These reviews replaced state  self-reporting of their compliance with federal requirements. State surveys conducted since about mid-2000  showed less variance from federal comparative surveys, suggesting that  (1) state surveyors’ performance in documenting serious deficiencies has  improved and (2) the decline in serious nursing home quality problems is  potentially real. Quality-of-Care Problems Were Understated in Homes with a History of Problems

Even with the reported decline in serious deficiencies, an unacceptably  high number of nursing homes—one in five nationwide—still had actual  harm or immediate jeopardy deficiencies. Weaknesses Persist in State Survey, Complaint, and Enforcement Activities

Widespread weaknesses persist in state survey, complaint investigation,  and enforcement activities despite increased attention to these issues in  recent years. Several factors at the state level contribute to the  understatement of serious quality-of-care problems, including poor  investigation and documentation of deficiencies, the absence of adequate  quality assurance processes, and a large number of inexperienced  surveyors in some states due to high attrition or hiring limitations. In  addition, our analysis of OSCAR data indicated that the timing of a  significant proportion of state surveys remained predictable, allowing  homes to conceal problems if they choose to do so. States failed to refer a substantial number of homes for  sanction, significantly undermining the policy’s intended deterrent effect. CMS Oversight of State Survey Activities Requires Further Strengthening

While CMS has increased its oversight of state survey and complaint  activities and instituted a more systematic oversight process by initiating  annual state performance reviews, CMS officials acknowledged that the  effectiveness of the reviews could be improved. In particular, CMS  officials told us that for the initial state performance review in fiscal year  2001, they lacked the capability to systematically distinguish between  minor lapses identified during the reviews and more serious problems that  require intervention. CMS oversight is also hampered by continuing  limitations in OSCAR data, the inability or reluctance of some CMS regions  to use such data to monitor state activities, and inadequate oversight of  certain areas, such as survey predictability and state referral of homes for  immediate enforcement actions. However, three federal initiatives critical to reducing  the subjectivity evident in the current survey process and the investigation  of complaints have been delayed. Our work, as  well as that of CMS, demonstrates the persistence of several long-standing  problems and also provides insights on factors that may be contributing to  these shortcomings:    state surveyors continue to understate serious deficiencies that caused  actual harm or placed residents in immediate jeopardy;    deficiencies are often poorly investigated and documented, making it  difficult to determine the appropriate severity category;    states focus considerable effort on reviewing proposed actual harm  deficiencies, but many have no quality assurance processes in place to  determine if less serious deficiencies are understated or have investigation  and documentation problems;  the timing of too many surveys remains predictable, allowing problems to  go undetected if a home chooses to conceal deficiencies;    numerous weaknesses persist in many states’ complaint processes,  including the lack of consumer toll-free hotlines in many states, confusion  over prioritization of complaints, inconsistent complaint investigation  procedures, and the failure of most states to investigate all complaints  alleging actual harm within 10 days, as required; and    states did not refer a substantial number of homes that had a pattern of  harming residents to CMS for immediate sanctions. Several  areas that require CMS’s ongoing attention include (1) the newly  established standard performance reviews to ensure that critical elements  of the review, such as assessing states’ ability to properly document  deficiencies, are successfully implemented, (2) the successful  modernization of CMS’s data system by 2005 to support the survey process  and provide key information for monitoring state survey activities, (3) the  planned expansion of comparative surveys to improve federal oversight of  the state survey process, (4) the survey methodology redesign intended to  make the survey process more systematic, (5) the development of more  structured guidance for surveyors to address inconsistencies in how the  scope and severity of deficiencies are cited across states, and (6) the  provision of detailed guidance to states to ensure thorough and consistent  complaint investigations. Nursing home deficiency trends. Enforcement. Four states accounted for  about 55 percent of cases that should have been referred. Nursing Homes: Success of Quality Initiatives Requires Sustained  Federal and State Commitment. California Nursing Homes: Care Problems Persist Despite Federal and  State Oversight.
Why GAO Did This Study

Since July 1998, GAO has reported numerous times on nursing home quality-of-care issues and identified significant weaknesses in federal and state oversight. GAO was asked to assess the extent of the progress made in improving the quality of care provided by nursing homes to vulnerable elderly and disabled individuals, including (1) trends in measured nursing home quality, (2) state responses to previously identified weaknesses in their survey, complaint, and enforcement activities, and (3) the status of oversight and quality improvement efforts by the Centers for Medicare & Medicaid Services (CMS).

What GAO Found

The proportion of nursing homes with serious quality problems remains unacceptably high, despite a decline in the incidence of such reported problems. Actual harm or more serious deficiencies were cited for 20 percent or about 3,500 nursing homes during an 18-month period ending January 2002, compared to 29 percent for an earlier period. Fewer discrepancies between federal and state surveys of the same homes suggests that state surveyors are doing a better job of documenting serious deficiencies and that the decline in serious quality problems is potentially real. Despite these improvements, the continuing prevalence of and state surveyor understatement of actual harm deficiencies is disturbing. For example, 39 percent of 76 state surveys from homes with a history of quality-of-care problems--but whose current survey found no actual harm deficiencies--had documented problems that should have been classified as actual harm or higher, such as serious, avoidable pressure sores. Weaknesses persist in state survey, complaint, and enforcement activities. According to CMS and states, several factors contribute to the understatement of serious quality problems, including poor investigation and documentation of deficiencies, limited quality assurance systems, and a large number of inexperienced surveyors in some states. In addition, GAO found that about one-third of the most recent state surveys nationwide remained predictable in their timing, allowing homes to conceal problems if they chose to do so. Considerable state variation remains regarding the ease of filing a complaint, the appropriateness of the investigation priorities, and the timeliness of investigations. Some states attributed timeliness problems to inadequate staff and an increase in the number of complaints. Although the agency strengthened enforcement policy by requiring states to refer for immediate sanction homes that had repeatedly harmed residents, GAO found that states failed to refer a substantial number of such homes, significantly undermining the policy's intended deterrent effect. CMS oversight of state survey activities has improved but requires continued attention to help ensure compliance with federal requirements. While CMS strengthened oversight by initiating annual state performance reviews, officials acknowledged that the reviews' effectiveness could be improved. For the initial fiscal year 2001 review, officials said they lacked the capability to systematically distinguish between minor lapses and more serious problems that required intervention. CMS oversight is also hampered by continuing database limitations, the inability of some CMS regions to use available data to monitor state activities, and inadequate oversight in areas such as survey predictability and state referral of homes for enforcement. Three key CMS initiatives have been significantly delayed--strengthening the survey methodology, improving surveyor guidance for determining the scope and severity of deficiencies, and producing greater standardization in state complaint processes. These initiatives are critical to reducing the subjectivity evident in current state survey and complaint activities.