For example, an advantage of comparative surveys is that they are an  independent evaluation of a nursing home recently surveyed by a state  survey agency team. Substantial Proportion of Federal Comparative Surveys Identify Missed Deficiencies

A substantial proportion of federal comparative surveys identify missed  deficiencies at the potential for more than minimal harm level or above. From fiscal year 2002 through 2007, about 15 percent of federal  comparative surveys nationwide identified state surveys that failed to cite  at least one deficiency at the most serious levels of noncompliance—the  actual harm and immediate jeopardy levels (G through L). Federal surveyors identified no missed serious  deficiencies in seven states (see app. Missed Deficiencies at the Potential for More Than Minimal Harm Level Were Widespread on Federal Comparative Surveys

In contrast to missed serious deficiencies, missed deficiencies at the  potential for more than minimal harm level (D through F) were  considerably more widespread on comparative surveys conducted during  fiscal years 2002 through 2007. Approximately 70 percent of comparative  surveys conducted nationwide identified state surveys that missed at least  one deficiency at the potential for more than minimal harm level (D  through F), with such missed deficiencies identified on greater than   40 percent of comparative surveys in all but five states—Alaska, Ohio,  Vermont, West Virginia, and Wisconsin. Undetected care problems at the D through F level  are of concern because they could become more serious over time if  nursing homes are not required to take corrective actions. Federal Observational Surveys and Prior GAO Reports Identified Factors That May Contribute to Deficiency Understatement by State Survey Teams

Both federal observational surveys and our prior reports have identified  factors that may contribute to the understatement of deficiencies by state  survey teams. Together, these two areas directly affect the  appropriate identification and citation of deficiencies. CMS Has Taken Steps to Improve the Federal Monitoring Survey Program, but Weaknesses in Management and Oversight Remain

CMS has taken steps to improve the federal monitoring survey program,  but weaknesses remain in program management and oversight. For  example, CMS has improved processes to ensure that comparative surveys  more accurately reflect conditions at the time of the state survey, has  switched control of the federal monitoring survey database to the office  responsible for ensuring the effectiveness of state surveys, and has begun  examining how to use monitoring survey data to improve oversight. Despite this progress, the management and oversight potential of the  program has not been fully realized. In particular, CMS (1) has only begun  exploring options for identifying understatement that occurs in cases  where state surveys cite deficiencies at too low a level, for possible  implementation in fiscal year 2009, and (2) is not effectively managing the  federal monitoring survey database or using the database to oversee  consistent implementation of the federal monitoring survey program by its  regional offices. As a result, comparative  surveys do not effectively capture the extent of the understatement of  serious deficiencies by state surveyors. For example, CMS was not (1) examining  comparative survey data to ensure that regional offices comply with CMS  guidance intended to ensure that comparative surveys more accurately  capture the conditions at the time of the state survey and (2) using the  database to identify inconsistencies between comparative and  observational survey results. Ensuring regional office compliance. These missed serious deficiencies most frequently involved Quality of  Care, reflecting shortcomings in fundamental provider responsibilities  such as ensuring proper nutrition and hydration, accident prevention, and  preventing pressure sores. For example, we found that the database was  missing a considerable number of comparative surveys. Nursing Home Care: Enhanced HCFA Oversight of State Programs  Would Better Ensure Quality.
Why GAO Did This Study

GAO reports since 1998 have demonstrated that state surveyors, who evaluate the quality of nursing home care on behalf of CMS, sometimes understate the extent of serious care problems in homes because they miss deficiencies. CMS oversees the effectiveness of state surveys through the federal monitoring survey program. In this program, federal surveyors in CMS's regional offices either independently evaluate state surveys by resurveying a home (comparative surveys) or directly observe state surveyors during a routine nursing home survey (observational surveys). GAO was asked to evaluate the information federal monitoring surveys provide on understatement and the effectiveness of CMS management and oversight of the survey program. To do this, GAO analyzed the results of federal monitoring surveys for fiscal years 2002 through 2007, reviewed CMS guidance for the survey program, and interviewed headquarters and regional office officials.

What GAO Found

A substantial proportion of federal comparative surveys identify missed deficiencies at the potential for more than minimal harm level or above. During fiscal years 2002 through 2007, about 15 percent of federal comparative surveys nationwide identified state surveys that failed to cite at least one deficiency at the most serious levels of noncompliance--actual harm and immediate jeopardy. Overall, nine states missed serious deficiencies on 25 percent or more of comparative surveys; in seven states federal surveyors identified no such missed deficiencies. During the same period, missed deficiencies at the lowest level of noncompliance--the potential for more than minimal harm--were more widespread: nationwide, approximately 70 percent of federal comparative surveys identified state surveys missing at least one deficiency at the lowest level of noncompliance, and in all but five states the number of state surveys with such missed deficiencies was greater than 40 percent. Undetected care problems at this level are a concern because they could become more serious if nursing homes are not required to take corrective action. The most frequently missed type of deficiency on comparative surveys, at the potential for more than minimal harm level and above, was poor quality of care, such as ensuring proper nutrition and hydration and preventing pressure sores. Federal observational surveys highlighted two factors that may contribute to understatement of deficiencies: weaknesses in state surveyors' (1) investigative skills and (2) ability to integrate and analyze information collected to make an appropriate deficiency determination. These factors may contribute to understatement because they directly affect the appropriate identification and citation of deficiencies. CMS has taken steps to improve the federal monitoring survey program, but weaknesses remain in program management and oversight. For example, CMS has improved processes to ensure that comparative surveys more accurately reflect conditions at the time of the state survey, such as requiring that comparative surveys occur within 30 working days of the state survey rather than within the 2 months set in statute. Despite these improvements, the management and oversight potential of the program has not been fully realized. For example, CMS has only begun to explore options for identifying understatement that occurs in cases where state surveys cite deficiencies at too low a level, for possible implementation in fiscal year 2009. In addition, CMS is not effectively managing the federal monitoring survey database to ensure that the regional offices are entering data accurately and reliably--CMS was unaware, for example, that a considerable number of comparative surveys had not been entered. Furthermore, CMS is not using the database to oversee consistent implementation of the program by the regional offices--for example, the agency is not using the database to identify inconsistencies between comparative and observational survey results.