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New GAO Report Recommends Reexamination of Nursing Home Oversight

WASHINGTON – Today Senators Chuck Grassley (R-IA) and Herb Kohl (D-WI) reintroduced the Nursing Home Transparency and Improvement Act, a bill that would give consumers more information about individual nursing homes and their track record of care, give the government better tools for enforcing high quality standards, and encourage homes to improve on their own.

"Improving the quality of care in nursing homes is a constant challenge. More transparency, better enforcement and improved staff training are needed, and this legislation works to make changes in those areas and improve the quality of life of nursing home residents and to empower the family members and loved ones of those residents," Grassley said.

"Twenty-two years have passed since Congress last addressed the safety and quality of America’s nursing homes in a comprehensive way," said Kohl. "As we prepare to debate reforms across our health care system, there has never been a better time to implement critical improvements to our nation’s system of nursing homes. And as the GAO report demonstrates, many of these improvements are past due."

In addition to the bill introduced today, Grassley and Kohl released a U.S. Government Accountability Office (GAO) report entitled "Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine Its Approach for Oversight of Health Care Facilities." This report suggests that the survey and certification system is significantly underfunded relative to the scope of its oversight responsibilities, which have greatly expanded in recent years. The report found that survey frequencies have greatly lengthened due to resource constraints, resulting in some facilities receiving inspections only once every ten years. The Nursing Home Transparency and Improvement Act seeks to bolster the federal government’s survey and certification system.

Grassley is ranking member and former chairman of the Committee on Finance, with jurisdiction over the federal health care programs that cover nursing home care, and former chairman of the Special Committee on Aging. Kohl is chairman of the Special Committee on Aging, a standing committee that conducts oversight of issues related to the health, safety, and financial well-being of older Americans. The Grassley-Kohl bill is the product of their work together on nursing home quality, which has helped to generate some positive results in recent years, including the government’s new five-star nursing home rating system and the release of the Special Focus Facility program participant list, consisting of the 135 worst nursing homes in the country.

A summary of the bill and introductory floor statements follow.

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Nursing Home Transparency and Improvement Act of 2009

Increases Transparency About and Accountability for Nursing Home Ownership and Operations

*Enables state and federal regulators to identify all persons and entities with a significant ownership interest in a nursing home, or that that play an important role in the management, financing and operation of a home.

*Strengthens accountability requirements for individual facilities and nursing home chains by requiring them to develop compliance and ethics plans to guard against civil, criminal and administrative violations.

*Provides for improved reporting of real-time nurse staffing information so that accurate comparisons can be made across nursing homes.

*Requires nursing homes to develop internal quality assurance and performance improvement standards to monitor and improve the quality of care provided to residents.

*Improves and expands the website, "Nursing Home Compare" to include information about and links to recent health and safety inspection reports.

*Requires CMS to develop and post a standardized complaint form online so that residents and families can readily voice their concerns. Also brings uniformity and structure to the complaint process by requiring states to establish organized processes that include complainant notification and response deadlines.

*Provides transparency on a nursing home’s expenditures on direct care by modifying skilled nursing facility cost reports to require that they separately account for staffing.

Strengthens Enforcement

*Authorizes the Secretary to place CMPs in escrow accounts following an independent informal dispute resolution process that generates a written record and is completed within 30 days. Facilities that successfully appeal receive the full CMP amount, with interest, back. Federal CMP funds that are not returned to facilities may be spent on resident and family councils and other activities benefiting nursing homes that are approved by the Secretary.

*Authorizes the Secretary to reduce civil monetary penalties (CMPs) for those facilities that self-report health deficiencies, in cases where the violations do not result in actual harm, immediate jeopardy, or the death of a resident.

*Equips the Secretary with tools to address corporate-level quality and safety problems in nursing home chains by providing HHS with the authority to develop a national independent monitor pilot program to analyze and address chain-wide problems.

*Provides greater protection to residents of nursing homes that voluntarily close by requiring facilities to provide ample advance notice of closure as well as the development of a transfer plan, taking into account resident preference, which is submitted to the state.

*Requires a GAO study on the role that financial issues play in poor-performing homes.

*Authorizes demonstration projects for nursing home "culture change" and for improving resident care through health information technology.

Improves Staff Training

*Improves staff training to include dementia management and abuse prevention training as part of pre-employment training.

*Requires a study on increased training requirements either in content or hours for nurse aides and supervisory staff.

Floor Statement of U.S. Senator Chuck Grassley of Iowa

Ranking Member of the Committee on Finance

Introduction of the Nursing Home Transparency and Improvement Act of 2009

Thursday, March 19, 2009

Mr. President, I am here today to introduce the Nursing Home Transparency and Improvement Act of 2009. I introduce this bill along with Senator Kohl, who serves as Chairman of the Special Committee on Aging, as I once did. This is a critical piece of legislation that brings overdue transparency to consumers regarding nursing home quality and operation. It also provides long needed improvements to our enforcement system.

In America today, there are well over 1.7 million elderly and disabled individuals in over 17,000 nursing home facilities. As the baby boom generation enters retirement, this number is going to rise dramatically. While many people are using alternatives such as community-based care, nursing homes are going to remain a critical option for our elderly and disabled populations.

As the Ranking Member of the Senate Finance Committee, I have a longstanding commitment to ensuring that nursing home residents receive the safe and quality care we expect for our loved ones. Unfortunately, as in many areas, with nursing homes a few bad apples often spoil the barrel. Too many Americans receive poor care, often in a subset of nursing homes.

Unfortunately, this subset of chronic offenders stays in business, often keeping their poor track records hidden from the public at large, and often facing little or no oversight or enforcement from the federal government. There is a lack of transparency, a lack of accountability, and sometimes in our approach to nursing homes, a lack of common sense. These are the things this legislation seeks to bring to nursing homes and their residents – transparency, accountability, and common sense.

First, let me talk about transparency. In the market for nursing home care, like in all markets, consumers must have adequate information to make informed choices. For years, people looking at a nursing home for themselves or a loved one had no way of knowing a nursing facility’s record of care, inspection history, or which individuals were ultimately responsible for caring for their loved ones. This bill is intended to help change that. This legislation requires nursing facilities to make available ownership information, including the individuals and entities that are ultimately responsible for a home’s operation and management. Too often, bad apples hide under layers of other entities designed to cloak and confuse. This leaves residents and their families without clear information about who is ultimately responsible for insuring that a resident is consistently provided with high quality care..

This legislation also requires more transparency concerning nursing home staffing and surveys. Homes differ widely in terms of the number of specialized staff available to residents as well as the number of registered nurses and certified nursing assistants who provide much of the hands on care. How a nursing home is staffed can greatly affect the care it provides, especially when dealing with complex conditions such as Alzheimer’s. This legislation requires better tracking of this information and requires that this information is available to prospective residents and their families.

In addition, this legislation will help families have a better idea of a nursing home’s track record in that it requires better transparency for nursing home inspection reports that are completed on a routine basis. The Secretary will also now be required to provide consumers with a summary of information on enforcement actions taken against a facility during the previous three years. This same transparency will also provide additional market incentives for poor homes to improve – if customers know about problems, that home is incentivized to improve or face going out of business. This effort also requires a strong, effective enforcement and monitoring system to ensure safe and quality care at facilities that wouldn’t take the necessary steps voluntarily.

But even with improved transparency, there are some nursing homes that won’t improve on their own. In the nursing home industry, most homes provide quality care on a consistent basis. So we need to give inspectors better enforcement tools. The current system provides incentives to correct problems only temporarily and allows homes to avoid regulatory sanctions while continuing to deliver substandard care to residents. This system must be fixed. Last year, CMS requested two things:

1. Statutory authority to collect civil monetary penalties sooner, and

2. The ability to hold those penalties in escrow pending appeal.

To that end, this bill requires nursing homes that have been found in violation of the law be given the opportunity to participate in an independent informal dispute resolution process within 30 days.

After that point, depending on the outcome of the appeal, penalties are collected and held in escrow pending the exhaustion of the appeals process. This will ensure that nursing homes found to be violating the rules actually pay the penalties assessed if it’s determined to be appropriate. But we shouldn’t have to resort to enforcement. Problems resulting in penalties should be avoided or detected and fixed immediately by the nursing home in the first place. That is why this bill would require all nursing homes to have compliance and ethics programs, as well as quality assurance and performance improvement programs.

In addition to increased transparency and improved enforcement, this bill provides common-sense solutions to a number of other problems as well. This legislation requires the Secretary of Health and Human Services to establish a national independent monitoring pilot program to tackle problems specific to interstate and large intrastate nursing home chains. And, in the case of a nursing home being closed due to poor safety or quality of care, this bill requires that residents and their representatives be given sufficient notice so that they can adequately plan a transfer to an appropriate setting.

I am very sensitive to the fact that nursing home residents are often elderly and fragile. Moving them into a new facility is often very traumatic. So we’ve got to make sure these residents are transferred appropriately and with adequate time and care. This bill also aims to help nursing homes who self-report their concerns and who remedy certain deficiencies. By doing so, nursing homes may have any penalties reduced by 50%. This will encourage facilities to take the lead in finding, flagging, and fixing violations. This bill is also intended to strengthen training requirements for nursing staff by including dementia and abuse prevention training as part of pre-employment training. So I’m proud to introduce this bill today along with Senator Kohl.

Mr. President, the Chairman of the Aging Committee and I have a long history of working together on elder care issues and I am happy to continue that work. I would also note that today the GAO is releasing a report critical of CMS’s funding of state oversight of entities such as nursing homes. This report notes that survey activity is sometimes so unreliable that certain homes haven’t even been inspected in more than 6 years. The report makes a number of recommendations to CMS and I will be looking at those very carefully. In the meantime, it’s important that we improve transparency and accountability for the inspections that are taking place.

We’ll continue to do everything we can to make sure America’s nursing home residents receive the safe and quality care they deserve. Increasing transparency, improving enforcement tools and strengthening training requirements will go a long way towards achieving this goal.

Floor Statement of Senator Herb Kohl (D-WI)

Chairman, Special Committee on Aging

Introduction of the Nursing Home Transparency and Improvement Act of 2009

Thursday, March 19, 2009

MR. KOHL: Mr. President, I ask unanimous consent to speak as if in Morning Business for up to five minutes.

Mr. President, my colleagues just heard Senator Grassley present an excellent overview of our bill, the Nursing Home Transparency and Improvement Act of 2009. As chairman of the Special Committee on Aging, the quality of care that is provided to nursing home residents is of great concern to me, and I am proud to be introducing this bill today.

I have worked with Senator Grassley on nursing home policy for several years. We have commissioned GAO reports, sought input from both industry and reform advocates, and collaborated with the executive branch on various initiatives. This work has generated some positive results, such as the government’s new five-star nursing home rating system.

But we must do more. We believe the bill we introduce today will raise the bar for nursing home quality and oversight nationwide, by strengthening the federal government’s ability to monitor and advance the level of care provided in nursing homes.

First, our bill would give the government better tools for enforcing high quality standards. For instance, nursing homes would be required to disclose information about all the principal business partners who play a role in the financing and management of the facility, so that the government can hold them accountable in the case of poor care or neglect. It would also create a national independent monitor pilot program to tackle tough quality and safety issues that must be addressed at the level of corporate management.

Second, our bill would give consumers more information about individual nursing homes and their track record of care. Our bill would grant consumers access to a facility’s most recent health and safety report online, and would develop a simple, standardized online complaint form for residents and their families to ensure that their concerns are addressed swiftly. And it would require the government to collect staffing information from nursing homes on a real-time basis, and make this information available to the public.

Finally, our bill would encourage homes to improve on their own. Under this legislation, facilities would develop compliance and ethics programs to decrease the risk of financial fraud, and quality assurance standards to internally monitor the quality of care provided to residents. We also authorize funds for a national demonstration project on "culture change," a new management style in nursing home care that rethinks relationships between management and frontline workers by empowering nursing aides to take charge of the personalized care of residents. Finally, our bill makes an investment in nursing home staff by offering training on how to handle residents with dementia.

Twenty-two years have passed since Congress last addressed the safety and quality of America’s nursing homes in a comprehensive way. As we prepare to debate reforms across our health care system, there has never been a better time to implement these critical improvements to our nation’s system of nursing homes. We ask our colleagues for their support.

Thank you, Mr. President, I yield the floor and note the absence of a quorum.

Ashley Glacel Press Secretary Special Committee on Aging Senator Herb Kohl, Chair Ph: (202) 224-5364


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