Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety (28-DEC-05,
GAO-06-117).
Since 1998, GAO has issued numerous reports on nursing home
quality and safety that identified significant weaknesses in
federal and state oversight. Under contract with the Centers for
Medicare & Medicaid Services (CMS), states conduct annual nursing
home inspections, known as surveys, to assess compliance with
federal quality and safety requirements. States also investigate
complaints filed by family members or others in between annual
surveys. When state surveys find serious deficiencies, CMS may
impose sanctions to encourage compliance with federal
requirements. GAO was asked to assess CMS's progress since 1998
in addressing oversight weaknesses. GAO (1) reviewed the trends
in nursing home quality from 1999 through January 2005, (2)
evaluated the extent to which CMS's initiatives have addressed
survey and oversight problems identified by GAO and CMS, and (3)
identified key challenges to continued progress in ensuring
resident health and safety. GAO reviewed federal data on the
results of state nursing home surveys and federal surveys
assessing state performance; conducted additional analyses in
five states with large numbers of nursing homes; reviewed the
status of its prior recommendations; and identified key workforce
and workload issues confronting CMS and states.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-117
ACCNO: A43917
TITLE: Nursing Homes: Despite Increased Oversight, Challenges
Remain in Ensuring High-Quality Care and Resident Safety
DATE: 12/28/2005
SUBJECT: Comparative analysis
Data collection
Health care facilities
Health surveys
Long-term care
Medicaid
Medicare
Noncompliance
Nursing homes
Patient care services
Performance measures
Quality control
Safety standards
Standards
State programs
Strategic planning
HCFA Online Survey, Certification, and
Reporting System
******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO Product. **
** **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced. Tables are included, but **
** may not resemble those in the printed version. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
******************************************************************
GAO-06-117
* Results in Brief
* Background
* Standard Surveys and Complaint Investigations
* Enforcement Policy
* Oversight
* Available Data Show Significant Overall Decrease in Serious
* CMS Has Addressed Many Shortcomings in Survey and Oversight
* Surveys: Key Initiatives Are under Development, but Most Hav
* Survey Methodology
* Investigative Protocols
* Definitions of Actual Harm and Immediate Jeopardy
* Additional Survey Initiatives
* Survey Predictability
* Complaint Investigations: CMS Has Strengthened State Guidanc
* Complaint Guidance
* Complaint Oversight
* Enforcement: CMS Has Strengthened the Potential Deterrent Ef
* Immediate Sanctions Policy
* Additional Enforcement Policy Issues
* Special Focus Facility Program
* Civil Money Penalties
* Past Noncompliance Policy
* Oversight: Intensity and Scope of Federal Efforts Has Increa
* Federal Comparative Surveys
* Smoke Detectors in Homes without Sprinklers
* Assessments of State Survey Activities
* Data Systems and Analysis
* Sharing Data with the Public
* Quality Improvement Organizations
* Coordination and Dissemination of Best Practices
* Resource and Workload Issues Pose Key Challenges to Further
* Cost Could Delay Retrofitting of Older Nursing Homes with Sp
* States Continue to Have Problems in Hiring and Retaining Sur
* Workload Issues and Competing Priorities Pose Challenges for
* Increased Workload Has Contributed to Delays
* Number of Providers Subject to Surveys Is Growing
* Key Nursing Home Initiatives Continue to Compete for Priorit
* Concluding Observations
* Agency and State Comments and Our Evaluation
* GAO Contact
* Acknowledgments
* GAO's Mission
* Obtaining Copies of GAO Reports and Testimony
* Order by Mail or Phone
* To Report Fraud, Waste, and Abuse in Federal Programs
* Congressional Relations
* Public Affairs
Report to Congressional Requesters
United States Government Accountability Office
GAO
December 2005
NURSING HOMES
Despite Increased Oversight, Challenges Remain in Ensuring High-Quality
Care and Resident Safety
Nursing Home Quality and Safety Initiatives
GAO-06-117
Contents
Letter 1
Results In Brief 4
Background 6
Available Data Show Significant Overall Decrease in Serious Quality
Problems but Indicate Continued Inconsistency and Understatement in State
Findings 9
CMS Has Addressed Many Shortcomings in Survey and Oversight Activities,
but Work Continues on Some Key Initiatives 15
Resource and Workload Issues Pose Key Challenges to Further Improving
Nursing Home Quality and Safety 37
Concluding Observations 45
Agency and State Comments and Our Evaluation 46
Appendix I Prior GAO Recommendations, Related CMS Initiatives, and
Implementation Status 50
Appendix II Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy during Standard Surveys 59
Appendix III Percentage of Homes Surveyed Within 15 Days of the 1-Year
Anniversary of Prior Survey 62
Appendix IV Percentage of State Nursing Home Surveyors with 2-Years'
Experience or Less, 2002 and 2005 65
Appendix V Comments from the Centers for Medicare & Medicaid Services 66
Appendix VI GAO Contact and Staff Acknowledgments 73
Related GAO Products 74
Tables
Table 1: Scope and Severity of Deficiencies Identified During Nursing Home
Surveys 8
Table 2: Percentage of Nursing Homes Identified as Having Serious
Deficiencies during State Nursing Home Surveys, July 2003 through January
2005 11
Table 3: Federal Comparative Surveys in Five States that Identified
Serious Deficiencies Missed by State Surveys and the Number of Missed
Deficiencies, March 2002 through December 2004 14
Table 4: Nursing Home Surveys: CMS Initiatives and Implementation Status
16
Table 5: Percentage of Predictable Current Nursing Home Surveys, as of
April 2002 and July 2005 20
Table 6: Complaint Investigations: CMS Initiatives and Implementation
Status 20
Table 7: Enforcement: CMS Initiatives and Implementation Status 24
Table 8: Oversight: CMS Initiatives and Implementation Status 28
Table 9: Percentage of Surveyors with 2 Years' Experience or Less, as of
July 2005 40
Table 10: Implementation Status of CMS's Initiatives Responding to GAO's
Nursing Home Quality and Safety Recommendations, July 1998 through
November 2004 51
Table 11: Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy, by State 60
Table 12: Percentage of Nursing Homes with Predictable Surveys, April 2002
and June 2005 63
Figures
Figure 1: Percentage of Nursing Homes Nationwide with Serious
Deficiencies, January 1999 through January 2005 10
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious
Deficiencies Not Identified in State Surveys 12
Abbreviations
AHFSA Association of Health Facility Survey Agencies
ASPEN Automated Survey Processing Environment
AST ASPEN Scheduling and Tracking
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
MDS minimum data set
MFCU Medicaid Fraud Control Unit
NFPA National Fire Protection Association
OSCAR On-Line Survey, Certification, and Reporting system
QIO Quality Improvement Organization
QIS Quality Indicator Survey
RN registered nurse
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.
United States Government Accountability Office
Washington, DC 20548
December 28, 2005
The Honorable Charles E. Grassley Chairman Committee on Finance United
States Senate
The Honorable Herb Kohl Ranking Minority Member Special Committee on Aging
United States Senate
Numerous congressional hearings since July 1998 have focused attention on
the need to improve the care and safety of the nation's 1.5 million
nursing home residents, a highly vulnerable population of elderly and
disabled individuals for whom remaining at home is no longer feasible.
Many nursing home residents require help with feeding, toileting,
grooming, or other routine activities of daily living; are cognitively
impaired; or have chronic health care conditions such as heart disease.
Some individuals with chronic conditions are long-term residents of
nursing homes, while others enter nursing homes for a short period, such
as after a hospitalization. With the aging of the baby boom generation,
the number of individuals needing nursing home care is expected to
increase in size dramatically. Combined Medicare and Medicaid payments for
nursing home services were about $65 billion in 2003, including a federal
share of about $43 billion.1
In a series of reports, we have identified significant weaknesses in
federal and state activities designed to detect and correct quality and
safety problems at nursing homes.2 Our key findings included the
following:
1Medicare is the federal health care program for elderly and disabled
people. In addition to other health and long-term care services, Medicare
covers up to 100 days of nursing home care following a hospital stay.
Medicaid is the joint federal-state health care financing program for
certain categories of low-income individuals. Medicaid also pays for
long-term care services, including nursing home care. Data for 2003 are
the most recent data available.
2See Related GAO Products at the end of this report.
o A small but unacceptable proportion of nursing homes repeatedly
caused actual harm to residents, such as worsening pressure sores
or untreated weight loss, or placed residents at risk of death or
serious injury.
o The results of state inspections, known as surveys, understated
the extent of serious quality-of-care and fire safety problems,
reflecting weaknesses in the survey methodology and an
inconsistent application of federal standards.
o Serious complaints by residents, family members, or staff
alleging harm to residents remained uninvestigated for weeks or
months, and delays in the reporting of abuse allegations
compromised the quality of available evidence, hindering
investigations.
o When serious deficiencies were identified, federal and state
enforcement policies did not ensure that the deficiencies were
addressed and remained corrected.
o Federal mechanisms for overseeing state monitoring of nursing
home quality and safety were limited in their scope and
effectiveness.
The Centers for Medicare & Medicaid Services (CMS)-the federal
agency responsible for managing the Medicare and Medicaid
programs, as well as overseeing compliance with federal nursing
home standards-announced a set of initiatives intended to address
many of the weaknesses we identified in July 1998 as well as
needed improvements CMS identified in its own self-assessment.3
Over time, CMS has refined and expanded these initiatives,
including launching a Web site-Nursing Home Compare-that has
progressively increased the data available to the public about the
care provided by nursing homes.4 You asked us to review the
progress made by CMS since 1998 in addressing quality and safety
problems in the nation's nursing homes. In response to your
request, we (1) reviewed the trends in nursing home quality by
analyzing nursing home survey results, (2) evaluated the extent to
which CMS's initiatives have addressed survey and oversight
shortcomings identified by us and CMS, and (3) identified key
remaining challenges to continued progress in ensuring resident
health and safety.
To assess trends in nursing home quality, we analyzed data from
the federal On-Line Survey, Certification, and Reporting system
(OSCAR), which compiles the results of state nursing home surveys;
we focused on trend data since CMS announced its nursing home
initiatives. We have used OSCAR data since 1997 to track trends in
the proportion of homes found to have harmed residents or placed
them at risk of immediate jeopardy. To better understand the
trends identified through our OSCAR analysis, we evaluated the
results of federal comparative surveys for all states for the
period March 2002 through December 2004 and compared the results
for two other time periods-October 1998 through May 2000 and June
2000 through February 2002. Federal comparative surveys are
conducted at nursing homes recently surveyed by the state to
assess the adequacy of the state surveys. We judgmentally selected
five large states-California, Florida, New York, Ohio, and
Texas-for additional analysis based on the change in the
proportion of homes cited with serious deficiencies, geographic
representation, and the number of nursing homes. These five states
account for almost 30 percent of the nation's nursing homes.5 CMS
officials generally recognize OSCAR data to be reliable. We have
used OSCAR data in prior work to examine nursing home quality
issues and we updated certain data for this report. Throughout the
course of our work, we discussed our analysis of OSCAR data with
CMS officials at both the central office and the regional offices
to ensure that the data accurately reflected state nursing home
survey activities. We determined that these data were accurate for
our purposes.
To evaluate the extent to which survey and oversight shortcomings
we identified had been addressed by CMS's initiatives, we reviewed
the status of our recommendations, and updated our understanding
of the initiatives by analyzing relevant documentation and
discussing their implementation status with CMS officials (see
app. I). We also discussed with CMS officials the initiatives
implemented as a result of CMS's self-assessment of needed
improvements. We focused on four areas: surveys, complaints,
enforcement, and oversight. We discussed the preliminary findings
from our OSCAR data trend analysis with CMS and state survey
agency officials. To assess the remaining challenges to continued
improvement of nursing home oversight, we identified through
interviews with CMS and state survey agency officials key
workforce and workload issues that confront states and CMS in
protecting the health and safety of nursing home residents. We
also contacted officials at the Association of Health Facility
Survey Agencies (AHFSA) to update information on surveyor turnover
and retention issues. We conducted our review from May through
December 2005 in accordance with generally accepted government
auditing standards.
CMS's nursing home survey data show a significant decrease in the
proportion of nursing homes with serious quality problems, from
about 29 percent in 1999 to about 16 percent by January 2005, but
this trend masks two important and continuing issues:
inconsistency among state surveyors in conducting surveys and
understatement by state surveyors of serious deficiencies.
Inconsistency in states' surveys is demonstrated by CMS data that
reveal continued wide interstate variability in the proportion of
homes found to have serious deficiencies. For example, in the most
recent time period, one state found such deficiencies in about 6
percent of homes, whereas another state found them in about 54
percent of homes. We previously reported that confusion about the
definition of actual harm contributed to inconsistency and
understatement in state surveys. In addition, state surveyors
continue to understate serious deficiencies, as shown by the
larger number of serious deficiencies identified in federal
comparative surveys than in state surveys of the same homes.
Although federal comparative surveys since October 1998 show an
overall decline in the proportion that identify serious
deficiencies not identified by state surveys, data for the two
most recent periods show an increase in such discrepancies, from
22 percent to 28 percent of comparative surveys. In the five large
states we reviewed, federal surveyors concluded that the state
surveyors had missed serious deficiencies in from 8 percent to 33
percent of comparative surveys-that is, these deficiencies existed
and should have been identified at the time of the state survey.
The federal surveyors' assessment is consistent with our July 2003
findings: a sample of deficiencies demonstrated considerable
understatement of quality-of-care problems such as serious,
avoidable pressure sores. The continuing evidence of inconsistency
in survey results among states and understated deficiencies
underscores the importance of CMS's initiatives to improve the
consistency and rigor of nursing home surveys.
CMS has addressed many of the shortcomings we identified in
nursing home survey and oversight activities, but several
important initiatives have not yet been implemented, such as those
intended to make state surveys more consistent across states and
to reduce the understatement of deficiencies. Important steps CMS
has taken include (1) revising the survey methodology, (2) issuing
states additional guidance to strengthen complaint investigations,
(3) implementing immediate sanctions for homes cited for repeat
serious violations, and (4) strengthening oversight by conducting
assessments of state survey activities. In addition, CMS has
undertaken initiatives of its own. For example, it has made
important information available to the public on nursing home
quality through its Nursing Home Compare Web site and has
contracted with independent quality organizations to work with
nursing homes to improve quality. Although CMS has addressed many
weaknesses in survey and oversight processes, other initiatives
either have not effectively targeted the problems identified or
have shortcomings that impair their effectiveness. For example,
CMS has not fully addressed issues with the accuracy and
reliability of the data underlying consumer information published
on its Web site.
CMS, states, and nursing homes face a number of key resource and
workload challenges in their efforts to further improve nursing
home quality and safety. CMS is moving to require older nursing
homes to install sprinkler systems, a proven life-saving device,
but implementation could be delayed because of concerns about the
cost of the retrofit to these homes. CMS indicated that it plans
to ask for public comment about the length of the phase-in period
rather than proposing one itself. States are continuing to
experience problems in hiring and retaining qualified surveyors, a
factor that survey agency officials believe contributes to
inconsistency and understatement in the citation of serious
deficiencies. State survey agencies attributed high turnover and
recruiting difficulties to the lack of competitive salaries for
registered nurses (RN), who are a major component of states'
surveyor workforce, and intense competition from hospitals and
other providers because of the RN shortage. Increased nursing home
oversight has strained both CMS and state survey agency resources,
resulting in delays for some key initiatives. For example, CMS has
undertaken time-consuming state survey agency performance reviews
and significantly increased the number of federal comparative
surveys performed. In addition, state survey agency workloads have
grown as a result of initiatives that require the prompt
investigation of complaints alleging resident harm and the need to
conduct on-site revisits at nursing homes to ensure that serious
problems actually have been corrected. However, the increased
number of quality and safety initiatives has required CMS to
establish priorities, with some initiatives taking precedence over
others. For example, CMS attached a high priority to including
quality indicator data on its public Web site and implemented this
initiative promptly, while the revision of the survey process has
encountered delays due to higher priorities. Continued attention
and commitment to improving nursing home oversight are essential
to maintaining the momentum built by CMS's accomplishments to date
and thus better ensuring quality care and safety for nursing home
residents.
In commenting on a draft of this report, CMS generally concurred
with our findings, describing the progress it has made in several
areas and agreeing that challenges remain. CMS also indicated that
while it remained concerned about understatement, it did not
believe that understatement was worsening. CMS described the
ongoing challenges it faces and the steps it will take to address
them. In commenting on the section of the draft report focused on
trends in nursing home quality, the states we reviewed commented
on the actions they have taken to improve nursing home survey
quality and the challenges they face in conducting nursing home
survey and oversight activities.
Oversight of nursing homes is a shared federal-state
responsibility. Based on statutory requirements, CMS defines
standards that nursing homes must meet to participate in the
Medicare and Medicaid programs and contracts with states to assess
whether homes meet these standards through annual surveys and
complaint investigations. A range of statutorily defined sanctions
is available to CMS and the states to help ensure that homes
maintain compliance with federal quality requirements. CMS also is
responsible for monitoring the adequacy of state survey
activities.6
Every nursing home receiving Medicare or Medicaid payment must
undergo a standard survey not less than once every 15 months, and
the statewide average interval for these surveys must not exceed
12 months.7 During a standard survey, separate teams of surveyors
conduct a comprehensive assessment of federal quality-of-care and
fire safety requirements. In contrast, complaint investigations
generally focus on a specific allegation regarding resident care
or safety.
The quality-of-care component of a survey focuses on determining
whether (1) the care and services provided meet the assessed needs
of the residents and (2) the home is providing adequate quality
care, including preventing avoidable pressure sores, weight loss,
and accidents. Nursing homes that participate in Medicare and
Medicaid are required to periodically assess residents' care needs
in 17 areas, such as mood and behavior, physical functioning, and
skin conditions, in order to develop an appropriate plan of care.
Such resident assessment data are known as the minimum data set
(MDS). To assess the care provided by a nursing home, surveyors
select a sample of residents and (1) review data derived from the
residents' MDS assessments and medical records; (2) interview
nursing home staff, residents, and family members; and (3) observe
care provided to residents during the course of the survey. CMS
establishes specific investigative protocols for state survey
teams-generally consisting of RNs, social workers, dieticians, and
other specialists-to use in conducting surveys. These procedural
instructions are intended to make the on-site surveys thorough and
consistent across states.
The fire safety component of a survey focuses on a home's
compliance with federal standards for health care facilities.8 The
fire safety standards cover 18 categories ranging from building
construction to furnishings. Examples of specific requirements
include the use of fire- or smoke-resistant construction
materials, the installation and testing of fire alarms and smoke
detectors, and the development and routine testing of a fire
emergency plan. Most states use fire safety specialists within the
same department as the state survey agency to conduct fire safety
inspections, but about one-third of states contract with their
state fire marshal's office.
Complaint investigations provide an opportunity for state
surveyors to intervene promptly if problems arise between standard
surveys. Complaints may be filed against a home by a resident, the
resident's family, or a nursing home employee either verbally, via
a complaint hotline, or in writing. Surveyors generally follow
state procedures when investigating complaints but must comply
with certain federal guidelines and time frames. In cases
involving resident abuse, such as pushing, slapping, beating, or
otherwise assaulting a resident by individuals to whom their care
has been entrusted, state survey agencies may notify state or
local law enforcement agencies that can initiate criminal
investigations. States must maintain a registry of qualified nurse
aides, the primary caregivers in nursing homes, that includes any
findings that an aide has been responsible for abuse, neglect, or
theft of a resident's property. The inclusion of such a finding
constitutes a ban on nursing home employment.
Deficiencies identified during either standard surveys or
complaint investigations are classified in 1 of 12 categories
according to their scope (i.e., the number of residents
potentially or actually affected) and their severity. An A-level
deficiency is the least serious and is isolated in scope, while an
L-level deficiency is the most serious and is considered to be
widespread in the nursing home (see table 1). States are required
to enter information about surveys and complaint investigations,
including the scope and severity of deficiencies identified, in
CMS's OSCAR database.
Table 1: Scope and Severity of Deficiencies Identified During
Nursing Home Surveys
Source: CMS.
aActual or potential for death/serious injury.
bNursing home is considered to be in "substantial compliance."
Ensuring that documented deficiencies are corrected is a shared
federal-state responsibility. CMS imposes sanctions on homes with
Medicare or dual Medicare and Medicaid certification on the basis
of state referrals. CMS normally accepts a state's recommendation
for sanctions but can modify it. The scope and severity of a
deficiency determine the applicable sanctions, which can involve,
among other things, requiring training for staff providing care to
residents, imposing money fines, denying the home Medicare and
Medicaid payments for new admissions, and terminating the home
from participation in these programs. States are responsible for
enforcing standards in homes with Medicaid-only
certification-about 14 percent of homes. They may use the federal
sanctions or rely on their own state licensure authority and
nursing home sanctions.
CMS is responsible for overseeing each state survey agency's
performance in ensuring quality of care in nursing homes
participating in Medicare or Medicaid. Its primary oversight tools
are statutorily required federal monitoring surveys conducted
annually in at least 5 percent of the state-surveyed Medicare and
Medicaid nursing homes in each state and annual state performance
reviews. 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 81 percent of the
approximately 800 federal monitoring surveys are observational.
Performance reviews examine state survey agency compliance with
seven standards: (1) timeliness of the survey, (2) documentation
of survey results, (3) quality of state agency investigations and
decision making, (4) timeliness of adverse action procedures, (5)
budget analysis, (6) timeliness and quality of complaint
investigations, and (7) timeliness and accuracy of data entry.
CMS's nursing home survey data show a significant decrease in
serious quality problems in recent years, but other information
indicates that this trend masks two important and continuing
issues: inconsistency in how states conduct surveys and
understatement of serious quality problems. OSCAR data continue to
show wide interstate variability in the proportion of homes found
to have serious deficiencies, suggesting inconsistency in states'
interpretation and application of federal regulations. We
previously reported that confusion about the definition of actual
harm contributed to inconsistency and understatement in state
surveys. Moreover, although federal comparative surveys conducted
from October 1998 through December 2004 showed a decline in the
proportion of serious deficiencies that were not identified by
state surveys, this overall trend masks a more recent increase
from 2002 through 2004 in federally identified understatement of
serious deficiencies. In five large states we examined with a
significant decline in the proportion of homes found to have
harmed residents, federal comparative surveys found that a
significant proportion of state surveys had missed serious
deficiencies, that is, state surveyors either failed to cite the
deficiencies altogether or cited them at too low a level of scope
and severity.
From January 1999 through January 2005, the proportion of nursing
homes nationwide with actual harm or immediate jeopardy
deficiencies declined from about 29 percent to about 16 percent.
Figure 1 shows the proportion of homes nationwide with these
deficiencies for four consecutive time periods from January 1999
through January 2005.9 During the 6-year time period, 41 states
had a decline in serious deficiencies ranging from about 5 to
about 36 percentage points (see app. II).
Figure 1: Percentage of Nursing Homes Nationwide with Serious
Deficiencies, January 1999 through January 2005
The nationwide data show a decline in nursing homes cited for
serious deficiencies; however, the data obscure the continued
significant interstate variation in the proportion of homes with
serious deficiencies, which suggests inconsistency in how states
conduct surveys. Table 2 shows that while 10 states identified
serious deficiencies in less than 10 percent of the homes
surveyed, 15 states found similar deficiencies in more than 20
percent of homes surveyed from July 2003 through January 2005. For
example, during that period California identified actual harm and
immediate jeopardy deficiencies in about 6 percent of the state's
nursing homes, while Connecticut found such deficiencies in
approximately 54 percent of its facilities. Since January 1999,
the proportion of homes with serious deficiencies had declined
nearly 23 percentage points in California but increased by about 6
percentage points in Connecticut.
Table 2: Percentage of Nursing Homes Identified as Having Serious
Deficiencies during State Nursing Home Surveys, July 2003 through
January 2005
Source: GAO analysis of OSCAR data.
We discussed the decline in serious deficiencies in the five large
states we examined with state survey agency officials and
officials from the responsible CMS regional offices. Officials in
four of the five states believed that there had been some
improvement in nursing home quality. CMS regional office
officials, however, were concerned about the magnitude of the
decline in serious deficiencies in two states-Texas and
California. The Texas state survey agency noted both some
improvement in quality as well as a significant number of
inexperienced surveyors who it believed were hesitant in citing
actual harm. The San Francisco regional office and state survey
agency officials acknowledged that confusion by state surveyors as
to what constituted actual harm had contributed to the decline in
California. The regional office staff discussed this issue with
California survey agency officials and believed that training
combined with the CMS inquiries might have contributed to a recent
increase in actual harm deficiency citations.
The overall decline in the proportion of federal comparative
surveys nationwide that noted serious deficiencies not identified
by state surveyors across the three time periods we examined masks
a reversal of this trend in the most recent time period analyzed,
suggesting ongoing understatement of deficiencies. The time
periods analyzed were October 1998 through May 2000, June 2000
through February 2002, and March 2002 through December 2004. From
October 1998 through February 2002, the proportion of federal
comparative surveys nationwide that noted serious deficiencies
that were not identified by state surveyors declined from 34
percent to 22 percent (see fig. 2). However, federal surveys
conducted from March 2002 through December 2004 that found serious
deficiencies not identified by state surveyors increased from 22
percent to 28 percent. In addition, our work in the five states we
examined demonstrates continued understatement by state surveyors
of serious deficiencies that cause actual harm or immediate
jeopardy.
Figure 2: Percentage of Federal Comparative Surveys That Noted
Serious Deficiencies Not Identified in State Surveys
Because some serious deficiencies found by federal, but not state,
surveyors may not have existed at the time of the state survey,10
CMS requires its regional offices to specifically identify on
worksheets which deficiencies state surveyors had missed during
the state survey. We analyzed CMS regional office worksheets for
73 comparative surveys in five large states-California, Florida,
New York, Ohio, and Texas-with a significant decline in serious
deficiencies from January 1999 through January 2005.11 Overall, 18
percent of these federal comparative surveys identified at least
one serious deficiency missed by state surveyors, ranging from a
low of 8 percent in Ohio to a high of 33 percent in Florida (see
table 3). Table 3 also shows that in comparative surveys noting
serious deficiencies that state surveyors missed, from one to
seven serious deficiencies were missed. Federal surveyors'
findings of understatement of serious deficiencies are consistent
with our own work. Our July 2003 report analyzed state surveys of
homes with a history of harming residents but whose most current
survey identified quality-of-care problems at below the level of
harm; we concluded that about 40 percent of the 76 homes we
analyzed had harmed residents, including instances of severe
weight loss; multiple falls resulting in broken bones and other
injuries; and serious, avoidable pressure sores. Similarly, our
November 2004 report on Arkansas nursing home deaths found
numerous instances of serious, understated quality-of-care
problems.
Table 3: Federal Comparative Surveys in Five States that
Identified Serious Deficiencies Missed by State Surveys and the
Number of Missed Deficiencies, March 2002 through December 2004
Source: GAO analysis of federal comparative surveys conducted from
March 2002 through December 2004.
aOn one comparative survey, federal surveyors did not provide
information on whether any of the deficiencies they identified
existed at the time of the state survey; therefore, this number
may be understated.
bThe number of serious missed deficiencies could be higher because
federal surveyors sometimes did not indicate whether they believed
that a serious deficiency they cited had existed at the time of
the state survey and therefore was missed by state surveyors.
Our prior reports identified five factors that we believe
contribute to inconsistency and the understatement of deficiencies
by state surveyors: (1) weaknesses in CMS's survey methodology;
(2) confusion about the definition of actual harm; (3)
predictability of surveys, which allows homes to conceal problems
if they so desire; (4) inadequate quality assurance processes at
the state level to help detect understatement in the scope and
severity of deficiencies; and (5) inexperienced state surveyors
due to retention problems. CMS has initiatives under way to revise
the survey methodology and address the confusion about what
constitutes harm, and it has taken some steps to reduce survey
predictability. However, CMS did not implement the recommendation
in our July 2003 report to strengthen the ability of state quality
assurance processes to detect understatement. While it agreed with
the intent of our recommendation, CMS indicated that its state
performance standards initiative already incorporated this
concept. The status of these initiatives and state workforce
issues are discussed in the following section.
CMS has addressed many shortcomings in nursing home survey and
oversight activities both in response to our recommendations and
as a result of its own assessment of needed improvements, but it
is still working on key initiatives that have not yet been
implemented.12 Appendix I provides a complete listing of our
previous recommendations and the implementation status of CMS
initiatives taken in response. Examples of CMS's initiatives to
address shortcomings include (1) revising the survey methodology,
(2) issuing states additional guidance to strengthen complaint
investigations, (3) implementing immediate sanctions for homes
cited for repeat serious violations, and (4) strengthening
oversight by conducting assessments of state survey activities.
CMS also has published information on its Web site about nursing
home quality and has engaged independent quality organizations to
work with nursing homes to improve quality.13 Despite CMS's
initiatives in four distinct areas-surveys, complaints,
enforcement, and oversight-some initiatives either have not
effectively targeted the problems we identified or have
shortcomings that impair their effectiveness.
Several CMS initiatives are intended to address shortcomings in
the survey process, but most of these initiatives are in the
developmental stage and have not yet been implemented. In
addition, despite CMS's efforts to make scheduling of surveys less
predictable, many remain predictable. (See table 4).
Table 4: Nursing Home Surveys: CMS Initiatives and Implementation
Status
Source: GAO analysis of CMS initiatives.
In response to our 1998 recommendation to improve the rigor of the
survey methodology to help ensure that surveyors do not miss
significant care problems, CMS took some interim steps and
launched a longer-term initiative. As interim steps, CMS
instructed state survey agencies in 1999 to (1) increase the
sample of residents reviewed during surveys and (2) review
available quality indicator information on the care provided to a
home's residents before actually visiting the home. By using the
quality indicators, which are essentially numeric warning signs of
the prevalence of care problems, to select a preliminary sample of
residents before the on-site review, surveyors are better prepared
to target their surveys and to identify potential care problems.14
Surveyors augment the preliminary sample with additional resident
cases once they arrive in the home.
For the longer term, CMS awarded a contract in 1998 to revise the
methodology used to survey nursing homes, and the agency plans to
pilot this new methodology in the fall 2005. Under development for
7 years, the proposed two-stage, data-driven Quality Indicator
Survey (QIS) is intended to systematically target potential
problems at nursing homes. Its expanded sample should help
surveyors better assess the scope of any deficiencies identified.
In stage 1, a large resident sample will be drawn and relevant
data from on- and off-site sources will be analyzed to develop a
set of quality-of-care indicators, which will be compared to
national benchmarks.15 Stage 2 will systematically investigate
potential quality-of-care concerns identified in stage 1. In June
2005, CMS selected five states to pilot test the new survey
methodology.16 The QIS pilot test will begin during the fall 2005,
with a final evaluation of the pilot due in the fall 2006. The
evaluation will examine the QIS's cost-effectiveness, focusing on
the time and surveyor team size required under QIS compared to the
current survey methodology, and on the QIS's impact on deficiency
citations. In developing the QIS, CMS has attempted to prevent
increases in the time required to complete surveys. Depending on
evaluation findings and any subsequent streamlining of the QIS,
national implementation could begin in mid-2007.
Since 2001, CMS has been developing surveyor investigative
protocols to ensure greater rigor in on-site investigations of
specific quality-of-care areas. We recommended in July 2003 that
CMS finalize the development of these important protocols;
however, CMS is still working on this initiative. In 2001, CMS
hired a contractor to facilitate the convening of expert panels
for the development and review of these protocols.17 In November
2004, more than 1 year later than scheduled, CMS implemented a
protocol on pressure sores. Since then, CMS has implemented
protocols in two other areas-incontinence and medical director
qualifications and responsibilities. The protocols provide
detailed interpretive guidelines and severity guidance. Protocols
in seven more areas are under development, with an issuance target
of fall 2005.18
To promote increased consistency among states in deficiency
citations, a work group of CMS central office, regional office,
and state survey agency staff was convened in early 2005 to
clarify the definitions of actual harm and immediate jeopardy. Our
July 2003 report noted that confusion about the definitions
contributed to the understatement of serious deficiencies.
According to CMS, the 2005 draft revised definition of actual harm
attempts to clarify the existing definition by eliminating
confusing language and identifying indicators and examples of
actual harm.19 The draft revised definition of immediate jeopardy
is intended to provide additional guidance on documenting whether
deficiencies are at the immediate jeopardy severity level,
including criteria for identifying whether immediate jeopardy
exists, and updates examples of immediate jeopardy. A CMS official
indicated that the draft revised definition of immediate jeopardy
stresses that action must be taken at once to prevent harm. As of
August 2005, CMS had no target issuance date for the revised
definitions.
CMS is implementing two additional survey initiatives-developing
guidance to ensure surveyors are able to report concerns to CMS
regional offices and studying surveyors' use of photographic
evidence.
o To address anecdotal reports that surveyors are sometimes asked
to overlook or downgrade survey findings, CMS has issued and is
obtaining state comments on draft guidance to ensure that
surveyors can cite survey findings without such inappropriate
pressure. Currently, surveyors report concerns to the state survey
agency. CMS officials indicated that the draft guidance tries to
(1) establish a nonthreatening option for voicing concerns to CMS
regional office staff without overburdening the regional offices
with additional investigations and (2) give CMS a way to identify
any patterns of problems. Implementation of this effort is
anticipated in late 2005.
o CMS also contracted for a study of the use of photographic
evidence by surveyors to support survey findings. In our 2004
report on Arkansas nursing home deaths, we reported that
photographs taken by coroners provided key evidence supporting
neglect of nursing home residents and the existence of serious,
avoidable care problems. The goal of CMS's study is to identify
issues and develop training materials related to surveyors' use of
photographic evidence. This study began in the summer 2005, with
final training materials to be issued in the summer 2006.
In 1998, we reported that nursing homes could mask certain
deficiencies if they chose to because of survey predictability.
CMS responded by directing states to (1) avoid scheduling a home's
survey for the same month of the year as the home's previous
standard survey and (2) begin at least 10 percent of standard
surveys outside the normal workday (either on weekends, early in
the morning, or late in the evening).20 However, our current
analysis showed that a significant proportion of state nursing
home surveys remain predictable. We consider surveys to be
predictable if they are conducted within 15 days of the
anniversary of a home's prior survey.21 From 2002 to 2005, the
proportion of predictable surveys increased from 13 percent to
14.5 percent (see app. III). Overall, 29 states had an increase in
survey predictability. As shown in table 5, as of July 2005, from
10 percent to over 50 percent of current nursing home surveys in
35 states were conducted within 15 days of the anniversary of a
home's last standard survey. CMS officials stated that avoiding
surveys close to the 12-month anniversary of a home's prior
survey, while meeting the requirements that surveys occur not less
than once every 15 months and maintaining a statewide average
interval of 12 months, could require increased funding because
more surveys would need to be accomplished within the first 9
months after a survey.22 However, CMS noted that states are not
currently funded to conduct surveys within the first 9 months
after the previous survey. CMS officials also told us that CMS had
introduced the ASPEN Scheduling and Tracking (AST) module for its
central and regional offices and the states in February 2004 as a
tool to reduce survey predictability; however, state officials we
spoke with about AST were unfamiliar with its survey
predictability features.23
Table 5: Percentage of Predictable Current Nursing Home Surveys,
as of April 2002 and July 2005
Source: GAO analysis of OSCAR data.
Notes: "Predictable surveys" are defined as surveys conducted
within 15 days of the anniversary of homes' prior surveys.
CMS has completed certain initiatives to ensure that quality
problems found during complaint investigations are promptly
addressed and has taken steps to address weaknesses in the
notification and investigation of abuse in nursing homes. CMS is
continuing work on (1) ensuring state compliance with federal
nurse aide registry requirements and (2) assessing the
effectiveness of conducting employee background checks. (See table
6).
Table 6: Complaint Investigations: CMS Initiatives and
Implementation Status
Source: GAO analysis of CMS initiatives.
CMS guidance issued since 1999 has helped to strengthen state
procedures for investigating complaints. In 1999, we reported that
complaints alleging that nursing home residents were being harmed
were not being investigated for weeks or months in several states
and recommended that CMS develop additional standards for the
prompt investigation of serious complaints alleging situations
that may harm residents but are categorized as less than immediate
jeopardy. CMS promptly instructed states to investigate complaints
alleging harm to a resident within 10 workdays of receiving the
complaint and later specified that investigations of these
complaints be conducted on-site at the nursing home.24 During
1999, CMS developed and issued guidance intended to help states
identify complaints that allege harm to residents. Also in 1999,
CMS hired a contractor to study and recommend improvements to
state complaint practices. CMS used the findings of this study to
develop more detailed guidance for states to help improve the
effectiveness of complaint investigations. In 2004, CMS issued
this guidance to states, which further clarified the 1999
instructions on identifying actual harm.
In March 2002, we recommended that CMS ensure that state survey
agencies immediately notify local law enforcement agencies or
Medicaid Fraud Control Units (MFCU) of allegations or confirmed
complaints of abuse.25 In response, CMS issued a March 2002 letter
to CMS regional offices and state survey agencies clarifying its
policies on abuse reporting time frames, requirements for
reporting to local law enforcement and/or the MFCU, displaying
complaint telephone numbers, and citing abuse on surveys. CMS
issued additional guidance in December 2004 clarifying nursing
home reporting requirements and definitions for alleged
violations, including mistreatment, neglect, abuse, injuries of
unknown source, and misappropriation of resident property. CMS has
not, however, implemented our March 2002 recommendation to
accelerate the agency's campaign to increase public awareness of
nursing home abuse through the development and distribution of
posters that are to be prominently displayed in nursing homes, and
other materials.26
CMS has taken three important steps to improve its oversight of
state complaint investigations, including allegations of abuse.
First, it required in its annual state performance review, which
was established in fiscal year 2001 and fully implemented in
fiscal year 2002, that federal surveyors review a sample of
complaints in each state to determine whether states properly
categorize complaints (i.e., determine how quickly they should be
investigated), investigate complaints within the time specified,
and properly include the results of investigations in CMS's
database. Our March 1999 report on complaints had recommended that
CMS strengthen its oversight in these areas. During its 2004
review of state performance, CMS identified 5 states that did not
meet the standard for properly categorizing complaints and 13
states that did not conduct timely investigations of all
complaints alleging immediate jeopardy to residents; however, 11
of the 13 states missed the requirement by a small margin.27
States failing state performance review standards are asked to
submit a corrective action plan to CMS.
Second, in January 2004, CMS implemented a new national automated
complaint tracking system, the ASPEN Complaints and Incidents
Tracking System. Our March 1999 report on enforcement noted that
the lack of a national complaint reporting system hindered CMS's
and states' ability to adequately track the status of complaint
investigations as well as CMS's ability to maintain a full
compliance history on each nursing home. To address these
concerns, we recommended the development of a better management
information system. One goal of CMS's new management information
system is to standardize reported complaints so that analysis can
be conducted across all states. This system is intended to provide
CMS with an effective tool for overseeing and managing state
complaint investigations.28
Third, in November 2004, CMS requested state survey agency
directors to self-assess their states' compliance with federal
requirements for maintaining and operating nurse aide registries,
to which states are required to report substantiated findings of
abuse, neglect, or theft of nursing home residents' property by
nurse aides. CMS has not issued a formal report of findings from
the state self-assessment, but CMS officials noted that as a
result of resource constraints some states reported having
difficulty maintaining compliance with certain federal
requirements, such as (1) timely entry by state survey staff of
information in nurse aide registries and (2) state notification to
nursing homes employing nurse aides found guilty of abuse at
another facility. In our March 2002 report, we recommended that
CMS shorten the state survey agencies' time frames for determining
whether to include findings of abuse in the nurse aide registry.
Annotations to nurse aide registries are made after final
determinations that abuse occurred, which entail completion of the
state's investigation as well as adjudication of any appeals.29
Until the final determination, residents may continue to be
exposed to aides who are allegedly abusive. CMS noted that while
most of the time frames are defined in regulation, it can review
the time frames when regulatory changes are considered. No changes
to the regulations had been made as of August 2005.
As part of its third effort, CMS also is conducting a Background
Check Pilot Program. Our March 2002 report recommended an
assessment of state policies and practices for complying with
federal requirements prohibiting employment of individuals
convicted of abusing nursing home residents. The pilot program
will test the effectiveness of state and national
fingerprint-based background checks on employees of long-term care
facilities, including nursing homes.30 Pilot programs in seven
states-Alaska, Idaho, Illinois, Michigan, Nevada, New Mexico, and
Wisconsin-will be phased in from fall 2005 through September 2007.
An independent evaluation is planned.
CMS significantly strengthened the potential deterrent effect of
enforcement actions by requiring immediate sanctions for homes
found to have a pattern of harming residents. Moreover, CMS
continues to develop new policies and to clarify existing ones in
order to strengthen enforcement activities and encourage nursing
home compliance with federal requirements. (See table 7).
Table 7: Enforcement: CMS Initiatives and Implementation Status
Source: GAO analysis of CMS initiatives.
Responding to our July 1998 recommendation to eliminate grace
periods for homes cited for repeat serious violations, CMS began a
two-stage phase-in of a new enforcement policy. In the first
stage, effective September 1998, CMS required states to refer for
immediate sanction homes found to have a pattern of harming
residents or of exposing them to actual harm or potential death or
serious injury (H-level deficiencies and above on CMS's scope and
severity grid). Effective January 2000, CMS expanded this policy,
requiring referral of homes found to have harmed one or a small
number of residents (G-level deficiencies) on successive standard
surveys.31 In response to our 2003 finding that states failed to
refer a substantial number of homes that met the criteria for the
immediate sanctions, CMS initiated oversight of state compliance
with this policy. To conduct this oversight, CMS analyzed
deficiency data for 2000 through 2003 to identify potential
instances of homes that should have been but were not referred for
immediate sanctions. In ongoing work, we are assessing the impact
and implementation of the immediate sanctions policy.
Based on recommendations in our July 1998 report and our March
1999 report on enforcement, CMS has addressed weaknesses in its
policies in three areas: nursing homes' correction of
deficiencies, the nursing home appeals process, and the
enforcement data tracking system.
o CMS now requires on-site follow-up, referred to as a revisit,
of homes with substandard quality of care or actual harm or
higher-level deficiencies until the state verifies correction of
each deficiency cited.32 Our 1998 report found that CMS's policy
of allowing nursing homes to self-report resumed compliance was
sometimes inappropriately applied to homes with deficiencies in
the immediate jeopardy category or that were found to have
substandard quality of care. We recommended that CMS require that
for homes with recurring serious violations, state surveyors
substantiate resumed compliance by means of an on-site revisit.
CMS also has issued additional guidance on the "reasonable
assurance period" during which terminated homes must demonstrate
that they have corrected the deficiencies that led to their
terminations.33 This guidance provided additional examples of
reasonable assurance decisions.
o CMS and the Department of Health and Human Services (HHS)
requested and received funding and staffing increases for the HHS
Departmental Appeals Board in fiscal years 1999 and 2000 to
address our March 1999 finding that the growing backlog of appeals
hampered the effectiveness of civil money penalties by delaying
their collection. The Board is responsible for adjudicating the
appeals. By August 2003, the backlog of appeals of civil money
penalties had been significantly reduced.
o CMS implemented the automated ASPEN Enforcement Manager on
October 1, 2004, to facilitate tracking of enforcement actions.
Prior to implementing this system, CMS had no centralized system
for tracking or managing federal and state enforcement actions.34
The ASPEN Enforcement Manager is intended to provide real-time
entry and tracking of enforcement actions, issue monitoring
alerts, generate enforcement letters, and facilitate analysis of
enforcement patterns. CMS expects that ASPEN Enforcement Manager
data will enable states, CMS regional offices, and the CMS central
office to more easily track and evaluate nursing home performance
and compliance status as well as respond to emerging issues. In
ongoing work, we are assessing whether data from the ASPEN
Enforcement Manager can be used to analyze nursing homes'
deficiency and enforcement histories.35
In December 2004, CMS revised the method for selecting nursing
homes for the Special Focus Facility Program to ensure that the
most poorly performing homes were included in the program and to
strengthen enforcement for those nursing homes with an ongoing
pattern of substandard care.36 For this program, first initiated
in January 1999, states were directed to select two nursing homes
to be special focus facilities, conduct two standard surveys each
year in the special focus facilities, and submit monthly status
reports on the selected homes. The revised guidance directs states
to select, from an expanded list of facilities, a minimum of up to
six nursing homes, depending on the number of nursing homes in the
state; the revised guidance gives states the option to select more
than the minimum.37 States are also given the flexibility to
remove from the list homes that have made significant
improvements. Enforcement authority over special focus facilities
has been strengthened so that while homes are in the Special Focus
Facility Program, immediate sanctions must be imposed if homes
fail to significantly improve performance from one survey to the
next; termination from participation in Medicare and Medicaid is
required for homes with no significant improvement in 18 months
and three surveys.
In April 2004, CMS launched a Civil Money Penalty Improvement
Project to improve its ability to track and collect civil money
penalties in an effort to make them a more effective enforcement
tool. CMS mapped out the current process for tracking and
collecting civil money penalties to identify weaknesses and
developed draft guidance with detailed policies and procedures for
addressing areas identified as needing improvement, with a target
release date of fall 2005. Also planned are enhancements to the
Civil Money Penalty Tracking System, CMS's information system for
civil money penalties. The enhancements are intended to streamline
the system, improve its reporting capabilities, and improve its
compatibility with the enforcement monitoring system. The system's
changes are planned to occur through 2005 and 2006.
Also in 2004, CMS, in conjunction with various state survey
agencies, began developing a civil money penalty grid-an optional
guideline for use by states and CMS regional offices to help
ensure greater consistency across states in the amounts of civil
money penalties recommended. The grid is expected to provide
ranges for minimum civil money penalties for deficiencies, while
allowing for flexibility to adjust the penalties on the basis of
factors such as the severity of an identified deficiency, the care
areas in which deficiencies were cited, and past history of
noncompliance.38 The target issuance date for a draft grid was
August 2005.
In October 2005, CMS issued a revised past noncompliance policy
that (1) clarifies how to address recently identified past
deficiencies, (2) further defines "past noncompliance," (3)
eliminates the use of the term "egregious," and (4) clarifies the
methods for determining whether past noncompliance has been
corrected. Past noncompliance occurs when a current survey reveals
no deficiencies but determines that an egregious violation of
federal standards occurred in the past and was not identified
during an earlier survey.39 In November 2004, we reported that
CMS's past noncompliance policy was ambiguous. The policy did not
define what constituted an egregious violation or relate egregious
violations to its scope and severity grid. Moreover, the policy
did not hold homes accountable for negligence associated with
resident deaths unless current residents are experiencing the same
quality-of-care problems and it obscures the nature of care
problems. CMS's revised policy responds to our recommendation and
holds homes accountable for all past noncompliance resulting in
harm to residents. We also recommended that past noncompliance
citations identify the specific nature of the care problem in the
OSCAR database and on the Nursing Home Compare Web site. In 2007,
CMS plans to enhance the information on the Nursing Home Compare
Web site to include the specific nature of the past noncompliance.
According to CMS officials, the delay is related to the
implementation of higher priority initiatives by the agency.
Currently, the Web site only indicates whether there were
instances of past noncompliance and does not identify the nature
of the care deficiency.
CMS has significantly improved the intensity and scope of its
oversight activities and has made significant improvements both in
its data systems and in its analysis and use of the data it
collects on survey activities. The effectiveness of several of
these oversight initiatives, however, is uneven, and more work
remains to be done. (See table 8).
Table 8: Oversight: CMS Initiatives and Implementation Status
Source: GAO analysis of CMS initiatives.
In response to recommendations in our November 1999 and July 2004
reports, CMS has (1) significantly increased the number of federal
comparative surveys both for quality of care and fire safety and
(2) decreased the time between the end of the state survey and the
start of the federal survey for quality-of-care comparative
surveys, allowing CMS to better distinguish between serious
problems missed by state surveyors and changes in a home that
occurred after the state survey. We found earlier that CMS was
making negligible use of comparative surveys, its most effective
tool for assessing a state survey agency's ability to identify
serious quality-of-care and fire safety deficiencies in a nursing
home, to fulfill its 5 percent monitoring mandate.40 Only 21
quality-of-care comparative surveys were conducted from November
1996 through October 1998. Our 2004 fire safety report found that
CMS had conducted only 40 fire safety comparative surveys in
fiscal year 2003, ranging from 4 in some states to none in others.
Since 2001, CMS has required its regional offices to complete at
least two quality-of-care comparative surveys per state per year,
but federal surveyors have been exceeding this minimum
threshold.41 During the period March 1, 2002, through December 31,
2004, CMS completed 424 comparative surveys, about 140 per year.
In addition, the average elapsed time between state and
comparative surveys has decreased from 33 calendar days for the 64
comparative surveys we reviewed in 1999 to 26 calendar days for
the 424 surveys completed through 2004.
CMS planned to further increase the number of comparative surveys
by contracting in the fall of 2003 for 170 quality-of-care
comparative surveys in addition to those conducted by federal
surveyors. However, an increase in the number of quality-of-care
comparative surveys is unlikely because of delays in contractor
readiness and the addition of fire safety comparative surveys to
the contract. CMS had expected to have a sufficient number of
contract surveyors trained and available to start surveys by the
winter of 2005, but it took longer than anticipated to train the
new surveyors. In addition, CMS modified the contract to include
fire safety comparative surveys. In fiscal year 2005, the
contractor conducted 34 quality-of-care comparative surveys and
250 fire safety comparative surveys. Together, the contractor and
CMS regional offices conducted a total of 859 fire safety
comparative surveys in fiscal year 2005. CMS also is using the
contract surveyors to augment federal survey teams. According to
CMS, it will use contract funds carried over from earlier years to
conduct quality-of-care comparative surveys during fiscal year
2006, and will only use fiscal year 2006 funds to conduct fire
safety comparative surveys.
In response to a recommendation in our July 2004 report to
strengthen fire safety standards, CMS published an interim final
rule in March 2005 requiring nonsprinklered nursing homes to
install battery-powered smoke detectors in resident rooms and
common areas, including resident dining, activity, and meeting
rooms. Previously, federal standards required smoke detectors in
(1) corridors or resident rooms only in homes built after 1981 and
(2) nonsprinklered resident rooms containing furniture brought
from the resident's home. We reported that the lack of smoke
detectors in resident rooms may delay staff response and fire
department notification, which in turn may increase the number of
nursing home fire-related fatalities. CMS will begin surveying
nursing homes' compliance with the new requirement in May 2006.
In October 2000, CMS regional offices began conducting on-site
state performance reviews to assess compliance with federal
standards.42 Previously, CMS permitted states to evaluate and
report on their own performance against a number of standards, a
technique that essentially allowed states to write their own
report cards because CMS did not independently validate
information provided by the states. In fiscal year 2005, CMS began
to tie funding increases for state survey agencies to one of the
seven performance standards-the timely conduct of standard
surveys-time frames that are established in federal statute.
Nevertheless, in our current analysis of the standard that is
intended to measure the supportability of survey findings, we
found that three key issues we identified in July 2003 still
exist. First, distinctions in state performance were hard to
identify because, while some states have consistently met the
standard for documentation of deficiencies, federal comparative
surveys completed during essentially the same time frame found
that surveyors in these states frequently missed serious
deficiencies. Second, CMS regional offices were inconsistent in
conducting state performance reviews. For fiscal year 2004, five
states nationwide did not meet this standard, but three of the
five states were in one CMS region. Third, the standard for
assessing the supportability of deficiencies is composed of 11
elements that mix major and minor issues.43 Although CMS has
simplified the standard for assessing the supportability of
deficiencies, we believe that many of the elements reviewed remain
essentially administrative in nature rather than substantive.44 Of
the elements that make up the standard, only 2 assess the
appropriateness of the cited scope and severity; the remaining
elements assess such issues as how the deficiency is written,
including avoiding the use of the passive voice. We do not believe
that this standard is sufficiently focused on identifying
understatement.
CMS did not implement our July 2003 recommendation that it require
states to review a sample of deficiencies cited at or below the
level of actual harm in order to detect understatement because,
according to CMS, the state performance review of the
supportability of deficiencies already accomplished this
objective. In discussing our current findings regarding the
standard intended to measure the supportability of survey
findings, CMS officials agreed that (1) measuring the quality of
state surveys, one goal of reviewing the supportability of
deficiencies, was particularly challenging because there is no one
agreed-upon way to measure quality; and (2) some standards are
complex, contributing to consistency problems.
In developing this report, we also noted two additional problems
with the state performance reviews that were not previously
reported. First, in its fiscal year 2004 review, CMS began
combining state performance review results across the different
provider types, such as nursing homes and home health agencies,
for which states have oversight responsibility. For example, CMS
calculates one overall state score on the supportability of
deficiencies across provider types, rather than issuing
provider-specific scores. One CMS region suggested that because
nursing homes are generally surveyed by a unique pool of
surveyors, combining results in this manner limits the usefulness
of the feedback to state survey agencies. Second, CMS provides
feedback to states regarding their performance each year, but it
does not publicly report the results. Doing so would appear to be
consistent with CMS's stated philosophy of sharing information
with the public to help improve nursing home quality.
CMS has pursued important upgrades in the system used to track the
results of state survey activities and has increased its analysis
of OSCAR and other data to improve oversight by CMS central and
regional offices and state survey agencies. Examples include the
following:
o In 2000, CMS began to produce 19 periodic reports to monitor
both state and regional office performance.45 Some reports, such
as survey timeliness, are used during state performance reviews,
while others are intended to help identify problems or
inconsistencies in state survey activities and the need for
intervention.
o In 2001, 2002, and 2005 CMS published a "Nursing Home Data
Compendium," which includes detailed tables and figures on nursing
homes, resident demographics, resident clinical characteristics,
and survey results.
o In 2004, CMS commissioned a series of "White Papers" on topics
ranging from enforcement to resource issues. The goal was to
stimulate discussion among key stakeholders and generate ideas for
"next steps" to help mitigate problems. The reports, authored by
CMS and state survey agency staff, relied on data analysis from
OSCAR and other CMS databases.
o In 2004, CMS prepared an internal study on enforcement trends
since the imposition of the immediate sanctions policy using data
from the Enforcement Tracking System.
o In 2005, CMS unveiled a Web site for use by regional offices
and state survey agencies that generates a series of standard
reports through a software program called Providing Data Quickly;
this software permits easier access to the data contained in
OSCAR. One such report identifies homes that have repeatedly
harmed residents and meet the criteria for imposition of immediate
sanctions.
CMS indicated that it is continuing to make progress in
redesigning the OSCAR system. In our March 1999 report on
enforcement, we recommended that the agency develop an improved
management information system that would help it to track the
status and history of deficiencies, integrate the results of
complaint investigations, and monitor enforcement actions.
Although the target implementation date for the redesigned system
has slipped from 2005 to 2008, depending on competing priorities
and available funding, CMS has implemented two key components of
the redesigned system-a complaint tracking system and a system to
track the status of enforcement actions. Both systems are intended
to provide CMS with critical management capabilities that it
previously lacked.
Using market forces to help drive quality improvement is an
important CMS objective behind sharing data with the public on
nursing home quality. Since CMS launched Nursing Home Compare in
1998, the agency has progressively expanded the information
available on this Web site. In addition to data on the
deficiencies identified during standard surveys, the Web site now
includes data on the results of complaint investigations,
information on nursing home staffing levels, and quality
indicators, such as the percentage of residents with pressure
sores. However, CMS continues to address ongoing problems with the
accuracy and reliability of the underlying data, such as the MDS,
quality indicators, and nurse staffing levels.
In February 2002, we concluded that CMS efforts to ensure the
accuracy of the underlying MDS data46 used to calculate the
quality indicators (1) relied too much on off- site review
activities by its contractor and (2) anticipated on-site reviews
in only 10 percent of its data accuracy assessments, representing
fewer than 200 of the nation's nursing homes.47 CMS did not concur
with our recommendation that it reorient its review program to
complement ongoing state MDS accuracy efforts as a more effective
and efficient way to ensure MDS data accuracy.48 CMS commented
that its efforts already provided adequate oversight of state
activities and complemented state efforts. In April 2005, CMS
ended work under its data assessment and verification contract
because of cost concerns, but signed a new contract in September
2005 that focuses on on-site reviews of MDS accuracy.49 According
to CMS officials, the on-site reviews were more effective in
identifying discrepancies because the reviewers were able to find
more information on-site that conflicted with the nursing homes'
assessments.50
In November 2002, CMS began reporting on its Web site quality
indicator data for each nursing home nationwide that participates
in Medicare and Medicaid, even though our October 2002 report
concluded that such reporting was premature given serious
questions about the sufficiency of CMS efforts to validate the
quality indicators and improve the accuracy of the underlying
data.51 CMS disagreed with our recommendation to postpone its
scheduled November 2002 public reporting of the data until these
problems were addressed. Since 2002, however, CMS has taken steps
to address the questions we raised about the validity of quality
indicators. For example, CMS dropped certain quality indicators
that it found were not sufficiently reliable for public reporting,
such as the facility-adjusted profile prevalence of pressure
sores. In addition, CMS worked with the National Quality Forum to
address measurement problems with the pressure sore quality
indicator by developing separate indicators for short- and
long-term nursing home residents; these new indicators were added
to the Web site in January 2004.52 A weight loss quality indicator
also was developed and added to the Web site in November 2004. Our
October 2002 report had noted the potential for consumer confusion
in interpreting and using quality indicator data. CMS conducted
consumer testing of new language and displays on Nursing Home
Compare during the summer of 2004.
Although nursing home staffing data have been available on the
Nursing Home Compare Web site since June 2000, a CMS official told
us that the agency has been aware of problems with these
self-reported data since the late 1990s.53 This official stressed
that, despite problems, they were the only available data on
nursing home staffing. Examples of erroneously reported data
include facilities with no nurse staffing hours or hours equal to
thousands of residents per day. In addition, the staffing data do
not address important issues such as turnover or retention.54 As a
temporary fix, CMS developed edits that examine staffing ratios to
determine whether any facility falls above or below certain
thresholds and, effective July 2005, temporarily excluded the
questionable staffing data from Nursing Home Compare until they
can be corrected or confirmed. To address this issue, CMS is
considering a proposal for a new system that relies on nursing
home payroll data. If approved, such a system could take 3 to 4
years to implement because of the need to solicit and consider
public comment and to develop software to transmit the staffing
data.
CMS's initiative to include quality indicator data on its Nursing
Home Compare Web site also established a new role for Quality
Improvement Organizations (QIO) with regard to nursing homes. From
2002 through 2005, QIOs worked intensively with at least 10
percent of nursing homes in each state to improve quality.55
Although we have not evaluated QIO nursing home quality
improvement activities, CMS's preliminary analyses indicate that
the QIO program has helped to reduce the use of daily physical
restraints, increased management and treatment of pain, and
reduced the incidence of delirium among post-acute-care residents.
However, less progress has been made in decreasing the prevalence
of pressure sores, according to CMS's analyses. In August 2004,
the QIO and state survey agency in 18 states launched a new pilot
program. Working together, they identified from one to five
nursing homes per state that had significant quality problems. The
QIO then worked with these homes to help them redesign their
clinical practices. According to CMS, the results of this pilot
indicated that these historically "troubled" nursing homes had
dramatically improved their clinical quality and decreased their
quality-of-care survey deficiencies.56 In 2005, the QIOs' role
with nursing homes was extended for an additional 3 years, and
QIOs will continue to focus on statewide improvement in four
areas-pressure sores, physical restraints, pain management, and
depression. In addition, QIOs will help nursing homes set
individual targets for quality improvement, implement and document
process-related clinical care, and assist in the development of a
more resident-focused care model. QIO expenditures on nursing home
quality improvement for the period of August 2002 through July
2008 are expected to total about $216 million.
CMS has taken certain actions to maximize the experience and
resources of state survey agencies as well as the CMS central and
regional offices to improve nursing home oversight. Specifically,
in 2004, CMS convened an internal Long-Term Care Task Force and
charged it with providing guidance on and coordinating long-term
care efforts within CMS and included representation across the
agency's divisions and the regional offices. Also in 2004, CMS
began an effort to collect and disseminate nursing home survey and
certification best practices developed by professional
associations, universities, and federal agencies.57 Through the
best practices effort, CMS plans to share successful strategies
used by states and regional offices in a broad range of issues
affecting survey and certification of nursing homes, such as
surveyor recruitment and complaint intake. A contractor will
identify, research, and document best practices, which CMS plans
to post on its Web site. One of the issues the best practices
effort will address is surveyor recruitment initiatives underway
in states. As of August 2005, these best practices had not been
published on the CMS Web site.
CMS, states, and nursing homes face a number of key challenges in
their efforts to further improve nursing home quality and safety,
including (1) the cost of retrofitting older nursing homes with
automatic sprinklers, a potentially costly requirement that has a
demonstrated ability to prevent deaths in the event of a fire; (2)
continuing problems in hiring and retaining qualified surveyors, a
factor that states indicated can contribute to variability in the
citation of serious deficiencies; and (3) an increasing federal
and state survey workload due to increased oversight, the
identification over time of additional initiatives, and growth in
the number of Medicare and Medicaid providers that must be
surveyed, including expected growth in nursing homes. The
increased workload has created competition for both staff and
financial resources and required the establishment of priorities,
which may have contributed to delays in developing and
implementing several key quality initiatives, such as the
implementation of a more rigorous survey methodology.
Although the substantial loss of life in two 2003 nursing home
fires could have been reduced or eliminated by the presence of
properly functioning automatic sprinkler systems, cost has been an
impediment to CMS's requiring them for all homes nationwide. Newly
constructed homes must incorporate sprinkler systems; however,
older homes constructed with noncombustible materials that have a
certain minimum ability to resist fire are not required to install
sprinklers. We previously reported that cost has been a barrier to
requiring sprinklers for all older nursing homes. In July 2005,
the National Fire Protection Association (NFPA) voted to require
retrofitting of older homes with sprinklers, a requirement that
will become a part of the 2006 edition of the NFPA code.
Anticipating this action, CMS indicated that it has been
developing a notice of proposed rule making, the first step in
adopting the NFPA requirement for all homes that serve Medicare
and Medicaid beneficiaries. A CMS official stated that the agency
plans to issue the notice in March 2006 and after reviewing public
comments, it will publish a final version of the rule and
stipulate an effective date for homes to come into compliance.58
One issue that remains unresolved is how much time older homes
will be given to install sprinklers. As we reported in 2004,
industry officials believe that a transition period must be
considered for homes to come into compliance and to determine how
to pay for the cost of installing sprinklers.59 Rather than
proposing a phase-in period, the proposed rule will request input
on how much time homes should be given to come into compliance
with the requirement. According to CMS, a longer phase-in period
could help alleviate concerns about the cost of retrofitting homes
with sprinklers. Based on our recommendation, CMS collected data
on the sprinkler status of homes nationwide and found that about
21 percent of nursing homes are unsprinklered or partially
sprinklered.60 Although CMS has not completed its cost analysis,
the agency believes that the costs associated with the retrofit
will be less than the industry's $1 billion estimate.
The hiring and retention of surveyors, particularly RNs, remains a
major, frequently discussed issue among state survey agency
directors, according to an AHFSA official, the association that
represents state survey agency directors. In July 2003, we
reported that the limited experience level of state surveyors
because of a high turnover rate was a contributing factor to (1)
variability in citing actual harm or higher-level deficiencies and
(2) understatement of such deficiencies. In more than half of the
42 states that responded to our inquiry, from 30 percent to more
than 50 percent of surveyors had 2 years' experience or less, as
of July 2002. Twenty-five states responded to our request for
updated information on surveyor workforce issues as of July 2005.
Of 23 states that provided data in both 2002 and 2005, 13 reported
an improvement in 2005 (i.e., a decline in the proportion of
inexperienced surveyors); 9 indicated that the situation had
worsened (e.g., an increase in the proportion of inexperienced
surveyors); and 1 state reported no change (see app. IV). As of
July 2005, however, 20 percent or more of surveyors in 20 of the
25 states had 2 years' experience or less (see table 9). Surveyor
vacancy rates in the 25 states ranged from about 3 percent in
Tennessee to 31 percent in Alabama and Florida; overall, 15 states
had double-digit vacancy rates. Officials in 18 states believed
that inexperienced surveyors contributed to interstate variability
in the citation of serious deficiencies. One state survey agency
indicated that staff attrition resulted in a workforce of less
experienced surveyors who demonstrated a hesitance to cite actual
harm and contributed to understatement. State survey agency
officials in several states, however, suggested that the problem
for less-experienced surveyors was not identifying harm but rather
investigating and documenting the circumstances that led to the
harm, including facility culpability, a skill that surveyors
develop as they gain more experience.61
Table 9: Percentage of Surveyors with 2 Years' Experience or Less,
as of July 2005
Source: AHFSA data from 25 states.
Because state survey agency salaries are rarely competitive with
the private sector, state survey agencies told us that it is
difficult to retain surveyors and to fill vacancies. RNs, a major
component of states' surveyor workforce, are in high demand and
short supply, according to AHFSA. Furthermore, 9 states responding
to our July 2005 inquiry indicated that state civil service
requirements can make it more difficult to fill vacancies. Several
of the 9 states characterized the hiring process as either
cumbersome or time-consuming, or both, and 1 state noted that the
process takes close to 9 months. Two states reported that they had
to select candidates to interview from a certified list. One of
the states indicated that the certified list often contained
unqualified applicants, while the other state noted that some of
the applicants were not the "best fit." Of the 25 states, 21
indicated that they had implemented initiatives to help retain
surveyors. The most popular retention strategies were to increase
starting salaries and to implement flexible surveyor work
schedules. For example, New York instituted a locality pay
differential for New York City. While 5 of the 25 states indicated
that they had a state-imposed hiring freeze, 1 state reported that
budget pressures prevented it from taking steps to improve
retention rates.62 A continuing problem cited by AHFSA is that
federal funds are distributed late in the fiscal year, which does
not tie into state budget cycles for approving additional
positions. This problem may be particularly acute in the 5 states
that reported having a hiring freeze.
CMS and states have experienced increased survey workloads due to
the greater intensity of nursing home oversight, the increasing
number of initiatives, and growth in the number of Medicare and
Medicaid providers requiring oversight. This workload growth
required the prioritization of initiatives that, in some cases,
has resulted in implementation delays for some key initiatives.
The consensus-building process necessary to bring initiatives to
fruition also has contributed to some delays. The initiatives
likely will continue to compete for priority with other CMS
programs, posing a challenge for efforts to further improve
nursing home quality and safety.
Greater nursing home oversight has increased demand on both CMS
and state survey agency resources, causing delays for some key
initiatives. CMS's increased workload is evident in the
labor-intensive state performance reviews. Since their
introduction in October 2000, the reviews have been gradually
expanded from nursing homes to several other Medicare and Medicaid
providers, such as home health agencies and hospitals. CMS also
has significantly increased the number of federal quality-of-care
and fire safety comparative surveys. Such surveys are more
labor-intensive than the alternative type of federal monitoring
surveys, known as observational surveys, because they require an
entire federal survey team rather than a smaller number of federal
surveyors. The agency also has committed considerable resources to
developing new data systems for complaints and enforcement actions
while simultaneously increasing its use of available data to
further improve federal and state oversight. Despite the increased
workload, CMS implemented survey staff reductions of 5 percent in
regional offices and 3 percent in its central office in January
2004. As of August 2005, these staff reductions have remained in
effect.
As state survey agency workloads grew with the implementation of
the initiatives, they also experienced resource pressures. States
are now required to conduct on-site revisits to ensure serious
deficiencies have been corrected, investigate complaints alleging
actual harm on-site and do so more promptly, and initiate off-hour
standard surveys. Thus, surveyors' presence in nursing homes has
increased and surveyors' work hours have effectively been expanded
to weekends, evenings, and early mornings. The requirement to
impose immediate sanctions on homes that repeatedly harm residents
also has had a workload impact because in the past a grace period
allowed homes to correct deficiencies before the sanctions went
into effect. The imposition of immediate sanctions requires states
to track, which some states do manually, the homes that must be
referred for immediate sanctions and requires CMS and states to
act to impose recommended sanctions that in the past would have
been rescinded because the homes could have corrected the
deficiencies during a grace period. While states' budget pressures
appear to be easing, many state survey agencies reported hiring
freezes, staff vacancies, or high turnover as of July 2002 when
all of these initiatives had already been fully implemented.
The number of initiatives that CMS has implemented on its own has
grown, further increasing its workload. For example, CMS added
quality indicator data to its Nursing Home Compare Web site and
has involved QIOs in helping nursing homes to improve quality of
care. In addition, CMS created a task force to develop guidance
intended to improve consistency across states in the imposition of
civil money penalties.
The number of nursing home initiatives simultaneously under
development or being implemented as well as other CMS
responsibilities, such as preparing to implement the new Medicare
prescription drug benefit in January 2006, have necessitated the
establishment of priorities and led to delays and queues.63 CMS
assigned some initiatives, such as the development and public
reporting of quality indicators, a high priority and implemented
them swiftly despite issues related to their validity and the
quality of the underlying data-problems that CMS is still working
to address. In contrast, the revision of the survey process has
encountered delays because of funding shortfalls and has been in
process for 7 years. For example, initial testing of the new
methodology in 2002 and 2003 was limited, even though CMS had
already invested $4.7 million in its development from initiation
in 1999 through September 2003. A pilot test of the new
methodology is scheduled to begin in the fall 2005; depending on
the results of the testing, implementation could begin in
mid-2007. Although CMS attaches a high priority to enhancing the
information available to the public on nursing home quality and
safety, adding information on past noncompliance and the fire
safety status of nursing homes are in a queue behind the
programming required to implement higher-priority projects. There
is also a regulatory queue, with other, higher-priority
regulations ahead of the notice of proposed rule making to require
retrofitting of nursing homes with automatic sprinklers.
Delays in implementing the nursing home initiatives are also
attributable to CMS's need to be responsive to stakeholder input.
Appropriately, CMS seeks input from various stakeholders such as
states, regional offices, the nursing home industry, and resident
advocates. For example, CMS sought input from experts in
developing investigative protocols for surveyors. Due to this
lengthy consultative process, combined with the prolonged delays
stemming from internal disagreement over the structure of the
process during the initial stages, CMS has only implemented two
investigative protocols since 2001. Likewise, implementation of
the ASPEN Complaint Tracking System was delayed because during the
system's pilot test, several states indicated their belief that
their existing systems were superior and opposed the idea of
either abandoning these systems or maintaining separate systems.
Both the overall growth in providers and the anticipated growth in
nursing homes pose additional workload challenges for CMS and
states. In addition to nursing homes, CMS and states are
responsible for surveys of other Medicare and Medicaid providers,
such as home health agencies and hospitals. The number of these
providers grew from 39,651 in October 2000 to 45,375 in January
2005, approximately 14 percent.64 While the number of nursing
homes has decreased slightly during the same period, from 17,012
to 16,146, the rate of decline has slowed; and as the baby boom
generation ages, increasing the number of elderly needing
long-term care services, the number of nursing homes is expected
to grow to meet the demand. In 2000, 35.1 million people were aged
65 or older. This number is expected to grow to about 54.7 million
by 2020.
Nursing home survey activities consume the majority of state
survey budgets and resources. Nursing homes make up about 31
percent of Medicare and Medicaid providers, but account for 73
percent of the federal budget for oversight of such providers.65
The funding for nursing home surveys is disproportionate because
the time frames for standard nursing home surveys are statutory.
For those survey requirements not in statute, CMS determines the
survey time frames; these surveys are therefore a lower
priority.66 Even among nursing home survey activities, however,
annual standard surveys are considered a higher priority than
complaint surveys or initial surveys for which the statute does
not dictate specific time frames.67 CMS and state survey agency
officials recognize that CMS may have shifted its focus and
resources to nursing homes at the expense of adequate oversight of
other providers serving Medicare and Medicaid beneficiaries, and
some states contend that the focus on nursing home standard
surveys has hampered their ability to investigate nursing home
complaints within mandated time frames. For example, according to
a California state survey agency official, California law mandates
that all nursing home resident complaints, not just complaints
alleging actual harm, be investigated within 10 days. Likewise, an
official from the Pennsylvania state survey agency stated that in
Pennsylvania, all complaints must be investigated within 48 hours.
California survey agency officials have told us that a complaint
alleging a care problem deserves a higher priority than a standard
survey, which may or may not identify deficiencies.
According to CMS officials, key nursing home initiatives continue
to compete for priority with other CMS projects. Examples of
nursing home initiatives that have been affected include revision
and testing of the new survey methodology, continued development
of the investigative protocols that surveyors use to investigate
care problems, and an increase in the number of quality-of-care
comparative surveys.
o Revised survey methodology. CMS officials have indicated that
nationwide implementation of the revised survey methodology could
be affected if its use requires additional survey time or a
greater number of surveyors to conduct each survey. The pilot test
of the new methodology, scheduled for 2005 and 2006, includes an
examination of steps to streamline the revised process, if
necessary. Cost considerations limited the pilot of the new
methodology to fewer states than the 20 that volunteered.
o Investigative protocols for quality-of-care problems. Only
three sets of investigative protocols had been implemented as of
November 2005, and it is unclear whether the contractor's
assessment of the protocols' effectiveness can be completed before
the contract ends in 2006. Furthermore, unless the contract for
the investigative protocols is re-bid, CMS expects to return to
the traditional revision process even though agency staff believe
that the expert panel process used under the contract produced a
high-quality product.
o Federal comparative surveys. CMS hired a contractor in 2003 to
further increase the number of federal quality-of-care comparative
surveys, but dropped funding for quality-of-care comparative
surveys from the fiscal year 2006 contract.68 The agency
reallocated the funds to help state survey agencies meet the
increased survey workload resulting from growth in the number of
other Medicare providers.
CMS has focused considerable attention since 1998 on addressing
weaknesses in state and federal oversight activities in order to
better care for and protect nursing home residents. The agency has
implemented many important improvements in the areas of surveys,
complaints, enforcement, and oversight, such as taking steps to
address survey predictability, issuing additional guidance to
ensure timely on-site investigations of complaints alleging harm
to residents, implementing an immediate sanctions policy to
eliminate grace periods for homes cited for repeat serious
violations, and strengthening oversight by conducting assessments
of state survey activities. However, some key activities are still
in process. For example, CMS's effort to revise the survey
methodology has been underway for 7 years. Given the pivotal role
played by surveys in helping to ensure that nursing home residents
receive high-quality care, the development and implementation of a
more rigorous survey methodology is one of the most important
contributions CMS can make to addressing oversight weaknesses.
Certain other initiatives, such as sharing data with the public in
an effort to use market forces to drive quality improvement, also
remain in process. Since launching Nursing Home Compare in 1998,
CMS has been aware of accuracy and reliability issues with the
underlying data and began changing its approach to data integrity
in 2005. The agency is working to address issues concerning data
on nursing home staffing that compelled it to temporarily exclude
questionable data from its Web site in July 2005 until its
accuracy can be verified. Because consumers use these data to make
decisions about nursing home care, ensuring the accuracy,
reliability, and timeliness of nursing home quality data is
critical. Even with CMS's increased efforts to improve nursing
home quality, the agency's continued attention and commitment to
these efforts is essential in order to maintain and build upon the
momentum of its accomplishments to date.
We provided CMS a draft of this report for review. CMS generally
concurred with our findings, noting that progress has been made in
many areas such as surveys and complaint investigations, oversight
activities, and citation of serious deficiencies, but that
challenges remain. (CMS's comments are reproduced in app. V.) CMS
also provided technical comments, which we included in the report
as appropriate. We also provided the five states we contacted an
opportunity to review the portion of the draft focused on trends
in nursing home quality. California, Florida, Ohio, New York, and
Texas provided written comments. California's comments focused on
clarifying its experience seeking CMS guidance on the definition
of actual harm, but did not state whether it agreed with our
findings. Ohio commented that our report's findings related to
continued inconsistency and understatement of serious deficiencies
by state surveyors did not apply to its state survey agency. New
York stated that including a more detailed description of states'
efforts to improve nursing home quality would provide a more
balanced view of the reasons for the decline in serious
deficiencies. Florida and Texas generally concurred, but Texas did
not provide specific comments. CMS and states' specific comments
focused primarily on four issues: understatement of serious
deficiencies, the definition of actual harm, data availability,
and challenges to conducting nursing home survey and oversight
activities.
CMS commented that it remains concerned about the possible
understatement or omission of serious deficiencies, but that it
did not believe that understatement caused the decline in serious
nursing home deficiencies or that understatement was worsening.
CMS noted its efforts to work with states that fail to improve
their ability to identify deficiencies such as withholding funding
increases until corrective action plans are developed. Florida,
New York, and Ohio similarly commented that efforts such as their
states' quality improvement initiatives, regulatory changes to
improve nursing home operations, and engagement of the provider
community have contributed to the decline.
CMS suggested that including the results of observational surveys
in our analysis of the percentage of federal surveys that found
serious deficiencies missed by states would show that the
percentage remained relatively constant from 2002 to 2004 rather
than increasing. As we noted in our 1999 report, however,
comparative surveys are more effective than observational surveys
in identifying serious deficiencies missed by state surveyors
because they are the only oversight tool that provides an
independent federal survey where results can be compared to those
of the state. Observational surveys can serve as an effective
training tool for state surveyors but, in our view, they do not
accurately represent typical state surveyor performance due to the
likelihood that state surveyors modify their performance when they
are aware that they are being observed by federal surveyors.
Florida and Ohio noted that in addition to comparative surveys,
CMS conducted many observational surveys during the time period
studied. Ohio disagreed that our analysis of federal comparative
surveys suggests that nursing home surveyors in Ohio missed
serious deficiencies, citing its combined performance ratings for
observational and comparative surveys. New York commented that
federal comparative surveys often do not include the same resident
sample used in the state survey and that only looking at
comparative surveys provides a narrow analysis of state survey
quality. New York suggested a more detailed analysis of
comparative survey data and consideration of state performance
review results. We note that, in 2002, CMS directed federal
surveyors to include at least 50 percent of the residents included
in the state survey sample. We also acknowledge that CMS is
conducting state performance reviews as part of its oversight of
state survey activities, but note that the reviews have
shortcomings as described in our July 2003 report. Florida noted
that our analysis of federal comparative surveys that identified
missed serious deficiencies is based on limited data. We
acknowledge that our analysis is based on a small number of
surveys, but note that it includes the full universe of
comparative surveys conducted from March 2002 through December
2004 in the five states we reviewed.
The range of comments from states reinforces the need for CMS to
clarify the definition of actual harm, as it plans to do.
California noted that while some of its state surveyors were
confused about the definition of actual harm, after discussions
with CMS from 1998 through 2004, the survey agency and CMS are now
in agreement on the definition of actual harm. New York stated
that confusion about the definition of actual harm has been
reduced. Ohio noted that its state surveyors are not confused by
the definition of actual harm, but that states have not received
clear and specific guidance from CMS. Florida agreed that clearer
guidance would be useful.
CMS indicated that it is taking steps to improve the reliability
and accuracy of publicly reported data by identifying suspect data
and posting more detailed information about past noncompliance. As
we state in our report, we believe that consumers should have
timely and accurate data to inform their decisions regarding
nursing home care.
CMS commented that the workload issues described in this report
present challenges beyond those we have previously reported. CMS
stated that continued constraint of resources could "likely cause
some erosion of the gains already made" in the survey and
oversight activities to date. To address the challenges it faces,
CMS plans to increase efforts to improve productivity, determine
the cost and value of policies, focus state performance standards
on substantive issues, prioritize survey activities, coordinate
with stakeholders, address increasing fuel costs, and enhance
emergency preparedness. California, Florida, New York, and Ohio
reiterated the staffing challenges they have experienced and the
steps they have taken to address them, some of which are described
in this report. Despite these efforts, California indicated that
its staffing challenges have negatively impacted the investigative
process. While we recognize the challenges CMS and states face, we
continue to believe that maintaining the momentum developed over
the last several years on key CMS initiatives, such as the
development of the revised survey methodology (i.e., Quality
Indicator Survey), is critical to addressing nursing home survey
and oversight weaknesses.
As arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after its issue date. At that time, we will send
copies of this report to the Administrator of the Centers for
Medicare & Medicaid Services and appropriate congressional
committees. We also will make copies available at no charge on the
GAO Web site at http://www.gao.gov .
If you or your staff have any questions about this report, please
contact me at (202) 512-7118 or [email protected] . Contact points
for our Offices of Congressional Relations and Public Affairs may
be found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix VI.
Kathryn G. Allen Director, Health Care
Table 10 summarizes our recommendations from 14 reports on nursing
home quality and safety, issued from July 1998 through November
2004; CMS's actions to address weaknesses we identified; and the
implementation status of CMS's initiatives. The recommendations
are grouped into four categories-surveys, complaints, enforcement,
and oversight. If a report contained recommendations related to
more than one category, the report appears more than once in the
table. For each report, the first two numbers identify the year in
which the report was issued. For example, HEHS-98-202 was released
in 1998. The Related GAO Products section at the end of this
report contains the full citation for each report. Of our 36
recommendations, CMS has fully implemented 13, implemented only
parts of 3, is taking steps to implement 13, and declined to
implement 7.
3Prior to July 2001, CMS was known as the Health Care Financing
Administration. Throughout this report, we refer to the agency as CMS,
even when describing initiatives taken prior to its name change.
4 http://www.medicare.gov/NHCompare/home.asp .
5In this report, we use the term "states" to include the 50 states and the
District of Columbia.
Results in Brief
Background
Standard Surveys and Complaint Investigations
6In addition to nursing homes, CMS and state survey agencies are
responsible for oversight of other Medicare and Medicaid providers such as
home health agencies, intermediate care facilities for the mentally
retarded, accredited and nonaccredited hospitals, end-stage renal dialysis
facilities, ambulatory surgical centers, rural health clinics, outpatient
physical therapy centers, hospices, portable x-ray suppliers,
comprehensive outpatient rehabilitation facilities, and Community Mental
Health Centers.
7CMS generally interprets these requirements to permit a statewide average
interval of 12.9 months and a maximum interval of 15.9 months for each
home.
8CMS requires nursing homes to meet applicable provisions of the fire
safety standards developed by the National Fire Protection Association
(NFPA), of which CMS is a member. NFPA is a nonprofit membership
organization that develops and advocates scientifically based consensus
standards on fire, building, and electrical safety.
Scope
Severity Isolated Pattern Widespread
Immediate jeopardya J K L
Actual harm G H I
Potential for more than minimal harm D E F
Potential for minimal harmb A B C
Enforcement Policy
Oversight
Available Data Show Significant Overall Decrease in Serious Quality Problems but
Indicate Continued Inconsistency and Understatement in State Findings
9In the time period prior to CMS's implementation of its quality
initiatives (January 1, 1997, through June 30, 1998), the proportion of
homes nationwide with actual harm or higher-level deficiencies was 27.7
percent. However, this report focuses on trend data following CMS's July
1998 announcement of the initiatives. In our September 2000 report on
CMS's quality initiatives, we compared trends in nursing home deficiency
citations for two time periods-one before (January 1, 1997, through June
30, 1998) and one after (January 1, 1999, through July 10, 2000) the
implementation of the nursing home initiatives. Since our 2000 report, we
have updated this trend analysis for three time periods: July 11, 2000,
through January 31, 2002; February 1, 2002, through July 10, 2003; and
July 11, 2003, through January 31, 2005.
Percentage of homes with serious deficiencies Number of states
More than 20 percent 15
10 percent to 20 percent 26
Less than 10 percent 10
10For example, a deficiency noted in a federal survey could involve a
resident who was not in the nursing home at the time of the state survey
but was admitted between the state and the federal surveys.
11The decline in serious deficiencies ranged from a low of 14.3 percentage
points in Texas to a high of 23 percentage points in California and New
York (see app. II).
Number of Federal comparative
federal surveys that found Total number of
comparative missed serious serious
surveys deficiencies deficiencies
State conducted Number missed Percentage
California 23 4 17 6b
Florida 12 4 33 7b
New York 11 2a 18a 6b
Ohio 12 1 8 1
Texas 15 2 13 5
Total 73 13 18 25
CMS Has Addressed Many Shortcomings in Survey and Oversight Activities, but Work
Continues on Some Key Initiatives
Surveys: Key Initiatives Are under Development, but Most Have Not Yet Been
Implemented
12CMS has independently identified shortcomings in areas such as survey
processes and consumer information and has developed initiatives to
address these problems.
13Under contract with CMS, 39 Quality Improvement Organizations (QIO)
(formerly known as Peer Review Organizations) help to ensure the quality
of care delivered to Medicare beneficiaries in each state. Prior to 2002,
QIO's work focused on care delivered in acute care settings such as
hospitals.
Initiative Status
Survey methodology: Revise to ensure that surveyors In process
do not miss significant care problems.
Investigative protocols: Strengthen to ensure greater In process
rigor in surveyors' on-site investigations of
specific areas.
Definitions of actual harm and immediate jeopardy: In process
Revise to promote increased interstate consistency in
deficiency citations.
Additional survey initiatives: Implement initiatives In process
to give surveyors a way to voice concerns and explore
the use of photographic evidence to improve the
survey process.
Survey predictability: Reduce to prevent nursing Selected initiatives
homes from potentially masking certain deficiencies implemented
if they so choose.
Survey Methodology
14Quality indicators, the result of a CMS-funded contract, are based on
nursing home resident assessment information-MDS-which is data on each
resident that homes are required to report periodically to CMS. Quality
indicators are derived from nursing homes' assessments of residents and
are used to rank a facility in 24 areas compared with other nursing homes
in the state.
Investigative Protocols
Definitions of Actual Harm and Immediate Jeopardy
15On-site sources include observations, interviews, and records review. An
example of an off-site data source is the MDS.
16The pilot states are California, Connecticut, Kansas, Louisiana, and
Ohio.
17Prior to this contract, surveyor protocols were developed by CMS, with
comments from stakeholder groups, but the development process did not
include an expert panel.
18Investigative protocols are being developed for accidents and
supervision, quality assurance, resident activities programs, psychosocial
severity, safe food handling/nutrition, pharmacy services/unnecessary
drugs, and end-of-life/pain management issues.
Additional Survey Initiatives
Survey Predictability
19For example, a CMS official informed us that the language, "limited
consequences to the resident," which is used in the current definition of
actual harm, confused states because it was vague and that states formed
their own interpretations of the language. The draft revised definition
eliminates this language.
20CMS disagreed with a portion of our predictability recommendation that
suggested segmenting the standard survey into more than one review to
provide more opportunities for surveyors to observe problematic homes. CMS
disagreed because of concerns that segmenting the survey would reduce the
effectiveness and increase the cost of surveys.
21CMS instructed the states to avoid, if possible, scheduling a home's
survey for the same month as the one in which the home's previous standard
survey was conducted.
22According to CMS, states consider 9 months to 15 months from the last
standard survey as the window for completing standard surveys because it
yields a 12-month average. CMS and states acknowledged that states
sometimes fall behind in conducting surveys and homes are not surveyed
until near or after the 15-month time frame. Thus, to maintain an average
survey interval of 12 months, more surveys would need to occur within 9
months of the last standard survey.
23ASPEN stands for the Automated Survey Processing Environment. ASPEN is
used by CMS central office, regional offices, and state survey agencies
for tracking surveys and survey findings. ASPEN comprises multiple modules
such as the ASPEN Enforcement Manager and the ASPEN Complaints and
Incidents Tracking System.
Number of states
Percentage of predictable surveys April 2002 July 2005
More than 50 percent 0 1
25 percent to 50 percent 5 7
10 percent to 24 percent 26 27
Less than 10 percent 20 16
Complaint Investigations: CMS Has Strengthened State Guidance and Oversight and
Is Continuing to Address Problems Involving Allegations of Abuse
Initiative Status
Complaint guidance: Issue additional guidance to Selected initiatives
states to strengthen complaint investigations, implemented
including allegations of abuse.
Complaint oversight: Enhance federal oversight of In process
state complaint investigations, including allegations
of abuse.
Complaint Guidance
Complaint Oversight
24Prior to this new requirement, federal guidelines required only that
complaints alleging immediate jeopardy to residents be investigated within
2 workdays. For all other complaints, states could establish their own
investigative time frame.
25MFCUs have authority to investigate the physical and sexual abuse of
nursing home residents, in addition to investigating fraud and abuse in
the Medicaid program. Typically, MFCUs are an investigative component of
the state's Office of the Attorney General but may be located in other
agencies, such as the state police, instead. Forty-eight states have a
MFCU.
26In 2002, CMS informed us that the posters were developed, but have not
yet been printed or distributed. According to a CMS official, the agency's
focus on higher-priority activities has contributed to the delay.
27Results for 2005 were not available at the time we conducted our work
for this report.
28We did not evaluate the effectiveness of the complaint tracking system.
Enforcement: CMS Has Strengthened the Potential Deterrent Effect of Sanctions
and Has Other Initiatives Under Way
29CMS requires state survey agencies to investigate allegations of nursing
home resident abuse, which can be submitted by residents, family members,
friends, physicians, and nursing home staff, within 2 days of learning of
the allegation, but does not impose a deadline for completing the
investigation. After the state survey agency has made an initial
determination, the nurse aide may request an appeal within 30 days.
Hearings may not be held for several months, and decisions are not always
immediate.
30The Background Check Pilot Program was mandated by Section 307 of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(Pub. L. No. 108-173, 117 Stat. 2066, 2257.). CMS issued grant
solicitation letters to states in July 2004 and made grants in January
2005.
Initiative Status
Immediate sanctions policy: Eliminate grace periods Fully implemented
for homes cited for repeat serious violations.
Additional enforcement policy issues: Address Selected initiatives
weaknesses in policies, the appeals process, and implemented
enforcement tracking.
Special Focus Facility Program: Revise to include the Fully implemented
most poorly performing homes and to strengthen
enforcement.
Civil money penalties: Improve tracking and In process
collection to make them a more effective enforcement
tool.
Past noncompliance policy: Revise by clarifying key In process
terms, increasing homes' accountability for past
quality-of-care problems, and posting on the CMS Web
site specific information about homes' past
noncompliance.
Immediate Sanctions Policy
Additional Enforcement Policy Issues
31States are now required to deny a grace period to homes that are
assessed one or more deficiencies at the actual harm level or above (G
through L on CMS's scope and severity grid) in each of two successive
surveys within a survey cycle. A survey cycle is two successive standard
surveys and any intervening survey, such as a complaint investigation.
32Substandard quality of care is defined as deficiencies cited at the F
level of scope and severity in certain care areas-quality of life, quality
of care, and resident behavior and facility practices.
33Before readmitting a terminated nursing home to Medicare, CMS requires
the home to address the situation that led to termination and provide
reasonable assurance that it will not recur. To give this assurance, a
home is required to have two surveys not more than 6 months apart, each of
which shows the problem to be corrected. The reasonable assurance period
is the time between these two surveys.
34From 2000 to 2004, CMS used a nationwide summary of the 10 regional
office enforcement databases known as the Long Term Care Enforcement
Tracking System.
Special Focus Facility Program
Civil Money Penalties
35We did not evaluate the performance of the ASPEN Enforcement Manager for
this report.
36In the Special Focus Facility Program, state survey agencies conduct
enhanced monitoring of nursing homes with histories of providing poor
care.
37The revised special focus facility selection methodology addressed
criticisms about the original state selection process from state survey
agencies, including that the process did not account for state size or
number of nursing homes, and used insufficient performance data in
selecting homes. Alaska is not required to select special focus
facilities.
Past Noncompliance Policy
38CMS's guidance to states describes the factors to be considered when
determining the amount of a civil money penalty.
39The assumption is that the nursing home identified and corrected this
earlier care problem.
Oversight: Intensity and Scope of Federal Efforts Has Increased Significantly,
but Work Remains
Initiatives Status
Federal comparative surveys: Increase number to Fully implemented
intensify oversight.
Smoke detectors: Require them in nursing homes Fully implemented
without sprinklers to strengthen fire safety.
Assessments of state survey activities: Review state Selected initiatives
survey agencies' compliance with federal standards. implemented
Data systems and analysis: Upgrade to improve In process
tracking and oversight of state survey activities.
Sharing data: Share quality data with the public to Selected initiatives
help drive quality improvement. implemented
Quality Improvement Organizations: Use Quality In process
Improvement Organizations to help nursing homes
improve the quality of care.
Coordination and dissemination of best practices: In process
Initiate activities to improve nursing home
oversight.
Federal Comparative Surveys
40CMS is statutorily required to conduct federal monitoring surveys in at
least 5 percent of the surveyed nursing homes in each state each year,
with a minimum of 5 facilities in each state. As of January 2005, there
were 16,146 nursing homes, which would require 807 federal monitoring
surveys. Until 1992, all federal monitoring surveys were comparative. In
part because comparative surveys were resource intensive, CMS began to
rely more heavily on observational surveys, which require a smaller number
of federal surveyors.
41During fiscal years 1999 and 2000, CMS required a minimum of one
comparative survey to be completed yearly in the 20 states having fewer
than 200 nursing homes, two in the 24 states that had from 200 to 599
homes, and three in the 7 states that had 600 or more homes.
Smoke Detectors in Homes without Sprinklers
Assessments of State Survey Activities
42Since fiscal year 2001, CMS has expanded the scope of state performance
reviews to include seven additional Medicare and Medicaid providers, such
as hospitals and renal dialysis facilities, in addition to nursing homes.
43The 11 elements are (1) the citation has the full regulatory reference;
(2) evidence supports determination of noncompliance at the cited
regulation; (3) each deficient practice statement clearly summarizes the
provider/supplier failure(s) and quantifies a relevant extent; (4) the
scope accurately reflects the evidence and the residents who are, or may
be, affected by the deficient practice; (5) the severity rating in nursing
homes or the condition, standard, or element level cited reflects the
evidence and the actual and/or potential outcomes to beneficiaries; (6)
each person referred to is uniquely identified; (7) the observations,
interviews, and record reviews support the deficient practice statement
and illustrate the entity's noncompliance; (8) descriptions of observation
of provider/supplier practice include date, time, duration, and location;
(9) descriptions of interviews include dates and times and who was
interviewed; (10) record review includes date of entry and exact title of
record, and verifies lack of additional records with a knowledgeable
person; and (11) evidence is written in plain language that is clear,
concise, and easily understood.
44CMS was unable to score the standard in fiscal year 2001 because the
standard was too complicated. The standard consisted of 33 elements in
fiscal year 2001 but was reduced to 7 elements for the subsequent 2 fiscal
years. In fiscal year 2004, the number of elements was increased to 11.
Data Systems and Analysis
45Examples include reports on pending nursing home terminations (weekly),
data entry timeliness (quarterly), tallies of state surveys that find
homes deficiency-free (semiannually), and analyses of the most frequently
cited deficiencies by states (annually).
Sharing Data with the Public
46The MDS, which is prepared periodically for each nursing home resident,
contributes to multiple functions, including establishing patient care
plans, assisting with quality oversight, and setting nursing home payments
that account for variation in resident care needs.
47This limited on-site presence was also inconsistent with a
recommendation in a 2001 report CMS commissioned regarding the benefits of
on-site reviews in detecting MDS accuracy problems and with the view of 9
of the 10 states with separate MDS review programs that an on-site
presence at a significant number of their nursing homes is central to
their review efforts.
48Such a shift in focus would include (1) taking full advantage of the
periodic on-site visits already conducted at every nursing home nationwide
through its routine survey process; (2) ensuring that the federal MDS
review process is designed and sufficient to consistently assess the
performance of all states' reviews for MDS accuracy; and (3) providing
additional guidance, training, and other technical assistance to states as
needed to facilitate their efforts.
49Although the focus of the prior data assessment and verification
contract was MDS accuracy reviews, the contract also included an
examination of issues of interest to other CMS components that sponsored
the contract. For example, the contractor examined facility assessment
data on Medicare beneficiaries who received home health services.
50While on-site, the contractor had access to a broader range of
information gleaned from observation, interviews with residents and staff,
and reassessments of residents. During the 3-1/2 years of the data
assessment and verification contract, 69 on-site reviews were completed,
less than the 200 anticipated in 2001 and less than the revised goal of
100 on-site reviews. According to the contractor's report, the highest
discrepancy rates identified during the 69 on-site reviews of 617
assessments included the number of medications (50 percent discrepancy
rate) and pain management (10 percent discrepancy rate).
51The November 2002 roll-out of quality indicator data included a combined
total of 10 chronic care and post-acute-care quality indicators. Chronic
care quality indicators included decline in activities of daily living,
pressure sores (with facility-level adjustment), pressure sores (without
facility-level adjustment), inadequate pain management, physical
restraints used daily, and infections. Post-acute-care quality indicators
included failure to improve and manage delirium (with facility-level
adjustment), failure to improve and manage delirium (without
facility-level adjustment), inadequate pain management, improvement in
walking, and rehospitalizations.
52The National Quality Forum is a nonprofit organization created to
develop and implement a national strategy for health care quality
measurement and reporting. It has broad participation from government and
private entities as well as all sectors of the health care industry.
53The Web site reports the nursing staff hours per resident per day and
certified nurse aides per resident per day.
54The National Quality Forum has discussed expanding staffing data to
include these and other issues such as use of nonnursing staff to provide
care, use of part-time and contract nurses, and the tenure of the director
of nursing and the administrator.
Quality Improvement Organizations
Coordination and Dissemination of Best Practices
55In smaller states, QIOs worked with at least 10 nursing homes.
56An evaluation of the pilot program reported on the results of the pilot
program; however, the evaluation was conducted by the same QIO responsible
for facilitating the pilot program.
Resource and Workload Issues Pose Key Challenges to Further Improving Nursing
Home Quality and Safety
Cost Could Delay Retrofitting of Older Nursing Homes with Sprinklers
57Best practices have been collected from organizations including the
American Medical Directors Association, University of Iowa Geriatric
Nursing Center, Association of Rehabilitation Nurses, American Diabetes
Association, National Kidney and Urologic Diseases Information
Clearinghouse, Feinberg School of Medicine (Northwestern University),
American Academy of Neurology, American Society of Consultant Pharmacists,
United Ostomy Association, and the Centers for Disease Control and
Prevention.
58To update federal fire safety standards, CMS issues notice and solicits
comments on the proposed new standards in the Federal Register, reviews
public comments, and publishes a final version of the standards with an
effective date. This process of adopting NFPA's 2000 standards in 2003
took CMS about 16 months.
59After the 2003 nursing home fire in Hartford, Connecticut, the state
passed a law requiring all nursing homes to install sprinklers not later
than July 1, 2005 (Conn. Spec. Acts 03-3, S:92.). In 2005, the state
extended the effective date to July 31, 2006 (Conn. Pub. Acts 05-187.).
Florida enacted a law in June 2005 that requires nursing homes in the
state to be protected with automatic sprinklers by December 31, 2010. A
loan guarantee program would be available in Florida because of concern
about the cost impact of retrofitting on homes (Fla. Laws Ch. 2005-234).
60This includes about 1 percent of homes whose sprinkler status is
unknown.
States Continue to Have Problems in Hiring and Retaining Surveyors
61According to CMS and state officials, the first year for a new surveyor
is essentially a training period with low productivity. It takes as long
as 3 years for a surveyor to gain sufficient knowledge, experience, and
confidence to perform the job well.
Percentage of surveyors with 2 years' experience or less Number of states
More than 50 percent 5
More than 30 percent to 50 percent 5
20 percent to 30 percent 10
10 percent to less than 20 percent 5
62As a result of the recession that began in 2001, states experienced
growing budget pressures and experienced significant budget shortfalls
from fiscal years 2003 through 2005. Although budget pressures diminished
at the end of fiscal year 2004, many states projected budget shortfalls in
fiscal year 2005.
Workload Issues and Competing Priorities Pose Challenges for CMS and States
Increased Workload Has Contributed to Delays
63The Medicare Prescription Drug, Improvement, and Modernization Act of
2003 created the new Medicare prescription drug benefit, which will offer
Medicare beneficiaries outpatient prescription drug coverage (Pub. L. No.
108-173, S:101, 117 Stat. 2066, 2071-2152 (adding S:S: 1860D-1-1860D-42 to
the Social Security Act, codified at 42 U.S.C. S:S: 1395w-101-1395w-152)).
On January 28, 2005, CMS issued the final regulations implementing the
Medicare prescription drug benefit.
Number of Providers Subject to Surveys Is Growing
64This increase includes a substantial increase in the number of end-stage
renal disease facilities and ambulatory surgical centers.
65The federal government funds 100 percent of costs associated with
certifying that nursing homes meet Medicare requirements and 75 percent of
the costs associated with Medicaid standards.
Key Nursing Home Initiatives Continue to Compete for Priority
66The time frames for home health agency surveys are also established by
statute.
67CMS has identified four priority tiers for ranking state workload. CMS's
guidance to states for formulating budgets puts standard surveys in Tier
I, the highest tier, and puts complaints and initial surveys in Tiers II
and III, respectively.
Concluding Observations
68As stated earlier, CMS set aside some fiscal year 2006 funds for
conducting fire safety comparative surveys.
Agency and State Comments and Our Evaluation
Appendix I: Prior GAO Recommendations, Related CMS Initiatives, and
Implementation Status Appendix I: Prior GAO Recommendations, Related CMS
Initiatives, and Implementation Status
Table 10: Implementation Status of CMS's Initiatives Responding to GAO's
Nursing Home Quality and Safety Recommendations, July 1998 through
November 2004
GAO report Implementation
number GAO recommendation CMS initiative status
Surveys
GAO/HEHS-98-202 1. Stagger or CMS took several 0R
otherwise vary the steps to reduce
scheduling of survey
standard surveys to predictability,
effectively reduce but some state
the predictability of surveys remain
surveyors' visits. predictable.
The variation could
include segmenting o In 1999, CMS
the standard survey instructed
into more than one state survey
review throughout the agencies to (1)
12- to 15-month conduct 10
period, which would percent of
provide more surveys on
opportunities for evenings and
surveyors to observe weekends, (2)
problematic homes and vary the
initiate broader sequencing of
reviews when surveys in a
warranted. geographical
area to avoid
alerting other
homes that the
surveyors are
in the area,
(3) vary the
scheduling of
surveys by day
of the week,
and (4) avoid
scheduling
surveys for the
same month as a
home's prior
survey.
o In 2004, CMS
provided states
with an
automated
scheduling and
tracking system
(AST) to assist
in scheduling
surveys. CMS
officials told
us that AST can
be used to
address survey
predictability.
States appeared
to be unaware
of this feature
and use of AST
is optional.
o CMS
disagreed with
and did not
implement the
recommendation
to segment the
standard survey
into more than
one review
throughout the
12- to 15-month
period.
2. Revise federal CMS has been
survey procedures to developing a
instruct surveyors to revised survey
take stratified methodology since
random samples of 1998. A pilot test
resident cases and of the new
review sufficient methodology is
numbers and types of scheduled to begin
resident cases so in the fall of
that surveyors can 2005.
better detect Implementation
problems and assess could begin in
their prevalence. mid-2007.
GAO-03-561 3. Finalize the See CMS action in
development, testing, response to
and implementation of recommendation to
a more rigorous revise federal
survey methodology, survey procedures
including (recommendation #2
investigative above).
protocols that
provide guidance to CMS began revising
surveyors in surveyors'
documenting investigative
deficiencies at the protocols in
appropriate scope and October 2000.
severity level. Three protocols
have been issued
and several more
are under
development. In
addition, CMS is
clarifying the
definitions of
actual harm and
immediate
jeopardy.
4. Require states to CMS has no plans
have a quality to implement this
assurance process recommendation,
that includes, at a indicating that
minimum, a review of regular workload
a sample of survey and priorities
reports below the take precedence
level of actual harm over it.
to assess the
appropriateness of
the scope and
severity cited and to
help reduce instances
of understated
quality-of-care
problems.
GAO-05-78 5. Hold homes CMS revised its
accountable for all definition of past
past noncompliance noncompliance. CMS
resulting in harm to plans to add the
residents, not just specific nature of
care problems deemed the care problem
to be egregious, and to its Web site,
develop an approach but programming
for citing such past required for the
noncompliance in a Medicare
manner that clearly prescription drug
identifies the benefit has
specific nature of delayed
the care problem both implementation.
in the OSCAR database
and on CMS's Nursing
Home Compare Web
site.
Complaints
GAO/HEHS-99-80 6. Develop additional In October 1999,
standards for the CMS issued a
prompt investigation policy letter
of serious complaints stating that
alleging situations complaints
that may harm alleging harm must
residents but are be investigated
categorized as less within 10 days.
than immediate
jeopardy. These In January 2004,
standards should CMS provided
include maximum detailed direction
allowable time frames and guidance to
for investigating states for
serious complaints managing complaint
and for complaints investigations for
that may be deferred numerous types of
until the next providers,
scheduled annual including nursing
survey. States may homes.
continue to set
priority levels and In June 2004, CMS
time frames that are made available
more stringent than updated guidance
these federal on the Internet
standards. that consolidates
complaint
investigation
procedures for
numerous types of
providers.
7. Strengthen federal In 2000, CMS began
oversight of state requiring its
complaint regional offices
investigations, to perform yearly
including monitoring assessments of
states' practices states' complaint
regarding investigations as
priority-setting, part of annual
on-site state performance
investigation, and reviews.
timely reporting of
serious health and
safety complaints.
GAO-03-561 8. Finalize the In January 2004,
development of CMS provided
guidance to states detailed direction
for their complaint and guidance to
investigation states for
processes and ensure managing complaint
that it addresses key investigations for
weaknesses, including numerous types of
the prioritization of providers,
complaints for including nursing
investigation, homes.
particularly those
alleging harm to In June 2004, CMS
residents; the made available
handling of facility updated guidance
self-reported on the Internet
incidents; and the that consolidates
use of appropriate complaint
complaint investigation
investigation procedures for
practices. numerous types of
providers.
GAO-02-312 9. Ensure that state In 2002, CMS
survey agencies issued a memo to
immediately notify the regional
local law enforcement offices and state
agencies or Medicaid survey agencies
Fraud Control Units emphasizing its
when nursing homes policy for
report allegations of preventing abuse
resident physical or in nursing homes
sexual abuse or when and for promptly
the survey agency has reporting it to
confirmed complaints the appropriate
of alleged abuse. agencies when it
occurs.
In 2004, CMS
informed GAO that
it continues to
hold discussions
with the
Department of
Justice and with
the HHS Office of
General Counsel
about CMS's
authority to
require, and
potential
effectiveness of
requiring, state
survey agencies to
immediately notify
local law
enforcement of
suspected physical
and sexual abuse.
10. Accelerate the CMS developed a
agency's education poster, but it is
campaign on reporting not yet released,
nursing home abuse by pending approval
(1) distributing its by the Secretary
new poster with of HHS.
clearly displayed
complaint telephone In 2002, CMS
numbers and (2) released a
requiring state memorandum to
survey agencies to regional offices
ensure that these and state agencies
numbers are that addresses
prominently listed in displaying
local telephone complaint
directories. telephone numbers.
CMS asked all
state agencies to
review how their
telephone number
is listed in the
local directory
and asked them to
ensure that their
complaint
telephone numbers
are prominently
listed.
11. Systematically CMS is conducting
assess state policies a Background Check
and practices for Pilot Program in
complying with the several states, as
federal requirement required by the
to prohibit Medicare
employment of Prescription Drug,
individuals convicted Improvement, and
of abusing nursing Modernization Act
home residents and, of 2003. The pilot
if necessary, develop is expected to run
more specific through September
guidance to ensure 2007, followed by
compliance. an evaluation of
the results.
12. Clarify the In 2002, CMS
definition of abuse released a
and otherwise ensure memorandum to its
that states apply regional offices
that definition and state survey
consistently and agency directors
appropriately. clarifying its
definition of
abuse and
instructing them
to report
suspected abuse to
law enforcement
authorities and,
if appropriate, to
the state's
Medicaid Fraud
Control Unit.a
13. Shorten the state CMS informed GAO
survey agencies' time that the
frames for regulations do not
determining whether specify time
to include findings frames that states
of abuse in nurse must follow in
aide registry files. substantiating
abuse, but agreed
to review this
matter when the
agency considers
changes to the
regulations. CMS
did not indicate
when this would be
done.
Enforcement
GAO/HEHS-98-202 14. Require that for In 1998, CMS
problem homes with issued guidance to
recurring serious regional offices
violations, state and state survey
surveyors agencies
substantiate, by strengthening its
means of an on-site revisit policy by
revisit, every report requiring on-site
to CMS of a home's revisits until all
resumed compliance serious
status. deficiencies are
corrected. Homes
are no longer
permitted to
self-report
resumed
compliance.
15. Eliminate the CMS phased in
grace period for implementation of
homes cited for its "double G"
repeated serious policy from
violations and impose September 1998
sanctions promptly, through January
as permitted under 2000.
existing regulations.
GAO/HEHS-99-46 16. Improve the As requested by
effectiveness of HHS, Congress
civil money approved increased
penalties: the funding and
Administrator should staffing levels
continue to take for the
those steps necessary Departmental
to shorten the delay Appeals Board in
in adjudicating fiscal years 1999
appeals, including and 2000.
monitoring progress
made in reducing the
backlog of appeals.
17. Strengthen the 0R
use and effect of
termination:
o Continue Medicare CMS conducted a
and Medicaid payments study and
beyond the concluded that it
termination date only was not practical
if the home and state to establish rules
Medicaid agency are to address this
making reasonable problem.
efforts to transfer
residents to other
homes or alternative
modes of care.
o Ensure that CMS added examples
reasonable assurance to the reasonable
periods associated assurance guidance
with reinstating in 2000, but
terminated homes are declined to
of sufficient lengthen the
duration to reasonable
effectively assurance period.
demonstrate that the
reason for
termination has been
resolved and will not
recur.
o Strengthen the use In 2000, CMS
and effect of revised its
termination: Revise guidance so that
existing policies so pretermination
that the history of a home
pretermination is considered in
history of a home is taking subsequent
considered in taking enforcement
a subsequent actions.
enforcement action.
18. Improve the In 2000, CMS
referral process: The revised its
Administrator should guidance to
revise CMS guidance require states to
so that states refer refer homes for
homes to CMS for possible sanction
possible sanction if they had been
(such as civil money cited for a
penalties) if they deficiency that
have been cited for a contributed to a
deficiency that resident's death.
contributed to a
resident's death.
Oversight
GAO/HEHS-99-46 19. Develop better CMS has
management implemented new
information systems. national
The Administrator enforcement and
should enhance OSCAR complaint tracking
or develop some other systems but does
information system not anticipate
that can be used by completing its
both by the states replacement of the
and CMS to integrate OSCAR data system
the results of until 2008.
complaint
investigations, track
the status and
history of
deficiencies, and
monitor enforcement
actions.
GAO/HEHS-99-80 20. Require that the In January 2004,
substantiated results CMS's new ASPEN
of complaint Complaint Tracking
investigations be system was
included in federal implemented
data systems or be nationwide.
accessible by federal
officials.
GAO/HEHS-00-6 21. Improve the scope
and rigor of CMS's
oversight process:
o Increase the CMS has
proportion of federal significantly
monitoring surveys increased the
conducted as number of
comparative surveys quality-of-care
to ensure that a comparative
sufficient number are surveys. In fiscal
completed in each year 2006,
state to assess however, the
whether the state agency will no
appropriately longer contract
identifies serious for additional
deficiencies. quality-of-care
comparative
surveys because of
funding
constraints.
o Ensure that To better ensure
comparative surveys that conditions in
are initiated closer a nursing home
to the time the state have not changed
agency completes the since the state
home's annual survey, CMS
standard survey. regional offices
have reduced the
average time
between the state
survey and the
initiation of a
federal
comparative survey
from 33 days in
1999 to 26 days by
2004.
o Require regions to CMS instructed the
provide more timely regions to report
written feedback to the results of
the states after the federal monitoring
completion of federal surveys to states
monitoring surveys. on a monthly
basis.
o Improve the data CMS developed a
system for separate database
observational surveys accessible to all
so that it is an regional offices
effective management that includes the
tool for CMS to results of
properly assess the observational
findings of surveys. Beginning
observational in fiscal year
surveys. 2002, CMS added
data on the
results of
comparative
surveys.
22. Improve the 0R
consistency in how
CMS holds state
survey agencies
accountable by
standardizing
procedures for
selecting state
surveys and
conducting federal
monitoring surveys:
o Ensure that the CMS did not
regions target implement our
surveys for review recommendation to
that will provide a select individual
comprehensive state surveys for
assessment of state federal review in
surveyor performance. a manner that
ensures its
regional offices
observe as many
state surveyors as
possible.
o Require federal In October 2002,
surveyors to include CMS instructed
as many of the same federal surveyors
residents as possible to select at least
in their comparative half of those
survey sample as the residents selected
state included in its by the state
sample (where CMS surveyors for
surveyors have their resident
determined that the sample.
state sample
selection process was
appropriate).
23. Further explore In December 1999,
the feasibility of CMS adopted new
appropriate state sanctions.
alternative remedies In fiscal year
or sanctions for 2005, CMS began to
those states that tie survey agency
prove unable or funding increases
unwilling to meet to the timely
CMS's performance conduct of
standards. standard surveys,
a step that we
believe offers a
strong incentive
for improved
compliance.
GAO/HEHS-02-279 24. Review the CMS disagreed with
adequacy of current and did not
state efforts to implement this
ensure the accuracy recommendation.
of minimum data set
(MDS) data, and
provide, where
necessary, additional
guidance, training,
and technical
assistance.
25. Monitor the CMS disagreed with
adequacy of state MDS and did not
accuracy activities implement this
on an ongoing basis, recommendation.
such as through the
use of the
established federal
comparative survey
process.
26. Provide guidance CMS disagreed with
to state agencies and and did not
nursing homes that implement this
sufficient recommendation.
evidentiary
documentation to
support the full MDS
assessment be
included in
residents' medical
records.
GAO-03-187 27. Delay the CMS disagreed with
implementation of and did not
nationwide reporting implement this
of quality indicators recommendation.
until there is
greater assurance
that the quality
indicators are
appropriate for
public
reporting-including
the validity of the
indicators selected
and the use of an
appropriate
risk-adjustment
methodology-based on
input from the
National Quality
Forum and other
experts and, if
necessary, additional
analysis and testing.
28. Delay the CMS disagreed with
implementation of and did not
nationwide reporting implement this
of quality indicators recommendation.
until a more thorough
evaluation of the
pilot is completed to
help improve the
initiative's
effectiveness,
including an
assessment of the
presentation of
information on the
Web site and the
resources needed to
assist consumers' use
of the information.
GAO-03-561 29. Further refine CMS did not
annual state implement this
performance reviews recommendation
so that they (1) because it
consistently believes that the
distinguish between state performance
systemic problems and standards take
less serious issues into account
regarding state statutory and
performance, (2) nonstatutory
analyze trends in the performance
proportion of homes standards.
that harm residents,
(3) assess state
compliance with the
immediate sanctions
policy for homes with
a pattern of harming
residents, and (4)
analyze the
predictability of
state surveys.
GAO-04-660 30. Ensure that CMS CMS's evaluation
regional offices of state
fully comply with the surveyors'
statutory requirement performance now
to conduct annual routinely includes
federal monitoring fire safety as
surveys by including part of the
an assessment of the statutory
fire safety component requirement to
of states' standard annually conduct
surveys, with an federal monitoring
emphasis on surveys in at
unsprinklered homes. least 5 percent of
surveyed nursing
homes in each
state.
31. Ensure that data As nursing homes
on sprinkler coverage are surveyed, CMS
in nursing homes are is in the process
consistently obtained of collecting
and reflected in the consistent data on
CMS database. the sprinkler
status of homes
and entering these
data into OSCAR.
32. Until sprinkler CMS has contacted
coverage data are state survey
routinely available agencies and
in CMS's database, collected data on
work with state all but about 5
survey agencies to percent of nursing
identify the extent homes. These data
to which each nursing will be verified
home is sprinklered during each home's
or not sprinklered. next annual
survey.
33. On an expedited CMS expects to
basis, review all complete its
waivers and Fire reviews of Fire
Safety Evaluation Safety Evaluation
Systemb assessments System Assessments
for homes that are by late 2005.
not fully sprinklered
to determine their
appropriateness.
34. Make information This information
on fire safety will not be
deficiencies available on the
available to the Nursing Home
public via the Compare Web site
Nursing Home Compare until 2007.
Web site, including
information on
whether a home has
automatic sprinklers.
35. Work with the CMS has issued an
National Fire interim final rule
Protection requiring the
Association to installation of
strengthen fire smoke detectors by
safety standards for May 24, 2006. It
unsprinklered nursing anticipates
homes, such as issuing a notice
requiring smoke of proposed rule
detectors in resident making requiring
rooms, exploring the older nursing
feasibility of homes to install
requiring sprinklers sprinklers early
in all nursing homes, in 2006 but will
and developing a ask for comments
strategy for on how much time
financing such homes should be
requirements. given to come into
compliance.
36. Ensure that CMS developed and
thorough issued a
investigations are standardized
conducted following procedure to
multiple-death ensure that both
nursing home fires so state survey
that fire safety agencies and its
standards can be own staff take
reevaluated and appropriate action
modified where to investigate
appropriate. fires that result
in serious injury
or death.
Fully implemented our recommendation
0R Implemented only part of our recommendation and no further steps are
planned
Taking steps to implement our recommendation
Did not implement our recommendation
Source: GAO analysis of CMS's responses to our recommendations.
aIn 1999, CMS had required the use of an investigative protocol on abuse
prohibition during every standard survey. The protocol's objective is to
determine if the facility has developed and operationalized policies and
procedures that prohibit abuse, neglect, involuntary seclusion, and
misappropriation of resident property.
bAs an alternative to correcting or receiving a waiver for deficiencies
identified on a standard survey, a home may undergo an assessment using
the Fire Safety Evaluation System. The system provides a means for nursing
homes to meet the fire safety objectives of CMS's standards without
necessarily being in full compliance with every standard.
Appendix II: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy during Standard Surveys Appendix II: Percentage of
Nursing Homes Cited for Actual Harm or Immediate Jeopardy during Standard
Surveys
In order to identify trends in the proportion of nursing homes cited with
actual harm or immediate jeopardy deficiencies, we analyzed data from
CMS's OSCAR database for four time periods: (1) January 1, 1999, through
July 10, 2000; (2) July 11, 2000, through January 31, 2002; (3) February
1, 2002, through July 10, 2003; and (4) July 11, 2003, through January 31,
2005. Because surveys are conducted at least every 15 months (with a
required 12-month statewide average), it is possible that a home was
surveyed twice in any time period. To avoid double counting of homes, we
included only homes' most recent survey from each time period.
Table 11: Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy, by State
Percentage
of homes
cited for
actual Percentage
harm or point
Number of immediate differenceb
homes jeopardy 1/1/99 -
surveyed, 7/10/00 and 2/1/02
7/03 - 1/1/99 - 7/11/03 - 7/11/00 - 7/11/03
State 1/05a 7/10/00 1/31/05 -1/31/02 7/10/03 -1/31/05
Increase of 5
percentage
points or
greater
District of 21 10.0 33.3 38.1 33.3 23.3
Columbia
Colorado 218 15.4 26.2 21.7 24.3 8.9
Connecticut 247 48.5 49.4 38.8 54.3 5.8
Change of less
than 5
percentage
points
South Carolina 178 28.7 17.8 27.0 32.0 3.4
Oklahoma 376 16.7 20.6 22.6 18.6 2.0
Vermont 42 15.2 17.8 9.5 16.7 1.4
Maine 117 10.3 9.7 9.0 9.4 -0.9
West Virginia 137 15.6 14.0 14.1 13.1 -2.5
Rhode Island 86 12.1 10.1 2.4 9.3 -2.8
Wisconsin 413 14.0 7.1 9.1 10.2 -3.8
Decrease of 5
percentage
points or
greater
Utah 94 15.8 15.8 22.6 10.6 -5.2
Iowa 492 19.3 9.9 7.7 14.0 -5.3
Georgia 365 22.6 20.5 20.1 16.4 -6.1
Kansas 380 37.1 29.0 24.9 30.5 -6.5
Tennessee 340 26.0 16.7 19.7 19.1 -6.9
New Mexico 81 31.7 17.1 16.2 24.7 -7.0
South Dakota 113 24.1 30.7 24.8 16.8 -7.3
Hawaii 45 25.5 15.2 12.8 17.8 -7.8
Maryland 239 25.6 20.2 14.6 17.6 -8.0
North Dakota 83 21.3 28.4 11.9 13.3 -8.1
Missouri 550 22.3 10.2 13.6 13.8 -8.4
Nebraska 238 26.0 18.9 19.6 16.4 -9.6
Louisiana 332 19.9 23.4 18.0 10.2 -9.7
Virginia 287 19.9 11.6 13.4 9.8 -10.1
Pennsylvania 729 32.2 11.6 14.4 20.6 -11.7
Nevada 43 32.7 9.8 6.7 20.9 -11.8
Illinois 833 29.3 15.4 15.3 16.2 -13.1
Nation 16,463 29.3 20.5 17.1 15.5 -13.8
Texas 1,185 26.9 25.5 18.5 12.7 -14.3
New Jersey 363 24.5 22.4 12.7 9.6 -14.9
Mississippi 209 33.2 19.6 14.4 18.2 -15.0
Florida 694 20.8 20.1 9.8 5.5 -15.4
New Hampshire 83 37.3 21.5 21.7 21.7 -15.7
Massachusetts 468 33.0 22.9 22.5 16.9 -16.1
Arkansas 254 37.7 27.3 15.8 20.5 -17.3
Ohio 1,009 29.0 23.7 21.8 11.6 -17.4
Idaho 80 54.2 31.0 38.3 36.3 -18.0
Minnesota 414 31.7 18.8 17.1 12.3 -19.3
Kentucky 296 28.8 25.2 25.0 9.5 -19.4
Michigan 433 42.1 24.7 30.0 22.6 -19.5
Montana 101 37.5 25.2 16.0 17.8 -19.7
Alaska 14 20.0 33.3 0.0 0.0 -20.0
North Carolina 425 40.8 30.1 24.0 20.2 -20.6
California 1,325 29.1 9.3 3.4 6.3 -22.8
Alabama 229 42.2 18.4 12.6 19.2 -23.0
New York 666 32.2 32.3 20.0 9.2 -23.0
Indiana 523 45.3 26.2 17.4 21.4 -23.8
Arizona 134 33.8 8.8 3.6 8.2 -25.6
Washington 257 54.1 38.5 36.6 26.5 -27.7
Wyoming 39 43.9 22.5 26.3 12.8 -31.1
Oregon 141 47.5 33.6 14.4 14.2 -33.3
Delaware 42 52.4 14.3 4.8 16.7 -35.7
Source: GAO analysis of OSCAR data.
Note: The first two time periods reflect data in OSCAR as of June 24,
2002. The last two time periods reflect OSCAR data as of July 10, 2003,
and April 13, 2005, respectively. The term states includes the 50 states
and the District of Columbia.
aThese data illustrate the significant variation in the number of nursing
homes across states.
bDifferences are based on numbers before rounding.
Appendix III: Percentage of Homes Surveyed Within 15 Days of the 1-Year
Anniversary of Prior Survey Appendix III: Percentage of Homes Surveyed
Within 15 Days of the 1-Year Anniversary of Prior Survey
In order to determine the predictability of nursing home surveys, we
analyzed data from CMS's OSCAR database for a home's current survey as of
April 9, 2002, and as of July 8, 2005 (see table 12). We considered
surveys to be predictable if homes were surveyed within 15 days of the
1-year anniversary of their prior survey.
Table 12: Percentage of Nursing Homes with Predictable Surveys, April 2002
and June 2005
Percentage of homes
surveyed within 15 days Percentage point
of 1-year anniversary difference,
Number of of prior survey 4/9/02 and
State homesa 4/9/02 7/8/05 7/8/05
More than 50
percent
North Dakota 83 28.2 51.8 23.6
More than 25
percent to 50
percent
District of 20 15.0 40.0 25.0
Columbia
Iowa 439 31.1 35.8 4.7
Kansas 357 13.6 29.1 15.5
Oregon 138 14.1 28.3 14.2
California 1,287 9.5 27.8 18.3
Nebraska 221 3.1 27.6 24.5
Maryland 236 20.7 27.5 6.8
10 percent to 25
percent
Virginia 270 30.5 20.4 -10.1
North Carolina 418 13.9 19.1 5.2
Wisconsin 396 19.6 18.7 -0.9
New Jersey 354 18.7 18.4 -0.3
Michigan 428 8.8 17.1 8.3
Alabama 227 5.8 16.7 10.9
Delaware 42 31.0 16.7 -14.3
Texas 1,111 15.7 16.7 1.0
Indiana 502 14.4 16.3 1.9
Massachusetts 461 17.3 16.3 -1.0
Wyoming 39 10.3 15.4 5.1
Colorado 213 9.0 15.0 6.0
Kentucky 294 10.6 15.0 4.4
Nation 15,827 13.0 14.5 1.5
Alaska 14 6.7 14.3 7.6
Rhode Island 92 12.5 13.0 0.5
Montana 100 8.7 13.0 4.3
New Mexico 78 13.8 12.8 -1.0
Pennsylvania 721 24.0 12.8 -11.2
Washington 246 22.4 12.6 -9.8
Vermont 41 11.6 12.2 0.6
Missouri 509 11.9 12.0 0.1
New Hampshire 81 12.0 11.1 -0.9
New York 659 14.8 11.1 -3.7
South Dakota 109 18.9 11.0 -7.9
Florida 685 9.3 10.4 1.1
Illinois 792 9.7 10.4 0.7
Maine 116 8.3 10.3 2.0
Less than 10
percent
Georgia 359 0.6 7.2 6.6
Nevada 43 24.4 7.0 -17.4
Hawaii 45 13.6 6.7 -6.9
Idaho 80 4.8 6.3 1.5
South Carolina 176 6.9 6.3 -0.6
Arizona 133 21.0 6.0 -15.0
Louisiana 288 19.0 5.9 -13.1
Tennessee 326 6.2 5.2 -1.0
Minnesota 408 4.4 4.7 0.3
West Virginia 129 8.7 3.9 -4.8
Arkansas 235 27.6 3.8 -23.8
Utah 87 1.1 3.4 2.3
Connecticut 245 15.8 2.9 -12.9
Ohio 960 3.0 2.2 -0.8
Mississippi 201 2.1 2.0 -0.1
Oklahoma 333 0.6 1.8 1.2
Source: GAO analysis of OSCAR data.
Note: The term states includes the 50 states and the District of Columbia.
aRepresents the number of nursing homes with a prior and a current survey
as of July 8, 2005.
Appendix IV: Percentage of State Nursing Home Surveyors with 2-Years'
Experience or Less, 2002 and 2005 Appendix IV: Percentage of State Nursing
Home Surveyors with 2-Years' Experience or Less, 2002 and 2005
State 2002 2005 Percentage point change
Increase
Arizona 20 53 33
Colorado 24 53 29
Alaska 29 57 28
Illinois 5 25 20
Rhode Island 9 23 14
North Carolina 33 44 11
Ohio 17 21 4
Virginia 21 25 4
Florida 55 57 2
Arkansas 33 33 0
Decrease
Indiana 20 18 -2
New Jersey 30 26 -4
Oregon 34 29 -5
Texas 32 26 -6
Wisconsin 25 19 -6
Nebraska 29 20 -9
Alabama 48 38 -10
Georgia 51 35 -16
Tennessee 45 28 -17
New York 40 18 -22
Washington 54 26 -28
Louisiana 48 19 -29
Maryland 70 14 -56
South Carolina a 52 N/A
Vermont a 38 N/A
Source: State survey agency responses to July 2002 GAO questions, and
updates obtained from AHFSA in July 2005.
Note: The term states includes the 50 states and the District of Columbia.
aThis state did not respond to our 2002 questions about surveyor
experience.
Appendix V: Comments from the Centers for Medicare & Medicaid Services
Appendix V: Comments from the Centers for Medicare & Medicaid Services
Appendix VI: A Appendix VI: GAO Contact and Staff Acknowledgments
GAO Contact
Kathryn G. Allen, (202) 512-7118 or [email protected]
Acknowledgments
In addition to the contact named above, Walter Ochinko, Assistant
Director; Jack Brennan; Joanne Jee; Elizabeth T. Morrison; and Christal
Stone made key contributions to this report.
Related GAO Products Related GAO Products
Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in
State and Federal Oversight of Quality of Care. GAO-05-78 . Washington,
D.C.: November 12, 2004.
Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal
Standards and Oversight. GAO-04-660 . Washington D.C.: July 16, 2004.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. GAO-03-561 . Washington,
D.C.: July 15, 2003.
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.
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 Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R . Washington, D.C.:
August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/HEHS-99-157 . Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/HEHS-99-80 . 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: Care Problems Persist Despite Federal and State
Oversight. GAO/HEHS-98-202 . Washington, D.C.: July 27, 1998.
(290460)
GAO's Mission
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting its
constitutional responsibilities and to help improve the performance and
accountability of the federal government for the American people. GAO
examines the use of public funds; evaluates federal programs and policies;
and provides analyses, recommendations, and other assistance to help
Congress make informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony
The fastest and easiest way to obtain copies of GAO documents at no cost
is through GAO's Web site ( www.gao.gov ). Each weekday, GAO posts newly
released reports, testimony, and correspondence on its Web site. To have
GAO e-mail you a list of newly posted products every afternoon, go to
www.gao.gov and select "Subscribe to Updates."
Order by Mail or Phone
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
D.C. 20548
To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061
To Report Fraud, Waste, and Abuse in Federal Programs
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: [email protected]
Automated answering system: (800) 424-5454 or (202) 512-7470
Congressional Relations
Gloria Jarmon, Managing Director, [email protected] (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125 Washington,
D.C. 20548
Public Affairs
Paul Anderson, Managing Director, [email protected] (202) 512-4800 U.S.
Government Accountability Office, 441 G Street NW, Room 7149 Washington,
D.C. 20548
www.gao.gov/cgi-bin/getrpt? GAO-06-117 .
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Kathryn G. Allen, (202) 512-7118,
[email protected].
Highlights of GAO-06-117 , a report to congressional requesters
December 2005
NURSING HOMES
Despite Increased Oversight, Challenges Remain in Ensuring High-Quality
Care and Resident Safety
Since 1998, GAO has issued numerous reports on nursing home quality and
safety that identified significant weaknesses in federal and state
oversight. Under contract with the Centers for Medicare & Medicaid
Services (CMS), states conduct annual nursing home inspections, known as
surveys, to assess compliance with federal quality and safety
requirements. States also investigate complaints filed by family members
or others in between annual surveys. When state surveys find serious
deficiencies, CMS may impose sanctions to encourage compliance with
federal requirements.
GAO was asked to assess CMS's progress since 1998 in addressing oversight
weaknesses. GAO
(1) reviewed the trends in nursing home quality from 1999 through January
2005, (2) evaluated the extent to which CMS's initiatives have addressed
survey and oversight problems identified by GAO and CMS, and (3)
identified key challenges to continued progress in ensuring resident
health and safety.
GAO reviewed federal data on the results of state nursing home surveys and
federal surveys assessing state performance; conducted additional analyses
in five states with large numbers of nursing homes; reviewed the status of
its prior recommendations; and identified key workforce and workload
issues confronting CMS and states.
CMS's nursing home survey data show a significant decline in the
proportion of nursing homes with serious quality problems since 1999, but
this trend masks two important and continuing issues: inconsistency in how
states conduct surveys and understatement of serious quality problems.
Inconsistency in states' surveys is demonstrated by wide interstate
variability in the proportion of homes found to have serious
deficiencies-for example, about 6 percent in one state and about 54
percent in another. Continued understatement of serious deficiencies 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. In five large
states that had a significant decline in serious deficiencies, federal
surveyors concluded that from 8 percent to 33 percent of the comparative
surveys identified serious deficiencies that state surveyors had missed.
This finding is consistent with earlier GAO work showing that state
surveyors missed serious care problems. These two issues underscore the
importance of CMS initiatives to improve the consistency and rigor of
nursing home surveys.
CMS has addressed many survey and oversight shortcomings, but it is still
developing or has not yet implemented several key initiatives,
particularly those intended to improve the consistency of the survey
process. Key steps CMS has taken include (1) revising the survey
methodology, (2) issuing states additional guidance to strengthen
complaint investigations, (3) implementing immediate sanctions for homes
cited for repeat serious violations, and (4) strengthening oversight by
conducting assessments of state survey activities. Some CMS initiatives,
however, either have shortcomings impairing their effectiveness or have
not effectively targeted problems GAO and CMS identified. For example, CMS
has not fully addressed issues with the accuracy and reliability of the
data underlying consumer information published on its Web site.
The key challenges CMS, states, and nursing homes face in their efforts to
further improve nursing home quality and safety include (1) the cost to
older homes to be retrofit with automatic sprinklers to help reduce the
loss of life in the event of a fire, (2) continuing problems with hiring
and retaining qualified surveyors, and (3) an expanded workload due to
increased oversight, identification of additional initiatives that compete
for staff and financial resources, and growth in the number of Medicare
and Medicaid providers. Despite CMS's increased nursing home oversight,
its continued attention and commitment are warranted in order to maintain
the momentum of its efforts to date and to better ensure high-quality care
and safety for nursing home residents.
CMS generally concurred with the report's findings. CMS noted several
areas of progress in nursing home quality and identified remaining
challenges to conducting nursing home survey and oversight activities.
*** End of document. ***