U.S. Senate Special Committee on Aging Chairman Bob Casey (D-PA) this week unveiled a new report, titled “Uninspected and Neglected,” detailing the results of a year-long investigation into the capacity of state survey agencies to oversee health and safety standards at the Nation’s 15,000 nursing homes. The report examines how decades of underfunding for state survey agencies has led to significant staffing shortages and inadequate oversight, putting nursing home residents at risk, while raising concerns about transparency for current and future nursing home residents and their families.
The investigation found that 32 survey agencies have vacancy rates of 20 percent or higher among nursing home surveyors, including nine states with vacancy rates of 50 percent or higher—shortages states directly linked to inspection delays. Federal data show that 28 percent of the Nation’s nursing homes are behind schedule for standard inspections, which federal law requires be conducted no later than every 15 months, including 1 in 9 that have not received a standard inspection in two years. Today, Chairman Casey held a hearing in the Aging Committee on this investigation, and heard from witnesses who attested that, despite rising costs to retain staff and increases in workload, survey agencies have not received a meaningful increase in federal funding to complete these critical oversight responsibilities since fiscal year 2015.
“The system responsible for ensuring that nursing homes meet health and safety standards is in crisis,” said Chairman Casey. “My investigation reveals unacceptable rates of vacancies at state survey agencies, threatening the safety and health of nursing home residents as their complaints collect dust while inspectors struggle to meet the demand. These staffing shortages mean that nursing home resident complaints—the same horror stories that we read about in the news about injured or abused seniors—are often not being investigated in a timely fashion. As my report makes clear, we need to invest in robust nursing home oversight and the workforce that carries it out. Without sufficient resources, nursing home residents will continue to be at risk of substandard care.”
In letters and data provided to the Committee by every state, the District of Columbia, and Puerto Rico, survey agencies reported an inability to effectively conduct their jobs due to severe staffing shortages, high turnover rates, and an inexperienced workforce. A major factor in these issues is federal funding that has remained largely flat for the last decade, despite calls from Democratic and Republican Administrations to increase funding. Survey agencies are unable to compete with competitive wages from hospitals, nursing homes, and the private sector; for example, officials in Pennsylvania’s survey agency compared their entry level pay for a registered nurse at $61,868 with that of nurses in clinical settings in the Commonwealth at $90,000 with an opportunity for an additional $20,000 sign-on bonus.
Delayed inspections also hinder nursing home transparency, as delayed inspections lead to unreliable and outdated public data on nursing homes. In some cases, the Centers for Medicare & Medicaid Services’ Care Compare website—which provides public information about the quality of nursing homes—relies on survey results from as early as 2015, undermining the integrity of the website’s rating system accuracy and potentially misleading consumers.
Chairman Casey’s investigation also found that in the midst of these staffing challenges and inspection delays, states are increasingly turning to costly contractors to fill the gaps, including three national companies that were paid more than $52 million since 2018 to conduct nursing home surveys on behalf of states. The investigation found these contractual arrangements present concerns about possible conflicts of interest related to survey agency use of third-party contracted inspectors, including instances of contractors rendering survey services to state or federal government entities while, at the same time, selling or marketing consulting services to health care providers.
Survey agencies oversee nursing homes by conducting proactive “standard” surveys on an annual basis, investigating complaints against the facilities, taking enforcement actions when warranted, and making public the results of survey findings. These inspection activities are meant to ensure that nursing homes are meeting federal standards for medical care, adequate staffing, emergency preparedness, and safeguarding residents from abuse and neglect.
In 2020, Chairman Casey secured a one-time $100 million funding boost for nursing home oversight in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which is set to expire in September 2023. Thirty-two states and Puerto Rico reported concern that the sunsetting of CARES Act funds will have a negative impact on their ability to complete their work.
In April of this year, Chairman Casey and U.S. Senator Ron Wyden (D-OR) sent a letter to the Senate Appropriations Committee urging that they provide $566 million in funding to CMS’s Survey and Certification program, which was supported in President Biden’s FY 2024 budget proposal.
In August 2021, Casey and Wyden introduced the Nursing Home Improvement and Accountability Act,which would address gaps in staffing, transparency, accountability and oversight of long-term care facilities. The legislation would further increase funding for nursing home surveys—$500 million in survey and certification funding—to improve oversight processes and hire, train, and retain surveyors, a provision the Biden Administration adopted in its fiscal year 2023 budget request.
Read Chairman Casey’s report, “Uninspected and Neglected,” here.
Find a two pager on the report here.
Watch Thursday’s hearing, “Residents at Risk: The Strained Nursing Home Inspection System and the Need to Improve Oversight, Transparency, and Accountability,” and read witness testimonies here.
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