"Nursing Home Improvement" Needs Improvement.

In an assessment of President Clinton's Nursing Home Initiative (NHI) after two years, the Senate Aging Committee produced at a September 28 hearing witnesses who found much need for improvement. And, in hindsight, perhaps the goals were too ambitious.

For example, to address the survey predictability problem, the Health Care Financing Administration (HCPA) required states to start at least 10% of standard surveys outside normal workday hours, i.e., in the early morning, in the evening or on weekends, beginning January 1, 1999. HCFA also instructed the states to avoid, if possible, scheduling a home's survey for the same month when the home's previous standard survey was conducted. William J. Scanlon, General Accounting Office (GAO) Health Financing and Public Health Issues director, testified that improvements in the predictable timing of the surveys "have been modest at best." The GAO reviewed survey data from California, Maryland, Michigan, Missouri, Tennessee and Washington.

"Our analysis of successive standard surveys shows that many homes in the six states we reviewed continued to have their annual inspection within a short time from the anniversary of their previous inspection or at the end of the maximum allowed 15-month period between consecutive surveys," Scanlon said. "Both circumstances allow a home to anticipate when their survey will occur." The GAO found that more than half the surveys in Tennessee were conducted within 15 days of the anniversary date. In California and Maryland, where a large share of the surveys occurred late within the 15-month cycle, state survey officials explained to GAO officials that an increased emphasis on conducting more prompt complaint investigations drew on the same surveyor staff who perform the annual surveys, which resulted in postponing many of the surveys until as late as possible. Scanlon suggested "dividing the survey into segments performed over several visits, particularly for those homes with a history of serious deficiencies, so that surveyors will be in the home more often."

The NHI also required: a more rigorous identification and classification of serious deficiencies; improved processes for investigating complaints; and states to refer for immediate sanctions any nursing home with a pattern of deficiencies on successive surveys that harmed residents.

However, Carol Benner, vice-president of the Association of Health Facility Survey Agencies, painted a picture of government funds, both federal and state, out of sync with the needs of the enhanced system. "The federal initiatives have significantly and dramatically increased state survey agency workload. The enhanced survey protocol requires more hours per survey; complaint investigations have doubled in some states; and, increased enforcement actions require additional surveys."

Even now, the additional federal funds that probably will be available to the states for fiscal 2001 (the year that began October 1,2000) might prove to be insufficient, Benner warned. "Next year, we will be here again, testifying that there are not enough resources and that we are still not meeting federal time frames."

Benner also referred to the lead time needed to implement an enhanced program. Many states need a full state budget cycle prior to allocation of federal funds to plan for additional positions. "After state legislatures have approved hiring additional staff and the federal monies are appropriated," she said, "it takes another 12 to 18 months to hire staff and provide orientation, training and testing before a surveyor is deemed satisfactory to survey independently." For example, in Maryland, where Benner works as director of the Office of Health Care Quality, the number of complaints from FY98 to FY00 that were investigated tripled and the number of followup visits more than tripled. Meanwhile, although the actual number of visits to nursing homes increased from an average of two per year to more than five per year, there was a decrease in the number of annual surveys conducted and an inability of the state to meet the 12-month average, Benner testified. "Although we have worked hard to correct this problem, this shift in workload and priority shows the impact of a policy change without adequate preparation."

The Senate Aging Committee's two-year assessment came at a time when the Clinton administration was about to hand off to a new administration that might have other ideas on assuring nursing home quality of care.