Nursing Homes: Prevalence of Serious Quality Problems Remains	 
Unacceptably High, Despite Some Decline (17-JUL-03,		 
GAO-03-1016T).							 
                                                                 
Since 1998, the Congress and Administration have focused	 
considerable attention on improving the quality of care in the	 
nation's nursing homes, which provide care for about 1.7 million 
elderly and disabled residents in about 17,000 homes. GAO has	 
earlier reported on serious weaknesses in processes for 	 
conducting routine state inspections (surveys) of nursing homes  
and complaint investigations, ensuring that homes with identified
deficiencies correct the problems without recurrence, and	 
providing consistent federal oversight of state survey activities
to ensure that nursing homes comply with federal quality	 
standards. GAO was asked to update its work on these issues and  
to testify on its findings, as reported in Nursing Home Quality: 
Prevalence of Serious Problems, While Declining, Reinforces	 
Importance of Enhanced Oversight, GAO-03-561 (July 15, 2003). In 
commenting on this report, the Centers for Medicare & Medicaid	 
Services (CMS) generally concurred with the recommendations to	 
address survey and oversight weaknesses. In this testimony, GAO  
addresses (1) the prevalence of serious nursing home quality	 
problems nationwide, (2) factors contributing to continuing	 
weaknesses in states' survey, complaint, and enforcement	 
activities, and (3) the status of key federal efforts to oversee 
state survey agency performance and improve quality.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-1016T					        
    ACCNO:   A07552						        
  TITLE:     Nursing Homes: Prevalence of Serious Quality Problems    
Remains Unacceptably High, Despite Some Decline 		 
     DATE:   07/17/2003 
  SUBJECT:   Elder care 					 
	     Elderly persons					 
	     Inspection 					 
	     Long-term care					 
	     Nursing homes					 
	     Surveys						 

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GAO-03-1016T

Testimony Before the Committee on Finance, U. S. Senate

United States General Accounting Office

GAO For Release on Delivery Expected at 10: 00 a. m. Thursday, July 17,
2003 NURSING HOMES

Prevalence of Serious Quality Problems Remains Unacceptably High, Despite
Some Decline

Statement of William J. Scanlon Director* Health Care Issues

GAO- 03- 1016T

The magnitude of documented serious deficiencies that harmed nursing home
residents remains unacceptably high, despite some decline. For the most
recent period reviewed, one in five nursing homes nationwide (about 3,500
homes) had serious deficiencies that caused residents actual harm or
placed them in immediate jeopardy. Moreover, GAO found significant
understatement of care problems that should have been classified as actual
harm or higher* serious avoidable pressure sores, severe weight loss, and
multiple falls resulting in broken bones and other injuries* for a sample
of homes with a history of harming residents. Several factors contributed
to such understatement, including confusion about the definition of harm;
inadequate state review of surveys to identify potential understatement;
large numbers of inexperienced state surveyors; and a continuing problem
with survey timing being predictable to nursing homes. States continue to
have difficulty identifying and responding in a timely fashion to public
complaints alleging actual harm* delays state officials attributed to an
increase in the volume of complaints and to insufficient staff. Although
federal enforcement policy was strengthened in January 2000 by requiring
state survey agencies to refer for immediate sanction homes that had a

pattern of harming residents, many states did not fully comply with this
new requirement, significantly undermining the policy*s intended deterrent
effect.

While CMS has increased its oversight of state survey and complaint
investigation activities, continued attention is required to help ensure
compliance with federal requirements. In October 2000, the agency
implemented new annual performance reviews to measure state performance in
seven areas, including the timeliness of survey and complaint
investigations and the proper documentation of survey findings. The first
round of results, however, did not produce information enabling the agency
to identify and initiate needed improvements. For example, some regional
office summary reports provided too little information to determine

if a state did not meet a particular standard by a wide or a narrow
margin* information that could help CMS to judge the seriousness of
problems identified and target remedial interventions. Rather than relying
on its regional offices, CMS plans to more centrally manage future state
performance reviews to improve consistency and to help ensure that the
results of those reviews could be used to more readily identify serious
problems. Finally, implementation has been significantly delayed for three
federal initiatives that are critical to reducing the variation evident in
the state survey process in categorizing the seriousness of deficiencies
and investigating complaints. These delayed initiatives were intended to
strengthen the methodology for conducting surveys, improve surveyor
guidance for determining the scope and severity of deficiencies, and
increase standardization in state complaint investigation processes. Since
1998, the Congress and

Administration have focused considerable attention on improving the
quality of care in the nation*s nursing homes, which provide care for
about 1. 7 million elderly and disabled residents in about 17, 000 homes.
GAO has

earlier reported on serious weaknesses in processes for conducting routine
state inspections (surveys) of nursing homes and complaint investigations,
ensuring that homes with identified deficiencies correct

the problems without recurrence, and providing consistent federal
oversight of state survey activities to ensure that nursing homes comply
with federal quality standards.

GAO was asked to update its work on these issues and to testify on its
findings, as reported in Nursing Home Quality: Prevalence of Serious
Problems, While Declining, Reinforces Importance of Enhanced Oversight,
GAO- 03561 (July 15, 2003). In commenting on this report, the Centers for
Medicare & Medicaid Services (CMS) generally concurred with the
recommendations to address survey and oversight weaknesses. In this
testimony, GAO addresses

(1) the prevalence of serious nursing home quality problems nationwide,
(2) factors contributing to continuing weaknesses in states* survey,
complaint, and enforcement activities, and (3) the status of key federal
efforts to oversee state survey agency performance and improve quality.
www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 1016T. To view the full product,
including the scope

and methodology, click on the link above. For more information, contact
Kathryn G. Allen on (202) 512- 7118. Highlights of GAO- 03- 1016T, a
testimony

before the Committee on Finance, U. S. Senate

July 17, 2003

NURSING HOMES

Prevalence of Serious Quality Problems Remains Unacceptably High, Despite
Some Decline

Page 1 GAO- 03- 1016T

Mr. Chairman and Members of the Committee: I am pleased to be here today
as you address the quality of care provided to the nation*s 1.7 million
nursing home residents, a highly vulnerable population of elderly and
disabled individuals. The federal government plays a major role in
ensuring nursing home quality and in financing nursing home care. Medicare
and Medicaid paid the nation*s approximately 17,000 homes an estimated $42
billion in 2002 to care for beneficiaries. More specifically, Medicaid
pays for care provided to about two- thirds of all nursing home residents
nationwide. In addition, the

Department of Veterans Affairs contracts with many of these same nursing
homes to provide long- term care to veterans at a cost of more than $250
million in fiscal year 2002. In 1998, the Senate Special Committee on
Aging

held a hearing to address nursing home care problems in California.
Troubled by our findings of poor care in that state*s homes and weak
federal oversight in general, the Committee held additional hearings on
nursing home quality nationwide in 1999 and 2000. In response to
congressional oversight and our recommendations, the Administration has
taken actions intended to address many of the weaknesses we identified.
These weaknesses included:

 periodic state inspections, known as surveys, that understated the
extent of serious care problems due to procedural weaknesses; 
considerable delays that occurred in states investigating complaints by

residents, family members or friends, and nursing home staff alleging
actual harm to residents;  federal enforcement policies that did not
ensure that identified deficiencies were addressed and remained corrected;
and  federal oversight of state survey activities that was often
inconsistent

across states and limited in scope and effectiveness. In September 2000,
we reported on progress made in addressing these weaknesses and concluded
that the success of the Administration*s actions to improve nursing home
quality required sustained federal and state commitment to reach their
full potential. My remarks today will

address federal and state progress made since our September 2000 report
and testimony, focusing in particular on (1) the prevalence of serious
nursing home quality problems, (2) factors contributing to continuing
weaknesses in states* survey, complaint, and enforcement activities, and
(3) the status of key federal efforts to oversee state survey agency

Page 2 GAO- 03- 1016T

performance and improve quality. My remarks are based on our report being
released today that addresses these issues in greater detail. 1 In
summary, the magnitude of serious deficiencies that harmed nursing

home residents remains unacceptably high, despite some decline. For the
most recent period we reviewed, one in five of all nursing homes
nationwide (about 3,500 homes) had serious deficiencies that caused
residents actual harm or placed them in immediate jeopardy. Moreover, we
found significant understatement of care problems that should have been
classified as actual harm or higher* serious avoidable pressure sores,
severe weight loss, and multiple falls resulting in broken bones and other
injuries* for a sample of homes with a history of harming residents. We
identified several factors that contributed to such understatement,
including confusion about the definition of harm; inadequate state
supervisory review of surveys to identify potential understatement; large
numbers of inexperienced state surveyors; and a continuing, significant
problem with survey timing being predictable to nursing homes. States also
continue to have difficulty identifying and responding in a timely fashion
to complaints alleging actual harm* delays that state officials attributed
to an increase in the volume of complaints and to insufficient staff.
Although federal enforcement policy was strengthened in January 2000 by
requiring state survey agencies to refer for immediate sanction homes that
had a pattern of harming residents, we found that many states did not
fully comply with this new requirement. States failed to refer hundreds of
homes for immediate sanction, significantly undermining the policy*s
intended deterrent effect.

While the Centers for Medicare & Medicaid Services (CMS) has increased its
oversight of state survey and complaint investigation activities,
continued attention is required to help ensure compliance with federal
requirements. 2 In October 2000, the agency implemented new annual
performance reviews to measure state performance in seven areas, including
the timeliness of survey and complaint investigations and the proper
documentation of survey findings. The first round of results,

1 U. S. General Accounting Office, Nursing Home Quality: Prevalence of
Serious Problems, While Declining, Reinforces Importance of Enhanced
Oversight, GAO- 03- 561 (Washington, D. C.: July 15, 2003). 2 Effective
July 1, 2001, the name of the Health Care Financing Administration (HCFA)
was changed to the Centers for Medicare & Medicaid Services. In this
testimony we continue to refer to HCFA where our findings apply to the
organizational structure and operations associated with that name.

Page 3 GAO- 03- 1016T

however, did not produce information enabling the agency to identify and
initiate needed improvements. For example, some regional office summary
reports provided too little information to determine if a state agency did
not meet a particular standard by a wide or a narrow margin* information
that could help CMS to judge the seriousness of problems identified and
target remedial actions. Rather than relying on its regional offices, CMS

plans to more centrally manage future state performance reviews to improve
consistency and to help ensure that the results of those reviews could be
used to more readily identify serious problems. Finally, implementation
has been significantly delayed for three federal initiatives that are
critical to reducing the variation evident in the state survey process in
categorizing the seriousness of deficiencies and investigating complaints.
These delayed initiatives were intended to strengthen the methodology for
conducting surveys, improve surveyor guidance for determining the scope
and severity of deficiencies, and increase standardization in state
complaint investigation processes. In our view, finalizing and
implementing these initiatives as quickly as possible would help bring
more clarity and consistency to the process for assessing and

improving the quality of care provided to the nation*s nursing home
residents.

Oversight of nursing homes is a shared federal and state responsibility.
CMS is the federal agency that manages Medicare and Medicaid and oversees
compliance with federal nursing home quality standards. On the basis of
statutory requirements, CMS defines standards that nursing homes must meet
to participate in the Medicare and Medicaid programs and contracts with
states to certify that homes meet these standards through annual
inspections and complaint investigations. The *annual* inspection, called
a survey, which must be conducted on average every 12 months and

no less than every 15 months at each home, entails a team of state
surveyors spending several days in the home to determine whether care and
services meet the assessed needs of the residents. CMS establishes
specific protocols, or investigative procedures, for state surveyors to
use in conducting these comprehensive surveys. In contrast, complaint
investigations, also conducted by state surveyors within certain federal
guidelines and time frames, typically target a single area in response to
a

complaint filed against a home by a resident, the resident*s family or
friends, or nursing home employees. Quality- of- care problems identified
during either standard surveys or complaint investigations are classified
in 1 of 12 categories according to their scope (the number of residents

potentially or actually affected) and their severity (potential for or
occurrence of harm to residents). Background

Page 4 GAO- 03- 1016T

Ensuring that documented deficiencies are corrected is likewise a shared
responsibility. CMS is responsible for enforcement actions involving homes
with Medicare or dual Medicare and Medicaid certification* about 86
percent of all homes. States are responsible for enforcing standards in
homes with Medicaid- only certification* about 14 percent of the total.
Enforcement actions can involve, among other things, requiring corrective
action plans, imposing monetary fines, denying the home Medicare and
Medicaid payments for new admissions until corrections are in place, and,
ultimately, terminating the home from participation in these programs.

Sanctions are imposed by CMS on the basis of state referrals. States may
also use their state licensure authority to impose state sanctions.

CMS is also responsible for overseeing each state survey agency*s
performance in ensuring quality of care in its nursing homes. One of its
primary oversight tools is the federal monitoring survey, which is
required annually for at least 5 percent of all Medicare- and Medicaid-
certified

nursing homes. Federal monitoring surveys can be either comparative or
observational. A comparative survey involves a federal survey team
conducting a complete, independent survey of a home within 2 months of

the completion of a state*s survey in order to compare and contrast the
findings. In an observational survey, one or more federal surveyors
accompany a state survey team to a nursing home to observe the team*s
performance. Roughly 85 percent of federal surveys are observational.
Based on prior work, we have concluded that the comparative survey is the
more effective of the two federal monitoring surveys for assessing state
agencies* abilities to identify serious deficiencies in nursing homes and
have recommended that more priority be given to them. A new federal
oversight tool, state performance reviews, implemented in October 2000,
measures state survey agency performance against seven standards,

including statutory requirements regarding survey frequency, requirements
for documenting deficiencies, and timeliness of complaint investigations.
These reviews replaced state self- reporting of their compliance with

federal requirements. CMS also maintains a central database* the On- Line
Survey, Certification, and Reporting (OSCAR) system* that compiles, among
other information, the results of every state survey conducted at
Medicare- and Medicaid- certified facilities nationwide.

Page 5 GAO- 03- 1016T

State survey data indicate that the proportion of nursing homes with
serious quality problems remains unacceptably high, despite a decline in
such reported problems since mid- 2000. For an 18- month period ending in
January 2002, 20 percent of nursing homes (about 3,500) were cited for

deficiencies involving actual harm or immediate jeopardy to residents.
This share is down from 29 percent (about 5,000 homes) for the previous
period. 3 (Appendix I provides trend data on the percentage of nursing
homes cited for serious deficiencies for all 50 states and the District of
Columbia.) Despite this decline, there is still considerable variation in
the proportion of homes cited for such serious deficiencies, ranging from
about 7 percent in Wisconsin to about 50 percent in Connecticut.

Federal comparative surveys completed during a recent 21- month period
found actual harm or higher- level deficiencies in about 10 percent fewer
homes where state surveyors found no such deficiencies, compared to an
earlier period. Fewer discrepancies between federal and state surveys
suggest that state surveyors* performance in documenting serious
deficiencies has improved. However, the magnitude of the state surveyors*
understatement of quality problems remains a serious issue. From June

2000 through February 2002, federal surveyors conducting comparative
surveys found examples of actual harm deficiencies in about one fifth of
homes that states had judged to be deficiency free. For example, federal
surveyors found that a home had failed to prevent pressure sores, failed
to consistently monitor pressure sores when they did develop, and failed
to

notify the physician promptly so that proper treatment could be started.
These federal surveyors noted that inadequate monitoring of pressure sores
was a problem during the state*s survey that should have been found and
cited. CMS plans to hire a contractor to perform approximately 170

additional comparative surveys each year, bringing the annual total to
330, including those conducted by CMS surveyors. 4 We continue to believe
that comparative surveys are the most effective technique for assessing
state

3 We analyzed OSCAR data for surveys performed from January 1, 1999,
through July 10, 2000, and from July 11, 2000, through January 31, 2002,
and entered into OSCAR as of June 24, 2002. Immediate jeopardy involves
situations with actual or potential for death/ serious

injury. 4 Contractor proposals are due to CMS on July 19, 2003. Magnitude
of

Problems Remains Cause for Concern, Even Though Fewer Serious Nursing Home
Quality Problems Were Reported

Page 6 GAO- 03- 1016T

agencies* ability to identify serious deficiencies in nursing homes
because they constitute an independent evaluation of the state survey. 5
Beyond the continuing high prevalence of actual harm or immediate

jeopardy deficiencies, we found a disturbing understatement of actual harm
or higher deficiencies in a sample of surveys that were conducted since
July 2000 at homes with a history of harming residents but whose current
surveys indicated no actual harm deficiencies. Overall, 39 percent of 76
surveys we reviewed had documented problems that should have been
classified as actual harm: serious, avoidable pressure sores; severe
weight loss; and multiple falls resulting in broken bones and other
injuries. We were unable to assess whether the scope and severity of other
deficiencies in our sample of surveys were also understated because of
weaknesses in how those deficiencies were documented.

Despite increased attention in recent years, widespread weaknesses persist
in state survey, complaint investigation, and enforcement activities. In
our view, this reflects not necessarily a lack of effort but rather the
magnitude of the challenge in effecting important and consistent systemic
change across all states. We identified several factors that contributed
to these weaknesses and the understatement of survey deficiencies,
including confusion over the definition of actual harm. Moreover, many
state complaint investigation systems still have timeliness problems and
some states did not comply with HCFA*s policy to refer to the agency for
immediate sanction those nursing homes that showed a pattern of harming

residents, resulting in hundreds of nursing homes not appropriately
referred for action.

5 In prior work completed on veterans* care in nursing homes, we
recommended that the VA consider contracting with CMS to conduct these
comparative surveys in order to better assess the quality of state data
that are used in placing veterans in nursing homes. See U. S. General
Accounting Office, VA Long- Term Care: Oversight of Community Nursing
Homes Needs Strengthening, GAO- 01- 768 (Washington, D. C.: July 27,
2001). VA has not contracted with CMS to conduct comparative surveys but
is beginning to discuss the issue with CMS. Weaknesses Persist in State
Survey,

Complaint, and Enforcement Activities

Page 7 GAO- 03- 1016T

We identified several factors at the state level that contributed to the
understatement of serious quality- of- care problems. State survey agency
officials expressed confusion about the definitions of *actual harm* and
*immediate jeopardy,* which may contribute to the variability in
identifying deficiencies among states. Several states* comments on our
draft report underscored how the lack of clear and consistent CMS guidance
on these definitions may have contributed to such confusion. For example,
supplementary guidance provided to one state by its CMS regional office on
how to assess the severity of a newly developing pressure sore was
inconsistent with CMS*s definition of actual harm.

Other factors that have contributed to the understatement of actual harm
include lack of adequate state supervisory review of survey findings,
large numbers of inexperienced surveyors, and continued survey
predictability. While most of the 16 states we contacted had processes for
supervisory review of deficiencies cited at the actual harm level and
higher, half did not have similar processes to help ensure that the scope
and severity of less serious deficiencies were not understated. 6
According to state officials, the large number of inexperienced surveyors,
which ranged from 25 percent to 70 percent in 27 states and the District
of Columbia and is

due to high attrition and hiring limitations, has also had a negative
impact on the quality of surveys. In addition, our analysis of OSCAR data
indicated that the timing of about one- third of the most recent state
surveys nationwide remained predictable* a slight reduction from homes*
prior surveys, about 38 percent of which were predictable. Predictable
surveys can allow quality- of- care problems to go undetected because
homes, if they choose to do so, may conceal certain problems such as
understaffing.

CMS*s 2001 review of a sample of complaints in all states demonstrated
that many states were not complying with CMS complaint investigation
timeliness requirements. Specifically, 12 states were not investigating
all immediate jeopardy complaints within the required 2 workdays, and 42
states were not complying with the new requirement established in 1999 to

6 Officials explained the focus on actual harm or higher- level
deficiencies by noting that the potential for sanctions increased the
likelihood that the deficiencies would be challenged by the nursing home
and perhaps appealed in an administrative hearing. Confusion about
Definition of Harm and Other Factors

Contribute to Underreporting of Care Problems

Many State Complaint Investigation Systems Still Have Timeliness Problems
and Other Weaknesses

Page 8 GAO- 03- 1016T

investigate actual harm complaints within 10 days. 7 Some states
attributed the timeliness problem to an increase in the number of
complaints and to insufficient staff. CMS also found that the triaging of
complaints to determine how quickly to investigate each complaint was
inadequate in some states. A CMS- sponsored study of the states* complaint
practices also raised concerns about state approaches to accepting and
investigating complaints. For example, 15 states did not provide toll-
free hotlines to

facilitate the filing of complaints and the majority of states lacked
adequate systems for managing complaints. To address the latter problem,
CMS planned to implement a new complaint tracking system nationwide in
October 2002, but as of today, the system is still being tested and its
implementation date is uncertain.

State survey agencies did not refer a significant number of cases where
nursing homes were found to have a pattern of harming residents to CMS for
immediate sanction as required by CMS policy, significantly undermining
the policy*s intended deterrent effect. Our earlier work found that
nursing homes tended to *yo- yo* in and out of compliance, in part because
HCFA rarely imposed sanctions on homes with a pattern of deficiencies that
harmed residents. 8 In response, the agency required that, as of January
2000, homes found to have harmed residents on successive standard surveys
be referred to it for immediate sanction. 9 While most states did not
forward at least some cases that should have been referred under this
policy, four states accounted for over half of the 700 nursing

7 In March 1999, we reported that inadequate state complaint intake and
investigation practices in states we reviewed had too often resulted in
extensive delays in investigating serious complaints. As a result of our
findings, HCFA began requiring states to investigate complaints that
allege actual harm, but do not rise to the level of immediate jeopardy,
within 10 working days. U. S. General Accounting Office, Nursing Homes:
Complaint Investigation Processes Often Inadequate to Protect Residents,
GAO/ HEHS- 99- 80 (Washington, D. C.: Mar. 22, 1999).

8 See GAO/ HEHS- 99- 46. 9 This policy was implemented in two stages, and
our analysis focused on implementation of the second stage beginning in
January 2000. As of September 1998, HCFA required states to refer homes
that had a pattern of harming a significant number of residents or placed
residents at high risk of death or serious injury. Effective January 14,
2000, HCFA expanded this policy by requiring state survey agencies to
refer for immediate sanction homes that had harmed residents on successive
surveys. States are now required to deny a grace period to correct
deficiencies without sanction to homes that are assessed one or more

deficiencies at the actual harm level or above in each of two surveys
within a survey cycle. A survey cycle is two successive standard surveys
and any intervening survey, such as a complaint investigation. Substantial
Number of Nursing Homes Were Not

Referred to CMS for Immediate Sanctions

Page 9 GAO- 03- 1016T

homes not referred. One of these states did not fully implement the new
CMS policy until mid- 2002 and another state implemented its own version
of the policy through September 2002, resulting in relatively few
referrals. In most other states, the failure to refer cases resulted from
a misunderstanding of the policy by both some states and CMS regional
offices and, in some states, from the lack of an adequate system for
tracking a home*s survey history to determine if it met the policy*s
criteria.

While CMS has instituted a more systematic oversight process of state
survey and complaint activities by initiating annual state performance
reviews, CMS officials acknowledged that the effectiveness of the reviews
could be improved. Major areas needing improvement as a result of the
fiscal year 2001 review include (1) distinguishing between minor and major
problems, (2) evaluating how well states document deficiencies, and (3)
ensuring consistency in how regions conduct reviews. Data limitations,
particularly involving complaints, and inconsistent use of periodic
monitoring reports also hampered the effectiveness of state performance
reviews. For subsequent reviews, CMS plans to more centrally manage the
process to improve consistency and to help ensure that future reviews

distinguish serious from minor problems. Implementation has been
significantly delayed for three federal initiatives that are critical to
reducing the subjectivity in the state survey process for identifying
deficiencies and determining the seriousness of complaints. These delayed
initiatives were intended to strengthen the methodology for conducting
surveys, improve surveyor guidance for determining the scope and severity
of deficiencies, and increase standardization in state complaint
investigation processes.

 Strengthening the survey methodology. Because surveyors often missed
significant care problems due to weaknesses in the survey process, HCFA
contracted in 1998 for the development of a revised survey

methodology. The agency*s contractor has proposed a two- phase survey
process. In the first phase, surveyors would initially identify potential
care problems using data generated off- site prior to the start of the
survey and

additional, standardized information collected on- site. During the second
phase, surveyors would conduct an onsite investigation to confirm and
document the care deficiencies initially identified. Compared to the
current survey process, the revised methodology under development is
designed to more systematically target potential problems at a home and
give surveyors new tools to more adequately document care outcomes and
conduct onsite investigations. In April 2003, a CMS official told us that
the CMS Oversight of

State Survey Activities Requires Further Strengthening

Page 10 GAO- 03- 1016T

agency lacked adequate funding to complete testing and implementation of
the revised methodology under development for almost 5 years. Through
September 2003, CMS will have committed about $4.7 million to this effort.
While CMS did not address the lack of adequate funding in its

comments on our draft report, a CMS official subsequently told us that
about $508,000 has now been slated for additional field testing. This
amount, however, has not yet been approved. Not funding the additional
field testing could jeopardize the entire initiative, in which a
substantial investment has already been made.  Developing clearer
guidance for surveyors. Recognizing

inconsistencies in how the scope and severity of deficiencies are cited
across states, in October 2000, HCFA began developing more structured
guidance for surveyors, including survey investigative protocols for
assessing specific deficiencies. The intent of this initiative is to
enable surveyors to better (1) identify specific deficiencies, (2)
investigate

whether a deficiency is the result of poor care, and (3) document the
level of harm resulting from a home*s identified deficient care practices.
Delays have occurred, and the first such guidance to be completed*
pressure sores* has not yet been released.

 Developing additional state guidance for investigating complaints.

Despite initiation of a complaint improvement project in 1999, CMS has not
yet developed detailed guidance for states to help improve their complaint
investigation systems. CMS received its contractor*s report in June 2002,
and indicated agreement with the report*s conclusion that reforming the
complaint system is urgently needed to achieve a more standardized,
consistent, and effective process. CMS told us that it plans to issue new
guidance to the states in late fiscal year 2003* about 4 years after the
complaint improvement project initiative was launched.

As we reported in September 2000, continued federal and state attention is
required to ensure necessary improvements in the quality of care provided
to the nation*s vulnerable nursing home residents. The proportion of homes
reported to have harmed residents is still unacceptably high, despite the
reported decline in the incidence of such problems. This decline is
consistent with the concerted congressional, federal, and state attention
focused on addressing quality of care problems. Despite these efforts,
however, CMS needs to continue its efforts to better ensure consistent
compliance with federal quality requirements. Several areas that require
CMS*s ongoing attention include: (1) developing more structured guidance
for surveyors to address inconsistencies in how the scope and severity of
deficiencies are cited across states, (2) finalizing and Conclusions

Page 11 GAO- 03- 1016T

implementing the survey methodology redesign intended to make the survey
process more systematic, (3) implementing a nationwide complaint tracking
system and providing states additional complaint investigation guidance,
and (4) refining the newly established state agency performance standard
reviews to ensure that states are held accountable for ensuring that
nursing homes comply with federal nursing home quality standards. Some of
these efforts have been underway for several years, with CMS consistently
extending their estimated completion and implementation dates. The need to
come to closure on these initiatives is clear. The report on which this
testimony is based contained several new recommendations for needed CMS
actions on these issues; CMS generally concurred with our recommendations.
10 We believe that effective and timely implementation of planned
improvements in each of these areas is critical to ensuring better quality
care for the nation*s 1.7 million vulnerable

nursing home residents. Mr. Chairman and Members of the Committee, this
concludes my prepared statement. I will be happy to answer any questions
you may have.

For further information about this testimony, please contact Kathryn G.
Allen at (202) 512- 7118 or Walter Ochinko at (202) 512- 7157. Jack
Brennan, Patricia A. Jones, and Dean Mohs also made key contributions to
this statement.

10 GAO- 03- 561. Contact and Staff

Acknowledgments

Page 12 GAO- 03- 1016T

Number of homes surveyed Percentage of homes cited for

actual harm or immediate jeopardy Percentage point difference a

State 1/ 97- 6/ 98 1/ 99- 7/ 00 7/ 00- 1/ 02 1/ 97- 6/ 98 1/ 99- 7/ 00 7/
00- 1/ 02 1/ 97- 6/ 98 and 1/ 99- 7/ 00 1/ 99- 7/ 00 and

7/ 00- 1/ 02

Alabama 227 225 228 51.1 42.2 18.4 -8.9 -23.8 Alaska 16 15 15 37.5 20.0
33.3 -17.5 13.3 Arizona 163 142 147 17.2 33.8 8.8 16.6 -25.0 Arkansas 285
273 267 14.7 37.7 27.3 23.0 -10.4 California 1,435 1,400 1,348 28.2 29.1
9.3 0.9 -19.9 Colorado 234 227 225 11.1 15.4 26.2 4.3 10.8 Connecticut 263
262 259 52.9 48.5 49.4 -4.4 0.9 Delaware 44 42 42 45.5 52.4 14.3 6.9 -38.1
District of Columbia 24 20 21 12.5 10.0 33.3 -2.5 23.3 Florida 730 753 742
36.3 20.8 20.1 -15.5 -0.8 Georgia 371 368 370 17.8 22.6 20.5 4.8 -2.0
Hawaii 45 47 46 24.4 25.5 15.2 1.1 -10.3 Idaho 86 83 84 55.8 54.2 31.0
-1.6 -23.3 Illinois 899 900 881 29.8 29.3 15.4 -0.5 -13.9 Indiana 602 590
573 40.5 45.3 26.2 4.8 -19.1 Iowa 525 492 494 39.2 19.3 9.9 -19.9 -9.4
Kansas 445 410 400 47.0 37.1 29.0 -9.9 -8.1 Kentucky 318 312 306 28.6 28.8
25.2 0.2 -3.7 Louisiana 433 387 367 12.7 19.9 23.4 7.2 3.5 Maine 135 126
124 7.4 10.3 9.7 2.9 -0.6 Maryland 258 242 248 19.0 25.6 20.2 6.6 -5.5
Massachusetts 576 542 512 24.0 33.0 22.9 9.0 -10.2 Michigan 451 449 441
43.7 42.1 24.7 -1.6 -17.4 Minnesota 446 439 431 29.6 31.7 18.8 2.1 -12.9
Mississippi 218 202 219 24.8 33.2 19.6 8.4 -13.5 Missouri 595 584 569 21.0
22.3 10.2 1.3 -12.1 Montana 106 104 103 38.7 37.5 25.2 -1.2 -12.3 Nebraska
263 242 243 32.3 26.0 18.9 -6.3 -7.1 Nevada 49 52 51 40.8 32.7 9.8 -8.1
-22.9 New Hampshire 86 83 79 30.2 37.3 21.5 7.1 -15.8 New Jersey 377 359
366 13.0 24.5 22.4 11.5 -2.1 New Mexico 88 82 82 11.4 31.7 17.1 20.3 -14.6
New York 662 668 671 13.3 32.2 32.3 18.9 0.2 North Carolina 407 414 419
31.0 40.8 30.1 9.8 -10.7 North Dakota 88 89 88 55.7 21.3 28.4 -34.4 7.1
Ohio 1,043 1,047 1,029 31.2 29.0 23.7 -2.2 -5.3 Oklahoma 463 432 394 8.4
16.7 20.6 8.3 3.9 Oregon 171 158 152 43.9 47.5 33.6 3.6 -13.9 Pennsylvania
811 788 764 29.3 32.2 11.6 2.9 -20.6

Appendix I: Trends in The Proportion of Nursing Homes Cited for Actual
Harm or Immediate Jeopardy Deficiencies, 1999- 2002

Page 13 GAO- 03- 1016T

Number of homes surveyed Percentage of homes cited for

actual harm or immediate jeopardy Percentage point difference a

State 1/ 97- 6/ 98 1/ 99- 7/ 00 7/ 00- 1/ 02 1/ 97- 6/ 98 1/ 99- 7/ 00 7/
00- 1/ 02 1/ 97- 6/ 98 and 1/ 99- 7/ 00 1/ 99- 7/ 00 and

7/ 00- 1/ 02

Rhode Island 102 99 99 11.8 12.1 10.1 0.3 -2.0 South Carolina 175 178 180
28.6 28.7 17.8 0.1 -10.9 South Dakota 124 112 114 40.3 24.1 30.7 -16.2 6.6
Tennessee 361 354 377 11.1 26.0 16.7 14.9 -9.3 Texas 1,381 1,336 1,275
22.2 26.9 25.5 4.7 -1.5 Utah 98 95 95 15.3 15.8 15.8 0.5 0.0 Vermont 45 46
45 20.0 15.2 17.8 -4.8 2.6 Virginia 279 287 285 24.7 19.9 11.6 -4.8 -8.3
Washington 288 279 275 63.2 54.1 38.5 -9.1 -15.6 West Virginia 130 147 143
12.3 15.6 14.0 3.3 -1.7 Wisconsin 438 428 421 17.1 14.0 7.1 -3.1 -6.9
Wyoming 38 41 40 28.9 43.9 22.5 15.0 -21.4

Nation 17,897 17,452 17,149 27.7 29.3 20.5 1.6 -8.8

Source: GAO analysis of OSCAR data as of June 24, 2002. a Differences are
based on numbers before rounding.

Page 14 GAO- 03- 1016T

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. GAO- 03- 187. Washington, D. C.:
October 31, 2002.

Nursing Homes: Quality of Care More Related to Staffing than Spending.

GAO- 02- 431R. Washington, D. C.: June 13, 2002.

Nursing Homes: More Can Be Done to Protect Residents from Abuse.

GAO- 02- 312. Washington, D. C.: March 1, 2002.

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data Should
Complement State Activities. GAO- 02- 279. Washington, D. C.: February 15,
2002.

VA Long- Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO- 01- 768. Washington, D. C.: July 27, 2001. Nursing
Homes: Success of Quality Initiatives Requires Sustained

Federal and State Commitment. GAO/ T- HEHS- 00- 209. Washington, D. C.:
September 28, 2000.

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the
Quality Initiatives. GAO/ HEHS- 00- 197. Washington, D. C.: September 28,
2000.

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better
Ensure Quality. GAO/ HEHS- 00- 6. Washington, D. C.: November 4, 1999.

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to
Better Ensure Quality of Care. GAO/ T- HEHS- 00- 27. Washington, D. C.:
November 4, 1999.

Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/ HEHS- 99- 154R. Washington, D.
C.: August 13, 1999.

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will
Require Continued Commitment. GAO/ T- HEHS- 99- 155. Washington, D. C.:
June 30, 1999.

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/ HEHS- 99- 157. Washington, D. C.: June 30, 1999. Related
GAO Products

Page 15 GAO- 03- 1016T

Nursing Homes: Complaint Investigation Processes in Maryland.

GAO/ T- HEHS- 99- 146. Washington, D. C.: June 15, 1999.

Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/ HEHS- 99- 80. Washington, D. C.: March 22, 1999.

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to
Better Ensure Adequate Care. GAO/ T- HEHS- 99- 89. Washington, D. C.:
March 22, 1999.

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. GAO/ HEHS- 99- 46. Washington, D. C.: March 18,
1999.

California Nursing Homes: Federal and State Oversight Inadequate to
Protect Residents in Homes with Serious Care Problems. GAO/ T- HEHS98-
219. Washington, D. C.: July 28, 1998.

California Nursing Homes: Care Problems Persist Despite Federal and State
Oversight. GAO/ HEHS- 98- 202. Washington, D. C.: July 27, 1998.

(290310)

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