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Nursing Home Quality: Continued Improvements Needed in CMS's Data and Oversight

GAO-18-694T Published: Sep 06, 2018. Publicly Released: Sep 06, 2018.
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Fast Facts

About 15,600 nursing homes participate in Medicare and Medicaid. To help ensure that residents receive quality care, the Centers for Medicare & Medicaid Services (CMS) collect data (such as nurse staffing levels) on these nursing homes.

We testified that CMS's data showed mixed results—they showed an increase in consumer complaints along with improvements in the quality of care. We found that data issues (e.g., different states using different data collection methods) complicated CMS’s ability to assess whether the results reflected actual changes. We made recommendations to address these issues in the report on which this testimony is based.


Photo of an elderly pair of hands.

Photo of an elderly pair of hands.

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What GAO Found

GAO's October 2015 report found mixed results in nursing home quality based on its analysis of trends reflected in key sources of quality data that the Centers for Medicare & Medicaid Services (CMS) collects.

An increase in reported consumer complaints suggested that consumers' concerns about nursing home quality increased.

In contrast, trends in care deficiencies, nurse staffing levels, and clinical quality measures indicated potential improvement in nursing home quality.

GAO also found that data issues complicated CMS's ability to assess nursing home quality trends. For example:

CMS allowed states to use different survey methodologies to measure deficiencies in nursing home care, which complicates the ability to make comparisons nationwide. GAO recommended that CMS implement a standardized survey methodology across states, and in November 2017 CMS completed national implementation.

CMS did not regularly audit selected quality data including nurse staffing and clinical data (for example, on residents with pressure ulcers) to ensure their accuracy. GAO recommended CMS implement a plan for ongoing auditing of quality data. The agency concurred with this recommendation and has been conducting regular audits of nurse staffing data but does not have a plan to audit other quality data on a continuing basis. GAO continues to believe that regular audits are needed to ensure the accuracy and comparability of nursing home quality data.

GAO's October 2015 report found that CMS had made numerous modifications to its nursing home oversight activities. However, CMS had not monitored how the modifications might affect its ability to assess nursing home quality. GAO found that some modifications expanded or added new activities—such as creating new training for state surveyors on unnecessary medication usage—while others reduced existing activities. For example, CMS reduced the number of nursing homes participating in the Special Focus Facility program—which provides additional oversight of certain homes with a history of poor performance—by over half from 2013 to 2014. CMS officials told GAO that some of the reductions to oversight activities were in response to an increase in oversight responsibilities and a limited number of staff and financial resources. To help ensure modifications do not adversely affect CMS's ability to assess nursing home quality, GAO recommended that CMS monitor modifications of essential oversight activities to better understand the effects on nursing home quality oversight. CMS concurred with this recommendation and told us it has begun to take steps to address it. Such monitoring is important for CMS to better understand how its oversight modifications affect nursing home quality and to improve its oversight given limited resources.

Why GAO Did This Study

Approximately 15,600 nursing homes participating in the Medicare and Medicaid programs provide care to 1.4 million residents—a population of elderly and disabled individuals. To help ensure nursing home residents receive quality care, CMS defines quality standards that homes must meet to participate in the Medicare and Medicaid programs. To monitor compliance with these standards, CMS enters into agreements with state survey agencies to conduct on-site surveys of the state's homes and also collects other data on nursing home quality.

Although CMS and others have reported some potential improvements in nursing home quality, questions have been raised about nursing home quality and weaknesses in CMS oversight.

This statement summarizes GAO's October 2015 report, GAO-16-33. Specifically, it describes (1) trends in nursing home quality through 2014, and (2) changes CMS had made to its oversight activities as of October 2015. It also includes the status of GAO's recommendations associated with these findings. GAO recently obtained information from CMS officials about steps they have taken to implement the 2015 GAO recommendations.

For more information, contact John Dicken at (202) 512-7114 or

Full Report

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Data collectionData integrityElderly personsHealth careHealth care facilitiesInternal controlsMedicaidMedicaid servicesMedicareNursing homesQuality controlQuality of careSkilled nursing facilitiesStaff utilizationSurveys