Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will
Require Continued Commitment (Testimony, 06/30/99, GAO/T-HEHS-99-155).

Pursuant to a congressional request, GAO discussed the Health Care
Financing Administration's (HCFA) progress in implementing its recent
initiatives to strengthen efforts to ensure the quality of care provided
by the nation's nursing homes.

GAO noted that: (1) HCFA has undertaken a wide array of changes in its
nursing home oversight that can be summarized in three key areas: (a)
strengthening the survey process to be better able to identify
violations of federal standards; (b) more strictly enforcing sanctions
for nursing homes that do not sustain compliance with these standards;
and (c) better educating consumers and nursing home administrators
regarding quality of care; (2) HCFA has provided directives to state
agencies on six initiatives, but GAO found that states have only
partially adopted these revised HCFA policies; (3) while in some cases
the states have largely implemented these directives, in other cases the
directives have not resulted in major changes in state practices because
states often indicated they already had similar practices in place,
considered the guidance as optional, or lacked the resources to
implement certain directives; (4) furthermore, some of the directives
have not had an appreciable effect on the number of homes receiving
focused reviews and stricter enforcement; (5) one of the most
controversial changes proposed related to the revised definition of
homes that would be categorized as "poorly performing" and would subject
them to immediate sanctions for deficiencies; (6) the revised
definition, which HCFA plans to implement later this year, would include
homes that have had deficiencies on consecutive surveys involving actual
harm to at least one resident--a "G" level deficiency in HCFA's scope
and severity lexicon--which previously had not been subject to immediate
sanctions; (7) GAO's review of a random sample of over 100 homes that
received at least G-level deficiency found that in virtually all cases
the home has a deficiency that represented a serious problem in the
nursing home's care that resulted in documented actual harm to at least
one resident; (8) these deficiencies most typically included failure to
prevent pressure sores, failure to prevent accidents, failure to ensure
adequate nutrition, and leaving dependent residents lying for hours in
their bodily wastes; (9) HCFA will soon start providing quality
indicator information on homes to surveyors to consider when selecting
sample cases; (10) but implementation of a more rigorous sampling
methodology that will better permit identifying a problem's prevalence
will not take place until mid-2000; and (11) furthermore, while much of
HCFA's enforcement and oversight efforts depend on complete, accurate,
and timely data, GAO's previous reports highlighted many flaws with its
survey and certification management information system.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-99-155
     TITLE:  Nursing Homes: HCFA Initiatives to Improve Care Are Under
	     Way but Will Require Continued Commitment
      DATE:  06/30/99
   SUBJECT:  Elder care
	     Nursing homes
	     Surveys
	     Sanctions
	     Patient care services
	     Safety standards
	     Negligence
	     Federal/state relations
	     Elderly persons
	     Noncompliance
IDENTIFIER:  Medicare Program
	     Medicaid Program

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Cover
================================================================ COVER

Before the Special Committee on Aging, U.S.  Senate

For Release on Delivery
Expected at 10:00 a.m.
Wednesday, June 30, 1999

NURSING HOMES - HCFA INITIATIVES
TO IMPROVE CARE ARE UNDER WAY BUT
WILL REQUIRE CONTINUED COMMITMENT

Statement of William J.  Scanlon, Director
Health Financing and Public Health Issues
Health, Education, and Human Services Division

GAO/T-HEHS-99-155

GAO/HEHS-99-155T

(101783)

Abbreviations
=============================================================== ABBREV

NURSING HOMES:  HCFA INITIATIVES
TO IMPROVE CARE ARE UNDER WAY BUT
WILL REQUIRE CONTINUED COMMITMENT
============================================================ Chapter 0

Mr.  Chairman and Members of the Committee: 

I am pleased to be here today to discuss the Health Care Financing
Administration's (HCFA) progress in implementing its recent
initiatives to strengthen efforts to ensure the quality of care
provided by the nation's nursing homes.  The nearly 1.6 million
Americans who rely on the nation's nursing homes for their care are
among the sickest and most vulnerable populations.  They frequently
depend on extensive assistance in basic activities, such as dressing,
grooming, and using the bathroom, and many require skilled nursing or
rehabilitative care.  The federal government will pay a projected $39
billion for nursing home care in 1999 and, in partnership with the
states, plays a key role in ensuring that nursing home residents
receive quality care. 

Quality-of-care problems in the nation's nursing homes had gone
largely unnoticed until you initiated your recent inquiries,
including requesting studies from us, and began your series of
hearings and oversight.  The Committee's earlier hearings, held in
July 1998 and March 1999, called attention to major concerns
regarding poor quality of care, inadequate response to complaints
alleging serious quality concerns, and the lack of enforcement of
Medicare and Medicaid requirements in the nation's nursing homes. 

During these hearings, we released three reports that focused on
problems in California nursing homes as well as the enforcement and
complaint investigation processes nationwide, and made a series of
recommendations intended to improve HCFA's role as the principal
federal entity responsible for nursing home oversight.\1 Major
findings in the three reports include the following: 

  -- One-fourth of the more than 17,000 nursing homes nationwide had
     serious deficiencies that caused actual harm to residents or
     placed them at risk of death or serious injury;

  -- 40 percent of these homes had repeated serious deficiencies;

  -- the extent of serious care problems portrayed in federal and
     state data is likely to be understated;

  -- complaints alleging serious care problems often remain
     uninvestigated for weeks or months; and

  -- even when serious deficiencies are identified, state and federal
     enforcement policies have not been effective in ensuring that
     the deficiencies are corrected and remain corrected. 

HCFA concurred with virtually all of our recommendations and has
developed about 30 initiatives to strengthen federal standards,
oversight, and enforcement for nursing homes.  As you requested, my
remarks today will focus on HCFA's progress in implementing these
initiatives.  In particular, I will discuss

  -- the overall scope of HCFA's initiatives,

  -- early implementation experience for initiatives for which HCFA
     has already issued revised guidance to the states,

  -- the implications of a proposed expansion of the category of
     nursing homes that would face more intensive review and
     immediate sanctions for deficiencies, and

  -- initiatives that will require a longer-term commitment for HCFA
     to implement. 

In summary, HCFA has undertaken a wide array of changes in its
nursing home oversight that can be summarized in three key areas: 
(1) strengthening the survey process to be better able to identify
violations of federal standards, (2) more strictly enforcing
sanctions for nursing homes that do not sustain compliance with these
standards, and (3) better educating consumers and nursing home
administrators regarding quality of care. 

HCFA has provided directives to state agencies on six initiatives,
but we found that states have only partially adopted these revised
HCFA policies.  While in some cases the states have largely
implemented these directives, in other cases the directives have not
resulted in major changes in state practices because states often
indicated they already had similar practices in place, considered the
guidance as optional, or lacked the resources to implement certain
directives.  Furthermore, some of the directives have not had an
appreciable effect on the number of homes receiving focused reviews
and stricter enforcement. 

One of the most controversial changes proposed relates to the revised
definition of homes that would be categorized as poorly performing
and would subject them to immediate sanctions for deficiencies.  The
revised definition, which HCFA plans to implement later this year,
would include homes that have had deficiencies on consecutive surveys
involving actual harm to at least one resident--a G level
deficiency in HCFA's scope and severity lexiconwhich previously had
not been subject to immediate sanctions.  We estimate that if this
change in definition had been in effect for the 15-month period
ending April 1999, it would have significantly increased the number
of homes classified as poorly performing and thus facing stricter
enforcement from about 137, or about 1 percent, to 2,275, or 15
percent.  Some homes claim that such deficiencies are not
sufficiently severe to warrant increased scrutiny and immediate
sanctions.  Our review of a random sample of over 100 homes that
received at least one G-level deficiency found that in virtually all
cases the home had a deficiency that represented a serious problem in
the nursing home's care that resulted in documented actual harm to at
least one resident.  These deficiencies most typically included
failure to prevent pressure sores, failure to prevent accidents,
failure to ensure adequate nutrition, and leaving dependent residents
lying for hours in their bodily wastes. 

Other HCFA initiatives will require longer-term efforts to develop
and implement.  For example, HCFA has issued a contract to improve
the methodology that state surveyors use to sample residents for
intensive review during annual on-site surveys.  The improved
methodology will use a more rigorous and more targeted sampling
technique.  This will better enable surveyors to identify potential
care problems in nursing homesincluding poor nutrition, dehydration,
neglect and abuse, and pressure sores--and to determine the
prevalence of such problems when they are found.  HCFA will soon
start providing quality indicator information on homes to surveyors
to consider when selecting sample cases.  But implementation of a
more rigorous sampling methodology that will better permit
identifying a problem's prevalence will not take place until
mid-2000.  Furthermore, while much of HCFA's enforcement and
oversight efforts depend on complete, accurate, and timely data, our
previous reports highlighted many flaws with its survey and
certification management information system.  HCFA is still planning
the redesign of this system, and implementation of a fully redesigned
system for nursing homes is unlikely before 2002. 

--------------------
\1 See California Nursing Homes:  Care Problems Persist Despite
Federal and State Oversight (GAO/HEHS-98-202, July 27, 1998); Nursing
Homes:  Additional Steps Needed to Strengthen Enforcement of Federal
Quality Standards (GAO/HEHS-99-46, Mar.  18, 1999); and Nursing
Homes:  Complaint Investigation Processes Often Inadequate to Protect
Residents (GAO/HEHS-99-80, Mar.  22, 1999). 

   BACKGROUND
---------------------------------------------------------- Chapter 0:1

On the basis of statutory requirements, HCFA, within the Department
of Health and Human Services, defines standards that nursing homes
must meet to participate in the Medicare and Medicaid programs and
contracts with states to certify that homes meet these standards
through annual inspections and complaint investigations.  The annual
survey, which must be conducted no less than once every 15 months at
each home, entails a team of state surveyors spending several days on
site conducting a broad review to determine whether care and services
meet the assessed needs of the residents.  HCFA establishes specific
protocols for state surveyors to use in conducting these
comprehensive reviews.  In addition, when a complaint is filed
against a home by a resident, his or her family or friends, the
concerned public, or nursing home employees, a complaint
investigation may be conducted that involves a targeted review of the
specific complaint. 

HCFA classifies nursing home deficiencies by their scopethe number
of residents potentially or actually affectedand severitythe
potential for more than minimal harm; actual harm; or serious injury,
death, or its potential (immediate jeopardy).  Deficiencies are
classified in one of 12 categories labeled A through L. The most
serious category (L) is for a widespread deficiency that causes death
or serious injury or creates the potential for death or serious
injury to residents; the least serious category (A) is for an
isolated deficiency that poses no actual harm and has potential only
for minimum harm.  (See table 1.) Homes with deficiencies that do not
exceed the C level are considered in substantial compliance, and as
such are deemed to be providing an acceptable level of care. 

                                          Table 1
                          
                             HCFA's Scope and Severity Grid for
                              Medicare and Medicaid Compliance
                                        Deficiencies

      Scope                                       Sanction\a
------------------  ----------------------------------------------------------------------
Severity category   Isolated      Pattern       Widespread    Required       Optional
------------------  ------------  ------------  ------------  -------------  -------------
Actual or           J             K             L             Group 3        Group 1 or 2
potential for
death/serious
injury\b

Other actual harm   G             H             I             Group 2        Group 1\c

Potential for more  D             E             F             Group 1 for    Group 2 for
than minimal harm                                             categories D   categories D
                                                              and E; group   and E; group
                                                              2 for          1 for
                                                              category F     category F

Potential for       A             B             C             None           None
minimal harm
(substantial
compliance)
------------------------------------------------------------------------------------------
\a Group 1 sanctions are a directed plan of correction, directed
in-service training, and/or state monitoring.  Group 2 sanctions are
denial of payment for new admissions or all individuals and/or civil
monetary penalties of $50 to $3,000 per day of noncompliance.  Group
3 sanctions are the appointment of a temporary manager, termination
from the Medicare and Medicaid programs, and/or civil monetary
penalties of $3,050 to $10,000 per day of noncompliance. 

\b This category is referred to in regulations as immediate
jeopardy.

\c Sanctions for this category also include the option for a
temporary manager. 

The federal government has the authority to impose a variety of
sanctions if homes are found to have a deficiency, including fines,
denying Medicare or Medicaid payment for new or all residents, or
ultimately terminating the home from participation in Medicare and
Medicaid.  The scope and severity of a deficiency determine the types
of applicable sanctions and whether they are required or optional. 
Under their shared contractual responsibility for Medicare-certified
nursing homes, state agencies identify and categorize deficiencies
and make referrals with proposed sanctions to HCFA.  Under HCFA's
current policies, most homes are given a grace period, usually 30 to
60 days, to correct deficiencies.  States do not refer homes to HCFA
for sanctions unless the homes fail to correct their deficiencies
within the grace period.  Exceptions are provided for homes with
deficiencies at the highest level of severity (J, K, or L) and for
homes that meet HCFA's definition of a poorly performing facilitya
special category of homes with repeat serious deficiencies.  HCFA
policies call for states to refer these homes immediately for
sanction.  HCFA also provides a notice period of 15 days before a
sanction takes effect, and if homes come into compliance during this
time, the sanction is waived.\2

--------------------
\2 Only civil monetary penalties can be assessed retroactively even
if a home corrects the problem.  For homes found to have a deficiency
at the highest severity level (J, K, or L), HCFA may put a sanction
into effect after a 2-day notice period. 

   HCFA HAS UNDERTAKEN A BROAD
   ARRAY OF INITIATIVES IN
   RESPONSE TO IDENTIFIED CONCERNS
---------------------------------------------------------- Chapter 0:2

HCFA has undertaken about 30 initiatives intended to improve nursing
home oversight and enforcement and has provided monthly status
reports to this Committee since last year.  HCFA's efforts over the
past year can be categorized in three broad categories: 

  -- Improved survey processes intended to result in better detection
     of noncompliance with federal requirements.  HCFA has already
     provided revised guidance to states in some survey process
     areas, such as requiring them to respond more rapidly to
     complaints alleging harm to residents and requiring states to
     begin some of their inspections on weekends or after normal
     working hours.  Over the longer term, HCFA is changing the
     standard inspection process to focus the sample of residents
     selected for review on problem areas identified using
     patient-specific data reported by the nursing home.  However,
     this major change will require time to design the new sampling
     methodology and train state surveyors in it. 

  -- Stricter enforcement aimed at ensuring that nursing homes
     maintain compliance with federal requirements.  HCFA's
     initiatives include requiring states to conduct more revisits
     to better ensure that homes correct serious deficiencies found
     in a prior survey and targeting a limited number of nursing
     homes with particularly poor compliance records for more
     frequent inspections.  In addition, HCFA has proposed broadening
     the category of homes that are defined as poor performers and
     thereby not granted a grace period to correct their
     deficiencies.  HCFA has also recently begun expanding the use of
     civil monetary penalties to apply penalties on a per-instance
     basis in addition to per day.  It is also reevaluating policies
     relating to terminated homes.  This includes developing
     standards (1) ensuring that federal payments are made to
     terminated homes only if they are actively transferring
     residents to other settings, (2) providing guidance on the
     appropriate length of a reasonable assurance period in which a
     home demonstrates it has eliminated deficiencies before the home
     is allowed to reenter the Medicare program, and (3) ensuring
     that a home's pre-termination compliance history is considered
     in any subsequent enforcement actions after it has been
     readmitted. 

  -- Better information to track homes' compliance status and assess
     quality of care as well as to educate consumers and nursing home
     administrators.  HCFA has begun posting the results of recent
     surveys for each nursing home in the nation on the Internet to
     enable consumers searching for a nursing home to better
     distinguish among homes on the basis of quality.  In addition,
     HCFA has initiated educational programs for nursing home
     administrators to better enable them to meet federal
     requirements.  Examples include developing and posting on the
     Internet best practice guidelines for caring for residents at
     risk for weight loss and dehydration and engaging in national
     efforts promoting awareness on prevention abuse, such as
     developing educational posters and other materials.  Finally,
     HCFA has embarked on a major redesign of its survey and
     certification management information systems.  This will include
     a redesign of its management information systemthe On-Line
     Survey, Certification, and Reporting (OSCAR) system--and
     development of a system to track chain ownership of providers,
     including nursing homes.  These projects are just beginning and
     will require several years to complete. 

See table I.1 for a complete list of HCFA initiatives and their
status. 

   STATES HAVE PARTIALLY ADOPTED
   REVISED HCFA GUIDANCE
---------------------------------------------------------- Chapter 0:3

Over the past year, HCFA has issued revised directives and guidance
to the states implementing several of the survey improvement and
enforcement initiatives.  In order to determine states' responses to
these initiatives and HCFA's monitoring of their implementation, we
requested information from each of the 10 HCFA regional offices and
the largest state in each region.\3 Some states have revised their
practices in response to several of the initiatives.  Other states
reported that the new HCFA guidance has not resulted in changed
practices because they believed existing state practices accomplished
similar goals or they chose not to implement the HCFA policy.  States
also highlighted some concerns or operational difficulties, including
resource constraints, associated with specific initiatives.  To date,
HCFA has conducted only limited monitoring of states' implementation
of these initiatives. 

--------------------
\3 The states we contacted were the largest in each HCFA region as
measured by the number of certified nursing home beds:  California,
Colorado, Florida, Illinois, Massachusetts, Missouri, New York,
Pennsylvania, Texas, and Washington.  These states represent 46
percent of all certified nursing home beds nationwide. 

      SEVERAL INITIATIVES REQUIRE
      STATES TO SIGNIFICANTLY
      INCREASE SURVEY ACTIVITY
-------------------------------------------------------- Chapter 0:3.1

Three of the initiatives that HCFA instructed the states to implement
can require a significant increase or modification in states' nursing
home survey activity.  For each initiative, some of the 10 states we
polled indicated that their existing practices were similar to the
change required by HCFA and thus they implemented no new practices. 
States that did not have similar existing practices often cited that
resources were a significant barrier to compliance. 

         REVISITS FOR SERIOUS
         DEFICIENCIES
------------------------------------------------------ Chapter 0:3.1.1

In July 1998, we reported that states often accepted homes'
self-reports that they had corrected serious deficiencies without
performing an independent, on-site follow-up.  In some cases, we
found that these deficiencies had not been corrected despite the
home's self-report.  We recommended that, for homes with recurring
serious violations, HCFA require state surveyors to substantiate by
an on-site review that the home has achieved compliance.  In
response, HCFA issued a policy letter in August 1998 directing state
agencies to perform revisits for all deficiencies where harm to one
or more residents was found until the state was assured that the
deficiencies were fully corrected.\4

More than half of the states we contacted informed us that prior to
the new HCFA policy they had been verifying that homes corrected
serious deficiencies through a revisit.  Additionally, Florida,
Massachusetts, and Texas indicated that they had implemented this new
policy, and California indicated that it had partially done so. 
California and Massachusetts reported that this change has led to a
sharp increase in the number of revisits they conduct and requires
additional resources.  As a result, their ability to timely meet
requirements for other types of surveys, such as complaint
investigations and annual surveys, may be restricted. 

--------------------
\4 Under earlier practice, if at the first revisit the state agency
found that the deficiency, while not fully corrected, continued at a
severity level of less than actual harm to a resident, it could
accept the nursing home's written assertion that it had corrected all
identified problems as evidence of correction without performing
another state on-site revisit. 

         COMPLAINTS ALLEGING
         ACTUAL HARM TO RESIDENTS
------------------------------------------------------ Chapter 0:3.1.2

In response to our March 22, 1999, report finding that states often
did not investigate serious complaints for weeks or months, HCFA
issued a policy letter in March 1999 instructing states to
investigate any complaint alleging actual harm within 10 workdays. 
We found that many states expressed concern that they would need
substantial additional resources to implement it.  Of the 10 states
we contacted, 4 reported that they were meeting this requirement. 
For example, in response to a state auditor's report, Pennsylvania
had begun investigating all complaints within 2 calendar days.  Three
other states, California, Illinois, and Washington, also had state
requirements that serious complaints be investigated within 10
workdays (7 calendar days for Illinois), but California and
Washington acknowledged that they were not fully able to investigate
all complaints within this time frame without additional resources. 
Washington, for example, estimated that it would require nine
additional surveyors to meet the 10-workday requirement in all
cases.\5 The remaining three statesColorado, Massachusetts, and
Missouriindicated that they had not implemented the more stringent
10-day investigation requirement for complaints alleging actual harm
situations, generally indicating that they were awaiting
clarification on this policy from HCFA before implementing it.  HCFA
continues to develop additional guidance for states regarding which
complaints should appropriately be considered as alleging actual harm
and thereby be investigated within 10 workdays. 

--------------------
\5 In our March 22, 1999, report, we found that Washington
categorized over 80 percent of its complaints in the priority level
requiring an investigation within 10 days, but the state met this
time frame for only about half of such complaints. 

         EVENING AND WEEKEND
         SURVEYS
------------------------------------------------------ Chapter 0:3.1.3

We previously reported that annual surveys are often predictable,
allowing nursing homes to prepare for surveys in ways that did not
represent the normal course of business or care, and we recommended
that HCFA require the states to stagger the starting months of
surveys in a way that reduces their predictability.  Although HCFA
disagreed that surveys are predictable and has not directly acted on
this recommendation, it issued instructions effective in January 1999
requiring that 10 percent of annual surveys be started on weekends or
outside normal working hours.  Because homes are often staffed
differently and exhibit different care environments on weekends,
evenings, and nights, this initiative is intended to allow state
surveyors a better opportunity to identify the actual operating
conditions of homes.  Eight of the 10 states we contacted indicated
that they had fully implemented this new policy.  One state noted
that it had previously conducted surveys during evening and weekend
hours but had not necessarily started the surveys at these times as
required by the new HCFA guidance.  However, several states also
indicated that conducting more surveys during these hours has posed
labor issues, including increased overtime pay, and may make it more
difficult to recruit or retain surveyors. 

Of the two states that had not fully implemented the revised HCFA
policy, Texas indicated that existing state policy requires that 20
percent of inspections be done during off hours but that this
included complaint investigations and permitted a less stringent
definition of off hours than HCFA's requirement.  Pennsylvania had
not implemented this HCFA policy, but commented that its aggressive
complaint investigation policy has resulted in increased surveillance
of nursing homes on weekends, evenings, and holidays. 

      RECENT INITIATIVES TARGETING
      POORLY PERFORMING HOMES HAVE
      FOCUSED ON FEW ADDITIONAL
      HOMES
-------------------------------------------------------- Chapter 0:3.2

Three HCFA initiatives were intended to enhance monitoring of, and
impose more immediate sanctions on, homes with records of poor
performance.  However, to date, these initiatives have not
significantly increased the number of homes receiving closer
scrutiny.  The impact of these initiatives has been limited because
the first was designed to target only a small number of homes; the
second, partially implemented initiative has not yet significantly
changed the number of homes considered poorly performing; and the
third was optional, and most states chose not to implement it. 

         SPECIAL-FOCUS FACILITIES
------------------------------------------------------ Chapter 0:3.2.1

In January 1999, HCFA implemented its program for enhanced monitoring
of 100 special-focus nursing homestwo per statewith records of
poor care.  HCFA identified four homes in each state with
persistently poor compliance records, and each state agency was
expected to select two of these homes for enhanced monitoring,
including conducting standard surveys every 6 months rather than
annually.  Although worthwhile, the very narrow scope of this
initiative excluded many homes providing poor care. 

All 10 states we contacted indicated that they had begun enhanced
monitoring of the special-focus facilities in their state.  Several
indicated that the additional resources required to focus on two
homes were minimal.  However, some states questioned HCFA's selection
criteria and indicated that they would have identified homes other
than those identified by HCFA as more appropriately warranting
increased scrutiny.  Some also suggested that HCFA should develop
clear criteria as to when a home should no longer be considered a
special-focus facility and replaced by another selected for focused
monitoring.  Also, a HCFA regional office questioned the
appropriateness of having an equal number of homes per state,
regardless of a state's total number of nursing homes.  For example,
Washington, with 284 homes, is focusing on the same number of homes
as Alaska, which has 15 homes.  Two states noted that they had begun
increased monitoring of a larger number of homes:  Illinois intends
to include all 4 HCFA-suggested homes in its enhanced monitoring
efforts, and California indicated that it had identified 34 nursing
homes for increased survey activity. 

         REDEFINITION OF POORLY
         PERFORMING HOMES
------------------------------------------------------ Chapter 0:3.2.2

In July 1998, we recommended that, for homes cited for repeated
serious violations, HCFA eliminate the grace period in which homes
were allowed to correct deficiencies without a sanction being
imposed.  In September 1998, HCFA modified its former policy
accordingly by expanding its definition of a poorly performing
facility to include those with recurring actual harm deficiencies. 
However, HCFA initially included only recurring actual harm
deficiencies that involved a pattern or were widespread in scope
(H-level or higher).  HCFA postponed including homes with isolated
actual harm deficiencies (G-level) in two consecutive surveys when it
recognized that the number of homes designated as poor performers and
the associated costs to states of dealing with them would increase
significantly.  Thus, HCFA currently considers any home a poorly
performing facility if it had been cited with a deficiency for a
pattern of actual harm to several residents (H-level) or worse in two
consecutive annual surveys or any intervening revisit or complaint
investigation.  Nursing homes given this designation are
automatically denied an opportunity to correct deficiencies before
sanctions are applied and are referred immediately to HCFA for
sanction.\6

Eight of the 10 states we contacted said that they had implemented
the policy including recurring H-level and higher deficiencies.  Most
of these states indicated that the revision has not significantly
changed the number of nursing homes designated as poorly performing. 
Our analysis of HCFA data nationwide also indicated that the new
definition, if it had been in effect for the 15-month period prior to
April 1999, would have actually reduced slightly the number of homes
meeting the definition of poor performers from about 146 homes to 137
homes (about 1 percent of homes).\7 Of the two states that had not
implemented the interim HCFA guidance, California reiterated that it
has implemented its own focused enforcement program for 34 homes with
a poor compliance history, and New York, while it is not complying
with this requirement, said that it is using the new HCFA criteria to
impose state fines. 

--------------------
\6 When states find serious violations of federal standards in a
Medicare-certified nursing home, they must refer the home to HCFA for
imposition of a sanction. 

\7 The previous definition of a poorly performing facility required
that a home be cited on its current standard survey for substandard
quality of care and cited in one of its two previous standard surveys
for substandard quality of care or immediate jeopardy violations. 
Violations are classified as substandard quality of care if (1) the
deficiencies are in one of three requirement categoriesquality of
care, quality of life, or resident behavior and facility practices;
and (2) their scope is widespread and they have a potential for
harming residents (F-level), or they have harmed more than a limited
number of residents or put the health and safety of one or more
residents in immediate jeopardy (H-level or higher). 

         POORLY PERFORMING CHAINS
------------------------------------------------------ Chapter 0:3.2.3

Also in September 1998, HCFA issued interim guidance to states
allowing but not requiring them to immediately refer chain-owned
homes with actual harm deficiencies for sanctions if any of the
chain's homes had poor performance records.  Of the 10 states we
contacted, only Pennsylvania indicated that it had implemented this
guidance, and Massachusetts and Florida said that they had
partially implemented it because they were already taking some
action against problem nursing home chains.  However, none of the
three states had referred any homes to HCFA for sanctions because
they belonged to poorly performing chains.  Some states, such as
California and Florida, indicated that they are using other
approaches, such as denying state licensure, to limit chains with
poor compliance records from expanding in their states.  The other
states indicated that they chose not to implement this guidance or
found HCFA's guidance to be unclear and were awaiting further
clarification of HCFA's policy.  Some were concerned that referrals
to HCFA that are based partially on the performance of other homes,
even with common ownership, are unfair or that the practice could
lead to increased informal dispute resolution\8 requests by homes. 

One significant barrier to implementing this initiative is that HCFA
is unable to reliably identify homes that belong to nursing home
chains and does not keep statistics on nursing home enforcement
actions according to ownership.  HCFA estimates that ownership
information will not be consistently and completely tracked for
several years. 

--------------------
\8 Nursing homes that disagree with surveyor-identified deficiencies
have one informal opportunity to dispute the citations when they
receive the official deficiency report.  This process, called
informal dispute resolution, involves the nursing home and the state
and may be used to refute the deficiency.  Nursing homes may appeal
to the Department of Health and Human Services' Departmental Appeals
Board any sanctions imposed as a result of deficiencies identified by
the state agency. 

      HCFA DOES NOT CONSISTENTLY
      MONITOR STATE IMPLEMENTATION
      OF ITS NEW POLICIES
-------------------------------------------------------- Chapter 0:3.3

HCFA's 10 regional offices are charged with monitoring state
implementation of its policies and directives related to enforcement
of federal nursing home requirements.  When we asked the regional
offices how they were monitoring states' implementation of these
initiatives, their responses ranged from no monitoring of most of the
implemented initiatives to requiring states to submit special
reports.  For example, the Dallas regional office stated that it does
not routinely monitor state implementation of any of these HCFA
initiatives.  The Denver regional office said that it was monitoring
most of these initiatives through the normal course of business.  In
contrast, the Boston regional office said that it was requiring
states in its region to submit monthly reports on how they were
implementing several of these initiatives. 

Because of these uneven monitoring practices, HCFA is not well
informed on what the states are doing with regard to these
initiatives.  For example, all regions reported to the HCFA central
office that the states in their region had implemented instructions
to reduce the predictability of surveys.  However, as noted, of the
10 states we contacted, one indicated that it had not implemented,
and another said that it had partially implemented, this policy. 
Furthermore, a HCFA central office official told us that, although
the regional offices had reported that all states had implemented
this policy, the board of the Association of Health Facility Survey
Agencies, representing the state survey agencies, had told HCFA that
12 states had not done so.  A HCFA official acknowledged that no
action has been taken regarding states that have not complied with
HCFA's initiatives. 

   PROPOSED EXPANSION OF "POOR
   PERFORMER" CATEGORY IS
   CONTROVERSIAL BUT HAS MERIT
---------------------------------------------------------- Chapter 0:4

HCFA's proposed expansion of the definition of a poorly performing
facility to include homes with G-level deficiencies in two
consecutive annual surveys or an intervening survey would greatly
increase the number of poorly performing homes that are immediately
referred to HCFA for sanction without a grace period to correct
deficiencies.  If this revised definition had been in effect for the
15-month period ending April 1999, we estimate that nearly 15 percent
of all homes nationwide, or 2,275 homes, would have been subject to
immediate sanction, compared with about 1 percent under the current
definition.  Industry representatives contend that the proposed
definition would inappropriately penalize homes, because G-level
deficiencies are often less serious problems not involving harm to
residents.  However, on the basis of our review of the G-level
deficiencies in over 100 surveys of randomly selected homes with such
deficiencies, we found that the vast majority appropriately
documented actual harm to at least one resident.\9

Of the 107 surveys with G-level deficiencies that we reviewed, 98
percent (all but 2 surveys) involved care or lack of care that harmed
residents.\10 Most commonly, these deficiencies related to failure to
prevent pressure sores (23 percent); accidents that resulted in
fractures, abrasions, or other injury (14 percent); poor nutrition (8
percent); abuse (4 percent); or other quality-of-care concerns (6
percent).  Quality-of-life deficiencies, such as failing to protect
resident dignity and rights to self-determination, were found to have
harmed residents in about 4 percent of these deficiencies.  Of the
107 homes with G-level deficiencies we reviewed, about two-thirds
would have been categorized as a poorly performing facility if the
proposed redefinition had been in effect in 1998. 

Some states are concerned that the broader definition could result in
increased enforcement activity, and more actual harm deficiencies
being contested through the informal dispute resolution process and
subsequent sanctions being appealed to the Department of Health and
Human Services' Departmental Appeals Board.  However, our analysis
suggests that almost all G-level deficiencies in fact involve
documented harm to residents, justifying increased enforcement
activity for homes with a history of them.  For those few cases where
harm to the resident is uncertain, mechanisms exist for homes to
request reconsideration of the initial surveyor's deficiency
citations. 

--------------------
\9 We analyzed a sample of 107 annual and complaint surveys with
G-level deficiencies using HCFA's OSCAR data.  These surveys were
randomly chosen from surveys with G-level deficiencies performed in
10 states during fiscal year 1998.  The states were the largest state
in each of the 10 HCFA regions, as measured by the number of
certified nursing home beds--California, Colorado, Florida, Illinois,
Massachusetts, Missouri, New York, Pennsylvania, Texas, and
Washington.  We requested copies of the survey reports from the state
survey agencies and abstracted each of the 201 G-level deficiencies
in these surveys.  For more detail, see Nursing Homes:  Proposal to
Enhance Oversight of Poorly Performing Homes Has Merit
(GAO/HEHS-99-157, June 30, 1999). 

\10 Another eight surveys with G-level deficiencies had a deficiency
that did not clearly document harm, but other G- or higher-level
deficiencies on the same survey resulted in harm to residents. 

   SEVERAL KEY INITIATIVES WILL
   REQUIRE HCFA'S LONG-TERM
   COMMITMENT
---------------------------------------------------------- Chapter 0:5

Several HCFA initiatives will require a longer-term commitment to
fully implement than those just discussed.  These initiatives involve
major changes to HCFA's nursing home survey process to enhance its
ability to detect and estimate the prevalence of serious
quality-related deficiencies and the enhancement of HCFA's management
information system to enable better tracking of homes' compliance
histories.  While these reforms are critical for improving the
effectiveness of HCFA's oversight and setting accurate baseline
measures of nursing home quality, their complexity means that these
initiatives will not be implemented until next year or several years
thereafter. 

      REDESIGN OF SURVEY PROCESS
      ENTAILS SEVERAL COMPONENTS
-------------------------------------------------------- Chapter 0:5.1

HCFA has begun a major redesign of its nursing home survey process. 
A considerable portion of a nursing home's survey has involved
selecting a sample of residents for focused review of their quality
of care.  This review may include examination of medical records,
physical observation, and, where possible, resident interviews.  In
an earlier report to this Committee, we found that HCFA's surveys
included too few residents not randomly selected, thereby precluding
surveyors from determining the prevalence of identified problems. 
The inability to estimate prevalence makes it difficult for surveyors
and state agencies to determine where a cited deficiency should fall
in HCFA's nursing home deficiency scope and severity grid, which in
turn determines whether a nursing home is offered an opportunity to
correct before sanctions are applied and the level of sanctions.  We
recommended that HCFA revise its survey procedures to instruct
inspectors to take stratified random samples of resident cases and
review sufficient numbers to permit surveyors to better detect
problems and assess their prevalence.\11

In response to our recommendation, HCFA has begun modifying the
sampling methodology of its nursing home survey protocol.  This
change has two parts.  First, effective July 1, HCFA will provide
surveyors with quality indicators that include comparative
information on areas such as nutrition, hydration, and pressure
sores.  It will also increase the sample size in areas of particular
concern, including nutrition, dehydration, and pressure sores. 
However, the sample will continue to be nonrandom and in large part
based on the judgment of the surveyors. 

The second stage of this change will introduce a more rigorous
sampling methodology, incorporating the quality indicators and other
data derived from medical records in a two-stage sampling process
designed to identify areas in which the nursing home departs
significantly from the average of other homes.  The methodology will
target these areas for focused sampling and permit surveyors to make
a reliable estimate of the prevalence of quality-of-care problems
identified in the nursing home.  This second stage is to be
implemented during 2000.  We believe that implementation of this
stage is necessary for HCFA to fully respond to our recommendation
and significantly improve the ability of surveys to effectively
identify the existence and extent of deficiencies. 

--------------------
\11 GAO/HEHS-98-202, July 27, 1998, pp.  20, 30. 

      REDESIGN OF HCFA'S
      MANAGEMENT INFORMATION
      SYSTEM WILL REQUIRE 3 YEARS
-------------------------------------------------------- Chapter 0:5.2

In a recent report, we recommended that HCFA develop an improved
management information system, which would help it track the status
and history of deficiencies, integrate the results of complaint
investigations, and monitor enforcement actions.\12 In response to
this recommendation, HCFA embarked on a 3-year project to redesign
its on-line management information system, the OSCAR system.  This
project is in its preliminary phase, with a contractor gathering
broad requirements for what the system will be required to do as a
first step in creating a system design.  Initially, this new system
will be brought on-line for a single provider typehome health
agenciesand subsequently expanded to other providers, with nursing
homes projected to come on-line in 2001.  HCFA then intends to link
this redesigned system with other HCFA quality-related databases,
such as the Minimum Data Set for nursing homes, by the end of January
2002.\13

The Minimum Data Set is potentially a key source of information for
tracking changes in quality of care.  However, these data have some
limitations, particularly in the short term.  Because the reporting
of these data has begun only recently, reporting is not consistent,
and most states lack a baseline for comparison.  Also, these data are
self-reported by nursing homes and are used to adjust Medicare
payments for level of care as well as serve as the basis for the
quality indicators now being incorporated into the nursing home
inspection process.  These multiple uses create a complex set of
reporting incentives for nursing homes, which suggests that unaudited
information from the Minimum Data Set should be treated with caution
as a data source for tracking quality changes.  Our earlier work
indicated that nursing homes' medical records often inaccurately
portray patient quality of care, suggesting that the Minimum Data Set
information also may not accurately reflect quality issues. 

In addition, HCFA plans to develop a database that will track nursing
home ownership to permit better identification of chains.  However, a
HCFA official told us that HCFA cannot even begin to design this
system until it develops the congressionally mandated national
provider ID system, which will give each Medicare-certified provider
a distinct tracking number.  Implementation of an ownership tracking
system is thus several years away. 

--------------------
\12 GAO/HEHS-99-46, Mar.  18, 1999. 

\13 The Minimum Data Set includes standardized information on a
patient's medical and psychological status at a point in time that
HCFA requires Medicare-certified providers, including nursing homes,
to report.  HCFA intends to use this information for adjusting
reimbursement to Medicare providers as well as developing indicators
of quality of care. 

   CONCLUDING OBSERVATIONS
---------------------------------------------------------- Chapter 0:6

During the last year, increased congressional and administration
attention to the inadequate care provided for many nursing home
residents has resulted in significant efforts to improve conditions. 
Some HCFA initiatives have already been implemented, such as
providing consumers with nursing home compliance information on the
Internet, increasing the number of state surveys beginning on
evenings and weekends, and allowing civil monetary penalties to be
imposed for each instance of a violation.  However, many other
efforts are still in process and will require HCFA's further effort
and commitment to complete.  Also, since HCFA must depend on the
states to implement many of these efforts, it will need to monitor
state implementation to ensure that implementation is consistent and
in line with HCFA's intentions.  HCFA must further rely on the
partnership between states and HCFA's regional offices to effectively
implement its initiatives and monitor progress.  But, at present,
this is complicated by inconsistencies in the monitoring practices of
the regional offices.  At your request, we are now examining HCFA's
regional office oversight of state agency performance in certifying
nursing homes. 

The purpose behind all these initiatives is, naturally, improvement
of the care given to nursing home residents.  Such improvements are
difficult to measure, especially in the short run.  Tracking the
results of nursing home surveys, particularly in quality of care
deficiencies such as pressure sores, nutrition, dehydration, and
abuse, can potentially provide some insights.  However, the changes
being made in the survey process are intended to result in improved
and more consistent detection of quality problems, potentially
increasing the number reported.  Thus, improvements to the survey
methodology could create a false impression that quality of care is
getting worse instead of better, because HCFA and the states will be
better able to identify and document deficiencies.  Nonetheless,
these initiatives are important steps toward improving the quality of
care America's nursing home residents receive.  If well implemented,
the initiatives should improve the effectiveness of the survey
process, strengthen the enforcement process, enhance HCFA's
management information systems, and provide better information to
consumers and nursing home administrators.  While in the short run it
may be difficult to assess the degree to which these changes improve
care to nursing home residents, over the long run HCFA and the
Congress will be better able to monitor the care nursing home
residents receive and determine what additional improvements are
necessary.  Continued commitment and oversight are also important
elements of the endeavor to improve nursing home quality of care. 

-------------------------------------------------------- Chapter 0:6.1

Mr.  Chairman, this concludes my statement.  I will be happy to
answer any questions that you or other Members of the Committee may
have. 

   GAO CONTACTS AND
   ACKNOWLEDGMENTS
---------------------------------------------------------- Chapter 0:7

For future contacts regarding this testimony, please call me at (202)
512-7114 or John Dicken at (202) 512-7043.  Gloria Eldridge, Terry
Saiki, and Peter Schmidt also made key contributions to this
statement. 

STATUS OF HCFA'S NURSING HOME
INITIATIVES
=========================================================== Appendix I

Since July 1998, HCFA has undertaken about 30 initiatives intended to
improve nursing home oversight and quality of care.  Many of these
initiatives respond to earlier GAO reports as well as concerns
identified by HCFA and others.  These initiatives can be broadly
categorized as

  -- improving the survey process to better detect noncompliance with
     federal nursing home requirements through strengthening annual
     surveys and complaint investigations;

  -- stricter enforcement to better ensure that poorly performing
     nursing homes are identified and appropriate sanctions are
     imposed to achieve sustained compliance with federal nursing
     home requirements; and

  -- better information to track homes' compliance and assess quality
     of care as well as to educate consumers and nursing home
     administrators. 

Table I.1 summarizes each of HCFA's nursing home initiatives within
these categories and our assessment of the current status of
implementation. 

                                        Table I.1
                         
                         Current Implementation Status of HCFA's
                                 Nursing Home Initiatives

Initiative\a                       Current status
---------------------------------  ------------------------------------------------------
Improving the survey process
-----------------------------------------------------------------------------------------
Stagger or otherwise vary the      HCFA instructed states on 1/1/99 to start 10 percent
scheduling of surveys to reduce    of annual surveys on weekends or outside of normal
the predictability of surveyor     working hours. Eight of 10 states we contacted have
visits. GAO-1, HCFA-1(d)           implemented this revised policy, but some are
                                   concerned about added cost and labor issues. HCFA
                                   disagreed with our findings that annual surveys are
                                   predictable and has not acted on our recommendation
                                   that the date of the survey be varied.

Take stratified random samples of  HCFA has contracted to modify the survey process in
resident cases and review          two phases:
sufficient numbers and types of    --The first phase will incorporate quality indicators
resident cases to establish        derived from the Minimum Data Set into the survey
prevalence of problems. GAO-2      beginning 7/01/99.
                                   --The second phase will introduce a stratified random
                                   sampling methodology into the survey process in 2000.

Inspect 100 nursing homes with     HCFA has identified two special-focus homes per
poor compliance histories more     state and notified states on 1/5/99. The 10 states we
frequently without decreasing      contacted have begun surveying the two homes in their
inspection frequency for other     state every six months, but some are concerned about
homes. HCFA-1(c)                   selection criteria and how homes are removed from
                                   list.

Provide training and other         A HCFA work group is developing performance measures
assistance to states, or           to assess state agencies' performance and related
terminate funding to states with   sanctions. HCFA has developed draft manual
inadequate survey functions.       instructions on the assessment of state agency
HCFA-2(a)                          performance that are expected to be finalized 8/31/
                                   99.

Enhance HCFA review of state       HCFA implemented changes to the federal monitoring
surveys. HCFA-2(b)                 survey process 9/30/98. Of the 5 percent of state
                                   surveys that HCFA regional offices must review, the
                                   new policy requires that at least one be an
                                   independent comparative survey, with the remaining
                                   federal reviews in the form of Federal Oversight/
                                   Support Survey (FOSS). A HCFA work group continues to
                                   refine FOSS protocols and scoring of state surveyor
                                   teams' performance. A forthcoming GAO report will
                                   further assess HCFA's review of state surveys.

Provide clearer guidance to        New survey interpretive procedures have been developed
surveyors on key quality-of-       in order to identify nutrition, hydration, and
life/quality-of-care issues in     pressure sore issues within nursing homes. These new
order to assist them in            interpretive procedures are to be implemented 6/30/99
identifying nutrition, hydration,  and are part of HCFA's surveyor training course.
and pressure sore care problems
in nursing homes. HCFA-3(c)

Add survey task to assess a        Incorporated new task into survey protocols that are
home's resident abuse              to be implemented 6/30/99.
intervention system. HCFA-4(a)

Develop standards for              HCFA instructed states on 3/16/99 to investigate any
investigating allegations of       complaint alleging actual harm within 10 workdays.
actual harm. GAO-C1                HCFA is developing additional guidance further
                                   clarifying this new policy. 4 of 10 states we
                                   contacted have not implemented the 10-workday policy,
                                   and 2 other states indicated that they are not fully
                                   meeting their existing 10-workday time frame. HCFA has
                                   established a Complaint Improvement Project to develop
                                   additional standards regarding complaint
                                   investigations, and has paired this project with an
                                   ongoing staffing study.

Strengthen federal oversight of    As of 7/31/99, some complaint investigations are to be
state complaint investigations.    reviewed in HCFA's federal monitoring survey process.
GAO-C2                             HCFA will analyze the results of a survey of regional
                                   office complaint logs by 8/30/99 and assess what
                                   additional steps may be necessary. Performance
                                   measures on complaint responsiveness and complaint
                                   data are to be incorporated into draft manual
                                   instructions on inadequate survey performance (see
                                   HCFA-2(a)).

Require substantiated complaints   HCFA directed states on 3/16/99 to cite federal
to be entered in federal data      deficiencies on complaint investigations and enter
systems. GAO-C3                    them into the federal data system even if also entered
                                   into a state licensure system. HCFA is developing a
                                   revised complaint form due 10/31/99. The OSCAR
                                   redesign will incorporate needed changes in order to
                                   track information and deficiencies resulting from
                                   complaint investigations more accurately.

Strengthening enforcement
-----------------------------------------------------------------------------------------
Eliminate the grace period for     HCFA issued implementing memo to states on 9/22/98 to
homes cited for repeated serious   include homes cited with repeated pattern of actual
violations and impose sanctions    harm (H-level or above) deficiencies in the poor-
promptly. GAO-3 (See HCFA-1(a)     performing facilities category that are denied a grace
below.)                            period.
                                   HCFA proposes expanding the category of homes denied a
                                   grace period to include isolated actual harm (G-
                                   level) deficiencies later in 1999. HCFA is developing
                                   new manual instructions, with final instructions due
                                   by 9/30/99.

Revise definition of "poor         See status of previous initiative. We estimate that
performer." HCFA-1(a) (See GAO-3   adding G-level deficiencies to the current poor-
above.)                            performer category would increase nursing homes
                                   referred for immediate sanction from 1 percent to 15
                                   percent of homes and could increase related informal
                                   dispute resolution hearings at the state level and
                                   appeals at the federal level.

Require on-site revisits for       HCFA issued revised revisit policy to states and
problem homes with recurring       regional offices on 8/20/98 and is monitoring
serious violations. GAO-4          implementation. Nine of the 10 states we contacted
                                   have implemented the revised policy. Two states
                                   expressed the need for additional resources to conduct
                                   the large increase in required revisits.

Permit states to impose civil      Final regulation went into effect 5/17/99 and final
monetary penalties for each       manual instructions are due 9/18/99. The American
instance. HCFA-1(b)               Health Care Association has filed litigation in court
                                   to enjoin the implementation of this new policy.

Focus enforcement efforts on       Issued optional implementing memo to states; final
nursing homes within chains that   manual instructions due 8/31/99. Only 1 of 10 states
have a record of noncompliance     we contacted has not fully implemented this guidance.
with federal requirements. HCFA-   HCFA's and states' lack of nursing home ownership data
1(e)                               will hinder the effectiveness of this initiative. A
                                   HCFA ownership database will require several years to
                                   develop.

Prosecute egregious violations.    Conference with the Department of Health and Human
HCFA-5                             Services (HHS) Office of Inspector General and the
                                   Department of Justice held 10/22/98. Although HCFA has
                                   listed this initiative as completed, HCFA and the
                                   Department of Justice have not yet established a
                                   formal agreement on when nursing homes should be
                                   referred to Justice for prosecution.

Reduce backlog of civil monetary   The Congress supplied a $1 million supplemental
penalty (CMP) appeals. GAO-E1      appropriation for FY 1999 for the HHS Departmental
                                   Appeals Board. HCFA has requested additional funds for
                                   the Board for FY 2000.

Continue federal payments to       HCFA is reviewing 30 involuntary termination cases
nursing homes past termination     from FY 1998 and will determine by 9/30/99 whether
only if homes are transferring     policy change is necessary.
residents to alternative
settings. GAO-E2(a)

Ensure that reasonable assurance   HCFA is developing additional examples of reasonable
periods are sufficient before      assurance periods for revised draft manual
readmitting a terminated nursing   instructions due 9/30/99.
home so that the reason for
termination will not recur. GAO-
E2(b)

Consider pre-termination history   HCFA included this change in draft revised manual
in subsequent enforcement actions  instructions, with final manual instructions due 9/
for terminated homes that are      30/99.
readmitted to the program. GAO-
E2(c)

Require states to refer homes      HCFA is providing training to states and added
that contribute to a resident's    instruction to the enforcement manual that CMPs should
death to HCFA for federal          be used for instances of past harm.
enforcement actions. GAO-E3        HCFA is revising its data system to collect
                                   information about deaths for which no CMP is imposed,
                                   due 6/30/00.

Enhancing information and education
-----------------------------------------------------------------------------------------
Develop better management          Contract recently let for development of system
information systems. GAO-E4        requirements. Implementation of revised data system
                                   for nursing homes scheduled for 2001 with final
                                   linkage to other data systems by 1/31/02.

Publish survey results on the      Internet site available as of 9/30/98, with public
Internet. HCFA-6                   rollout completed 3/16/99. See http///
                                   www.medicare.gov/nursing/home.asp.

Develop repository of best         Internet site with guidelines made available 11/15/98
practices guidelines for care for  at http//www.hcfa.gov/medicaid/siq/siqhmpg.htm.
residents at risk of weight loss
and dehydration. HCFA-3(a)

Develop a national campaign to     A work group has been formed and a contract awarded to
increase awareness on the          develop an information campaign scheduled to begin 8/
prevention of malnutrition and     16/99.
dehydration. HCFA-3(b)

Establish guidelines and methods   Manual instructions to be implemented 6/30/99 to
for using effective drugs. HCFA-   assist nursing homes and surveyors to identify the
3(d)                               appropriate method and proper administration of some
                                   drugs. A list of drugs that are not appropriate for
                                   use under most circumstances because there are better
                                   alternatives or other associated risks has also been
                                   developed and validated.

Develop an abuse intervention      Abuse-related poster and messages have been developed.
campaign. HCFA 4(b)                Pilot project in 10 states due to begin 7/15/99.

Develop legislative proposals      HCFA submitted legislative language 7/29/98. HCFA
for                                considers these initiatives completed, although
--criminal background checks,      according to a HCFA official the 105\th Congress did
--national registry to             not approve relevant legislation and no legislation is
incorporate state nursing          pending in the current Congress.
assistant registries, and
--increasing the number of staff
to feed residents. HCFA 7(a, b,
and c)

Study staffing. 3/16/99 HCFA       HCFA is conducting a study of the potential costs and
press release                      benefits of minimum staffing levels, scheduled for
                                   draft review in 1/2000.
-----------------------------------------------------------------------------------------
\a HCFA has developed a tracking and coding system to organize
initiatives.  These tracking codes follow the brief description of
the initiative(s). 

*** End of document. ***