Specifically, CMS central office (1) oversees the federal  quality standards nursing homes must meet to participate in the Medicare  and Medicaid programs and (2) establishes the responsibilities of CMS’s  regional offices and state survey agencies to ensure federal quality  standards for nursing homes are met. CMS collects data on nursing home quality through annual standard  surveys and complaint investigations, as well as other sources, such as  staffing data and clinical quality measures. During  an investigation, state surveyors evaluate the nursing home’s  compliance with a specific federal quality standard. In a 2016  report, we found that CMS did not have a systematic process for  prioritizing recommended changes to improve its Nursing Home Compare  website and that several factors limited the ability of CMS’s Five-Star  Quality Rating System to help consumers understand nursing home  quality and choose a home. Nursing Home Quality Data Show Mixed Results, Although Data Issues Complicate Ability to Assess Quality Trends Data on Nursing Home Quality Showed Mixed Results

In our October 2015 report examining trend data that give insight into  nursing home quality, we found that four key data sets showed mixed  results, and data issues complicated the ability to assess quality trends. Nationally, one of the four data sets—consumer complaints—suggested  consumers’ concerns over nursing home quality increased from 2005 to  2014. However, the other three data sets—deficiencies, staffing levels,  and clinical quality measures—indicated potential improvement in nursing  home quality (see Table 1). Data Issues Complicated CMS’s Ability to Assess Quality Trends

In our October 2015 report, we found CMS’s ability to use available data  to assess nursing home quality trends was complicated by various issues  with these data, which made it difficult to determine whether observed  trends reflect actual changes in quality, data issues, or both. In our October  2015 report, we recommended CMS implement the same survey  methodology across all states; HHS agreed with this recommendation  and in November 2017 completed its national implementation of this  electronic survey methodology. We recommended in 2015 that CMS  establish and implement a clear plan for ongoing auditing of its staffing  data and other quality data. HHS agreed with this recommendation and in  July 2018 CMS provided us with documentation that it was conducting  regular audits of this new nurse staffing data. As of August 2018, CMS has  not provided us a plan for ongoing auditing of its clinical quality measures  and we continue to believe that CMS should establish and carry out such  a plan. CMS Had Modified Oversight Activities by 2015, But Had Not Monitored Potential Effect on Nursing Home Quality Oversight

Our 2015 report found that CMS had made numerous modifications to its  nursing home oversight activities in recent years, but had not monitored  the potential effect of these modifications on nursing home quality  oversight. Some of these modifications expanded or added new oversight  activities—for example, CMS expanded the number of tools available to  state surveyors when investigating medication-related adverse events,  increased the amount of nursing home quality data available to the public,  and created new trainings for surveyors on unnecessary medication  usage. However, other modifications reduced existing oversight  activities. Special Focus Facilities: CMS reduced the number of nursing  homes participating in the SFF program. In 2015, CMS said some of the reductions to oversight activities were in  response to an increase in oversight responsibilities and limited number  of staff and financial resources. In the  October 2015 report, we recommended CMS monitor oversight  modifications to better assess their effects; HHS agreed with the  recommendation and told us they are beginning to take steps to address  this issue. We maintain the importance of monitoring to help CMS better  understand how its oversight modifications affect nursing home quality  and to improve its oversight given limited resources. GAO-16-33. GAO-15-11. Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine  Its Approach for Funding State Oversight of Health Care Facilities.
Why GAO Did This Study

Approximately 15,600 nursing homes participating in the Medicare and Medicaid programs provide care to 1.4 million residents—a population of elderly and disabled individuals. To help ensure nursing home residents receive quality care, CMS defines quality standards that homes must meet to participate in the Medicare and Medicaid programs. To monitor compliance with these standards, CMS enters into agreements with state survey agencies to conduct on-site surveys of the state's homes and also collects other data on nursing home quality.
Although CMS and others have reported some potential improvements in nursing home quality, questions have been raised about nursing home quality and weaknesses in CMS oversight.
This statement summarizes GAO's October 2015 report, GAO-16-33 . Specifically, it describes (1) trends in nursing home quality through 2014, and (2) changes CMS had made to its oversight activities as of October 2015. It also includes the status of GAO's recommendations associated with these findings. GAO recently obtained information from CMS officials about steps they have taken to implement the 2015 GAO recommendations.

What GAO Found

GAO's October 2015 report found mixed results in nursing home quality based on its analysis of trends reflected in key sources of quality data that the Centers for Medicare & Medicaid Services (CMS) collects.
An increase in reported consumer complaints suggested that consumers' concerns about nursing home quality increased.
In contrast, trends in care deficiencies, nurse staffing levels, and clinical quality measures indicated potential improvement in nursing home quality.
GAO also found that data issues complicated CMS's ability to assess nursing home quality trends. For example:
CMS allowed states to use different survey methodologies to measure deficiencies in nursing home care, which complicates the ability to make comparisons nationwide. GAO recommended that CMS implement a standardized survey methodology across states, and in November 2017 CMS completed national implementation.
CMS did not regularly audit selected quality data including nurse staffing and clinical data (for example, on residents with pressure ulcers) to ensure their accuracy. GAO recommended CMS implement a plan for ongoing auditing of quality data. The agency concurred with this recommendation and has been conducting regular audits of nurse staffing data but does not have a plan to audit other quality data on a continuing basis. GAO continues to believe that regular audits are needed to ensure the accuracy and comparability of nursing home quality data.
GAO's October 2015 report found that CMS had made numerous modifications to its nursing home oversight activities. However, CMS had not monitored how the modifications might affect its ability to assess nursing home quality. GAO found that some modifications expanded or added new activities—such as creating new training for state surveyors on unnecessary medication usage—while others reduced existing activities. For example, CMS reduced the number of nursing homes participating in the Special Focus Facility program—which provides additional oversight of certain homes with a history of poor performance—by over half from 2013 to 2014. CMS officials told GAO that some of the reductions to oversight activities were in response to an increase in oversight responsibilities and a limited number of staff and financial resources. To help ensure modifications do not adversely affect CMS's ability to assess nursing home quality, GAO recommended that CMS monitor modifications of essential oversight activities to better understand the effects on nursing home quality oversight. CMS concurred with this recommendation and told us it has begun to take steps to address it. Such monitoring is important for CMS to better understand how its oversight modifications affect nursing home quality and to improve its oversight given limited resources.