Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse

GAO-19-671T Published: Jul 23, 2019. Publicly Released: Jul 23, 2019.
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Fast Facts

To protect vulnerable nursing home residents from abuse, the Centers for Medicare & Medicaid Services (CMS) contracts with state agencies—known as survey agencies—that can cite nursing homes for incidents of abuse.

While abuse in nursing homes is often underreported, we found that abuse citations more than doubled from 2013-2017. We also found that gaps in CMS’s oversight make it harder to protect residents. Oversight is critical in addressing and preventing abuse.

We testified on other key findings from our recent report and highlighted recommendations we made to CMS.

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What GAO Found

This testimony summarizes information in our recent report on abuse of nursing home residents and the Centers for Medicare & Medicaid Services' (CMS) oversight. CMS is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents. GAO analysis of CMS data found that, while relatively rare, abuse deficiencies cited in nursing homes more than doubled, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. In light of the increased number and severity of abuse deficiencies, it is imperative that CMS have strong nursing home oversight in place to protect residents from abuse; however, we found oversight gaps that may limit the agency's ability to do so, including:

Information on abuse and perpetrator type is not readily available. CMS does not require the state survey agencies to record the type of abuse and perpetrator and, when this information is recorded, it cannot be easily analyzed. Therefore, GAO reviewed a representative sample of abuse deficiency narratives from 2016 through 2017. Physical and mental/verbal abuse occurred most often in nursing homes, followed by sexual abuse, and staff were more often the perpetrators of the abuse deficiencies cited. CMS officials told us they have not conducted a systematic review to gather information on abuse and perpetrator type. Without this, CMS lacks key information and, therefore, cannot take actions—such as tailoring prevention and investigation activities—to address the most prevalent types of abuse or perpetrators.

Facility-reported incidents lack key information. Despite federal law requiring nursing homes to self-report allegations of abuse and covered individuals to report reasonable suspicions of crimes against residents, CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. This contributes to a lack of information for state survey agencies and delays in investigations. Specifically, officials from all of the state survey agencies in our review told us that facility-reported incidents can lack key information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.

Gaps in CMS processes that can result in delayed referrals to law enforcement. CMS requires a state survey agency to make referrals to law enforcement only after abuse is substantiated—a process that can often take weeks or months. As a result, law enforcement investigations can be significantly delayed. Some officials we interviewed told us the delay in receiving referrals limits their ability to collect evidence and prosecute cases—for example, bedding associated with potential sexual abuse may have been washed, and a victim's wounds may have healed.

Why GAO Did This Study

This testimony summarizes the information contained in GAO's June 2019 report, entitled Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse (GAO-19-433).

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The report on which this testimony is based made six recommendations, including that CMS: require state survey agencies to submit data on abuse and perpetrator type; develop guidance on what abuse information nursing homes should self-report; and require state survey agencies to immediately refer to law enforcement any suspicion of a crime. The Department of Health and Human Services concurred with all of GAO's recommendations and identified actions it will take to implement them.

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