Nursing Home Care

The Health Care Financing Administration (HCFA) oversees how well each state agency ensures quality care in nursing homes, but the mechanisms HCFA uses are of limited scope and effectiveness. Because the mechanisms are not applied consistently in HCFA's 10 regional offices, HCFA lacks sufficient, consistent, and reliable data with which to evaluate the effectiveness of state agencies' performance or the success of its recent initiatives to improve nursing home care. HCFA cannot be certain whether some states are failing to identify serious deficiencies that harm nursing home residents. HCFA also lacks an adequate array of effective sanctions to encourage state agencies to correct serious or widespread problems. GAO recommends that HCFA improve (1) the scope and the rigor of its oversight process through the state surveys and (2) the consistency in how it holds state survey agencies accountable by standardizing procedures for selecting state surveys and conducting federal monitoring surveys. GAO summarized this report in testimony before Congress; see: Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to Better Ensure Quality Care, by William J. Scanlon, Director of Health, Financing, and Public Health Issues, before the Senate Special Committee on Aging. GAO/T-HEHS-00-27, Nov. 4 (10 pages).

GAO noted that: (1) since last year, HCFA has undertaken a series of initiatives intended to address quality problems facing the nation's nursing home residents, including redesigning its program for overseeing state agencies that survey nursing homes to ensure quality care; (2) the objective of HCFA's oversight program is to evaluate the adequacy of each state agency's performance in ensuring quality care in nursing homes, but the mechanisms it has created to do so are limited in their scope and effectiveness; (3) HCFA's oversight mechanisms are not applied consistently across each of its 10 regional offices; (4) HCFA does not have sufficient, consistent, and reliable data to evaluate the effectiveness of state agency performance or the success of its recent initiatives to improve nursing home care; (5) given the wide range in the frequencies with which states identify serious deficiencies, HCFA cannot be certain whether some states are failing to identify serious deficiencies that harm nursing home residents; (6) HCFA does not have an adequate array of effective sanctions to encourage a state agency to correct serious or widespread problems with its survey process; (7) HCFA's primary mechanism to monitor state survey performance stems from its statutory requirement to survey annually at least 5 percent of the nation's 17,000 nursing homes that states have certified as eligible for Medicare or Medicaid funds; (8) but HCFA's approach to these federal monitoring surveys does not produce sufficient information to assess the adequacy of state agency performance; (9) to fulfill its 5 percent monitoring mandate, HCFA makes negligible use of its most effective technique--an independent survey done by HCFA surveyors following completion of a state's survey--for assessing state agencies' abilities to identify serious deficiencies in nursing homes; (10) a second HCFA oversight mechanism also has significant shortcomings; (11) about 3 years ago, HCFA implemented the State Agency Quality Improvement Program (SAQIP), a program under which the state agency does a self-assessment to inform HCFA, at least once a year, whether the state is in compliance with seven standard requirements; and (12) SAQIP is limited as an oversight program, however, because HCFA: (a) does not independently validate the information that the states provide, so it is uncertain whether all serious problems are identified or whether identified problems are being corrected; and (b) has no policy regarding consequences for states that do not comply.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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