Nursing Homes:

Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear

GAO-10-434R: Published: Apr 28, 2010. Publicly Released: May 27, 2010.

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Federal and state governments share responsibility for ensuring that nursing homes provide quality care in a safe environment for vulnerable elderly or disabled individuals who can no longer care for themselves. States survey nursing homes annually under contract with the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for ensuring the effectiveness of state surveys. To evaluate state surveyors' performance, CMS conducts federal comparative surveys in which federal surveyors independently resurvey a home recently inspected by state surveyors and compare and contrast the deficiencies identified during the two surveys. Federal comparative surveys can find two types of understatement: (1) missed deficiencies, which can occur when a state surveyor fails to cite a deficiency altogether, or (2) cases where state surveyors cite deficiencies at too low a level. In May 2008, we reported that a substantial proportion of federal comparative surveys conducted from fiscal years 2002 through 2007 identified missed deficiencies that either had the potential to or did result in harm, death, or serious injury to nursing home residents.

We found that 12.3 percent of fiscal year 2008 comparative surveys identified at least one missed serious deficiency, compared to 14.7 percent in fiscal year 2007. Because the percentage of comparative surveys identifying at least one missed serious deficiency has fluctuated from as low as 11.1 percent to as high as 17.5 percent since fiscal year 2002, the longer-term trend is unclear. Overall, the number of states with missed serious deficiencies on 25 percent or more of their comparative surveys declined from nine to six states, with eight of those states improving their overall performance. As we reported in 2008, understatement can also occur when state survey teams cite some serious deficiencies at too low a level, and we found that the extent of such understatement in fiscal year 2008 was consistent with prior fiscal years. Although, combining such understatement with missed serious deficiencies increased overall understatement nationwide by about 1 percentage point for the entire period, total understatement for fiscal year 2008 declined to 14.1 percent from the 16.5 percent observed in fiscal year 2007. Finally, we found that missed deficiencies at lower-levels continued to remain more widespread than serious missed deficiencies on fiscal year 2008 comparative surveys, increasing slightly from 73.5 percent of comparative surveys with at least one lower-level missed deficiency in fiscal year 2007 to 74.8 percent in fiscal year 2008. Over the period fiscal years 2002 through 2008, the level of missed deficiencies at lower-levels remained steady with about 70 percent of federal comparative surveys identifying at least one such lower-level missed deficiency.

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