Chairman Grassley, Senator Breaux, distinguished Committee Members, thank you for
inviting me to discuss our efforts to improve quality of care for Americas 1.6
million nursing home residents and to address the issue of nursing home staffing levels.
Protecting nursing home residents is a priority for this Administration and our Agency.
Through the Medicare and Medicaid programs, the federal government provides funding to the
States to pay for care and protect resident safety.
In 1995, the Clinton Administration began enforcing the toughest nursing home
regulations ever. They have brought about measurable improvement. However, our report to
Congress and GAO investigations have shown that much more needs to be done. That is why
President Clinton last July announced a major new initiative to increase protections for
vulnerable nursing home residents and crack down on problem providers. Since then, we have
worked diligently with your Committee, States, providers, advocates, residents, and their
families, to implement and build upon this initiative.
We also are conducting a comprehensive study to help determine what the appropriate
level of staffing in nursing homes should be, and whether minimum nursing home staffing
ratios may be in order.
This study is critical to our efforts to improve oversight and ensure safety and high
quality care for vulnerable nursing home residents. We expect to have the first phase of
this report completed by this coming summer.
NURSING HOME INITIATIVE PROGRESS
We have made substantial progress in implementing many facets of this nursing home
initiative, announced by President Clinton in July of last year.
- We issued new protocols for conducting nursing home surveys which specifically address
areas where there have been significant problems, including hydration, nutrition, and
pressure sores. These protocols, released in July 1999, are vital to guiding and training
State surveyors and will assure a new level of consistency of surveying among the States.
- We provided training and guidance to States on the Presidents nursing home
initiative, including enforcement, use of quality indicators in the survey process, survey
tasks in the areas of medication review, pressure sores, dehydration, weight loss, and
- We required States to evaluate all complaints alleging actual harm within 10 days. Last
month we issued detailed guidance on how to conduct such evaluations and prioritize
complaints. Key staff from each of our regional offices will be meeting with State survey
agencies to discuss these guidelines and facilitate sharing of best practices in complaint
- We identified facilities in each State for more frequent inspection and intense
monitoring, based on results of most recent annual inspections and any substantiated
complaints during the previous two years. States have begun monitoring these facilities
- We vigorously encouraged States to impose sanctions on facilities that do not comply
with health and safety regulations.
- We urged States to impose especially close scrutiny and immediate sanctions for
facilities that demonstrate "yo-yo" compliance by fixing problems temporarily,
only to be cited again in subsequent surveys.
- We instructed States to stagger surveys and conduct a set amount on weekends, early
mornings, and evenings.
- We required States to revisit facilities in person to confirm that violations have been
corrected before lifting sanctions.
- We issued regulations that enable States to impose civil money penalties for each
- We have been working with the Department of Justice to improve referral for potential
prosecution of egregious cases in which residents have been harmed.
- And we are testing an abuse intervention campaign in 10 States, with posters and other
printed messages in nursing homes to inform residents and families about the signs of
abuse and how to report it.
We also are taking steps to protect residents from any disruptions or dislocations in
facilities that may be experiencing financial or other difficulties. We have made clear
that filing for Chapter 11 bankruptcy does not diminish a facilitys responsibility
to provide residents with high quality care and a good quality of life. We issued
monitoring protocols designed to help State surveyors and ombudsmen uncover early warning
signals that might indicate the possibility that a facility in financial difficulty will
fail to continue providing quality care to residents. And we developed a management
contingency plan spelling out responsibilities of State and federal governments so we can
respond quickly and effectively if a facilitys financial situation places resident
health or safety at risk.
To improve consistency in how these efforts are implemented across the country, we have
established a workgroup that includes key central and regional office staff. This
workgroup is promoting clear and consistent communication among all involved staff. And it
is specifically addressing areas where inconsistencies have been identified.
We also continue to target our efforts toward increasing nursing home accountability by
making information on each facilitys care and safety record available to residents,
their families, care givers, and advocates. We have launched a new Internet site, Nursing
Home Compare at www.medicare.gov, which allows consumers to compare survey results and
safety records when choosing a nursing home.
Some evidence suggests that staffing levels and staff-to-patient ratios may be an
important contributing factor to some nursing home problems. However, there is as yet
little systematic evidence available to substantiate such a link for specific ratios. That
is why further study is so critical.
We are conducting a study and developing a report to Congress that will help to
determine the appropriateness of establishing minimum caregiver-to-resident ratios. We
have faced challenges in conducting this study, in part due to the paucity of preexisting
data on the subject. However, we are on track and expect to provide the first phase of
this report to Congress in the summer of 2000.
With the assistance of our contractor, Abt Associates, we expect to analyze two years
of data from nearly all nursing homes in Ohio, New York, and Texas, representing
approximately 2,700 facilities that are home to over 240,000 Americans. Our study focuses
on three key areas:
- Whether staffing ratios improve care;
- Whether minimum nurse staffing ratio requirements are appropriate; and
- The potential cost and budgetary implications of minimum ratio requirements.
In developing the study, we have met, and continue to meet, with a variety of
individuals, including consumer groups, labor organizations, and industry representatives.
We also have established an external Technical Expert Panel to provide us with
independent advice in analyzing the data. This expert panel will review our study design
and provide ongoing assistance to us throughout the study process.
We were careful to select those experts who we believed could be objective and who had
not publicly staked out a prior position on the appropriateness of minimum staffing
ratios. While all the panelists are expert in long-term care, they represent very
different disciplines that we viewed as critical to our study, including nursing and
qualitative research, quality indicators, clinical expertise, and cost analysis.
Once we are confident that we have reliable and meaningful data on staffing, we will
include information about staffing levels at individual nursing facilities on our Nursing
Home Compare web site. We know there are concerns about the accuracy of the staffing data
available to us today. We have research underway to help us get better data. And we feel
it is essential to wait until we are certain the data are not flawed or misleading before
they are posted.
We continue to move forward on both our comprehensive nursing home initiative and our
study of nursing home staffing. We greatly appreciate the assistance provided to us in
these efforts by resident advocates, labor and trade groups, other experts, and this
Committee. And we look forward to consulting further with you when our staffing study is
complete on how to interpret and act upon its findings. I thank you again for inviting us
to this forum, and I am happy to answer any questions.