New survey process expands sanctions. HCFA proposes more enforcement remedies and broader disclosure requirements for nursing facilities.

The Health Care Financing Administration (HCFA) has proposed a new process for surveying and certifying nursing facilities for participation in Medicare and Medicaid. The process would be grounded in the principle that all federal requirements must be met and enforced. Surveyors would use a severity and scope scale to evaluate a deficiency's seriousness and determine the appropriate corrective remedy. The more severe or pervasive the facility's shortcomings, the harsher the sanction. HCFA and the states have been reluctant to use the traditional remedy for noncompliant facilities--terminating their participation in Medicare or Medicaid. The available remedies would be expanded to include intermediate sanctions such as temporary management, denial of payment, directed plan of correction, and civil money penalties. The critical factors for determining the remedy would be the severity and scope of the deficiencies and whether they pose an immediate and serious threat to resident well-being. A facility could appeal the specific remedy, but not the conclusion that violations have occurred. Importantly, except for civil money penalties, the states would have to impose enforcement remedies at the time violations are uncovered, regardless of any other provision of state law, such as a policy precluding penalties while a hearing is pending. The proposed regulations also would impose two new notification requirements on nursing facilities--one for any facility that receives a nursing staff waiver, and the other for a facility rendering substandard care.