Audit of Nursing Homes and Denial of Payment Remedies - State of Illinois, A-05-03-00085

EXECUTIVE SUMMARY OBJECTIVES The objectives of our audit were to ensure that the mandatory denial of payment remedy for substandard quality of care was applied to nursing homes that were not in substantial compliance with the prescribed Medicaid participation requirements and to evaluate whether State controls were adequate to prevent improper Medicaid payments to nursing homes under the denial of payment remedy. BACKGROUND This audit was initiated to address the general public concern with nursing home quality of care. Our primary focus was on measures for enforcing nursing home compliance with quality of care standards for Medicaid recipients. We audited denial of payment sanctions, which were in effect from October 1, 1999 to September 30, 2001. Due to widespread need for nursing home reform, Congress passed the Omnibus Budget Reconciliation Act of 1987. This legislation included the Nursing Home Reform Act, which ensured residents received quality care in nursing homes through the establishment of a Residents’ Bill of Rights and the provision of certain services to each resident. It also required nursing homes participating in the Medicaid and Medicare programs to comply with the requirements for standards of care as prescribed by Federal laws. Title XIX, section 1919 of the Social Security Act, established these requirements for nursing facilities, which are implemented by the State and the Secretary of the Department ...