nursing homes. |
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| Quality of Care in Nursing Homes: An Overview |
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| OEI-02-99-00060 |
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| Other procedures have also been established to coordinate the reporting of resident abuse |
| allegations. Each State is required to designate a coordinator with central State authority to |
| receive complaints of mistreatment or neglect of nursing home residents. While this |
| individual or entity may be located in any number of State agencies or within a designated |
| complaint unit, the responsibility is often assigned to an employee of the State survey and |
| certification agency. |
|
|
| Families. Families are in the best position to help choose a nursing home and to monitor |
| the care provided in that home. To do this, they need accurate and timely information |
| about the quality of care in the nursing home they choose. A nursing home’s most recent |
| annual survey results are, theoretically, ideally suited for this purpose. Various laws and |
| regulations are intended to make these results available to the public, including the |
| requirement that nursing homes post a notice giving the location and availability of its most |
| recent survey results. |
|
|
| Law enforcement. Several different agencies have responsibility for nursing home law |
| enforcement, including the Department of Justice, the OIG, and State agencies such as the |
| State Attorney General. The local police force also plays an enforcement role. A nursing |
| home facility, owner, or other employee (such as a nurse aide or administrator) may be |
| excluded from participation in Medicare and Medicaid after appropriate enforcement action |
| is taken. |
|
|
| Recently, poor quality of care has been the basis of a prosecution under the False Claims |
| Act. When providers submit claims for reimbursement, they certify either explicitly or |
| implicitly that the services provided meet professional standards; if they "knowingly" |
| present a claim for substandard services, they could be liable under the False Claims Act. |
| Thus, under appropriate circumstances, the Government can use the False Claims Act to |
| prosecute a provider who knowingly presents false or fraudulent claims to the government |
| for substandard care in nursing homes. The two major cases where the False Claims Act |
| has been used involve grossly deficient diabetes monitoring, pressure sore care, and other |
| nursing care. In both the landmark 1996 case against Geriatric & Medical Cos., Inc. and its |
| Tucker House facility and the 1998 case against the Chester Care chain of four nursing |
| homes, the OIG obtained civil settlements for $500,000 each. As part of the settlement |
| agreements, the companies were required to develop comprehensive compliance programs. |
| In addition, in the Chester Care case, the company was required to pay for a temporary |
| manager and monitor to oversee provision of care. |
|
|
| Legislative reforms (OBRA 1987). As previously noted, the OBRA 1987 legislation and |
| ensuing regulations established a framework for nursing home reform. It specifically |
| provided an agenda for nursing home care by mandating that residents be given certain |
| rights and services, and adding several administrative standards that nursing homes were |
| required to meet. It also established new survey and enforcement requirements, including |
| making surveys more resident focused and augmenting existing enforcement options. |
|
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| Quality of Care in Nursing Homes: An Overview |
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| Prior Studies and Recent Initiatives |
|
|
| Several studies have been completed which have examined the survey and certification |
| process. One recent study entitled “The Regulation and Enforcement of Federal Nursing |
| Home Standards,” written by Charlene Harrington and published in March of 1998, details |
| problems with nursing home certification. She challenges the declining State deficiency |
| averages by raising the notion that the enforcement process may be weakening rather than |
| nursing facilities improving quality of care. |
|
|
| Furthermore, “The National State Auditors Association Joint Performance Audit on Long- |
| Term Care,” completed in May of 1998 by the Louisiana Office of the Legislative Auditor, |
| compiled information from ten States regarding survey and certification concerns. Issues |
| discussed include licensing, inspection, sanctions, complaints, and reimbursement. The |
| audit findings conclude that States should vary the timing of inspections, evaluate how |
| aggressively they are imposing State sanctions on facilities with deficiencies, and avoid |
| delaying the investigation of complaints. |
|
|
| Many studies have also reported on the progress and impact of the Ombudsman Program. |
| One of the most recent, “Real People, Real Problems,” published in 1995 by the National |
| Academy of Sciences’ Institute of Medicine, looked at the Ombudsman program overall. |
| This study reported on State compliance, conflicts of interest, effectiveness, resources, and |
| the need for future expansion of the program. It found that, overall, the Ombudsman |
| program is effective. It also reported lack of access to ombudsman services by residents |
| and their families, disparities in ombudsman visitation patterns and service provision, and |
| uneven legal services available to ombudsmen. |
|
|
| Additionally, the Inspector General issued several reports on the Program in 1991 and |
| 1992. First, “Successful Ombudsman Programs,” (OEI-02-90-02120), the main report in a |
| series of reports on the Ombudsman program, found that successful programs are highly |
| visible and obtain adequate funding and support. Furthermore, “State Implementation of |
| the Ombudsman Requirements of the Older Americans Act,” (OEI-02-91-01516), found, |
| among other things, that State program staffing and long term care facility visitation varies |
| significantly. It also found that ombudsmen use many methods to increase their visibility. |
|
|
| In July, 1998, the President announced a new nursing home care initiative to provide |
| enhanced protections and to target needed improvement in nursing home care. Proposed |
| actions include checking criminal backgrounds of nursing home workers, establishing a |
| national registry of employees convicted of abusing patients, targeting nursing home chains |
| with poor records, cutting off inspection funds to States with poor records of citing |
| substandard quality of care, publishing annual nursing home surveys on the Internet, |
| increasing Federal oversight of State inspections, providing additional training to State |
| officials, changing the survey schedule to make them more unpredictable, and increasing the |
|
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| Quality of Care in Nursing Homes: An Overview |
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| 13 |
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| OEI-02-99-00060 |
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| number of night and weekend surveys. |
|
|
| In conjunction with the President’s nursing home initiative, the Secretary released a report |
| to Congress in July of 1998, a “Study of Private Accreditation (Deeming) of Nursing |
| Homes, Regulatory Incentives and Non-Regulatory Initiatives, and Effectiveness of the |
| Survey and Certification System,” indicating that significant improvements in the quality of |
| care had been made since 1995. These improvements included more appropriate use of |
| physical restraints, anti-psychotic drugs, anti-depressants, urinary catheters, and hearing |
| aids. However, the report did find a need for further improvements by States, nursing |
| homes, and others. Additional steps will be taken to address the problems identified in the |
| report and include tougher enforcement of Medicare and/or Medicaid rules. Efforts will be |
| aimed at preventing instances of pressure sores, dehydration, and nutrition problems. The |
| following are new approaches aimed at improving quality of care: facilities that have repeat |
| offenses will face sanctions without a grace period; inspections will be conducted more |
| frequently for repeat offenders without decreasing inspections at other facilities; inspections |
| will be staggered; a set amount of inspections will be conducted on weekends; and efforts |
| will be focused on facilities within chains that have a record of non-compliance. |
| One week after the President’s initiative, the General Accounting Office (GAO) published a |
| report examining the quality of care in 1,370 California nursing homes that were inspected |
| from 1995 to 1998. They found 30 percent of the homes had violations that caused death |
| or life-threatening harm to residents, or had understated the frequency of poor care by |
| falsifying medical records. As a result of this report, the US Senate Special Committee on |
| Aging held hearings in July 1998 to discuss the findings on the quality of care in nursing |
| homes. |
|
|
| METHODOLOGY |
|
|
| Multiple methods were used for this report. They include an analysis of national nursing |
| home program data, a review of written program procedures, structured telephone |
| interviews, a literature review, and an analysis of nursing home legislation. |
|
|
| Description of nursing home conditions |
|
|
| Data Analysis |
|
|
| Survey and certification data. We used a purposive sample of 10 States which represent |
| 55.8 percent of total skilled nursing beds nationally. These States are New York, |
| California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida, New Jersey, and |
| Tennessee. The OSCAR contains data for the current and 3 previous surveys and |
| categorizes deficiencies into 17 major categories. Using the most recently available |
| OSCAR data (from August 4, 1998), 3 of the 17 categories which could determine poor |
| quality of care were analyzed. These are: 1) resident behavior and facility practices, |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| 14 |
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| OEI-02-99-00060 |
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| including the areas of restraints, abuse and staff treatment of residents; 2) quality of life, |
| including the resident’s ability to make decisions about his or her daily activities and the |
| nursing home’s accommodation of his or her needs; and 3) quality of care, including the |
| technical ability of the nursing home to prevent and treat the medical conditions of its |
| residents. Substandard quality of care deficiencies repeated over the last four surveys and |
| abuse complaint data were also examined. |
|
|
| Ombudsman data. Using the same purposive sample of 10 States, we analyzed 2 sets of |
| Ombudsman program data. For 1996 and 1997, data from the National Ombudsman |
| Reporting System (NORS) was examined; from 1989 to 1994, data from the pre-NORS |
| reporting system was used. Data from 1995 is not analyzed due to a lack of comparable |
| data elements for that year. For both pre-NORS and NORS data, figures for both total |
| complaints and broad complaint categories are presented; for NORS data, 125 specific |
| complaint types were also looked at. Finally, data on Ombudsman program staffing, |
| visitation rates, advocacy activities, and coordination with survey and certification agencies |
| was also examined. |
|
|
| Abuse complaints. Using a fax survey, we obtained data from all 10 States on the |
| numbers and types of nursing home resident abuse complaints. We specifically analyzed |
| data on four types of complaints selected as key indicators of recent abuse trends: physical |
| abuse, inappropriate use of restraints, physical neglect, and medical neglect. |
|
|
| OIG convictions. We reviewed data from the Office of Inspector General on nursing home |
| convictions relating to resident abuse or neglect, from 1995 to 1998. |
|
|
| Literature review |
|
|
| We examined findings on nursing home conditions from several studies, particularly the |
| recent GAO report entitled “California Nursing Homes: Care Problems Persist Despite |
| Federal and State Oversight.” |
|
|
| Assessment of nursing home systems |
|
|
| Procedures review |
|
|
| Survey and certification procedures. For the eight States that have their own survey |
| guidelines which they use in addition to HCFA guidelines, we obtained and reviewed their |
| written program procedures and other related documents. The remaining two States had no |
| survey requirements of their own. |
|
|
| Ombudsman procedures. Written procedures for all 10 sample State Ombudsman |
| programs were obtained and reviewed. Using a structured review guide, these procedures |
| were reviewed to determine the different processes used by ombudsmen to monitor and |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 15 |
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| OEI-02-99-00060 |
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| promote quality of care in nursing homes. Standards mandated for these processes, such as |
| complaint response times, were also looked at. |
|
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| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 16 |
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| OEI-02-99-00060 |
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|
| Interviews |
|
|
| Survey and certification telephone interviews. A total of thirty structured telephone |
| interviews were conducted. In each of the 10 sample States, one interview was conducted |
| with the State survey and certification director (or designee) and two State surveyors. The |
| two State surveyors were selected randomly from a list of at least 10 surveyors submitted |
| by the State director. During these interviews, information was obtained about the State |
| survey and certification program structure, the processes utilized to monitor quality of care, |
| how deficiencies are addressed, and the satisfaction of State survey and certification |
| directors and surveyors with the process. Information provided by the directors was |
| compared to that provided by surveyors, and special attention was given to consensus |
| within and among the groups. |
|
|
| Ombudsman telephone interviews. A total of 30 structured telephone interviews were |
| conducted. In each of the 10 sample States, one interview was conducted with the State |
| ombudsman, one local program ombudsman, and the State Aging Unit Director or |
| designee. In selecting ombudsmen from local programs to interview, individuals from a |
| variety of local program structures were chosen. These three groups of respondents were |
| selected to obtain their different perspectives of the program and consensus among the |
| groups was particularly noted while analyzing the interviews. |
|
|
| Examination of nursing home survey results availability |
|
|
| To examine the availability of survey results, we used a different sample and methodology. |
| We selected a purposive sample of eight cities, each one having a regional Office of |
| Evaluations and Inspections (San Francisco, Atlanta, Chicago, Boston, Kansas City, New |
| York, Philadelphia, and Boston). We then combined five methods to assess the availability |
| of survey results: telephone interviews with 155 family members; a simulation by OIG staff |
| of families’ access to nursing home results; telephone requests to HCFA and State officials |
| for survey results; a review of HCFA’s new internet site for survey results; and a review of |
| Federal rules and procedures regarding access to survey results. |
|
|
| Literature review |
|
|
| We also conducted a literature review of recent nursing home studies which assessed |
| nursing home systems. We particularly used an OIG report entitled “Safeguarding Long |
| Term Care Residents.” |
|
|
| Legislation review |
|
|
| Finally, we reviewed nursing home legislation, particularly OBRA 1987. We identified each |
| of the individual reforms outlined in OBRA 87 and determined which ones had been |
| assessed for impact and outcome. Lastly, we reviewed the mission statement and agenda |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 17 |
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| OEI-02-99-00060 |
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|
| for recent nursing home law enforcement initiatives. |
|
|
| This inspection was conducted in accordance with the Quality Standards for Inspections |
| issued by the President’s Council on Integrity and Efficiency. |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 18 |
|
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| OEI-02-99-00060 |
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|
| F I N D I N G S |
|
|
| Serious quality of care problems persist in nursing homes |
|
|
| Survey and certification deficiencies. An analysis of survey and certification deficiencies |
| indicates that problems with quality of care continue to exist in nursing homes. Deficiencies |
| are grouped into one of three main categories, and while two of these categories have been |
| decreasing, many deficiencies in the “quality of care” category have actually been |
| increasing. More specifically, 13 of the 25 deficiencies that make up this category are |
| higher now than they were on the last 3 surveys. These 13 deficiencies were cited 6,413 |
| times on the current survey, compared to 5,246 times three surveys prior, an increase of |
| almost 25 percent. They include a lack of adequate supervision to prevent accidents, a lack |
| of appropriate care for activities of daily living, and improper care for pressure sores. |
| Graph A below shows how some of these serious deficiencies have grown over the prior 3 |
| surveys. |
|
|
| Graph A |
| Some Serious Quality of Care Deficiencies Have Been Increasing |
|
|
| Deficiencies often lead to further medical problems or indicate other issues. For example, |
| pressure sores could be an indication that residents also have other problems, such as |
| urinary incontinence, malnutrition, or dehydration. Table 1 below shows the nature and |
| extent of the top 10 substandard quality of care deficiencies from the latest standard survey |
| in the 10 sample States. |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 19 |
|
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| OEI-02-99-00060 |
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|
| Table 1 |
| The Top 10 Substandard Quality of Care Deficiencies |
| Include Some Serious Problems |
|
|
| Deficiency |
|
|
| # of Sample State |
| Deficiencies |
|
|
| % of Sample State |
| Facilities |
|
|
| Proper treatment to prevent |
| or treat pressure sores |
|
|
| Facility free of accident |
| hazards |
|
|
| Facility promotes care that |
| maintains/enhances dignity |
|
|
| Housekeeping and |
| maintenance |
|
|
| Provides necessary care for |
| highest practicable well- |
| being |
|
|
| Right to be free from |
| physical restraints |
|
|
| Should have policies that |
| accommodate needs |
|
|
| Drug regimen free from |
| unnecessary drugs |
|
|
| Appropriate treatment for |
| incontinence |
|
|
| “Activities of daily living” |
| care provided for dependent |
| residents |
|
|
| 1186 |
|
|
| 1164 |
|
|
| 1115 |
|
|
| 1023 |
|
|
| 972 |
|
|
| 958 |
|
|
| 787 |
|
|
| 768 |
|
|
| 750 |
|
|
| 699 |
|
|
| 16% |
|
|
| 16% |
|
|
| 16% |
|
|
| 14% |
|
|
| 14% |
|
|
| 13% |
|
|
| 11% |
|
|
| 11% |
|
|
| 10% |
|
|
| 10% |
|
|
| In its recent report entitled “California Nursing Homes: Care Problems Persist Despite |
| Federal and State Oversight” the GAO examined the quality of care in 1,370 nursing homes |
| in California. It found that 30 percent had violations that caused death or life-threatening |
| harm to residents, or had understated the frequency of poor care by falsifying records. |
| Among the problems it reports are poor nutrition, dehydration, and improper care of |
| incontinent and immobile residents which leads to pressure sores. |
|
|
| Ombudsman complaints. Ombudsman nursing home complaints have also been steadily |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 20 |
|
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| OEI-02-99-00060 |
|
|
| increasing, as illustrated in graph B below. Based on data from 1989 to 1994, total |
| complaints in the 10 sample States grew from 57,954 to 83,669, an increase of 44 percent. |
| (Due to the transition to a new data system in 1995, we do not have comparable complaint |
| rates for that year). |
|
|
| Graph B |
| At the Same Time, Ombudsman Program Complaints |
| Increased from 1989 to 1994 |
|
|
| Beginning in 1996, a new Ombudsman program reporting system was used that counted |
| complaints differently from the prior system. Data from 1996 and 1997 also show that |
| complaints increased seven percent between these two years, from 60,926 to 65,123, as |
| illustrated in Graph C below. |
|
|
| Graph C |
| Ombudsman Program Complaints Also Increased from 1996 to 1997 |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 21 |
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| OEI-02-99-00060 |
|
|
| Ombudsman complaints about resident care have been particulary prevalent. Of the five |
| main Ombudsman program complaint categories, the resident care category increased the |
| most from 1996 to 1997, growing by 13 percent. This category includes specific |
| complaints about personal care (such as pressure sores and hygiene), lack of rehabilitation, |
| and the inappropriate use of restraints. On a more specific level, 12 complaints had |
| increases of 24 percent or more from 1996 to 1997. Two of these -- staff turnover and lack |
| of staff training -- may indicate other problems with resident care. |
|
|
| In 1997, the majority of all Ombudsman program complaints (63 percent) fell into 2 of 5 |
| categories -- resident care (32 percent) and residents’ rights (31 percent). The top 10 |
| complaints for that year include 3 related to inadequate nursing home staffing, as well as |
| specific complaints about poor quality of care, such as poor hygiene, physical abuse, and |
| improper handling and accidents. |
|
|
| Resident abuse complaints. Data obtained from nursing home abuse complaint |
| coordinators in the 10 sample States lack common definitions and are therefore inconsistent. |
| Furthermore, these complaints are not always substantiated. Among the 10 States, there |
| are no obvious trends in reported complaints; some States have upward trends and others |
| downward trends. Nevertheless, approximately one percent or more of nursing home |
| residents in the 10 States have had an experience serious enough to register an abuse |
| complaint. |
|
|
| Additionally, since 1995 the OIG has excluded 668 nursing home workers from |
| participation in the Medicare or Medicaid programs as a result of a conviction related to |
| patient abuse or neglect. The excluded workers were primarily nurses and nurse aides. |
|
|
| Chronically substandard homes. Some nursing homes appear to be chronically |
| substandard. Data from OSCAR show that some are repeatedly deficient; 463 nursing |
| homes have been cited with the same deficiencies over their last past four surveys, |
| representing 6 percent of all homes in the 10 sample States. State directors and surveyors |
| also report that between 1 to 20 percent of nursing homes in their State have chronic quality |
| of care problems. Finally, three-fourths of ombudsmen say there are some homes (10 |
| percent or fewer) that routinely treat residents poorly. |
|
|
| Insiders’ perspectives. Survey and certification staff and ombudsmen express some |
| reservations about relying exclusively on program data to identify nursing home problems. |
| While generally satisfied with OSCAR data, more than half of State directors and surveyors |
| believe it is not a true indicator of nursing home quality of care since it only portrays the |
| situation of the nursing home at the time surveyors are physically conducting the survey. |
| Ombudsmen also say that higher complaint rates do not always indicate more problems, |
| pointing out that higher complaint rates could be due to a greater presence of Ombudsman |
| staff in nursing homes. |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 22 |
|
|
| OEI-02-99-00060 |
|
|
| Nevertheless, in all 10 sample States, State surveyors and survey directors, State and local |
| ombudsmen, and State Aging Unit Directors confirm that problems with care persist in |
| nursing homes. These are many of the same problems reported in program data. State |
| surveyors and survey directors say the biggest problems they see are resident abuse, failure |
| to treat incontinent patients, and improper medication distribution. Ombudsmen and State |
| Aging Unit Directors identify malnutrition and other dietary concerns, bed sores, |
| dehydration, poor hygiene, over-medication, toileting, and physical abuse as problems |
| nursing home residents face. |
|
|
| Evidence suggests inadequate levels of nursing home staff |
| contribute to quality of care problems |
|
|
| In all 10 sample States, survey and certification staff, State and local ombudsmen, and State |
| Aging Unit Directors identify inadequate staffing levels as one of the major problems with |
| nursing homes in their States. Most believe that these staffing shortages leads to chronic |
| quality of care problems, such as failure to adequately treat and prevent pressure sores. |
| They cite further concerns about the proficiency and training of nursing home staff. |
|
|
| The type and extent of survey deficiencies and Ombudsman program complaints also |
| suggest that nursing home staffing levels are inadequate. Common personal care problems |
| such as lack of nutrition and poor care for incontinence suggest that staffing is inadequate |
| to provide the level of care needed to avoid these problems. Furthermore, specific |
| complaints about nursing home staff are some of the most common types of Ombudsman |
| program complaints. The top complaint in 1997 was unanswered call lights and requests |
| for assistance, while staff attitudes and lack of respect was third and shortage of staff was |
| ninth. |
|
|
| Survey and certification agencies are following required |
| standard protocols but weaknesses in the survey system |
| itself limit their effectiveness |
|
|
| State survey and certification agencies monitor nursing home care with timely and standard |
| surveys, complaint procedures, and additional State processes. Based on OSCAR data over |
| the last 4 standard surveys, all sample States completed 97 percent of their standard surveys |
| in the mandated time frame of 9 to 15 months. Furthermore, all State survey directors and |
| surveyors report following HCFA guidelines for their surveys, including starting with an |
| entrance conference, touring the facility, interviewing residents and family members, |
| reviewing medical records, and concluding with an exit conference. They also report |
| having a complaint process to address complaints about nursing home practices. Seven |
| States have their own survey guidelines which they use in addition to HCFA guidelines, and |
| some have additional databases and information sources. |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 23 |
|
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| OEI-02-99-00060 |
|
|
| Despite following standard procedures, however, the survey and certification system has |
| several weaknesses, including the predictability of surveys. Although all States use |
| unannounced nursing home surveys, almost all directors and surveyors believe that facilities |
| can anticipate the survey start date. They say that facilities often modify their normal daily |
| procedures to reduce potential deficiencies, such as increasing staff on certain shifts. In |
| most States, surveyors also do not begin or continue standard surveys on the weekend or in |
| evening hours. State directors and surveyors therefore voice concerns about whether |
| standard surveys represent an accurate reflection of quality of care in nursing homes. |
|
|
| The survey and certification process is also limited by weak enforcement, including inaction |
| on abuse complaints. From January 1997 to July 1998, OSCAR data reports 4,707 abuse |
| complaints (involving almost one third of all nursing homes) in the 10 sample States. Two- |
| thirds of these were unsubstantiated and the remaining third were substantiated. Over 90 |
| percent of both substantiated and unsubstantiated complaints concluded with no action, |
| plans of correction, or other remedy. Furthermore, half of the State directors and three- |
| fourths of surveyors indicate that current enforcement measures are questionable. They |
| express concern that civil monetary penalties do not compel nursing homes to observe |
| Federal regulations, are insufficient to influence nursing home chains, and are not imposed |
| immediately, allowing facilities to remain non-compliant for longer periods of time. Others |
| believe that current enforcement process allows deficient facilities far too many |
| opportunities to avoid enforcement action. |
|
|
| Finally, survey and certification agencies have a number of staffing constraints. The overall |
| number of surveyors varies by State, thereby affecting the number of standard, follow-up, |
| and complaint surveys each team can conduct. For example, the number of standard |
| surveys on the 10 States ranges from 12 to 26 per year. State directors also express |
| concern about high staff turnover rates, difficulties replacing staff once they leave, and |
| limited surveyor training. They additionally report weaknesses in coordination between |
| their staff and ombudsman staff. Surveyors received 13 percent of all Ombudsman program |
| abuse complaints per month in 1997. |
|
|
| While the Ombudsman program is well designed, inadequate |
| resources limit its capacity |
|
|
| The Ombudsman program has several functions to promote and monitor quality of care in |
| nursing homes, including identifying and resolving complaints, making regular visits to |
| nursing homes, and engaging in a variety of different advocacy activities. Discussions with |
| State and local ombudsmen, as well as State Aging Unit Directors, emphasize the |
| uniqueness of this program. In contrast to other programs, ombudsmen lack enforcement |
| and regulatory oversight authorities. As independent advocates, they work solely on behalf |
| of residents and are often the only voice residents have in their own care. An ongoing, |
| routine nursing home presence is therefore essential to the ombudsman role. In fact, most |
|
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| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 24 |
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| OEI-02-99-00060 |
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|
| State ombudsmen (6 of 10) believe this presence is the most important part of their |
| program. This presence provides ombudsmen with the opportunity to develop personal and |
| confidential relationships with residents and enables them to identify and address individual |
| issues before they become larger, systemic problems. |
|
|
| Nevertheless, the overall capacity of the Ombudsman program is limited by inadequate |
| resources, including inadequate staffing. Paid staffing and volunteer levels among the 10 |
| States vary considerably, ranging from 4,618 nursing home beds per paid staff in one State |
| to 1,115 beds per paid staff in another. While no minimum staffing ratios are required by |
| law, a 1995 Institute of Medicine study on the Ombudsman program recommends a |
| standard staffing ratio of 1 paid Ombudsman staff person per 2,000 long term care facility |
| beds; only 1 in the 10 sample States, Massachusetts, meets this standard. Furthermore, a |
| majority of State and local Ombudsmen identify insufficient program staffing and an |
| inadequate number of volunteers as obstacles which detract from their program’s |
| effectiveness. |
|
|
| Inadequate program staffing is particularly evident in the limited extent to which |
| ombudsmen make regular nursing home visits. In the nine States that make such visits, |
| volunteers are generally assigned to just one nursing home and visit this home on a weekly |
| basis. However, most nursing homes in the 10 States do not have volunteers assigned to |
| them, and these homes are usually visited by paid staff just once or twice a year for no |
| longer than one to three hours. In fact, in four States there are nursing homes that are |
| never visited by volunteers or paid staff. |
|
|
| Other limitations affect the Ombudsman program’s overall capacity. Lacking a common |
| standard for complaint response and resolution, ombudsman staff in some States are not |
| consistently handling complaints in a timely manner. Ombudsman staff also devote varying |
| amounts of time to outreach and advocacy activities, with some spending relatively little |
| time on community education, work with the media, work on laws and policy, and nursing |
| home staff training. Also, half of State and local ombudsmen believe their program’s lack |
| of support in the State diminishes its capacity and limits their ability to influence nursing |
| home policies. Lastly, they believe better collaboration is needed with the survey and |
| certification agency. |
|
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| Quality of Care in Nursing Homes: An Overview |
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|
| State systems to safeguard nursing home residents from |
| abuse are inconsistent and unreliable |
|
|
| Based on findings from a recent OIG audit, “Safeguarding Long Term Care Residents,” (A- |
| 12-97-0003) it appears that some weaknesses exist in State efforts to safeguard nursing |
| home residents from abuse. This audit revealed great diversity in the way States |
| systematically identify, report, and investigate suspected abuse. While no Federal |
| requirement exists for criminal background checks of nursing home staff, 33 States do |
| mandate that such checks occur. However, the methods used to identify individuals who |
| pose a risk of abuse and the criteria followed for prohibiting employment vary widely |
| among these States. Furthermore, not all States systematically report convictions to central |
| databases, such as the certified nurses aide registry. It therefore appears that there is no |
| assurance that individuals who may pose a risk to residents are systematically identified and |
| barred from nursing home employment. |
|
|
| A more in-depth audit of Maryland also found problems with nursing home hiring practices |
| in that State. In particular, this audit found that five percent of employees in eight nursing |
| homes had criminal records. It also noted that some of these individuals were not reported |
| in the State or Federal systems used for criminal background checks, despite the fact that |
| they had been convicted of elder abuse. |
|
|
| Public awareness and access to nursing home survey results |
| is limited |
|
|
| Two-thirds of 155 families interviewed in eight sample cities did not know that the results |
| of Federal and State nursing home inspections are available on request. Half were also |
| unaware that such inspections are required. Only 15 of the 155 individuals we interviewed |
| had ever requested a copy of the survey results, and of the 11 who obtained a copy, 6 said |
| the results were not based on a recent survey conducted within the past 15 months. |
|
|
| Most of the 32 sampled nursing homes visited by staff from the Office of Inspector General |
| did not fully meet the requirements for making survey results available. In a majority of |
| these homes, the notice identifying the location of the survey results was not posted and/or |
| the survey results were in locations directly observed by staff, contrary to regulations. Staff |
| from the OIG had to ask for the survey results in 24 of the 32 homes they visited. While |
| most (27) did ultimately make the survey results available, the OIG staff had an advantage |
| over other members of the public since they were aware of what to look for and how to ask |
| for it. |
|
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| Quality of Care in Nursing Homes: An Overview |
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| 26 |
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|
| The HCFA has recently established a more easily accessible version of nursing home survey |
| results with an internet site entitled Nursing Home Compare. For families with access to |
| the internet, this is a promising development. When staff from the OIG located this site, |
| they found it easy to understand. Most of the families interviewed said it could be very |
| helpful in providing useful nursing home information. |
|
|
| New initiatives based on law enforcement approaches are |
| being considered |
|
|
| Initiatives to strengthen nursing home law enforcement are relatively new. Particularly |
| noteworthy is the formation of nursing home task forces at the local, State, and national |
| levels, comprised of representatives from the Department of Justice, HCFA, OIG, and other |
| agencies. These groups will examine and develop action plans for several enforcement |
| strategic areas and will address the full range of nursing home enforcement issues. They will |
| collaborate with Medicaid Fraud Control Units, the State Attorneys General, State survey |
| agencies, and other oversight agencies. Among the strategic areas targeted are: improving |
| the handling of civil monetary penalty referrals; reviewing patient abuse and neglect |
| legislation for model State legislation; recommending possible new legislation for |
| prosecuting abuse and neglect; reviewing current services available to abuse victims; and |
| identifying emerging quality of care and fraud problems in nursing homes. |
|
|
| By targeting key strategic areas and coordinating among the various agencies responsible |
| for nursing home enforcement, these initiatives appear promising. If successful, they should |
| strengthen enforcement of nursing home problems. However, it is too soon to determine |
| the full impact of these enforcement initiatives. Some of the task forces and action plans |
| will not be fully developed until early 1999, and at the earliest, preliminary results will not |
| be available until later in that year. |
|
|
| Nursing home reforms established by OBRA 1987 have not |
| been systematically assessed |
|
|
| The nursing home reforms created by OBRA 1987 impacted both nursing home systems |
| and nursing home care. First, these reforms essentially changed the focus from a nursing |
| home’s ability to provide care to the quality of the care actually provided. The OBRA 87 |
| requires nursing homes participating in Medicare and Medicaid to comply with extensive |
| standards. These standards include ensuring various resident rights, rights related to |
| admission, transfer and discharge, and the right to be free from restraints and abuse. The |
| OBRA 87 also requires nursing homes to promote residents’ quality of life, conduct |
| periodic resident assessments, and provide the necessary care needed for residents to |
| maintain the highest practicable physical, mental, and psychosocial well-being. Additionally, |
| OBRA 87 requires nursing homes to provide certain services, including nursing, dietary, |
| physician, rehabilitative, dental, and pharmacy services. Finally, several administrative |
|
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| Quality of Care in Nursing Homes: An Overview |
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| OEI-02-99-00060 |
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|
| standards were also established, including requirements for nurse aide training, a medical |
| director, and clinical records. |
|
|
| The OBRA 87 also changed nursing home enforcement and survey procedures. Among |
| these changes are: the development of the Resident Assessment Instrument (RAI), which is |
| a standardized assessment instrument for nursing home residents; a more outcome oriented |
| survey that emphasizes gathering information by observing and interviewing residents; and |
| new intermediate enforcement remedies that augment existing options for noncompliant |
| nursing homes. |
|
|
| While it has now been more than a decade since OBRA 1987 was first passed, there has |
| been no systematic assessment of its extensive agenda and no methodical evaluation of |
| whether or not the reforms it intended are actually working. In its 1998 Report to |
| Congress, HCFA attributes positive changes in the use and outcomes of resident assessment |
| instruments and psycho-pharmacological medications to OBRA 87. The HCFA also |
| concludes that new enforcement and survey regulations have been effective. Other studies |
| have addressed additional OBRA reforms, including OIG reports on nursing home |
| prescription drug use and resident abuse. Furthermore, data from survey and certification |
| and Ombudsman program reporting systems suggest the OBRA requirement that residents |
| be free from restraints is having some effect; deficiencies on restraints and ombudsman |
| restraint complaints have been decreasing over the past several years. Nevertheless, the |
| success of this major legislation has not yet been established. A definitive assessment of the |
| extent to which OBRA reforms have bettered conditions in nursing homes is therefore |
| needed. |
|
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| Quality of Care in Nursing Homes: An Overview |
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| 28 |
|
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| OEI-02-99-00060 |
|
|
| AN AGENDA FOR CONTINUING IMPROVEMENT IN |
| NURSING HOME CARE |
|
|
| Since OBRA 1987 was first passed, real improvements have been made in nursing home |
| care. More recently, considerable attention has been paid to addressing persisting concerns |
| about nursing home conditions and systems. In particular, we commend the Health Care |
| Financing Administration (HCFA) for its extensive nursing home initiative since it addresses |
| many of these persisting problems. This initiative includes many individual action items |
| which should result in positive changes. Additionally, the Administration on Aging (AoA) |
| has been taking steps to enhance the Ombudsman program, including improving the |
| program reporting system and conducting annual training of ombudsman staff. |
|
|
| The problems we describe in this report will require continuing attention, possibly for |
| several years. The broad outline of an effective strategy would include actions to: |
|
|
| < |
| < |
| < |
| < |
|
|
| enhance the survey and certification process; |
|
|
| strengthen the Ombudsman program with increased resources; |
|
|
| improve nursing home staffing levels; and |
|
|
| improve coordination between State survey agencies and ombudsmen. |
|
|
| We also believe that further evaluation and progress measurement would make an important |
| contribution to efforts to advance nursing home care. We specifically suggest: |
|
|
| < |
| < |
|
|
| a systematic assessment of OBRA 1987; and |
|
|
| the creation of a periodic report card on conditions in nursing homes. |
|
|
| We have incorporated action items from HCFA’s nursing home initiative, AoA’s |
| Ombudsman program activities, recommendations for additional steps to be taken, current |
| OIG work, and areas requiring further evaluation into one comprehensive, long term agenda |
| to continue improvements in nursing home care. This agenda consists of a three stage |
| approach of immediate action, research and evaluation, and continued progress |
| measurement. It is outlined below. |
|
|
| I. |
|
|
| Immediate Action |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| 29 |
|
|
| OEI-02-99-00060 |
|
|
| We believe immediate action should be taken to strengthen the capacity of systems designed |
| to oversee nursing home care. We also believe improvements should be made in nursing |
| home staffing levels, since this directly impacts on the care residents receive. |
|
|
| Survey and Certification |
|
|
| Survey enforcement efforts. Strengthen survey enforcement |
| efforts by: making surveys more timely, effective, and |
| unpredictable; increasing the number of night and weekend |
| surveys and surveys at chronically substandard homes; |
| focusing on specific problems, such as pressure sores; |
| eliminating grace periods for homes with repeat serious |
| violations; proposing new civil monetary penalties; and placing |
| survey results on the internet. |
|
|
| Addressed in |
| HCFA initiative |
|
|
| Enhanced monitoring. Enhance monitoring of special focus |
| facilities. |
|
|
| Addressed in |
| HCFA initiative. |
|
|
| Surveyor training. Provide additional training and assistance |
| to State surveyors. |
|
|
| Surveyor staffing. Evaluate State surveyor staffing to assure |
| adequate staffing is available. |
|
|
| Surveyor coordination. Provide a forum for surveyors to meet |
| and discuss common issues. |
|
|
| Abuse. Add survey task to look at provider’s abuse |
| intervention system, develop national abuse intervention |
| campaign, and promote prosecution of egregious violators. |
|
|
| Ombudsman Program |
|
|
| Visibility. Develop guidelines for minimum levels of |
| Ombudsman program visibility, including criteria for |
| frequency and length of regular visits and staffing ratios. |
|
|
| Volunteers. Formulate strategies for recruiting, training, and |
| supervising more ombudsman volunteers. |
|
|
| Partially |
| addressed in |
| HCFA initiative |
|
|
| Action under |
| consideration by |
| HCFA |
|
|
| Action under |
| consideration by |
| HCFA |
|
|
| Addressed in |
| HCFA initiative |
|
|
| Partially |
| addressed by |
| AoA through |
| annual training |
|
|
| Partially |
| addressed by |
| AoA through |
| annual training |
| and Ombudsman |
| Resource Center |
|
|
| Quality of Care in Nursing Homes: An Overview |
|
|
| ))))))))))) |
| 30 |
|
|
| OEI-02-99-00060 |
|
|
| Complaint response and resolution. Develop guidelines for |
| ombudsman complaint response and resolution times. |
|
|
| Not currently |
| addressed |
|
|
| Reporting system. Continue to refine and improve the |
| Ombudsman program’s data reporting system. |
|
|
| Continuing |
| attention by AoA |
|
|
| Coordination with Survey and Certification. Establish ways |
| to enhance coordination between survey and certification and |
| Ombudsman programs. |
|
|
| Continuously |
| addressed |
|
|
| Resident Abuse Safeguards |
|
|
| Employment safeguards. Improve the safety of residents and |
| strengthen safeguards against employment of abusive workers. |
|
|
| Addressed in |
| HCFA initiative |
|
|
| Nursing Home Staffing |
|
|
| Staffing standards. Develop staffing standards for registered |
| nurses and certified nurse assistants in nursing homes to assure |
| sufficient staff on all shifts to enable residents to have proper |
| care. |
|
|
| Currently being |
| studied by HCFA |
|
|
| Care Guidelines |
|
|
| Malnutrition and dehydration. Develop best practice |
| guidelines for malnutrition and dehydration care and national |
| campaign to increase awareness of these problems. |
|
|
| Addressed in |
| HCFA initiative |
|
|
| Drug usage. Develop guidelines and protocols for using |
| effective drugs. |
|
|
| Addressed in |
| HCFA initiative |
|
|
| Family Involvement |
|
|
| Family awareness and access. Promote and facilitate greater |
| awareness and access to survey results by strengthening |
| existing avenues for receiving information and identifying new |
| avenues. |
|
|
| Action under |
| consideration by |
| HCFA |
|
|
| II. |
|
|
| Research and Evaluation |
|
|
| We also propose the development of a research and evaluation program to assess the |
| quality of care in nursing homes, including a systematic look at each of the legislative |
| reforms established with OBRA 1987 and other quality of care issues. In the following |
| table, we indicate where the OIG is conducting or planning work. As the Office of |
| Inspector General, we have a particular interest in assuring that the standards mandated by |
| OBRA 1987 are being met. Since we do not expect to address all of the nursing home |
| requirements and issues we have identified, we invite others to join us in this evaluation. |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 31 |
|
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| OEI-02-99-00060 |
|
|
| OBRA 1987 |
|
|
| Prescription Drugs. Assess the extent and appropriateness of |
| prescription drug use by nursing home residents and describe |
| consultant pharmacists’ concerns about drug use. |
|
|
| OIG report |
| issued |
|
|
| Resident assessment. Determine the systems used by nursing |
| homes to conduct periodic resident assessments and plans of |
| care and evaluate how this impacts reimbursement. |
|
|
| OIG study |
| underway |
|
|
| Nurse aide training. Evaluate nurse aide training |
|
|
| In OIG workplan |
|
|
| Abuse reporting. Examine the extent to which States have |
| implemented abuse reporting requirements. |
|
|
| In OIG workplan |
|
|
| Medical director. Examine the role medical directors play in |
| assuring quality of care. |
|
|
| In OIG workplan |
|
|
| Resident rights. Assess the extent to which nursing homes are |
| assuring resident rights. |
|
|
| Admission rights. Assess the extent to which nursing homes |
| are assuring admission, transfer, and discharge rights. |
|
|
| Restraints and abuse. Assess whether rights to be free from |
| restraints and abuse are being met. |
|
|
| Quality of life. Assess whether or not nursing homes are |
| providing care which promotes each resident’s quality of life. |
|
|
| Resident well-being. Determine if nursing homes are |
| providing care and services to maintain the highest levels of |
| residents’ physical, mental, and psychosocial well-being. |
|
|
| Nursing home services. Determine if nursing home staffing |
| levels are adequate to provide required nursing, dietary, |
| physician, rehabilitative, dental, and pharmacy services. |
|
|
| Physical environment. Determine if nursing homes are |
| maintaining a healthy and safe physical environment. |
|
|
| Other Quality of Care |
|
|
| Resident satisfaction. Determine the level of resident |
| satisfaction with nursing home care. |
|
|
| Immunizations. Examine the obstacles to immunizing 80% of |
| nursing home residents against pneumoccocal disease and |
| influenza. |
|
|
| OIG study |
| underway |
|
|
| OIG study |
| underway |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 32 |
|
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| OEI-02-99-00060 |
|
|
| III. |
|
|
| Progress Measurement |
|
|
| Finally, an independent, continuous assessment is needed to measure the progress made in |
| raising the standard of nursing home care. |
|
|
| Periodic Assessments |
|
|
| Periodic report card. Conduct periodic evaluations describing |
| conditions in nursing homes based on deficiency trends, |
| ombudsman complaints, resident satisfaction, and insiders’ |
| perspectives. |
|
|
| Under |
| consideration by |
| OIG |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 33 |
|
|
| OEI-02-99-00060 |
|
|
| A G E N C Y C O M M E N T S |
|
|
| This report is based primarily on a series of recent studies conducted by the Office of |
| Inspector General on nursing home care. They are: |
|
|
| Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331; |
|
|
| Nursing Home Survey and Certification: Overall Capacity, OEI 02-98-00330; |
|
|
| Long Term Care Ombudsman Program: Complaints Trends, OEI-02-98-00350; |
|
|
| Long Term Care Ombudsman: Overall Capacity, OEI-02-98-00351; |
|
|
| Public Access to Nursing Home Survey and Certification Results, OEI-06-98- |
|
|
| 00280; and |
|
|
| Safeguarding Long Term Care Residents, A-12-97-0003. |
|
|
| We received detailed comments from HCFA, AoA, and the Assistant Secretary for Planning |
| and Evaluation on the above reports. We made modifications in each report to respond to |
| the comments received and to reflect the actions already being taken to improve nursing |
| home conditions. This overview report also incorporates many of these modifications. We |
| encourage everyone to read the individual reports and the comments we received on them. |
| The comments are included in each report. |
|
|
| Quality of Care in Nursing Homes: An Overview |
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| ))))))))))) |
| 34 |
|
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| OEI-02-99-00060 |
|
|
|
|
