February 14,2008

Grassley, Kohl Work to Improve Care in Nursing Homes


WASHINGTON — Senators Chuck Grassley and Herb Kohl today are introducinglegislation to improve the quality of care in nursing homes with more and better information forconsumers provided by the federal government on the Nursing Home Compare website,requirements for accurate reporting of the staff who are providing direct services in nursing homes,stiffer penalties for serious quality deficiencies, and greater accountability and transparency aboutwho owns and operates nursing homes.

“Improving nursing home care requires constant vigilance,” Grassley said. “Some problemskeep coming up. They need to be fixed so nursing home quality continues to improve and stayimproved. More transparency, enforcement, and staff training are all needed. That’s what our billaddresses.”

“The federal government now spends $75 billion annually on nursing homes throughMedicare and Medicaid, and spending is projected to rise as costs associated with the boomergeneration increase,” Kohl said. “Congress has a responsibility to demand high quality services forresidents and accountability from the nursing home industry in return for this huge investment ofpublic resources.”

Grassley is ranking member and former chairman of the Committee on Finance, withjurisdiction over the federal health care programs that cover nursing home care, and former chairmanof the Special Committee on Aging. Kohl is chairman of the Special Committee on Aging, astanding committee that conducts oversight of issues related to the health, safety, and financial wellbeingof older Americans. The Grassley-Kohl bill is the product of their attention to nursing homequality over recent months in their respective capacities.

Supporting the bipartisan bill are the Service Employees International Union (SEIU) and theNational Citizens’ Coalition for Nursing Home Reform (NCCNHR).

A summary of the bill follows here. The senators’ floor statements of introduction followthat.

Nursing Home Transparency and Improvement Act of 2008

Increases Transparency About Nursing Home Ownership and Operations

* Enables the residents and the government to know who actually owns the nursing home* Strengthens accountability requirements for individual facilities and nursing home chains,including annual independent audits for nursing home chains* Improves Nursing Home Compare by including a nursing home’s ownership information, theidentity of participants in the Special Focus Facility program, a standardized complaint form andlinks to nursing home inspection reports* Provides more transparency of a nursing home’s expenditures by requiring more detail in costreporting* Provides for improved reporting of nurse staffing information so that apples-to-apples comparisonscan be made across nursing homes* Brings uniformity and structure to the nursing home complaint process by requiring a standardizedcomplaint form and complaint resolution processes that includes complainant notification andresponse deadlines

Strengthens Enforcement

* Strengthens available penalties by making them more meaningful.--Instead of imposing civil money penalties (CMPs) up to $10,000, the Secretary would be able toimpose a range of penalties of up to $100,000 for a deficiency resulting in death, $3,000-$25,000for deficiencies at the level of actually harm or immediate jeopardy and not more than $3,000 forother deficiencies.--The Secretary would be able to reduce CMPs for facilities that do not appeal CMPs and for selfreportingdeficiencies below the immediate jeopardy level or the actual harm level if the harm isfound to be a “pattern” or “widespread” or those resulting in death.--Penalties must be collected within 90 days, following a hearing.* Equips the Secretary with tools to address corporate-level problems in nursing home chains bygiving the authority to develop a national independent monitor program specific to multistate andlarge intrastate nursing home chains* Provides greater protection to residents of nursing homes that close by requiring advance noticeof the closure as well as the development of a transfer and relocation plan of residents* Requires a study on the role that financial issues play in poor-performing homes* Requires a study on best practices for the appointment of temporary management for nursinghomes as well as barriers* Requires a study on barriers to purchasing facilities with a record of poor care* Authorizes demonstration projects for nursing home “culture change” and for improving residentcare through health information technologyImproves Staff Training*Improves staff training to include dementia management and abuse prevention training as part ofpre-employment training* Requires a study on increased training requirements either in content or hours for nurse aides andsupervisory staff

Statement of Senator Charles E. GrassleyBefore the United States Senate

Introduction of the Nursing Home Transparency and Improvement Act of 2008

February 14, 2008

Mr. President, I rise today to introduce the Nursing Home Transparency and Improvement Act of2008. I introduce this bill along with Senator Kohl, who serves, as I once did, as chairman of theSpecial Committee on Aging. This is an important piece of legislation that aims to bring someoverdue transparency to consumers regarding nursing home quality. It also provides long neededimprovements to our enforcement system. This legislation also further strengthens nursing homestaff training requirements.

In America today, there are over 1.7 million elderly and disabled individuals in roughly 17,000nursing home facilities. As the baby boom generation ages, this number is going to riseconsiderably.

While many people are using alternatives such as home care or other methods of community-basedcare, nursing homes are going to remain a critical option for our elderly and disabled populations.We owe it to them to make sure that they receive the safe and quality care they deserve.Unfortunately, as in many areas, with nursing homes a few bad apples often spoil the barrel. Toomany Americans receive poor care, often in a subset of nursing homes.

Unfortunately, this subset of chronic offenders stays in business, in many ways keeping their poortrack records hidden from the public at large, and often facing little or no enforcement from thefederal government.

As the Ranking Member of the Senate Finance Committee, I have a longstanding commitment toensuring that nursing home residents receive the safe and quality care we expect for our loved ones.But this effort requires transparency in the nursing home industry so that consumers are armed withthe information they need to make the best decisions possible. This same transparency also providesadditional market incentives for bad homes to improve.

This effort also requires a strong, mandatory enforcement and monitoring system to ensure safe andquality care at facilities that wouldn’t take the steps needed voluntarily.

This piece of legislation seeks to strengthen both areas: transparency and enforcement. It’s a billthat’s good for consumers, good for nursing home residents and good for the nursing homecommunity.

First, let me talk to you about transparency.

In the market for nursing home care, like in all markets, consumers must have adequate data to makeinformed choices.

For years, people looking at a nursing home for themselves or loved ones had no way of knowingwhether that home was a “Special Focus Facility,” a designation meaning they had been singled outas a consistently poor performer.

Why shouldn’t consumers have access to this information? The government has it and so shouldconsumers. To that end, this bill requires that Special Focus Facility designation be placed on theCMS website “Nursing Home Compare.” By giving consumers this information, we will both giveconsumers information necessary to make informed choices and poorly performing homes an extraincentive to shape up, or consumers will go elsewhere.

This bill also requires more transparency about ownership information and inspection reports, moreaccountability for large nursing home chains, and the development and availability of a standardizedresident complaint form so there’s a clear and easy way to report problems and have them resolved.The bill would also bring more transparency on what portion of a nursing home’s spending is usedfor the direct care of residents and also bring more uniformity in the reporting of nurse staffinglevels so that people can make apples-to-apples comparisons between nursing homes.

But even with improved transparency, there are some nursing homes that won’t improve on theirown. In the nursing home industry, most homes provide quality care on a consistent basis. But asin many sectors – this industry is given a bad name by a few bad apples that spoil the barrel.So we need to give inspectors better enforcement tools.

The current system provides incentives to correct problems only temporarily and allows homes toavoid regulatory sanctions while continuing to deliver substandard care to residents.This system must be fixed.

In ongoing correspondence I’ve had with Kerry Weems, the acting administrator of CMS, thatagency has requested the statutory authority to collect civil monetary penalties sooner, and holdthem in escrow pending appeal. To that end, this bill requires penalties to be collected within 90days, following a hearing. After that, they’re held in escrow pending appeal.

Penalties should also be meaningful – too often, they are assessed at the lowest possible amount, ifat all.

Penalties should be more than merely the cost of doing business; they should be collected in areasonable timeframe; and should not be rescinded easily.

These changes would help prod the industry’s bad actors to get their act together or get out of thebusiness.

In addition to increased transparency and improved enforcement, this bill provides common-sensesolutions to a number of other problems as well. This legislation requires the Secretary of Healthand Human Services to establish a national independent monitoring program to tackle problemsspecific to interstate and large intrastate nursing home chains.

This legislation directs the Government Accountability Office to:

-conduct studies on the role, if any, of financial problems in the poor performance of Special FocusFacilities,-identify best practices at the state level in temporary management programs, and-determine what are the barriers preventing the purchase of nursing homes with a record of poorquality care.

Finally, in the case of a nursing home being closed due to poor safety or quality of care, this billrequires that residents and their representatives be given sufficient notice so that they can adequatelyplan a transfer to a better performing home.

I am very sensitive to the fact that nursing home residents are often old and fragile. Moving theminto a new facility is often very traumatic. So---we’ve got to make sure these residents aretransferred appropriately and with the time and care they deserve.

This bill would also strengthen training requirements for nursing staff by including dementia andabuse prevention training as part of pre-employment training.

The Grassley-Kohl Bill also requires a study on the appropriateness of increasing trainingrequirements for nurse aides or supervisory staff.

So I’m glad to introduce this bill today along with Senator Kohl. Mr. President, the Chairman of theAging Committee and I have a long history of working on elder care issues.

We’ll continue to do everything we can to make sure America’s nursing home residents receive thesafe and quality care they deserve. Increasing transparency, improving enforcement tools andstrengthening training requirements will go a long way towards achieving this goal.

Statement of Senator Herb Kohl (D-WI)Before the United States Senate

Introduction of the Nursing Home Transparency and Improvement Act of 2008

February 14, 2008

Mr. President, I rise today to introduce the Nursing Home Transparency and Improvement Act of2008 with my distinguished colleague, Senator Grassley. Senator Grassley conducted a great dealof valuable oversight for nursing homes during his tenure as Aging Committee Chairman from 1997through 2000, and he continues to make major contributions in this area today. Working towardhigher standards of nursing home quality is a tradition of which I am proud to be a part.

It is staggering to think that the most recent major law dictating federal standards for quality, fordata reporting, and for enforcement was passed in 1987. Twenty-one years later, we know that it hasspurred important improvements in the quality of care provided in nursing homes. Yet we are farfrom finished, and there are additional improvements that need to be made.

The first is in the area of transparency. If consumers can easily tell which homes have a solidenforcement track record, which are well-staffed, which are owned by a chain with a good reputationfor providing excellent services—and which homes are not—then this sort of disclosure can serveas a powerful motivation for homes to provide the best possible care, to hire and keep the mostdedicated staff, and to always prioritize the interests of residents. The court of public opinion andthe strength of market forces are powerful and inexpensive tools we should be putting to good use.

Our legislation will make sure all this information is available to consumers in a timely and easy-tousefashion. We want Americans to be able to use the federal government’s website, Nursing HomeCompare, with ease. We want Americans to have access to the type of information that matters, suchas the number of hours of care their loved one will receive from staff every day. We want Americansto be able to use this website to lodge complaints of mistreatment or neglect. These are simple,effective ideas, and our bill will make them a reality.

The second area in need of improvement is our government’s system of nursing home qualityenforcement. Under the current system, nursing homes that are not providing good care, or — evenworse — are putting their residents in harms way, can escape penalty from the government byabusing a lengthy appeal process, while they slip in and out of compliance with federal regulations.This is unacceptable. We need the threat of sanctions to mean something—and under my bill withSenator Grassley, they will. Our legislation will require that all civil monetary penalties be collectedand placed in an escrow account as soon as they are levied, pending the final resolution of anyappeal. Financial penalties will be increased for serious quality deficiencies that cause actual harmto nursing home residents, or put them in “immediate jeopardy.”

In addition, our policy enables regulators to respond effectively when serious quality problems areevident in order to protect the safety of residents. The bill requires that states and facilities providea secure and orderly process when relocating residents due to a nursing home closure. It alsoproposes national demonstrations to promote innovations in information technology and “culturechange” in order to improve resident care.

The federal government now spends $75 billion annually on nursing homes through Medicare andMedicaid, and spending is projected to rise as costs associated with the boomer generation increase.Congress has a responsibility to demand high quality services for residents and accountability fromthe nursing home industry in return for this huge investment of public resources. I urge mycolleagues to join Senator Grassley and myself in sponsoring this commonsense piece of legislation.Thank you, Mr. President, I yield the floor.