A new federal  oversight tool, state performance reviews, implemented in October 2000,  measures state survey agency performance against seven standards,  including statutory requirements regarding survey frequency, requirements  for documenting deficiencies, and timeliness of complaint investigations. Magnitude of Problems Remains Cause for Concern, Even Though Fewer Serious Nursing Home Quality Problems Were Reported

State survey data indicate that the proportion of nursing homes with  serious quality problems remains unacceptably high, despite a decline in  such reported problems since mid-2000. Beyond the continuing high prevalence of actual harm or immediate  jeopardy deficiencies, we found a disturbing understatement of actual  harm or higher deficiencies in a sample of surveys that were conducted  since July 2000 at homes with a history of harming residents but whose  current surveys indicated no actual harm deficiencies. Overall, 39 percent  of 76 surveys we reviewed had documented problems that should have  been classified as actual harm: serious, avoidable pressure sores; severe  weight loss; and multiple falls resulting in broken bones and other injuries. Weaknesses Persist in State Survey, Complaint, and Enforcement Activities

Despite increased attention in recent years, widespread weaknesses  persist in state survey, complaint investigation, and enforcement activities. Moreover, many  state complaint investigation systems still have timeliness problems and  some states did not comply with HCFA’s policy to refer to the agency for  immediate sanction those nursing homes that showed a pattern of harming  residents, resulting in hundreds of nursing homes not appropriately  referred for action. Confusion about Definition of Harm and Other Factors Contribute to Underreporting of Care Problems

We identified several factors at the state level that contributed to the  understatement of serious quality-of-care problems. Some states attributed  the timeliness problem to an increase in the number of complaints and to  insufficient staff. Substantial Number of Nursing Homes Were Not Referred to CMS for Immediate Sanctions

State survey agencies did not refer a significant number of cases where  nursing homes were found to have a pattern of harming residents to CMS  for immediate sanction as required by CMS policy, significantly  undermining the policy’s intended deterrent effect. CMS Oversight of State Survey Activities Requires Further Strengthening

While CMS has instituted a more systematic oversight process of state  survey and complaint activities by initiating annual state performance  reviews, CMS officials acknowledged that the effectiveness of the reviews  could be improved. For subsequent reviews, CMS plans to more centrally manage the  process to improve consistency and to help ensure that future reviews  distinguish serious from minor problems. Implementation has been significantly delayed for three federal initiatives  that are critical to reducing the subjectivity in the state survey process for  identifying deficiencies and determining the seriousness of complaints. These delayed initiatives were intended to strengthen the methodology for  conducting surveys, improve surveyor guidance for determining the scope  and severity of deficiencies, and increase standardization in state  complaint investigation processes. Conclusions

As we reported in September 2000, continued federal and state attention is  required to ensure necessary improvements in the quality of care provided  to the nation’s vulnerable nursing home residents. Despite these  efforts, however, CMS needs to continue its efforts to better ensure  consistent compliance with federal quality requirements. Several areas  that require CMS’s ongoing attention include: (1) developing more  structured guidance for surveyors to address inconsistencies in how the  scope and severity of deficiencies are cited across states, (2) finalizing and  implementing the survey methodology redesign intended to make the  survey process more systematic, (3) implementing a nationwide complaint  tracking system and providing states additional complaint investigation  guidance, and (4) refining the newly established state agency performance  standard reviews to ensure that states are held accountable for ensuring  that nursing homes comply with federal nursing home quality standards. The report  on which this testimony is based contained several new recommendations  for needed CMS actions on these issues; CMS generally concurred with  our recommendations. GAO-03-187. California Nursing Homes: Federal and State Oversight Inadequate to  Protect Residents in Homes with Serious Care Problems.
Why GAO Did This Study

Since 1998, the Congress and Administration have focused considerable attention on improving the quality of care in the nation's nursing homes, which provide care for about 1.7 million elderly and disabled residents in about 17,000 homes. GAO has earlier reported on serious weaknesses in processes for conducting routine state inspections (surveys) of nursing homes and complaint investigations, ensuring that homes with identified deficiencies correct the problems without recurrence, and providing consistent federal oversight of state survey activities to ensure that nursing homes comply with federal quality standards. GAO was asked to update its work on these issues and to testify on its findings, as reported in Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561 (July 15, 2003). In commenting on this report, the Centers for Medicare & Medicaid Services (CMS) generally concurred with the recommendations to address survey and oversight weaknesses. In this testimony, GAO addresses (1) the prevalence of serious nursing home quality problems nationwide, (2) factors contributing to continuing weaknesses in states' survey, complaint, and enforcement activities, and (3) the status of key federal efforts to oversee state survey agency performance and improve quality.

What GAO Found

The magnitude of documented serious deficiencies that harmed nursing home residents remains unacceptably high, despite some decline. For the most recent period reviewed, one in five nursing homes nationwide (about 3,500 homes) had serious deficiencies that caused residents actual harm or placed them in immediate jeopardy. Moreover, GAO found significant understatement of care problems that should have been classified as actual harm or higher--serious avoidable pressure sores, severe weight loss, and multiple falls resulting in broken bones and other injuries--for a sample of homes with a history of harming residents. Several factors contributed to such understatement, including confusion about the definition of harm; inadequate state review of surveys to identify potential understatement; large numbers of inexperienced state surveyors; and a continuing problem with survey timing being predictable to nursing homes. States continue to have difficulty identifying and responding in a timely fashion to public complaints alleging actual harm--delays state officials attributed to an increase in the volume of complaints and to insufficient staff. Although federal enforcement policy was strengthened in January 2000 by requiring state survey agencies to refer for immediate sanction homes that had a pattern of harming residents, many states did not fully comply with this new requirement, significantly undermining the policy's intended deterrent effect. While CMS has increased its oversight of state survey and complaint investigation activities, continued attention is required to help ensure compliance with federal requirements. In October 2000, the agency implemented new annual performance reviews to measure state performance in seven areas, including the timeliness of survey and complaint investigations and the proper documentation of survey findings. The first round of results, however, did not produce information enabling the agency to identify and initiate needed improvements. For example, some regional office summary reports provided too little information to determine if a state did not meet a particular standard by a wide or a narrow margin--information that could help CMS to judge the seriousness of problems identified and target remedial interventions. Rather than relying on its regional offices, CMS plans to more centrally manage future state performance reviews to improve consistency and to help ensure that the results of those reviews could be used to more readily identify serious problems. Finally, implementation has been significantly delayed for three federal initiatives that are critical to reducing the variation evident in the state survey process in categorizing the seriousness of deficiencies and investigating complaints. These delayed initiatives were intended to strengthen the methodology for conducting surveys, improve surveyor guidance for determining the scope and severity of deficiencies, and increase standardization in state complaint investigation processes.