Nursing Home Reform: Continued Attention Is Needed to Improve
Quality of Care in Small but Significant Share of Homes
(02-MAY-07, GAO-07-794T).
With the Omnibus Budget Reconciliation Act of 1987 (OBRA '87),
Congress responded to growing concerns about the quality of care
that nursing home residents received by requiring reforms in the
federal certification and oversight of nursing homes. These
reforms included revising care requirements that homes must meet
to participate in the Medicare or Medicaid programs, modifying
the survey process for certifying a home's compliance with
federal standards, and introducing additional sanctions and
decertification procedures for noncompliant homes. GAO's
testimony addresses its work in evaluating the quality of nursing
home care and the enforcement and oversight functions intended to
ensure high-quality care, the progress made in each of these
areas since the passage of OBRA '87, and the challenges that
remain. GAO's testimony is based on its prior work; analysis of
data from the Centers for Medicare & Medicaid Services' (CMS)
On-Line Survey, Certification, and Reporting system (OSCAR),
which compiles the results of state nursing home surveys; and
evaluation of federal comparative surveys for selected states
(2005-2007). Federal comparative surveys are conducted at nursing
homes recently surveyed by each state to assess the adequacy of
the state's surveys.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-07-794T
ACCNO: A68988
TITLE: Nursing Home Reform: Continued Attention Is Needed to
Improve Quality of Care in Small but Significant Share of Homes
DATE: 05/02/2007
SUBJECT: Elder care
Health care reform
Long-term care
Medicaid
Medicare
Noncompliance
Nursing homes
Quality of care
Quality of life
Sanctions
Standards
Surveys
Executive agency oversight
HCFA Online Survey, Certification, and
Reporting System
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GAO-07-794T
* [1]Background
* [2]Survey Process
* [3]Enforcement
* [4]Oversight
* [5]Quality of Care Remains a Problem for a Small but Significan
* [6]CMS Has Strengthened Its Enforcement Capabilities, although
* [7]Despite Changes in Federal Enforcement Policy, Immediate San
* [8]While CMS Collects Valuable Enforcement Data, Its Enforcemen
* [9]CMS Has Strengthened Oversight, although Competing Prioritie
* [10]Intensity of Federal Efforts Has Increased Significantly
* [11]Complaint Investigations
* [12]Federal Comparative Surveys
* [13]Fire Safety Standards
* [14]Upgrades to Data Systems
* [15]Competing Priorities Impede Certain Key CMS Initiatives
* [16]Concluding Observations
* [17]GAO Contact and Acknowledgments
* [18]Appendix I: Prior GAO Recommendations, Related CMS Initiativ
* [19]Appendix II: Percentage of Nursing Homes Cited for Actual Ha
* [20]Related GAO Products
* [21]Order by Mail or Phone
Testimony
Before the Special Committee on Aging, U.S. Senate
United States Government Accountability Office
GAO
For Release on Delivery
Expected at 10:30 a.m. EDT
Wednesday, May 2, 2007
NURSING HOME REFORM
Continued Attention Is Needed to Improve Quality of Care in Small but
Significant Share of Homes
Statement of Kathryn G. Allen
Director, Health Care
GAO-07-794T
Mr. Chairman and Members of the Committee:
I am pleased to be here today as you acknowledge the 20th anniversary of
the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA `87),
which contained nursing home reform provisions. In March 1986, the
National Academy of Sciences' Institute of Medicine (IOM) released a
report concluding that quality of care and quality of life in many nursing
homes were not satisfactory, despite the existence of government
regulation, and that more effective government regulation could
substantially improve nursing home quality.^1 In July 1987, we issued a
report recommending that Congress pass legislation that would strengthen
enforcement of federal nursing home requirements, consistent with the
IOM's recommendations.^2 Largely in response to these reports, Congress
passed the nursing home reform provisions of OBRA `87, which was
significant in that it changed the focus of quality standards from a
home's capability to provide care to its actual delivery of care and
resident outcomes. OBRA `87 directed the Health Care Financing
Administration, now known as the Centers for Medicare & Medicaid Services
(CMS), to reform its certification and oversight of nursing homes for
Medicare and Medicaid, which includes surveys to ensure the quality of
resident care, complaint investigations, and remedies and penalties for
nursing homes not in compliance with federal standards.^3
The nation's 1.5 million nursing home residents are a highly vulnerable
population of elderly and disabled individuals for whom remaining at home
is no longer feasible. With the aging of the baby boom generation, the
number of individuals needing nursing home care and the associated costs
are expected to increase dramatically. Combined Medicare and Medicaid
payments for nursing home services were about $72.7 billion in 2005,
including a federal share of about $49 billion. The federal government
plays a key role in ensuring that nursing home residents receive
appropriate care by setting quality-of-care, quality-of-life, and life
safety requirements that nursing homes must meet to participate in the
Medicare and Medicaid programs and by contracting with states to routinely
inspect homes and conduct complaint investigations.^4 To encourage
compliance with these requirements, Congress has authorized certain
enforcement actions.
^1See Institute of Medicine, National Academy of Sciences, Improving the
Quality of Care in Nursing Homes (Washington, D.C.: March 1986).
^2GAO, Medicare and Medicaid: Stronger Enforcement of Nursing Home
Requirements Needed, [22]GAO/HRD-87-113 (Washington, D.C.: July 22, 1987).
^3Prior to July 2001, CMS was known as the Health Care Financing
Administration. Throughout this testimony, we refer to the agency as CMS,
even when describing initiatives taken prior to its name change. Medicare
is the federal health care program for elderly and disabled people.
Medicare may cover up to 100 days of skilled 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.
Since this Committee requested us to investigate California nursing homes
in 1997, we have reported to Congress and testified numerous times on the
quality of resident care, identified significant weaknesses in federal and
state activities designed to detect and correct quality problems in
nursing homes, and made many recommendations to improve the survey process
and federal oversight of nursing home quality.^5 In response to our
recommendations as well as needed improvements CMS identified in its own
self-assessment in 1998, CMS announced a set of initiatives intended to
address many of these weaknesses. Over time, CMS has refined and expanded
these initiatives in order to continue to improve nursing home quality.
My remarks today will focus on GAO's work in evaluating the quality of
nursing home care and the enforcement and oversight functions intended to
ensure high-quality care.^6 I will address the progress made in these
three areas since OBRA `87, as well as the challenges that remain. This
statement is based primarily on prior GAO work. In addition, we
interviewed CMS officials; analyzed data from CMS's On-Line Survey,
Certification, and Reporting system (OSCAR), which compiles the results of
state nursing home surveys; and evaluated the results of federal
comparative surveys for selected states for the period January 2005
through March 2007. Federal comparative surveys are conducted at nursing
homes recently surveyed by each state to assess the adequacy of the
state's surveys. We considered these data sufficiently reliable for our
purposes. We discussed the highlights of this statement including our new
analyses with CMS officials, and they provided us additional information,
which we incorporated as appropriate. We conducted our work from March
through April 2007 in accordance with generally accepted government
auditing standards.
^4In this report, we use the term states to include the 50 states and the
District of Columbia.
^5Related GAO products are included at the end of this statement. See
appendix I for recommendations GAO has made, related CMS initiatives, and
the implementation status of these initiatives.
^6OBRA `87 included other requirements pertaining to nursing homes, such
as staffing, services, and specific rights of residents, including
privacy, restricted use of physical or chemical restraints, and voicing of
grievances, but GAO has not examined these issues.
In summary, despite the reforms of OBRA `87 and subsequent efforts by CMS
and the nursing home industry to improve the quality of nursing home care,
a small but significant share of nursing homes nationwide continues to
experience quality-of-care problems. In 2006, one in five nursing homes
nationwide was cited for serious deficiencies--those deficiencies that
cause actual harm or place residents in immediate jeopardy. While this
rate has fluctuated over the last 7 years, we have regularly found (1)
significant variation across states in their citation of serious
deficiencies, indicating inconsistencies in states' assessments of quality
of care and (2) understatement of these deficiencies--when deficiencies
are found on federal comparative surveys but not cited on corresponding
state surveys. Among the five large states we reviewed--California,
Florida, New York, Ohio, and Texas--understatement of serious deficiencies
has declined from 18 percent prior to December 2004 to 11 percent for the
most recent time period ending in March 2007, but understatement has
continued at varying levels.
Since the passage of OBRA `87, CMS has strengthened its enforcement
capabilities--for example, by implementing sanctions authorized in the
legislation, establishing an immediate sanctions policy for nursing homes
found to repeatedly harm residents, and developing a new enforcement
management data system--but several key initiatives require refinement.
The immediate sanctions policy is complex and appears to have induced only
temporary compliance in certain nursing homes with histories of repeated
noncompliance. In addition, the term "immediate sanctions" policy is
misleading because it requires only that homes be notified immediately of
CMS's intent to implement sanctions, not that sanctions be implemented
immediately. Furthermore, when a sanction, such as a denial of payment for
new admissions (DPNA), is implemented, there is a lag time between when
the deficiency citation occurs and the effective date of the sanction.
Finally, although CMS has developed a new data system, the system's
components are not integrated and the national reporting capabilities are
incomplete, hampering the agency's ability to track and monitor
enforcement.
CMS oversight of nursing home quality and state surveys has increased
since OBRA `87, but certain key initiatives continue to compete for
resources. To increase its oversight of quality of care in nursing homes,
CMS has focused its resources and attention in areas such as prompt
investigation of complaints and allegations of abuse, more frequent
federal comparative surveys, stronger fire safety standards, and upgrades
to data systems. However, this increased emphasis on nursing home
oversight coupled with growth in the number of Medicare and Medicaid
providers has caused greater demand on limited resources, which, in turn,
has led to queues and delays in certain key initiatives. For example, the
implementation of a new survey methodology, the Quality Indicator Survey
(QIS), has been in development for over 8 years and resource constraints
threaten the planned expansion of this methodology beyond the initial five
demonstration states.
Significant attention from the Special Committee on Aging, the Institute
of Medicine, and others served as a catalyst to focus national attention
on nursing home quality issues, culminating in the nursing home reform
provisions of OBRA `87. Since then, in response to many GAO
recommendations and at its own initiative, CMS has taken many important
steps to respond in a timelier, more rigorous, more consistent manner to
identified problems. Nevertheless, the task of ensuring high-quality
nursing home care is still not complete. To guarantee that all nursing
home residents receive high-quality care, it is important to maintain the
momentum begun by the reforms of OBRA `87 and continue to focus national
attention on those homes that cause actual harm to vulnerable residents.
Background
Titles XVIII and XIX of the Social Security Act establish minimum
requirements that all nursing homes must meet to participate in the
Medicare and Medicaid programs, respectively. With the passage of OBRA
`87, Congress responded to growing concerns about the quality of care that
nursing home residents received by requiring major reforms in the federal
regulation of nursing homes. Among other things, these reforms revised
care requirements that facilities must meet to participate in the Medicare
or Medicaid programs, modified the survey process for certifying a home's
compliance with federal standards, and introduced additional sanctions and
decertification procedures for homes that fail to meet federal standards.
Following OBRA `87, CMS published a series of regulations and transmittals
to implement the changes. Key implementation actions have included the
following: In October 1990, CMS implemented new survey standards; in July
1995, it established enforcement actions for nursing homes found to be out
of compliance; and it enhanced oversight through more rigorous federal
monitoring surveys beginning in October 1998 and annual state performance
reviews in fiscal year 2001. CMS has continued to revise and refine many
of these actions since their initial implementation.
Survey Process
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 life safety requirements. In
contrast, complaint investigations, also conducted by surveyors, generally
focus on a specific allegation regarding resident care or safety.^8
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
registered nurses, 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.
^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. In 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.
^8CMS contracts with state survey agencies to conduct surveys and
complaint investigations.
The life safety component of a survey focuses on a home's compliance with
federal fire safety requirements for health care facilities.^9 The fire
safety requirements cover 18 categories, ranging from building
construction to furnishings. Most states use fire safety specialists
within the same department as the state survey agency to conduct fire
safety inspections, but some 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.
Effective July 1995, CMS established a classification system for
deficiencies identified during either standard surveys or complaint
investigations. Deficiencies 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.
^9CMS 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.
Table 1: Scope and Severity of Deficiencies Identified during Nursing Home
Surveys
Scope
Severity Isolated Pattern Widespread
Immediate jeopardy^a J K L
Actual harm G H I
Potential for more than minimal harm D E F
Potential for minimal harm^b A B C
Source: CMS.
aActual or potential for death/serious injury.
bNursing home is considered to be in "substantial compliance."
Enforcement
In an effort to better ensure that nursing homes achieve and maintain
compliance with the new survey standards, OBRA `87 expanded the range of
enforcement sanctions. Prior to OBRA `87, the only sanctions available
were terminations from Medicare or Medicaid or, under certain
circumstances, DPNAs. OBRA `87 added several new alternative sanctions,
such as civil money penalties (CMP) and requiring training for staff
providing care to residents, and expanded the types of deficiencies that
could result in DPNAs. To implement OBRA `87, CMS published enforcement
regulations, effective July 1995. According to these regulations, the
scope and severity of a deficiency determine the applicable sanctions. CMS
imposes sanctions on homes with Medicare or dual Medicare and Medicaid
certification on the basis of state referrals.^10 CMS normally accepts a
state's recommendation for sanctions but can modify it.
Effective January 2000, CMS required states to refer for immediate
sanction homes found to have harmed one or a small number of residents or
to have a pattern of harming or exposing residents to actual harm or
potential death or serious injury (G-level or higher deficiencies on the
agency's scope and severity grid) on successive surveys. This is known as
the double G immediate sanctions policy. Additionally, in January 1999,
CMS launched the Special Focus Facility program. This initiative was
intended to increase the oversight of homes with a history of providing
poor care. When CMS established this program, it instructed each state to
select two homes for enhanced monitoring. For these homes, states are to
conduct surveys at 6-month intervals rather than annually. In December
2004, CMS expanded this program to require immediate sanctions for those
homes that fail to significantly improve their performance from one survey
to the next and termination for homes with no significant improvement
after three surveys over an 18-month period.^11
10Ensuring that documented deficiencies are corrected is a shared
federal-state responsibility. 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.
Unlike other sanctions, CMPs do not require a notification period before
they go into effect. However, if a nursing home appeals the deficiency, by
statute, payment of the CMP--whether received directly from the home or
withheld from the home's Medicare and Medicaid payments--is deferred until
the appeal is resolved.^12 In contrast to CMPs, other sanctions, including
DPNAs, cannot go into effect until homes have been provided a notice
period of at least 15 days, according to CMS regulations; the notice
period is shortened to 2 days in the case of immediate jeopardy. Although
nursing homes can be terminated involuntarily from participation in
Medicare and Medicaid, which can result in a home's closure, termination
is used infrequently.^13
Oversight
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 (1) statutorily required federal
monitoring surveys and (2) annual state performance reviews. Pursuant to
OBRA `87, CMS is required to conduct annual monitoring surveys in at least
5 percent of the state-surveyed Medicare and Medicaid nursing homes in
each state, with a minimum of five facilities in each state. These 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. State
performance reviews measure state survey agency compliance with seven
standards: timeliness of the survey, documentation of survey results,
quality of state agency investigations and decision making, timeliness of
enforcement actions, budget analysis, timeliness and quality of complaint
investigations, and timeliness and accuracy of data entry. These reviews
replaced state self-reporting of their compliance with federal
requirements.
^11As of December 2004, Alaska is not required to select Special Focus
Facilities, because there were fewer than 21 nursing homes in the state at
that time.
^12If efforts to collect the CMP directly from the home fail, Medicare and
Medicaid payments are withheld.
^13Homes also can choose to close voluntarily, but we do not consider
voluntary closure to be a sanction. When a home is terminated, it loses
any income from Medicare and Medicaid, which accounted for about 40
percent of nursing home payments in 2004. Residents who receive support
through Medicare or Medicaid must be moved to other facilities. However, a
terminated home generally can apply for reinstatement if it corrects its
deficiencies.
Quality of Care Remains a Problem for a Small but Significant Proportion of
Nursing Homes Nationwide
A small but significant proportion of nursing homes nationwide continue to
experience quality-of-care problems--as evidenced by the almost 1 in 5
nursing homes nationwide that were cited for serious deficiencies in
2006--despite the reforms of OBRA `87 and subsequent efforts by CMS and
the nursing home industry to improve the quality of nursing home care.
Although there has been an overall decline in the numbers of nursing homes
found to have serious deficiencies since fiscal year 2000, variation among
states in the proportion of homes with serious deficiencies indicates
state survey agencies are not consistently conducting surveys. Challenges
associated with the recruitment and retention of state surveyors, combined
with increased surveyor workloads, can affect survey consistency. In
addition, federal comparative surveys conducted after state surveys found
more serious quality-of-care problems than were cited by state surveyors.
Although understatement of serious deficiencies identified by federal
surveyors in five states has declined since 2004, understatement continues
at varying levels across these states.
CMS data indicate an overall decline in reported serious deficiencies from
fiscal year 2000 through 2006. The proportion of nursing homes nationwide
cited with serious deficiencies declined from 28 percent in fiscal year
2000 to a low of 16 percent in 2004, and then increased to 19 percent in
fiscal year 2006 (see fig. 1).
Figure 1: Percentage of Nursing Homes Nationwide with Serious
Deficiencies, Fiscal Years 2000-2006
Despite this national trend, significant interstate variation in the
proportion of homes with serious deficiencies indicates that states
conduct surveys inconsistently. (App. II shows the percentage of homes, by
state, cited for serious deficiencies in standard surveys across a 7-year
period.). In fiscal year 2006, 6 states identified serious deficiencies in
30 percent or more of homes surveyed, 16 states found such deficiencies in
20 to 30 percent of homes, 22 found these deficiencies in 10 to 19 percent
of homes, and 7 found these deficiencies in less than 10 percent of homes.
For example, in fiscal year 2006, the percentage of nursing homes cited
for serious deficiencies ranged from a low of approximately 2 percent in
one state to a high of almost 51 percent in another state.
The inconsistency of state survey findings may reflect challenges in
recruiting and retaining state surveyors and increasing state surveyor
workloads. We reported in 2005 that, according to state survey agency
officials, it is difficult to retain surveyors and fill vacancies because
state survey agency salaries are rarely competitive with the private
sector.^14 Moreover, the first year for a new surveyor is essentially a
training period with low productivity. It can take as long as 3 years for
a surveyor to gain sufficient knowledge, experience, and confidence to
perform the job well. We also reported that limited experience levels of
state surveyors resulting from high turnover rates was a contributing
factor to (1) variability in citing actual harm or higher-level
deficiencies and (2) understatement of such deficiencies. In addition, the
implementation of CMS's nursing home initiatives has increased state
survey agencies' workload. States are now required to conduct on-site
revisits to ensure serious deficiencies have been corrected, promptly
investigate complaints alleging actual harm on-site, and initiate off-hour
standard surveys in addition to quality-of-care surveys. As a result,
surveyor presence in nursing homes has increased and surveyor work hours
have effectively been expanded to weekends, evenings, and early mornings.
In addition, data from federal comparative surveys indicate that
quality-of-care problems remain for a significant proportion of nursing
homes. In fiscal year 2006, 28 percent of federal comparative surveys
found more serious deficiencies than did state quality-of-care surveys.
Since 2002, federal surveyors have found serious deficiencies in 21
percent or more of comparative surveys that were not cited in
corresponding state quality-of-care surveys (see fig. 2). However, some
serious deficiencies found by federal, but not state surveyors, may not
have existed at the time the state survey occurred.^15
14GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety, [23]GAO-06-117
(Washington, D.C.: Dec. 28, 2005).
^15For 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.
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious
Deficiencies Not Identified in State Surveys
In December 2005, we reported on understatement of serious deficiencies in
five states--California, Florida, New York, Ohio, and Texas--from March
2002 through December 2004.^16 We selected these states for our analysis
because the percentage of their state surveys that cited serious
deficiencies decreased significantly from January 1999 through January
2005.^17 Our analysis of more recent data from these states showed that
understatement of serious deficiencies continues at varying levels.
Altogether, we examined 139 federal comparative surveys conducted from
March 2002 through March 2007 in the five states. Understatement of
serious deficiencies decreased from 18 percent for federal comparative
surveys during the original time period to 11 percent for federal
comparative surveys during the period January 2005 through March 2007.
Federal comparative surveys for Florida and Ohio for this most recent time
period found that state surveys had not missed any serious deficiencies;
however, since 2004 all five states experienced increases in the
percentage of homes cited with serious deficiencies on state surveys (see
app. II). Understatement of serious deficiencies varied across these five
states, as the percentage of serious missed deficiencies ranged from a low
of 4 percent in Ohio to a high of 26 percent in New York during the 5-year
period March 2002 to March 2007. Figure 3 summarizes our analysis by
state, from March 2002 through March 2007.
^16 [24]GAO-06-117 . CMS requires its federal surveyors to specifically
identify which deficiencies state surveyors missed during the state
survey.
^17These declines in serious deficiencies were 14.3 percentage points for
Texas, 15.4 percentage points for Florida, 17.4 percentage points for
Ohio, 22.8 percentage points for California, and 23.0 percentage points
for New York.
Figure 3: Federal Comparative Surveys in Five States That Identified
Serious Deficiencies Missed by State Surveys, March 2002-March 2007
Notes: The total number of federal comparative surveys conducted in each
state for the 5-year period, March 2002 to March 2007, is listed in
parentheses following the name of the state. The percentage of federal
comparative surveys that noted serious deficiencies missed by state
surveyors in each state was California, 11 percent; Florida, 19 percent;
New York, 26 percent; Ohio, 4 percent; and Texas, 16 percent.
aOn two comparative surveys, 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.
bOn 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.
CMS Has Strengthened Its Enforcement Capabilities, although Key Initiatives
Still Need Refinement
CMS has strengthened its enforcement capabilities since OBRA `87 by, for
example, implementing additional sanctions and an immediate sanctions
policy for nursing homes found to repeatedly harm residents and developing
a new enforcement management data system; however, several key initiatives
require refinement. The immediate sanctions policy is complex and appears
to have induced only temporary compliance in certain nursing homes with
histories of repeated noncompliance. The term "immediate sanctions" is
misleading because the policy requires only that homes be notified
immediately of CMS's intent to implement sanctions, not that sanctions
must be implemented immediately. Furthermore, when a sanction is
implemented, there is a lag time between when the deficiency citation
occurs and the sanction's effective date. In addition to the immediate
sanctions policy, CMS has taken other steps that are intended to address
enforcement weaknesses, but their effectiveness remains unclear. Finally,
although CMS has developed a new data system, the system's components are
not integrated and the national reporting capabilities are incomplete,
hampering the agency's ability to track and monitor enforcement.
Despite Changes in Federal Enforcement Policy, Immediate Sanctions Do Not Always
Deter Noncompliance and Often Are Not Immediate
Despite CMS's efforts to strengthen federal enforcement policy, it has not
deterred some homes from repeatedly harming residents. Effective January
2000, CMS implemented its double G immediate sanctions policy. The policy
is complex and does not always appear to deter noncompliance, nor are the
sanctions always implemented immediately. We recently reported that the
immediate sanctions policy's complex rules, and the exceptions they
include, allowed homes to escape immediate sanctions even if they
repeatedly harmed residents.^18 CMS acknowledged that the complexity of
the policy may be an inherent limitation and indicated that it intends to
either strengthen the policy or replace it with a policy that achieves
similar goals through alternative methods.
In addition to the complexity of the policy, it does not appear to always
deter noncompliance. We recently reported that our review of 63 homes with
prior serious quality problems in four states indicated that sanctions may
have induced only temporary compliance in these homes because surveyors
found that many of the homes with implemented sanctions were again out of
compliance on subsequent surveys.^19 From fiscal year 2000 through 2005,
31 of these 63 homes cycled in and out of compliance more than once,
harming residents, even after sanctions had been implemented, including 8
homes that did so seven times or more. During this same time period, 27 of
the 63 homes were cited 69 times for deficiencies that warranted immediate
sanctions, but 15 of these cases did not result in immediate sanctions.^20
18GAO, Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
Deterred Some Homes from Repeatedly Harming Residents, [25]GAO-07-241
(Washington, D.C.: Mar. 26, 2007).
We also recently reported that the term "immediate sanctions" is
misleading because the policy is silent on how quickly sanctions should be
implemented and there is a lag time between the state's identification of
deficiencies during the survey and when the sanction (i.e., a CMP or DPNA)
is implemented (i.e., when it goes into effect). The immediate sanctions
policy requires that sanctions be imposed immediately. A sanction is
considered imposed when a home is notified of CMS's intent to implement a
sanction--15 days from the date of the notice. If during the 15-day notice
period the nursing home corrects the deficiencies, no sanction is
implemented. Thus, nursing homes have a de facto grace period. In
addition, there is a lag time between the state's identification of
deficiencies and the implementation of a sanction. CMS implemented about
68 percent of the DPNAs for double Gs among the homes we reviewed during
fiscal year 2000 through 2005 more than 30 days after the survey.^21 In
contrast, CMPs can go into effect as early as the first day the home was
out of compliance, even if that date is prior to the survey date because,
unlike DPNAs, CMPs do not require a notice period. About 98 percent of
CMPs imposed for double Gs took effect on or before the survey date.
However, the deterrent effect of CMPs was diluted because CMS imposed CMPs
at the lower end of the allowable range for the homes we reviewed. For
example, the median per day CMP amount imposed for deficiencies that do
not cause immediate jeopardy to residents was $500 in fiscal year 2000
through 2002 and $350 in fiscal year 2003 through 2005; the allowable
range is $50 to $3,000 per day.
^19 [26]GAO-07-241 . In this report, we analyzed federal sanctions from
fiscal year 2000 through 2005 against 63 nursing homes with a history of
harming residents and whose prior compliance and enforcement histories
formed the basis for the conclusions in our March 1999 report. The homes
were located in California, Michigan, Pennsylvania, and Texas.
^20In 2003, we reported that we found over 700 cases that should have been
referred for immediate sanctions but were not, from January 2000 through
March 2002. See GAO, Nursing Home Quality: Prevalence of Serious Problems,
While Declining, Reinforces Importance of Enhanced Oversight,
[27]GAO-03-561 (Washington, D.C.: July 15, 2003).
^21CMPs and DPNAs accounted for 80 percent of federal sanctions from
fiscal year 2000 through 2005. The majority of federal sanctions
implemented during this time period--about 54 percent--were CMPs. During
this time period, DPNAs and terminations accounted for about 26 percent
and less than 1 percent of federal sanctions, respectively.
Although CMPs can be implemented closer to the date of survey than DPNAs,
the immediacy and the effect of CMPs may be diminished by (1) the
significant time that can pass between the citation of deficiencies on a
survey and the home's payment of the CMP and (2) the low amounts imposed,
as described earlier. By statute, payment of CMPs is delayed until appeals
are exhausted. For example, one home we reviewed did not pay its CMP of
$21,600 until more than 2 years after a February 2003 survey had cited a
G-level deficiency. This citation was a repeat deficiency: less than a
month earlier, the home had received another G-level deficiency in the
same quality-of-care area. This finding is consistent with a 2005 report
from the Department of Health and Human Services' (HHS) Office of
Inspector General that found that the collection of CMPs in appealed cases
takes an average of 420 days--a 110 percent increase in time over
nonappealed cases--and "consequently, nursing homes are insulated from the
repercussions of enforcement by well over a year."^22
CMS has taken additional steps intended to improve enforcement of nursing
home quality requirements; however, the extent to which--or when--these
initiatives will address enforcement weaknesses remains unclear. First, to
ensure greater consistency in CMP amounts proposed by states and imposed
by regions, CMS, in conjunction with state survey agencies, developed a
grid that provides guidance for states and regions. The CMP grid lists
ranges for minimum CMP amounts while allowing for flexibility to adjust
the penalties for factors such as the deficiency's scope and severity, the
care areas where the deficiency was cited, and a home's past history of
noncompliance. In August 2006, CMS completed the regional office pilot of
its CMP grid but had not completed its analysis of the pilot as of April
2007. CMS plans to disseminate the final grid to states soon.^23 Second,
in December 2004, CMS expanded the Special Focus Facility program from
about 100 homes to include about 135 homes. CMS also modified the program
by requiring immediate sanctions for those homes that failed to
significantly improve their performance from one survey to the next and by
requiring termination for homes with no significant improvement after
three surveys over an 18-month period. According to CMS, 11 Special Focus
Facilities were terminated in fiscal year 2005 and 7 were terminated in
fiscal year 2006. Despite the expansion of the program, many homes that
could benefit from enhanced oversight and enforcement are still excluded
from the program. For example, of the 63 homes with prior serious quality
problems that we recently reviewed, only 2 were designated Special Focus
Facilities in 2005, and the number increased to 4 in 2006.
^22See HHS, Office of Inspector General, Nursing Home Enforcement: The Use
of Civil Money Penalties, OEI-06-02-00720 (April 2005).
^23Use of the CMP grid would be optional to provide states flexibility to
tailor sanctions to specific circumstances.
While CMS Collects Valuable Enforcement Data, Its Enforcement Monitoring Data
Systems Need Improvement
In March 1999, we reported that CMS lacked a system for effectively
integrating enforcement data nationwide and that the lack of such a system
weakened oversight. Since 1999, CMS has made progress developing such a
system--ASPEN Enforcement Manager (AEM)--and, since October 1, 2004, CMS
has used AEM to collect state and regional data on sanctions and improve
communications between state survey agencies and CMS regional offices. CMS
expects that the data collected in AEM will enable states, CMS regional
offices, and the CMS central office to more easily track and evaluate
sanctions against nursing homes as well as respond to emerging issues.
Developed by CMS's central office primarily for use by states and regions,
AEM is one of many modules of a broader data collection system called
ASPEN. However, the ASPEN modules--and other data systems related to
enforcement such as the financial management system for tracking CMP
collections--are fragmented and lack automated interfaces with each other.
As a result, enforcement officials must pull discrete bits of data from
the various systems and manually combine the data to develop a full
enforcement picture.
Furthermore, CMS has not defined a plan for using the AEM data to inform
the tracking and monitoring of enforcement through national enforcement
reports. While CMS is developing a few such reports, it has not developed
a concrete plan and timeline for producing a full set of reports that use
the AEM data to help assess the effectiveness of sanctions and its
enforcement policies. In addition, while the full complement of
enforcement data being recorded by the states and regional offices in AEM
is now being uploaded to CMS's national system, CMS does not intend to
upload any historical data, which could greatly enhance enforcement
monitoring efforts. Finally, AEM has quality control weaknesses, such as
the lack of systematic quality control mechanisms to ensure accuracy of
data entry.
CMS officials told us they will continue to develop and implement
enhancements to AEM to expand its capabilities over the next several
years. However, until CMS develops a plan for integrating the fragmented
systems and for using AEM data--along with other data the agency
collects--efficient and effective tracking and monitoring of enforcement
will continue to be hampered. As a result, CMS will have difficulty
assessing the effectiveness of sanctions and its enforcement policies.^24
CMS Has Strengthened Oversight, although Competing Priorities Impede Certain Key
Initiatives
CMS oversight of nursing home quality and state surveys has increased
significantly through several efforts, but CMS initiatives for nursing
home quality oversight continue to compete with each other, as well as
with other CMS programs, for staff and financial resources. Since OBRA `87
required CMS to annually conduct federal monitoring surveys for a sample
of nursing homes to test the adequacy of state surveys, CMS has developed
a number of initiatives to strengthen its oversight. These initiatives
have increased federal surveyors' workload and the demand for resources.
Greater demand on limited resources has led to queues and delays in
certain key initiatives. In particular, the implementation of three key
initiatives--the new Quality Indicator Survey (QIS), investigative
protocols for quality-of-care problems, and an increase in the number of
federal quality-of-care comparative surveys--was delayed because they
compete for priority with other CMS projects.
Intensity of Federal Efforts Has Increased Significantly
CMS has used both federal monitoring surveys and annual state performance
reviews to increase its oversight of quality of care in nursing homes.
Through these two mechanisms it has focused its resources and attention on
(1) prompt investigation of complaints and allegations of abuse, (2) more
frequent and timely federal comparative surveys, (3) stronger fire safety
standards, and (4) upgrades to data systems.
Complaint Investigations
To ensure that complaints and allegations of abuse are investigated and
addressed in accordance with OBRA `87, CMS has issued guidance and taken
other steps. CMS guidance issued since 1999 has helped strengthen state
procedures for investigating complaints. For example, CMS instructed
states to investigate complaints alleging harm to a resident within 10
workdays; previously states could establish their own time frames for
complaints at this level of severity. In addition, CMS guidance to states
in 2002 and 2004 clarified policies on reporting abuse, including
requiring notification of local law enforcement and Medicaid Fraud Control
Units, establishing time frames, and citing abuse on surveys.
^24We recently recommended that the Administrator of CMS undertake a
number of steps to strengthen enforcement capabilities. CMS generally
concurred with our recommendations, although it pointed out some resource
constraints to implementing certain ones. See GAO-07-241.
CMS has taken three additional steps to improve its oversight of state
complaint investigations, including allegations of abuse. First, in its
annual state performance reviews implemented in 2002, it required that
federal surveyors review a sample of complaints in each state.^25 These
reviews were done to determine whether states (1) properly categorized
complaints in terms of how quickly they should be investigated, (2)
investigated complaints within the time specified, and (3) properly
included the results of the investigations in CMS's database. Second, in
January 2004, CMS implemented a new national automated complaint tracking
system, the ASPEN Complaints and Incidents Tracking System. The lack of a
national complaint reporting system had hindered CMS's and states' ability
to adequately track the status of complaint investigations and CMS's
ability to maintain a full compliance history on each nursing home. 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. CMS has not issued a
formal report of findings from these assessments, but in 2005 we reported
that CMS officials noted that resource constraints have impeded states'
compliance with certain federal requirements.^26 As a part of this effort,
CMS is also conducting a Background Check Pilot Program. 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.^27
Federal Comparative Surveys
CMS has increased the number of federal comparative surveys for both
quality of care and fire safety and decreased the time between the end of
the state survey and the start of the federal comparative surveys. These
improvements allow CMS to better distinguish between serious problems
missed by state surveyors and changes in the home that occurred after the
state survey. The number of comparative quality-of-care surveys nationwide
per year increased from about 10 surveys a year during the 24-month period
prior to October 1998 to about 160 per year for fiscal years 2005 and
2006.^28 The number of fire safety comparative surveys increased as well
from 40 in fiscal year 2003 to 536 in fiscal year 2006. In addition, the
average elapsed time between state and comparative quality-of-care surveys
has decreased from 33 calendar days for the 64 comparative surveys we
reviewed in 1999 to 26 days for all federal comparative surveys completed
through fiscal year 2006.
^25Annual state performance reviews were established in fiscal year 2001
and fully implemented in fiscal year 2002.
^26 [28]GAO-06-117 .
^27Pilot programs have been phased in from fall 2005 through September
2007 in seven states--Alaska, Idaho, Illinois, Michigan, Nevada, New
Mexico, and Wisconsin. An independent evaluation is expected in spring
2008.
Fire Safety Standards
In addition to conducting more frequent federal comparative surveys for
fire safety, CMS has strengthened fire safety standards. In response to a
recommendation in our July 2004 report to strengthen fire safety
standards,^29 CMS issued a final rule in September 2006 requiring
nonsprinklered nursing homes to install battery-powered smoke detectors in
resident rooms and common areas.^30 In addition, CMS has issued a proposed
rule that would require all nursing homes to be equipped with sprinkler
systems and, after reviewing public comment, intends to publish a final
version of the rule and stipulate an effective date for all homes to
comply.^31
Upgrades to Data Systems
CMS has pursued important upgrades to data systems, expanded dissemination
of data and information, and addressed accuracy issues in the MDS in
addition to implementing complaint and enforcement systems. One such
upgrade increased state and federal surveyors' access to OSCAR data. CMS
now uses OSCAR data to produce periodic reports to monitor both state and
federal survey performance. 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. In addition, CMS created a Web-accessible software
program called Providing Data Quickly (PDQ) that allows regional offices
and state survey agencies easier access to standard OSCAR reports,
including one that identifies the homes that have repeatedly harmed
residents and meet the criteria for imposition of immediate sanctions.
^28As of fiscal year 2006, there were about 16,000 nursing homes which
would require over 800 federal monitoring surveys. Since 1992 when all
federal monitoring surveys were comparative, CMS has begun to rely more
heavily on observational surveys, which require a smaller number of
federal surveyors. In fiscal year 2006, roughly 77 percent of federal
monitoring surveys were observational.
^29GAO, Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in
Federal Standards and Oversight, [29]GAO-04-660 (Washington D.C.: July 16,
2004).
^3071 Fed. Reg. 55326 (Sept. 22, 2006) (codified in pertinent part at 42
C.F.R. S483.70). CMS began surveying nursing homes' compliance with the
new requirement in May 2006.
^3171 Fed. Reg. 62957 (Oct. 27, 2006) (to be codified at 42 C.F.R.
S483.70).
Since launching its Nursing Home Compare Web site in 1998, CMS has
expanded its dissemination of information to the public on individual
nursing homes participating in Medicare or Medicaid.^32 In addition to
data on any 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 measures, such as the
percentage of residents with pressure sores. On the basis of our
recommendations, CMS is now reporting fire safety deficiencies on the Web
site, including information on whether a home has automatic sprinklers to
suppress a fire, and may include information on impending sanctions in the
future. However, CMS continues to address ongoing problems with the
accuracy and reliability of some of the underlying data. For example, CMS
has evaluated the validity of quality measures and staffing information it
makes available on the Web, and it has removed or excluded questionable
data.
In addition to building the quality measures reported on Nursing Home
Compare, the MDS data are the basis for patient care plans, adjusting
Medicare nursing home payments as well as Medicaid payments in some
states, and assisting with quality oversight. Thus the accuracy of the MDS
has implications for the identification of quality problems and the level
of nursing home payments. OBRA `87 required nursing homes that participate
in the Medicare and Medicaid programs to perform periodic resident
assessments; these resident assessments are known as the MDS. In February
2002, we assessed federal government efforts to ensure the accuracy of the
MDS data.^33 We reported that on-site reviews of MDS data that compared
the MDS to supporting documentation were a very effective method of
assessing the accuracy of the data. However, CMS's efforts to ensure the
accuracy of the underlying MDS data were too reliant on off-site reviews,
which were limited to documentation reviews or data analysis. To ensure
the accuracy of the MDS, CMS signed a new contract for on-site reviews in
September 2005; these reviews are ongoing.
^32 http://www.medicare.gov/NHCompare/home.asp .
^33GAO, Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities, [31]GAO-02-279 (Washington, D.C.: Feb.
15, 2002).
Competing Priorities Impede Certain Key CMS Initiatives
CMS initiatives for nursing home quality oversight continue to compete
with each other, as well as with other CMS programs, for staff and
financial resources. Greater nursing home oversight and growth in the
number of Medicare and Medicaid providers has created increased demand for
staff and financial resources. Greater demand on limited resources has led
to queues and delays in key initiatives. Three key initiatives--the new
Quality Indicator Survey (QIS), investigative protocols for
quality-of-care problems, and an increase in the number of federal
quality-of-care comparative surveys--were delayed because they compete for
priority with other CMS projects.
The implementation of the QIS, in process for over 8 years, continues to
encounter delays because of a lack of resources. The QIS is a two-stage,
data-driven, structured survey process intended to systematically target
potential problems at nursing homes by using an expanded sample and
structured interviews to help surveyors better assess the scope of any
identified deficiencies. CMS is currently concluding a five-state
demonstration of the QIS system. A preliminary evaluation by CMS indicates
that surveyors have spent less time in homes that are performing well,
deficiency citations were linked to more defensible documentation, and
serious deficiencies were more frequently cited in some demonstration
states. However, CMS officials recently reported that resource constraints
in fiscal year 2007 threaten the planned expansion of this process beyond
the five demonstration states. Although 13 states applied to transition to
QIS, resource limitations may prevent this expansion. In addition, at
least $2 million is needed over 2 years to develop a production quality
software package for the QIS.
Since hiring a contractor in 2001 to facilitate convening expert panels
for the development and review of new investigative protocols, CMS has
implemented eight sets of investigative protocols. In December 2005, we
reported that these investigative protocols provided surveyors with
detailed interpretive guidance and ensured greater rigor in on-site
investigations of specific quality-of-care areas, such as pressure sores,
incontinence, and medical director qualifications. However, the issuance
of additional protocols was slowed because of lengthy consultation with
experts and prolonged delays related to internal disagreement over the
structure of the process. Instead, it has returned to the traditional
revision process even though agency staff believes that the expert panel
process produced a high-quality product. Since issuing several protocols
in 2006, CMS has plans to issue two additional protocols.
Although CMS hired a contractor in 2003 to further increase the number of
federal quality-of-care comparative surveys, it stopped funding this
initiative in fiscal year 2006. The agency reallocated the funds to help
state survey agencies meet the increased workload resulting from growth in
the number of other Medicare providers.
Concluding Observations
About 20 years ago, significant attention from the Special Committee on
Aging, the Institute of Medicine, and others served as a catalyst to focus
national attention on nursing home quality issues, culminating in the
nursing home reform provisions of OBRA `87. Beginning in 1998, the
Committee again served as a catalyst to focus national attention on the
fact that the task was not complete; through a series of hearings, it held
the various stakeholders publicly accountable for the substandard care
reported in a small but significant share of nursing homes nationwide.
Since then, in response to many GAO recommendations and on its own
initiative, CMS has taken many important steps and invested resources to
respond in a timelier, more rigorous, and more consistent manner to
identified problems and improve its oversight process for the care of
vulnerable nursing home residents. This is admittedly no small
undertaking, given the large number and diversity of stakeholders and
caregivers involved at the federal, state, and provider levels.
Nevertheless, despite the passage of time and the level of investment and
effort, the work begun after OBRA `87 is still not complete. It is
important to continue to focus national attention on and ensure public
accountability for homes that harm residents. With these ongoing efforts,
the momentum of earlier initiatives can be sustained and perhaps even
enhanced and the quality of care for nursing home residents can be
secured, as intended by Congress when it passed this legislation.
Mr. Chairman, this concludes my prepared remarks. I would be pleased to
respond to any questions that you or other Members of the Committee may
have.
GAO Contact and Acknowledgments
For future contacts regarding this testimony, please contact Kathryn G.
Allen at (202) 512-7118 or at [email protected] . Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this testimony. Walter Ochinko, Assistant Director; Kaycee M.
Glavich; Leslie V. Gordon; K. Nicole Haeberle; Daniel Lee; and Elizabeth
T. Morrison made key contributions to this statement.
Appendix I: Prior GAO Recommendations, Related CMS Initiatives, and
Implementation Status
Table 2 summarizes our recommendations from 11 reports on nursing home
quality and safety, issued from July 1998 through March 2007; CMS's
actions to address weaknesses we identified; and the implementation status
of CMS's initiatives as of April 2007. 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 fiscal 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 statement contains the full citation for each
report. Of our 42 recommendations, CMS has fully implemented 18,
implemented only parts of 7, is taking steps to implement 10, and declined
to implement 7.
Table 2: Implementation Status of CMS's Initiatives Responding to GAO's
Nursing Home Quality and Safety Recommendations, July 1998 through April
2007
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, but
effectively reduce some state surveys
the predictability remain predictable.
of surveyors'
visits. The o In 1999, CMS
variation could instructed state
include segmenting survey agencies
the standard survey to (1) conduct
into more than one 10 percent of
review throughout surveys on
the 12- to 15-month evenings and
period, which would weekends, (2)
provide more vary the
opportunities for sequencing of
surveyors to observe surveys in a
problematic homes geographical
and initiate broader area to avoid
reviews when alerting other
warranted. 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 us
survey procedures to developing a
instruct surveyors revised survey
to take stratified methodology since
random samples of 1998. A pilot test
resident cases and of the new
review sufficient methodology began
numbers and types of in the fall of
resident cases so 2005.
that surveyors can Implementation
better detect could begin in
problems and assess mid-2007.
their prevalence.
GAO-03-561 3. Finalize the See CMS action in
development, response to
testing, and recommendation to
implementation of a revise federal
more rigorous survey survey procedures
methodology, (recommendation #2
including above).
investigative
protocols that CMS began revising
provide guidance to surveyors'
surveyors in investigative
documenting protocols in
deficiencies at the October 2000. Eight
appropriate scope protocols have been
and severity level. issued, and two
additional
protocols are under
development. Due to
issues with
interpretation, CMS
is no longer
planning to issue
definitions of
actual harm and
immediate jeopardy
outside of the
regulations.
4. Require states to CMS has no plans to
have a quality implement this
assurance process recommendation,
that includes, at a indicating that
minimum, a review of regular workload
a sample of survey and priorities take
reports below the precedence over it.
level of actual harm
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.
resulting in harm to While CMS has not
residents, not just ruled out placing
care problems deemed enforcement
to be egregious, and information on its
develop an approach Nursing Home
for citing such past Compare Web site in
noncompliance in a the future, CMS
manner that clearly officials told us
identifies the that resource
specific nature of constraints limit
the care problem the agency's
both in the OSCAR ability to do so at
database and on the current time.
CMS's Nursing Home
Compare Web site.
Complaints
GAO/HEHS-99-80 6. Develop In October 1999,
additional standards CMS issued a policy
for the prompt letter stating that
investigation of complaints alleging
serious complaints harm must be
alleging situations investigated within
that may harm 10 days.
residents but are
categorized as less In January 2004,
than immediate CMS provided
jeopardy. These detailed direction
standards should and guidance to
include maximum states for managing
allowable time complaint
frames for investigations for
investigating numerous types of
serious complaints providers,
and for complaints including nursing
that may be deferred homes.
until the next
scheduled annual In June 2004, CMS
survey. States may made available
continue to set updated guidance on
priority levels and the Internet that
time frames that are consolidates
more stringent than complaint
these federal investigation
standards. procedures for
numerous types of
providers.
7. Strengthen In 2000, CMS began
federal oversight of requiring its
state complaint regional offices to
investigations, 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 managing
processes and ensure complaint
that it addresses investigations for
key weaknesses, numerous types of
including the providers,
prioritization of including nursing
complaints for homes.
investigation,
particularly those In June 2004, CMS
alleging harm to made available
residents; the updated guidance on
handling of facility the Internet that
self-reported consolidates
incidents; and the complaint
use of appropriate investigation
complaint procedures for
investigation numerous types of
practices. providers.
GAO-02-312 9. Ensure that state In 2002, CMS issued 0R
survey agencies a memorandum to the
immediately notify regional offices
local law and state survey
enforcement agencies agencies
or Medicaid Fraud emphasizing its
Control Units when policy for
nursing homes report preventing abuse in
allegations of nursing homes and
resident physical or for promptly
sexual abuse or when reporting it to the
the survey agency appropriate
has confirmed agencies when it
complaints of occurs.
alleged abuse.
CMS determined it
does not have the
legal authority to
require state
survey agencies to
report suspected
physical and sexual
abuse of nursing
home residents.
10. Accelerate the In 2002, CMS 0R
agency's education released a
campaign on memorandum to
reporting nursing regional offices
home abuse by (1) and state agencies
distributing its new that addresses
poster with clearly displaying
displayed complaint complaint telephone
telephone numbers numbers. CMS asked
and (2) requiring all state agencies
state survey to review how their
agencies to ensure telephone number is
that these numbers listed in the local
are prominently directory and asked
listed in local them to ensure that
telephone their complaint
directories. telephone numbers
are prominently
listed.
In 2007, CMS
officials told us
that it has not and
is not likely to
release the poster.
11. Systematically CMS is conducting a
assess state Background Check
policies and Pilot Program in
practices for several states, as
complying with the required by the
federal requirement Medicare
to prohibit Prescription Drug,
employment of Improvement, and
individuals Modernization Act
convicted of abusing of 2003. The pilot
nursing home is expected to run
residents and, if through September
necessary, develop 2007 and will be
more specific followed by an
guidance to ensure independent
compliance. evaluation. The
final study is
targeted for
submission by
spring of 2008.
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 CMS informed GAO 0R
state survey that federal
agencies' time regulations specify
frames for that if an
determining whether investigation finds
to include findings an individual has
of abuse in nurse neglected or abused
aide registry files. a resident or
misappropriated
resident property,
the state must
report the findings
in writing within
10 working days to
the nurse aide
registry.
However, CMS stated
it does not specify
a time frame for
completion of such
investigations due
to concerns that a
time limit could
compromise
complaint
investigations in
some instances.
Enforcement
GAO/HEHS-98-202 14. Require that for In 1998, CMS issued
problem homes with 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 requiring on-site
report to CMS of a revisits until all
home's resumed serious
compliance 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 policy
repeated serious from September 1998
violations and through January
impose sanctions 2000.
promptly, as
permitted under
existing
regulations.
GAO/HEHS-99-46 16. Improve the As requested by
effectiveness of HHS, Congress
civil monetary approved increased
penalties: The funding and
Administrator should staffing levels for
continue to take the Departmental
those steps Appeals Board in
necessary to shorten fiscal years 1999
the delay in and 2000.
adjudicating
appeals, including
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 study and concluded
payments beyond the that it was not
termination date practical to
only if the home and establish rules to
state Medicaid address this
agency are making problem.
reasonable 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: revised its
The Administrator guidance to require
should revise CMS states to refer
guidance so that homes for possible
states refer homes sanction if they
to CMS for possible had been cited for
sanction (such as a deficiency that
civil monetary contributed to a
penalties) if they resident's death.
have been cited for
a deficiency that
contributed to a
resident's death.
GAO-07-241 19. Reassess and CMS acknowledged
revise the immediate that the complexity
sanctions policy to of its immediate
ensure that it sanctions policy
accomplishes the may be an inherent
following: limitation and
indicated that it
intends to either
strengthen the
policy or replace
it with a policy
that achieves
similar goals
through alternative
methods.
o Reduce the lag CMS agreed to
time between reduce the lag time
citation of a double between citation
G and the and implementation
implementation of a of a double G
sanction. immediate sanction
by limiting the
prospective
effective date for
DPNAs to no more
than 30 to 60 days.
o Prevent nursing CMS indicated it
homes that will remove the
repeatedly harm limitation in the
residents or place double G policy on
them in immediate applying an
jeopardy from additional sanction
escaping sanctions. simply because a
nursing home has
not completed
corrections to a
deficiency that
gave rise to a
previous sanction.
o Hold states CMS agreed to
accountable for collect additional
reporting in federal information on
data systems serious complaints for
deficiencies which data are not
identified during reported in federal
complaint data systems.
investigations so
that all complaint
findings are
considered in
determining when
immediate sanctions
are warranted.
20. Strengthen the
deterrent effect of
available sanctions
and ensure that
sanctions are used
to their fullest
potential:
o Ensure the CMS agreed to issue
consistency of CMPs a CMP analytic
by issuing guidance, tool, or grid, and
such as the to provide states
standardized CMP with further
grid piloted during guidance on
2006. discretionary DPNAs
and terminations.
o Increase use of CMS indicated it
discretionary DPNAs will issue further
to help ensure the guidance for states
speedier on factors to be
implementation of considered in
appropriate determining whether
sanctions. a discretionary
DPNA is imposed or
a termination date
is set earlier than
the time periods
required by law
o Strengthen the CMS stated it will
criteria for work with states,
terminating homes consumer
with a history of organizations,
serious, repeated stakeholders, and
noncompliance by others to design
limiting the proposals for a
extension of better combination
termination dates, of enforcement
increasing the use actions for homes
of discretionary with repeated
terminations, and quality-of-care
exploring deficiencies.
alternative
thresholds for
termination, such as
the cumulative
duration of
noncompliance.
21. Develop an CMS agreed to seek
administrative legislative
process under which authority to
CMPs would be collect CMPs prior
paid--or Medicare to the exhaustion
and Medicaid of appeals.
payments in
equivalent amounts
would be
withheld--prior to
exhaustion of
appeals and seek
legislation for the
implementation of
this process, as
appropriate.
22. Further expand CMS agreed with the
the Special Focus concept of
Facility program expanding the
with enhanced Special Focus
enforcement Facility program to
requirements to include all homes
include all homes that meet a
that meet a threshold
threshold to qualify qualifying them as
as poorly performing poorly performing
homes. homes, but said it
lacks the resources
needed for this
expansion. CMS also
identified other
initiatives it will
implement to
improve the
program.
23. Improve the
effectiveness of the
new enforcement data
system:
o Develop the CMS agreed to study
enforcement-related the feasibility of
data systems' linking the
abilities to separate data
interface with each systems used for
other in order to enforcement;
improve the tracking however, it
and monitoring of indicated that
enforcement. available resources
may limit further
action.
o Expedite the CMS agreed to study
development of the feasibility of
national enforcement developing national
reports and a standard
concrete plan for enforcement
using the reports. reports, but stated
that further action
on these reports
may be limited by
resource
availability.
o Develop and CMS agreed to
institute a system develop and
of quality checks to implement a system
ensure the accuracy of quality checks
and integrity of AEM to ensure the
data. accuracy of its
data systems,
including AEM.
24. Expand CMS's CMS proposed 0R
Nursing Home Compare reporting
Web site to include implemented
implemented sanctions only for
sanctions and homes poorly performing
subjected to homes that meet an
immediate sanctions. undefined
threshold--this is
not fully
responsive to our
recommendation.
Oversight
GAO/HEHS-99-46 25. Develop better CMS has implemented
management new national
information systems. enforcement and
The Administrator complaint tracking
should enhance OSCAR systems but has
or develop some delayed its
other information replacement of the
system that can be OSCAR data system
used by both by the until 2009 as a
states and CMS to result of funding
integrate the cuts and CMS focus
results of complaint on other
investigations, initiatives.
track the status and
history of
deficiencies, and
monitor enforcement
actions.
GAO/HEHS-99-80 26. Require that the In January 2004,
substantiated CMS's new ASPEN
results 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 27. Improve the
scope and rigor of
CMS's oversight
process:
o Increase the CMS has
proportion of significantly
federal monitoring increased the
surveys conducted as number of
comparative surveys quality-of-care
to ensure that a comparative
sufficient number surveys. In fiscal
are completed in year 2006, however,
each state to assess the agency will no
whether the state longer contract for
appropriately additional
identifies serious quality-of-care
deficiencies. comparative surveys
because of funding
constraints.
o Ensure that To better ensure
comparative surveys that conditions in
are initiated closer a nursing home have
to the time the not changed since
state agency the state survey,
completes the home's CMS regional
annual standard offices reduced the
survey. 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 surveys to states
federal monitoring on a monthly basis.
surveys.
o Improve the data CMS developed a
system for separate database
observational accessible to all
surveys so that it regional offices
is an effective that includes the
management tool for results of
CMS to properly observational
assess the findings surveys. Beginning
of observational in fiscal year
surveys. 2002, CMS added
data on the results
of comparative
surveys.
28. 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 a
surveyor manner that ensures
performance. 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 to select at least
possible in their half of those
comparative survey residents selected
sample as the state by the state
included in its surveyors for their
sample (where CMS resident sample.
surveyors have
determined that the
state sample
selection process
was appropriate).
29. Further explore In December 1999,
the feasibility of CMS adopted new
appropriate state sanctions. In
alternative remedies fiscal year 2005,
or sanctions for CMS began to tie
those states that survey agency
prove unable or funding increases
unwilling to meet to the timely
CMS's performance conduct of standard
standards. surveys, a step
that we believe
offers a strong
incentive for
improved
compliance.
GAO/HEHS-02-279 30. 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.
31. Monitor the CMS disagreed with
adequacy of state and did not
MDS accuracy implement this
activities on an recommendation.
ongoing basis, such
as through the use
of the established
federal comparative
survey process.
32. Provide guidance CMS disagreed with
to state agencies and did not
and nursing homes implement this
that sufficient recommendation.
evidentiary
documentation to
support the full MDS
assessment be
included in
residents' medical
records.
GAO-03-187 33. Delay the CMS disagreed with
implementation of and did not
nationwide reporting implement this
of quality recommendation.
indicators 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.
34. Delay the CMS disagreed with
implementation of and did not
nationwide reporting implement this
of quality recommendation.
indicators 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 35. Further refine CMS did not
annual state implement this
performance reviews recommendation
so that they (1) because it believes
consistently that the state
distinguish between performance
systemic problems standards take into
and less serious account statutory
issues regarding and nonstatutory
state performance, performance
(2) analyze trends standards.
in the proportion of
homes 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 36. Ensure that CMS CMS's evaluation of
regional offices state surveyors'
fully comply with performance now
the statutory routinely includes
requirement to fire safety as part
conduct annual of the statutory
federal monitoring requirement to
surveys by including annually conduct
an assessment of the federal monitoring
fire safety surveys in at least
component of states' 5 percent of
standard surveys, surveyed nursing
with an emphasis on homes in each
unsprinklered homes. state.
37. Ensure that data CMS now obtains the
on sprinkler sprinkler status of
coverage in nursing over 99 percent of
homes are nursing homes
consistently during routine
obtained and surveys and inputs
reflected in the CMS this information
database. into OSCAR.
38. Until sprinkler See CMS action in
coverage data are response to
routinely available recommendation for
in CMS's database, ensuring that data
work with state on sprinkler
survey agencies to coverage in nursing
identify the extent homes are
to which each consistently
nursing home is obtained
sprinklered or not (recommendation #37
sprinklered. above).
39. On an expedited CMS has completed
basis, review all reviews of all
waivers and Fire waiver requests and
Safety Evaluation FSES assessments
System (FSES) and noted that the
assessments for number of homes
homes that are not using FSES dropped
fully sprinklered to significantly as a
determine their result of the
appropriateness.^b review.
40. Make information This information
on fire safety was made available
deficiencies on the Nursing Home
available to the Compare Web site as
public via the of October 2006.
Nursing Home Compare
Web site, including
information on
whether a home has
automatic
sprinklers.
41. Work with the CMS issued
National Fire regulations
Protection effective May 24,
Association to 2005, requiring
strengthen fire nursing facilities
safety standards for to install smoke
unsprinklered detectors in
nursing homes, such resident rooms and
as requiring smoke public areas if
detectors in they do not have a
resident rooms, sprinkler system
exploring the installed
feasibility of throughout the
requiring sprinklers facility or a
in all nursing hard-wired smoke
homes, and detection system in
developing a those areas.
strategy for Facilities were
financing such given 1 year, until
requirements. May 24, 2006, to
comply with this
requirement. In
addition, the
National Fire
Protection
Association
approved a revision
to the 2006 Life
Safety Code which
requires the
installation of
automatic sprinkler
systems in all
existing
facilities.
42. Ensure that CMS developed and
thorough issued a
investigations are standardized
conducted following procedure to ensure
multiple-death that both state
nursing home fires survey agencies and
so that fire safety its own staff take
standards can be appropriate action
reevaluated and to investigate
modified where fires that result
appropriate. 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
In order to identify trends in the percentage of nursing homes cited with
actual harm or immediate jeopardy deficiencies, we analyzed data from
CMS's OSCAR database for fiscal years 2000 through 2006 (see table 3).
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 period.
Table 3: Percentage of Nursing Homes Cited for Actual Harm or Immediate
Jeopardy, by State, Fiscal Years 2000-2006
Fiscal year
Number of homes
State 2006 2000 2001 2002 2003 2004 2005 2006
Alabama 231 35.5 23.0 12.7 18.1 15.6 23.1 24.2
Alaska 15 28.6 26.7 26.7 0.0 0.0 0.0 26.7
Arizona 135 24.2 12.6 7.3 6.6 9.4 9.9 24.8
Arkansas 245 38.1 27.7 22.3 24.7 19.5 15.9 14.5
California 1,304 24.1 10.9 5.1 3.7 6.1 8.0 14.1
Colorado 215 20.4 26.4 32.7 20.9 25.9 40.4 44.8
Connecticut 245 41.9 51.6 45.8 43.1 54.4 44.2 50.8
Delaware 44 47.5 14.6 10.8 5.3 15.0 35.7 36.8
District of Columbia 20 17.7 28.6 30.0 41.2 40.0 30.0 25.0
Florida 688 22.8 20.2 14.9 10.2 7.8 4.2 9.1
Georgia 371 19.5 21.0 23.7 24.6 16.6 18.0 15.9
Hawaii 48 23.8 14.3 21.2 12.1 22.9 2.8 2.1
Idaho 80 51.4 29.7 39.2 31.9 27.3 38.4 47.8
Illinois 816 28.4 19.2 15.3 18.3 15.1 15.7 21.7
Indiana 526 45.0 29.4 23.2 19.7 24.1 28.3 33.4
Iowa 466 14.7 12.0 8.0 9.1 11.8 11.2 11.7
Kansas 361 37.9 30.7 32.9 26.5 30.3 34.9 38.3
Kentucky 298 26.8 29.1 23.2 26.1 14.6 7.7 11.4
Louisiana 307 21.8 29.9 21.7 16.2 12.0 15.4 15.8
Maine 114 11.1 13.9 6.6 11.1 12.8 7.0 9.8
Maryland 235 22.4 16.5 26.1 15.4 17.8 7.6 7.6
Massachusetts 456 29.1 24.4 24.6 25.9 16.7 22.6 20.9
Michigan 429 42.8 24.5 29.7 26.9 22.9 22.9 29.7
Minnesota 404 30.4 17.3 22.3 18.3 14.3 14.4 18.8
Mississippi 207 33.0 19.8 18.7 16.0 18.9 18.1 9.4
Missouri 526 19.8 13.0 15.6 12.5 11.7 15.4 15.6
Montana 97 33.3 29.7 12.0 20.0 18.0 17.9 16.7
Nebraska 229 19.2 21.1 20.1 14.8 15.3 14.4 25.7
Nevada 47 34.8 14.6 11.9 9.1 17.5 19.6 21.3
New Hampshire 83 37.8 31.1 29.4 24.1 25.6 26.3 22.9
New Jersey 363 25.5 27.8 18.8 10.5 13.5 18.2 15.5
New Mexico 75 23.7 16.9 14.9 21.3 24.3 29.4 25.0
New York 658 33.8 37.1 34.2 15.2 11.0 14.0 18.5
North Carolina 424 43.6 35.8 25.6 29.0 21.1 18.5 17.2
North Dakota 83 25.9 28.7 17.9 12.4 13.6 17.7 21.7
Ohio 980 26.6 27.3 25.4 19.1 11.4 13.8 14.6
Oklahoma 359 19.3 21.3 22.0 26.3 13.9 23.2 20.1
Oregon 142 45.5 32.6 23.7 20.3 15.9 19.8 18.6
Pennsylvania 724 30.3 19.2 13.5 17.2 19.5 15.2 13.6
Rhode Island 90 14.3 12.9 5.6 6.7 9.3 9.5 4.5
South Carolina 178 26.4 17.2 19.8 29.6 32.7 24.8 17.1
South Dakota 111 27.1 26.7 26.8 32.1 21.6 12.8 21.7
Tennessee 332 28.2 20.2 20.7 21.8 22.9 17.3 12.5
Texas 1,175 29.7 30.5 22.4 18.0 12.0 16.2 18.3
Utah 93 19.5 14.1 25.6 19.0 11.1 8.4 17.9
Vermont 41 22.5 18.2 15.0 10.0 19.5 23.7 13.5
Virginia 281 19.2 14.3 11.6 13.7 10.2 15.5 15.8
Washington 247 46.9 38.3 37.0 30.9 28.1 27.2 24.1
West Virginia 132 12.1 17.7 20.4 12.7 9.8 15.0 9.7
Wisconsin 403 15.8 15.6 11.2 10.9 13.1 18.2 23.0
Wyoming 39 52.8 32.4 25.0 22.9 17.1 11.8 16.2
Nation 16,172 28.4 23.3 20.2 17.8 15.7 16.8 18.9
Source: GAO analysis of OSCAR and PDQ data.
Related GAO Products
Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred
Some Homes from Repeatedly Harming Residents. GAO-07-241. Washington,
D.C.: March 26, 2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring
High-Quality Care and Resident Safety. [33]GAO-06-117 . Washington, D.C.:
December 28, 2005.
Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in
State and Federal Oversight of Quality of Care. [34]GAO-05-78 .
Washington, D.C.: November 12, 2004.
Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal
Standards and Oversight. [35]GAO-04-660 . Washington D.C.: July 16, 2004.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. [36]GAO-03-561 . Washington,
D.C.: July 15, 2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. [37]GAO-03-187 . Washington, D.C.:
October 31, 2002.
Nursing Homes: Quality of Care More Related to Staffing than Spending.
[38]GAO-02-431R . Washington, D.C.: June 13, 2002.
Nursing Homes: More Can Be Done to Protect Residents from Abuse.
[39]GAO-02-312 . Washington, D.C.: March 1, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data Should
Complement State Activities. [40]GAO-02-279 . Washington, D.C.: February
15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the
Quality Initiatives. [41]GAO/HEHS-00-197 . Washington, D.C.: September 28,
2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better
Ensure Quality. [42]GAO/HEHS-00-6 . Washington, D.C.: November 4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. [43]GAO/HEHS-99-154R . Washington,
D.C.: August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. [44]GAO/HEHS-99-157 . Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. [45]GAO/HEHS-99-80 . Washington, D.C.: March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [46]GAO/HEHS-99-46 . Washington, D.C.: March
18, 1999.
California Nursing Homes: Care Problems Persist Despite Federal and State
Oversight. [47]GAO/HEHS-98-202 . Washington, D.C.: July 27, 1998.
(290628)
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Highlights of [55]GAO-07-794T , a testimony before the Special Committee
on Aging, U.S. Senate
May 2, 2007
NURSING HOME REFORM
Continued Attention Is Needed to Improve Quality of Care in Small but
Significant Share of Homes
With the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), Congress
responded to growing concerns about the quality of care that nursing home
residents received by requiring reforms in the federal certification and
oversight of nursing homes. These reforms included revising care
requirements that homes must meet to participate in the Medicare or
Medicaid programs, modifying the survey process for certifying a home's
compliance with federal standards, and introducing additional sanctions
and decertification procedures for noncompliant homes.
GAO's testimony addresses its work in evaluating the quality of nursing
home care and the enforcement and oversight functions intended to ensure
high-quality care, the progress made in each of these areas since the
passage of OBRA `87, and the challenges that remain.
GAO's testimony is based on its prior work; analysis of data from the
Centers for Medicare & Medicaid Services' (CMS) On-Line Survey,
Certification, and Reporting system (OSCAR), which compiles the results of
state nursing home surveys; and evaluation of federal comparative surveys
for selected states (2005-2007). Federal comparative surveys are conducted
at nursing homes recently surveyed by each state to assess the adequacy of
the state's surveys.
The reforms of OBRA '87 and subsequent efforts by CMS and the nursing home
industry to improve the quality of nursing home care have focused on
resident outcomes, yet a small but significant share of nursing homes
nationwide continue to experience quality-of-care problems. In fiscal year
2006, almost one in five nursing homes was cited for serious deficiencies,
those that caused actual harm or placed residents in immediate jeopardy.
While this rate has fluctuated over the last 7 years, GAO has found
persistent variation in the proportion of homes with serious deficiencies
across states. In addition, although the understatement of serious
deficiencies--that is, when federal surveyors identified deficiencies that
were missed by state surveyors--has declined since 2004 in states GAO
reviewed, it has continued at varying levels.
CMS has strengthened its enforcement capabilities since OBRA '87 in order
to better ensure that nursing homes achieve and maintain high-quality
care, but several key initiatives require refinement. CMS has implemented
additional sanctions authorized in the legislation, established an
immediate sanctions policy for homes found to repeatedly harm residents,
and developed a new enforcement management data system. However, the
immediate sanctions policy is complex and appears to have induced only
temporary compliance in some homes with a history of repeated
noncompliance. Furthermore, CMS's new data system's components are not
integrated and national reporting capabilities are incomplete, which
hamper CMS's ability to track and monitor enforcement.
CMS oversight of nursing home quality has increased significantly, but CMS
initiatives continue to compete for staff and financial resources.
Attention to oversight has led to greater demand on limited resources, and
to queues and delays in certain key initiatives. For example, a new survey
methodology has been in development for over 8 years and resource
constraints threaten the planned expansion of this methodology beyond the
initial demonstration states.
Significant attention from the Special Committee on Aging, the Institute
of Medicine, and others served as a catalyst to focus national attention
on nursing home quality issues, culminating in the nursing home reform
provisions of OBRA '87. In response to many GAO recommendations and at its
own initiative, CMS has taken many important steps; however, the task of
ensuring high-quality nursing home care for all residents is not complete.
In order to guarantee that all nursing home residents receive high-quality
care, it is important to maintain the momentum begun by the reforms of
OBRA '87 and continue to focus national attention on those homes that
cause actual harm to vulnerable residents.
References
Visible links
22. http://www.gao.gov/cgi-bin/getrpt?GAO/HRD-87-113
23. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
24. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
25. http://www.gao.gov/cgi-bin/getrpt?GAO-07-241
26. http://www.gao.gov/cgi-bin/getrpt?GAO-07-241
27. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
28. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
29. http://www.gao.gov/cgi-bin/getrpt?GAO-04-660
31. http://www.gao.gov/cgi-bin/getrpt?GAO-02-279
33. http://www.gao.gov/cgi-bin/getrpt?GAO-06-117
34. http://www.gao.gov/cgi-bin/getrpt?GAO-05-78
35. http://www.gao.gov/cgi-bin/getrpt?GAO-04-660
36. http://www.gao.gov/cgi-bin/getrpt?GAO-03-561
37. http://www.gao.gov/cgi-bin/getrpt?GAO-03-187
38. http://www.gao.gov/cgi-bin/getrpt?GAO-02-431R
39. http://www.gao.gov/cgi-bin/getrpt?GAO-02-312
40. http://www.gao.gov/cgi-bin/getrpt?GAO-02-279
41. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-197
42. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-6
43. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-154R
44. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-157
45. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-80
46. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46
47. http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202
55. http://www.gao.gov/cgi-bin/getrpt?GAO-07-794T
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