Nursing Home Reform
Continued Attention Is Needed to Improve Quality of Care in Small but Significant Share of Homes Gao ID: GAO-07-794T May 2, 2007With 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.
GAO-07-794T, Nursing Home Reform: Continued Attention Is Needed to Improve Quality of Care in Small but Significant Share of Homes
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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:
GAO Highlights:
Highlights of GAO-07-794T, a testimony before the Special Committee on
Aging, U.S. Senate
Why GAO Did This Study:
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.
What GAO Found:
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.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-794T].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at (202)
512-7118 or allenk@gao.gov.
[End of section]
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.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 4] To encourage compliance with these
requirements, Congress has authorized certain enforcement actions.
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.[Footnote 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.[Footnote 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.
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.[Footnote
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.[Footnote 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.
The life safety component of a survey focuses on a home's compliance
with federal fire safety requirements for health care
facilities.[Footnote 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.
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Severity: Immediate jeopardy[A];
Scope: Isolated: J;
Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm;
Scope: Isolated: G;
Scope: Pattern: H;
Scope: Widespread: I.
Severity: Potential for more than minimal harm;
Scope: Isolated: D;
Scope: Pattern: E;
Scope: Widespread: F.
Severity: Potential for minimal harm[B];
Scope: Isolated: A;
Scope: Pattern: B;
Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in "substantial compliance."
[End of table]
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.[Footnote 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.[Footnote 11]
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.[Footnote 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.[Footnote 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.
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:
[See PDF for image]
Source: GAO analysis of OSCAR data.
[End of figure]
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.[Footnote 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.[Footnote 15]
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious
Deficiencies Not Identified in State Surveys:
[See PDF for image]
Source: GAO analysis of OSCAR data.
[End of figure]
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.[Footnote 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.[Footnote 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.
Figure 3: Federal Comparative Surveys in Five States That Identified
Serious Deficiencies Missed by State Surveys, March 2002-March 2007:
[See PDF for image]
Source: GAO analysis of federal comparative surveys for five years.
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.
[A] On 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.
[B] On 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.
[End of figure]
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.[Footnote 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.[Footnote
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.[Footnote 20]
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.[Footnote 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.
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."[Footnote 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.[Footnote 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.
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.[Footnote 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.
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.[Footnote
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.[Footnote 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.[Footnote 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.[Footnote 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.
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,[Footnote 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.[Footnote 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.[Footnote 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.
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.[Footnote 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.[Footnote 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.
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 allenk@gao.gov. 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.
[End of section]
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:
Surveys.
GAO report number: GAO/HEHS-98-202;
GAO recommendation: 1. Stagger or otherwise vary the scheduling of
standard surveys to effectively reduce the predictability of surveyors'
visits. The variation could include segmenting the standard survey into
more than one review throughout the 12-to 15-month period, which would
provide more opportunities for surveyors to observe problematic homes
and initiate broader reviews when warranted;
CMS initiative: CMS took several steps to reduce survey predictability,
but some state surveys remain predictable;
* In 1999, CMS instructed state survey agencies to (1) conduct 10
percent of surveys on evenings and weekends, (2) vary the sequencing of
surveys in a geographical area to avoid alerting other homes that the
surveyors are in the area, (3) vary the scheduling of surveys by day of
the week, and (4) avoid scheduling surveys for the same month as a
home's prior survey;
* 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;
* 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;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation: 2. Revise federal survey procedures to instruct
surveyors to take stratified random samples of resident cases and
review sufficient numbers and types of resident cases so that surveyors
can better detect problems and assess their prevalence;
CMS initiative: CMS has been developing a revised survey methodology
since 1998. A pilot test of the new methodology began in the fall of
2005.
Implementation could begin in mid-2007; Implementation status: Taking
steps to implement our recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 3. Finalize the development, testing, and
implementation of a more rigorous survey methodology, including
investigative protocols that provide guidance to surveyors in
documenting deficiencies at the appropriate scope and severity level;
CMS initiative: See CMS action in response to recommendation to revise
federal survey procedures (recommendation #2 above); CMS began revising
surveyors' investigative protocols in October 2000. Eight protocols
have been 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;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 4. Require states to have a quality assurance
process that includes, at a minimum, a review of a sample of survey
reports below the 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;
CMS initiative: CMS has no plans to implement this recommendation,
indicating that regular workload and priorities take precedence over
it;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-05-78; GAO recommendation: 5. Hold homes
accountable for all past noncompliance resulting in harm to residents,
not just care problems deemed to be egregious, and develop an approach
for citing such past noncompliance in a manner that clearly identifies
the specific nature of the care problem both in the OSCAR database and
on CMS's Nursing Home Compare Web site; CMS initiative: CMS revised its
definition of past noncompliance. While CMS has not ruled out placing
enforcement information on its Nursing Home Compare Web site in the
future, CMS officials told us that resource constraints limit the
agency's ability to do so at the current time; Implementation status:
Taking steps to implement our recommendation.
Complaints.
GAO report number: GAO/HEHS-99-80;
GAO recommendation: 6. Develop additional standards for the prompt
investigation of serious complaints alleging situations that may harm
residents but are categorized as less than immediate jeopardy. These
standards should include maximum allowable time frames for
investigating serious complaints and for complaints that may be
deferred until the next scheduled annual survey. States may continue to
set priority levels and time frames that are more stringent than these
federal standards;
CMS initiative: In October 1999, CMS issued a policy letter stating
that complaints alleging harm must be investigated within 10 days; In
January 2004, CMS provided detailed direction and guidance to states
for managing complaint investigations for numerous types of providers,
including nursing homes; In June 2004, CMS made available updated
guidance on the Internet that consolidates complaint investigation
procedures for numerous types of providers;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 7. Strengthen federal oversight of state complaint
investigations, including monitoring states' practices regarding
priority-setting, on-site investigation, and timely reporting of
serious health and safety complaints;
CMS initiative: In 2000, CMS began requiring its regional offices to
perform yearly assessments of states' complaint investigations as part
of annual state performance reviews;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 8. Finalize the development of guidance to states
for their complaint investigation processes and ensure that it
addresses key weaknesses, including the prioritization of complaints
for investigation, particularly those alleging harm to residents; the
handling of facility self-reported incidents; and the use of
appropriate complaint investigation practices;
CMS initiative: In January 2004, CMS provided detailed direction and
guidance to states for managing complaint investigations for numerous
types of providers, including nursing homes; In June 2004, CMS made
available updated guidance on the Internet that consolidates complaint
investigation procedures for numerous types of providers;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO-02-312;
GAO recommendation: 9. Ensure that state survey agencies immediately
notify local law enforcement agencies or Medicaid Fraud Control Units
when nursing homes report allegations of resident physical or sexual
abuse or when the survey agency has confirmed complaints of alleged
abuse;
CMS initiative: In 2002, CMS issued a memorandum to the regional
offices and state survey agencies emphasizing its policy for preventing
abuse in nursing homes and for promptly reporting it to the appropriate
agencies when it occurs; 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;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation: 10. Accelerate the agency's education campaign on
reporting nursing home abuse by (1) distributing its new poster with
clearly displayed complaint telephone numbers and (2) requiring state
survey agencies to ensure that these numbers are prominently listed in
local telephone directories;
CMS initiative: In 2002, CMS released a memorandum to regional offices
and state agencies that addresses displaying complaint telephone
numbers. CMS asked all state agencies to review how their telephone
number is listed in the local directory and asked them to ensure that
their complaint telephone numbers are prominently listed; In 2007, CMS
officials told us that it has not and is not likely to release the
poster;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation: 11. Systematically assess state policies and
practices for complying with the federal requirement to prohibit
employment of individuals convicted of abusing nursing home residents
and, if necessary, develop more specific guidance to ensure compliance;
CMS initiative: CMS is conducting a Background Check Pilot Program in
several states, as required by the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003. The pilot is expected to
run through September 2007 and will be followed by an independent
evaluation. The final study is targeted for submission by spring of
2008;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 12. Clarify the definition of abuse and otherwise
ensure that states apply that definition consistently and
appropriately;
CMS initiative: In 2002, CMS released a memorandum to its regional
offices and state survey agency directors 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];
Implementation status: Fully implemented our recommendation.
GAO recommendation: 13. Shorten the state survey agencies' time frames
for determining whether to include findings of abuse in nurse aide
registry files;
CMS initiative: CMS informed GAO that federal regulations specify that
if an investigation finds an individual has neglected or abused 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;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
Enforcement.
GAO report number: GAO/HEHS-98-202;
GAO recommendation: 14. Require that for problem homes with recurring
serious violations, state surveyors substantiate, by means of an on-
site revisit, every report to CMS of a home's resumed compliance
status;
CMS initiative: In 1998, CMS issued guidance to regional offices and
state survey agencies strengthening its revisit policy by requiring on-
site revisits until all serious deficiencies are corrected. Homes are
no longer permitted to self-report resumed compliance;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 15. Eliminate the grace period for homes cited for
repeated serious violations and impose sanctions promptly, as permitted
under existing regulations;
CMS initiative: CMS phased in implementation of its double G policy
from September 1998 through January 2000;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO/HEHS-99-46;
GAO recommendation: 16. Improve the effectiveness of civil monetary
penalties: The Administrator should continue to take those steps
necessary to shorten the delay in adjudicating appeals, including
monitoring progress made in reducing the backlog of appeals;
CMS initiative: As requested by HHS, Congress approved increased
funding and staffing levels for the Departmental Appeals Board in
fiscal years 1999 and 2000;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 17. Strengthen the use and effect of termination:
* Continue Medicare and Medicaid payments beyond the termination date
only if the home and state Medicaid agency are making reasonable
efforts to transfer residents to other homes or alternative modes of
care;
CMS initiative: CMS conducted a study and concluded that it was not
practical to establish rules to address this problem;
* Ensure that reasonable assurance periods associated with reinstating
terminated homes are of sufficient duration to effectively demonstrate
that the reason for termination has been resolved and will not recur;
CMS initiative: CMS added examples to the reasonable assurance guidance
in 2000, but declined to lengthen the reasonable assurance period;
* Strengthen the use and effect of termination: Revise existing
policies so that the pretermination history of a home is considered in
taking a subsequent enforcement action;
CMS initiative: In 2000, CMS revised its guidance so that
pretermination history of a home is considered in taking subsequent
enforcement actions;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation: 18. Improve the referral process: The Administrator
should revise CMS guidance so that states refer homes to CMS for
possible sanction (such as civil monetary penalties) if they have been
cited for a deficiency that contributed to a resident's death;
CMS initiative: In 2000, CMS revised its guidance to require states to
refer homes for possible sanction if they had been cited for a
deficiency that contributed to a resident's death;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO-07-241;
GAO recommendation: 19. Reassess and revise the immediate sanctions
policy to ensure that it accomplishes the following:
* Reduce the lag time between citation of a double G and the
implementation of a sanction;
* Prevent nursing homes that repeatedly harm residents or place them in
immediate jeopardy from escaping sanctions;
* Hold states accountable for reporting in federal data systems serious
deficiencies identified during complaint investigations so that all
complaint findings are considered in determining when immediate
sanctions are warranted;
CMS initiative: CMS acknowledged that the complexity of its immediate
sanctions 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;
CMS agreed to reduce the lag time between citation and implementation
of a double G immediate sanction by limiting the prospective effective
date for DPNAs to no more than 30 to 60 days;
CMS indicated it will remove the limitation in the double G policy on
applying an additional sanction simply because a nursing home has not
completed corrections to a deficiency that gave rise to a previous
sanction;
CMS agreed to collect additional information on complaints for which
data are not reported in federal data systems;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 20. Strengthen the deterrent effect of available
sanctions and ensure that sanctions are used to their fullest
potential:
* Ensure the consistency of CMPs by issuing guidance, such as the
standardized CMP grid piloted during 2006;
* Increase use of discretionary DPNAs to help ensure the speedier
implementation of appropriate sanctions;
* Strengthen the criteria for terminating homes with a history of
serious, repeated noncompliance by limiting the extension of
termination dates, increasing the use of discretionary terminations,
and exploring alternative thresholds for termination, such as the
cumulative duration of noncompliance;
CMS initiative: CMS agreed to issue a CMP analytic tool, or grid, and
to provide states with further guidance on discretionary DPNAs and
terminations;
CMS indicated it will issue further guidance for states on factors to
be considered in determining whether a discretionary DPNA is imposed or
a termination date is set earlier than the time periods required by
law.
CMS stated it will work with states, consumer organizations,
stakeholders, and others to design proposals for a better combination
of enforcement actions for homes with repeated quality-of-care
deficiencies;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 21. Develop an administrative process under which
CMPs would be paid--or Medicare and Medicaid payments in equivalent
amounts would be withheld--prior to exhaustion of appeals and seek
legislation for the implementation of this process, as appropriate;
CMS initiative: CMS agreed to seek legislative authority to collect
CMPs prior to the exhaustion of appeals;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 22. Further expand the Special Focus Facility
program with enhanced enforcement requirements to include all homes
that meet a threshold to qualify as poorly performing homes;
CMS initiative: CMS agreed with the concept of expanding the Special
Focus Facility program to include all homes that meet a threshold
qualifying them as poorly performing homes, but said it lacks the
resources needed for this expansion. CMS also identified other
initiatives it will implement to improve the program;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 23. Improve the effectiveness of the new
enforcement data system:
* Develop the enforcement-related data systems' abilities to interface
with each other in order to improve the tracking and monitoring of
enforcement;
* Expedite the development of national enforcement reports and a
concrete plan for using the reports;
* Develop and institute a system of quality checks to ensure the
accuracy and integrity of AEM data;
CMS initiative: CMS agreed to study the feasibility of linking the
separate data systems used for enforcement; however, it indicated that
available resources may limit further action;
CMS agreed to study the feasibility of developing national standard
enforcement reports, but stated that further action on these reports
may be limited by resource availability;
CMS agreed to develop and implement a system of quality checks to
ensure the accuracy of its data systems, including AEM;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 24. Expand CMS's Nursing Home Compare Web site to
include implemented sanctions and homes subjected to immediate
sanctions;
CMS initiative: CMS proposed reporting implemented sanctions only for
poorly performing homes that meet an undefined threshold--this is not
fully responsive to our recommendation;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
Oversight.
GAO report number: GAO/HEHS-99-46;
GAO recommendation: 25. Develop better management information systems.
The Administrator should enhance OSCAR or develop some other
information system that can be used by both by the states and CMS to
integrate the results of complaint investigations, track the status and
history of deficiencies, and monitor enforcement actions;
CMS initiative: CMS has implemented new national enforcement and
complaint tracking systems but has delayed its replacement of the OSCAR
data system until 2009 as a result of funding cuts and CMS focus on
other initiatives;
Implementation status: Taking steps to implement our recommendation.
GAO report number: GAO/HEHS-99-80;
GAO recommendation: 26. Require that the substantiated results of
complaint investigations be included in federal data systems or be
accessible by federal officials;
CMS initiative: In January 2004, CMS's new ASPEN Complaint Tracking
system was implemented nationwide;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO/HEHS-00-6;
GAO recommendation: 27. Improve the scope and rigor of CMS's oversight
process:
* Increase the proportion of federal monitoring surveys conducted as
comparative surveys to ensure that a sufficient number are completed in
each state to assess whether the state appropriately identifies serious
deficiencies;
* Ensure that comparative surveys are initiated closer to the time the
state agency completes the home's annual standard survey;
* Require regions to provide more timely written feedback to the states
after the completion of federal monitoring surveys;
* Improve the data system for observational surveys so that it is an
effective management tool for CMS to properly assess the findings of
observational surveys;
CMS has significantly increased the number of quality-of-care
comparative surveys. In fiscal year 2006, however, the agency will no
longer contract for additional quality-of- care comparative surveys
because of funding constraints;
To better ensure that conditions in a nursing home have not changed
since the state survey, CMS regional offices reduced the average time
between the state survey and the initiation of a federal comparative
survey from 33 days in 1999 to 26 days by 2004;
CMS instructed the regions to report the results of federal monitoring
surveys to states on a monthly basis;
CMS developed a separate database accessible to all regional offices
that includes the results of observational surveys. Beginning in fiscal
year 2002, CMS added data on the results of comparative surveys;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 28. Improve the consistency in how CMS holds state
survey agencies accountable by standardizing procedures for selecting
state surveys and conducting federal monitoring surveys:
* Ensure that the regions target surveys for review that will provide a
comprehensive assessment of state surveyor performance;
* Require federal surveyors to include as many of the same residents as
possible in their comparative survey sample as the state included in
its sample (where CMS surveyors have determined that the state sample
selection process was appropriate);
CMS initiative: CMS did not implement our recommendation to select
individual state surveys for federal review in a manner that ensures
its regional offices observe as many state surveyors as possible;
In October 2002, CMS instructed federal surveyors to select at least
half of those residents selected by the state surveyors for their
resident sample;
Implementation status: GAO report number: Implemented only part of our
recommendation and no further steps are planned.
GAO recommendation: 29. Further explore the feasibility of appropriate
alternative remedies or sanctions for those states that prove unable or
unwilling to meet CMS's performance standards;
CMS initiative: In December 1999, CMS adopted new state sanctions. In
fiscal year 2005, CMS began to tie survey agency funding increases to
the timely conduct of standard surveys, a step that we believe offers a
strong incentive for improved compliance;
Implementation status: Fully implemented our recommendation.
GAO report number: GAO/HEHS-02-279;
GAO recommendation: 30. Review the adequacy of current state efforts to
ensure the accuracy of minimum data set (MDS) data, and provide, where
necessary, additional guidance, training, and technical assistance;
CMS initiative: CMS disagreed with and did not implement this
recommendation;
Implementation status: Did not implement our recommendation.
GAO recommendation: 31. Monitor the adequacy of state MDS accuracy
activities on an ongoing basis, such as through the use of the
established federal comparative survey process;
CMS initiative: CMS disagreed with and did not implement this
recommendation;
Implementation status: GAO report number: Did not implement our
recommendation.
GAO recommendation: 32. Provide guidance to state agencies and nursing
homes that sufficient evidentiary documentation to support the full MDS
assessment be included in residents' medical records;
CMS initiative: CMS disagreed with and did not implement this
recommendation;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-03-187;
GAO recommendation: 33. Delay the implementation of nationwide
reporting of quality 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;
CMS initiative: CMS disagreed with and did not implement this
recommendation;
Implementation status: Did not implement our recommendation.
GAO recommendation: 34. Delay the implementation of nationwide
reporting of quality 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;
CMS initiative: CMS disagreed with and did not implement this
recommendation;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 35. Further refine annual state performance reviews
so that they (1) consistently distinguish between systemic problems and
less serious issues regarding state performance, (2) analyze trends 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;
CMS initiative: CMS did not implement this recommendation because it
believes that the state performance standards take into account
statutory and nonstatutory performance standards;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-04-660;
GAO recommendation: 36. Ensure that CMS regional offices fully comply
with the statutory requirement to conduct annual federal monitoring
surveys by including an assessment of the fire safety component of
states' standard surveys, with an emphasis on unsprinklered homes;
CMS initiative: CMS's evaluation of state surveyors' performance now
routinely includes fire safety as part of the statutory requirement to
annually conduct federal monitoring surveys in at least 5 percent of
surveyed nursing homes in each state;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 37. Ensure that data on sprinkler coverage in
nursing homes are consistently obtained and reflected in the CMS
database;
CMS initiative: CMS now obtains the sprinkler status of over 99 percent
of nursing homes during routine surveys and inputs this information
into OSCAR;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 38. Until sprinkler coverage data are routinely
available in CMS's database, work with state survey agencies to
identify the extent to which each nursing home is sprinklered or not
sprinklered;
CMS initiative: See CMS action in response to recommendation for
ensuring that data on sprinkler coverage in nursing homes are
consistently obtained (recommendation #37 above);
Implementation status: Fully implemented our recommendation.
GAO recommendation: 39. On an expedited basis, review all waivers and
Fire Safety Evaluation System (FSES) assessments for homes that are not
fully sprinklered to determine their appropriateness.[B];
CMS initiative: CMS has completed reviews of all waiver requests and
FSES assessments and noted that the number of homes using FSES dropped
significantly as a result of the review;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 40. Make information on fire safety deficiencies
available to the public via the Nursing Home Compare Web site,
including information on whether a home has automatic sprinklers;
CMS initiative: This information was made available on the Nursing Home
Compare Web site as of October 2006;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 41. Work with the National Fire Protection
Association to strengthen fire safety standards for unsprinklered
nursing homes, such as requiring smoke detectors in resident rooms,
exploring the feasibility of requiring sprinklers in all nursing homes,
and developing a strategy for financing such requirements;
CMS initiative: CMS issued regulations effective May 24, 2005,
requiring nursing facilities to install smoke detectors in resident
rooms and public areas if they do not have a sprinkler system installed
throughout the facility or a hard-wired smoke detection system in those
areas. Facilities were given 1 year, until 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;
Implementation status: Fully implemented our recommendation.
GAO recommendation: 42. Ensure that thorough investigations are
conducted following multiple-death nursing home fires so that fire
safety standards can be reevaluated and modified where appropriate;
CMS initiative: CMS developed and issued a standardized procedure to
ensure that both state survey agencies and its own staff take
appropriate action to investigate fires that result in serious injury
or death;
Implementation status: Fully implemented our recommendation.
Source: GAO analysis of CMS's responses to our recommendations.
[A] In 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.
[B] As 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.
[End of table]
[End of section]
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:
State: Alabama;
Number of homes 2006: 231;
Fiscal year: 2000: 35.5;
Fiscal year: 2001: 23.0;
Fiscal year: 2002: 12.7;
Fiscal year: 2003: 18.1;
Fiscal year: 2004: 15.6;
Fiscal year: 2005: 23.1;
Fiscal year: 2006: 24.2.
State: Alaska;
Number of homes 2006: 15;
Fiscal year: 2000: 28.6;
Fiscal year: 2001: 26.7;
Fiscal year: 2002: 26.7;
Fiscal year: 2003: 0.0;
Fiscal year: 2004: 0.0;
Fiscal year: 2005: 0.0;
Fiscal year: 2006: 26.7.
State: Arizona;
Number of homes 2006: 135;
Fiscal year: 2000: 24.2;
Fiscal year: 2001: 12.6;
Fiscal year: 2002: 7.3;
Fiscal year: 2003: 6.6;
Fiscal year: 2004: 9.4;
Fiscal year: 2005: 9.9;
Fiscal year: 2006: 24.8.
State: Arkansas;
Number of homes 2006: 245;
Fiscal year: 2000: 38.1;
Fiscal year: 2001: 27.7;
Fiscal year: 2002: 22.3;
Fiscal year: 2003: 24.7;
Fiscal year: 2004: 19.5;
Fiscal year: 2005: 15.9;
Fiscal year: 2006: 14.5.
State: California;
Number of homes 2006: 1,304;
Fiscal year: 2000: 24.1;
Fiscal year: 2001: 10.9;
Fiscal year: 2002: 5.1;
Fiscal year: 2003: 3.7;
Fiscal year: 2004: 6.1;
Fiscal year: 2005: 8.0;
Fiscal year: 2006: 14.1.
State: Colorado;
Number of homes 2006: 215;
Fiscal year: 2000: 20.4;
Fiscal year: 2001: 26.4;
Fiscal year: 2002: 32.7;
Fiscal year: 2003: 20.9;
Fiscal year: 2004: 25.9;
Fiscal year: 2005: 40.4;
Fiscal year: 2006: 44.8.
State: Connecticut;
Number of homes 2006: 245;
Fiscal year: 2000: 41.9;
Fiscal year: 2001: 51.6;
Fiscal year: 2002: 45.8;
Fiscal year: 2003: 43.1;
Fiscal year: 2004: 54.4;
Fiscal year: 2005: 44.2;
Fiscal year: 2006: 50.8.
State: Delaware;
Number of homes 2006: 44;
Fiscal year: 2000: 47.5;
Fiscal year: 2001: 14.6;
Fiscal year: 2002: 10.8;
Fiscal year: 2003: 5.3;
Fiscal year: 2004: 15.0;
Fiscal year: 2005: 35.7;
Fiscal year: 2006: 36.8.
State: District of Columbia;
Number of homes 2006: 20;
Fiscal year: 2000: 17.7;
Fiscal year: 2001: 28.6;
Fiscal year: 2002: 30.0;
Fiscal year: 2003: 41.2;
Fiscal year: 2004: 40.0;
Fiscal year: 2005: 30.0;
Fiscal year: 2006: 25.0.
State: Florida;
Number of homes 2006: 688;
Fiscal year: 2000: 22.8;
Fiscal year: 2001: 20.2;
Fiscal year: 2002: 14.9;
Fiscal year: 2003: 10.2;
Fiscal year: 2004: 7.8;
Fiscal year: 2005: 4.2;
Fiscal year: 2006: 9.1.
State: Georgia;
Number of homes 2006: 371;
Fiscal year: 2000: 19.5;
Fiscal year: 2001: 21.0;
Fiscal year: 2002: 23.7;
Fiscal year: 2003: 24.6;
Fiscal year: 2004: 16.6;
Fiscal year: 2005: 18.0;
Fiscal year: 2006: 15.9.
State: Hawaii;
Number of homes 2006: 48;
Fiscal year: 2000: 23.8;
Fiscal year: 2001: 14.3;
Fiscal year: 2002: 21.2;
Fiscal year: 2003: 12.1;
Fiscal year: 2004: 22.9;
Fiscal year: 2005: 2.8;
Fiscal year: 2006: 2.1.
State: Idaho;
Number of homes 2006: 80;
Fiscal year: 2000: 51.4;
Fiscal year: 2001: 29.7;
Fiscal year: 2002: 39.2;
Fiscal year: 2003: 31.9;
Fiscal year: 2004: 27.3;
Fiscal year: 2005: 38.4;
Fiscal year: 2006: 47.8.
State: Illinois;
Number of homes 2006: 816;
Fiscal year: 2000: 28.4;
Fiscal year: 2001: 19.2;
Fiscal year: 2002: 15.3;
Fiscal year: 2003: 18.3;
Fiscal year: 2004: 15.1;
Fiscal year: 2005: 15.7;
Fiscal year: 2006: 21.7.
State: Indiana;
Number of homes 2006: 526;
Fiscal year: 2000: 45.0;
Fiscal year: 2001: 29.4;
Fiscal year: 2002: 23.2;
Fiscal year: 2003: 19.7;
Fiscal year: 2004: 24.1;
Fiscal year: 2005: 28.3;
Fiscal year: 2006: 33.4.
State: Iowa;
Number of homes 2006: 466;
Fiscal year: 2000: 14.7;
Fiscal year: 2001: 12.0;
Fiscal year: 2002: 8.0;
Fiscal year: 2003: 9.1;
Fiscal year: 2004: 11.8;
Fiscal year: 2005: 11.2;
Fiscal year: 2006: 11.7.
State: Kansas;
Number of homes 2006: 361;
Fiscal year: 2000: 37.9;
Fiscal year: 2001: 30.7;
Fiscal year: 2002: 32.9;
Fiscal year: 2003: 26.5;
Fiscal year: 2004: 30.3;
Fiscal year: 2005: 34.9;
Fiscal year: 2006: 38.3.
State: Kentucky;
Number of homes 2006: 298;
Fiscal year: 2000: 26.8;
Fiscal year: 2001: 29.1;
Fiscal year: 2002: 23.2;
Fiscal year: 2003: 26.1;
Fiscal year: 2004: 14.6;
Fiscal year: 2005: 7.7;
Fiscal year: 2006: 11.4.
State: Louisiana;
Number of homes 2006: 307;
Fiscal year: 2000: 21.8;
Fiscal year: 2001: 29.9;
Fiscal year: 2002: 21.7;
Fiscal year: 2003: 16.2;
Fiscal year: 2004: 12.0;
Fiscal year: 2005: 15.4;
Fiscal year: 2006: 15.8.
State: Maine;
Number of homes 2006: 114;
Fiscal year: 2000: 11.1;
Fiscal year: 2001: 13.9;
Fiscal year: 2002: 6.6;
Fiscal year: 2003: 11.1;
Fiscal year: 2004: 12.8;
Fiscal year: 2005: 7.0;
Fiscal year: 2006: 9.8.
State: Maryland;
Number of homes 2006: 235;
Fiscal year: 2000: 22.4;
Fiscal year: 2001: 16.5;
Fiscal year: 2002: 26.1;
Fiscal year: 2003: 15.4;
Fiscal year: 2004: 17.8;
Fiscal year: 2005: 7.6;
Fiscal year: 2006: 7.6.
State: Massachusetts;
Number of homes 2006: 456;
Fiscal year: 2000: 29.1;
Fiscal year: 2001: 24.4;
Fiscal year: 2002: 24.6;
Fiscal year: 2003: 25.9;
Fiscal year: 2004: 16.7;
Fiscal year: 2005: 22.6;
Fiscal year: 2006: 20.9.
State: Michigan;
Number of homes 2006: 429;
Fiscal year: 2000: 42.8;
Fiscal year: 2001: 24.5;
Fiscal year: 2002: 29.7;
Fiscal year: 2003: 26.9;
Fiscal year: 2004: 22.9;
Fiscal year: 2005: 22.9;
Fiscal year: 2006: 29.7.
State: Minnesota;
Number of homes 2006: 404;
Fiscal year: 2000: 30.4;
Fiscal year: 2001: 17.3;
Fiscal year: 2002: 22.3;
Fiscal year: 2003: 18.3;
Fiscal year: 2004: 14.3;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 18.8.
State: Mississippi;
Number of homes 2006: 207;
Fiscal year: 2000: 33.0;
Fiscal year: 2001: 19.8;
Fiscal year: 2002: 18.7;
Fiscal year: 2003: 16.0;
Fiscal year: 2004: 18.9;
Fiscal year: 2005: 18.1;
Fiscal year: 2006: 9.4.
State: Missouri;
Number of homes 2006: 526;
Fiscal year: 2000: 19.8;
Fiscal year: 2001: 13.0;
Fiscal year: 2002: 15.6;
Fiscal year: 2003: 12.5;
Fiscal year: 2004: 11.7;
Fiscal year: 2005: 15.4;
Fiscal year: 2006: 15.6.
State: Montana;
Number of homes 2006: 97;
Fiscal year: 2000: 33.3;
Fiscal year: 2001: 29.7;
Fiscal year: 2002: 12.0;
Fiscal year: 2003: 20.0;
Fiscal year: 2004: 18.0;
Fiscal year: 2005: 17.9;
Fiscal year: 2006: 16.7.
State: Nebraska;
Number of homes 2006: 229;
Fiscal year: 2000: 19.2;
Fiscal year: 2001: 21.1;
Fiscal year: 2002: 20.1;
Fiscal year: 2003: 14.8;
Fiscal year: 2004: 15.3;
Fiscal year: 2005: 14.4;
Fiscal year: 2006: 25.7.
State: Nevada;
Number of homes 2006: 47;
Fiscal year: 2000: 34.8;
Fiscal year: 2001: 14.6;
Fiscal year: 2002: 11.9;
Fiscal year: 2003: 9.1;
Fiscal year: 2004: 17.5;
Fiscal year: 2005: 19.6;
Fiscal year: 2006: 21.3.
State: New Hampshire;
Number of homes 2006: 83;
Fiscal year: 2000: 37.8;
Fiscal year: 2001: 31.1;
Fiscal year: 2002: 29.4;
Fiscal year: 2003: 24.1;
Fiscal year: 2004: 25.6;
Fiscal year: 2005: 26.3;
Fiscal year: 2006: 22.9.
State: New Jersey;
Number of homes 2006: 363;
Fiscal year: 2000: 25.5;
Fiscal year: 2001: 27.8;
Fiscal year: 2002: 18.8;
Fiscal year: 2003: 10.5;
Fiscal year: 2004: 13.5;
Fiscal year: 2005: 18.2;
Fiscal year: 2006: 15.5.
State: New Mexico;
Number of homes 2006: 75;
Fiscal year: 2000: 23.7;
Fiscal year: 2001: 16.9;
Fiscal year: 2002: 14.9;
Fiscal year: 2003: 21.3;
Fiscal year: 2004: 24.3;
Fiscal year: 2005: 29.4;
Fiscal year: 2006: 25.0.
State: New York;
Number of homes 2006: 658;
Fiscal year: 2000: 33.8;
Fiscal year: 2001: 37.1;
Fiscal year: 2002: 34.2;
Fiscal year: 2003: 15.2;
Fiscal year: 2004: 11.0;
Fiscal year: 2005: 14.0;
Fiscal year: 2006: 18.5.
State: North Carolina;
Number of homes 2006: 424;
Fiscal year: 2000: 43.6;
Fiscal year: 2001: 35.8;
Fiscal year: 2002: 25.6;
Fiscal year: 2003: 29.0;
Fiscal year: 2004: 21.1;
Fiscal year: 2005: 18.5;
Fiscal year: 2006: 17.2.
State: North Dakota;
Number of homes 2006: 83;
Fiscal year: 2000: 25.9;
Fiscal year: 2001: 28.7;
Fiscal year: 2002: 17.9;
Fiscal year: 2003: 12.4;
Fiscal year: 2004: 13.6;
Fiscal year: 2005: 17.7;
Fiscal year: 2006: 21.7.
State: Ohio;
Number of homes 2006: 980;
Fiscal year: 2000: 26.6;
Fiscal year: 2001: 27.3;
Fiscal year: 2002: 25.4;
Fiscal year: 2003: 19.1;
Fiscal year: 2004: 11.4;
Fiscal year: 2005: 13.8;
Fiscal year: 2006: 14.6.
State: Oklahoma;
Number of homes 2006: 359;
Fiscal year: 2000: 19.3;
Fiscal year: 2001: 21.3;
Fiscal year: 2002: 22.0;
Fiscal year: 2003: 26.3;
Fiscal year: 2004: 13.9;
Fiscal year: 2005: 23.2;
Fiscal year: 2006: 20.1.
State: Oregon;
Number of homes 2006: 142;
Fiscal year: 2000: 45.5;
Fiscal year: 2001: 32.6;
Fiscal year: 2002: 23.7;
Fiscal year: 2003: 20.3;
Fiscal year: 2004: 15.9;
Fiscal year: 2005: 19.8;
Fiscal year: 2006: 18.6.
State: Pennsylvania;
Number of homes 2006: 724;
Fiscal year: 2000: 30.3;
Fiscal year: 2001: 19.2;
Fiscal year: 2002: 13.5;
Fiscal year: 2003: 17.2;
Fiscal year: 2004: 19.5;
Fiscal year: 2005: 15.2;
Fiscal year: 2006: 13.6.
State: Rhode Island;
Number of homes 2006: 90;
Fiscal year: 2000: 14.3;
Fiscal year: 2001: 12.9;
Fiscal year: 2002: 5.6;
Fiscal year: 2003: 6.7;
Fiscal year: 2004: 9.3;
Fiscal year: 2005: 9.5;
Fiscal year: 2006: 4.5.
State: South Carolina;
Number of homes 2006: 178;
Fiscal year: 2000: 26.4;
Fiscal year: 2001: 17.2;
Fiscal year: 2002: 19.8;
Fiscal year: 2003: 29.6;
Fiscal year: 2004: 32.7;
Fiscal year: 2005: 24.8;
Fiscal year: 2006: 17.1.
State: South Dakota;
Number of homes 2006: 111;
Fiscal year: 2000: 27.1;
Fiscal year: 2001: 26.7;
Fiscal year: 2002: 26.8;
Fiscal year: 2003: 32.1;
Fiscal year: 2004: 21.6;
Fiscal year: 2005: 12.8;
Fiscal year: 2006: 21.7.
State: Tennessee;
Number of homes 2006: 332;
Fiscal year: 2000: 28.2;
Fiscal year: 2001: 20.2;
Fiscal year: 2002: 20.7;
Fiscal year: 2003: 21.8;
Fiscal year: 2004: 22.9;
Fiscal year: 2005: 17.3;
Fiscal year: 2006: 12.5.
State: Texas;
Number of homes 2006: 1,175;
Fiscal year: 2000: 29.7;
Fiscal year: 2001: 30.5;
Fiscal year: 2002: 22.4;
Fiscal year: 2003: 18.0;
Fiscal year: 2004: 12.0;
Fiscal year: 2005: 16.2;
Fiscal year: 2006: 18.3.
State: Utah;
Number of homes 2006: 93;
Fiscal year: 2000: 19.5;
Fiscal year: 2001: 14.1;
Fiscal year: 2002: 25.6;
Fiscal year: 2003: 19.0;
Fiscal year: 2004: 11.1;
Fiscal year: 2005: 8.4;
Fiscal year: 2006: 17.9.
State: Vermont;
Number of homes 2006: 41;
Fiscal year: 2000: 22.5;
Fiscal year: 2001: 18.2;
Fiscal year: 2002: 15.0;
Fiscal year: 2003: 10.0;
Fiscal year: 2004: 19.5;
Fiscal year: 2005: 23.7;
Fiscal year: 2006: 13.5.
State: Virginia;
Number of homes 2006: 281;
Fiscal year: 2000: 19.2;
Fiscal year: 2001: 14.3;
Fiscal year: 2002: 11.6;
Fiscal year: 2003: 13.7;
Fiscal year: 2004: 10.2;
Fiscal year: 2005: 15.5;
Fiscal year: 2006: 15.8.
State: Washington;
Number of homes 2006: 247;
Fiscal year: 2000: 46.9;
Fiscal year: 2001: 38.3;
Fiscal year: 2002: 37.0;
Fiscal year: 2003: 30.9;
Fiscal year: 2004: 28.1;
Fiscal year: 2005: 27.2;
Fiscal year: 2006: 24.1.
State: West Virginia;
Number of homes 2006: 132;
Fiscal year: 2000: 12.1;
Fiscal year: 2001: 17.7;
Fiscal year: 2002: 20.4;
Fiscal year: 2003: 12.7;
Fiscal year: 2004: 9.8;
Fiscal year: 2005: 15.0;
Fiscal year: 2006: 9.7.
State: Wisconsin;
Number of homes 2006: 403;
Fiscal year: 2000: 15.8;
Fiscal year: 2001: 15.6;
Fiscal year: 2002: 11.2;
Fiscal year: 2003: 10.9;
Fiscal year: 2004: 13.1;
Fiscal year: 2005: 18.2;
Fiscal year: 2006: 23.0.
State: Wyoming;
Number of homes 2006: 39;
Fiscal year: 2000: 52.8;
Fiscal year: 2001: 32.4;
Fiscal year: 2002: 25.0;
Fiscal year: 2003: 22.9;
Fiscal year: 2004: 17.1;
Fiscal year: 2005: 11.8;
Fiscal year: 2006: 16.2.
State: Nation;
Number of homes 2006: 16,172;
Fiscal year: 2000: 28.4;
Fiscal year: 2001: 23.3;
Fiscal year: 2002: 20.2;
Fiscal year: 2003: 17.8;
Fiscal year: 2004: 15.7;
Fiscal year: 2005: 16.8;
Fiscal year: 2006: 18.9.
Source: GAO analysis of OSCAR and PDQ data.
[End of table]
[End of section]
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. 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. GAO-05-78. Washington,
D.C.: November 12, 2004.
Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal
Standards and Oversight. GAO-04-660. Washington D.C.:
July 16, 2004.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. GAO-03-561. Washington,
D.C.: July 15, 2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. GAO-03-187. Washington, D.C.:
October 31, 2002.
Nursing Homes: Quality of Care More Related to Staffing than Spending.
GAO-02-431R. Washington, D.C.: June 13, 2002.
Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. GAO-02-279. Washington, D.C.:
February 15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4,
1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,
D.C.: August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18,
1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.
FOOTNOTES
[1] See Institute of Medicine, National Academy of Sciences, Improving
the Quality of Care in Nursing Homes (Washington, D.C.: March 1986).
[2] GAO, Medicare and Medicaid: Stronger Enforcement of Nursing Home
Requirements Needed, GAO/HRD-87-113 (Washington, D.C.: July 22, 1987).
[3] Prior 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.
[4] In this report, we use the term states to include the 50 states and
the District of Columbia.
[5] Related 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.
[6] OBRA '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.
[7] CMS 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.
[8] CMS contracts with state survey agencies to conduct surveys and
complaint investigations.
[9] CMS 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.
[10] Ensuring 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.
[11] As 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.
[12] If efforts to collect the CMP directly from the home fail,
Medicare and Medicaid payments are withheld.
[13] Homes 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.
[14] GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain
in Ensuring High-Quality Care and Resident Safety, GAO-06-117
(Washington, D.C.: Dec. 28, 2005).
[15] For 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.
[16] GAO-06-117. CMS requires its federal surveyors to specifically
identify which deficiencies state surveyors missed during the state
survey.
[17] These 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.
[18] GAO, Nursing Homes: Efforts to Strengthen Federal Enforcement Have
Not Deterred Some Homes from Repeatedly Harming Residents, GAO-07-241
(Washington, D.C.:
Mar. 26, 2007).
[19] 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.
[20] In 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, GAO-03-561 (Washington, D.C.: July 15, 2003).
[21] CMPs 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.
[22] See HHS, Office of Inspector General, Nursing Home Enforcement:
The Use of Civil Money Penalties, OEI-06-02-00720 (April 2005).
[23] Use of the CMP grid would be optional to provide states
flexibility to tailor sanctions to specific circumstances.
[24] We 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.
[25] Annual state performance reviews were established in fiscal year
2001 and fully implemented in fiscal year 2002.
[26] GAO-06-117.
[27] Pilot 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.
[28] As 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.
[29] GAO, Nursing Home Fire Safety: Recent Fires Highlight Weaknesses
in Federal Standards and Oversight, GAO-04-660 (Washington D.C.: July
16, 2004).
[30] 71 Fed. Reg. 55326 (Sept. 22, 2006) (codified in pertinent part at
42 C.F.R. §483.70). CMS began surveying nursing homes' compliance with
the new requirement in May 2006.
[31] 71 Fed. Reg. 62957 (Oct. 27, 2006) (to be codified at 42 C.F.R.
§483.70).
[32] Hyperlink, http://www.medicare.gov/NHCompare/home.asp.
[33] GAO, Nursing Homes: Federal Efforts to Monitor Resident Assessment
Data Should Complement State Activities, GAO-02-279 (Washington, D.C.:
Feb. 15, 2002).
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