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How Tough Are Nursing Home Inspectors?

By Kathleen Murphy, Stateline.org Staff Writer

Aug. 24, 2005 - A third of U.S. nursing homes have food sanitation problems, and nursing homes in California, Nevada, Delaware, West Virginia and Hawaii scored more bad marks on state inspections than in other states in 2004.

The most serious problems – failures that cause actual harm to residents – were reported in Connecticut, Idaho, Kansas, South Carolina and Washington.

These are the latest findings based on the U.S. government's system for checking up on nursing homes. But experts say it’s still hard to know whether trends seen in the federal database of state inspection reports are changes in the quality of care or differences in how states inspect.

For example, the number of U.S. facilities cited for infractions that could put residents in harm's way declined sharply, from 30 percent in 1998 to 15.5 percent in 2004, according to an August report by Charlene Harrington, a University of California San Francisco researcher and a national expert on nursing home deficiencies. While the numbers might suggest that the quality of care has improved, Harrington concludes instead that states are becoming less likely to cite homes for serious deficiencies. She points to increases in the number of residents with pressure sores or who are bedridden.

"There is some evidence that some state agencies may be downgrading the severity ratings for deficiencies," Harrington's report said. Thirty states saw severity ratings for deficiencies decline in 2004 from the previous year, the report said, even as more total deficiencies were found in 2004 in all states except Mississippi, Oregon and Wyoming.

The average number of violations per facility increased from 5.2 in 1998 to 9.2 in 2004, indicating compliance with federal regulations is deteriorating, Harrington said. The report found that the District of Columbia ranked No. 1 in the average number of nursing home deficiencies, and that Wisconsin had the lowest percentage of violations. 

Evvie Munley, senior health policy analyst for the American Association of Homes and Services to the Aging, a group of not-for-profit nursing homes, said there's widespread agreement that inconsistency tarnishes the inspection process and that improvements are needed.

"The survey process is one tool. How do we know there is quality for people looking for a nursing home? You have to go visit," Munley said.

Congress authorized the first set of nursing home regulations in 1967, and nursing homes that use Medicaid and Medicare must follow the guidelines or lose funding. State inspectors check nursing homes on behalf of federal regulators annually, making observations about how residents behave, whether they have bruises or scrapes and whether the facility smells of ammonia. They inspect the kitchen, observe how drugs are distributed and interview staff members about abuse prevention.

Until last year, federal funding paid for an analysis of the inspection reports. This year, Harrington's report was paid for by the Service Employees International Union.

 Mary Kahn, spokeswoman for the federal Centers for Medicare and Medicaid Services, which oversees state nursing home inspections, said, "States are the first line of defense" against nursing home deficiencies. She said CMS is reviewing Harrington's report.

Each state can decide how to punish a nursing home for violations but most defer to the federal government, which can fine a facility as much as $10,000 a day. A Washington Post analysis of a federal database this year showed that since 1995, Medicare has charged more than $100 million in fines against the country's 17,000 nursing homes based on violations found in state inspections. Most fines go to homes in the Midwest and Southeast, the Post said.

Instead of deferring to federal fines, Louisiana is one among a few states that by law imposes its own fines with a $5,000 per month maximum. After statistics showed the state's nursing homes were far less likely to be fined than homes in other Southern states, Health and Hospitals Secretary Fred Cerise decided this month to compare Louisiana's regulatory system to other states and consider adopting stronger penalties.