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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