Who Regulates Nursing Homes?

Nursing homes in Illinois are licensed, regulated, inspected and/or certified by a number of public and private agencies at the state and federal levels, including the Illinois Department of Public Health (IDPH) and the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS). These agencies have separate -- yet sometimes overlapping -- jurisdictions.

The Illinois Department of Public Health is responsible for ensuring nursing homes comply fully with mandatory state regulations. The Department, under a cooperative agreement with CMS, is also responsible for ensuring that facilities accepting Medicare and Medicaid payment for services rendered to program beneficiaries meet federal regulations and certification rules. Each year, the Department conducts approximately 1,300 full, on-site licensure inspections of nursing homes and responds to approximately 6,000 complaints. These inspections, called surveys, are conducted to evaluate the fitness and adequacy of the nursing home, its equipment, staff, policies, procedures and finances.

In addition to inspection by the state, some Illinois nursing homes are members of national accrediting organization, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which independently inspects member facilities to assess performance.

Illinois, which has approximately 200 surveyors, employs a team concept in inspecting nursing homes. Teams consist of a registered professional nurse (RN), a nutritionist and an environmental health practitioner. On some inspections, the teams may be joined by other professionals, such as life safety code experts. Complaint surveys are conducted by surveyors with expertise is the area involved in the allegations of the complaint.

Illinois’ licensure surveys are generally conducted on-site over a three- to four-day period during which the state’s inspection teams evaluate all aspects of resident care and nursing home procedures and practices, assessing facility compliance with more than 1,500 specific state and federal standards. Samples of specific areas of care reviewed include resident rights, access to care, activities, assessment and care plans, health care and dietary services, housekeeping, staffing, quality of care and quality assurance.

The Department’s evaluation may include an inspection of medical records, observation of resident care, inspection of all areas of the nursing home, and interviews of residents, family members, staff or other individuals. The Department also may evaluate the quality of resident care through an analysis of statistical data reported by nursing homes or by a review of reportable event information or other notices filed with IDPH. Reportable events include administrator or director of nursing personnel changes; interruptions of three or more hours of services essential to the health and safety of residents; alleged or suspected crimes investigated at the facility by police; and all fires, disasters, deaths or other risks to resident life or health resulting form accidents or incidents at the facility.

Inspections in response to complaints are generally shorter in duration than licensure surveys and focus primarily on those areas of resident care alleged to be at fault. If, during the course of a complaint investigation, additional problems are uncovered, a full on-site inspection may be initiated.

Nursing homes are inspected at least once every six to 15 months. The state average is once every 12 months. Nursing home inspections, whether standard or in response to complaints, are conducted without notice to the facility. Survey schedules are changed annually to make it difficult for facilities to anticipate when inspections will be conducted. Generally, facilities with poor surveys and numerous verified complaints are surveyed more frequently than facilities with deficiency-free surveys.

Long-term care surveys are typically conducted on weekdays although survey teams can and have conducted inspections at night, on weekends and during holidays.
At the conclusion of each inspection, the Department’s findings are shared with nursing home administrative staff in an exit interview and are included in a survey report that is forwarded to the facility. If the Department has determined that the nursing home failed to comply with all applicable state and federal licensure standards, the facility will be cited for deficiencies.

A deficiency is a determination by the Department that a nursing home has violated one or more specific licensure or certification regulations. Deficiencies range in scope and severity from isolated violations with no actual harm to residents to widespread violations that cause injuries or put residents in immediate jeopardy of harm. Deficiencies may be cited as a result of an on-site inspection or evaluation of written reports or documentation.

When deficiencies are alleged, the facility is given an opportunity to rebut the deficiencies. If deficiencies are cited, the Department requires the nursing home to submit a written plan of correction within 10 days detailing how and when each deficiency will be corrected. In some cases, IDPH will direct specific corrective measures that must be implemented. In situations where current conditions at the facility pose a serious risk to the health and safety of residents or staff, the Department can demand or initiate immediate corrective actions.

In many cases, nursing homes are given the opportunity to correct less serious deficiencies without incurring fines or other penalties. If warranted, however, the Department may impose a fine, curtail admissions, appoint a temporary manager, issue a provisional license, suspend or revoke a nursing home’s license, close an unlicensed facility, or use other remedies for violations of statutes as provided by state or federal law, or as authorized by federal survey, certification, and enforcement regulations and agreements.

The most common penalty imposed by the Department is a $10,000 per violation civil monetary fine. Fines for violations of federal standards range from $50 to $10,000 per day. While the Department can impose state fines, it can only recommend to CMS that a federal fine be imposed. CMS may then impose, modify or waive the recommended fine, often based on the facility’s cooperation in addressing deficiencies cited.

Nursing homes with repeat or severe violations of federal licensing standards may have their Medicare or Medicaid certification suspended or revoked by CMS. These nursing homes do not receive reimbursement for services given to program participants while the facility is under such a sanction.

When a nursing home is cited for a regulation deficiency that results in a fine, suspension or revocation of a license, or placement on a provisional license, the Department issues a penalty letter identifying the specific violations, charges or reasons for its enforcement action.

Nursing homes have the opportunity to dispute survey findings and penalties imposed. Facilities may ask to discuss the accuracy of survey findings during the course of a survey or during the exit interview.

Nursing homes also may request a formal hearing before an administrative law judge through IDPH’s Division of Legal Services to appeal deficiencies and enforcement actions. At any time before or during the hearing, the Department and the nursing home may agree to a settlement.

All penalty monies collected on violations of state standards are deposited into a special fund used by IDPH to monitor health care facilities that violate licensure standards and in which the owner or operator is unable or unwilling to make necessary corrections. The Long Term Care Monitor and Receivership Fund allows the Department to monitor facilities not in compliance with licensure standards and to safeguard facility patients or residents whether or not the owner is cooperative.

All nursing facilities in Illinois are required to meet mandatory state standards that set the minimum and essential requirements of care that must be provided. Facilities are required to comply with the standards to provide the highest quality of care possible.

Survey teams inspect and evaluate whether facilities meet the required standards and, if so, certify their success in meeting specific care standards. Facilities failing to meet the standards are subject to fine or other enforcement actions.

The information on state and federal inspections and complaint investigations is available from the Department. As you review an inspection report, it is important to remember that nursing homes have the right to appeal survey findings and penalties imposed. Such appeals may be pending at the time the report is issued. On appeal, the department’s decision may be upheld or reversed, or a settlement may be reached in which fines are reduced.

Please note that these inspection reports show only a one-time “snap-shot” of nursing home compliance with established standards. To more fully assess the quality of care provided by a facility, it is important that you review current and past survey reports. You may also wish to discuss services and performance levels with your doctor and with family members or friends who have used the facility.

Complete survey reports and nursing home plans of correction, edited to ensure patient confidentiality, are available at each nursing home as well as at IDPH. The most recent federal inspection surveys are posted on the web at www.medicare.gov/NHCompare/home.asp.

To request a copy of an inspection file through IDPH, write to

Illinois Department of Public Health
Freedom of Information Officer
535 W. Jefferson St.
Springfield, IL 62761
Attn: Division of Communications

Media inquiries must be made to the Division of Communications at 217-782-5750.

If you wish to file a complaint about an Illinois nursing home, call the Department’s toll-free hotline at 1-800-252-4343.
 

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