Making US nursing homes better. GAO study finds some still have major shortcomings

Once again the challenge has been handed to Congress, the states, government inspectors, and to US nursing homes themselves: force facilities that are substandard to make major improvements in the care and safety of those who cannot care for themselves. This time the challenge stems from a sharply critical report on conditions in American nursing homes, just issued by the General Accounting Office. The GAO found that in three consecutive annual inspections more than a third of the nation's 14,000 nursing homes failed to meet ``one or more of the requirements most likely to affect resident health or safety.''

Further, the GAO found that, in many cases, no effective deterrent exists that would spur substandard nursing homes to improve. Different kinds of penalties should be written into law, it concluded, and the federal government should gain the resolve, not now evident, to use the sanctions it already has.

This report reaffirms basic findings of two previous probes within the past year and a half, which also cited major deficiencies in a substantial minority of nursing homes. One report was by the Institute of Medicine of the National Academy of Sciences, the other by the Senate Aging Committee, then chaired by Sen. John Heinz (R) of Pennsylvania.

The most serious findings of the GAO report mirror those of the previous two. Senator Heinz identified them as: ``the failure to provide adequate nursing care, to follow safety requirements, ... the failure to provide a proper diet for the residents, and, finally, the abuse of patients or physically restraining them improperly.''

The current criticism of many nursing homes comes against a backdrop of major progress in the industry in the past 15 years. One expert calls it a ``tremendous improvement in quality'' of care. It came after major efforts during the early 1970s in Congress and some legislatures to expose nursing-home inadequacies and attempt to bring about change.

Sen. George Mitchell (D) of Maine, one of the authors of current legislation to reform nursing homes, says that ``most nursing homes ... are of high quality and provide good care'' to their residents. He notes that for several years his own mother has been in a nursing home ``where she receives very good care.''

Yet a serious problem remains in a few nursing homes, as even the industry agrees. The federal government has a lever: It provides part of the funding, in cooperation with states, for the medicaid payments that make up about half the payment that nursing homes receive for long-term care of their elderly residents.

At present the federal government's principal threat to substandard facilities is that it can make them ineligible for medicaid payments, which would force many to close. But that would only exacerbate the national shortage of nursing home beds and, perhaps in part for that reason, the threat is rarely used. This, reports point out, leads substandard nursing homes to believe that no long-term improvement is necessary. As a consequence little may be done about inadequate staffing, persistently unsanitary conditions, or woefully inadequate patient care.

``Two alternatives,'' the GAO report notes, ``are civil monetary penalties and bans of new admissions until deficiencies are corrected.'' These are precisely the steps recommended last year by both the Heinz and Institute of Medicine studies. Two legislative proposals, one in the Senate and another in the House, would write these alternatives into law. It is possible that they could be passed late this year, as part of Congress's major effort to reconcile its programs with the Gramm-Rudman budget targets.

Something else Heinz recommends is that states, which do the checking on nursing homes, have an official spend a good deal of time at a substandard nursing home to monitor what actually is going on day to day. At present most states inspect a nursing home just once or twice a year. Sometimes nursing homes are told in advance when the inspections will occur.

Some states are already improving their inspection approaches, says Margery Blood of the American Association for Retired Persons, because they are ``beginning to focus'' on the care residents receive. As a result, more important deficiences are being noted.