Nursing Homes:

HCFA Should Strengthen Its Oversight of State Agencies to Better Ensure Quality Care

T-HEHS-00-27: Published: Nov 4, 1999. Publicly Released: Nov 4, 1999.

Additional Materials:


William J. Scanlon
(202) 512-7114


Office of Public Affairs
(202) 512-4800

Pursuant to a congressional request, GAO discussed its study of the Health Care Financing Administration's (HFCA) implementation of two of its nursing home initiatives.

GAO noted that: (1) HCFA's mechanisms for assessing state agency survey performance are limited in their scope and effectiveness and are not being applied consistently across each of HCFA's 10 regional offices; (2) as a result, HCFA does not have sufficient, consistent, and reliable data to evaluate state agencies or to measure the success of its other nursing home initiatives; (3) given the wide range in the frequencies with which states identify serious deficiencies, HCFA cannot be certain whether states with lower rates of deficiencies have better quality homes or are failing to identify deficiencies that harm nursing home residents; (4) this uncertainty results, in part, because HCFA makes negligible use of independent inspections, known as comparative surveys, that could surface information about whether states appropriately cite deficiencies; (5) generally, only one to two comparative surveys per state were conducted in the more than 17,000 nursing homes over the last year; (6) nevertheless, two-thirds of these surveys found deficiencies that were more serious than those found by state surveyors during their reviews conducted typically 1 or 2 months earlier; (7) about 90 percent of the inspections HCFA conducts nationwide are, instead, observational surveys; (8) these surveys, in which HCFA surveyors accompany state survey teams, are useful in helping HCFA to provide training to state surveyors, are limited as a method for evaluating state agencies' performance; (9) beyond these surveys, HCFA also relies on a quality improvement program that is largely based on states' self-reported performance measures, which do not accurately or completely reflect problems in state's performance; (10) these limitations in HCFA's oversight methods are compounded by inconsistencies in how the methods are applied by its regions; (11) for example, the regions vary in how they select nursing home surveys to review and how they choose samples of residents to review; (12) regions also commit differing amounts of time to conduct observational surveys, ranging on average from 27 to 71 hours, which raises questions about whether the level of effort some regions dedicate to observational surveys is sufficient to thoroughly review state surveyors' performance; and (13) furthermore, for state agencies whose performance has been found inadequate, HCFA has not developed a sufficient array of alternatives to encourage agencies to correct serious deficiencies in their processes.

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