Overseeing Patient Care and Safety

HHS faces several challenges in overseeing patient care and safety in nursing homes, facilities for beneficiaries with developmental disabilities, and hospitals.

• CMS's oversight of the quality of nursing home care has increased significantly in recent years, but continued attention is required. Under contract with the CMS, states conduct surveys at nursing homes to help ensure compliance with federal quality standards, but a substantial percentage of state nursing home surveyors and state agency directors identified weaknesses in CMS’s survey methodology and guidance. In addition to weaknesses in the survey process, workforce shortages and insufficient training, inconsistencies in the focus and frequency of the supervisory review of deficiencies, and external pressure from the nursing home industry may lead to understatement of serious care problems. CMS established the Special Facility Focus (SFF) Program in 1998 to help address poor nursing home performance. The SFF Program is limited to 136 homes because of resource constraints, but according to GAO's estimate, almost 4 percent (580) of the roughly 16,000 nursing homes in the United States could be considered the most poorly performing. Furthermore, GAO found that when selecting SFFs from the candidate list, state officials considered factors other than rank on that list and some states did not consistently follow CMS's basic SFF Program requirements. While CMS can temporarily take over management of a nursing home instead of terminating it from participating in Medicare and Medicaid when nursing homes place residents at risk of death or serious injury or at widespread risk of actual harm, this authority is rarely used.
  

  Highlights of GAO-09-689 (PDF), Full Report of GAO-10-37R (PDF), Highlights of GAO-10-70 (PDF)

• CMS's current approach for funding state surveys of facilities participating in Medicare and Medicaid is ineffective yet these surveys are meant to ensure that these facilities provide safe, high-quality care. We found serious weaknesses in CMS's ability to (1)equitably allocate more than $250 million in federal Medicare funding to states according to their workload, (2) determine the extent to which funding or other factors affected states ability to accomplish their workload, and (3) guarantee appropriate state contributions. These weaknesses make assessing the adequacy of funding difficult.
  

  Highlights of GAO-09-64 (PDF)

• Regarding hospitals, HHS agencies have taken steps to oversee patient safety. CMS issued a final rule stating that for any one of eight specific adverse outcomes that could have been avoided with proper treatment — such as objects accidentally left in a patient's body after surgery — Medicare will not pay hospitals more to treat patients who experience those adverse outcomes.
  

  Highlights of GAO-08-283 (PDF)

• Regarding health-care-associated infections, CDC issued 13 guidelines for hospitals with almost 1,200 recommended practices on infection control and prevention. However, HHS has not identified priorities among these practices or how its agencies can promote them. In January 2009, the department released the HHS Action Plan to Prevent Healthcare-Associated Infections for comment; however, it remains uncertain when this plan will be implemented.
  

  Highlights of GAO-08-283 (PDF) and GAO-09-516T (PDF)

• Additionally, to increase information available about health-care-associated infections, HHS faces the challenge of having to establish greater consistency and compatibility of the data collected on these infections across the department. For example, the increasing volume of procedures and evidence of infection control lapses in Ambulatory Surgical Centers (ASCs) create a compelling need for current and nationally representative data on health-care-associated infections in ASCs in order to reduce their risk. However, only disparate sources of data on health-care-associated infections in ASCs are available, none of which provide information on the extent of the problem nationwide. Such data are useful for guiding federal policies aimed at preventing the lapses in infection control practices.
  

  Highlights of GAO-08-283 (PDF) and GAO-09-213 (PDF)

^ Back to topWhat Needs to Be Done

Action should be taken by HHS and CMS to strengthen federal oversight of the safety and care of patients. Specifically, CMS should

• strengthen the SFF program by notifying homes that are on the SFF candidate list and seek legislative authority to charge SFFs for the costs associated with conducting additional surveys
  

  Highlights of GAO-09-689 (PDF), Highlights of GAO-10-197

• refine its method for evaluating nursing home performance;
  

  Highlights of GAO-09-689 (PDF), Highlights of GAO-07-373

• improve its monitoring of nursing homes with records of serious care problemsby addressing state agency and nursing home surveyor issues related to CMS’s survey methodology and guidance, workforce shortages and insufficient training, inconsistencies in the focus and frequency of the supervisory review of deficiencies, and external pressure from the nursing home industry.
  

  Highlights of GAO-10-70 (PDF)

• create and maintain lists of qualified temporary managers; develop information that identifies best practices such as when and how to use the sanction; and develop guidance for states to help ensure the longer-term compliance of homes that have undergone temporary management

  Full Report of GAO-10-37R (PDF)

• increase the survey priority assigned to facilities that have not been surveyed in at least 6 years in the annual instructions given to state survey agencies with the goal of surveying them as quickly as possible.
  

  Highlights of GAO-09-64 (PDF)

• HHS should develop and implement a written plan to use a data collection instrument and methodology to conduct recurring periodic surveys of randomly selected ASCs to obtain nationally representative and standardized information on infection control practices.
  

  Highlights of GAO-09-213 (PDF)

^ Back to topKey Reports

Poorly Performing Nursing Homes

Nursing Homes

Nursing Homes

Medicare and Medicaid Participating Facilities

Health-Care-Associated Infections in Hospitals

More Reports