U.S. nursing home oversight faulted

WASHINGTON — WASHINGTON -- Federal health officials impose only minimal penalties on nursing homes repeatedly cited for mistreatment of patients, congressional investigators say in a new report.

As a result, they said, some nursing homes cycle in and out of compliance with federal standards and pose a continued threat to the health and safety of patients.


"Some of these homes repeatedly harmed residents over a six-year period and yet remain in the Medicare and Medicaid programs," said the report, to be issued this week by the Government Accountability Office, an investigative arm of Congress.

The Department of Health and Human Services "fails to hold homes with a long history of harming residents accountable for the poor care provided," the investigators said.


Congress established stringent standards for nursing homes in 1987. In 1998, the GAO reported that "homes can repeatedly harm residents without facing sanctions." Since then, the White House and the nursing home industry have announced many initiatives to improve care.

But in its new report, the accountability office says that little seems to have changed at the worst-performing homes. The Bush administration rarely uses its authority to deny payment to homes with a history of compliance problems and typically imposes fines far less than the maximum of $10,000 a day, the report said.

Sen. Charles E. Grassley, an Iowa Republican, said the conclusions of the study - an exhaustive review of progress over the last decade - were "very discouraging."

"After the tremendous reform effort of the last 10 years," Grassley said, "the federal agency that's supposed to coordinate regulatory efforts is taking an approach that is undermining the sanctions that are available to try to improve care in the most questionable nursing homes."

Grassley, who requested the study, is the senior Republican on the Finance Committee, which has authority over Medicaid and Medicare.

Members of Congress are likely to use the report as a map for legislation requiring stiffer penalties for the most serious violations. Administration officials agreed that higher fines were appropriate in some cases. They said they would ask Congress for the power to collect fines more swiftly, without waiting for all appeals to be resolved.

The nation's 16,400 nursing homes are home to about 1.5 million people, and more than 3 million people receive nursing home care at some point each year. Medicaid and Medicare pay for more than two-thirds of patients.

Federal health officials accepted many findings in the GAO report. Leslie V. Norwalk, acting administrator of the Centers for Medicare and Medicaid Services, said her agency was taking steps to strengthen enforcement.


The investigators said they had purposely focused on nursing homes with a history of compliance problems. Bruce A. Yarwood, president of the American Health Care Association, a trade group, said he believed that care at the average nursing home had improved in the past decade.

The GAO said federal health officials hesitated to impose fines of more than $200 a day, in part because they believed that larger penalties "could bankrupt some homes." Fines are generally so small that nursing homes view them as a "cost of doing business," with "no more effect than a slap on the wrist," the report said.

In the rare cases in which federal officials try to exclude a nursing home from Medicaid and Medicare, the home often avoids the penalty by making temporary improvements and then lapsing back into noncompliance, the investigators said.

Under federal policy, the government is supposed to take immediate enforcement action against nursing homes that repeatedly cause "actual harm" to patients. But the accountability office said that "immediate sanctions are often not immediate" because the administration gives homes a grace period.

As a result, "the immediate sanctions policy does not appear to deter homes from harming residents in the future," the report said, and "some homes with the worst compliance histories escape immediate sanctions."

Norwalk, the official in charge of Medicaid and Medicare, said more fines "may simply not be very effective" in dealing with the worst homes. And, she said, patients could lose access to care if their nursing homes were denied payment under Medicaid and Medicare. Deprived of such income, a nursing home might decide to close.