April 12,2006

Grassley Works to Improve Nation’s Nursing Homes

WASHINGTON --- Sen. Chuck Grassley, Chairman of the Senate Committee on
Finance, today asked the federal government's top official for health and safety standards in
nursing homes to report on how the federal agency in charge will respond to recommendations
made late last year for improving the process in place to survey and certify the nation's nursing

As chairman of the Senate Aging Committee in the late 1990s, Grassley exposed neglect
in some of the nation's 17,000 nursing homes. He continues work to improve standards of care,
staffing issues and consumer information.

The text of Grassley's letter to Administrator Mark McClellan follows here. A story from
The News Journal in Wilmington, Delaware, is attached.

April 12, 2006

The Honorable Mark McClellan, M.D., Ph.D.
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Dear Dr. McClellan:

As Chairman of the Senate Committee on Finance ("Committee") and former Chairman
of the Senate Committee on Aging, I have spent considerable effort conducting oversight of
nursing home quality and specifically the survey and certification process. Residents in nursing
home facilities account for some of the most vulnerable citizens of our country. With nearly 1.7
million elderly and disabled residents in approximately 17,000 facilities, there is a substantial
risk that residents can fall victim to abuse and/or neglect. I have made a longstanding
commitment to ensure that these residents receive the quality care they deserve.
The Centers for Medicare and Medicaid ("CMS") has responsibility for oversight of
health and safety standards for long-term care and skilled nursing facilities. As you are aware,
the bulk of this oversight is conducted through the survey and certification process by state
survey agencies. These state agencies are often "on the front lines" in improving the quality of
care for our nation's elderly and disabled populations. With combined payments from both
Medicare and Medicaid for these facilities totaling nearly $63 million, oversight is not a
part-time job.

There is an unfortunate history of malfeasance in the survey and certification process. All
too often I hear stories of state survey agencies "toning-down" reports of nursing home abuse and
neglect. In the past, my Committee staff has interviewed numerous surveyors from around the
country to obtain their views, guidance and opinions regarding the survey and certification
process. Interviews with these surveyors reveal that they often times face top-down pressure
from superiors in order to "cleanse" negative reports. In fact, a series of articles in the Delaware
News Journal ("Journal") makes clear that this serious problem still exists (see attached). One
article reveals numerous disturbing facts relating to nursing home care and the challenges
surveyors face on a daily basis. For example, a state surveyor with more than 24 years
experience criticized the recent findings of a Delaware state surveyor report. This surveyor
complained that many of the negative findings were "toned-down" and even removed by the state
director of long-term care. In one instance, it was reported that violations such as reporting a
malfunctioning alarm bell for a patient who was susceptible to falls was removed from a
surveyors' final report entirely. In another instance, reports of improper care for a diabetic patient
were also completely removed from a report. Unfortunately, these types of improper care
probably happen all too often and are never reported because of such tampering with surveyor

A December 2005 Government Accountability Office ("GAO") Report on the quality of
nursing home oversight acknowledged the improvements that both CMS and the nursing home
surveyor community have made in the past few years. The GAO revealed improvements
including: implementation of additional guidance to strengthen investigations, improvements in
survey methodology, the implementation of sanctions for serious repeat offenders and conducting
state survey activities. In addition, improvements have been made in both the scope and intensity
of CMS oversight. I applaud these efforts as steps in the right direction.

While improvements have been made in the survey and certification process, there are
indications that serious oversight challenges still persist. In particular, the GAO discovered two
consistent and longstanding problems: serious inconsistencies in the results of state surveys and
the continual understating of negative findings. In addition, it has been reported that there is an
imbalance in the effectiveness of CMS oversight initiatives. Some oversight activities are being
fully implemented while several are stalling.

Ineffective oversight is not only disappointing, indicating that the responsible public
agencies are not properly carrying out their duties, but results in potentially continuous poor
quality care for beneficiaries. I look forward to working with CMS on improving the oversight
of all of our nations nursing facilities and learning how CMS is working to improve all aspects of
nursing home oversight. In particular, I would like to hear how CMS intends to respond to the
findings of the GAO report in question. In this regard, please address the following:

-- It is evident that there is questionable data resulting from state surveys in terms of
both its accuracy and consistency. Often, the information is understated, misconstrued, or just
plain inaccurate. What is CMS doing specifically to address the inconsistencies in survey

-- The accuracy of information on the CMS Nursing Home Compare website has
been called into question on several occasions. As you know, this is often the first and most
accessible resource for those seeking information on the quality of a nursing home. Please
provide to the Committee a detailed description of how CMS handles data or information
discovered to be false or misleading.

-- A chronic and serious problem in the process has been the understating of negative
findings by state surveyor agencies. GAO revealed this to be a continual challenge to CMS as
well. Please provide a detailed description of efforts CMS is taking to rectify this problem.

-- "Random" nursing home surveys are many times not random at all. The level of
predictability of these visits are sometimes all too predictable and this permits nursing home staff
to conceal instances of poor quality care. Please provide a detailed description of current CMS
initiatives aimed at resolving this problem and the improvements that you have documented
resulting from any such initiatives.

I understand that CMS, like most federal agencies, is working during a time of limited
resources and we all can expect these resources to be continually strained for some time. As you
noted in your comments to GAO, the combination of more providers and fewer resources poses a
significant challenge to CMS. However, it is important to empha that we cannot let the gains
we've made be eroded by the trends I have outlined in this letter. In my capacity as Chairman of
the Committee on Finance, I am ready and willing to accommodate you in any way possible to
help CMS achieve the highest level of quality for Medicare and Medicaid beneficiaries,
especially those in our nation's long-term care facilities.

In responding to these requests, please repeat each enumerated question and provide your
response no later than May 1, 2006. I share your commitment to ensuring that our nation's
seniors and beneficiaries are served with the highest level of quality.


Charles E. Grassley