Reports/Studies

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Table of Contents:

• CANHR Reports
• Assisted Living/Residential Care
• Conservatorship & Guardianship
• Elder Financial Abuse
• Litigation
• Long Term Care Demographics
• Long Term Care Insurance
• Home and Community Based Services
• Medi-Cal/Medicaid
• Asset Transfers
• Deficit Reduction Act of 2005
• Estate Recovery
• Fraud and Abuse
• Payments for Long Term Care
• Nursing Homes
  • Abuse
  • Disaster Preparedness
  • Oversight and Enforcement
  • Racial Discrimination
  • Public Information
  • Public Opinion
  • Quality
  • Resident Characteristics
  • Staffing

CANHR Reports

	Nursing Home Residents at Risk. The Administration is prioritizing nursing home lobbyists over residents. Nursing home lobbyists have urged the Centers for Medicare & Medicaid Services (CMS) to eliminate or delay regulations and dramatically reduce enforcement of violations.
	Don't Believe the Hype: Inappropriate Psychotropic Drug Use in Nursing Homes Still an Epidemic In 2012, the Centers for Medicare and Medicaid Services (CMS) announced the Partnership to Improve Dementia Care in Nursing Homes following a withering Office of Inspector General (OIG) report finding rampant misuse of antipsychotic drugs in nursing homes throughout the country. A centerpiece of the Partnership was a series of antipsychotic reduction goals, which ultimately called for a 30% reduction in antipsychotic use in nursing homes by the end of 2016...
	No Standards: How Nursing Homes Attempted to Undermine California’s Standard Admission Agreement and Diminish Residents’ Rights (2014) (pdf) California nursing homes are required to use a standard admission agreement (SAA) to set forth all the contractual terms of service with their residents.  The adoption of the SAA took twelve contentious years, due to concerns over the content highlighted by a facility-led lawsuit against the state’s Department of Public Health (DPH).  When the dust settled, California had a nursing home SAA that had been through two rounds of regulatory adoption procedures with extensive public comment and a lawsuit where all of the nursing home industry’s objections were heard by a state Superior Court judge.
	Residential Care in California - Unsafe, Unregulated & Unaccountable (2013) (pdf) California Advocates for Nursing Home Reform (CANHR) released the attached report on the crisis in care at California's 7,500 Residential Care Facilities for the Elderly (RCFEs). The recent abandonment of 14 bedridden residents at Valley Springs Manor in Castro Valley highlights the serious problems in oversight and enforcement.
	Citation Report 2013 (8/2014) (pdf) A listing of Nursing Home Citations in California, arranged by county, with summaries & fines issued. In an effort to provide concise yet meaningful information about fines (“citations”) received by California’s ~1,235 nursing homes, CANHR has summarized the citations issued by the Licensing and Certification Division of the Department of Public Health to nursing homes in 2013.
	In a Stupor: What California’s Antipsychotic Drug Collaborative Reveals About Illegal Nursing Home Drugging. (2012) (pdf) This report analyzes the findings of the Department of Public Health's Antipsychotic Drug Collaborative with which the Department has investigated 24 nursing homes and found 147 violations of state rules regarding the use of antipsychotics on residents. The Department's investigations confirm that misuse of antipsychotics is rampant in California nursing homes and deserves immediate remedial action.
	New! Your Right to Leave: a Guide for Battling Forced Placement in Long-Term Care Facilities (2015) (pdf) A free guide to the rights of long-term care consumers to be free from false imprisonment. Residents are often illegally held in nursing homes or assisted living facilities against their will despite no judicial decision or legal process. "Your Right to Leave" explains how and why this happens but more importantly, details residents' rights to be free from forced placement and gives guidance on remedies.
	Your Right To Visit: A Guide To Visiting Residents of Long-Term Care Facilities and Hospitals (2011) (pdf) updated: 8/2015 Visitation is extremely important to hospital patients and residents of long-term care facilities. Studies show visitation is highly correlated with improved quality of life for patients and residents. Visitors to hospitals and long-term care facilities often defer to the institution’s rules about visitation, legal or not. However, such deference lacks the perspective that these institutions are also often the homes of the residents. Visitation rules are only enforceable if they honor the basic rights of the residents.
	Physician Orders for Life Sustaining Treatment "POLST" - Problems and Recommendations (10/2010) (pdf) CANHR's report on POLST in California explains how it has created several problems for health care consumers, particularly nursing home residents. The report also includes recommendations for improving POLST.
	Toxic Medicine: What You Should Know to Fight the Misuse of Psychoactive Drugs in Nursing Homes (2012 ed.) (pdf) This guidebook covers the basics regarding psychoactive drugs in nursing homes, from a description of their uses and side effects to an examination of the applicable laws. Most importantly, the guide gives practical tips for nursing home residents or their family members to prevent misuse of psychoactive drugs.
	Nursing Home Abuse & California’s Broken Enforcement System (5/2006) (pdf)
	Much Ado About Nothing: Debunking the Myths of Frequent and Frivolous Nursing Home Lawsuits in California (11/2003) (pdf, 2.76mb)
	Better Read the Small Print! An Analysis of Admission Agreements in California’s Residential Care Facilities for the Elderly (3/2003) (pdf)

Assisted Living/Residential Care Studies

• Quality of Care in Residential Care for the Elderly, A Study of the Limitations & Potential of Community Care Licensing’s Current Data Systems
  University of California, San Francisco with California Advocates for Nursing Home Reform (CANHR), Final Report, March 2008.
• Residential Care and Assisted Living: State Oversight Practices and State Information Available to Consumers Agency for Healthcare Research and Quality, No. 06-M051-EF, 09/2006
• Environmental Scan of Instruments to Inform Consumer Choice in Assisted Living Facilities Agency for Healthcare Research and Quality, No. 07-0032-EF, (12/2006)
• National Academy of State Health Policy: NASHP publishes reports on assisted living including:
• State Residential Care and Assisted Living Policy (2004)
• Informing Consumers about Assisted Living: State Practices
  (February 2005); and
• Aging in Place in Assisted Living: State Regulations and Practice
  (February 2005)
• Critical Issues in Assisted Living National Senior Citizens Law Center. Analyzes how consumers are protected, or harmed, by states' assisted living policies. Available through NSCLC website, $14.95 + s/h (5/2005)
• Assisted Living: Examples of State Efforts to Improve Consumer Protections
  — GAO Report GAO 04-684 (pdf) (4/2004)
• CANHR Report Reveals Problems with Residential Care Admission Agreements (3/2003)
• Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings, State Policy Maker and Stakeholder Views in Six States
  DHHS (12/2003)
• Department of Social Services: Continuing Weaknesses in the Department's Community Care Licensing Programs May Put the Health and Safety of Vulnerable Clients at Risk California State Auditor 2002-114 (8/2003)
• Residential Care for the Elderly: Supply, Demand and Quality Assurance Prepared for the California Healthcare Foundation by Robert Newcomer & Robert Maynard, UCSF (1/2002)
• Assisted Living Industry Organizes to Stop Consumer Protections (6/2002)

Conservatorship & Guardianship

• Conservatorship Reform in California: Three Cost-Effective Recommendations CANHR asked a group of students at UC Berkeley's Goldman School of Public Policy to investigate probate conservatorships in San Francisco and assess the legal system's effectiveness in protecting the rights and welfare of elderly Californians. They accumulated conservatorship data and analyzed it to identify problems and make policy recommendations aimed at improving the process by which conservatorships are considered. (5/2009)
• Guardianships: Little Progress in Ensuring Protection for Incapacitated Elderly People GAO Testimony (9/2006)
• Guardianship Monitoring: A National Survey of Court Practices AARP Public Policy Institute and ABA Commission on Law and Aging (6/2006)
• Guardians for Profit: When a Family Matter Turns Into a Business Los Angeles Times (11/13/06 – 11/16/06)


• Wards of the State: A National Study of Public Guardianship American Bar Association Commission on Law & Aging and Graduate Center for Gerontology, University of Kentucky (4/2005)
• Guardianships: Collaboration Needed to Protect Incapacitated Elderly People
  GAO-04-655, (7/2004)

Elder Financial Abuse

• Elder Financial Abuse Estimated at $2.9 Billion a Year By Bill Benson and Nancy Aldrich, Health Benefits ABCs (smpresource.org November 2011)
• Prevalence of Cognitive Impairment without Dementia in the United States (Duke University)
• The Orbitofrontal Cortex, Real-World Decision Making, and Normal Aging (University of Iowa)

Litigation

• Nursing Home Liability Insurance: An Overview, Bernadette Wright, Ph.D. AARP Public Policy Institute (July 2003)

Long Term Care Demographics

• Long Term Care Facts and Figures: California Health Care Foundation (pdf) (2/2007)

Long Term Care Insurance

• Aged, Frail and Denied Care by Their Insurers New York Times (3/26/07)
• Private Long Term Care Insurance: A Viable Option for Low and Middle-Income Seniors? The Kaiser Commission on Medicaid and the Uninsured (2/2006)
• Do You Need Long-Term Care Insurance?
  Consumer Reports Magazine (11/03)
• Long-Term Care Insurance, Better Information Critical to Prospective Purchasers GAO Testimony Before the Senate Special Committee on Aging GAO/T-HEHS-00-196 (9/2000)

Home and Community Based Services

• Caregiver Roulette: California Fails to Screen those who Care for the Elderly at Home.
  Prepared by John Hill, California Senate Office of Oversight and Outcomes (April 21, 2011)
• Home and Community-Based Long-Term Care: Recommendations to Improve Access for Californians.
  Prepared for: California Community Choices & California Health and Human Services Agency (Nov. 2009)
• Do Noninstitutional Long-Term Care Services Reduce Medicaid Spending?
  By H. Stephen Kaye, Mitchell P. LaPlante, and Charlene Harrington, Health Affairs (Jan/Feb 2009)

Medicaid/Medi-Cal

Asset Transfers

• MediCal Care Research and Review Sage Journals Online (06/2007)
• Medicaid Long-Term Care: Few Transferred Assets before Appling for Nursing Home Coverage; Impact of Deficit Reduction Act is Uncertain
  GAO-07-280 (03/2007)
• Asset Transfer and Nursing Home Use: Empirical Evidence and Policy Significance Kaiser Family Foundation (04/2006)
• Frontline Perspectives on Long-Term Care Financing Decisions and Medicaid Asset Transfer Practices Kaiser Family Foundation (02/2006)
• Medicaid's Coverage of Nursing Home Costs: Asset Shelter for the Wealthy or Essential Safety Net Georgetown University Long Term Care Financing Project (5/2005)

Deficit Reduction Act of 2005

• Medicaid Long-Term Care: Few Transferred Assets before Appling for Nursing Home Coverage; Impact of Deficit Reduction Act is Uncertain
  GAO-07-280 (03/2007)
• Deficit Reduction Act of 2005: Implications for Medicaid Kaiser Family Foundation (02/2006)
• Self–Declaration of U.S. Citizenship for Medicaid OEI-02-03-00190 (7/2005)
• Medicaid: Transfers of Assets by Elderly Individuals to Obtain Long-Term Care Coverage GAO-05-968 (9/2005)

Estate Recovery

• Protections in Medicaid Estate Recovery: Findings, Promising Practices, and Model Notices Erica F. Wood and Ellen M. Klem, ABA Commission on Law and Aging, Published by AARP Public Policy Institute (5/2007)

Fraud & Abuse

• Medicaid Fraud and Abuse: CMS's Commitment to Helping States Safeguard Program Dollars is Limited GAO Testimony, GAO-05-855T (6/2005)
• Medicaid: States' Efforts to Maximize Federal Reimbursements Highlight Need for Improved Federal Oversight GAO Testimony, GAO-05-836T (6/2005)

Payments for Long Term Care

• Impact of California's Medi-Cal Long Term Care Reimbursement Act On Access, Quality and Costs, Harrington, C., et al, University of California at San Francisco (4/2008)
• Department of Health Services: It Has Not Yet Fully Implemented Legislation Intended to Improve the Quality of Care in Skilled Nursing Facilities
  California State Auditor, Bureau of State Audits, 2006-035 (2/2007)
• Medicaid Nursing Home Payments: States' Payment Rates Largely Unaffected by Recent Fiscal Pressures GAO-04-143 (10/2003)

Nursing Homes

Abuse

• Don't Believe the Hype: Inappropriate Psychotropic Drug Use in Nursing Homes Still an Epidemic (12/18/2017)
• Toxic Medicine: What You Should Know to Fight the Misuse of Psychoactive Drugs in Nursing Homes
  This guidebook covers all of the basics regarding psychoactive drugs in nursing homes, from a description of their uses and side effects to an examination of the applicable laws. Most importantly, the guide gives practical tips for nursing home residents or their family members to prevent misuse of psychoactive drugs. (2/2010)
• The Faces of Neglect: Behind the Closed Doors of Nursing Homes
  National Citizens Coalition for Nursing Home Reform (5/2006)
• Elder Abuse in Residential Long-Term Care Facilities: What is Known About Prevalence, Causes and Prevention Catherine Hawes, Testimony Before the U.S. Senate Committee on Finance (6/2002)
• Nursing Homes: More Can Be Done to Protect Residents from Abuse — GAO Report GAO-02-312 (pdf) (3/2002)
• Abuse of Residents Is a Major Problem in U.S. Nursing Homes Report for Rep. Henry Waxman, Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives (7/2001)
• Abuse and Neglect of the Elderly in Nursing Homes and Long-Term Care Facilities
  This National Center on Elder Abuse bibliography highlights many articles, books, reports, and online resources regarding many aspects of abuse, neglect, and exploitation in nursing homes and assisted living facilities.

Disaster Preparedness

• Nursing Home Emergency Preparedness and Response During Recent Hurricanes DHHS Office of Inspector General, OEI-06-06-00020 (8/2006)
• Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should Be Addressed GAO-06-826 (7/2006)

Oversight & Enforcement

• California’s Elder Abuse Investigators: Ombudsman Shackled by Conflicting Laws and Duties, Senate Office of Oversight & Outcomes (11/2009)
• CMS Needs to Reexamine Its Approach for Funding State Oversight of Health Care Facilities, GAO-09-64 (2/2009)
• Nursing Homes: Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses, GAO-08-517 (5/2008)
• Department of Health Services: Its Licensing and Certification Division Is Struggling to Meet State and Federal Oversight Requirements for Skilled Nursing Facilities California State Auditor, Bureau of State Audits, 2006-106 (4/2007)
• Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents, GAO-07-241 (3/2007)
• Improving Nursing Home Enforcement: Findings From Enforcement Case Studies Health Care Policy and Research Center, University of Colorado (3/2007)
• Snapshot: Changing Face of Nursing Homes, California Health Care Foundation (2/2007)
• Nursing Home Enforcement: Application of Mandatory Remedies, DHHS Office of Inspector General, OEI-06-03-00410 (5/2006)
• Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety — Highlights of GAO-06-117 — (pdf) (12/2005)
• Nursing Home Enforcement: Collection of Civil Money Penalties DHHS Office of Inspector General, OEI-06-03-00420 (pdf) (7/2005)
• Nursing Home Enforcement: The Use of Civil Money Penalties — OEI-06-02-00720, Office of the Inspector General, Department of Health and Human Services — (pdf) (4/2005)
• Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of Quality of Care GAO-05-78 (pdf) (11/2004)
• U.S. Senator Charles Grassley's (R - Iowa) letter to the U.S. Dept. of Health and Human Services regarding the corruption of the nursing home inspection system. (7/2004)
• Prevalence of Serious Problems,While Declining, Reinforces Importance of Enhanced Oversight — GAO Report GAO-03-561 — (pdf) (7/2003)
• Nursing Home Deficiency Trends and Survey and Certification Process Consistency DHHS Office of Inspector General, OEI-02-01-00600 (3/2003)
• Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents GAO-99-80 (3/1999)
• Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards GAO 99-46 (3/1999)
• California Nursing Homes: Care Problems Persist Despite Federal and State Oversight GAO 98-202 (7/1998)

Racial Discrimination

• Separate and Unequal: Racial Segregation and Disparities in Quality Across U.S. Nursing Homes: Residential segregation in U.S. cities disproportionately places blacks in poorer-performing nursing homes. (pdf)
  By David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor. Data Watch (Sept./Oct. 2007).

Public Information

• Nursing Homes: Business as Usual Consumer Reports Magazine (5/2006)
• Inspection Results on Nursing Home Compare: Completeness and Accuracy, DHHS Office of Inspector General, OEI-01-03-00130 (6/2004)
• A Consumer Guide to Choosing a Nursing Home (2005) — NCCNHR's perspective on the new 'Nursing Home Compare' site.
• HHS Nursing Home Compare Site Has Major Flaws Prepared for Rep. Henry Waxman and Senator Charles Grassley, Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives (2/2002)

Public Opinion

• The Public’s Views on Nursing Homes
  Kaiser Family Foundation Public Opinion Spotlight (12/2007)
• National Survey on Nursing Homes Kaiser Family Foundation/NewsHour (10/2001)

Quality

• Nursing Facilities, Staffing and Facility Deficiencies, 2001 Through 2007, Charlene Harrington, Helen Carrillo and Brandee Woleslagle Blank, UCSF (9/2008)
• Trends in Nursing Home Deficiencies and Complaints, OEI-02-08-00140, Office of Inspector General, U.S. Department of Health and Human Services (9/2008)
• The Faces of Neglect: Behind the Closed Doors of Nursing Homes National Citizens Coalition for Nursing Home Reform (pdf) (5/2006)
• Nursing Homes: Business as Usual Consumer Reports Magazine (5/2006)
• Long-Term Care Facilities: Information on Residents Who Are Registered Sex Offenders or Are Paroled for Other Crimes GAO-06-326 (3/2006)
• State of Neglect The New Orleans Times-Picayune, April 17-21, 2005
• Report on California's Nursing Homes, Home Health Agencies and Hospice Programs, prepared by Charlene Harrington and Janis O'Meara, UCSF, for the California HealthCare Foundation (12/2004)
• Operation Guardians 2001-02 and 2002-03 Results, California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse (1/2004)
• Nursing Home Conditions in Los Angeles County: Many Homes Fail to Meet Federal Standards for Adequate Care Prepared for Rep. Henry Waxman, Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives (2/2003)
• Nursing Home Care: When Will We Get it Right? Alliance for Retired Americans (6/2002)

Resident Characteristics

• Characteristics of Nursing Home Residents
  Kaiser Commission on Medicaid and the Uninsured (6/2007)

Staffing

• Nurse Aide Registries: Long Term Care Facility Compliance and Practices DHHS Office of Inspector General, OEI-07-04-00140 (7/2005)
• We Shall Travel On: Quality of Care, Economic Development, and the International Migration of Long-Term Care Workers AARP Public Policy Institute (2005)


• Relationship of Nursing Home Staffing to Quality of Care — John F Schnelle, Sandra F Simmons, Charlene Harrington, Mary Cadogan, Emily Garcia, and Barbara M Bates-Jensen; Health Services Research, 39 (2):225-250 — (pdf) (4/2004)
• Nursing Home Medical Directors Survey U.S. Office of Inspector General, Department of Health and Human Services (2/2003)
• Nurse Aide Training, DHHS Office of Inspector General, OEI-05-01-00030 (11/2002)
• Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase — GAO Report GAO-03-176 (pdf) (11/2002)


• Quality of Care More Related to Staffing than Spending GAO-02-431R (pdf) (6/2002)


• Government Study Provides 'Compelling Evidence' for Nurse Staffing Standards in Nursing Home" — National Citizens’ Coalition for Nursing Home Reform Press Release (2/2002)
• Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress: Phase II Final U.S. Centers for Medicare and Medicaid Services, prepared by Abt Associates Inc. (2005)

To access additional General Accounting Office (GAO) reports, visit the GAO web site at http://www.gao.gov