oversight

Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline

Published by the Government Accountability Office on 2003-07-17.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                          United States General Accounting Office

GAO                       Testimony
                          Before the Committee on Finance,
                          U.S. Senate


For Release on Delivery
Expected at 10:00 a.m.
Thursday, July 17, 2003   NURSING HOMES
                          Prevalence of Serious
                          Quality Problems Remains
                          Unacceptably High, Despite
                          Some Decline
                          Statement of William J. Scanlon
                          Director—Health Care Issues




GAO-03-1016T
                                                July 17, 2003


                                                NURSING HOMES

                                                Prevalence of Serious Quality Problems
Highlights of GAO-03-1016T, a testimony         Remains Unacceptably High, Despite
before the Committee on Finance, U.S.
Senate                                          Some Decline



Since 1998, the Congress and                    The magnitude of documented serious deficiencies that harmed nursing
Administration have focused                     home residents remains unacceptably high, despite some decline. For the
considerable attention on                       most recent period reviewed, one in five nursing homes nationwide (about
improving the quality of care in the            3,500 homes) had serious deficiencies that caused residents actual harm or
nation’s nursing homes, which                   placed them in immediate jeopardy. Moreover, GAO found significant
provide care for about 1.7 million
elderly and disabled residents in
                                                understatement of care problems that should have been classified as actual
about 17,000 homes. GAO has                     harm or higher—serious avoidable pressure sores, severe weight loss, and
earlier reported on serious                     multiple falls resulting in broken bones and other injuries—for a sample of
weaknesses in processes for                     homes with a history of harming residents. Several factors contributed to
conducting routine state                        such understatement, including confusion about the definition of harm;
inspections (surveys) of nursing                inadequate state review of surveys to identify potential understatement;
homes and complaint                             large numbers of inexperienced state surveyors; and a continuing problem
investigations, ensuring that homes             with survey timing being predictable to nursing homes. States continue to
with identified deficiencies correct            have difficulty identifying and responding in a timely fashion to public
the problems without recurrence,                complaints alleging actual harm—delays state officials attributed to an
and providing consistent federal                increase in the volume of complaints and to insufficient staff. Although
oversight of state survey activities
to ensure that nursing homes
                                                federal enforcement policy was strengthened in January 2000 by requiring
comply with federal quality                     state survey agencies to refer for immediate sanction homes that had a
standards.                                      pattern of harming residents, many states did not fully comply with this new
                                                requirement, significantly undermining the policy’s intended deterrent effect.
GAO was asked to update its work
on these issues and to testify on its           While CMS has increased its oversight of state survey and complaint
findings, as reported in Nursing                investigation activities, continued attention is required to help ensure
Home Quality: Prevalence of                     compliance with federal requirements. In October 2000, the agency
Serious Problems, While                         implemented new annual performance reviews to measure state
Declining, Reinforces Importance                performance in seven areas, including the timeliness of survey and
of Enhanced Oversight, GAO-03-                  complaint investigations and the proper documentation of survey findings.
561 (July 15, 2003). In commenting
on this report, the Centers for
                                                The first round of results, however, did not produce information enabling the
Medicare & Medicaid Services                    agency to identify and initiate needed improvements. For example, some
(CMS) generally concurred with                  regional office summary reports provided too little information to determine
the recommendations to address                  if a state did not meet a particular standard by a wide or a narrow margin—
survey and oversight weaknesses.                information that could help CMS to judge the seriousness of problems
In this testimony, GAO addresses                identified and target remedial interventions. Rather than relying on its
(1) the prevalence of serious                   regional offices, CMS plans to more centrally manage future state
nursing home quality problems                   performance reviews to improve consistency and to help ensure that the
nationwide, (2) factors contributing            results of those reviews could be used to more readily identify serious
to continuing weaknesses in states’             problems. Finally, implementation has been significantly delayed for three
survey, complaint, and                          federal initiatives that are critical to reducing the variation evident in the
enforcement activities, and (3) the
status of key federal efforts to
                                                state survey process in categorizing the seriousness of deficiencies and
oversee state survey agency                     investigating complaints. These delayed initiatives were intended to
performance and improve quality.                strengthen the methodology for conducting surveys, improve surveyor
                                                guidance for determining the scope and severity of deficiencies, and increase
www.gao.gov/cgi-bin/getrpt?GAO-03-1016T.
                                                standardization in state complaint investigation processes.
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Kathryn G.
Allen on (202) 512-7118.
    Mr. Chairman and Members of the Committee:

    I am pleased to be here today as you address the quality of care provided
    to the nation’s 1.7 million nursing home residents, a highly vulnerable
    population of elderly and disabled individuals. The federal government
    plays a major role in ensuring nursing home quality and in financing
    nursing home care. Medicare and Medicaid paid the nation’s
    approximately 17,000 homes an estimated $42 billion in 2002 to care for
    beneficiaries. More specifically, Medicaid pays for care provided to about
    two-thirds of all nursing home residents nationwide. In addition, the
    Department of Veterans Affairs contracts with many of these same nursing
    homes to provide long-term care to veterans at a cost of more than $250
    million in fiscal year 2002. In 1998, the Senate Special Committee on Aging
    held a hearing to address nursing home care problems in California.
    Troubled by our findings of poor care in that state’s homes and weak
    federal oversight in general, the Committee held additional hearings on
    nursing home quality nationwide in 1999 and 2000. In response to
    congressional oversight and our recommendations, the Administration has
    taken actions intended to address many of the weaknesses we identified.
    These weaknesses included:

•   periodic state inspections, known as surveys, that understated the extent
    of serious care problems due to procedural weaknesses;
•   considerable delays that occurred in states investigating complaints by
    residents, family members or friends, and nursing home staff alleging
    actual harm to residents;
•   federal enforcement policies that did not ensure that identified
    deficiencies were addressed and remained corrected; and
•   federal oversight of state survey activities that was often inconsistent
    across states and limited in scope and effectiveness.

    In September 2000, we reported on progress made in addressing these
    weaknesses and concluded that the success of the Administration’s
    actions to improve nursing home quality required sustained federal and
    state commitment to reach their full potential. My remarks today will
    address federal and state progress made since our September 2000 report
    and testimony, focusing in particular on (1) the prevalence of serious
    nursing home quality problems, (2) factors contributing to continuing
    weaknesses in states’ survey, complaint, and enforcement activities, and
    (3) the status of key federal efforts to oversee state survey agency




    Page 1                                                        GAO-03-1016T
performance and improve quality. My remarks are based on our report
being released today that addresses these issues in greater detail.1

In summary, the magnitude of serious deficiencies that harmed nursing
home residents remains unacceptably high, despite some decline. For the
most recent period we reviewed, one in five of all nursing homes
nationwide (about 3,500 homes) had serious deficiencies that caused
residents actual harm or placed them in immediate jeopardy. Moreover,
we found significant understatement of care problems that should have
been classified as actual harm or higher—serious avoidable pressure
sores, severe weight loss, and multiple falls resulting in broken bones and
other injuries—for a sample of homes with a history of harming residents.
We identified several factors that contributed to such understatement,
including confusion about the definition of harm; inadequate state
supervisory review of surveys to identify potential understatement; large
numbers of inexperienced state surveyors; and a continuing, significant
problem with survey timing being predictable to nursing homes. States
also continue to have difficulty identifying and responding in a timely
fashion to complaints alleging actual harm—delays that state officials
attributed to an increase in the volume of complaints and to insufficient
staff. Although federal enforcement policy was strengthened in January
2000 by requiring state survey agencies to refer for immediate sanction
homes that had a pattern of harming residents, we found that many states
did not fully comply with this new requirement. States failed to refer
hundreds of homes for immediate sanction, significantly undermining the
policy’s intended deterrent effect.

While the Centers for Medicare & Medicaid Services (CMS) has increased
its oversight of state survey and complaint investigation activities,
continued attention is required to help ensure compliance with federal
requirements.2 In October 2000, the agency implemented new annual
performance reviews to measure state performance in seven areas,
including the timeliness of survey and complaint investigations and the
proper documentation of survey findings. The first round of results,


1
 U.S. General Accounting Office, Nursing Home Quality: Prevalence of Serious Problems,
While Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561
(Washington, D.C.: July 15, 2003).
2
 Effective July 1, 2001, the name of the Health Care Financing Administration (HCFA) was
changed to the Centers for Medicare & Medicaid Services. In this testimony we continue to
refer to HCFA where our findings apply to the organizational structure and operations
associated with that name.




Page 2                                                                    GAO-03-1016T
             however, did not produce information enabling the agency to identify and
             initiate needed improvements. For example, some regional office summary
             reports provided too little information to determine if a state agency did
             not meet a particular standard by a wide or a narrow margin—information
             that could help CMS to judge the seriousness of problems identified and
             target remedial actions. Rather than relying on its regional offices, CMS
             plans to more centrally manage future state performance reviews to
             improve consistency and to help ensure that the results of those reviews
             could be used to more readily identify serious problems. Finally,
             implementation has been significantly delayed for three federal initiatives
             that are critical to reducing the variation evident in the state survey
             process in categorizing the seriousness of deficiencies and investigating
             complaints. These delayed initiatives were intended to strengthen the
             methodology for conducting surveys, improve surveyor guidance for
             determining the scope and severity of deficiencies, and increase
             standardization in state complaint investigation processes. In our view,
             finalizing and implementing these initiatives as quickly as possible would
             help bring more clarity and consistency to the process for assessing and
             improving the quality of care provided to the nation’s nursing home
             residents.


             Oversight of nursing homes is a shared federal and state responsibility.
Background   CMS is the federal agency that manages Medicare and Medicaid and
             oversees compliance with federal nursing home quality standards. On the
             basis of statutory requirements, CMS defines standards that nursing homes
             must meet to participate in the Medicare and Medicaid programs and
             contracts with states to certify that homes meet these standards through
             annual inspections and complaint investigations. The “annual” inspection,
             called a survey, which must be conducted on average every 12 months and
             no less than every 15 months at each home, entails a team of state
             surveyors spending several days in the home to determine whether care
             and services meet the assessed needs of the residents. CMS establishes
             specific protocols, or investigative procedures, for state surveyors to use
             in conducting these comprehensive surveys. In contrast, complaint
             investigations, also conducted by state surveyors within certain federal
             guidelines and time frames, typically target a single area in response to a
             complaint filed against a home by a resident, the resident’s family or
             friends, or nursing home employees. Quality-of-care problems identified
             during either standard surveys or complaint investigations are classified in
             1 of 12 categories according to their scope (the number of residents
             potentially or actually affected) and their severity (potential for or
             occurrence of harm to residents).


             Page 3                                                         GAO-03-1016T
Ensuring that documented deficiencies are corrected is likewise a shared
responsibility. CMS is responsible for enforcement actions involving
homes with Medicare or dual Medicare and Medicaid certification—about
86 percent of all homes. States are responsible for enforcing standards in
homes with Medicaid-only certification—about 14 percent of the total.
Enforcement actions can involve, among other things, requiring corrective
action plans, imposing monetary fines, denying the home Medicare and
Medicaid payments for new admissions until corrections are in place, and,
ultimately, terminating the home from participation in these programs.
Sanctions are imposed by CMS on the basis of state referrals. States may
also use their state licensure authority to impose state sanctions.

CMS is also responsible for overseeing each state survey agency’s
performance in ensuring quality of care in its nursing homes. One of its
primary oversight tools is the federal monitoring survey, which is required
annually for at least 5 percent of all Medicare- and Medicaid-certified
nursing homes. Federal monitoring surveys can be either comparative or
observational. A comparative survey involves a federal survey team
conducting a complete, independent survey of a home within 2 months of
the completion of a state’s survey in order to compare and contrast the
findings. In an observational survey, one or more federal surveyors
accompany a state survey team to a nursing home to observe the team’s
performance. Roughly 85 percent of federal surveys are observational.
Based on prior work, we have concluded that the comparative survey is
the more effective of the two federal monitoring surveys for assessing
state agencies’ abilities to identify serious deficiencies in nursing homes
and have recommended that more priority be given to them. A new federal
oversight tool, state performance reviews, implemented in October 2000,
measures state survey agency performance against seven standards,
including statutory requirements regarding survey frequency, requirements
for documenting deficiencies, and timeliness of complaint investigations.
These reviews replaced state self-reporting of their compliance with
federal requirements. CMS also maintains a central database—the On-Line
Survey, Certification, and Reporting (OSCAR) system—that compiles,
among other information, the results of every state survey conducted at
Medicare- and Medicaid-certified facilities nationwide.




Page 4                                                        GAO-03-1016T
                     State survey data indicate that the proportion of nursing homes with
Magnitude of         serious quality problems remains unacceptably high, despite a decline in
Problems Remains     such reported problems since mid-2000. For an 18-month period ending in
                     January 2002, 20 percent of nursing homes (about 3,500) were cited for
Cause for Concern,   deficiencies involving actual harm or immediate jeopardy to residents.
Even Though Fewer    This share is down from 29 percent (about 5,000 homes) for the previous
                     period.3 (Appendix I provides trend data on the percentage of nursing
Serious Nursing      homes cited for serious deficiencies for all 50 states and the District of
Home Quality         Columbia.) Despite this decline, there is still considerable variation in the
Problems Were        proportion of homes cited for such serious deficiencies, ranging from
                     about 7 percent in Wisconsin to about 50 percent in Connecticut.
Reported
                     Federal comparative surveys completed during a recent 21-month period
                     found actual harm or higher-level deficiencies in about 10 percent fewer
                     homes where state surveyors found no such deficiencies, compared to an
                     earlier period. Fewer discrepancies between federal and state surveys
                     suggest that state surveyors’ performance in documenting serious
                     deficiencies has improved. However, the magnitude of the state surveyors’
                     understatement of quality problems remains a serious issue. From June
                     2000 through February 2002, federal surveyors conducting comparative
                     surveys found examples of actual harm deficiencies in about one fifth of
                     homes that states had judged to be deficiency free. For example, federal
                     surveyors found that a home had failed to prevent pressure sores, failed to
                     consistently monitor pressure sores when they did develop, and failed to
                     notify the physician promptly so that proper treatment could be started.
                     These federal surveyors noted that inadequate monitoring of pressure
                     sores was a problem during the state’s survey that should have been found
                     and cited. CMS plans to hire a contractor to perform approximately 170
                     additional comparative surveys each year, bringing the annual total to 330,
                     including those conducted by CMS surveyors.4 We continue to believe that
                     comparative surveys are the most effective technique for assessing state




                     3
                      We analyzed OSCAR data for surveys performed from January 1, 1999, through July 10,
                     2000, and from July 11, 2000, through January 31, 2002, and entered into OSCAR as of June
                     24, 2002. Immediate jeopardy involves situations with actual or potential for death/serious
                     injury.
                     4
                     Contractor proposals are due to CMS on July 19, 2003.




                     Page 5                                                                      GAO-03-1016T
                        agencies’ ability to identify serious deficiencies in nursing homes because
                        they constitute an independent evaluation of the state survey.5

                        Beyond the continuing high prevalence of actual harm or immediate
                        jeopardy deficiencies, we found a disturbing understatement of actual
                        harm or higher deficiencies in a sample of surveys that were conducted
                        since July 2000 at homes with a history of harming residents but whose
                        current surveys indicated no actual harm deficiencies. Overall, 39 percent
                        of 76 surveys we reviewed had documented problems that should have
                        been classified as actual harm: serious, avoidable pressure sores; severe
                        weight loss; and multiple falls resulting in broken bones and other injuries.
                        We were unable to assess whether the scope and severity of other
                        deficiencies in our sample of surveys were also understated because of
                        weaknesses in how those deficiencies were documented.


                        Despite increased attention in recent years, widespread weaknesses
Weaknesses Persist in   persist in state survey, complaint investigation, and enforcement activities.
State Survey,           In our view, this reflects not necessarily a lack of effort but rather the
                        magnitude of the challenge in effecting important and consistent systemic
Complaint, and          change across all states. We identified several factors that contributed to
Enforcement             these weaknesses and the understatement of survey deficiencies,
                        including confusion over the definition of actual harm. Moreover, many
Activities              state complaint investigation systems still have timeliness problems and
                        some states did not comply with HCFA’s policy to refer to the agency for
                        immediate sanction those nursing homes that showed a pattern of harming
                        residents, resulting in hundreds of nursing homes not appropriately
                        referred for action.




                        5
                         In prior work completed on veterans’ care in nursing homes, we recommended that the VA
                        consider contracting with CMS to conduct these comparative surveys in order to better
                        assess the quality of state data that are used in placing veterans in nursing homes. See U.S.
                        General Accounting Office, VA Long-Term Care: Oversight of Community Nursing
                        Homes Needs Strengthening, GAO-01-768 (Washington, D.C.: July 27, 2001). VA has not
                        contracted with CMS to conduct comparative surveys but is beginning to discuss the issue
                        with CMS.




                        Page 6                                                                       GAO-03-1016T
Confusion about Definition    We identified several factors at the state level that contributed to the
of Harm and Other Factors     understatement of serious quality-of-care problems. State survey agency
Contribute to                 officials expressed confusion about the definitions of “actual harm” and
                              “immediate jeopardy,” which may contribute to the variability in
Underreporting of Care        identifying deficiencies among states. Several states’ comments on our
Problems                      draft report underscored how the lack of clear and consistent CMS
                              guidance on these definitions may have contributed to such confusion. For
                              example, supplementary guidance provided to one state by its CMS
                              regional office on how to assess the severity of a newly developing
                              pressure sore was inconsistent with CMS’s definition of actual harm.

                              Other factors that have contributed to the understatement of actual harm
                              include lack of adequate state supervisory review of survey findings, large
                              numbers of inexperienced surveyors, and continued survey predictability.
                              While most of the 16 states we contacted had processes for supervisory
                              review of deficiencies cited at the actual harm level and higher, half did
                              not have similar processes to help ensure that the scope and severity of
                              less serious deficiencies were not understated.6 According to state
                              officials, the large number of inexperienced surveyors, which ranged from
                              25 percent to 70 percent in 27 states and the District of Columbia and is
                              due to high attrition and hiring limitations, has also had a negative impact
                              on the quality of surveys. In addition, our analysis of OSCAR data
                              indicated that the timing of about one-third of the most recent state
                              surveys nationwide remained predictable—a slight reduction from homes’
                              prior surveys, about 38 percent of which were predictable. Predictable
                              surveys can allow quality-of-care problems to go undetected because
                              homes, if they choose to do so, may conceal certain problems such as
                              understaffing.


Many State Complaint          CMS’s 2001 review of a sample of complaints in all states demonstrated
Investigation Systems Still   that many states were not complying with CMS complaint investigation
Have Timeliness Problems      timeliness requirements. Specifically, 12 states were not investigating all
                              immediate jeopardy complaints within the required 2 workdays, and 42
and Other Weaknesses          states were not complying with the new requirement established in 1999 to




                              6
                               Officials explained the focus on actual harm or higher-level deficiencies by noting that the
                              potential for sanctions increased the likelihood that the deficiencies would be challenged
                              by the nursing home and perhaps appealed in an administrative hearing.




                              Page 7                                                                        GAO-03-1016T
                         investigate actual harm complaints within 10 days.7 Some states attributed
                         the timeliness problem to an increase in the number of complaints and to
                         insufficient staff. CMS also found that the triaging of complaints to
                         determine how quickly to investigate each complaint was inadequate in
                         some states. A CMS-sponsored study of the states’ complaint practices
                         also raised concerns about state approaches to accepting and investigating
                         complaints. For example, 15 states did not provide toll-free hotlines to
                         facilitate the filing of complaints and the majority of states lacked
                         adequate systems for managing complaints. To address the latter problem,
                         CMS planned to implement a new complaint tracking system nationwide
                         in October 2002, but as of today, the system is still being tested and its
                         implementation date is uncertain.


Substantial Number of    State survey agencies did not refer a significant number of cases where
Nursing Homes Were Not   nursing homes were found to have a pattern of harming residents to CMS
Referred to CMS for      for immediate sanction as required by CMS policy, significantly
                         undermining the policy’s intended deterrent effect. Our earlier work found
Immediate Sanctions      that nursing homes tended to “yo-yo” in and out of compliance, in part
                         because HCFA rarely imposed sanctions on homes with a pattern of
                         deficiencies that harmed residents.8 In response, the agency required that,
                         as of January 2000, homes found to have harmed residents on successive
                         standard surveys be referred to it for immediate sanction.9 While most
                         states did not forward at least some cases that should have been referred
                         under this policy, four states accounted for over half of the 700 nursing


                         7
                          In March 1999, we reported that inadequate state complaint intake and investigation
                         practices in states we reviewed had too often resulted in extensive delays in investigating
                         serious complaints. As a result of our findings, HCFA began requiring states to investigate
                         complaints that allege actual harm, but do not rise to the level of immediate jeopardy,
                         within 10 working days. U.S. General Accounting Office, Nursing Homes: Complaint
                         Investigation Processes Often Inadequate to Protect Residents, GAO/HEHS-99-80
                         (Washington, D.C.: Mar. 22, 1999).
                         8
                         See GAO/HEHS-99-46.
                         9
                          This policy was implemented in two stages, and our analysis focused on implementation of
                         the second stage beginning in January 2000. As of September 1998, HCFA required states to
                         refer homes that had a pattern of harming a significant number of residents or placed
                         residents at high risk of death or serious injury. Effective January 14, 2000, HCFA expanded
                         this policy by requiring state survey agencies to refer for immediate sanction homes that
                         had harmed residents on successive surveys. States are now required to deny a grace
                         period to correct deficiencies without sanction to homes that are assessed one or more
                         deficiencies at the actual harm level or above in each of two surveys within a survey cycle.
                         A survey cycle is two successive standard surveys and any intervening survey, such as a
                         complaint investigation.




                         Page 8                                                                       GAO-03-1016T
                        homes not referred. One of these states did not fully implement the new
                        CMS policy until mid-2002 and another state implemented its own version
                        of the policy through September 2002, resulting in relatively few referrals.
                        In most other states, the failure to refer cases resulted from a
                        misunderstanding of the policy by both some states and CMS regional
                        offices and, in some states, from the lack of an adequate system for
                        tracking a home’s survey history to determine if it met the policy’s criteria.


                        While CMS has instituted a more systematic oversight process of state
CMS Oversight of        survey and complaint activities by initiating annual state performance
State Survey            reviews, CMS officials acknowledged that the effectiveness of the reviews
                        could be improved. Major areas needing improvement as a result of the
Activities Requires     fiscal year 2001 review include (1) distinguishing between minor and
Further Strengthening   major problems, (2) evaluating how well states document deficiencies, and
                        (3) ensuring consistency in how regions conduct reviews. Data limitations,
                        particularly involving complaints, and inconsistent use of periodic
                        monitoring reports also hampered the effectiveness of state performance
                        reviews. For subsequent reviews, CMS plans to more centrally manage the
                        process to improve consistency and to help ensure that future reviews
                        distinguish serious from minor problems.

                        Implementation has been significantly delayed for three federal initiatives
                        that are critical to reducing the subjectivity in the state survey process for
                        identifying deficiencies and determining the seriousness of complaints.
                        These delayed initiatives were intended to strengthen the methodology for
                        conducting surveys, improve surveyor guidance for determining the scope
                        and severity of deficiencies, and increase standardization in state
                        complaint investigation processes.

                    •   Strengthening the survey methodology. Because surveyors often
                        missed significant care problems due to weaknesses in the survey process,
                        HCFA contracted in 1998 for the development of a revised survey
                        methodology. The agency’s contractor has proposed a two-phase survey
                        process. In the first phase, surveyors would initially identify potential care
                        problems using data generated off-site prior to the start of the survey and
                        additional, standardized information collected on-site. During the second
                        phase, surveyors would conduct an onsite investigation to confirm and
                        document the care deficiencies initially identified. Compared to the
                        current survey process, the revised methodology under development is
                        designed to more systematically target potential problems at a home and
                        give surveyors new tools to more adequately document care outcomes and
                        conduct onsite investigations. In April 2003, a CMS official told us that the



                        Page 9                                                           GAO-03-1016T
                  agency lacked adequate funding to complete testing and implementation
                  of the revised methodology under development for almost 5 years.
                  Through September 2003, CMS will have committed about $4.7 million to
                  this effort. While CMS did not address the lack of adequate funding in its
                  comments on our draft report, a CMS official subsequently told us that
                  about $508,000 has now been slated for additional field testing. This
                  amount, however, has not yet been approved. Not funding the additional
                  field testing could jeopardize the entire initiative, in which a substantial
                  investment has already been made.

              •   Developing clearer guidance for surveyors. Recognizing
                  inconsistencies in how the scope and severity of deficiencies are cited
                  across states, in October 2000, HCFA began developing more structured
                  guidance for surveyors, including survey investigative protocols for
                  assessing specific deficiencies. The intent of this initiative is to enable
                  surveyors to better (1) identify specific deficiencies, (2) investigate
                  whether a deficiency is the result of poor care, and (3) document the level
                  of harm resulting from a home’s identified deficient care practices. Delays
                  have occurred, and the first such guidance to be completed—pressure
                  sores—has not yet been released.

              •   Developing additional state guidance for investigating complaints.
                  Despite initiation of a complaint improvement project in 1999, CMS has
                  not yet developed detailed guidance for states to help improve their
                  complaint investigation systems. CMS received its contractor’s report in
                  June 2002, and indicated agreement with the report’s conclusion that
                  reforming the complaint system is urgently needed to achieve a more
                  standardized, consistent, and effective process. CMS told us that it plans to
                  issue new guidance to the states in late fiscal year 2003—about 4 years
                  after the complaint improvement project initiative was launched.


                  As we reported in September 2000, continued federal and state attention is
Conclusions       required to ensure necessary improvements in the quality of care provided
                  to the nation’s vulnerable nursing home residents. The proportion of
                  homes reported to have harmed residents is still unacceptably high,
                  despite the reported decline in the incidence of such problems. This
                  decline is consistent with the concerted congressional, federal, and state
                  attention focused on addressing quality of care problems. Despite these
                  efforts, however, CMS needs to continue its efforts to better ensure
                  consistent compliance with federal quality requirements. Several areas
                  that require CMS’s ongoing attention include: (1) developing more
                  structured guidance for surveyors to address inconsistencies in how the
                  scope and severity of deficiencies are cited across states, (2) finalizing and


                  Page 10                                                          GAO-03-1016T
                    implementing the survey methodology redesign intended to make the
                    survey process more systematic, (3) implementing a nationwide complaint
                    tracking system and providing states additional complaint investigation
                    guidance, and (4) refining the newly established state agency performance
                    standard reviews to ensure that states are held accountable for ensuring
                    that nursing homes comply with federal nursing home quality standards.
                    Some of these efforts have been underway for several years, with CMS
                    consistently extending their estimated completion and implementation
                    dates. The need to come to closure on these initiatives is clear. The report
                    on which this testimony is based contained several new recommendations
                    for needed CMS actions on these issues; CMS generally concurred with
                    our recommendations.10 We believe that effective and timely
                    implementation of planned improvements in each of these areas is critical
                    to ensuring better quality care for the nation’s 1.7 million vulnerable
                    nursing home residents.


                    Mr. Chairman and Members of the Committee, this concludes my prepared
                    statement. I will be happy to answer any questions you may have.


                    For further information about this testimony, please contact Kathryn G.
Contact and Staff   Allen at (202) 512-7118 or Walter Ochinko at (202) 512-7157. Jack Brennan,
Acknowledgments     Patricia A. Jones, and Dean Mohs also made key contributions to this
                    statement.




                    10
                     GAO-03-561.




                    Page 11                                                        GAO-03-1016T
Appendix I: Trends in The Proportion of
Nursing Homes Cited for Actual Harm or
Immediate Jeopardy Deficiencies, 1999-2002

                                                             Percentage of homes cited for
                                                               actual harm or immediate
                        Number of homes surveyed                       jeopardy                  Percentage point differencea
                                                                                                 1/97-6/98 and 1/99-7/00 and
State                  1/97-6/98   1/99-7/00     7/00-1/02   1/97-6/98   1/99-7/00   7/00-1/02       1/99-7/00      7/00-1/02
Alabama                      227         225           228        51.1        42.2        18.4             -8.9          -23.8
Alaska                        16          15            15        37.5        20.0        33.3            -17.5           13.3
Arizona                      163         142           147        17.2        33.8         8.8             16.6          -25.0
Arkansas                     285         273           267        14.7        37.7        27.3             23.0          -10.4
California                 1,435       1,400         1,348        28.2        29.1         9.3              0.9          -19.9
Colorado                     234         227           225        11.1        15.4        26.2              4.3           10.8
Connecticut                  263         262           259        52.9        48.5        49.4             -4.4            0.9
Delaware                      44          42            42        45.5        52.4        14.3              6.9          -38.1
District of Columbia          24          20            21        12.5        10.0        33.3             -2.5           23.3
Florida                      730         753           742        36.3        20.8        20.1            -15.5           -0.8
Georgia                      371         368           370        17.8        22.6        20.5              4.8           -2.0
Hawaii                        45          47            46        24.4        25.5        15.2              1.1          -10.3
Idaho                         86          83            84        55.8        54.2        31.0             -1.6          -23.3
Illinois                     899         900           881        29.8        29.3        15.4             -0.5          -13.9
Indiana                      602         590           573        40.5        45.3        26.2              4.8          -19.1
Iowa                         525         492           494        39.2        19.3         9.9            -19.9           -9.4
Kansas                       445         410           400        47.0        37.1        29.0             -9.9           -8.1
Kentucky                     318         312           306        28.6        28.8        25.2              0.2           -3.7
Louisiana                    433         387           367        12.7        19.9        23.4              7.2            3.5
Maine                        135         126           124         7.4        10.3         9.7              2.9           -0.6
Maryland                     258         242           248        19.0        25.6        20.2              6.6           -5.5
Massachusetts                576         542           512        24.0        33.0        22.9              9.0          -10.2
Michigan                     451         449           441        43.7        42.1        24.7             -1.6          -17.4
Minnesota                    446         439           431        29.6        31.7        18.8              2.1          -12.9
Mississippi                  218         202           219        24.8        33.2        19.6              8.4          -13.5
Missouri                     595         584           569        21.0        22.3        10.2              1.3          -12.1
Montana                      106         104           103        38.7        37.5        25.2             -1.2          -12.3
Nebraska                     263         242           243        32.3        26.0        18.9             -6.3           -7.1
Nevada                        49          52            51        40.8        32.7         9.8             -8.1          -22.9
New Hampshire                 86          83            79        30.2        37.3        21.5              7.1          -15.8
New Jersey                   377         359           366        13.0        24.5        22.4             11.5           -2.1
New Mexico                    88          82            82        11.4        31.7        17.1             20.3          -14.6
New York                     662         668           671        13.3        32.2        32.3             18.9            0.2
North Carolina               407         414           419        31.0        40.8        30.1              9.8          -10.7
North Dakota                  88          89            88        55.7        21.3        28.4            -34.4            7.1
Ohio                       1,043       1,047         1,029        31.2        29.0        23.7             -2.2           -5.3
Oklahoma                     463         432           394         8.4        16.7        20.6              8.3            3.9
Oregon                       171         158           152        43.9        47.5        33.6              3.6          -13.9
Pennsylvania                 811         788           764        29.3        32.2        11.6              2.9          -20.6



                                       Page 12                                                                  GAO-03-1016T
                                                                                    Percentage of homes cited for
                                                                                      actual harm or immediate
                                                                                                                                                     a
                                          Number of homes surveyed                            jeopardy                   Percentage point difference
                                                                                                                         1/97-6/98 and 1/99-7/00 and
 State                                 1/97-6/98          1/99-7/00     7/00-1/02   1/97-6/98   1/99-7/00    7/00-1/02       1/99-7/00      7/00-1/02
 Rhode Island                                102                 99            99        11.8        12.1         10.1              0.3           -2.0
 South Carolina                              175                178           180        28.6        28.7         17.8              0.1          -10.9
 South Dakota                                124                112           114        40.3        24.1         30.7            -16.2            6.6
 Tennessee                                   361                354           377        11.1        26.0         16.7             14.9           -9.3
 Texas                                     1,381              1,336         1,275        22.2        26.9         25.5              4.7           -1.5
 Utah                                         98                 95            95        15.3        15.8         15.8              0.5            0.0
 Vermont                                      45                 46            45        20.0        15.2         17.8             -4.8            2.6
 Virginia                                    279                287           285        24.7        19.9         11.6             -4.8           -8.3
 Washington                                  288                279           275        63.2        54.1         38.5             -9.1          -15.6
 West Virginia                               130                147           143        12.3        15.6         14.0              3.3           -1.7
 Wisconsin                                   438                428           421        17.1        14.0          7.1             -3.1           -6.9
 Wyoming                                      38                 41            40        28.9        43.9         22.5             15.0          -21.4
 Nation                                   17,897             17,452        17,149        27.7        29.3         20.5              1.6           -8.8
Source: GAO analysis of OSCAR data as of June 24, 2002.
                                                              a
                                                              Differences are based on numbers before rounding.




                                                              Page 13                                                                   GAO-03-1016T
Related GAO Products


             Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
             National Implementation Is Premature. GAO-03-187. Washington, D.C.:
             October 31, 2002.

             Nursing Homes: Quality of Care More Related to Staffing than Spending.
             GAO-02-431R. Washington, D.C.: June 13, 2002.

             Nursing Homes: More Can Be Done to Protect Residents from Abuse.
             GAO-02-312. Washington, D.C.: March 1, 2002.

             Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
             Should Complement State Activities. GAO-02-279. Washington, D.C.:
             February 15, 2002.

             VA Long-Term Care: Oversight of Community Nursing Homes Needs
             Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.

             Nursing Homes: Success of Quality Initiatives Requires Sustained
             Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.:
             September 28, 2000.

             Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
             the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September
             28, 2000.

             Nursing Home Care: Enhanced HCFA Oversight of State Programs
             Would Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.:
             November 4, 1999.

             Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies
             to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.:
             November 4, 1999.

             Nursing Home Oversight: Industry Examples Do Not Demonstrate That
             Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,
             D.C.: August 13, 1999.

             Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but
             Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington,
             D.C.: June 30, 1999.

             Nursing Homes: Proposal to Enhance Oversight of Poorly Performing
             Homes Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.


             Page 14                                                    GAO-03-1016T
           Nursing Homes: Complaint Investigation Processes in Maryland.
           GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999.

           Nursing Homes: Complaint Investigation Processes Often Inadequate to
           Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.

           Nursing Homes: Stronger Complaint and Enforcement Practices Needed
           to Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.:
           March 22, 1999.

           Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
           Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March
           18, 1999.

           California Nursing Homes: Federal and State Oversight Inadequate to
           Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS-
           98-219. Washington, D.C.: July 28, 1998.

           California Nursing Homes: Care Problems Persist Despite Federal and
           State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.




(290310)
           Page 15                                                  GAO-03-1016T
This is a work of the U.S. government and is not subject to copyright protection in the
United States. It may be reproduced and distributed in its entirety without further
permission from GAO. However, because this work may contain copyrighted images or
other material, permission from the copyright holder may be necessary if you wish to
reproduce this material separately.
                         The General Accounting Office, the audit, evaluation and investigative arm of
GAO’s Mission            Congress, exists to support Congress in meeting its constitutional
                         responsibilities and to help improve the performance and accountability of the
                         federal government for the American people. GAO examines the use of public
                         funds; evaluates federal programs and policies; and provides analyses,
                         recommendations, and other assistance to help Congress make informed
                         oversight, policy, and funding decisions. GAO’s commitment to good
                         government is reflected in its core values of accountability, integrity, and
                         reliability.


                         The fastest and easiest way to obtain copies of GAO documents at no cost is
Obtaining Copies of      through the Internet. GAO’s Web site (www.gao.gov) contains abstracts and full-
GAO Reports and          text files of current reports and testimony and an expanding archive of older
                         products. The Web site features a search engine to help you locate documents
Testimony                using key words and phrases. You can print these documents in their entirety,
                         including charts and other graphics.

                         Each day, GAO issues a list of newly released reports, testimony, and
                         correspondence. GAO posts this list, known as “Today’s Reports,” on its Web
                         site daily. The list contains links to the full-text document files. To have GAO e-
                         mail this list to you every afternoon, go to www.gao.gov and select “Subscribe to
                         e-mail alerts” under the “Order GAO Products” heading.


Order by Mail or Phone   The first copy of each printed report is free. Additional copies are $2 each. A
                         check or money order should be made out to the Superintendent of Documents.
                         GAO also accepts VISA and Mastercard. Orders for 100 or more copies mailed to
                         a single address are discounted 25 percent. Orders should be sent to:

                         U.S. General Accounting Office
                         441 G Street NW, Room LM
                         Washington, D.C. 20548

                         To order by Phone:    Voice:     (202) 512-6000
                                               TDD:       (202) 512-2537
                                               Fax:       (202) 512-6061


                         Contact:
To Report Fraud,
                         Web site: www.gao.gov/fraudnet/fraudnet.htm
Waste, and Abuse in      E-mail: fraudnet@gao.gov
Federal Programs         Automated answering system: (800) 424-5454 or (202) 512-7470


                         Jeff Nelligan, Managing Director, NelliganJ@gao.gov (202) 512-4800
Public Affairs           U.S. General Accounting Office, 441 G Street NW, Room 7149
                         Washington, D.C. 20548