Management Report:

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

GAO-19-313R: Published: Apr 15, 2019. Publicly Released: Apr 15, 2019.

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Contact:

John Dicken
(202) 512-7114
dickenj@gao.gov

 

Office of Public Affairs
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The Centers for Medicare & Medicaid Services contracts with state agencies—known as survey agencies—to investigate abuse allegations in nursing homes. CMS uses information from these investigations for oversight. It's also available on CMS's site Nursing Home Compare for the public to check homes' ratings.

We found that an Oregon agency that was not the survey agency led key nursing home abuse investigations for over 15 years. As a result, CMS didn't get information from those investigations and the results weren't included on its site.

We made 3 recommendations, including that CMS alert consumers to the missing Oregon data on the CMS site.

 

Photo of an elderly person's hands.

Photo of an elderly person's hands.

Additional Materials:

Contact:

John Dicken
(202) 512-7114
dickenj@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), is responsible for ensuring that the approximately 1.4 million residents in 15,600 nursing homes nationwide receive quality care and are free from abuse. To monitor compliance with nursing home quality standards, CMS enters into agreements with agencies in each state government—known as state survey agencies—and oversees the work of the survey agencies. These survey agencies investigate complaints from the public and facility-reported incidents regarding resident care or safety, such as abuse. The survey agencies, which are often housed in the health or human services departments of state governments, report the results of these investigations to CMS; CMS can then take action, such as applying appropriate federal penalties.

In the course of ongoing work examining oversight of abuse in nursing homes in five selected states, GAO became aware that the Oregon survey agency was not following federal requirements that the survey agency investigate all complaints and facility-reported incidents. Instead, complaints and facility-reported incidents alleging sexual, physical, verbal/mental and some other types of abuse in nursing homes were primarily investigated by Oregon’s Adult Protective Services (APS). APS staff are not trained in investigating abuse according to federal nursing home regulations. Moreover, the results of APS investigations were not reported to CMS or included in federal reporting to consumers. Specifically, GAO found that for more than 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. Because abuse allegations from complaints and facility-reported incidents in Oregon were investigated primarily by the state’s APS agency through October 2018, CMS may have missed patterns of abuse, failed to impose federal fines for nursing homes with serious abuse, and continues to have incomplete information on nursing home quality indicators for both internal CMS purposes and Oregon consumers.

An Oregon policy change effective October 29, 2018, requires the state survey agency to investigate all complaints and facility-reported incidents of abuse in nursing homes. CMS officials told GAO that they had been informed by Oregon officials of the policy change, and CMS officials plan to confirm Oregon’s compliance. However, gaps in investigations of nursing home abuse stemming from Oregon’s longstanding non-compliance resulted in incomplete information for CMS and consumers, and CMS has not ensured there are no other states with similar noncompliance.

Why GAO Did This Study

GAO was asked to review CMS’s oversight of abuse in nursing homes and in the course of that work became aware that one of the selected state survey agencies in the national review—Oregon—was not following federal law for nursing home oversight, prompting further review.[1]

This management report reviews CMS oversight of the Oregon state survey agency’s investigation of complaints and facility-reported incidents of abuse in nursing homes in Oregon. To conduct this work, GAO reviewed CMS policies, interviewed officials from CMS and Oregon’s Department of Human Services, and examined information on abuse from publicly available CMS and Oregon online resources.

What GAO Recommends

GAO is making three recommendations, including that CMS should: 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; identify options for incorporating information on Oregon’s investigations of abuse into oversight of Oregon nursing homes; and clearly communicate to consumers the lack of data on abuse in Oregon nursing homes. HHS concurred with the recommendations.  


[1]Oregon was one of the five states GAO selected as part of an ongoing review of CMS oversight of abuse in nursing homes, requested by the Permanent Subcommittee on Investigations of the Senate Committee on Homeland Security and Governmental Affairs. The selected states reflect variation in geography, CMS regional oversight, the number of nursing homes in the state, and the participation of Adult Protective Services (APS) in nursing home oversight, as well as congressional interest.  GAO anticipates issuing the broader report on oversight of abuse in nursing homes later this year. 

For more information, contact John Dicken at 202-512-7114 or dickenj@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

    Recommendation: 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)

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Open

    Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

    Recommendation: 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)

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Implemented

    Comments: In October 2019 CMS updated the Nursing Home Compare website to include a note on the lack of data on abuse complaints and facility-reported incidents when consumers search for nursing homes in Oregon. Specifically, the note (1) indicates that state health inspectors may not have investigated some instances of abuse and "as a result, potential findings of abuse may not be shown on the Nursing Home Compare website" and (2) includes a link to the Oregon department of Adult Protective Services website where consumers can check to see if that department identified any issues related to abuse.

    Recommendation: 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)

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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