Nursing Homes
Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline Gao ID: GAO-03-1016T July 17, 2003Since 1998, the Congress and Administration have focused considerable attention on improving the quality of care in the nation's nursing homes, which provide care for about 1.7 million elderly and disabled residents in about 17,000 homes. GAO has earlier reported on serious weaknesses in processes for conducting routine state inspections (surveys) of nursing homes and complaint investigations, ensuring that homes with identified deficiencies correct the problems without recurrence, and providing consistent federal oversight of state survey activities to ensure that nursing homes comply with federal quality standards. GAO was asked to update its work on these issues and to testify on its findings, as reported in Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561 (July 15, 2003). In commenting on this report, the Centers for Medicare & Medicaid Services (CMS) generally concurred with the recommendations to address survey and oversight weaknesses. In this testimony, GAO addresses (1) the prevalence of serious nursing home quality problems nationwide, (2) factors contributing to continuing weaknesses in states' survey, complaint, and enforcement activities, and (3) the status of key federal efforts to oversee state survey agency performance and improve quality.
The magnitude of documented serious deficiencies that harmed nursing home residents remains unacceptably high, despite some decline. For the most recent period reviewed, one in five nursing homes nationwide (about 3,500 homes) had serious deficiencies that caused residents actual harm or placed them in immediate jeopardy. Moreover, GAO found significant understatement of care problems that should have been classified as actual harm or higher--serious avoidable pressure sores, severe weight loss, and multiple falls resulting in broken bones and other injuries--for a sample of homes with a history of harming residents. Several factors contributed to such understatement, including confusion about the definition of harm; inadequate state review of surveys to identify potential understatement; large numbers of inexperienced state surveyors; and a continuing problem with survey timing being predictable to nursing homes. States continue to have difficulty identifying and responding in a timely fashion to public complaints alleging actual harm--delays state officials attributed to an increase in the volume of complaints and to insufficient staff. Although federal enforcement policy was strengthened in January 2000 by requiring state survey agencies to refer for immediate sanction homes that had a pattern of harming residents, many states did not fully comply with this new requirement, significantly undermining the policy's intended deterrent effect. While CMS has increased its oversight of state survey and complaint investigation activities, continued attention is required to help ensure compliance with federal requirements. In October 2000, the agency implemented new annual performance reviews to measure state performance in seven areas, including the timeliness of survey and complaint investigations and the proper documentation of survey findings. The first round of results, however, did not produce information enabling the agency to identify and initiate needed improvements. For example, some regional office summary reports provided too little information to determine if a state did not meet a particular standard by a wide or a narrow margin--information that could help CMS to judge the seriousness of problems identified and target remedial interventions. Rather than relying on its regional offices, CMS plans to more centrally manage future state performance reviews to improve consistency and to help ensure that the results of those reviews could be used to more readily identify serious problems. Finally, implementation has been significantly delayed for three federal initiatives that are critical to reducing the variation evident in the state survey process in categorizing the seriousness of deficiencies and investigating complaints. These delayed initiatives were intended to strengthen the methodology for conducting surveys, improve surveyor guidance for determining the scope and severity of deficiencies, and increase standardization in state complaint investigation processes.
GAO-03-1016T, Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline
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Testimony:
Before the Committee on Finance, U.S. Senate:
United States General Accounting Office:
GAO:
For Release on Delivery Expected at 10:00 a.m.
Thursday, July 17, 2003:
NURSING HOMES:
Prevalence of Serious Quality Problems Remains Unacceptably High,
Despite Some Decline:
Statement of William J. Scanlon:
Director--Health Care Issues:
GAO-03-1016T:
GAO Highlights:
Highlights of GAO-03-1016T, a testimony before the Committee on
Finance, U.S. Senate
Why GAO Did This Study:
Since 1998, the Congress and Administration have focused considerable
attention on improving the quality of care in the nation‘s nursing
homes, which provide care for about 1.7 million elderly and disabled
residents in about 17,000 homes. GAO has earlier reported on serious
weaknesses in processes for conducting routine state inspections
(surveys) of nursing homes and complaint investigations, ensuring that
homes with identified deficiencies correct the problems without
recurrence, and providing consistent federal oversight of state survey
activities to ensure that nursing homes comply with federal quality
standards.
GAO was asked to update its work on these issues and to testify on its
findings, as reported in Nursing Home Quality: Prevalence of Serious
Problems, While Declining, Reinforces Importance of Enhanced
Oversight, GAO-03-561 (July 15, 2003). In commenting on this report,
the Centers for Medicare & Medicaid Services (CMS) generally concurred
with the recommendations to address survey and oversight weaknesses.
In this testimony, GAO addresses (1) the prevalence of serious nursing
home quality problems nationwide, (2) factors contributing to
continuing weaknesses in states‘ survey, complaint, and enforcement
activities, and (3) the status of key federal efforts to oversee state
survey agency performance and improve quality.
What GAO Found:
The magnitude of documented serious deficiencies that harmed nursing
home residents remains unacceptably high, despite some decline. For
the most recent period reviewed, one in five nursing homes nationwide
(about 3,500 homes) had serious deficiencies that caused residents
actual harm or placed them in immediate jeopardy. Moreover, GAO found
significant understatement of care problems that should have been
classified as actual harm or higher”serious avoidable pressure sores,
severe weight loss, and multiple falls resulting in broken bones and
other injuries”for a sample of homes with a history of harming
residents. Several factors contributed to such understatement,
including confusion about the definition of harm; inadequate state
review of surveys to identify potential understatement; large numbers
of inexperienced state surveyors; and a continuing problem with survey
timing being predictable to nursing homes. States continue to have
difficulty identifying and responding in a timely fashion to public
complaints alleging actual harm”delays state officials attributed to
an increase in the volume of complaints and to insufficient staff.
Although federal enforcement policy was strengthened in January 2000
by requiring state survey agencies to refer for immediate sanction
homes that had a pattern of harming residents, many states did not
fully comply with this new requirement, significantly undermining the
policy‘s intended deterrent effect.
While CMS has increased its oversight of state survey and complaint
investigation activities, continued attention is required to help
ensure compliance with federal requirements. In October 2000, the
agency implemented new annual performance reviews to measure state
performance in seven areas, including the timeliness of survey and
complaint investigations and the proper documentation of survey
findings. The first round of results, however, did not produce
information enabling the agency to identify and initiate needed
improvements. For example, some regional office summary reports
provided too little information to determine if a state did not meet a
particular standard by a wide or a narrow margin”information that
could help CMS to judge the seriousness of problems identified and
target remedial interventions. Rather than relying on its regional
offices, CMS plans to more centrally manage future state performance
reviews to improve consistency and to help ensure that the results of
those reviews could be used to more readily identify serious problems.
Finally, implementation has been significantly delayed for three
federal initiatives that are critical to reducing the variation
evident in the state survey process in categorizing the seriousness of
deficiencies and investigating complaints. These delayed initiatives
were intended to strengthen the methodology for conducting surveys,
improve surveyor guidance for determining the scope and severity of
deficiencies, and increase standardization in state complaint
investigation processes.
www.gao.gov/cgi-bin/getrpt?GAO-03-1016T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Kathryn G. Allen on
(202) 512-7118.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today as you address the quality of care
provided to the nation's 1.7 million nursing home residents, a highly
vulnerable population of elderly and disabled individuals. The federal
government plays a major role in ensuring nursing home quality and in
financing nursing home care. Medicare and Medicaid paid the nation's
approximately 17,000 homes an estimated $42 billion in 2002 to care for
beneficiaries. More specifically, Medicaid pays for care provided to
about two-thirds of all nursing home residents nationwide. In addition,
the Department of Veterans Affairs contracts with many of these same
nursing homes to provide long-term care to veterans at a cost of more
than $250 million in fiscal year 2002. In 1998, the Senate Special
Committee on Aging held a hearing to address nursing home care problems
in California. Troubled by our findings of poor care in that state's
homes and weak federal oversight in general, the Committee held
additional hearings on nursing home quality nationwide in 1999 and
2000. In response to congressional oversight and our recommendations,
the Administration has taken actions intended to address many of the
weaknesses we identified. These weaknesses included:
* periodic state inspections, known as surveys, that understated the
extent of serious care problems due to procedural weaknesses;
* considerable delays that occurred in states investigating complaints
by residents, family members or friends, and nursing home staff
alleging actual harm to residents;
* federal enforcement policies that did not ensure that identified
deficiencies were addressed and remained corrected; and:
* federal oversight of state survey activities that was often
inconsistent across states and limited in scope and effectiveness.
In September 2000, we reported on progress made in addressing these
weaknesses and concluded that the success of the Administration's
actions to improve nursing home quality required sustained federal and
state commitment to reach their full potential. My remarks today will
address federal and state progress made since our September 2000 report
and testimony, focusing in particular on (1) the prevalence of serious
nursing home quality problems, (2) factors contributing to continuing
weaknesses in states' survey, complaint, and enforcement activities,
and (3) the status of key federal efforts to oversee state survey
agency performance and improve quality. My remarks are based on our
report being released today that addresses these issues in greater
detail.[Footnote 1]
In summary, the magnitude of serious deficiencies that harmed nursing
home residents remains unacceptably high, despite some decline. For the
most recent period we reviewed, one in five of all nursing homes
nationwide (about 3,500 homes) had serious deficiencies that caused
residents actual harm or placed them in immediate jeopardy. Moreover,
we found significant understatement of care problems that should have
been classified as actual harm or higher--serious avoidable pressure
sores, severe weight loss, and multiple falls resulting in broken bones
and other injuries--for a sample of homes with a history of harming
residents. We identified several factors that contributed to such
understatement, including confusion about the definition of harm;
inadequate state supervisory review of surveys to identify potential
understatement; large numbers of inexperienced state surveyors; and a
continuing, significant problem with survey timing being predictable to
nursing homes. States also continue to have difficulty identifying and
responding in a timely fashion to complaints alleging actual harm--
delays that state officials attributed to an increase in the volume of
complaints and to insufficient staff. Although federal enforcement
policy was strengthened in January 2000 by requiring state survey
agencies to refer for immediate sanction homes that had a pattern of
harming residents, we found that many states did not fully comply with
this new requirement. States failed to refer hundreds of homes for
immediate sanction, significantly undermining the policy's intended
deterrent effect.
While the Centers for Medicare & Medicaid Services (CMS) has increased
its oversight of state survey and complaint investigation activities,
continued attention is required to help ensure compliance with federal
requirements.[Footnote 2] In October 2000, the agency implemented new
annual performance reviews to measure state performance in seven areas,
including the timeliness of survey and complaint investigations and the
proper documentation of survey findings. The first round of results,
however, did not produce information enabling the agency to identify
and initiate needed improvements. For example, some regional office
summary reports provided too little information to determine if a state
agency did not meet a particular standard by a wide or a narrow margin-
-information that could help CMS to judge the seriousness of problems
identified and target remedial actions. Rather than relying on its
regional offices, CMS plans to more centrally manage future state
performance reviews to improve consistency and to help ensure that the
results of those reviews could be used to more readily identify serious
problems. Finally, implementation has been significantly delayed for
three federal initiatives that are critical to reducing the variation
evident in the state survey process in categorizing the seriousness of
deficiencies and investigating complaints. These delayed initiatives
were intended to strengthen the methodology for conducting surveys,
improve surveyor guidance for determining the scope and severity of
deficiencies, and increase standardization in state complaint
investigation processes. In our view, finalizing and implementing these
initiatives as quickly as possible would help bring more clarity and
consistency to the process for assessing and improving the quality of
care provided to the nation's nursing home residents.
Background:
Oversight of nursing homes is a shared federal and state
responsibility. CMS is the federal agency that manages Medicare and
Medicaid and oversees compliance with federal nursing home quality
standards. On the basis of statutory requirements, CMS defines
standards that nursing homes must meet to participate in the Medicare
and Medicaid programs and contracts with states to certify that homes
meet these standards through annual inspections and complaint
investigations. The "annual" inspection, called a survey, which must be
conducted on average every 12 months and no less than every 15 months
at each home, entails a team of state surveyors spending several days
in the home to determine whether care and services meet the assessed
needs of the residents. CMS establishes specific protocols, or
investigative procedures, for state surveyors to use in conducting
these comprehensive surveys. In contrast, complaint investigations,
also conducted by state surveyors within certain federal guidelines and
time frames, typically target a single area in response to a complaint
filed against a home by a resident, the resident's family or friends,
or nursing home employees. Quality-of-care problems identified during
either standard surveys or complaint investigations are classified in 1
of 12 categories according to their scope (the number of residents
potentially or actually affected) and their severity (potential for or
occurrence of harm to residents).
Ensuring that documented deficiencies are corrected is likewise a
shared responsibility. CMS is responsible for enforcement actions
involving homes with Medicare or dual Medicare and Medicaid
certification--about 86 percent of all homes. States are responsible
for enforcing standards in homes with Medicaid-only certification--
about 14 percent of the total. Enforcement actions can involve, among
other things, requiring corrective action plans, imposing monetary
fines, denying the home Medicare and Medicaid payments for new
admissions until corrections are in place, and, ultimately, terminating
the home from participation in these programs. Sanctions are imposed by
CMS on the basis of state referrals. States may also use their state
licensure authority to impose state sanctions.
CMS is also responsible for overseeing each state survey agency's
performance in ensuring quality of care in its nursing homes. One of
its primary oversight tools is the federal monitoring survey, which is
required annually for at least 5 percent of all Medicare-and Medicaid-
certified nursing homes. Federal monitoring surveys can be either
comparative or observational. A comparative survey involves a federal
survey team conducting a complete, independent survey of a home within
2 months of the completion of a state's survey in order to compare and
contrast the findings. In an observational survey, one or more federal
surveyors accompany a state survey team to a nursing home to observe
the team's performance. Roughly 85 percent of federal surveys are
observational. Based on prior work, we have concluded that the
comparative survey is the more effective of the two federal monitoring
surveys for assessing state agencies' abilities to identify serious
deficiencies in nursing homes and have recommended that more priority
be given to them. A new federal oversight tool, state performance
reviews, implemented in October 2000, measures state survey agency
performance against seven standards, including statutory requirements
regarding survey frequency, requirements for documenting deficiencies,
and timeliness of complaint investigations. These reviews replaced
state self-reporting of their compliance with federal requirements. CMS
also maintains a central database--the On-Line Survey, Certification,
and Reporting (OSCAR) system--that compiles, among other information,
the results of every state survey conducted at Medicare-and Medicaid-
certified facilities nationwide.
Magnitude of Problems Remains Cause for Concern, Even Though Fewer
Serious Nursing Home Quality Problems Were Reported:
State survey data indicate that the proportion of nursing homes with
serious quality problems remains unacceptably high, despite a decline
in such reported problems since mid-2000. For an 18-month period ending
in January 2002, 20 percent of nursing homes (about 3,500) were cited
for deficiencies involving actual harm or immediate jeopardy to
residents. This share is down from 29 percent (about 5,000 homes) for
the previous period.[Footnote 3] (Appendix I provides trend data on the
percentage of nursing homes cited for serious deficiencies for all 50
states and the District of Columbia.) Despite this decline, there is
still considerable variation in the proportion of homes cited for such
serious deficiencies, ranging from about 7 percent in Wisconsin to
about 50 percent in Connecticut.
Federal comparative surveys completed during a recent 21-month period
found actual harm or higher-level deficiencies in about 10 percent
fewer homes where state surveyors found no such deficiencies, compared
to an earlier period. Fewer discrepancies between federal and state
surveys suggest that state surveyors' performance in documenting
serious deficiencies has improved. However, the magnitude of the state
surveyors' understatement of quality problems remains a serious issue.
From June 2000 through February 2002, federal surveyors conducting
comparative surveys found examples of actual harm deficiencies in about
one fifth of homes that states had judged to be deficiency free. For
example, federal surveyors found that a home had failed to prevent
pressure sores, failed to consistently monitor pressure sores when they
did develop, and failed to notify the physician promptly so that proper
treatment could be started. These federal surveyors noted that
inadequate monitoring of pressure sores was a problem during the
state's survey that should have been found and cited. CMS plans to hire
a contractor to perform approximately 170 additional comparative
surveys each year, bringing the annual total to 330, including those
conducted by CMS surveyors.[Footnote 4] We continue to believe that
comparative surveys are the most effective technique for assessing
state agencies' ability to identify serious deficiencies in nursing
homes because they constitute an independent evaluation of the state
survey.[Footnote 5]
Beyond the continuing high prevalence of actual harm or immediate
jeopardy deficiencies, we found a disturbing understatement of actual
harm or higher deficiencies in a sample of surveys that were conducted
since July 2000 at homes with a history of harming residents but whose
current surveys indicated no actual harm deficiencies. Overall, 39
percent of 76 surveys we reviewed had documented problems that should
have been classified as actual harm: serious, avoidable pressure sores;
severe weight loss; and multiple falls resulting in broken bones and
other injuries. We were unable to assess whether the scope and severity
of other deficiencies in our sample of surveys were also understated
because of weaknesses in how those deficiencies were documented.
Weaknesses Persist in State Survey, Complaint, and Enforcement
Activities:
Despite increased attention in recent years, widespread weaknesses
persist in state survey, complaint investigation, and enforcement
activities. In our view, this reflects not necessarily a lack of effort
but rather the magnitude of the challenge in effecting important and
consistent systemic change across all states. We identified several
factors that contributed to these weaknesses and the understatement of
survey deficiencies, including confusion over the definition of actual
harm. Moreover, many state complaint investigation systems still have
timeliness problems and some states did not comply with HCFA's policy
to refer to the agency for immediate sanction those nursing homes that
showed a pattern of harming residents, resulting in hundreds of nursing
homes not appropriately referred for action.
Confusion about Definition of Harm and Other Factors Contribute to
Underreporting of Care Problems:
We identified several factors at the state level that contributed to
the understatement of serious quality-of-care problems. State survey
agency officials expressed confusion about the definitions of "actual
harm" and "immediate jeopardy," which may contribute to the variability
in identifying deficiencies among states. Several states' comments on
our draft report underscored how the lack of clear and consistent CMS
guidance on these definitions may have contributed to such confusion.
For example, supplementary guidance provided to one state by its CMS
regional office on how to assess the severity of a newly developing
pressure sore was inconsistent with CMS's definition of actual harm.
Other factors that have contributed to the understatement of actual
harm include lack of adequate state supervisory review of survey
findings, large numbers of inexperienced surveyors, and continued
survey predictability. While most of the 16 states we contacted had
processes for supervisory review of deficiencies cited at the actual
harm level and higher, half did not have similar processes to help
ensure that the scope and severity of less serious deficiencies were
not understated.[Footnote 6] According to state officials, the large
number of inexperienced surveyors, which ranged from 25 percent to 70
percent in 27 states and the District of Columbia and is due to high
attrition and hiring limitations, has also had a negative impact on the
quality of surveys. In addition, our analysis of OSCAR data indicated
that the timing of about one-third of the most recent state surveys
nationwide remained predictable--a slight reduction from homes' prior
surveys, about 38 percent of which were predictable. Predictable
surveys can allow quality-of-care problems to go undetected because
homes, if they choose to do so, may conceal certain problems such as
understaffing.
Many State Complaint Investigation Systems Still Have Timeliness
Problems and Other Weaknesses:
CMS's 2001 review of a sample of complaints in all states demonstrated
that many states were not complying with CMS complaint investigation
timeliness requirements. Specifically, 12 states were not investigating
all immediate jeopardy complaints within the required 2 workdays, and
42 states were not complying with the new requirement established in
1999 to investigate actual harm complaints within 10 days.[Footnote 7]
Some states attributed the timeliness problem to an increase in the
number of complaints and to insufficient staff. CMS also found that the
triaging of complaints to determine how quickly to investigate each
complaint was inadequate in some states. A CMS-sponsored study of the
states' complaint practices also raised concerns about state approaches
to accepting and investigating complaints. For example, 15 states did
not provide toll-free hotlines to facilitate the filing of complaints
and the majority of states lacked adequate systems for managing
complaints. To address the latter problem, CMS planned to implement a
new complaint tracking system nationwide in October 2002, but as of
today, the system is still being tested and its implementation date is
uncertain.
Substantial Number of Nursing Homes Were Not Referred to CMS for
Immediate Sanctions:
State survey agencies did not refer a significant number of cases where
nursing homes were found to have a pattern of harming residents to CMS
for immediate sanction as required by CMS policy, significantly
undermining the policy's intended deterrent effect. Our earlier work
found that nursing homes tended to "yo-yo" in and out of compliance, in
part because HCFA rarely imposed sanctions on homes with a pattern of
deficiencies that harmed residents.[Footnote 8] In response, the agency
required that, as of January 2000, homes found to have harmed residents
on successive standard surveys be referred to it for immediate
sanction.[Footnote 9] While most states did not forward at least some
cases that should have been referred under this policy, four states
accounted for over half of the 700 nursing homes not referred. One of
these states did not fully implement the new CMS policy until mid-2002
and another state implemented its own version of the policy through
September 2002, resulting in relatively few referrals. In most other
states, the failure to refer cases resulted from a misunderstanding of
the policy by both some states and CMS regional offices and, in some
states, from the lack of an adequate system for tracking a home's
survey history to determine if it met the policy's criteria.
CMS Oversight of State Survey Activities Requires Further
Strengthening:
While CMS has instituted a more systematic oversight process of state
survey and complaint activities by initiating annual state performance
reviews, CMS officials acknowledged that the effectiveness of the
reviews could be improved. Major areas needing improvement as a result
of the fiscal year 2001 review include (1) distinguishing between minor
and major problems, (2) evaluating how well states document
deficiencies, and (3) ensuring consistency in how regions conduct
reviews. Data limitations, particularly involving complaints, and
inconsistent use of periodic monitoring reports also hampered the
effectiveness of state performance reviews. For subsequent reviews, CMS
plans to more centrally manage the process to improve consistency and
to help ensure that future reviews distinguish serious from minor
problems.
Implementation has been significantly delayed for three federal
initiatives that are critical to reducing the subjectivity in the state
survey process for identifying deficiencies and determining the
seriousness of complaints. These delayed initiatives were intended to
strengthen the methodology for conducting surveys, improve surveyor
guidance for determining the scope and severity of deficiencies, and
increase standardization in state complaint investigation processes.
* Strengthening the survey methodology. Because surveyors often missed
significant care problems due to weaknesses in the survey process, HCFA
contracted in 1998 for the development of a revised survey methodology.
The agency's contractor has proposed a two-phase survey process. In the
first phase, surveyors would initially identify potential care problems
using data generated off-site prior to the start of the survey and
additional, standardized information collected on-site. During the
second phase, surveyors would conduct an onsite investigation to
confirm and document the care deficiencies initially identified.
Compared to the current survey process, the revised methodology under
development is designed to more systematically target potential
problems at a home and give surveyors new tools to more adequately
document care outcomes and conduct onsite investigations. In April
2003, a CMS official told us that the agency lacked adequate funding to
complete testing and implementation of the revised methodology under
development for almost 5 years. Through September 2003, CMS will have
committed about $4.7 million to this effort. While CMS did not address
the lack of adequate funding in its comments on our draft report, a CMS
official subsequently told us that about $508,000 has now been slated
for additional field testing. This amount, however, has not yet been
approved. Not funding the additional field testing could jeopardize the
entire initiative, in which a substantial investment has already been
made.
* Developing clearer guidance for surveyors. Recognizing
inconsistencies in how the scope and severity of deficiencies are cited
across states, in October 2000, HCFA began developing more structured
guidance for surveyors, including survey investigative protocols for
assessing specific deficiencies. The intent of this initiative is to
enable surveyors to better (1) identify specific deficiencies, (2)
investigate whether a deficiency is the result of poor care, and (3)
document the level of harm resulting from a home's identified deficient
care practices. Delays have occurred, and the first such guidance to be
completed--pressure sores--has not yet been released.
* Developing additional state guidance for investigating complaints.
Despite initiation of a complaint improvement project in 1999, CMS has
not yet developed detailed guidance for states to help improve their
complaint investigation systems. CMS received its contractor's report
in June 2002, and indicated agreement with the report's conclusion that
reforming the complaint system is urgently needed to achieve a more
standardized, consistent, and effective process. CMS told us that it
plans to issue new guidance to the states in late fiscal year 2003--
about 4 years after the complaint improvement project initiative was
launched.
Conclusions:
As we reported in September 2000, continued federal and state attention
is required to ensure necessary improvements in the quality of care
provided to the nation's vulnerable nursing home residents. The
proportion of homes reported to have harmed residents is still
unacceptably high, despite the reported decline in the incidence of
such problems. This decline is consistent with the concerted
congressional, federal, and state attention focused on addressing
quality of care problems. Despite these efforts, however, CMS needs to
continue its efforts to better ensure consistent compliance with
federal quality requirements. Several areas that require CMS's ongoing
attention include: (1) developing more structured guidance for
surveyors to address inconsistencies in how the scope and severity of
deficiencies are cited across states, (2) finalizing and implementing
the survey methodology redesign intended to make the survey process
more systematic, (3) implementing a nationwide complaint tracking
system and providing states additional complaint investigation
guidance, and (4) refining the newly established state agency
performance standard reviews to ensure that states are held accountable
for ensuring that nursing homes comply with federal nursing home
quality standards. Some of these efforts have been underway for several
years, with CMS consistently extending their estimated completion and
implementation dates. The need to come to closure on these initiatives
is clear. The report on which this testimony is based contained several
new recommendations for needed CMS actions on these issues; CMS
generally concurred with our recommendations.[Footnote 10] We believe
that effective and timely implementation of planned improvements in
each of these areas is critical to ensuring better quality care for the
nation's 1.7 million vulnerable nursing home residents.
Mr. Chairman and Members of the Committee, this concludes my prepared
statement. I will be happy to answer any questions you may have.
Contact and Staff Acknowledgments:
For further information about this testimony, please contact Kathryn G.
Allen at (202) 512-7118 or Walter Ochinko at (202) 512-7157. Jack
Brennan, Patricia A. Jones, and Dean Mohs also made key contributions
to this statement.
[End of section]
Appendix I: Trends in The Proportion of Nursing Homes Cited for Actual
Harm or Immediate Jeopardy Deficiencies, 1999-2002:
Table 1:
State: Alabama; Number of homes surveyed: 1/97-6/98: 227;
Number of homes surveyed: 1/99-7/00: 225; Number of homes surveyed: 7/
00-1/02: 228; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 51.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 42.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -8.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -23.8.
State: Alaska; Number of homes surveyed: 1/97-6/98: 16; Number
of homes surveyed: 1/99-7/00: 15; Number of homes surveyed: 7/00-1/02:
15; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 37.5; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 20.0; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 33.3; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -17.5; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: 13.3.
State: Arizona; Number of homes surveyed: 1/97-6/98: 163;
Number of homes surveyed: 1/99-7/00: 142; Number of homes surveyed: 7/
00-1/02: 147; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 33.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 8.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 16.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -25.0.
State: Arkansas; Number of homes surveyed: 1/97-6/98: 285;
Number of homes surveyed: 1/99-7/00: 273; Number of homes surveyed: 7/
00-1/02: 267; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 14.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 27.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 23.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.4.
State: California; Number of homes surveyed: 1/97-6/98: 1,435;
Number of homes surveyed: 1/99-7/00: 1,400; Number of homes surveyed:
7/00-1/02: 1,348; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 9.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.9.
State: Colorado; Number of homes surveyed: 1/97-6/98: 234;
Number of homes surveyed: 1/99-7/00: 227; Number of homes surveyed: 7/
00-1/02: 225; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 15.4; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 10.8.
State: Connecticut; Number of homes surveyed: 1/97-6/98: 263;
Number of homes surveyed: 1/99-7/00: 262; Number of homes surveyed: 7/
00-1/02: 259; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 52.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 48.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 49.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.9.
State: Delaware; Number of homes surveyed: 1/97-6/98: 44;
Number of homes surveyed: 1/99-7/00: 42; Number of homes surveyed: 7/
00-1/02: 42; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 45.5; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 52.4; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 14.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -38.1.
State: District of Columbia; Number of homes surveyed: 1/97-6/
98: 24; Number of homes surveyed: 1/99-7/00: 20; Number of homes
surveyed: 7/00-1/02: 21; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 12.5; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 10.0; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 33.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 23.3.
State: Florida; Number of homes surveyed: 1/97-6/98: 730;
Number of homes surveyed: 1/99-7/00: 753; Number of homes surveyed: 7/
00-1/02: 742; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 36.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 20.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -15.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -0.8.
State: Georgia; Number of homes surveyed: 1/97-6/98: 371;
Number of homes surveyed: 1/99-7/00: 368; Number of homes surveyed: 7/
00-1/02: 370; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 22.6; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.
State: Hawaii; Number of homes surveyed: 1/97-6/98: 45; Number
of homes surveyed: 1/99-7/00: 47; Number of homes surveyed: 7/00-1/02:
46; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 24.4; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 25.5; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 15.2; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 1.1; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -10.3.
State: Idaho; Number of homes surveyed: 1/97-6/98: 86; Number
of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/00-1/02:
84; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 55.8; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 54.2; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 31.0; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -23.3.
State: Illinois; Number of homes surveyed: 1/97-6/98: 899;
Number of homes surveyed: 1/99-7/00: 900; Number of homes surveyed: 7/
00-1/02: 881; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 15.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -0.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.
State: Indiana; Number of homes surveyed: 1/97-6/98: 602;
Number of homes surveyed: 1/99-7/00: 590; Number of homes surveyed: 7/
00-1/02: 573; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 40.5; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 45.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 26.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -19.1.
State: Iowa; Number of homes surveyed: 1/97-6/98: 525; Number
of homes surveyed: 1/99-7/00: 492; Number of homes surveyed: 7/00-1/02:
494; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 39.2; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 19.3; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.9; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -19.9; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -9.4.
State: Kansas; Number of homes surveyed: 1/97-6/98: 445;
Number of homes surveyed: 1/99-7/00: 410; Number of homes surveyed: 7/
00-1/02: 400; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 47.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 29.0;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.1.
State: Kentucky; Number of homes surveyed: 1/97-6/98: 318;
Number of homes surveyed: 1/99-7/00: 312; Number of homes surveyed: 7/
00-1/02: 306; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 28.8; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -3.7.
State: Louisiana; Number of homes surveyed: 1/97-6/98: 433;
Number of homes surveyed: 1/99-7/00: 387; Number of homes surveyed: 7/
00-1/02: 367; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 12.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.5.
State: Maine; Number of homes surveyed: 1/97-6/98: 135; Number
of homes surveyed: 1/99-7/00: 126; Number of homes surveyed: 7/00-1/02:
124; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 7.4; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 10.3; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.7; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -0.6.
State: Maryland; Number of homes surveyed: 1/97-6/98: 258;
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 248; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 19.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 25.6; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 6.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.5.
State: Massachusetts; Number of homes surveyed: 1/97-6/98:
576; Number of homes surveyed: 1/99-7/00: 542; Number of homes
surveyed: 7/00-1/02: 512; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 24.0; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 33.0; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 22.9;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.2.
State: Michigan; Number of homes surveyed: 1/97-6/98: 451;
Number of homes surveyed: 1/99-7/00: 449; Number of homes surveyed: 7/
00-1/02: 441; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 43.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 42.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 24.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -17.4.
State: Minnesota; Number of homes surveyed: 1/97-6/98: 446;
Number of homes surveyed: 1/99-7/00: 439; Number of homes surveyed: 7/
00-1/02: 431; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.6; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.9.
State: Mississippi; Number of homes surveyed: 1/97-6/98: 218;
Number of homes surveyed: 1/99-7/00: 202; Number of homes surveyed: 7/
00-1/02: 219; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 24.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 33.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 19.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.5.
State: Missouri; Number of homes surveyed: 1/97-6/98: 595;
Number of homes surveyed: 1/99-7/00: 584; Number of homes surveyed: 7/
00-1/02: 569; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 21.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 22.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.1.
State: Montana; Number of homes surveyed: 1/97-6/98: 106;
Number of homes surveyed: 1/99-7/00: 104; Number of homes surveyed: 7/
00-1/02: 103; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 38.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.2;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -1.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -12.3.
State: Nebraska; Number of homes surveyed: 1/97-6/98: 263;
Number of homes surveyed: 1/99-7/00: 242; Number of homes surveyed: 7/
00-1/02: 243; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 32.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 18.9;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -6.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -7.1.
State: Nevada; Number of homes surveyed: 1/97-6/98: 49; Number
of homes surveyed: 1/99-7/00: 52; Number of homes surveyed: 7/00-1/02:
51; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 40.8; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 32.7; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 9.8; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: -8.1; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: -22.9.
State: New Hampshire; Number of homes surveyed: 1/97-6/98: 86;
Number of homes surveyed: 1/99-7/00: 83; Number of homes surveyed: 7/
00-1/02: 79; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 30.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 37.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 21.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 7.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.8.
State: New Jersey; Number of homes surveyed: 1/97-6/98: 377;
Number of homes surveyed: 1/99-7/00: 359; Number of homes surveyed: 7/
00-1/02: 366; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 13.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 24.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 11.5;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.1.
State: New Mexico; Number of homes surveyed: 1/97-6/98: 88;
Number of homes surveyed: 1/99-7/00: 82; Number of homes surveyed: 7/
00-1/02: 82; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.4; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 31.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 20.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -14.6.
State: New York; Number of homes surveyed: 1/97-6/98: 662;
Number of homes surveyed: 1/99-7/00: 668; Number of homes surveyed: 7/
00-1/02: 671; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 13.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 32.3;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 18.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 0.2.
State: North Carolina; Number of homes surveyed: 1/97-6/98:
407; Number of homes surveyed: 1/99-7/00: 414; Number of homes
surveyed: 7/00-1/02: 419; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 31.0; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 40.8; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 30.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 9.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.7.
State: North Dakota; Number of homes surveyed: 1/97-6/98: 88;
Number of homes surveyed: 1/99-7/00: 89; Number of homes surveyed: 7/
00-1/02: 88; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 55.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 21.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 28.4;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -34.4;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 7.1.
State: Ohio; Number of homes surveyed: 1/97-6/98: 1,043;
Number of homes surveyed: 1/99-7/00: 1,047; Number of homes surveyed:
7/00-1/02: 1,029; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 31.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 23.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -2.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -5.3.
State: Oklahoma; Number of homes surveyed: 1/97-6/98: 463;
Number of homes surveyed: 1/99-7/00: 432; Number of homes surveyed: 7/
00-1/02: 394; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 8.4; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 16.7; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 8.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 3.9.
State: Oregon; Number of homes surveyed: 1/97-6/98: 171;
Number of homes surveyed: 1/99-7/00: 158; Number of homes surveyed: 7/
00-1/02: 152; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 43.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 47.5; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 33.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -13.9.
State: Pennsylvania; Number of homes surveyed: 1/97-6/98: 811;
Number of homes surveyed: 1/99-7/00: 788; Number of homes surveyed: 7/
00-1/02: 764; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 29.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 32.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 2.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -20.6.
State: Rhode Island; Number of homes surveyed: 1/97-6/98: 102;
Number of homes surveyed: 1/99-7/00: 99; Number of homes surveyed: 7/
00-1/02: 99; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.8; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 12.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 10.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -2.0.
State: South Carolina; Number of homes surveyed: 1/97-6/98:
175; Number of homes surveyed: 1/99-7/00: 178; Number of homes
surveyed: 7/00-1/02: 180; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 28.6; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 28.7; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 0.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -10.9.
State: South Dakota; Number of homes surveyed: 1/97-6/98: 124;
Number of homes surveyed: 1/99-7/00: 112; Number of homes surveyed: 7/
00-1/02: 114; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 40.3; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 24.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 30.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -16.2;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 6.6.
State: Tennessee; Number of homes surveyed: 1/97-6/98: 361;
Number of homes surveyed: 1/99-7/00: 354; Number of homes surveyed: 7/
00-1/02: 377; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 11.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 16.7;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 14.9;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -9.3.
State: Texas; Number of homes surveyed: 1/97-6/98: 1,381;
Number of homes surveyed: 1/99-7/00: 1,336; Number of homes surveyed:
7/00-1/02: 1,275; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 22.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 26.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 25.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 4.7;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.5.
State: Utah; Number of homes surveyed: 1/97-6/98: 98; Number
of homes surveyed: 1/99-7/00: 95; Number of homes surveyed: 7/00-1/02:
95; Percentage of homes cited for actual harm or immediate
jeopardy: 1/97-6/98: 15.3; Percentage of homes cited for actual harm or
immediate jeopardy: 1/99-7/00: 15.8; Percentage of homes cited for
actual harm or immediate jeopardy: 7/00-1/02: 15.8; Percentage
point difference[A]: 1/97-6/98 and 1/99-7/00: 0.5; Percentage point
difference[A]: 1/99-7/00 and 7/00-1/02: 0.0.
State: Vermont; Number of homes surveyed: 1/97-6/98: 45;
Number of homes surveyed: 1/99-7/00: 46; Number of homes surveyed: 7/
00-1/02: 45; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 20.0; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 15.2; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 17.8;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: 2.6.
State: Virginia; Number of homes surveyed: 1/97-6/98: 279;
Number of homes surveyed: 1/99-7/00: 287; Number of homes surveyed: 7/
00-1/02: 285; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 24.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 19.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 11.6;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -4.8;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.3.
State: Washington; Number of homes surveyed: 1/97-6/98: 288;
Number of homes surveyed: 1/99-7/00: 279; Number of homes surveyed: 7/
00-1/02: 275; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 63.2; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 54.1; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 38.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -9.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -15.6.
State: West Virginia; Number of homes surveyed: 1/97-6/98:
130; Number of homes surveyed: 1/99-7/00: 147; Number of homes
surveyed: 7/00-1/02: 143; Percentage of homes cited for actual
harm or immediate jeopardy: 1/97-6/98: 12.3; Percentage of homes cited
for actual harm or immediate jeopardy: 1/99-7/00: 15.6; Percentage of
homes cited for actual harm or immediate jeopardy: 7/00-1/02: 14.0;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 3.3;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -1.7.
State: Wisconsin; Number of homes surveyed: 1/97-6/98: 438;
Number of homes surveyed: 1/99-7/00: 428; Number of homes surveyed: 7/
00-1/02: 421; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 17.1; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 14.0; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 7.1;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: -3.1;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -6.9.
State: Wyoming; Number of homes surveyed: 1/97-6/98: 38;
Number of homes surveyed: 1/99-7/00: 41; Number of homes surveyed: 7/
00-1/02: 40; Percentage of homes cited for actual harm or
immediate jeopardy: 1/97-6/98: 28.9; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 43.9; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 22.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 15.0;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -21.4.
State: Nation; Number of homes surveyed: 1/97-6/98: 17,897;
Number of homes surveyed: 1/99-7/00: 17,452; Number of homes surveyed:
7/00-1/02: 17,149; Percentage of homes cited for actual harm
or immediate jeopardy: 1/97-6/98: 27.7; Percentage of homes cited for
actual harm or immediate jeopardy: 1/99-7/00: 29.3; Percentage of homes
cited for actual harm or immediate jeopardy: 7/00-1/02: 20.5;
Percentage point difference[A]: 1/97-6/98 and 1/99-7/00: 1.6;
Percentage point difference[A]: 1/99-7/00 and 7/00-1/02: -8.8.
Source: GAO analysis of OSCAR data as of June 24, 2002.
[A] Differences are based on numbers before rounding.
[End of table]
[End of section]
Related GAO Products:
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. GAO-03-187. Washington, D.C.:
October 31, 2002.
Nursing Homes: Quality of Care More Related to Staffing than Spending.
GAO-02-431R. Washington, D.C.: June 13, 2002.
Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. GAO-02-279. Washington, D.C.:
February 15, 2002.
VA Long-Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.
Nursing Homes: Success of Quality Initiatives Requires Sustained
Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.:
September 28, 2000.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September
28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4,
1999.
Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies
to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.:
November 4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,
D.C.: August 13, 1999.
Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will
Require Continued Commitment. GAO/T-HEHS-99-155. Washington, D.C.:
June 30, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes in Maryland. GAO/T-
HEHS-99-146. Washington, D.C.: June 15, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.
Nursing Homes: Stronger Complaint and Enforcement Practices Needed to
Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.: March
22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18,
1999.
California Nursing Homes: Federal and State Oversight Inadequate to
Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS-98-
219. Washington, D.C.: July 28, 1998.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.
FOOTNOTES
[1] U.S. General Accounting Office, Nursing Home Quality: Prevalence of
Serious Problems, While Declining, Reinforces Importance of Enhanced
Oversight, GAO-03-561 (Washington, D.C.: July 15, 2003).
[2] Effective July 1, 2001, the name of the Health Care Financing
Administration (HCFA) was changed to the Centers for Medicare &
Medicaid Services. In this testimony we continue to refer to HCFA where
our findings apply to the organizational structure and operations
associated with that name.
[3] We analyzed OSCAR data for surveys performed from January 1, 1999,
through July 10, 2000, and from July 11, 2000, through January 31,
2002, and entered into OSCAR as of June 24, 2002. Immediate jeopardy
involves situations with actual or potential for death/serious injury.
[4] Contractor proposals are due to CMS on July 19, 2003.
[5] In prior work completed on veterans' care in nursing homes, we
recommended that the VA consider contracting with CMS to conduct these
comparative surveys in order to better assess the quality of state data
that are used in placing veterans in nursing homes. See U.S. General
Accounting Office, VA Long-Term Care: Oversight of Community Nursing
Homes Needs Strengthening, GAO-01-768 (Washington, D.C.: July 27,
2001). VA has not contracted with CMS to conduct comparative surveys
but is beginning to discuss the issue with CMS.
[6] Officials explained the focus on actual harm or higher-level
deficiencies by noting that the potential for sanctions increased the
likelihood that the deficiencies would be challenged by the nursing
home and perhaps appealed in an administrative hearing.
[7] In March 1999, we reported that inadequate state complaint intake
and investigation practices in states we reviewed had too often
resulted in extensive delays in investigating serious complaints. As a
result of our findings, HCFA began requiring states to investigate
complaints that allege actual harm, but do not rise to the level of
immediate jeopardy, within 10 working days. U.S. General Accounting
Office, Nursing Homes: Complaint Investigation Processes Often
Inadequate to Protect Residents, GAO/HEHS-99-80 (Washington, D.C.: Mar.
22, 1999).
[8] See GAO/HEHS-99-46.
[9] This policy was implemented in two stages, and our analysis focused
on implementation of the second stage beginning in January 2000. As of
September 1998, HCFA required states to refer homes that had a pattern
of harming a significant number of residents or placed residents at
high risk of death or serious injury. Effective January 14, 2000, HCFA
expanded this policy by requiring state survey agencies to refer for
immediate sanction homes that had harmed residents on successive
surveys. States are now required to deny a grace period to correct
deficiencies without sanction to homes that are assessed one or more
deficiencies at the actual harm level or above in each of two surveys
within a survey cycle. A survey cycle is two successive standard
surveys and any intervening survey, such as a complaint investigation.
[10] GAO-03-561.
