GAO was asked to assess the effectiveness of nursing home oversight by considering the effect of a unique Arkansas law that requires county coroners to investigate all nursing home deaths. Coroners refer cases of suspected neglect to the state survey agency and law enforcement entities such as the state Medicaid Fraud Control Unit (MFCU). The Centers for Medicare & Medicaid Services (CMS) contracts with survey agencies in every state to periodically inspect nursing homes and investigate allegations of poor care or neglect. MFCUs are charged with investigating and prosecuting resident neglect. GAO examined (1) the results of Arkansas coroner investigations, (2) the state survey agency's experience in investigating coroner referrals, and (3) whether weaknesses in state and federal nursing home oversight identified in prior GAO reports were evident in the survey agency's investigation of coroner referrals.
Recommendations for Executive Action
|Centers for Medicare and Medicaid Services||1. The Administrator of CMS should revise the agency's current policy on citing deficiencies for past noncompliance with federal quality standards by holding homes accountable for all past noncompliance resulting in harm to residents, not just care problems deemed to be egregious.|
|Centers for Medicare and Medicaid Services||2. The Administrator of CMS should revise the agency's current policy on citing deficiencies for past noncompliance with federal quality standards by developing an approach for citing such past noncompliance in a manner that clearly identifies the specific nature of the care problem both in the OSCAR database and on CMS's Nursing Home Compare Web site.|