The Clinton administration is proposing to scale back inspections of many nursing homes that care for elderly people under Medicaid and Medicare.
The Department of Health and Human Services outlined the proposed changes in documents sent recently to federal and state health officials around the country.
Government data show that more than two-thirds of nursing homes are not complying fully with current federal standards. Federal officials said the proposed changes would allow them to concentrate on homes with serious problems.
The proposed changes would narrow the scope of reviews at many nursing homes and reduce the number of residents who must be interviewed. They also would reduce the number of medical records and other documents that must be examined.
Inspectors would focus on “areas of concern” identified in advance, rather than conducting “comprehensive reviews,” and they would have fewer opportunities to observe the dispensing of medications.
Anthony Tirone, deputy director of the Health Standards and Quality Bureau at the fedearl department, said in a memorandum that the new procedures would “increase the effectiveness and efficiency” of nursing home inspections. In an informal test, Tirone said, “we saved time while obtaining better information” in most cases.
But state officials and consumer groups denounced the proposed changes, saying they significantly would reduce the protection of nursing home residents.
Ellen Reap of Delaware, president of the national organization of state officials who inspect hospitals and nursing homes, said she was shocked to see the proposal.
“These changes will, in effect, authorize drive-by surveys,” said Reap, who is president of the national Association of Health Facility Survey Agencies. “Inspectors could walk into a facility, spend a short amount of time, see if it’s clean or dirty and if it smells OK. Fewer deficiencies would be cited. The federal government is weakening the inspection program, and it’s very dangerous.”
The proposals are the latest twist in a 15-year struggle over the regulation of nursing homes. Efforts by President Ronald Reagan to relax the rules for nursing home care died in a storm of bipartisan protest. After a study by the National Academy of Sciences, Congress in 1987 wrote stringent new standards into federal law. President Clinton last year blocked efforts by Republicans in Congress to repeal many of the federal standards.
Now, the Clinton administration is not trying to change the standards itself. But experts in long-term care said the standards would be ineffective if the inspections were not rigorous.
The federal government pays for an ombudsman in each state to investigate the complaints of nursing home residents. Mark Miller, the ombudsman in Virginia, said the proposed changes were “most definitely” contrary to the interests of nursing home residents.
“The changes essentially emasculate the survey and enforcement process,” Miller said.
Under one proposal, inspectors would not have to observe how medications are prepared and given to patients in some nursing homes that score well in the first round of a survey. Robyn Grant, president of the National Association of State Long-Term Care Ombudsman Programs, said this proposal was “dangerous and irresponsible” because nursing home residents received many drugs, and medication errors “may have life-threatening consequences.”
The American Association of Retired Persons, the National Citizens’ Coalition for Nursing Home Reform and other consumer groups echoed these concerns.
Toby Edelman, a lawyer at the National Senior Citizens Law Center, said the proposed changes would “put blinders on the eyes of nursing home inspectors,” reducing their ability to detect violations of residents’ rights, medication errors and deficiencies in the quality of life.
Nursing homes must meet federal standards to obtain payment from Medicaid or Medicare. In upholding the government’s right to conduct wide-ranging inspections, the 2nd U.S. Circuit Court of Appeals, in New York, declared recently that “many patients in nursing homes are helpless, and their physical and mental well-being and quality of life are often at the mercy of the operators and the staff.”
About $80 billion a year is spent on the care of 1.6 million people in more than 17,000 nursing homes.
State agencies, working under contract with the federal government, inspect the homes for compliance with federal standards, and federal officials then inspect at least 5 percent of the homes to verify the state findings.
Tirone referred questions about the proposals to Bruce Vladeck, administrator of the Federal Health Care Financing Administration, which runs Medicaid and Medicare. While declining to discuss details, Vladeck said: “You want to concentrate your survey resources on people with problems. In order to do that, you have to have reliable information on everybody so you know who has problems and who doesn’t.”
Federal officials said the proposed new procedures would help elicit such information.
Under current rules, inspectors routinely examine the contracts that elderly people sign when they are admitted to nursing homes. The inspectors must also examine menus, activity calendars, accident reports and the written information given to residents about their rights. The proposed new procedures would eliminate the requirement for inspectors to analyze such documents.
Inspectors say they have found objectionable or illegal provisions in many contracts. Some require nursing home residents to surrender their right to make decisions about their care. Others require friends or relatives to guarantee payment of nursing home charges, even though federal law prohibits such requirements.
The proposed new procedures, known as a “survey protocol for long-term care facilities,” are part of a manual issued by the federal government for state inspectors. The manual is important because it tells inspectors what to look for and how to find it. Copies of the proposals were obtained from officials who had serious doubts about the changes.
Reap, the Delaware official, said, “The proposals are intended, in part, to save money, but in the long run they will cost taxpayers more.” Researchers have found that poor-quality care leads to costly complications, in part because more patients must be hospitalized.