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. 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. 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 understatement of serious deficiencies  identified by federal surveyors in five states has declined since 2004,  understatement continues at varying levels across these states. Despite this national trend, significant interstate variation in the  proportion of homes with serious deficiencies indicates that states  conduct surveys inconsistently. 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. 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 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. 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. Greater demand on limited  resources has led to queues and delays in key initiatives. However, CMS officials recently reported that  resource constraints in fiscal year 2007 threaten the planned expansion of  this process beyond the five demonstration states. 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. 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. It is important to continue  to focus national attention on and ensure public accountability for homes  that harm residents. Nursing Homes: Despite Increased Oversight, Challenges Remain in  Ensuring High-Quality Care and Resident Safety. This is a work of the U.S. government and is not subject to copyright protection in the  United States.
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.