Its primary oversight tools are statutorily required federal  monitoring surveys conducted annually in at least 5 percent of the state- surveyed Medicare and Medicaid nursing homes in each state and annual  state performance reviews. Available Data Show Significant Overall Decrease in Serious Quality Problems but Indicate Continued Inconsistency and Understatement in State Findings

CMS’s nursing home survey data show a significant decrease in serious  quality problems in recent years, but other information indicates that this  trend masks two important and continuing issues: inconsistency in how  states conduct surveys and understatement of serious quality problems. Moreover, although  federal comparative surveys conducted from October 1998 through  December 2004 showed a decline in the proportion of serious deficiencies  that were not identified by state surveys, this overall trend masks a more  recent increase from 2002 through 2004 in federally identified  understatement of serious deficiencies. In five large states we examined  with a significant decline in the proportion of homes found to have  harmed residents, federal comparative surveys found that a significant  proportion of state surveys had missed serious deficiencies, that is, state  surveyors either failed to cite the deficiencies altogether or cited them at  too low a level of scope and severity. From January 1999 through January 2005, the proportion of nursing homes  nationwide with actual harm or immediate jeopardy deficiencies declined  from about 29 percent to about 16 percent. CMS Has Addressed Many Shortcomings in Survey and Oversight Activities, but Work Continues on Some Key Initiatives

CMS has addressed many shortcomings in nursing home survey and  oversight activities both in response to our recommendations and as a  result of its own assessment of needed improvements, but it is still  working on key initiatives that have not yet been implemented. Examples of  CMS’s initiatives to address shortcomings include (1) revising the survey  methodology, (2) issuing states additional guidance to strengthen  complaint investigations, (3) implementing immediate sanctions for homes  cited for repeat serious violations, and (4) strengthening oversight by  conducting assessments of state survey activities. CMS also has published  information on its Web site about nursing home quality and has engaged  independent quality organizations to work with nursing homes to improve  quality. Despite CMS’s initiatives in four distinct areas—surveys,  complaints, enforcement, and oversight—some initiatives either have not  effectively targeted the problems we identified or have shortcomings that  impair their effectiveness. An independent  evaluation is planned. In response to recommendations in our November 1999 and July 2004  reports, CMS has (1) significantly increased the number of federal  comparative surveys both for quality of care and fire safety and   (2) decreased the time between the end of the state survey and the start of  the federal survey for quality-of-care comparative surveys, allowing CMS  to better distinguish between serious problems missed by state surveyors  and changes in a home that occurred after the state survey. However, CMS  continues to address ongoing problems with the accuracy and reliability of  the underlying data, such as the MDS, quality indicators, and nurse staffing  levels. Resource and Workload Issues Pose Key Challenges to Further Improving Nursing Home Quality and Safety

CMS, states, and nursing homes face a number of key challenges in their  efforts to further improve nursing home quality and safety, including   (1) the cost of retrofitting older nursing homes with automatic sprinklers,  a potentially costly requirement that has a demonstrated ability to prevent  deaths in the event of a fire; (2) continuing problems in hiring and  retaining qualified surveyors, a factor that states indicated can contribute  to variability in the citation of serious deficiencies; and (3) an increasing  federal and state survey workload due to increased oversight, the  identification over time of additional initiatives, and growth in the number  of Medicare and Medicaid providers that must be surveyed, including  expected growth in nursing homes. For example, CMS sought  input from experts in developing investigative protocols for surveyors. Even with CMS’s increased efforts to  improve nursing home quality, the agency’s continued attention and  commitment to these efforts is essential in order to maintain and build  upon the momentum of its accomplishments to date. California Nursing Homes: Care Problems Persist Despite Federal and  State Oversight.
Why GAO Did This Study

Since 1998, GAO has issued numerous reports on nursing home quality and safety that identified significant weaknesses in federal and state oversight. Under contract with the Centers for Medicare & Medicaid Services (CMS), states conduct annual nursing home inspections, known as surveys, to assess compliance with federal quality and safety requirements. States also investigate complaints filed by family members or others in between annual surveys. When state surveys find serious deficiencies, CMS may impose sanctions to encourage compliance with federal requirements. GAO was asked to assess CMS's progress since 1998 in addressing oversight weaknesses. GAO (1) reviewed the trends in nursing home quality from 1999 through January 2005, (2) evaluated the extent to which CMS's initiatives have addressed survey and oversight problems identified by GAO and CMS, and (3) identified key challenges to continued progress in ensuring resident health and safety. GAO reviewed federal data on the results of state nursing home surveys and federal surveys assessing state performance; conducted additional analyses in five states with large numbers of nursing homes; reviewed the status of its prior recommendations; and identified key workforce and workload issues confronting CMS and states.

What GAO Found

CMS's nursing home survey data show a significant decline in the proportion of nursing homes with serious quality problems since 1999, but this trend masks two important and continuing issues: inconsistency in how states conduct surveys and understatement of serious quality problems. Inconsistency in states' surveys is demonstrated by wide interstate variability in the proportion of homes found to have serious deficiencies--for example, about 6 percent in one state and about 54 percent in another. Continued understatement of serious deficiencies is shown by the increase in discrepancies between federal and state surveys of the same homes from 2002 through 2004, despite an overall decline in such discrepancies from October 1998 through December 2004. In five large states that had a significant decline in serious deficiencies, federal surveyors concluded that from 8 percent to 33 percent of the comparative surveys identified serious deficiencies that state surveyors had missed. This finding is consistent with earlier GAO work showing that state surveyors missed serious care problems. These two issues underscore the importance of CMS initiatives to improve the consistency and rigor of nursing home surveys. CMS has addressed many survey and oversight shortcomings, but it is still developing or has not yet implemented several key initiatives, particularly those intended to improve the consistency of the survey process. Key steps CMS has taken include (1) revising the survey methodology, (2) issuing states additional guidance to strengthen complaint investigations, (3) implementing immediate sanctions for homes cited for repeat serious violations, and (4) strengthening oversight by conducting assessments of state survey activities. Some CMS initiatives, however, either have shortcomings impairing their effectiveness or have not effectively targeted problems GAO and CMS identified. For example, CMS has not fully addressed issues with the accuracy and reliability of the data underlying consumer information published on its Web site. The key challenges CMS, states, and nursing homes face in their efforts to further improve nursing home quality and safety include (1) the cost to older homes to be retrofit with automatic sprinklers to help reduce the loss of life in the event of a fire, (2) continuing problems with hiring and retaining qualified surveyors, and (3) an expanded workload due to increased oversight, identification of additional initiatives that compete for staff and financial resources, and growth in the number of Medicare and Medicaid providers. Despite CMS's increased nursing home oversight, its continued attention and commitment are warranted in order to maintain the momentum of its efforts to date and to better ensure high-quality care and safety for nursing home residents. CMS generally concurred with the report's findings. CMS noted several areas of progress in nursing home quality and identified remaining challenges to conducting nursing home survey and oversight activities.