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Highlights

GAO reports since 1998 have demonstrated that state surveyors, who evaluate the quality of nursing home care on behalf of CMS, sometimes understate the extent of serious care problems in homes because they miss deficiencies. CMS oversees the effectiveness of state surveys through the federal monitoring survey program. In this program, federal surveyors in CMS's regional offices either independently evaluate state surveys by resurveying a home (comparative surveys) or directly observe state surveyors during a routine nursing home survey (observational surveys). GAO was asked to evaluate the information federal monitoring surveys provide on understatement and the effectiveness of CMS management and oversight of the survey program. To do this, GAO analyzed the results of federal monitoring surveys for fiscal years 2002 through 2007, reviewed CMS guidance for the survey program, and interviewed headquarters and regional office officials.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare and Medicaid Services 1. To address weaknesses in CMS's management of the federal monitoring survey database that also affect the agency's ability to effectively track understatement, the Administrator of CMS should require regional offices to determine if there was understatement when state surveyors cite a deficiency at a lower scope and severity level than federal surveyors do and to track this information in the federal monitoring survey database.
Closed - Implemented
In response to our recommendation, in October 2008 CMS added specific fields to the federal monitoring survey database addressing the understatement of scope and severity and instructed regional offices on how to collect such information.
Centers for Medicare and Medicaid Services 2. To address weaknesses in CMS's management of the federal monitoring survey database that also affect the agency's ability to effectively track understatement, the Administrator of CMS should establish quality controls to improve the accuracy and reliability of information entered into the federal monitoring survey database.
Closed - Implemented
In response to our recommendation, in April 2008 CMS implemented a database user manual and issued instructions to the regional offices on procedures for entering all data into the federal monitoring survey database, including newly developed fields.
Centers for Medicare and Medicaid Services 3. To address weaknesses that affect CMS's ability to oversee regional office implementation of the federal monitoring survey program, the Administrator of CMS should routinely examine comparative survey data and hold regional offices accountable for implementing CMS guidance that is intended to ensure that comparative surveys more accurately capture the conditions at the time of the state survey.
Closed - Implemented
In response to our recommendation, CMS officials reported that in November 2008 the agency began convening quarterly teleconferences with regional offices to discuss the results of their regular analysis of comparative survey data and how accurately it reflects the conditions at the time of the state survey.
Centers for Medicare and Medicaid Services 4. To address weaknesses that affect CMS's ability to oversee regional office implementation of the federal monitoring survey program, the Administrator of CMS should regularly analyze and compare federal comparative and observational survey results.
Closed - Implemented
In response to our recommendation, CMS officials reported that in January 2008 CMS began to analyze comparative and observational survey data quarterly and in July 2008 CMS began to monitor the federal monitoring survey database to ensure that regional offices were downloading data to CMS headquarters.

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