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Nursing Home Reform Law Turns Twenty:
Is Care Any Better?

The 20th Anniversary of the 1987 federal Nursing Home Reform Act is sparking reflection on whether nursing homes are meeting its historic promise—that each resident receive care and services in a homelike setting to attain and maintain his or her highest practicable physical, mental, and psychosocial well–being. Without question, the reform law has helped many nursing home residents. Some nursing homes took its goals to heart and countless residents have used it to assert their rights and seek improved care.

However, the fundamental promise of the reform law is no closer to being realized today than it was 20 years ago. Few nursing homes offer the best possible care and most still resemble institutions rather than homelike settings. Many residents suffer serious harm and death due to persistent poor care.

What Went Wrong?

Two primary problems account for residents’ dire circumstances. First, the reform law doesn’t establish specific minimum staffing requirements. Second, the federal and state governments don’t enforce the law, allowing many nursing homes to ignore its landmark requirements without consequence.

Low Staffing Leads to Neglect

It is impossible to provide quality care without sufficient staff. Yet the overwhelming majority of nursing homes are understaffed. A 2001 study ordered by Congress found that nursing home residents generally require at least 4.1 hours of care per day to avoid harm. Very few nursing homes meet this standard and almost a quarter of California nursing homes routinely violate California’s much lower minimum staffing standard of 3.2 hours of care per day.

Making matters worse, nursing home staffing by RNs—always inadequate—has declined by 25 percent in US nursing homes since 2000.

More money hasn’t helped. Since 2005, California nursing homes have made windfall profits under a new Medi–Cal rate system designed by the industry and Service Employees International Union (SEIU). Over a four–year period, Medi–Cal payments to California nursing homes are increasing by over $2 billion. According to a recent SEIU analysis, nursing homes are spending very little of the money on more staffing or better wages. See related article in Long Term Care News.

Some progress may begin on July 1, when a CANHR led reform takes effect. A 2006 law (SB 1312, Alquist) requires the California Department of Health Services (DHS) to evaluate compliance with the many California standards that exceed federal law, including the minimum staffing requirements. In recent years, DHS has ignored California laws during inspections, rendering them meaningless. This neglect has allowed nursing homes to disregard California’s staffing requirement with impunity.

Enforcing the minimum staffing requirement will be a good first step, but much more must be done. Nursing homes should be required to report verifiable staffing information, based on audited payroll data, and this information should be disclosed to the public as it is reported. Nursing homes should meet the federally recommended staffing levels, including those for licensed nurses. And California should not renew its Medi–Cal rate system for skilled nursing facilities without demanding that increased rates be used to improve staffing and wages.

Weak Enforcement Erodes Law’s Promise

New studies continue to demonstrate what most nursing home residents know only too well. California and federal laws demand good care, but they are seldom enforced.

In February, the California HealthCare Foundation released a report showing DHS substantiated only 16 percent of nursing home complaints in 2005, a drastic decline from 41 percent in 2000. Few complaints result in corrective action, no matter how serious.

On April 12, the California State Auditor released her report—prompted partly by CANHR’s recommendation—on DHS’ nursing home oversight system. The audit found that DHS investigates complaints slowly, does not track complaints effectively, understates the seriousness of nursing home violations, and has not established an online information system required by a 1999 law.

On the heels of the California audit, the U.S. Government Accountability Office (GAO) issued its latest in a decade–long series of highly critical reports on the federal nursing home enforcement system. The GAO analyzed federal sanctions against 63 nursing homes in four states, including California, with long histories of harming residents. The study found that substandard nursing homes repeatedly cycle in and out of compliance, federal officials routinely grant grace periods that allow nursing homes to escape sanctions for neglect, and the few fines that are imposed are usually issued at the lowest levels.

Decades of weak enforcement have led many nursing home operators to believe that compliance with federal and state standards is voluntary. Knowing the risk of sanctions is slight, many operators put profit over care. This culture won’t change until regulatory officials recognize they exist to protect nursing home residents and begin putting residents’ interests first.

In California, some progress is being made but much remains to be done. CANHR’s lawsuit against DHS has quickened initial complaint investigations. AB 399, a CANHR sponsored bill, would take additional steps to improve complaint investigations. SB 535, another CANHR bill, would ensure that DHS implements its long delayed nursing home information system, allowing consumers on’line access to information about nursing homes in their area.

Call to Action

Many of CANHR’s supporters have joined the fight against inadequate oversight and negligent care by joining our 2007 Campaign for Quality Care. None of the reform measures would have moved this far through the legislature without the many letters and calls from consumers. As these bills move through the legislative cycle, your support is more important than ever. Detailed information on all of the legislative measures sponsored by CANHR can be found on our web site at Become a CANHR Advocate and help change the way we provide long term care in California.