Nursing Homes:

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

GAO-03-1016T: Published: Jul 17, 2003. Publicly Released: Jul 17, 2003.

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William J. Scanlon
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Since 1998, the Congress and Administration have focused considerable attention on improving the quality of care in the nation's nursing homes, which provide care for about 1.7 million elderly and disabled residents in about 17,000 homes. GAO has earlier reported on serious weaknesses in processes for conducting routine state inspections (surveys) of nursing homes and complaint investigations, ensuring that homes with identified deficiencies correct the problems without recurrence, and providing consistent federal oversight of state survey activities to ensure that nursing homes comply with federal quality standards. GAO was asked to update its work on these issues and to testify on its findings, as reported in Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight, GAO-03-561 (July 15, 2003). In commenting on this report, the Centers for Medicare & Medicaid Services (CMS) generally concurred with the recommendations to address survey and oversight weaknesses. In this testimony, GAO addresses (1) the prevalence of serious nursing home quality problems nationwide, (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 performance and improve quality.

The magnitude of documented serious deficiencies that harmed nursing home residents remains unacceptably high, despite some decline. For the most recent period reviewed, one in five nursing homes nationwide (about 3,500 homes) had serious deficiencies that caused residents actual harm or placed them in immediate jeopardy. Moreover, GAO 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. Several factors contributed to such understatement, including confusion about the definition of harm; inadequate state review of surveys to identify potential understatement; large numbers of inexperienced state surveyors; and a continuing problem with survey timing being predictable to nursing homes. States continue to have difficulty identifying and responding in a timely fashion to public complaints alleging actual harm--delays 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, many states did not fully comply with this new requirement, significantly undermining the policy's intended deterrent effect. While CMS has increased its oversight of state survey and complaint investigation activities, continued attention is required to help ensure compliance with federal requirements. 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, 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 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 interventions. 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.

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