Surveyors said that they were "instructed" by their superiors to downgrade citations or not write up facilities for certain high level deficiencies.
Some surveyors said that if a high level deficiency was cited, most of the time it would be reduced to a lower level deficiency or completely deleted from the final report by management without consultation with the reporting surveyor.
Others said that they were told to "rewrite" or "change" survey findings to make the facility "look better" than it really was. And still others described how multiple violations were sometimes bundled and cited as one violation instead of several.
The majority of surveyors interviewed complained that surveys remain too predictable. The predictability of surveys has been a major concern for many years and the reality is that most nursing home administrators know when a surveyor is coming. In fact, the GAO reported in July 2003, that one-third of the most recent surveys nationwide occurred on a predictable schedule.
Indianapolis Attorney Kennard Bennett agrees that surveyors are too predictable in their patterns of annual surveys. If it occurred the second week of March one year, he says, it's most likely to occur the second week of March the next year.
"I have also known too many residents and their family caregivers," he adds, "who are able to see patterns of "sprucing-up" activity that just happen to come right before a survey.
Some surveyors said that they were told to rewrite survey findings to make facilities look better than they really were.
But then, none of these charges are new. The GAO has documented these and other serious problems throughout the nursing home industry repeatedly since 1998.
In one instance, the GAO reviewed a sample of nursing homes with a history of problems, but showed no actual harm deficiencies in their most recent inspections and determined that 40% of these homes had documented incidents of serious harm including avoidable pressure sores, severe weight loss, and multiple falls resulting in broken bones and other injuries, despite the fact that none were listed by the surveyors.
In the recent study released in December 2005, the GAO listed the exact same problems, that while the CMS's survey data shows a decline in the number of nursing homes with serious deficiencies since 1999, it said, the trend masks two continuing problems: (1) serious inconsistency in how states conduct surveys; and (2) the understatement of negative findings.
Inconsistency in states' surveys, it noted, is evidenced by vast interstate variability in the proportion of homes found to have serious deficiencies. For instance, from 2003 to 2005, the report said, California cited only 6% of its nursing homes for serious violations, while Connecticut cited 54% of its facilities.
The investigators found pervasive understatement of "serious deficiencies that cause actual harm or immediate jeopardy to patients," and includes severe weight loss, "multiple falls resulting in broken bones and other injuries, and serious, avoidable pressure sores," the report said.
In 5 large states that had a decline in deficiencies, federal surveyors determined that between 8% and 33% of the comparative surveys identified serious deficiencies that state surveyors missed. This finding is the same problem identified in earlier reports by the GAO showing that state surveyors missed serious care problems.
"Continued understatement of serious deficiencies," the GAO said, "is shown by the increase in discrepancies between federal and state surveys of the same homes from 2002 through 2004, despite an overall decline in such discrepancies from October 1998 through December 2004."
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