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Enforcement of Quality Standards in Nursing Homes

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The 1987 Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, established quality standards for nursing homes nationwide and defined the state survey and certification process to enforce the standards (see PPI Fact Sheet: "The Nursing Home Reform Act of 1987").

Since 1998, however, a series of federal studies and Senate hearings has called attention to weaknesses in federal and state monitoring and enforcement activities and serious quality problems in many nursing homes.

Monitoring and Enforcement

Between 1997 and 2003, the proportion of homes with no deficiencies declined from 21.6% to 9.5% (see Chart 1), and the average number of deficiencies per home increased from 4.9 to 6.9.1 The proportion of homes cited for deficiencies that caused actual harm or immediate jeopardy to residents, however, has sharply declined, suggesting that homes are being cited for less serious deficiencies (see Chart 1).

Chart 1: Deficiency Trends, 1997-2003



Recent studies have found evidence of state surveyors understating quality problems. Between June 2000 and February 2002, federal surveyors found actual harm or higher-level deficiencies in 22% of homes where state surveyors had documented no such deficiencies.2 Moreover, in a 2003 study, the U.S. General Accountability Office found understated actual harm or higher-level deficiencies in 39% of the 76 surveys the agency reviewed. A 2003 study by the Office of the Inspector General (OIG) found that states varied widely in the average number of deficiencies cited per home and in which specific deficiency(ies) they would cite for the same problem.3

Factors contributing to the understatement of quality problems included:4

  • poor investigation and documentation of deficiencies;
  • lack of a common review process for draft survey reports;
  • inconsistency in whether the surveys had a consultative or enforcement focus (the stated functions of the survey are to ensure compliance and to provide "nonconsultative information");
  • unclear federal guidelines on which deficiencies to cite for specific problems;
  • high surveyor turnover and a large number of inexperienced surveyors; and
  • predictable timing of the surveys.

During a 2004 review of the state survey process by staff of Senator Charles Grassley, chair of the Senate Committee on Finance, surveyors frequently said that their superiors instructed them to overlook or understate deficiencies.5 Some surveyors said that they were told to rewrite survey findings to make facilities look better than they really were.

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