oversight

Management Report: CMS Needs to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations That Persisted in Oregon for at Least 15 Years

Published by the Government Accountability Office on 2019-04-15.

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

441 G St. N.W.
Washington, DC 20548


April 15, 2019

The Honorable Alex M. Azar II
Secretary of Health and Human Services

Management Report: CMS Needs to Address Gaps in Federal Oversight of Nursing
Home Abuse Investigations That Persisted in Oregon for at Least 15 Years

Nationwide, approximately 15,600 nursing homes provide care to about 1.4 million nursing
home residents, a population of elderly and disabled individuals. To help ensure this population
receives quality care and is free from abuse, consistent with federal statutory requirements, the
Centers for Medicare & Medicaid Services (CMS) defines the standards nursing homes must
meet in order to participate in the Medicare and Medicaid programs, including standards for
resident care and safety. 1 To monitor compliance with these standards, CMS enters into
agreements with agencies in each state government—known as state survey agencies—and
oversees the work the survey agencies do. 2

Survey agencies are required to conduct standard surveys, or evaluations, approximately once
each year of the state’s nursing homes and investigate both complaints from the public and
facility-reported incidents regarding resident care or safety, such as abuse. 3 Investigations of
nursing homes based on public complaints and facility-reported incidents offer a unique
opportunity for the state survey agencies to identify potential abuse, as these can provide a
timely alert of acute issues that otherwise might not be addressed until the standard survey.
Deficiencies found as a result of federal nursing home surveys and investigations of complaints
and facility-reported incidents can be cited and tracked by CMS, providing valuable information
about nursing home quality. In addition, federal sanctions can be imposed on the nursing home



1
CMS is an agency within the Department of Health and Human Services (HHS).

CMS defines abuse in its guidance as “the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an
individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and
psychosocial well-being.”
2
 In Oregon, the state survey agency is the Nursing Facility Survey Unit, which is part of Oregon’s Department of
Human Services. Survey agencies are frequently housed in the health or human services departments of state
governments and may have different names in different states.
3
 By law, every nursing home receiving Medicare or Medicaid payment must undergo a standard survey during which
teams of state surveyors conduct a comprehensive on-site evaluation of compliance with federal quality standards.
These surveys must occur at least once every fifteen months, with a statewide average interval for surveys not to
exceed 12 months. 42 U.S.C. §§ 1395i-3(g)(1)(A), (g)(2)(A)(iii), 1396r(g)(1)(A), (g)(2)(A)(iii).

State survey agencies are also required to investigate allegations of neglect and abuse in nursing homes in response
to complaints and facility-reported incidents filed with state survey agencies. 42 U.S.C. §§ 1395i-3(g)(1)(C),
1396r(g)(1)(C). During an investigation, state surveyors evaluate the nursing home’s compliance with a specific
federal quality standard.


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in order to prompt the correction of deficiencies, and quality information about deficiencies can
be monitored by CMS and communicated to consumers.

In October 2017, we began work reviewing CMS oversight of nursing home abuse in response
to a request from the Senate Homeland Security and Governmental Affairs Permanent
Subcommittee on Investigations. As part of this review, we interviewed officials from survey
agencies about how they investigate complaints and facility-reported incidents of resident abuse
in nursing homes in five selected states. 4 We became aware that Oregon—a state with 135
nursing homes caring for approximately 7,000 residents, as of December 2018—was not
following federal requirements that the survey agency investigate all complaints and facility-
reported incidents. 5 Specifically, instead of the survey agency, Oregon’s Adult Protective
Services (APS)—a state program that is part of Oregon’s Department of Human Services but is
separate from the survey agency—was investigating complaints and facility-reported incidents
of abuse—including physical, sexual, and mental/verbal abuse—in nursing homes. 6 While APS
investigators in Oregon are trained to provide protection and intervention for older adults across
the state in various settings and to play a valuable role in helping protect nursing home
residents from abuse, they are not trained in, or focused on, investigating abuse according to
federal nursing home regulations. In addition, abuse investigated by APS is not reflected in




4
 Oregon was one of the five states we selected as part of the initial request. The selected states reflect variation in
geography, CMS regional oversight, the number of nursing homes in the state, and the involvement of Adult
Protective Services (APS) in nursing home oversight, as well as congressional interest. We expect to issue the report
on CMS oversight of nursing home abuse later this year.
5
 In the context of this report, “investigate” denotes the process by which an agency does the intake and triage of
complaints and facility-reported incidents, as well as the investigation of complaints and facility-reported incidents.

CMS data identified 135 nursing homes in Oregon as of December 2018, but Oregon officials told us there were 132
active nursing homes in Oregon as of December 2018, and information we received from Oregon identified three
nursing homes on CMS’s list had closed.
6
 Oregon APS is a state program that provides protection and intervention for older adults and adults with physical
disabilities in licensed long term care facilities, as well as in the general community, who are unable to protect
themselves from abuse and self-neglect. In all states, APS is charged with receiving and responding to reports of
adult maltreatment and working closely with clients and a wide variety of allied professionals to maximize client safety
and independence, according to the Administration for Community Living. In some states, APS may not have
jurisdiction in nursing homes, and the Administration for Community Living noted in a 2018 report that in 38 states,
APS investigates allegations of maltreatment when they occur in at least some types of residential facilities.
Department of Health and Human Services, Administration for Community Living, NAMRS FFY 2017 Report 1:
Agency Component (Sept. 27, 2018).

A 2005 Oregon policy stated that APS should investigate nursing home complaints and facility-reported incidents that
allege financial, verbal/mental, sexual, and physical abuse, involuntary seclusion, and neglect of care, and that the
survey agency should investigate nursing home complaints and facility-reported incidents alleging falls, bone
fractures, pressure ulcers, hospitalizations, emergency room visits, urgent care visits, deaths, and concerns relating
to restraints. The policy notes that for complaints involving multiple allegations, if one or more of the allegations meet
the referral criteria for the survey agency, all allegations contained in the complaint will be referred to the survey
agency. According to Oregon survey agency officials, this delineation of responsibilities continued until October 29,
2018.


Page 2                                                       GAO-19-313R CMS Nursing Home Incident Oversight
nursing home federal reporting to consumers, nor does it result in federal nursing home
enforcement actions. 7

When we learned that the Oregon survey agency was not investigating all complaints and
facility-reported incidents of abuse in nursing homes, we collected more detailed information
from CMS and Oregon. Specifically, we reviewed policy documents from CMS, including the
State Operations Manual and the Oregon survey agency’s agreement with CMS, and
interviewed officials from CMS Central Office, CMS Regional Office 10, and Oregon’s
Department of Human Services (DHS)—which includes the survey agency and APS—to gather
more information on CMS’s oversight of the Oregon survey agency and the Oregon survey
agency’s activities. 8 In addition, we examined information on substantiated nursing home abuse
deficiencies from publicly available CMS and Oregon online resources. 9 We also assessed
CMS’s oversight activities in the context of federal standards for internal control for monitoring
activities and using quality information. 10

We conducted this performance audit from December 2018 through April 2019 in accordance
with generally accepted government auditing standards. Those standards require that we plan
and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions based on our audit
objectives.

CMS Failed to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations
in Oregon for at Least 15 Years

We found that, for at least 15 years, CMS’s oversight failed to address that the Oregon survey
agency was not investigating all abuse complaints and facility-reported incidents, as required by
federal law. From at least the early 2000s through October 29, 2018, the Oregon survey agency
did not investigate all allegations of abuse in nursing homes that came from complaints or
facility-reported incidents—some of those, including allegations of sexual, physical, and
mental/verbal abuse, were instead investigated by Oregon’s APS, and the results of those




7
 Under federal law, if a state survey agency finds that a nursing facility does not meet federal requirements and finds
that the facility’s deficiencies immediately jeopardize the health or safety of its residents, the survey agency must
recommend to CMS that enforcement action be taken. Such actions include the imposition of civil money penalties,
denial of payment, assignment of a temporary manager, installation of a state monitor, and termination from
participation in Medicare or Medicaid. In addition, if a survey agency finds that a nurse aide has engaged in abuse or
neglect of a nursing facility resident (or misappropriation of resident’s property), the agency must report this
information to the state’s nurse aide registry. 42 U.S.C. §§ 1395i-3(g)(1)(C), (h), 1396r(g)(1)(C), (h).
8
CMS’s 10 regional offices oversee state activities and report back to CMS central office the results of their efforts.
9
 CMS Nursing Home Compare: https://www.medicare.gov/nursinghomecompare/search.html? Accessed Nov. 7,
2018. Oregon’s Facilities Search: https://ltclicensing.oregon.gov/Facilities Accessed Aug. 14, 2018.
10
  GAO, Standards for Internal Control in the Federal Government. GAO-14-704G (Washington, D.C.: Sept. 10,
2014). Internal control is a process effected by an entity’s oversight body, management, and other personnel that
provides reasonable assurance that the objectives of an entity will be achieved.




Page 3                                                      GAO-19-313R CMS Nursing Home Incident Oversight
investigations were not shared with CMS. 11 Complaints and facility-reported incidents are
especially important in the context of abuse—in 2017, CMS data show that about three-quarters
of the total abuse deficiencies nationwide originated from complaints or facility self-reported
incidents. 12

According to current CMS officials, CMS became aware that Oregon had been relying on APS
and not the survey agency to investigate complaints and facility-reported incidents of abuse in a
July 2016 conversation at a regularly scheduled meeting between state agencies and CMS
regional office officials. CMS regional office officials said that, subsequent to that July 2016
conversation, they conducted additional analysis to better understand the issue, including an
onsite visit with Oregon survey agency officials in 2017. According to CMS officials, at this
onsite visit CMS officials confirmed that complaints and facility-reported incidents were not
being properly handled in Oregon, and they informed the Oregon survey agency that it was not
meeting the requirements of its agreement with CMS.

However, evidence suggests CMS had previously been aware of the issue in the early 2000s,
and its oversight activities either did not detect or pursue Oregon’s noncompliance. Oregon DHS
officials told us that CMS has been aware of their practices for many years and said state policy
changes made in 2002 regarding nursing home abuse complaints and facility-reported incidents
were made at the direction of CMS. In addition, Oregon’s abuse investigation practices were
briefly noted in a 2003 GAO report, which cited CMS regional office officials explaining Oregon’s
longstanding practice of contracting out investigations of complaints and facility-reported
incidents to local government entities not under the control of the Oregon survey agency,
resulting in information about the investigations, including deficiencies identified, not being
entered into CMS’s database. 13

In September 2018, Oregon survey agency officials provided a draft plan documenting a goal of
having staff hired and being able to survey independently by September 2020, at which point
they could be in compliance with the CMS requirement to have all nursing home complaints and
facility-reported incidents screened, triaged and investigated by survey agency staff. Oregon
officials told us in December 2018 that the timeline was subsequently accelerated when CMS
required the Oregon survey agency to assume complete responsibility for investigating all
nursing home complaints and facility-reported incidents. Oregon officials told us that, as of
October 29, 2018, the policy of the Oregon survey agency is to be responsible for all nursing




11
  We have previously reported on concerns with the complaint process more broadly. See GAO, Nursing Homes:
Complaint Investigation Processes Often Inadequate to Protect Residents, HEHS-99-80 (Washington, D.C.: Mar. 22,
1999) and GAO, Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of
State Complaint Investigations, GAO-11-280 (Washington, D.C.: Apr. 7, 2011).
12
  See CMS’s nursing home abuse reports available on its publicly available website: https://qcor.cms.gov/main.jsp
Accessed 1/9/19. According to Oregon APS officials, they investigated nearly 1,000 complaints and facility-reported
incidents of nursing home abuse in 2017, though the definition of abuse used by Oregon differs from the federal
definition. Federal law requires that abuse allegations be investigated by federally contracted and trained survey
agency surveyors. 42 U.S.C. §§ 1395i-3(g)(1)(C), 1396r(g)(1)(C).
13
  See GAO, Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of
Enhanced Oversight, GAO-03-561, (Washington, D.C.: July 15, 2003). This irregularity was noted in a report section
highlighting shortcomings with CMS’s state performance standards and review, and the report included a
recommendation to CMS that it further refine its annual state performance reviews.


Page 4                                                    GAO-19-313R CMS Nursing Home Incident Oversight
home complaint and facility-reported incident investigations. 14 CMS officials told us that Oregon
officials communicated this policy change assuming responsibility for all nursing home
complaints and facility-reported incidents as of October 29, 2018, and that CMS is planning
additional follow up to confirm.

CMS officials told us they have not seen indications of other states being out of compliance for
not assuming responsibility for all complaints and facility-reported incidents of abuse, but that
their current approach for overseeing survey agencies does not specifically examine whether
survey agencies are taking responsibility for investigating all nursing home complaints or facility-
reported incidents. Federal standards for internal control direct management to establish and
operate monitoring activities to monitor the internal control system and evaluate the results. 15
Until CMS evaluates state survey agency processes specifically to ensure that state agencies
are responsible for directly receiving and investigating complaints from the public and facility
reported incidents from nursing homes, the agency cannot ensure all states are in compliance
with this critical aspect of abuse investigations.

Gaps in Federal Oversight of Nursing Home Abuse Investigations in Oregon Resulted in
Lack of CMS Oversight and Consumer Information

While transitioning responsibility of all nursing home investigations to the survey agency is an
important first step, Oregon’s longstanding non-compliance with CMS complaint and facility-
reported incident investigation requirements means that CMS does not have information on
more than 15 years of complaint and facility-reported abuse incidents in Oregon. Complete
information on nursing home abuse for at least the last several years is important to several
aspects of how CMS oversees nursing home quality, including CMS’s ability to identify and
address patterns of abuse within and across nursing homes in Oregon.


Example of patterns of abuse in Oregon not captured in Centers for Medicare & Medicaid
Services (CMS) records. In March 2016, a CMS survey cited a nursing home for being slow to
initiate an investigation when a resident had inappropriate sexual contact with another resident
who was not able cognitively to consent. A pattern of the nursing home failing to adequately
address similar incidents showed up in an Adult Protective Services (APS) report of two
subsequent incidents. Specifically, an August 2016 APS investigation found that the nursing
home failed to prevent a resident from inappropriately touching another resident. Three months
later, another APS investigation found the nursing home failed to protect the same resident from
abuse from the same resident perpetrator. As these last two incidents were not reported to
CMS, CMS could not identify an overall pattern of the nursing home failing to prevent,
investigate, or report abuse, nor could federal nursing home deficiency penalties be imposed.
Source: GAO analysis of CMS and Oregon Department of Human Services data | GAO-19-313R




14
  An Oregon survey agency official said the accelerated transition has resulted in a significant increase in staff
workload, which will affect, among other things, the survey agency’s ability to meet CMS timeliness standards for
conducting standard nursing home surveys. Oregon officials told us they are hiring new staff to increase their
capacity and expect to have staff hired, trained, and working independently to survey by early 2020. Oregon’s long-
term plan estimates that Oregon will be within CMS approved survey intervals by October 2020.
15
  GAO-14-704G.


Page 5                                                                        GAO-19-313R CMS Nursing Home Incident Oversight
This incomplete information may make it more difficult for CMS to recognize when nursing
homes in Oregon are not meeting program standards. 16 In addition, because nursing home
abuse complaints and facility-reported incidents were primarily investigated by APS for more
than fifteen years, nursing homes in Oregon were subject only to state-imposed financial
penalties for those complaints and facility-reported incidents, which were not investigated or
enforced under federal nursing home regulations. Federal penalties, which can escalate for
repeated violations, may only be imposed in response to a federal survey.

Finally, consumers looking for information on Oregon nursing homes using CMS’s Nursing
Home Compare, the CMS website used by consumers for information about nursing home
quality, have not received a complete picture of nursing home quality, particularly related to
issues of abuse. Specifically, information on abuse complaints and facility-reported incidents in
Oregon investigated by APS instead of the survey agency has not been included on CMS’s
Nursing Home Compare, and CMS officials told us they have not incorporated APS information
on nursing home abuse in Oregon from previous investigations into its monitoring and oversight
efforts. 17 While this information may be difficult for CMS and the survey agency to incorporate
directly into Nursing Home Compare because the assessments were done by APS investigators
using state standards, the information from APS investigations is still valuable.


Example of abuse information not available to consumers on Nursing Home Compare
about Oregon nursing homes. Our analysis found instances of sexual and physical abuse
substantiated by Adult Protective Services (APS) in Oregon that were not on the Centers for
Medicare & Medicaid Services’ (CMS) Nursing Home Compare website. In 2015, for example,
Oregon APS investigated and substantiated an allegation of sexual abuse by a staff member,
noting that the facility failed to protect the resident from sexual abuse and did not immediately
report the suspected sexual abuse to law enforcement. GAO found no record of this incident on
CMS’s Nursing Home Compare website at the time of our review.
Source: GAO analysis of CMS and Oregon Department of Human Services data | GAO-19-313R


Further, CMS’s Nursing Home Compare website did not note the lack of information from
Oregon on all nursing home complaints and facility-reported incidents of abuse made through
October 29, 2018. Without a complete picture of Oregon nursing home compliance, CMS and
consumers have incomplete information on the actual quality of nursing homes in Oregon based
on federal standards. These gaps in information are inconsistent with federal internal control
standards directing management to use quality information to achieve program objectives—in
this instance, internally for CMS and with regard to its stated objective for the Nursing Home
Compare website to provide detailed information to consumers. 18 CMS officials said they could



16
  Oregon survey agency officials told us that prior to October 29, 2018, state surveyors would review APS reports
prior to a survey at a nursing home to identify patterns of abuse.
17
  Nursing Home Compare is a CMS website that allows consumers to find and compare nursing homes and that,
according to CMS, provides “detailed information about every Medicare and Medicaid certified nursing home in the
country.” The Five Star Rating program, part of CMS’s Nursing Home Compare, allows nursing home consumers,
their families, and caregivers the ability to compare nursing homes more easily and to help identify areas about which
they may want to ask questions. https://www.medicare.gov/nursinghomecompare/search.html? Accessed Nov. 7,
2018.Oregon’s Facilities Search: https://ltclicensing.oregon.gov/Facilities Accessed Aug. 14, 2018.
18
  GAO-14-704G.


Page 6                                                                        GAO-19-313R CMS Nursing Home Incident Oversight
not use APS complaint investigation information because APS investigators do not have the
authority to survey for noncompliance with CMS’s federal nursing home requirements.

Conclusions
Investigations of complaints and facility-reported incidents of abuse in nursing homes provide a
critical opportunity for CMS to quickly identify and correct abuse to safeguard residents. Without
information from these investigations, the period of time in which residents potentially could be
harmed may be prolonged and necessary corrective actions may be delayed. For many years,
CMS’s oversight failed to address the fact that the Oregon survey agency was not performing all
of these investigations as required by federal law. Instead, abuse allegations from complaints
and facility-reported incidents related to allegations of sexual, physical, mental/verbal and some
other types of abuse were investigated by the state’s APS program and not by the state survey
agency, potentially resulting in CMS missing patterns of abuse, a lack of federal penalties for
abuse-related deficiencies, and incomplete information on nursing home quality indicators on
the CMS Nursing Home Compare website.

CMS and Oregon worked together to have the survey agency assume responsibility in October
2018 for investigating all complaints and facility-reported incidents, and CMS officials told us
they are working to confirm Oregon’s compliance with CMS policies. However, CMS has not
performed oversight focusing on whether other state survey agencies are responsible for all
nursing home complaints and facility-reported incidents to ensure that there are no other states
with similar compliance concerns. Additionally, CMS officials told us they have not incorporated
APS information on nursing home abuse in Oregon from previous investigations into its
monitoring and oversight efforts. Without this information, CMS will continue to have incomplete
information on nursing homes’ histories of abuse in Oregon. This incomplete information
significantly understates occurrences of abuse in Oregon nursing homes in CMS data, limits
CMS’s ability to take appropriate oversight action in situations where a pattern of abuse may
exist, and makes it harder for consumers to make informed decisions about nursing homes.

Recommendations for Executive Action
We are making the following three recommendations to the administrator of CMS:

CMS should evaluate state survey agency processes in all states to ensure all state survey
agencies are meeting federal requirements that state survey agencies are responsible for
investigating complaints and facility-reported incidents alleging abuse in nursing homes, and
that the results of those investigations are being shared with CMS. (Recommendation 1)

CMS should identify options for capturing information from Oregon’s APS investigations of
complaints and facility-reported incidents of abuse and incorporate this information into
oversight of Oregon nursing homes. (Recommendation 2)

CMS should clearly communicate to consumers the lack of data on abuse complaints and
facility-reported incidents in Oregon nursing homes contained in the CMS Nursing Home
Compare website. (Recommendation 3)




Page 7                                           GAO-19-313R CMS Nursing Home Incident Oversight
Agency Comments

We provided a draft of this report to HHS and the Oregon Department of Human Services for
review and comment. In its comments, reproduced in Enclosure I, HHS concurred with our three
recommendations. HHS indicated that it will take action to confirm states are using appropriate
personnel to investigate nursing home complaints and facility-reported incidents. HHS also
indicated it has directed Oregon survey agency officials to develop a plan for identifying APS
cases, if any, requiring additional investigation. Finally, HHS told us that until relevant data
regarding cases requiring additional investigation are captured and reflected on the Nursing
Home Compare website, HHS will post a notice on the Nursing Home Compare website
directing consumers to Oregon’s APS website for details on previous complaints and facility-
reported incidents. The Oregon Department of Human Services also provided written
comments, reproduced in Enclosure II, which described its prior practice in investigating
allegations of abuse in nursing homes and noted understanding the need to shift responsibility
to conduct investigations to the state survey agency as of October 2018. Oregon’s comments
also noted that the state Department of Human Services is coordinating with CMS to explore
providing a link on the Nursing Home Compare website to state data. In addition, HHS and the
Oregon Department of Human Services provided technical comments, which we incorporated
as appropriate.
                                                   ---
We are sending copies of this report to the appropriate congressional offices and other
interested parties. In addition, the report is available at no charge on the GAO Web site at
http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or
at dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. Major contributors to this report were Karin
Wallestad (Assistant Director), Luke Baron (Analyst-in-Charge), and Sarah-Lynn McGrath. Also
contributing were Kathryn Richter, Summar Corley, Jennifer Whitworth, and Laurie Pachter.




John E. Dicken
Director, Health Care




Page 8                                           GAO-19-313R CMS Nursing Home Incident Oversight
Enclosure I: Comments from the Department of Health and Human Services




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Enclosure I: Comments from the Department of Health and Human Services




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Enclosure I: Comments from the Department of Health and Human Services




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Enclosure I: Comments from the Department of Health and Human Services




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Enclosure II: Comments from the Oregon Department of Human Services




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Enclosure II: Comments from the Oregon Department of Human Services




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Enclosure II: Comments from the Oregon Department of Human Services




Page 15                                  GAO-19-313R CMS Nursing Home Incident Oversight
Enclosure II: Comments from the Oregon Department of Human Services




(103233)


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