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entitled 'Nursing Homes: Despite Increased Oversight, Challenges Remain
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
December 2005:
Nursing Homes:
Despite Increased Oversight, Challenges Remain in Ensuring High-Quality
Care and Resident Safety:
GAO-06-117:
GAO Highlights:
Highlights of GAO-06-117, a report to congressional requesters:
Why GAO Did This Study:
Since 1998, GAO has issued numerous reports on nursing home quality and
safety that identified significant weaknesses in federal and state
oversight. Under contract with the Centers for Medicare & Medicaid
Services (CMS), states conduct annual nursing home inspections, known
as surveys, to assess compliance with federal quality and safety
requirements. States also investigate complaints filed by family
members or others in between annual surveys. When state surveys find
serious deficiencies, CMS may impose sanctions to encourage compliance
with federal requirements.
GAO was asked to assess CMS’s progress since 1998 in addressing
oversight weaknesses. GAO (1) reviewed the trends in nursing home
quality from 1999 through January 2005, (2) evaluated the extent to
which CMS’s initiatives have addressed survey and oversight problems
identified by GAO and CMS, and (3) identified key challenges to
continued progress in ensuring resident health and safety.
GAO reviewed federal data on the results of state nursing home surveys
and federal surveys assessing state performance; conducted additional
analyses in five states with large numbers of nursing homes; reviewed
the status of its prior recommendations; and identified key workforce
and workload issues confronting CMS and states.
What GAO Found:
CMS’s nursing home survey data show a significant decline in the
proportion of nursing homes with serious quality problems since 1999,
but this trend masks two important and continuing issues: inconsistency
in how states conduct surveys and understatement of serious quality
problems. Inconsistency in states’ surveys is demonstrated by wide
interstate variability in the proportion of homes found to have serious
deficiencies—for example, about 6 percent in one state and about 54
percent in another. Continued understatement of serious deficiencies is
shown by the increase in discrepancies between federal and state
surveys of the same homes from 2002 through 2004, despite an overall
decline in such discrepancies from October 1998 through December 2004.
In five large states that had a significant decline in serious
deficiencies, federal surveyors concluded that from 8 percent to 33
percent of the comparative surveys identified serious deficiencies that
state surveyors had missed. This finding is consistent with earlier GAO
work showing that state surveyors missed serious care problems. These
two issues underscore the importance of CMS initiatives to improve the
consistency and rigor of nursing home surveys.
CMS has addressed many survey and oversight shortcomings, but it is
still developing or has not yet implemented several key initiatives,
particularly those intended to improve the consistency of the survey
process. Key steps CMS has taken include (1) revising the survey
methodology, (2) issuing states additional guidance to strengthen
complaint investigations, (3) implementing immediate sanctions for
homes cited for repeat serious violations, and (4) strengthening
oversight by conducting assessments of state survey activities. Some
CMS initiatives, however, either have shortcomings impairing their
effectiveness or have not effectively targeted problems GAO and CMS
identified. For example, CMS has not fully addressed issues with the
accuracy and reliability of the data underlying consumer information
published on its Web site.
The key challenges CMS, states, and nursing homes face in their efforts
to further improve nursing home quality and safety include (1) the cost
to older homes to be retrofit with automatic sprinklers to help reduce
the loss of life in the event of a fire, (2) continuing problems with
hiring and retaining qualified surveyors, and (3) an expanded workload
due to increased oversight, identification of additional initiatives
that compete for staff and financial resources, and growth in the
number of Medicare and Medicaid providers. Despite CMS’s increased
nursing home oversight, its continued attention and commitment are
warranted in order to maintain the momentum of its efforts to date and
to better ensure high-quality care and safety for nursing home
residents.
CMS generally concurred with the report’s findings. CMS noted several
areas of progress in nursing home quality and identified remaining
challenges to conducting nursing home survey and oversight activities.
What GAO Recommends:
www.gao.gov/cgi-bin/getrpt?GAO-06-117.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen, (202)
512-7118, allenk@gao.gov.
[End of section]
Contents:
Letter:
Results In Brief:
Background:
Available Data Show Significant Overall Decrease in Serious Quality
Problems but Indicate Continued Inconsistency and Understatement in
State Findings:
CMS Has Addressed Many Shortcomings in Survey and Oversight Activities,
but Work Continues on Some Key Initiatives:
Resource and Workload Issues Pose Key Challenges to Further Improving
Nursing Home Quality and Safety:
Concluding Observations:
Agency and State Comments and Our Evaluation:
Appendix I: Prior GAO Recommendations, Related CMS Initiatives, and
Implementation Status:
Appendix II: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy during Standard Surveys:
Appendix III: Percentage of Homes Surveyed Within 15 Days of the 1-Year
Anniversary of Prior Survey:
Appendix IV: Percentage of State Nursing Home Surveyors with 2-Years'
Experience or Less, 2002 and 2005:
Appendix V: Comments from the Centers for Medicare & Medicaid Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Scope and Severity of Deficiencies Identified During Nursing
Home Surveys:
Table 2: Percentage of Nursing Homes Identified as Having Serious
Deficiencies during State Nursing Home Surveys, July 2003 through
January 2005:
Table 3: Federal Comparative Surveys in Five States that Identified
Serious Deficiencies Missed by State Surveys and the Number of Missed
Deficiencies, March 2002 through December 2004:
Table 4: Nursing Home Surveys: CMS Initiatives and Implementation
Status:
Table 5: Percentage of Predictable Current Nursing Home Surveys, as of
April 2002 and July 2005:
Table 6: Complaint Investigations: CMS Initiatives and Implementation
Status:
Table 7: Enforcement: CMS Initiatives and Implementation Status:
Table 8: Oversight: CMS Initiatives and Implementation Status:
Table 9: Percentage of Surveyors with 2 Years' Experience or Less, as
of July 2005:
Table 10: Implementation Status of CMS's Initiatives Responding to
GAO's Nursing Home Quality and Safety Recommendations, July 1998
through November 2004:
Table 11: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy, by State:
Table 12: Percentage of Nursing Homes with Predictable Surveys, April
2002 and June 2005:
Figures:
Figure 1: Percentage of Nursing Homes Nationwide with Serious
Deficiencies, January 1999 through January 2005:
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious
Deficiencies Not Identified in State Surveys:
Abbreviations:
AHFSA: Association of Health Facility Survey Agencies:
ASPEN; Automated Survey Processing Environment:
AST: ASPEN Scheduling and Tracking:
CMS; Centers for Medicare & Medicaid Services:
HHS: Department of Health and Human Services:
MDS: minimum data set:
MFCU: Medicaid Fraud Control Unit:
NFPA: National Fire Protection Association:
OSCAR: On-Line Survey, Certification, and Reporting system:
QIO: Quality Improvement Organization:
QIS: Quality Indicator Survey:
RN: registered nurse:
United States Government Accountability Office:
Washington, DC 20548:
December 28, 2005:
The Honorable Charles E. Grassley: Chairman:
Committee on Finance:
United States Senate:
The Honorable Herb Kohl:
Ranking Minority Member:
Special Committee on Aging:
United States Senate:
Numerous congressional hearings since July 1998 have focused attention
on the need to improve the care and safety of the nation's 1.5 million
nursing home residents, a highly vulnerable population of elderly and
disabled individuals for whom remaining at home is no longer feasible.
Many nursing home residents require help with feeding, toileting,
grooming, or other routine activities of daily living; are cognitively
impaired; or have chronic health care conditions such as heart disease.
Some individuals with chronic conditions are long-term residents of
nursing homes, while others enter nursing homes for a short period,
such as after a hospitalization. With the aging of the baby boom
generation, the number of individuals needing nursing home care is
expected to increase in size dramatically. Combined Medicare and
Medicaid payments for nursing home services were about $65 billion in
2003, including a federal share of about $43 billion.[Footnote 1]
In a series of reports, we have identified significant weaknesses in
federal and state activities designed to detect and correct quality and
safety problems at nursing homes.[Footnote 2] Our key findings included
the following:
* A small but unacceptable proportion of nursing homes repeatedly
caused actual harm to residents, such as worsening pressure sores or
untreated weight loss, or placed residents at risk of death or serious
injury.
* The results of state inspections, known as surveys, understated the
extent of serious quality-of-care and fire safety problems, reflecting
weaknesses in the survey methodology and an inconsistent application of
federal standards.
* Serious complaints by residents, family members, or staff alleging
harm to residents remained uninvestigated for weeks or months, and
delays in the reporting of abuse allegations compromised the quality of
available evidence, hindering investigations.
* When serious deficiencies were identified, federal and state
enforcement policies did not ensure that the deficiencies were
addressed and remained corrected.
* Federal mechanisms for overseeing state monitoring of nursing home
quality and safety were limited in their scope and effectiveness.
The Centers for Medicare & Medicaid Services (CMS)--the federal agency
responsible for managing the Medicare and Medicaid programs, as well as
overseeing compliance with federal nursing home standards--announced a
set of initiatives intended to address many of the weaknesses we
identified in July 1998 as well as needed improvements CMS identified
in its own self-assessment.[Footnote 3] Over time, CMS has refined and
expanded these initiatives, including launching a Web site--Nursing
Home Compare--that has progressively increased the data available to
the public about the care provided by nursing homes.[Footnote 4] You
asked us to review the progress made by CMS since 1998 in addressing
quality and safety problems in the nation's nursing homes. In response
to your request, we (1) reviewed the trends in nursing home quality by
analyzing nursing home survey results, (2) evaluated the extent to
which CMS's initiatives have addressed survey and oversight
shortcomings identified by us and CMS, and (3) identified key remaining
challenges to continued progress in ensuring resident health and
safety.
To assess trends in nursing home quality, we analyzed data from the
federal On-Line Survey, Certification, and Reporting system (OSCAR),
which compiles the results of state nursing home surveys; we focused on
trend data since CMS announced its nursing home initiatives. We have
used OSCAR data since 1997 to track trends in the proportion of homes
found to have harmed residents or placed them at risk of immediate
jeopardy. To better understand the trends identified through our OSCAR
analysis, we evaluated the results of federal comparative surveys for
all states for the period March 2002 through December 2004 and compared
the results for two other time periods--October 1998 through May 2000
and June 2000 through February 2002. Federal comparative surveys are
conducted at nursing homes recently surveyed by the state to assess the
adequacy of the state surveys. We judgmentally selected five large
states--California, Florida, New York, Ohio, and Texas--for additional
analysis based on the change in the proportion of homes cited with
serious deficiencies, geographic representation, and the number of
nursing homes. These five states account for almost 30 percent of the
nation's nursing homes.[Footnote 5] CMS officials generally recognize
OSCAR data to be reliable. We have used OSCAR data in prior work to
examine nursing home quality issues and we updated certain data for
this report. Throughout the course of our work, we discussed our
analysis of OSCAR data with CMS officials at both the central office
and the regional offices to ensure that the data accurately reflected
state nursing home survey activities. We determined that these data
were accurate for our purposes.
To evaluate the extent to which survey and oversight shortcomings we
identified had been addressed by CMS's initiatives, we reviewed the
status of our recommendations, and updated our understanding of the
initiatives by analyzing relevant documentation and discussing their
implementation status with CMS officials (see app. I). We also
discussed with CMS officials the initiatives implemented as a result of
CMS's self-assessment of needed improvements. We focused on four areas:
surveys, complaints, enforcement, and oversight. We discussed the
preliminary findings from our OSCAR data trend analysis with CMS and
state survey agency officials. To assess the remaining challenges to
continued improvement of nursing home oversight, we identified through
interviews with CMS and state survey agency officials key workforce and
workload issues that confront states and CMS in protecting the health
and safety of nursing home residents. We also contacted officials at
the Association of Health Facility Survey Agencies (AHFSA) to update
information on surveyor turnover and retention issues. We conducted our
review from May through December 2005 in accordance with generally
accepted government auditing standards.
Results in Brief:
CMS's nursing home survey data show a significant decrease in the
proportion of nursing homes with serious quality problems, from about
29 percent in 1999 to about 16 percent by January 2005, but this trend
masks two important and continuing issues: inconsistency among state
surveyors in conducting surveys and understatement by state surveyors
of serious deficiencies. Inconsistency in states' surveys is
demonstrated by CMS data that reveal continued wide interstate
variability in the proportion of homes found to have serious
deficiencies. For example, in the most recent time period, one state
found such deficiencies in about 6 percent of homes, whereas another
state found them in about 54 percent of homes. We previously reported
that confusion about the definition of actual harm contributed to
inconsistency and understatement in state surveys. In addition, state
surveyors continue to understate serious deficiencies, as shown by the
larger number of serious deficiencies identified in federal comparative
surveys than in state surveys of the same homes. Although federal
comparative surveys since October 1998 show an overall decline in the
proportion that identify serious deficiencies not identified by state
surveys, data for the two most recent periods show an increase in such
discrepancies, from 22 percent to 28 percent of comparative surveys. In
the five large states we reviewed, federal surveyors concluded that the
state surveyors had missed serious deficiencies in from 8 percent to 33
percent of comparative surveys--that is, these deficiencies existed and
should have been identified at the time of the state survey. The
federal surveyors' assessment is consistent with our July 2003
findings: a sample of deficiencies demonstrated considerable
understatement of quality-of-care problems such as serious, avoidable
pressure sores. The continuing evidence of inconsistency in survey
results among states and understated deficiencies underscores the
importance of CMS's initiatives to improve the consistency and rigor of
nursing home surveys.
CMS has addressed many of the shortcomings we identified in nursing
home survey and oversight activities, but several important initiatives
have not yet been implemented, such as those intended to make state
surveys more consistent across states and to reduce the understatement
of deficiencies. Important steps CMS has taken include (1) revising the
survey methodology, (2) issuing states additional guidance to
strengthen complaint investigations, (3) implementing immediate
sanctions for homes cited for repeat serious violations, and (4)
strengthening oversight by conducting assessments of state survey
activities. In addition, CMS has undertaken initiatives of its own. For
example, it has made important information available to the public on
nursing home quality through its Nursing Home Compare Web site and has
contracted with independent quality organizations to work with nursing
homes to improve quality. Although CMS has addressed many weaknesses in
survey and oversight processes, other initiatives either have not
effectively targeted the problems identified or have shortcomings that
impair their effectiveness. For example, CMS has not fully addressed
issues with the accuracy and reliability of the data underlying
consumer information published on its Web site.
CMS, states, and nursing homes face a number of key resource and
workload challenges in their efforts to further improve nursing home
quality and safety. CMS is moving to require older nursing homes to
install sprinkler systems, a proven life-saving device, but
implementation could be delayed because of concerns about the cost of
the retrofit to these homes. CMS indicated that it plans to ask for
public comment about the length of the phase-in period rather than
proposing one itself. States are continuing to experience problems in
hiring and retaining qualified surveyors, a factor that survey agency
officials believe contributes to inconsistency and understatement in
the citation of serious deficiencies. State survey agencies attributed
high turnover and recruiting difficulties to the lack of competitive
salaries for registered nurses (RN), who are a major component of
states' surveyor workforce, and intense competition from hospitals and
other providers because of the RN shortage. Increased nursing home
oversight has strained both CMS and state survey agency resources,
resulting in delays for some key initiatives. For example, CMS has
undertaken time-consuming state survey agency performance reviews and
significantly increased the number of federal comparative surveys
performed. In addition, state survey agency workloads have grown as a
result of initiatives that require the prompt investigation of
complaints alleging resident harm and the need to conduct on-site
revisits at nursing homes to ensure that serious problems actually have
been corrected. However, the increased number of quality and safety
initiatives has required CMS to establish priorities, with some
initiatives taking precedence over others. For example, CMS attached a
high priority to including quality indicator data on its public Web
site and implemented this initiative promptly, while the revision of
the survey process has encountered delays due to higher priorities.
Continued attention and commitment to improving nursing home oversight
are essential to maintaining the momentum built by CMS's
accomplishments to date and thus better ensuring quality care and
safety for nursing home residents.
In commenting on a draft of this report, CMS generally concurred with
our findings, describing the progress it has made in several areas and
agreeing that challenges remain. CMS also indicated that while it
remained concerned about understatement, it did not believe that
understatement was worsening. CMS described the ongoing challenges it
faces and the steps it will take to address them. In commenting on the
section of the draft report focused on trends in nursing home quality,
the states we reviewed commented on the actions they have taken to
improve nursing home survey quality and the challenges they face in
conducting nursing home survey and oversight activities.
Background:
Oversight of nursing homes is a shared federal-state responsibility.
Based on statutory requirements, CMS defines standards that nursing
homes must meet to participate in the Medicare and Medicaid programs
and contracts with states to assess whether homes meet these standards
through annual surveys and complaint investigations. A range of
statutorily defined sanctions is available to CMS and the states to
help ensure that homes maintain compliance with federal quality
requirements. CMS also is responsible for monitoring the adequacy of
state survey activities.[Footnote 6]
Standard Surveys and Complaint Investigations:
Every nursing home receiving Medicare or Medicaid payment must undergo
a standard survey not less than once every 15 months, and the statewide
average interval for these surveys must not exceed 12 months.[Footnote
7] During a standard survey, separate teams of surveyors conduct a
comprehensive assessment of federal quality-of-care and fire safety
requirements. In contrast, complaint investigations generally focus on
a specific allegation regarding resident care or safety.
The quality-of-care component of a survey focuses on determining
whether (1) the care and services provided meet the assessed needs of
the residents and (2) the home is providing adequate quality care,
including preventing avoidable pressure sores, weight loss, and
accidents. Nursing homes that participate in Medicare and Medicaid are
required to periodically assess residents' care needs in 17 areas, such
as mood and behavior, physical functioning, and skin conditions, in
order to develop an appropriate plan of care. Such resident assessment
data are known as the minimum data set (MDS). To assess the care
provided by a nursing home, surveyors select a sample of residents and
(1) review data derived from the residents' MDS assessments and medical
records; (2) interview nursing home staff, residents, and family
members; and (3) observe care provided to residents during the course
of the survey. CMS establishes specific investigative protocols for
state survey teams--generally consisting of RNs, social workers,
dieticians, and other specialists--to use in conducting surveys. These
procedural instructions are intended to make the on-site surveys
thorough and consistent across states.
The fire safety component of a survey focuses on a home's compliance
with federal standards for health care facilities.[Footnote 8] The fire
safety standards cover 18 categories ranging from building construction
to furnishings. Examples of specific requirements include the use of
fire-or smoke-resistant construction materials, the installation and
testing of fire alarms and smoke detectors, and the development and
routine testing of a fire emergency plan. Most states use fire safety
specialists within the same department as the state survey agency to
conduct fire safety inspections, but about one-third of states contract
with their state fire marshal's office.
Complaint investigations provide an opportunity for state surveyors to
intervene promptly if problems arise between standard surveys.
Complaints may be filed against a home by a resident, the resident's
family, or a nursing home employee either verbally, via a complaint
hotline, or in writing. Surveyors generally follow state procedures
when investigating complaints but must comply with certain federal
guidelines and time frames. In cases involving resident abuse, such as
pushing, slapping, beating, or otherwise assaulting a resident by
individuals to whom their care has been entrusted, state survey
agencies may notify state or local law enforcement agencies that can
initiate criminal investigations. States must maintain a registry of
qualified nurse aides, the primary caregivers in nursing homes, that
includes any findings that an aide has been responsible for abuse,
neglect, or theft of a resident's property. The inclusion of such a
finding constitutes a ban on nursing home employment.
Deficiencies identified during either standard surveys or complaint
investigations are classified in 1 of 12 categories according to their
scope (i.e., the number of residents potentially or actually affected)
and their severity. An A-level deficiency is the least serious and is
isolated in scope, while an L-level deficiency is the most serious and
is considered to be widespread in the nursing home (see table 1).
States are required to enter information about surveys and complaint
investigations, including the scope and severity of deficiencies
identified, in CMS's OSCAR database.
Table 1: Scope and Severity of Deficiencies Identified During Nursing
Home Surveys:
Severity: Immediate jeopardy[A];
Scope: Isolated: J;
Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm;
Scope: Isolated: G;
Scope: Pattern: H;
Scope: Widespread: I.
Severity: Potential for more than minimal harm; Scope: Isolated: D;
Scope: Pattern: E;
Scope: Widespread: F.
Severity: Potential for minimal harm[B]; Scope: Isolated: A;
Scope: Pattern: B;
Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in "substantial compliance."
[End of table]
Enforcement Policy:
Ensuring that documented deficiencies are corrected is a shared federal-
state responsibility. CMS imposes sanctions on homes with Medicare or
dual Medicare and Medicaid certification on the basis of state
referrals. CMS normally accepts a state's recommendation for sanctions
but can modify it. The scope and severity of a deficiency determine the
applicable sanctions, which can involve, among other things, requiring
training for staff providing care to residents, imposing money fines,
denying the home Medicare and Medicaid payments for new admissions, and
terminating the home from participation in these programs. States are
responsible for enforcing standards in homes with Medicaid-only
certification--about 14 percent of homes. They may use the federal
sanctions or rely on their own state licensure authority and nursing
home sanctions.
Oversight:
CMS is responsible for overseeing each state survey agency's
performance in ensuring quality of care in nursing homes participating
in Medicare or Medicaid. Its primary oversight tools are statutorily
required federal monitoring surveys conducted annually in at least 5
percent of the state-surveyed Medicare and Medicaid nursing homes in
each state and annual state performance reviews. Federal monitoring
surveys can be either comparative or observational. A comparative
survey involves a federal survey team conducting a complete,
independent survey of a home within 2 months of the completion of a
state's survey in order to compare and contrast the findings. In an
observational survey, one or more federal surveyors accompany a state
survey team to a nursing home to observe the team's performance.
Roughly 81 percent of the approximately 800 federal monitoring surveys
are observational. Performance reviews examine state survey agency
compliance with seven standards: (1) timeliness of the survey, (2)
documentation of survey results, (3) quality of state agency
investigations and decision making, (4) timeliness of adverse action
procedures, (5) budget analysis, (6) timeliness and quality of
complaint investigations, and (7) timeliness and accuracy of data
entry.
Available Data Show Significant Overall Decrease in Serious Quality
Problems but Indicate Continued Inconsistency and Understatement in
State Findings:
CMS's nursing home survey data show a significant decrease in serious
quality problems in recent years, but other information indicates that
this trend masks two important and continuing issues: inconsistency in
how states conduct surveys and understatement of serious quality
problems. OSCAR data continue to show wide interstate variability in
the proportion of homes found to have serious deficiencies, suggesting
inconsistency in states' interpretation and application of federal
regulations. We previously reported that confusion about the definition
of actual harm contributed to inconsistency and understatement in state
surveys. Moreover, although federal comparative surveys conducted from
October 1998 through December 2004 showed a decline in the proportion
of serious deficiencies that were not identified by state surveys, this
overall trend masks a more recent increase from 2002 through 2004 in
federally identified understatement of serious deficiencies. In five
large states we examined with a significant decline in the proportion
of homes found to have harmed residents, federal comparative surveys
found that a significant proportion of state surveys had missed serious
deficiencies, that is, state surveyors either failed to cite the
deficiencies altogether or cited them at too low a level of scope and
severity.
From January 1999 through January 2005, the proportion of nursing homes
nationwide with actual harm or immediate jeopardy deficiencies declined
from about 29 percent to about 16 percent. Figure 1 shows the
proportion of homes nationwide with these deficiencies for four
consecutive time periods from January 1999 through January
2005.[Footnote 9] During the 6-year time period, 41 states had a
decline in serious deficiencies ranging from about 5 to about 36
percentage points (see app. II).
Figure 1: Percentage of Nursing Homes Nationwide with Serious
Deficiencies, January 1999 through January 2005:
[See PDF for image]
[End of figure]
The nationwide data show a decline in nursing homes cited for serious
deficiencies; however, the data obscure the continued significant
interstate variation in the proportion of homes with serious
deficiencies, which suggests inconsistency in how states conduct
surveys. Table 2 shows that while 10 states identified serious
deficiencies in less than 10 percent of the homes surveyed, 15 states
found similar deficiencies in more than 20 percent of homes surveyed
from July 2003 through January 2005. For example, during that period
California identified actual harm and immediate jeopardy deficiencies
in about 6 percent of the state's nursing homes, while Connecticut
found such deficiencies in approximately 54 percent of its facilities.
Since January 1999, the proportion of homes with serious deficiencies
had declined nearly 23 percentage points in California but increased by
about 6 percentage points in Connecticut.
Table 2: Percentage of Nursing Homes Identified as Having Serious
Deficiencies during State Nursing Home Surveys, July 2003 through
January 2005:
Percentage of homes with serious deficiencies: More than 20 percent;
Number of states: 15.
Percentage of homes with serious deficiencies: 10 percent to 20
percent; Number of states: 26.
Percentage of homes with serious deficiencies: Less than 10 percent;
Number of states: 10.
Source: GAO analysis of OSCAR data.
[End of table]
We discussed the decline in serious deficiencies in the five large
states we examined with state survey agency officials and officials
from the responsible CMS regional offices. Officials in four of the
five states believed that there had been some improvement in nursing
home quality. CMS regional office officials, however, were concerned
about the magnitude of the decline in serious deficiencies in two
states--Texas and California. The Texas state survey agency noted both
some improvement in quality as well as a significant number of
inexperienced surveyors who it believed were hesitant in citing actual
harm. The San Francisco regional office and state survey agency
officials acknowledged that confusion by state surveyors as to what
constituted actual harm had contributed to the decline in California.
The regional office staff discussed this issue with California survey
agency officials and believed that training combined with the CMS
inquiries might have contributed to a recent increase in actual harm
deficiency citations.
The overall decline in the proportion of federal comparative surveys
nationwide that noted serious deficiencies not identified by state
surveyors across the three time periods we examined masks a reversal of
this trend in the most recent time period analyzed, suggesting ongoing
understatement of deficiencies. The time periods analyzed were October
1998 through May 2000, June 2000 through February 2002, and March 2002
through December 2004. From October 1998 through February 2002, the
proportion of federal comparative surveys nationwide that noted serious
deficiencies that were not identified by state surveyors declined from
34 percent to 22 percent (see fig. 2). However, federal surveys
conducted from March 2002 through December 2004 that found serious
deficiencies not identified by state surveyors increased from 22
percent to 28 percent. In addition, our work in the five states we
examined demonstrates continued understatement by state surveyors of
serious deficiencies that cause actual harm or immediate jeopardy.
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious
Deficiencies Not Identified in State Surveys:
[See PDF for image]
[End of figure]
Because some serious deficiencies found by federal, but not state,
surveyors may not have existed at the time of the state
survey,[Footnote 10] CMS requires its regional offices to specifically
identify on worksheets which deficiencies state surveyors had missed
during the state survey. We analyzed CMS regional office worksheets for
73 comparative surveys in five large states--California, Florida, New
York, Ohio, and Texas--with a significant decline in serious
deficiencies from January 1999 through January 2005.[Footnote 11]
Overall, 18 percent of these federal comparative surveys identified at
least one serious deficiency missed by state surveyors, ranging from a
low of 8 percent in Ohio to a high of 33 percent in Florida (see table
3). Table 3 also shows that in comparative surveys noting serious
deficiencies that state surveyors missed, from one to seven serious
deficiencies were missed. Federal surveyors' findings of understatement
of serious deficiencies are consistent with our own work. Our July 2003
report analyzed state surveys of homes with a history of harming
residents but whose most current survey identified quality-of-care
problems at below the level of harm; we concluded that about 40 percent
of the 76 homes we analyzed had harmed residents, including instances
of severe weight loss; multiple falls resulting in broken bones and
other injuries; and serious, avoidable pressure sores. Similarly, our
November 2004 report on Arkansas nursing home deaths found numerous
instances of serious, understated quality-of-care problems.
Table 3: Federal Comparative Surveys in Five States that Identified
Serious Deficiencies Missed by State Surveys and the Number of Missed
Deficiencies, March 2002 through December 2004:
State: California;
Number of federal comparative surveys conducted: 23; Federal
comparative surveys that found missed serious deficiencies: Number: 4;
Federal comparative surveys that found missed serious deficiencies:
Percentage: 17; Total number of serious deficiencies missed: 6[B].
State: Florida;
Number of federal comparative surveys conducted: 12; Federal
comparative surveys that found missed serious deficiencies: Number: 4;
Federal comparative surveys that found missed serious deficiencies:
Percentage: 33; Total number of serious deficiencies missed: 7[B].
State: New York;
Number of federal comparative surveys conducted: 11; Federal
comparative surveys that found missed serious deficiencies: Number:
2[A]; Federal comparative surveys that found missed serious
deficiencies: Percentage: 18[A]; Total number of serious deficiencies
missed: 6[B].
State: Ohio;
Number of federal comparative surveys conducted: 12; Federal
comparative surveys that found missed serious deficiencies: Number: 1;
Federal comparative surveys that found missed serious deficiencies:
Percentage: 8; Total number of serious deficiencies missed: 1.
State: Texas;
Number of federal comparative surveys conducted: 15; Federal
comparative surveys that found missed serious deficiencies: Number: 2;
Federal comparative surveys that found missed serious deficiencies:
Percentage: 13; Total number of serious deficiencies missed: 5.
State: Total;
Number of federal comparative surveys conducted: 73; Federal
comparative surveys that found missed serious deficiencies: Number: 13;
Federal comparative surveys that found missed serious deficiencies:
Percentage: 18; Total number of serious deficiencies missed: 25.
Source: GAO analysis of federal comparative surveys conducted from
March 2002 through December 2004.
[A] On one comparative survey, federal surveyors did not provide
information on whether any of the deficiencies they identified existed
at the time of the state survey; therefore, this number may be
understated.
[B] The number of serious missed deficiencies could be higher because
federal surveyors sometimes did not indicate whether they believed that
a serious deficiency they cited had existed at the time of the state
survey and therefore was missed by state surveyors.
[End of table]
Our prior reports identified five factors that we believe contribute to
inconsistency and the understatement of deficiencies by state
surveyors: (1) weaknesses in CMS's survey methodology; (2) confusion
about the definition of actual harm; (3) predictability of surveys,
which allows homes to conceal problems if they so desire; (4)
inadequate quality assurance processes at the state level to help
detect understatement in the scope and severity of deficiencies; and
(5) inexperienced state surveyors due to retention problems. CMS has
initiatives under way to revise the survey methodology and address the
confusion about what constitutes harm, and it has taken some steps to
reduce survey predictability. However, CMS did not implement the
recommendation in our July 2003 report to strengthen the ability of
state quality assurance processes to detect understatement. While it
agreed with the intent of our recommendation, CMS indicated that its
state performance standards initiative already incorporated this
concept. The status of these initiatives and state workforce issues are
discussed in the following section.
CMS Has Addressed Many Shortcomings in Survey and Oversight Activities,
but Work Continues on Some Key Initiatives:
CMS has addressed many shortcomings in nursing home survey and
oversight activities both in response to our recommendations and as a
result of its own assessment of needed improvements, but it is still
working on key initiatives that have not yet been implemented.[Footnote
12] Appendix I provides a complete listing of our previous
recommendations and the implementation status of CMS initiatives taken
in response. Examples of CMS's initiatives to address shortcomings
include (1) revising the survey methodology, (2) issuing states
additional guidance to strengthen complaint investigations, (3)
implementing immediate sanctions for homes cited for repeat serious
violations, and (4) strengthening oversight by conducting assessments
of state survey activities. CMS also has published information on its
Web site about nursing home quality and has engaged independent quality
organizations to work with nursing homes to improve quality.[Footnote
13] Despite CMS's initiatives in four distinct areas--surveys,
complaints, enforcement, and oversight--some initiatives either have
not effectively targeted the problems we identified or have
shortcomings that impair their effectiveness.
Surveys: Key Initiatives Are under Development, but Most Have Not Yet
Been Implemented:
Several CMS initiatives are intended to address shortcomings in the
survey process, but most of these initiatives are in the developmental
stage and have not yet been implemented. In addition, despite CMS's
efforts to make scheduling of surveys less predictable, many remain
predictable. (See table 4).
Table 4: Nursing Home Surveys: CMS Initiatives and Implementation
Status:
Initiative: Survey methodology: Revise to ensure that surveyors do not
miss significant care problems; Status: In process.
Initiative: Investigative protocols: Strengthen to ensure greater rigor
in surveyors' on-site investigations of specific areas; Status: In
process.
Initiative: Definitions of actual harm and immediate jeopardy: Revise
to promote increased interstate consistency in deficiency citations;
Status: In process.
Initiative: Additional survey initiatives: Implement initiatives to
give surveyors a way to voice concerns and explore the use of
photographic evidence to improve the survey process; Status: In
process.
Initiative: Survey predictability: Reduce to prevent nursing homes from
potentially masking certain deficiencies if they so choose; Status:
Selected initiatives implemented.
Source: GAO analysis of CMS initiatives.
[End of table]
Survey Methodology:
In response to our 1998 recommendation to improve the rigor of the
survey methodology to help ensure that surveyors do not miss
significant care problems, CMS took some interim steps and launched a
longer-term initiative. As interim steps, CMS instructed state survey
agencies in 1999 to (1) increase the sample of residents reviewed
during surveys and (2) review available quality indicator information
on the care provided to a home's residents before actually visiting the
home. By using the quality indicators, which are essentially numeric
warning signs of the prevalence of care problems, to select a
preliminary sample of residents before the on-site review, surveyors
are better prepared to target their surveys and to identify potential
care problems.[Footnote 14] Surveyors augment the preliminary sample
with additional resident cases once they arrive in the home.
For the longer term, CMS awarded a contract in 1998 to revise the
methodology used to survey nursing homes, and the agency plans to pilot
this new methodology in the fall 2005. Under development for 7 years,
the proposed two-stage, data-driven Quality Indicator Survey (QIS) is
intended to systematically target potential problems at nursing homes.
Its expanded sample should help surveyors better assess the scope of
any deficiencies identified. In stage 1, a large resident sample will
be drawn and relevant data from on-and off-site sources will be
analyzed to develop a set of quality-of-care indicators, which will be
compared to national benchmarks.[Footnote 15] Stage 2 will
systematically investigate potential quality-of-care concerns
identified in stage 1. In June 2005, CMS selected five states to pilot
test the new survey methodology.[Footnote 16] The QIS pilot test will
begin during the fall 2005, with a final evaluation of the pilot due in
the fall 2006. The evaluation will examine the QIS's cost-
effectiveness, focusing on the time and surveyor team size required
under QIS compared to the current survey methodology, and on the QIS's
impact on deficiency citations. In developing the QIS, CMS has
attempted to prevent increases in the time required to complete
surveys. Depending on evaluation findings and any subsequent
streamlining of the QIS, national implementation could begin in mid-
2007.
Investigative Protocols:
Since 2001, CMS has been developing surveyor investigative protocols to
ensure greater rigor in on-site investigations of specific quality-of-
care areas. We recommended in July 2003 that CMS finalize the
development of these important protocols; however, CMS is still working
on this initiative. In 2001, CMS hired a contractor to facilitate the
convening of expert panels for the development and review of these
protocols.[Footnote 17] In November 2004, more than 1 year later than
scheduled, CMS implemented a protocol on pressure sores. Since then,
CMS has implemented protocols in two other areas--incontinence and
medical director qualifications and responsibilities. The protocols
provide detailed interpretive guidelines and severity guidance.
Protocols in seven more areas are under development, with an issuance
target of fall 2005.[Footnote 18]
Definitions of Actual Harm and Immediate Jeopardy:
To promote increased consistency among states in deficiency citations,
a work group of CMS central office, regional office, and state survey
agency staff was convened in early 2005 to clarify the definitions of
actual harm and immediate jeopardy. Our July 2003 report noted that
confusion about the definitions contributed to the understatement of
serious deficiencies. According to CMS, the 2005 draft revised
definition of actual harm attempts to clarify the existing definition
by eliminating confusing language and identifying indicators and
examples of actual harm.[Footnote 19] The draft revised definition of
immediate jeopardy is intended to provide additional guidance on
documenting whether deficiencies are at the immediate jeopardy severity
level, including criteria for identifying whether immediate jeopardy
exists, and updates examples of immediate jeopardy. A CMS official
indicated that the draft revised definition of immediate jeopardy
stresses that action must be taken at once to prevent harm. As of
August 2005, CMS had no target issuance date for the revised
definitions.
Additional Survey Initiatives:
CMS is implementing two additional survey initiatives--developing
guidance to ensure surveyors are able to report concerns to CMS
regional offices and studying surveyors' use of photographic evidence.
* To address anecdotal reports that surveyors are sometimes asked to
overlook or downgrade survey findings, CMS has issued and is obtaining
state comments on draft guidance to ensure that surveyors can cite
survey findings without such inappropriate pressure. Currently,
surveyors report concerns to the state survey agency. CMS officials
indicated that the draft guidance tries to (1) establish a
nonthreatening option for voicing concerns to CMS regional office staff
without overburdening the regional offices with additional
investigations and (2) give CMS a way to identify any patterns of
problems. Implementation of this effort is anticipated in late 2005.
* CMS also contracted for a study of the use of photographic evidence
by surveyors to support survey findings. In our 2004 report on Arkansas
nursing home deaths, we reported that photographs taken by coroners
provided key evidence supporting neglect of nursing home residents and
the existence of serious, avoidable care problems. The goal of CMS's
study is to identify issues and develop training materials related to
surveyors' use of photographic evidence. This study began in the summer
2005, with final training materials to be issued in the summer 2006.
Survey Predictability:
In 1998, we reported that nursing homes could mask certain deficiencies
if they chose to because of survey predictability. CMS responded by
directing states to (1) avoid scheduling a home's survey for the same
month of the year as the home's previous standard survey and (2) begin
at least 10 percent of standard surveys outside the normal workday
(either on weekends, early in the morning, or late in the
evening).[Footnote 20] However, our current analysis showed that a
significant proportion of state nursing home surveys remain
predictable. We consider surveys to be predictable if they are
conducted within 15 days of the anniversary of a home's prior
survey.[Footnote 21] From 2002 to 2005, the proportion of predictable
surveys increased from 13 percent to 14.5 percent (see app. III).
Overall, 29 states had an increase in survey predictability. As shown
in table 5, as of July 2005, from 10 percent to over 50 percent of
current nursing home surveys in 35 states were conducted within 15 days
of the anniversary of a home's last standard survey. CMS officials
stated that avoiding surveys close to the 12-month anniversary of a
home's prior survey, while meeting the requirements that surveys occur
not less than once every 15 months and maintaining a statewide average
interval of 12 months, could require increased funding because more
surveys would need to be accomplished within the first 9 months after a
survey.[Footnote 22] However, CMS noted that states are not currently
funded to conduct surveys within the first 9 months after the previous
survey. CMS officials also told us that CMS had introduced the ASPEN
Scheduling and Tracking (AST) module for its central and regional
offices and the states in February 2004 as a tool to reduce survey
predictability; however, state officials we spoke with about AST were
unfamiliar with its survey predictability features.[Footnote 23]
Table 5: Percentage of Predictable Current Nursing Home Surveys, as of
April 2002 and July 2005:
Percentage of predictable surveys.
More than 50 percent;
Number of states: April 2002: 0;
Number of states: July 2005: 1.
25 percent to 50 percent;
Number of states: April 2002: 5;
Number of states: July 2005: 7.
10 percent to 24 percent;
Number of states: April 2002: 26; Number of states: July 2005: 27.
Less than 10 percent;
Number of states: April 2002: 20; Number of states: July 2005: 16.
Source: GAO analysis of OSCAR data.
Notes: "Predictable surveys" are defined as surveys conducted within 15
days of the anniversary of homes' prior surveys.
[End of table]
Complaint Investigations: CMS Has Strengthened State Guidance and
Oversight and Is Continuing to Address Problems Involving Allegations
of Abuse:
CMS has completed certain initiatives to ensure that quality problems
found during complaint investigations are promptly addressed and has
taken steps to address weaknesses in the notification and investigation
of abuse in nursing homes. CMS is continuing work on (1) ensuring state
compliance with federal nurse aide registry requirements and (2)
assessing the effectiveness of conducting employee background checks.
(See table 6).
Table 6: Complaint Investigations: CMS Initiatives and Implementation
Status:
Initiative: Complaint guidance: Issue additional guidance to states to
strengthen complaint investigations, including allegations of abuse;
Status: Selected initiatives implemented.
Initiative: Complaint oversight: Enhance federal oversight of state
complaint investigations, including allegations of abuse; Status: In
process.
Source: GAO analysis of CMS initiatives.
[End of table]
Complaint Guidance:
CMS guidance issued since 1999 has helped to strengthen state
procedures for investigating complaints. In 1999, we reported that
complaints alleging that nursing home residents were being harmed were
not being investigated for weeks or months in several states and
recommended that CMS develop additional standards for the prompt
investigation of serious complaints alleging situations that may harm
residents but are categorized as less than immediate jeopardy. CMS
promptly instructed states to investigate complaints alleging harm to a
resident within 10 workdays of receiving the complaint and later
specified that investigations of these complaints be conducted on-site
at the nursing home.[Footnote 24] During 1999, CMS developed and issued
guidance intended to help states identify complaints that allege harm
to residents. Also in 1999, CMS hired a contractor to study and
recommend improvements to state complaint practices. CMS used the
findings of this study to develop more detailed guidance for states to
help improve the effectiveness of complaint investigations. In 2004,
CMS issued this guidance to states, which further clarified the 1999
instructions on identifying actual harm.
In March 2002, we recommended that CMS ensure that state survey
agencies immediately notify local law enforcement agencies or Medicaid
Fraud Control Units (MFCU) of allegations or confirmed complaints of
abuse.[Footnote 25] In response, CMS issued a March 2002 letter to CMS
regional offices and state survey agencies clarifying its policies on
abuse reporting time frames, requirements for reporting to local law
enforcement and/or the MFCU, displaying complaint telephone numbers,
and citing abuse on surveys. CMS issued additional guidance in December
2004 clarifying nursing home reporting requirements and definitions for
alleged violations, including mistreatment, neglect, abuse, injuries of
unknown source, and misappropriation of resident property. CMS has not,
however, implemented our March 2002 recommendation to accelerate the
agency's campaign to increase public awareness of nursing home abuse
through the development and distribution of posters that are to be
prominently displayed in nursing homes, and other materials.[Footnote
26]
Complaint Oversight:
CMS has taken three important steps to improve its oversight of state
complaint investigations, including allegations of abuse. First, it
required in its annual state performance review, which was established
in fiscal year 2001 and fully implemented in fiscal year 2002, that
federal surveyors review a sample of complaints in each state to
determine whether states properly categorize complaints (i.e.,
determine how quickly they should be investigated), investigate
complaints within the time specified, and properly include the results
of investigations in CMS's database. Our March 1999 report on
complaints had recommended that CMS strengthen its oversight in these
areas. During its 2004 review of state performance, CMS identified 5
states that did not meet the standard for properly categorizing
complaints and 13 states that did not conduct timely investigations of
all complaints alleging immediate jeopardy to residents; however, 11 of
the 13 states missed the requirement by a small margin.[Footnote 27]
States failing state performance review standards are asked to submit a
corrective action plan to CMS.
Second, in January 2004, CMS implemented a new national automated
complaint tracking system, the ASPEN Complaints and Incidents Tracking
System. Our March 1999 report on enforcement noted that the lack of a
national complaint reporting system hindered CMS's and states' ability
to adequately track the status of complaint investigations as well as
CMS's ability to maintain a full compliance history on each nursing
home. To address these concerns, we recommended the development of a
better management information system. One goal of CMS's new management
information system is to standardize reported complaints so that
analysis can be conducted across all states. This system is intended to
provide CMS with an effective tool for overseeing and managing state
complaint investigations.[Footnote 28]
Third, in November 2004, CMS requested state survey agency directors to
self-assess their states' compliance with federal requirements for
maintaining and operating nurse aide registries, to which states are
required to report substantiated findings of abuse, neglect, or theft
of nursing home residents' property by nurse aides. CMS has not issued
a formal report of findings from the state self-assessment, but CMS
officials noted that as a result of resource constraints some states
reported having difficulty maintaining compliance with certain federal
requirements, such as (1) timely entry by state survey staff of
information in nurse aide registries and (2) state notification to
nursing homes employing nurse aides found guilty of abuse at another
facility. In our March 2002 report, we recommended that CMS shorten the
state survey agencies' time frames for determining whether to include
findings of abuse in the nurse aide registry. Annotations to nurse aide
registries are made after final determinations that abuse occurred,
which entail completion of the state's investigation as well as
adjudication of any appeals.[Footnote 29] Until the final
determination, residents may continue to be exposed to aides who are
allegedly abusive. CMS noted that while most of the time frames are
defined in regulation, it can review the time frames when regulatory
changes are considered. No changes to the regulations had been made as
of August 2005.
As part of its third effort, CMS also is conducting a Background Check
Pilot Program. Our March 2002 report recommended an assessment of state
policies and practices for complying with federal requirements
prohibiting employment of individuals convicted of abusing nursing home
residents. The pilot program will test the effectiveness of state and
national fingerprint-based background checks on employees of long-term
care facilities, including nursing homes.[Footnote 30] Pilot programs
in seven states--Alaska, Idaho, Illinois, Michigan, Nevada, New Mexico,
and Wisconsin--will be phased in from fall 2005 through September 2007.
An independent evaluation is planned.
Enforcement: CMS Has Strengthened the Potential Deterrent Effect of
Sanctions and Has Other Initiatives Under Way:
CMS significantly strengthened the potential deterrent effect of
enforcement actions by requiring immediate sanctions for homes found to
have a pattern of harming residents. Moreover, CMS continues to develop
new policies and to clarify existing ones in order to strengthen
enforcement activities and encourage nursing home compliance with
federal requirements. (See table 7).
Table 7: Enforcement: CMS Initiatives and Implementation Status:
Initiative: Immediate sanctions policy: Eliminate grace periods for
homes cited for repeat serious violations; Status: Fully implemented.
Initiative: Additional enforcement policy issues: Address weaknesses in
policies, the appeals process, and enforcement tracking; Status:
Selected initiatives implemented.
Initiative: Special Focus Facility Program: Revise to include the most
poorly performing homes and to strengthen enforcement; Status: Fully
implemented.
Initiative: Civil money penalties: Improve tracking and collection to
make them a more effective enforcement tool; Status: In process.
Initiative: Past noncompliance policy: Revise by clarifying key terms,
increasing homes' accountability for past quality-of-care problems, and
posting on the CMS Web site specific information about homes' past
noncompliance; Status: In process.
Source: GAO analysis of CMS initiatives.
[End of table]
Immediate Sanctions Policy:
Responding to our July 1998 recommendation to eliminate grace periods
for homes cited for repeat serious violations, CMS began a two-stage
phase-in of a new enforcement policy. In the first stage, effective
September 1998, CMS required states to refer for immediate sanction
homes found to have a pattern of harming residents or of exposing them
to actual harm or potential death or serious injury (H-level
deficiencies and above on CMS's scope and severity grid). Effective
January 2000, CMS expanded this policy, requiring referral of homes
found to have harmed one or a small number of residents (G-level
deficiencies) on successive standard surveys.[Footnote 31] In response
to our 2003 finding that states failed to refer a substantial number of
homes that met the criteria for the immediate sanctions, CMS initiated
oversight of state compliance with this policy. To conduct this
oversight, CMS analyzed deficiency data for 2000 through 2003 to
identify potential instances of homes that should have been but were
not referred for immediate sanctions. In ongoing work, we are assessing
the impact and implementation of the immediate sanctions policy.
Additional Enforcement Policy Issues:
Based on recommendations in our July 1998 report and our March 1999
report on enforcement, CMS has addressed weaknesses in its policies in
three areas: nursing homes' correction of deficiencies, the nursing
home appeals process, and the enforcement data tracking system.
* CMS now requires on-site follow-up, referred to as a revisit, of
homes with substandard quality of care or actual harm or higher-level
deficiencies until the state verifies correction of each deficiency
cited.[Footnote 32] Our 1998 report found that CMS's policy of allowing
nursing homes to self-report resumed compliance was sometimes
inappropriately applied to homes with deficiencies in the immediate
jeopardy category or that were found to have substandard quality of
care. We recommended that CMS require that for homes with recurring
serious violations, state surveyors substantiate resumed compliance by
means of an on-site revisit. CMS also has issued additional guidance on
the "reasonable assurance period" during which terminated homes must
demonstrate that they have corrected the deficiencies that led to their
terminations.[Footnote 33] This guidance provided additional examples
of reasonable assurance decisions.
* CMS and the Department of Health and Human Services (HHS) requested
and received funding and staffing increases for the HHS Departmental
Appeals Board in fiscal years 1999 and 2000 to address our March 1999
finding that the growing backlog of appeals hampered the effectiveness
of civil money penalties by delaying their collection. The Board is
responsible for adjudicating the appeals. By August 2003, the backlog
of appeals of civil money penalties had been significantly reduced.
* CMS implemented the automated ASPEN Enforcement Manager on October 1,
2004, to facilitate tracking of enforcement actions. Prior to
implementing this system, CMS had no centralized system for tracking or
managing federal and state enforcement actions.[Footnote 34] The ASPEN
Enforcement Manager is intended to provide real-time entry and tracking
of enforcement actions, issue monitoring alerts, generate enforcement
letters, and facilitate analysis of enforcement patterns. CMS expects
that ASPEN Enforcement Manager data will enable states, CMS regional
offices, and the CMS central office to more easily track and evaluate
nursing home performance and compliance status as well as respond to
emerging issues. In ongoing work, we are assessing whether data from
the ASPEN Enforcement Manager can be used to analyze nursing homes'
deficiency and enforcement histories.[Footnote 35]
Special Focus Facility Program:
In December 2004, CMS revised the method for selecting nursing homes
for the Special Focus Facility Program to ensure that the most poorly
performing homes were included in the program and to strengthen
enforcement for those nursing homes with an ongoing pattern of
substandard care.[Footnote 36] For this program, first initiated in
January 1999, states were directed to select two nursing homes to be
special focus facilities, conduct two standard surveys each year in the
special focus facilities, and submit monthly status reports on the
selected homes. The revised guidance directs states to select, from an
expanded list of facilities, a minimum of up to six nursing homes,
depending on the number of nursing homes in the state; the revised
guidance gives states the option to select more than the
minimum.[Footnote 37] States are also given the flexibility to remove
from the list homes that have made significant improvements.
Enforcement authority over special focus facilities has been
strengthened so that while homes are in the Special Focus Facility
Program, immediate sanctions must be imposed if homes fail to
significantly improve performance from one survey to the next;
termination from participation in Medicare and Medicaid is required for
homes with no significant improvement in 18 months and three surveys.
Civil Money Penalties:
In April 2004, CMS launched a Civil Money Penalty Improvement Project
to improve its ability to track and collect civil money penalties in an
effort to make them a more effective enforcement tool. CMS mapped out
the current process for tracking and collecting civil money penalties
to identify weaknesses and developed draft guidance with detailed
policies and procedures for addressing areas identified as needing
improvement, with a target release date of fall 2005. Also planned are
enhancements to the Civil Money Penalty Tracking System, CMS's
information system for civil money penalties. The enhancements are
intended to streamline the system, improve its reporting capabilities,
and improve its compatibility with the enforcement monitoring system.
The system's changes are planned to occur through 2005 and 2006.
Also in 2004, CMS, in conjunction with various state survey agencies,
began developing a civil money penalty grid--an optional guideline for
use by states and CMS regional offices to help ensure greater
consistency across states in the amounts of civil money penalties
recommended. The grid is expected to provide ranges for minimum civil
money penalties for deficiencies, while allowing for flexibility to
adjust the penalties on the basis of factors such as the severity of an
identified deficiency, the care areas in which deficiencies were cited,
and past history of noncompliance.[Footnote 38] The target issuance
date for a draft grid was August 2005.
Past Noncompliance Policy:
In October 2005, CMS issued a revised past noncompliance policy that
(1) clarifies how to address recently identified past deficiencies, (2)
further defines "past noncompliance," (3) eliminates the use of the
term "egregious," and (4) clarifies the methods for determining whether
past noncompliance has been corrected. Past noncompliance occurs when a
current survey reveals no deficiencies but determines that an egregious
violation of federal standards occurred in the past and was not
identified during an earlier survey.[Footnote 39] In November 2004, we
reported that CMS's past noncompliance policy was ambiguous. The policy
did not define what constituted an egregious violation or relate
egregious violations to its scope and severity grid. Moreover, the
policy did not hold homes accountable for negligence associated with
resident deaths unless current residents are experiencing the same
quality-of-care problems and it obscures the nature of care problems.
CMS's revised policy responds to our recommendation and holds homes
accountable for all past noncompliance resulting in harm to residents.
We also recommended that past noncompliance citations identify the
specific nature of the care problem in the OSCAR database and on the
Nursing Home Compare Web site. In 2007, CMS plans to enhance the
information on the Nursing Home Compare Web site to include the
specific nature of the past noncompliance. According to CMS officials,
the delay is related to the implementation of higher priority
initiatives by the agency. Currently, the Web site only indicates
whether there were instances of past noncompliance and does not
identify the nature of the care deficiency.
Oversight: Intensity and Scope of Federal Efforts Has Increased
Significantly, but Work Remains:
CMS has significantly improved the intensity and scope of its oversight
activities and has made significant improvements both in its data
systems and in its analysis and use of the data it collects on survey
activities. The effectiveness of several of these oversight
initiatives, however, is uneven, and more work remains to be done. (See
table 8).
Table 8: Oversight: CMS Initiatives and Implementation Status:
Initiatives: Federal comparative surveys: Increase number to intensify
oversight; Status: Fully implemented.
Initiatives: Smoke detectors: Require them in nursing homes without
sprinklers to strengthen fire safety; Status: Fully implemented.
Initiatives: Assessments of state survey activities: Review state
survey agencies' compliance with federal standards; Status: Selected
initiatives implemented.
Initiatives: Data systems and analysis: Upgrade to improve tracking and
oversight of state survey activities; Status: In process.
Initiatives: Sharing data: Share quality data with the public to help
drive quality improvement; Status: Selected initiatives implemented.
Initiatives: Quality Improvement Organizations: Use Quality Improvement
Organizations to help nursing homes improve the quality of care;
Status: In process.
Initiatives: Coordination and dissemination of best practices: Initiate
activities to improve nursing home oversight; Status: In process.
Source: GAO analysis of CMS initiatives.
[End of table]
Federal Comparative Surveys:
In response to recommendations in our November 1999 and July 2004
reports, CMS has (1) significantly increased the number of federal
comparative surveys both for quality of care and fire safety and (2)
decreased the time between the end of the state survey and the start of
the federal survey for quality-of-care comparative surveys, allowing
CMS to better distinguish between serious problems missed by state
surveyors and changes in a home that occurred after the state survey.
We found earlier that CMS was making negligible use of comparative
surveys, its most effective tool for assessing a state survey agency's
ability to identify serious quality-of-care and fire safety
deficiencies in a nursing home, to fulfill its 5 percent monitoring
mandate.[Footnote 40] Only 21 quality-of-care comparative surveys were
conducted from November 1996 through October 1998. Our 2004 fire safety
report found that CMS had conducted only 40 fire safety comparative
surveys in fiscal year 2003, ranging from 4 in some states to none in
others.
Since 2001, CMS has required its regional offices to complete at least
two quality-of-care comparative surveys per state per year, but federal
surveyors have been exceeding this minimum threshold.[Footnote 41]
During the period March 1, 2002, through December 31, 2004, CMS
completed 424 comparative surveys, about 140 per year. In addition, the
average elapsed time between state and comparative surveys has
decreased from 33 calendar days for the 64 comparative surveys we
reviewed in 1999 to 26 calendar days for the 424 surveys completed
through 2004.
CMS planned to further increase the number of comparative surveys by
contracting in the fall of 2003 for 170 quality-of-care comparative
surveys in addition to those conducted by federal surveyors. However,
an increase in the number of quality-of-care comparative surveys is
unlikely because of delays in contractor readiness and the addition of
fire safety comparative surveys to the contract. CMS had expected to
have a sufficient number of contract surveyors trained and available to
start surveys by the winter of 2005, but it took longer than
anticipated to train the new surveyors. In addition, CMS modified the
contract to include fire safety comparative surveys. In fiscal year
2005, the contractor conducted 34 quality-of-care comparative surveys
and 250 fire safety comparative surveys. Together, the contractor and
CMS regional offices conducted a total of 859 fire safety comparative
surveys in fiscal year 2005. CMS also is using the contract surveyors
to augment federal survey teams. According to CMS, it will use contract
funds carried over from earlier years to conduct quality-of-care
comparative surveys during fiscal year 2006, and will only use fiscal
year 2006 funds to conduct fire safety comparative surveys.
Smoke Detectors in Homes without Sprinklers:
In response to a recommendation in our July 2004 report to strengthen
fire safety standards, CMS published an interim final rule in March
2005 requiring nonsprinklered nursing homes to install battery-powered
smoke detectors in resident rooms and common areas, including resident
dining, activity, and meeting rooms. Previously, federal standards
required smoke detectors in (1) corridors or resident rooms only in
homes built after 1981 and (2) nonsprinklered resident rooms containing
furniture brought from the resident's home. We reported that the lack
of smoke detectors in resident rooms may delay staff response and fire
department notification, which in turn may increase the number of
nursing home fire-related fatalities. CMS will begin surveying nursing
homes' compliance with the new requirement in May 2006.
Assessments of State Survey Activities:
In October 2000, CMS regional offices began conducting on-site state
performance reviews to assess compliance with federal
standards.[Footnote 42] Previously, CMS permitted states to evaluate
and report on their own performance against a number of standards, a
technique that essentially allowed states to write their own report
cards because CMS did not independently validate information provided
by the states. In fiscal year 2005, CMS began to tie funding increases
for state survey agencies to one of the seven performance standards--
the timely conduct of standard surveys--time frames that are
established in federal statute.
Nevertheless, in our current analysis of the standard that is intended
to measure the supportability of survey findings, we found that three
key issues we identified in July 2003 still exist. First, distinctions
in state performance were hard to identify because, while some states
have consistently met the standard for documentation of deficiencies,
federal comparative surveys completed during essentially the same time
frame found that surveyors in these states frequently missed serious
deficiencies. Second, CMS regional offices were inconsistent in
conducting state performance reviews. For fiscal year 2004, five states
nationwide did not meet this standard, but three of the five states
were in one CMS region. Third, the standard for assessing the
supportability of deficiencies is composed of 11 elements that mix
major and minor issues.[Footnote 43] Although CMS has simplified the
standard for assessing the supportability of deficiencies, we believe
that many of the elements reviewed remain essentially administrative in
nature rather than substantive.[Footnote 44] Of the elements that make
up the standard, only 2 assess the appropriateness of the cited scope
and severity; the remaining elements assess such issues as how the
deficiency is written, including avoiding the use of the passive voice.
We do not believe that this standard is sufficiently focused on
identifying understatement.
CMS did not implement our July 2003 recommendation that it require
states to review a sample of deficiencies cited at or below the level
of actual harm in order to detect understatement because, according to
CMS, the state performance review of the supportability of deficiencies
already accomplished this objective. In discussing our current findings
regarding the standard intended to measure the supportability of survey
findings, CMS officials agreed that (1) measuring the quality of state
surveys, one goal of reviewing the supportability of deficiencies, was
particularly challenging because there is no one agreed-upon way to
measure quality; and (2) some standards are complex, contributing to
consistency problems.
In developing this report, we also noted two additional problems with
the state performance reviews that were not previously reported. First,
in its fiscal year 2004 review, CMS began combining state performance
review results across the different provider types, such as nursing
homes and home health agencies, for which states have oversight
responsibility. For example, CMS calculates one overall state score on
the supportability of deficiencies across provider types, rather than
issuing provider-specific scores. One CMS region suggested that because
nursing homes are generally surveyed by a unique pool of surveyors,
combining results in this manner limits the usefulness of the feedback
to state survey agencies. Second, CMS provides feedback to states
regarding their performance each year, but it does not publicly report
the results. Doing so would appear to be consistent with CMS's stated
philosophy of sharing information with the public to help improve
nursing home quality.
Data Systems and Analysis:
CMS has pursued important upgrades in the system used to track the
results of state survey activities and has increased its analysis of
OSCAR and other data to improve oversight by CMS central and regional
offices and state survey agencies. Examples include the following:
* In 2000, CMS began to produce 19 periodic reports to monitor both
state and regional office performance.[Footnote 45] Some reports, such
as survey timeliness, are used during state performance reviews, while
others are intended to help identify problems or inconsistencies in
state survey activities and the need for intervention.
* In 2001, 2002, and 2005 CMS published a "Nursing Home Data
Compendium," which includes detailed tables and figures on nursing
homes, resident demographics, resident clinical characteristics, and
survey results.
* In 2004, CMS commissioned a series of "White Papers" on topics
ranging from enforcement to resource issues. The goal was to stimulate
discussion among key stakeholders and generate ideas for "next steps"
to help mitigate problems. The reports, authored by CMS and state
survey agency staff, relied on data analysis from OSCAR and other CMS
databases.
* In 2004, CMS prepared an internal study on enforcement trends since
the imposition of the immediate sanctions policy using data from the
Enforcement Tracking System.
* In 2005, CMS unveiled a Web site for use by regional offices and
state survey agencies that generates a series of standard reports
through a software program called Providing Data Quickly; this software
permits easier access to the data contained in OSCAR. One such report
identifies homes that have repeatedly harmed residents and meet the
criteria for imposition of immediate sanctions.
CMS indicated that it is continuing to make progress in redesigning the
OSCAR system. In our March 1999 report on enforcement, we recommended
that the agency develop an improved management information system that
would help it to track the status and history of deficiencies,
integrate the results of complaint investigations, and monitor
enforcement actions. Although the target implementation date for the
redesigned system has slipped from 2005 to 2008, depending on competing
priorities and available funding, CMS has implemented two key
components of the redesigned system--a complaint tracking system and a
system to track the status of enforcement actions. Both systems are
intended to provide CMS with critical management capabilities that it
previously lacked.
Sharing Data with the Public:
Using market forces to help drive quality improvement is an important
CMS objective behind sharing data with the public on nursing home
quality. Since CMS launched Nursing Home Compare in 1998, the agency
has progressively expanded the information available on this Web site.
In addition to data on the deficiencies identified during standard
surveys, the Web site now includes data on the results of complaint
investigations, information on nursing home staffing levels, and
quality indicators, such as the percentage of residents with pressure
sores. However, CMS continues to address ongoing problems with the
accuracy and reliability of the underlying data, such as the MDS,
quality indicators, and nurse staffing levels.
In February 2002, we concluded that CMS efforts to ensure the accuracy
of the underlying MDS data[Footnote 46] used to calculate the quality
indicators (1) relied too much on off-site review activities by its
contractor and (2) anticipated on-site reviews in only 10 percent of
its data accuracy assessments, representing fewer than 200 of the
nation's nursing homes.[Footnote 47] CMS did not concur with our
recommendation that it reorient its review program to complement
ongoing state MDS accuracy efforts as a more effective and efficient
way to ensure MDS data accuracy.[Footnote 48] CMS commented that its
efforts already provided adequate oversight of state activities and
complemented state efforts. In April 2005, CMS ended work under its
data assessment and verification contract because of cost concerns, but
signed a new contract in September 2005 that focuses on on-site reviews
of MDS accuracy.[Footnote 49] According to CMS officials, the on-site
reviews were more effective in identifying discrepancies because the
reviewers were able to find more information on-site that conflicted
with the nursing homes' assessments.[Footnote 50]
In November 2002, CMS began reporting on its Web site quality indicator
data for each nursing home nationwide that participates in Medicare and
Medicaid, even though our October 2002 report concluded that such
reporting was premature given serious questions about the sufficiency
of CMS efforts to validate the quality indicators and improve the
accuracy of the underlying data.[Footnote 51] CMS disagreed with our
recommendation to postpone its scheduled November 2002 public reporting
of the data until these problems were addressed. Since 2002, however,
CMS has taken steps to address the questions we raised about the
validity of quality indicators. For example, CMS dropped certain
quality indicators that it found were not sufficiently reliable for
public reporting, such as the facility-adjusted profile prevalence of
pressure sores. In addition, CMS worked with the National Quality Forum
to address measurement problems with the pressure sore quality
indicator by developing separate indicators for short-and long-term
nursing home residents; these new indicators were added to the Web site
in January 2004.[Footnote 52] A weight loss quality indicator also was
developed and added to the Web site in November 2004. Our October 2002
report had noted the potential for consumer confusion in interpreting
and using quality indicator data. CMS conducted consumer testing of new
language and displays on Nursing Home Compare during the summer of
2004.
Although nursing home staffing data have been available on the Nursing
Home Compare Web site since June 2000, a CMS official told us that the
agency has been aware of problems with these self-reported data since
the late 1990s.[Footnote 53] This official stressed that, despite
problems, they were the only available data on nursing home staffing.
Examples of erroneously reported data include facilities with no nurse
staffing hours or hours equal to thousands of residents per day. In
addition, the staffing data do not address important issues such as
turnover or retention.[Footnote 54] As a temporary fix, CMS developed
edits that examine staffing ratios to determine whether any facility
falls above or below certain thresholds and, effective July 2005,
temporarily excluded the questionable staffing data from Nursing Home
Compare until they can be corrected or confirmed. To address this
issue, CMS is considering a proposal for a new system that relies on
nursing home payroll data. If approved, such a system could take 3 to 4
years to implement because of the need to solicit and consider public
comment and to develop software to transmit the staffing data.
Quality Improvement Organizations:
CMS's initiative to include quality indicator data on its Nursing Home
Compare Web site also established a new role for Quality Improvement
Organizations (QIO) with regard to nursing homes. From 2002 through
2005, QIOs worked intensively with at least 10 percent of nursing homes
in each state to improve quality.[Footnote 55] Although we have not
evaluated QIO nursing home quality improvement activities, CMS's
preliminary analyses indicate that the QIO program has helped to reduce
the use of daily physical restraints, increased management and
treatment of pain, and reduced the incidence of delirium among post-
acute-care residents. However, less progress has been made in
decreasing the prevalence of pressure sores, according to CMS's
analyses. In August 2004, the QIO and state survey agency in 18 states
launched a new pilot program. Working together, they identified from
one to five nursing homes per state that had significant quality
problems. The QIO then worked with these homes to help them redesign
their clinical practices. According to CMS, the results of this pilot
indicated that these historically "troubled" nursing homes had
dramatically improved their clinical quality and decreased their
quality-of-care survey deficiencies.[Footnote 56] In 2005, the QIOs'
role with nursing homes was extended for an additional 3 years, and
QIOs will continue to focus on statewide improvement in four areas--
pressure sores, physical restraints, pain management, and depression.
In addition, QIOs will help nursing homes set individual targets for
quality improvement, implement and document process-related clinical
care, and assist in the development of a more resident-focused care
model. QIO expenditures on nursing home quality improvement for the
period of August 2002 through July 2008 are expected to total about
$216 million.
Coordination and Dissemination of Best Practices:
CMS has taken certain actions to maximize the experience and resources
of state survey agencies as well as the CMS central and regional
offices to improve nursing home oversight. Specifically, in 2004, CMS
convened an internal Long-Term Care Task Force and charged it with
providing guidance on and coordinating long-term care efforts within
CMS and included representation across the agency's divisions and the
regional offices. Also in 2004, CMS began an effort to collect and
disseminate nursing home survey and certification best practices
developed by professional associations, universities, and federal
agencies.[Footnote 57] Through the best practices effort, CMS plans to
share successful strategies used by states and regional offices in a
broad range of issues affecting survey and certification of nursing
homes, such as surveyor recruitment and complaint intake. A contractor
will identify, research, and document best practices, which CMS plans
to post on its Web site. One of the issues the best practices effort
will address is surveyor recruitment initiatives underway in states. As
of August 2005, these best practices had not been published on the CMS
Web site.
Resource and Workload Issues Pose Key Challenges to Further Improving
Nursing Home Quality and Safety:
CMS, states, and nursing homes face a number of key challenges in their
efforts to further improve nursing home quality and safety, including
(1) the cost of retrofitting older nursing homes with automatic
sprinklers, a potentially costly requirement that has a demonstrated
ability to prevent deaths in the event of a fire; (2) continuing
problems in hiring and retaining qualified surveyors, a factor that
states indicated can contribute to variability in the citation of
serious deficiencies; and (3) an increasing federal and state survey
workload due to increased oversight, the identification over time of
additional initiatives, and growth in the number of Medicare and
Medicaid providers that must be surveyed, including expected growth in
nursing homes. The increased workload has created competition for both
staff and financial resources and required the establishment of
priorities, which may have contributed to delays in developing and
implementing several key quality initiatives, such as the
implementation of a more rigorous survey methodology.
Cost Could Delay Retrofitting of Older Nursing Homes with Sprinklers:
Although the substantial loss of life in two 2003 nursing home fires
could have been reduced or eliminated by the presence of properly
functioning automatic sprinkler systems, cost has been an impediment to
CMS's requiring them for all homes nationwide. Newly constructed homes
must incorporate sprinkler systems; however, older homes constructed
with noncombustible materials that have a certain minimum ability to
resist fire are not required to install sprinklers. We previously
reported that cost has been a barrier to requiring sprinklers for all
older nursing homes. In July 2005, the National Fire Protection
Association (NFPA) voted to require retrofitting of older homes with
sprinklers, a requirement that will become a part of the 2006 edition
of the NFPA code. Anticipating this action, CMS indicated that it has
been developing a notice of proposed rule making, the first step in
adopting the NFPA requirement for all homes that serve Medicare and
Medicaid beneficiaries. A CMS official stated that the agency plans to
issue the notice in March 2006 and after reviewing public comments, it
will publish a final version of the rule and stipulate an effective
date for homes to come into compliance.[Footnote 58]
One issue that remains unresolved is how much time older homes will be
given to install sprinklers. As we reported in 2004, industry officials
believe that a transition period must be considered for homes to come
into compliance and to determine how to pay for the cost of installing
sprinklers.[Footnote 59] Rather than proposing a phase-in period, the
proposed rule will request input on how much time homes should be given
to come into compliance with the requirement. According to CMS, a
longer phase-in period could help alleviate concerns about the cost of
retrofitting homes with sprinklers. Based on our recommendation, CMS
collected data on the sprinkler status of homes nationwide and found
that about 21 percent of nursing homes are unsprinklered or partially
sprinklered.[Footnote 60] Although CMS has not completed its cost
analysis, the agency believes that the costs associated with the
retrofit will be less than the industry's $1 billion estimate.
States Continue to Have Problems in Hiring and Retaining Surveyors:
The hiring and retention of surveyors, particularly RNs, remains a
major, frequently discussed issue among state survey agency directors,
according to an AHFSA official, the association that represents state
survey agency directors. In July 2003, we reported that the limited
experience level of state surveyors because of a high turnover rate was
a contributing factor to (1) variability in citing actual harm or
higher-level deficiencies and (2) understatement of such deficiencies.
In more than half of the 42 states that responded to our inquiry, from
30 percent to more than 50 percent of surveyors had 2 years' experience
or less, as of July 2002. Twenty-five states responded to our request
for updated information on surveyor workforce issues as of July 2005.
Of 23 states that provided data in both 2002 and 2005, 13 reported an
improvement in 2005 (i.e., a decline in the proportion of inexperienced
surveyors); 9 indicated that the situation had worsened (e.g., an
increase in the proportion of inexperienced surveyors); and 1 state
reported no change (see app. IV). As of July 2005, however, 20 percent
or more of surveyors in 20 of the 25 states had 2 years' experience or
less (see table 9). Surveyor vacancy rates in the 25 states ranged from
about 3 percent in Tennessee to 31 percent in Alabama and Florida;
overall, 15 states had double-digit vacancy rates. Officials in 18
states believed that inexperienced surveyors contributed to interstate
variability in the citation of serious deficiencies. One state survey
agency indicated that staff attrition resulted in a workforce of less
experienced surveyors who demonstrated a hesitance to cite actual harm
and contributed to understatement. State survey agency officials in
several states, however, suggested that the problem for less-
experienced surveyors was not identifying harm but rather investigating
and documenting the circumstances that led to the harm, including
facility culpability, a skill that surveyors develop as they gain more
experience.[Footnote 61]
Table 9: Percentage of Surveyors with 2 Years' Experience or Less, as
of July 2005:
Percentage of surveyors with 2 years' experience or less: More than 50
percent; Number of states: 5.
Percentage of surveyors with 2 years' experience or less: More than 30
percent to 50 percent; Number of states: 5.
Percentage of surveyors with 2 years' experience or less: 20 percent to
30 percent; Number of states: 10.
Percentage of surveyors with 2 years' experience or less: 10 percent to
less than 20 percent; Number of states: 5.
Source: AHFSA data from 25 states.
[End of table]
Because state survey agency salaries are rarely competitive with the
private sector, state survey agencies told us that it is difficult to
retain surveyors and to fill vacancies. RNs, a major component of
states' surveyor workforce, are in high demand and short supply,
according to AHFSA. Furthermore, 9 states responding to our July 2005
inquiry indicated that state civil service requirements can make it
more difficult to fill vacancies. Several of the 9 states characterized
the hiring process as either cumbersome or time-consuming, or both, and
1 state noted that the process takes close to 9 months. Two states
reported that they had to select candidates to interview from a
certified list. One of the states indicated that the certified list
often contained unqualified applicants, while the other state noted
that some of the applicants were not the "best fit." Of the 25 states,
21 indicated that they had implemented initiatives to help retain
surveyors. The most popular retention strategies were to increase
starting salaries and to implement flexible surveyor work schedules.
For example, New York instituted a locality pay differential for New
York City. While 5 of the 25 states indicated that they had a state-
imposed hiring freeze, 1 state reported that budget pressures prevented
it from taking steps to improve retention rates.[Footnote 62] A
continuing problem cited by AHFSA is that federal funds are distributed
late in the fiscal year, which does not tie into state budget cycles
for approving additional positions. This problem may be particularly
acute in the 5 states that reported having a hiring freeze.
Workload Issues and Competing Priorities Pose Challenges for CMS and
States:
CMS and states have experienced increased survey workloads due to the
greater intensity of nursing home oversight, the increasing number of
initiatives, and growth in the number of Medicare and Medicaid
providers requiring oversight. This workload growth required the
prioritization of initiatives that, in some cases, has resulted in
implementation delays for some key initiatives. The consensus-building
process necessary to bring initiatives to fruition also has contributed
to some delays. The initiatives likely will continue to compete for
priority with other CMS programs, posing a challenge for efforts to
further improve nursing home quality and safety.
Increased Workload Has Contributed to Delays:
Greater nursing home oversight has increased demand on both CMS and
state survey agency resources, causing delays for some key initiatives.
CMS's increased workload is evident in the labor-intensive state
performance reviews. Since their introduction in October 2000, the
reviews have been gradually expanded from nursing homes to several
other Medicare and Medicaid providers, such as home health agencies and
hospitals. CMS also has significantly increased the number of federal
quality-of-care and fire safety comparative surveys. Such surveys are
more labor-intensive than the alternative type of federal monitoring
surveys, known as observational surveys, because they require an entire
federal survey team rather than a smaller number of federal surveyors.
The agency also has committed considerable resources to developing new
data systems for complaints and enforcement actions while
simultaneously increasing its use of available data to further improve
federal and state oversight. Despite the increased workload, CMS
implemented survey staff reductions of 5 percent in regional offices
and 3 percent in its central office in January 2004. As of August 2005,
these staff reductions have remained in effect.
As state survey agency workloads grew with the implementation of the
initiatives, they also experienced resource pressures. States are now
required to conduct on-site revisits to ensure serious deficiencies
have been corrected, investigate complaints alleging actual harm on-
site and do so more promptly, and initiate off-hour standard surveys.
Thus, surveyors' presence in nursing homes has increased and surveyors'
work hours have effectively been expanded to weekends, evenings, and
early mornings. The requirement to impose immediate sanctions on homes
that repeatedly harm residents also has had a workload impact because
in the past a grace period allowed homes to correct deficiencies before
the sanctions went into effect. The imposition of immediate sanctions
requires states to track, which some states do manually, the homes that
must be referred for immediate sanctions and requires CMS and states to
act to impose recommended sanctions that in the past would have been
rescinded because the homes could have corrected the deficiencies
during a grace period. While states' budget pressures appear to be
easing, many state survey agencies reported hiring freezes, staff
vacancies, or high turnover as of July 2002 when all of these
initiatives had already been fully implemented.
The number of initiatives that CMS has implemented on its own has
grown, further increasing its workload. For example, CMS added quality
indicator data to its Nursing Home Compare Web site and has involved
QIOs in helping nursing homes to improve quality of care. In addition,
CMS created a task force to develop guidance intended to improve
consistency across states in the imposition of civil money penalties.
The number of nursing home initiatives simultaneously under development
or being implemented as well as other CMS responsibilities, such as
preparing to implement the new Medicare prescription drug benefit in
January 2006, have necessitated the establishment of priorities and led
to delays and queues.[Footnote 63] CMS assigned some initiatives, such
as the development and public reporting of quality indicators, a high
priority and implemented them swiftly despite issues related to their
validity and the quality of the underlying data--problems that CMS is
still working to address. In contrast, the revision of the survey
process has encountered delays because of funding shortfalls and has
been in process for 7 years. For example, initial testing of the new
methodology in 2002 and 2003 was limited, even though CMS had already
invested $4.7 million in its development from initiation in 1999
through September 2003. A pilot test of the new methodology is
scheduled to begin in the fall 2005; depending on the results of the
testing, implementation could begin in mid-2007. Although CMS attaches
a high priority to enhancing the information available to the public on
nursing home quality and safety, adding information on past
noncompliance and the fire safety status of nursing homes are in a
queue behind the programming required to implement higher-priority
projects. There is also a regulatory queue, with other, higher-priority
regulations ahead of the notice of proposed rule making to require
retrofitting of nursing homes with automatic sprinklers.
Delays in implementing the nursing home initiatives are also
attributable to CMS's need to be responsive to stakeholder input.
Appropriately, CMS seeks input from various stakeholders such as
states, regional offices, the nursing home industry, and resident
advocates. For example, CMS sought input from experts in developing
investigative protocols for surveyors. Due to this lengthy consultative
process, combined with the prolonged delays stemming from internal
disagreement over the structure of the process during the initial
stages, CMS has only implemented two investigative protocols since
2001. Likewise, implementation of the ASPEN Complaint Tracking System
was delayed because during the system's pilot test, several states
indicated their belief that their existing systems were superior and
opposed the idea of either abandoning these systems or maintaining
separate systems.
Number of Providers Subject to Surveys Is Growing:
Both the overall growth in providers and the anticipated growth in
nursing homes pose additional workload challenges for CMS and states.
In addition to nursing homes, CMS and states are responsible for
surveys of other Medicare and Medicaid providers, such as home health
agencies and hospitals. The number of these providers grew from 39,651
in October 2000 to 45,375 in January 2005, approximately 14
percent.[Footnote 64] While the number of nursing homes has decreased
slightly during the same period, from 17,012 to 16,146, the rate of
decline has slowed; and as the baby boom generation ages, increasing
the number of elderly needing long-term care services, the number of
nursing homes is expected to grow to meet the demand. In 2000, 35.1
million people were aged 65 or older. This number is expected to grow
to about 54.7 million by 2020.
Nursing home survey activities consume the majority of state survey
budgets and resources. Nursing homes make up about 31 percent of
Medicare and Medicaid providers, but account for 73 percent of the
federal budget for oversight of such providers.[Footnote 65] The
funding for nursing home surveys is disproportionate because the time
frames for standard nursing home surveys are statutory. For those
survey requirements not in statute, CMS determines the survey time
frames; these surveys are therefore a lower priority.[Footnote 66] Even
among nursing home survey activities, however, annual standard surveys
are considered a higher priority than complaint surveys or initial
surveys for which the statute does not dictate specific time
frames.[Footnote 67] CMS and state survey agency officials recognize
that CMS may have shifted its focus and resources to nursing homes at
the expense of adequate oversight of other providers serving Medicare
and Medicaid beneficiaries, and some states contend that the focus on
nursing home standard surveys has hampered their ability to investigate
nursing home complaints within mandated time frames. For example,
according to a California state survey agency official, California law
mandates that all nursing home resident complaints, not just complaints
alleging actual harm, be investigated within 10 days. Likewise, an
official from the Pennsylvania state survey agency stated that in
Pennsylvania, all complaints must be investigated within 48 hours.
California survey agency officials have told us that a complaint
alleging a care problem deserves a higher priority than a standard
survey, which may or may not identify deficiencies.
Key Nursing Home Initiatives Continue to Compete for Priority:
According to CMS officials, key nursing home initiatives continue to
compete for priority with other CMS projects. Examples of nursing home
initiatives that have been affected include revision and testing of the
new survey methodology, continued development of the investigative
protocols that surveyors use to investigate care problems, and an
increase in the number of quality-of-care comparative surveys.
* Revised survey methodology. CMS officials have indicated that
nationwide implementation of the revised survey methodology could be
affected if its use requires additional survey time or a greater number
of surveyors to conduct each survey. The pilot test of the new
methodology, scheduled for 2005 and 2006, includes an examination of
steps to streamline the revised process, if necessary. Cost
considerations limited the pilot of the new methodology to fewer states
than the 20 that volunteered.
* Investigative protocols for quality-of-care problems. Only three sets
of investigative protocols had been implemented as of November 2005,
and it is unclear whether the contractor's assessment of the protocols'
effectiveness can be completed before the contract ends in 2006.
Furthermore, unless the contract for the investigative protocols is re-
bid, CMS expects to return to the traditional revision process even
though agency staff believe that the expert panel process used under
the contract produced a high-quality product.
* Federal comparative surveys. CMS hired a contractor in 2003 to
further increase the number of federal quality-of-care comparative
surveys, but dropped funding for quality-of-care comparative surveys
from the fiscal year 2006 contract.[Footnote 68] The agency reallocated
the funds to help state survey agencies meet the increased survey
workload resulting from growth in the number of other Medicare
providers.
Concluding Observations:
CMS has focused considerable attention since 1998 on addressing
weaknesses in state and federal oversight activities in order to better
care for and protect nursing home residents. The agency has implemented
many important improvements in the areas of surveys, complaints,
enforcement, and oversight, such as taking steps to address survey
predictability, issuing additional guidance to ensure timely on-site
investigations of complaints alleging harm to residents, implementing
an immediate sanctions policy to eliminate grace periods for homes
cited for repeat serious violations, and strengthening oversight by
conducting assessments of state survey activities. However, some key
activities are still in process. For example, CMS's effort to revise
the survey methodology has been underway for 7 years. Given the pivotal
role played by surveys in helping to ensure that nursing home residents
receive high-quality care, the development and implementation of a more
rigorous survey methodology is one of the most important contributions
CMS can make to addressing oversight weaknesses. Certain other
initiatives, such as sharing data with the public in an effort to use
market forces to drive quality improvement, also remain in process.
Since launching Nursing Home Compare in 1998, CMS has been aware of
accuracy and reliability issues with the underlying data and began
changing its approach to data integrity in 2005. The agency is working
to address issues concerning data on nursing home staffing that
compelled it to temporarily exclude questionable data from its Web site
in July 2005 until its accuracy can be verified. Because consumers use
these data to make decisions about nursing home care, ensuring the
accuracy, reliability, and timeliness of nursing home quality data is
critical. Even with CMS's increased efforts to improve nursing home
quality, the agency's continued attention and commitment to these
efforts is essential in order to maintain and build upon the momentum
of its accomplishments to date.
Agency and State Comments and Our Evaluation:
We provided CMS a draft of this report for review. CMS generally
concurred with our findings, noting that progress has been made in many
areas such as surveys and complaint investigations, oversight
activities, and citation of serious deficiencies, but that challenges
remain. (CMS's comments are reproduced in app. V.) CMS also provided
technical comments, which we included in the report as appropriate. We
also provided the five states we contacted an opportunity to review the
portion of the draft focused on trends in nursing home quality.
California, Florida, Ohio, New York, and Texas provided written
comments. California's comments focused on clarifying its experience
seeking CMS guidance on the definition of actual harm, but did not
state whether it agreed with our findings. Ohio commented that our
report's findings related to continued inconsistency and understatement
of serious deficiencies by state surveyors did not apply to its state
survey agency. New York stated that including a more detailed
description of states' efforts to improve nursing home quality would
provide a more balanced view of the reasons for the decline in serious
deficiencies. Florida and Texas generally concurred, but Texas did not
provide specific comments. CMS and states' specific comments focused
primarily on four issues: understatement of serious deficiencies, the
definition of actual harm, data availability, and challenges to
conducting nursing home survey and oversight activities.
CMS commented that it remains concerned about the possible
understatement or omission of serious deficiencies, but that it did not
believe that understatement caused the decline in serious nursing home
deficiencies or that understatement was worsening. CMS noted its
efforts to work with states that fail to improve their ability to
identify deficiencies such as withholding funding increases until
corrective action plans are developed. Florida, New York, and Ohio
similarly commented that efforts such as their states' quality
improvement initiatives, regulatory changes to improve nursing home
operations, and engagement of the provider community have contributed
to the decline.
CMS suggested that including the results of observational surveys in
our analysis of the percentage of federal surveys that found serious
deficiencies missed by states would show that the percentage remained
relatively constant from 2002 to 2004 rather than increasing. As we
noted in our 1999 report, however, comparative surveys are more
effective than observational surveys in identifying serious
deficiencies missed by state surveyors because they are the only
oversight tool that provides an independent federal survey where
results can be compared to those of the state. Observational surveys
can serve as an effective training tool for state surveyors but, in our
view, they do not accurately represent typical state surveyor
performance due to the likelihood that state surveyors modify their
performance when they are aware that they are being observed by federal
surveyors.
Florida and Ohio noted that in addition to comparative surveys, CMS
conducted many observational surveys during the time period studied.
Ohio disagreed that our analysis of federal comparative surveys
suggests that nursing home surveyors in Ohio missed serious
deficiencies, citing its combined performance ratings for observational
and comparative surveys. New York commented that federal comparative
surveys often do not include the same resident sample used in the state
survey and that only looking at comparative surveys provides a narrow
analysis of state survey quality. New York suggested a more detailed
analysis of comparative survey data and consideration of state
performance review results. We note that, in 2002, CMS directed federal
surveyors to include at least 50 percent of the residents included in
the state survey sample. We also acknowledge that CMS is conducting
state performance reviews as part of its oversight of state survey
activities, but note that the reviews have shortcomings as described in
our July 2003 report. Florida noted that our analysis of federal
comparative surveys that identified missed serious deficiencies is
based on limited data. We acknowledge that our analysis is based on a
small number of surveys, but note that it includes the full universe of
comparative surveys conducted from March 2002 through December 2004 in
the five states we reviewed.
The range of comments from states reinforces the need for CMS to
clarify the definition of actual harm, as it plans to do. California
noted that while some of its state surveyors were confused about the
definition of actual harm, after discussions with CMS from 1998 through
2004, the survey agency and CMS are now in agreement on the definition
of actual harm. New York stated that confusion about the definition of
actual harm has been reduced. Ohio noted that its state surveyors are
not confused by the definition of actual harm, but that states have not
received clear and specific guidance from CMS. Florida agreed that
clearer guidance would be useful.
CMS indicated that it is taking steps to improve the reliability and
accuracy of publicly reported data by identifying suspect data and
posting more detailed information about past noncompliance. As we state
in our report, we believe that consumers should have timely and
accurate data to inform their decisions regarding nursing home care.
CMS commented that the workload issues described in this report present
challenges beyond those we have previously reported. CMS stated that
continued constraint of resources could "likely cause some erosion of
the gains already made" in the survey and oversight activities to date.
To address the challenges it faces, CMS plans to increase efforts to
improve productivity, determine the cost and value of policies, focus
state performance standards on substantive issues, prioritize survey
activities, coordinate with stakeholders, address increasing fuel
costs, and enhance emergency preparedness. California, Florida, New
York, and Ohio reiterated the staffing challenges they have experienced
and the steps they have taken to address them, some of which are
described in this report. Despite these efforts, California indicated
that its staffing challenges have negatively impacted the investigative
process. While we recognize the challenges CMS and states face, we
continue to believe that maintaining the momentum developed over the
last several years on key CMS initiatives, such as the development of
the revised survey methodology (i.e., Quality Indicator Survey), is
critical to addressing nursing home survey and oversight weaknesses.
As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies of this report
to the Administrator of the Centers for Medicare & Medicaid Services
and appropriate congressional committees. We also will make copies
available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please
contact me at (202) 512-7118 or allenk@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix VI.
Kathryn G. Allen:
Director, Health Care:
[End of section]
Appendix I: Prior GAO Recommendations, Related CMS Initiatives, and
Implementation Status:
Table 10 summarizes our recommendations from 14 reports on nursing home
quality and safety, issued from July 1998 through November 2004; CMS's
actions to address weaknesses we identified; and the implementation
status of CMS's initiatives. The recommendations are grouped into four
categories--surveys, complaints, enforcement, and oversight. If a
report contained recommendations related to more than one category, the
report appears more than once in the table. For each report, the first
two numbers identify the year in which the report was issued. For
example, HEHS-98-202 was released in 1998. The Related GAO Products
section at the end of this report contains the full citation for each
report. Of our 36 recommendations, CMS has fully implemented 13,
implemented only parts of 3, is taking steps to implement 13, and
declined to implement 7.
Table 10: Implementation Status of CMS's Initiatives Responding to
GAO's Nursing Home Quality and Safety Recommendations, July 1998
through November 2004:
Surveys:
GAO report number: GAO/HEHS-98-202; GAO recommendation: 1. Stagger or
otherwise vary the scheduling of standard surveys to effectively reduce
the predictability of surveyors' visits. The variation could include
segmenting the standard survey into more than one review throughout the
12-to 15-month period, which would provide more opportunities for
surveyors to observe problematic homes and initiate broader reviews
when warranted; CMS initiative: CMS took several steps to reduce survey
predictability, but some state surveys remain predictable;
* In 1999, CMS instructed state survey agencies to (1) conduct 10
percent of surveys on evenings and weekends, (2) vary the sequencing of
surveys in a geographical area to avoid alerting other homes that the
surveyors are in the area, (3) vary the scheduling of surveys by day of
the week, and (4) avoid scheduling surveys for the same month as a
home's prior survey;
* In 2004, CMS provided states with an automated scheduling and
tracking system (AST) to assist in scheduling surveys. CMS officials
told us that AST can be used to address survey predictability. States
appeared to be unaware of this feature and use of AST is optional;
* CMS disagreed with and did not implement the recommendation to
segment the standard survey into more than one review throughout the 12-
to 15-month period; Implementation status: Implemented only part of our
recommendation and no further steps are planned.
GAO recommendation: 2. Revise federal survey procedures to instruct
surveyors to take stratified random samples of resident cases and
review sufficient numbers and types of resident cases so that surveyors
can better detect problems and assess their prevalence; CMS initiative:
CMS has been developing a revised survey methodology since 1998. A
pilot test of the new methodology is scheduled to begin in the fall of
2005. Implementation could begin in mid-2007; Implementation status:
Taking steps to implement our recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 3. Finalize the development, testing, and
implementation of a more rigorous survey methodology, including
investigative protocols that provide guidance to surveyors in
documenting deficiencies at the appropriate scope and severity level;
CMS initiative: See CMS action in response to recommendation to revise
federal survey procedures (recommendation #2 above); CMS began revising
surveyors' investigative protocols in October 2000. Three protocols
have been issued and several more are under development. In addition,
CMS is clarifying the definitions of actual harm and immediate
jeopardy; Implementation status: Taking steps to implement our
recommendation.
GAO recommendation: 4. Require states to have a quality assurance
process that includes, at a minimum, a review of a sample of survey
reports below the level of actual harm to assess the appropriateness of
the scope and severity cited and to help reduce instances of
understated quality-of-care problems; CMS initiative: CMS has no plans
to implement this recommendation, indicating that regular workload and
priorities take precedence over it; Implementation status: Did not
implement our recommendation.
GAO report number: GAO-05-78;
GAO recommendation: 5. Hold homes accountable for all past
noncompliance resulting in harm to residents, not just care problems
deemed to be egregious, and develop 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; CMS initiative: CMS revised its definition of
past noncompliance. CMS plans to add the specific nature of the care
problem to its Web site, but programming required for the Medicare
prescription drug benefit has delayed implementation; Implementation
status: Taking steps to implement our recommendation.
Complaints:
GAO report number: GAO/HEHS-99-80; GAO recommendation: 6. Develop
additional standards for the prompt investigation of serious complaints
alleging situations that may harm residents but are categorized as less
than immediate jeopardy. These standards should include maximum
allowable time frames for investigating serious complaints and for
complaints that may be deferred until the next scheduled annual survey.
States may continue to set priority levels and time frames that are
more stringent than these federal standards; CMS initiative: In October
1999, CMS issued a policy letter stating that complaints alleging harm
must be investigated within 10 days; In January 2004, CMS provided
detailed direction and guidance to states for managing complaint
investigations for numerous types of providers, including nursing
homes; In June 2004, CMS made available updated guidance on the
Internet that consolidates complaint investigation procedures for
numerous types of providers; Implementation status: Fully implemented
our recommendation.
GAO recommendation: 7. Strengthen federal oversight of state complaint
investigations, including monitoring states' practices regarding
priority-setting, on-site investigation, and timely reporting of
serious health and safety complaints; CMS initiative: In 2000, CMS
began requiring its regional offices to perform yearly assessments of
states' complaint investigations as part of annual state performance
reviews; Implementation status: Fully implemented our recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 8. Finalize the development of guidance to states
for their complaint investigation processes and ensure that it
addresses key weaknesses, including the prioritization of complaints
for investigation, particularly those alleging harm to residents; the
handling of facility self-reported incidents; and the use of
appropriate complaint investigation practices; CMS initiative: In
January 2004, CMS provided detailed direction and guidance to states
for managing complaint investigations for numerous types of providers,
including nursing homes; In June 2004, CMS made available updated
guidance on the Internet that consolidates complaint investigation
procedures for numerous types of providers; Implementation status:
Fully implemented our recommendation.
GAO report number: GAO-02-312;
GAO recommendation: 9. Ensure that state survey agencies immediately
notify local law enforcement agencies or Medicaid Fraud Control Units
when nursing homes report allegations of resident physical or sexual
abuse or when the survey agency has confirmed complaints of alleged
abuse; CMS initiative: In 2002, CMS issued a memo to the regional
offices and state survey agencies emphasizing its policy for preventing
abuse in nursing homes and for promptly reporting it to the appropriate
agencies when it occurs; In 2004, CMS informed GAO that it continues to
hold discussions with the Department of Justice and with the HHS Office
of General Counsel about CMS's authority to require, and potential
effectiveness of requiring, state survey agencies to immediately notify
local law enforcement of suspected physical and sexual abuse;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 10. Accelerate the agency's education campaign on
reporting nursing home abuse by (1) distributing its new poster with
clearly displayed complaint telephone numbers and (2) requiring state
survey agencies to ensure that these numbers are prominently listed in
local telephone directories; CMS initiative: CMS developed a poster,
but it is not yet released, pending approval by the Secretary of HHS;
In 2002, CMS released a memorandum to regional offices and state
agencies that addresses displaying complaint telephone numbers. CMS
asked all state agencies to review how their telephone number is listed
in the local directory and asked them to ensure that their complaint
telephone numbers are prominently listed; Implementation status: Taking
steps to implement our recommendation.
GAO recommendation: 11. Systematically assess state policies and
practices for complying with the federal requirement to prohibit
employment of individuals convicted of abusing nursing home residents
and, if necessary, develop more specific guidance to ensure compliance;
CMS initiative: CMS is conducting a Background Check Pilot Program in
several states, as required by the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003. The pilot is expected to
run through September 2007, followed by an evaluation of the results;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 12. Clarify the definition of abuse and otherwise
ensure that states apply that definition consistently and
appropriately; CMS initiative: In 2002, CMS released a memorandum to
its regional offices and state survey agency directors clarifying its
definition of abuse and instructing them to report suspected abuse to
law enforcement authorities and, if appropriate, to the state's
Medicaid Fraud Control Unit.[A]; Implementation status: Fully
implemented our recommendation.
GAO recommendation: 13. Shorten the state survey agencies' time frames
for determining whether to include findings of abuse in nurse aide
registry files; CMS initiative: CMS informed GAO that the regulations
do not specify time frames that states must follow in substantiating
abuse, but agreed to review this matter when the agency considers
changes to the regulations. CMS did not indicate when this would be
done; Implementation status: Taking steps to implement our
recommendation.
Enforcement:
GAO report number: GAO/HEHS-98-202; GAO recommendation: 14. Require
that for problem homes with recurring serious violations, state
surveyors substantiate, by means of an on-site revisit, every report to
CMS of a home's resumed compliance status; CMS initiative: In 1998, CMS
issued guidance to regional offices and state survey agencies
strengthening its revisit policy by requiring on-site revisits until
all serious deficiencies are corrected. Homes are no longer permitted
to self-report resumed compliance; Implementation status: Fully
implemented our recommendation.
GAO recommendation: 15. Eliminate the grace period for homes cited for
repeated serious violations and impose sanctions promptly, as permitted
under existing regulations; CMS initiative: CMS phased in
implementation of its "double G" policy from September 1998 through
January 2000; Implementation status: Fully implemented our
recommendation.
GAO report number: GAO/HEHS-99-46; GAO recommendation: 16. Improve the
effectiveness of civil money penalties: the Administrator should
continue to take those steps necessary to shorten the delay in
adjudicating appeals, including monitoring progress made in reducing
the backlog of appeals; CMS initiative: As requested by HHS, Congress
approved increased funding and staffing levels for the Departmental
Appeals Board in fiscal years 1999 and 2000; Implementation status:
Fully implemented our recommendation.
GAO recommendation: 17. Strengthen the use and effect of termination:
* Continue Medicare and Medicaid payments beyond the termination date
only if the home and state Medicaid agency are making reasonable
efforts to transfer residents to other homes or alternative modes of
care; CMS initiative: CMS conducted a study and concluded that it was
not practical to establish rules to address this problem;
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation:
* Ensure that reasonable assurance periods associated with reinstating
terminated homes are of sufficient duration to effectively demonstrate
that the reason for termination has been resolved and will not recur;
CMS initiative: CMS added examples to the reasonable assurance guidance
in 2000, but declined to lengthen the reasonable assurance period.
GAO recommendation:
* Strengthen the use and effect of termination: Revise existing
policies so that the pretermination history of a home is considered in
taking a subsequent enforcement action; CMS initiative: In 2000, CMS
revised its guidance so that pretermination history of a home is
considered in taking subsequent enforcement actions.
GAO recommendation: 18. Improve the referral process: The Administrator
should revise CMS guidance so that states refer homes to CMS for
possible sanction (such as civil money penalties) if they have been
cited for a deficiency that contributed to a resident's death; CMS
initiative: In 2000, CMS revised its guidance to require states to
refer homes for possible sanction if they had been cited for a
deficiency that contributed to a resident's death; Implementation
status: Fully implemented our recommendation.
Oversight:
GAO report number: GAO/HEHS-99-46; GAO recommendation: 19. Develop
better management information systems. The Administrator should enhance
OSCAR or develop some other information system that can be used by both
by the states and CMS to integrate the results of complaint
investigations, track the status and history of deficiencies, and
monitor enforcement actions; CMS initiative: CMS has implemented new
national enforcement and complaint tracking systems but does not
anticipate completing its replacement of the OSCAR data system until
2008; Implementation status: Taking steps to implement our
recommendation.
GAO report number: GAO/HEHS-99-80; GAO recommendation: 20. Require that
the substantiated results of complaint investigations be included in
federal data systems or be accessible by federal officials; CMS
initiative: In January 2004, CMS's new ASPEN Complaint Tracking system
was implemented nationwide; Implementation status: Fully implemented
our recommendation.
GAO report number: GAO/HEHS-00-6; GAO recommendation: 21. Improve the
scope and rigor of CMS's oversight process: Implementation status:
Fully implemented our recommendation.
GAO recommendation:
* Increase the proportion of federal monitoring surveys conducted as
comparative surveys to ensure that a sufficient number are completed in
each state to assess whether the state appropriately identifies serious
deficiencies; CMS initiative: CMS has significantly increased the
number of quality-of-care comparative surveys. In fiscal year 2006,
however, the agency will no longer contract for additional quality-of-
care comparative surveys because of funding constraints.
GAO recommendation:
* Ensure that comparative surveys are initiated closer to the time the
state agency completes the home's annual standard survey; CMS
initiative: To better ensure that conditions in a nursing home have not
changed since the state survey, CMS regional offices have reduced the
average time between the state survey and the initiation of a federal
comparative survey from 33 days in 1999 to 26 days by 2004.
GAO recommendation:
* Require regions to provide more timely written feedback to the states
after the completion of federal monitoring surveys; CMS initiative: CMS
instructed the regions to report the results of federal monitoring
surveys to states on a monthly basis.
GAO recommendation:
* Improve the data system for observational surveys so that it is an
effective management tool for CMS to properly assess the findings of
observational surveys; CMS initiative: CMS developed a separate
database accessible to all regional offices that includes the results
of observational surveys. Beginning in fiscal year 2002, CMS added data
on the results of comparative surveys.
GAO recommendation: 22. Improve the consistency in how CMS holds state
survey agencies accountable by standardizing procedures for selecting
state surveys and conducting federal monitoring surveys:
GAO recommendation:
* Ensure that the regions target surveys for review that will provide a
comprehensive assessment of state surveyor performance; CMS initiative:
CMS did not implement our recommendation to select individual state
surveys for federal review in a manner that ensures its regional
offices observe as many state surveyors as possible.
GAO recommendation:
* Require federal surveyors to include as many of the same residents as
possible in their comparative survey sample as the state included in
its sample (where CMS surveyors have determined that the state sample
selection process was appropriate); CMS initiative: In October 2002,
CMS instructed federal surveyors to select at least half of those
residents selected by the state surveyors for their resident sample.
Implementation status: Implemented only part of our recommendation and
no further steps are planned.
GAO recommendation: 23. Further explore the feasibility of appropriate
alternative remedies or sanctions for those states that prove unable or
unwilling to meet CMS's performance standards; CMS initiative: In
December 1999, CMS adopted new state sanctions. In fiscal year 2005,
CMS began to tie survey agency funding increases to the timely conduct
of standard surveys, a step that we believe offers a strong incentive
for improved compliance; Implementation status: Fully implemented our
recommendation.
GAO report number: GAO/HEHS-02-279; GAO recommendation: 24. Review the
adequacy of current state efforts to ensure the accuracy of minimum
data set (MDS) data, and provide, where necessary, additional guidance,
training, and technical assistance; CMS initiative: CMS disagreed with
and did not implement this recommendation; Implementation status: Did
not implement our recommendation.
GAO recommendation: 25. Monitor the adequacy of state MDS accuracy
activities on an ongoing basis, such as through the use of the
established federal comparative survey process; CMS initiative: CMS
disagreed with and did not implement this recommendation;
Implementation status: Did not implement our recommendation.
GAO recommendation: 26. Provide guidance to state agencies and nursing
homes that sufficient evidentiary documentation to support the full MDS
assessment be included in residents' medical records; CMS initiative:
CMS disagreed with and did not implement this recommendation;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-03-187;
GAO recommendation: 27. Delay the implementation of nationwide
reporting of quality indicators until there is greater assurance that
the quality indicators are appropriate for public reporting--including
the validity of the indicators selected and the use of an appropriate
risk-adjustment methodology--based on input from the National Quality
Forum and other experts and, if necessary, additional analysis and
testing; CMS initiative: CMS disagreed with and did not implement this
recommendation; Implementation status: Did not implement our
recommendation.
GAO recommendation: 28. Delay the implementation of nationwide
reporting of quality indicators until a more thorough evaluation of the
pilot is completed to help improve the initiative's effectiveness,
including an assessment of the presentation of information on the Web
site and the resources needed to assist consumers' use of the
information; CMS initiative: CMS disagreed with and did not implement
this recommendation; Implementation status: Did not implement our
recommendation.
GAO report number: GAO-03-561;
GAO recommendation: 29. Further refine annual state performance reviews
so that they (1) consistently distinguish between systemic problems and
less serious issues regarding state performance, (2) analyze trends in
the proportion of homes that harm residents, (3) assess state
compliance with the immediate sanctions policy for homes with a pattern
of harming residents, and (4) analyze the predictability of state
surveys; CMS initiative: CMS did not implement this recommendation
because it believes that the state performance standards take into
account statutory and nonstatutory performance standards;
Implementation status: Did not implement our recommendation.
GAO report number: GAO-04-660;
GAO recommendation: 30. Ensure that CMS regional offices fully comply
with the statutory requirement to conduct annual federal monitoring
surveys by including an assessment of the fire safety component of
states' standard surveys, with an emphasis on unsprinklered homes; CMS
initiative: CMS's evaluation of state surveyors' performance now
routinely includes fire safety as part of the statutory requirement to
annually conduct federal monitoring surveys in at least 5 percent of
surveyed nursing homes in each state; Implementation status: Fully
implemented our recommendation.
GAO recommendation: 31. Ensure that data on sprinkler coverage in
nursing homes are consistently obtained and reflected in the CMS
database; CMS initiative: As nursing homes are surveyed, CMS is in the
process of collecting consistent data on the sprinkler status of homes
and entering these data into OSCAR; Implementation status: Taking steps
to implement our recommendation.
GAO recommendation: 32. Until sprinkler coverage data are routinely
available in CMS's database, work with state survey agencies to
identify the extent to which each nursing home is sprinklered or not
sprinklered; CMS initiative: CMS has contacted state survey agencies
and collected data on all but about 5 percent of nursing homes. These
data will be verified during each home's next annual survey;
Implementation status: Taking steps to implement our recommendation.
GAO recommendation: 33. On an expedited basis, review all waivers and
Fire Safety Evaluation System[B] assessments for homes that are not
fully sprinklered to determine their appropriateness; CMS initiative:
CMS expects to complete its reviews of Fire Safety Evaluation System
Assessments by late 2005; Implementation status: Taking steps to
implement our recommendation.
GAO recommendation: 34. Make information on fire safety deficiencies
available to the public via the Nursing Home Compare Web site,
including information on whether a home has automatic sprinklers; CMS
initiative: This information will not be available on the Nursing Home
Compare Web site until 2007; Implementation status: Taking steps to
implement our recommendation.
GAO recommendation: 35. Work with the National Fire Protection
Association to strengthen fire safety standards for unsprinklered
nursing homes, such as requiring smoke detectors in resident rooms,
exploring the feasibility of requiring sprinklers in all nursing homes,
and developing a strategy for financing such requirements; CMS
initiative: CMS has issued an interim final rule requiring the
installation of smoke detectors by May 24, 2006. It anticipates issuing
a notice of proposed rule making requiring older nursing homes to
install sprinklers early in 2006 but will ask for comments on how much
time homes should be given to come into compliance; Implementation
status: Taking steps to implement our recommendation.
GAO recommendation: 36. Ensure that thorough investigations are
conducted following multiple-death nursing home fires so that fire
safety standards can be reevaluated and modified where appropriate; CMS
initiative: CMS developed and issued a standardized procedure to ensure
that both state survey agencies and its own staff take appropriate
action to investigate fires that result in serious injury or death;
Implementation status: Fully implemented our recommendation.
Source: GAO analysis of CMS's responses to our recommendations.
[A] In 1999, CMS had required the use of an investigative protocol on
abuse prohibition during every standard survey. The protocol's
objective is to determine if the facility has developed and
operationalized policies and procedures that prohibit abuse, neglect,
involuntary seclusion, and misappropriation of resident property.
[B] As an alternative to correcting or receiving a waiver for
deficiencies identified on a standard survey, a home may undergo an
assessment using the Fire Safety Evaluation System. The system provides
a means for nursing homes to meet the fire safety objectives of CMS's
standards without necessarily being in full compliance with every
standard.
[End of table]
[End of section]
Appendix II: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy during Standard Surveys:
In order to identify trends in the proportion of nursing homes cited
with actual harm or immediate jeopardy deficiencies, we analyzed data
from CMS's OSCAR database for four time periods: (1) January 1, 1999,
through July 10, 2000; (2) July 11, 2000, through January 31, 2002; (3)
February 1, 2002, through July 10, 2003; and (4) July 11, 2003, through
January 31, 2005. Because surveys are conducted at least every 15
months (with a required 12-month statewide average), it is possible
that a home was surveyed twice in any time period. To avoid double
counting of homes, we included only homes' most recent survey from each
time period.
Table 11: Percentage of Nursing Homes Cited for Actual Harm or
Immediate Jeopardy, by State:
State:
State: District of Columbia;
Number of homes surveyed, 7/03 - 1/05[A]: 21; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 10.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 33.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 38.1; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 33.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
23.3.
State: Colorado;
Number of homes surveyed, 7/03 - 1/05[A]: 218; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 15.4;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 26.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 21.7; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 24.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
8.9.
State: Connecticut;
Number of homes surveyed, 7/03 - 1/05[A]: 247; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 48.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 49.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 38.8; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 54.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
5.8.
Change of less than 5 percentage points:
State: South Carolina;
Number of homes surveyed, 7/03 - 1/05[A]: 178; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 28.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 17.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 27.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 32.0;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
3.4.
State: Oklahoma;
Number of homes surveyed, 7/03 - 1/05[A]: 376; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 16.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 20.6; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 22.6; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 18.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
2.0.
State: Vermont;
Number of homes surveyed, 7/03 - 1/05[A]: 42; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 15.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 17.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 9.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 16.7; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: 1.4.
State: Maine;
Number of homes surveyed, 7/03 - 1/05[A]: 117; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 10.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 9.7; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 9.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 9.4; Percentage point difference[B] 1/1/99
- 7/10/00 and 7/11/03 - 1/31/05: -0.9.
State: West Virginia;
Number of homes surveyed, 7/03 - 1/05[A]: 137; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 15.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 14.0; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 14.1; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 13.1;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
-2.5.
State: Rhode Island;
Number of homes surveyed, 7/03 - 1/05[A]: 86; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 12.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 10.1; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 2.4; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 9.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
2.8.
State: Wisconsin;
Number of homes surveyed, 7/03 - 1/05[A]: 413; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 14.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 7.1; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 9.1; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 10.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
3.8.
State: Decrease of 5 percentage points or greater:
State: Utah;
Number of homes surveyed, 7/03 - 1/05[A]: 94; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 15.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 15.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 22.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 10.6; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -5.2.
State: Iowa;
Number of homes surveyed, 7/03 - 1/05[A]: 492; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 19.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 9.9; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 7.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 14.0; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -5.3.
State: Georgia;
Number of homes surveyed, 7/03 - 1/05[A]: 365; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 22.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 20.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 20.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 16.4; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -6.1.
State: Kansas;
Number of homes surveyed, 7/03 - 1/05[A]: 380; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 37.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 29.0; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 24.9;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 30.5; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -6.5.
State: Tennessee;
Number of homes surveyed, 7/03 - 1/05[A]: 340; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 26.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 16.7; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 19.7; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 19.1;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
6.9.
State: New Mexico;
Number of homes surveyed, 7/03 - 1/05[A]: 81; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 31.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 17.1; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 16.2; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 24.7;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
7.0.
State: South Dakota;
Number of homes surveyed, 7/03 - 1/05[A]: 113; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 24.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 30.7; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 24.8; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 16.8;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
7.3.
State: Hawaii;
Number of homes surveyed, 7/03 - 1/05[A]: 45; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 25.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 15.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 12.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 17.8; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -7.8.
State: Maryland;
Number of homes surveyed, 7/03 - 1/05[A]: 239; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 25.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 20.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 14.6; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 17.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
8.0.
State: North Dakota;
Number of homes surveyed, 7/03 - 1/05[A]: 83; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 21.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 28.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 11.9; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 13.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
8.1.
State: Missouri;
Number of homes surveyed, 7/03 - 1/05[A]: 550; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 22.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 10.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 13.6; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 13.8;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
8.4.
State: Nebraska;
Number of homes surveyed, 7/03 - 1/05[A]: 238; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 26.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 18.9; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 19.6; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 16.4;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
9.6.
State: Louisiana;
Number of homes surveyed, 7/03 - 1/05[A]: 332; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 19.9;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 23.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 18.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 10.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
9.7.
State: Virginia;
Number of homes surveyed, 7/03 - 1/05[A]: 287; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 19.9;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 11.6; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 13.4; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 9.8;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
10.1.
State: Pennsylvania;
Number of homes surveyed, 7/03 - 1/05[A]: 729; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 32.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 11.6; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 14.4; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 20.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
11.7.
State: Nevada;
Number of homes surveyed, 7/03 - 1/05[A]: 43; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 32.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 9.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 6.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 20.9; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -11.8.
State: Illinois;
Number of homes surveyed, 7/03 - 1/05[A]: 833; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 29.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 15.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 15.3; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 16.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
13.1.
State: Nation;
Number of homes surveyed, 7/03 - 1/05[A]: 16,463; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 29.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 20.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 17.1; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 15.5;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
13.8.
State: Texas;
Number of homes surveyed, 7/03 - 1/05[A]: 1,185; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 26.9;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 25.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 18.5; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 12.7;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
14.3.
State: New Jersey;
Number of homes surveyed, 7/03 - 1/05[A]: 363; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 24.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 22.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 12.7; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 9.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
14.9.
State: Mississippi;
Number of homes surveyed, 7/03 - 1/05[A]: 209; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 33.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 19.6; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 14.4; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 18.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
15.0.
State: Florida;
Number of homes surveyed, 7/03 - 1/05[A]: 694; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 20.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 20.1; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 9.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 5.5; Percentage point difference[B] 1/1/99
- 7/10/00 and 7/11/03 - 1/31/05: -15.4.
State: New Hampshire;
Number of homes surveyed, 7/03 - 1/05[A]: 83; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 37.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 21.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 21.7; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 21.7;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
-15.7.
State: Massachusetts;
Number of homes surveyed, 7/03 - 1/05[A]: 468; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 33.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 22.9; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 22.5; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 16.9;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
-16.1.
State: Arkansas;
Number of homes surveyed, 7/03 - 1/05[A]: 254; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 37.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 27.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 15.8; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 20.5;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
17.3.
State: Ohio;
Number of homes surveyed, 7/03 - 1/05[A]: 1,009; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 29.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 23.7; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 21.8; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 11.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
17.4.
State: Idaho;
Number of homes surveyed, 7/03 - 1/05[A]: 80; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 54.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 31.0; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 38.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 36.3; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -18.0.
State: Minnesota;
Number of homes surveyed, 7/03 - 1/05[A]: 414; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 31.7;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 18.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 17.1; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 12.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
19.3.
State: Kentucky;
Number of homes surveyed, 7/03 - 1/05[A]: 296; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 28.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 25.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 25.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 9.5;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
19.4.
State: Michigan;
Number of homes surveyed, 7/03 - 1/05[A]: 433; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 42.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 24.7; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 30.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 22.6;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
19.5.
State: Montana;
Number of homes surveyed, 7/03 - 1/05[A]: 101; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 37.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 25.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 16.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 17.8; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -19.7.
State: Alaska;
Number of homes surveyed, 7/03 - 1/05[A]: 14; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 20.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 33.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 0.0;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 0.0; Percentage point difference[B] 1/1/99
- 7/10/00 and 7/11/03 - 1/31/05: -20.0.
State: North Carolina;
Number of homes surveyed, 7/03 - 1/05[A]: 425; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 40.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 30.1; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 24.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 20.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05:
-20.6.
State: California;
Number of homes surveyed, 7/03 - 1/05[A]: 1,325; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 29.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 9.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 3.4; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 6.3;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
22.8.
State: Alabama;
Number of homes surveyed, 7/03 - 1/05[A]: 229; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 42.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 18.4; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 12.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 19.2; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -23.0.
State: New York;
Number of homes surveyed, 7/03 - 1/05[A]: 666; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 32.2;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 32.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 20.0; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 9.2;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
23.0.
State: Indiana;
Number of homes surveyed, 7/03 - 1/05[A]: 523; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 45.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 26.2; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 17.4;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 21.4; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -23.8.
State: Arizona;
Number of homes surveyed, 7/03 - 1/05[A]: 134; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 33.8;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 8.8; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 3.6;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 8.2; Percentage point difference[B] 1/1/99
- 7/10/00 and 7/11/03 - 1/31/05: -25.6.
State: Washington;
Number of homes surveyed, 7/03 - 1/05[A]: 257; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 54.1;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 38.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 36.6; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 26.5;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
27.7.
State: Wyoming;
Number of homes surveyed, 7/03 - 1/05[A]: 39; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 43.9;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 22.5; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 26.3;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 12.8; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -31.1.
State: Oregon;
Number of homes surveyed, 7/03 - 1/05[A]: 141; Percentage of homes
cited for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 47.5;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 33.6; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02
- 7/10/03: 14.4;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/03 - 1/31/05: 14.2; Percentage point difference[B] 1/1/99 -
7/10/00 and 7/11/03 - 1/31/05: -33.3.
State: Delaware;
Number of homes surveyed, 7/03 - 1/05[A]: 42; Percentage of homes cited
for actual harm or immediate jeopardy: 1/1/99 - 7/10/00: 52.4;
Percentage of homes cited for actual harm or immediate jeopardy:
7/11/00 - 1/31/02: 14.3; Percentage of homes cited for actual harm or
immediate jeopardy: 2/1/02 - 7/10/03: 4.8; Percentage of homes cited
for actual harm or immediate jeopardy: 7/11/03 - 1/31/05: 16.7;
Percentage point difference[B] 1/1/99 - 7/10/00 and 7/11/03 - 1/31/05: -
35.7.
Source: GAO analysis of OSCAR data.
Note: The first two time periods reflect data in OSCAR as of June 24,
2002. The last two time periods reflect OSCAR data as of July 10, 2003,
and April 13, 2005, respectively. The term states includes the 50
states and the District of Columbia.
[A] These data illustrate the significant variation in the number of
nursing homes across states.
[B] Differences are based on numbers before rounding.
[End of table]
[End of section]
Appendix III: Percentage of Homes Surveyed Within 15 Days of the 1-Year
Anniversary of Prior Survey:
In order to determine the predictability of nursing home surveys, we
analyzed data from CMS's OSCAR database for a home's current survey as
of April 9, 2002, and as of July 8, 2005 (see table 12). We considered
surveys to be predictable if homes were surveyed within 15 days of the
1-year anniversary of their prior survey.
Table 12: Percentage of Nursing Homes with Predictable Surveys, April
2002 and June 2005:
More than 50 percent:
State: North Dakota;
Number of homes[A]: 83;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 28.2; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 51.8; Percentage point
difference, 4/9/02 and 7/8/05: 23.6.
More than 25 percent to 50 percent:
State: District of Columbia;
Number of homes[A]: 20;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 15.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 40.0; Percentage point
difference, 4/9/02 and 7/8/05: 25.0.
State: Iowa;
Number of homes[A]: 439;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 31.1; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 35.8; Percentage point
difference, 4/9/02 and 7/8/05: 4.7.
State: Kansas;
Number of homes[A]: 357;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 13.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 29.1; Percentage point
difference, 4/9/02 and 7/8/05: 15.5.
State: Oregon;
Number of homes[A]: 138;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 14.1; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 28.3; Percentage point
difference, 4/9/02 and 7/8/05: 14.2.
State: California;
Number of homes[A]: 1,287;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 9.5; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 27.8; Percentage point
difference, 4/9/02 and 7/8/05: 18.3.
State: Nebraska;
Number of homes[A]: 221;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 3.1; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 27.6; Percentage point
difference, 4/9/02 and 7/8/05: 24.5.
State: Maryland;
Number of homes[A]: 236;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 20.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 27.5; Percentage point
difference, 4/9/02 and 7/8/05: 6.8.
10 percent to 25 percent:
State: Virginia;
Number of homes[A]: 270;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 30.5; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 20.4; Percentage point
difference, 4/9/02 and 7/8/05: -10.1.
State: North Carolina;
Number of homes[A]: 418;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 13.9; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 19.1; Percentage point
difference, 4/9/02 and 7/8/05: 5.2.
State: Wisconsin;
Number of homes[A]: 396;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 19.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 18.7; Percentage point
difference, 4/9/02 and 7/8/05: -0.9.
State: New Jersey;
Number of homes[A]: 354;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 18.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 18.4; Percentage point
difference, 4/9/02 and 7/8/05: -0.3.
State: Michigan;
Number of homes[A]: 428;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 8.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 17.1; Percentage point
difference, 4/9/02 and 7/8/05: 8.3.
State: Alabama;
Number of homes[A]: 227;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 5.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 16.7; Percentage point
difference, 4/9/02 and 7/8/05: 10.9.
State: Delaware;
Number of homes[A]: 42;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 31.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 16.7; Percentage point
difference, 4/9/02 and 7/8/05: -14.3.
State: Texas;
Number of homes[A]: 1,111;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 15.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 16.7; Percentage point
difference, 4/9/02 and 7/8/05: 1.0.
State: Indiana;
Number of homes[A]: 502;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 14.4; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 16.3; Percentage point
difference, 4/9/02 and 7/8/05: 1.9.
State: Massachusetts;
Number of homes[A]: 461;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 17.3; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 16.3; Percentage point
difference, 4/9/02 and 7/8/05: -1.0.
State: Wyoming;
Number of homes[A]: 39;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 10.3; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 15.4; Percentage point
difference, 4/9/02 and 7/8/05: 5.1.
State: Colorado;
Number of homes[A]: 213;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 9.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 15.0; Percentage point
difference, 4/9/02 and 7/8/05: 6.0.
State: Kentucky;
Number of homes[A]: 294;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 10.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 15.0; Percentage point
difference, 4/9/02 and 7/8/05: 4.4.
State: Nation;
Number of homes[A]: 15,827;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 13.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 14.5; Percentage point
difference, 4/9/02 and 7/8/05: 1.5.
State: Alaska;
Number of homes[A]: 14;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 6.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 14.3; Percentage point
difference, 4/9/02 and 7/8/05: 7.6.
State: Rhode Island;
Number of homes[A]: 92;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 12.5; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 13.0; Percentage point
difference, 4/9/02 and 7/8/05: 0.5.
State: Montana;
Number of homes[A]: 100;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 8.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 13.0; Percentage point
difference, 4/9/02 and 7/8/05: 4.3.
State: New Mexico;
Number of homes[A]: 78;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 13.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 12.8; Percentage point
difference, 4/9/02 and 7/8/05: -1.0.
State: Pennsylvania;
Number of homes[A]: 721;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 24.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 12.8; Percentage point
difference, 4/9/02 and 7/8/05: -11.2.
State: Washington;
Number of homes[A]: 246;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 22.4; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 12.6; Percentage point
difference, 4/9/02 and 7/8/05: -9.8.
State: Vermont;
Number of homes[A]: 41;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 11.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 12.2; Percentage point
difference, 4/9/02 and 7/8/05: 0.6.
State: Missouri;
Number of homes[A]: 509;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 11.9; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 12.0; Percentage point
difference, 4/9/02 and 7/8/05: 0.1.
State: New Hampshire;
Number of homes[A]: 81;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 12.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 11.1; Percentage point
difference, 4/9/02 and 7/8/05: -0.9.
State: New York;
Number of homes[A]: 659;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 14.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 11.1; Percentage point
difference, 4/9/02 and 7/8/05: -3.7.
State: South Dakota;
Number of homes[A]: 109;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 18.9; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 11.0; Percentage point
difference, 4/9/02 and 7/8/05: -7.9.
State: Florida;
Number of homes[A]: 685;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 9.3; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 10.4; Percentage point
difference, 4/9/02 and 7/8/05: 1.1.
State: Illinois;
Number of homes[A]: 792;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 9.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 10.4; Percentage point
difference, 4/9/02 and 7/8/05: 0.7.
State: Maine;
Number of homes[A]: 116;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 8.3; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 10.3; Percentage point
difference, 4/9/02 and 7/8/05: 2.0.
Less than 10 percent:
State: Georgia;
Number of homes[A]: 359;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 0.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 7.2; Percentage point
difference, 4/9/02 and 7/8/05: 6.6.
State: Nevada;
Number of homes[A]: 43;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 24.4; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 7.0; Percentage point
difference, 4/9/02 and 7/8/05: -17.4.
State: Hawaii;
Number of homes[A]: 45;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 13.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 6.7; Percentage point
difference, 4/9/02 and 7/8/05: -6.9.
State: Idaho;
Number of homes[A]: 80;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 4.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 6.3; Percentage point
difference, 4/9/02 and 7/8/05: 1.5.
State: South Carolina;
Number of homes[A]: 176;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 6.9; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 6.3; Percentage point
difference, 4/9/02 and 7/8/05: -0.6.
State: Arizona;
Number of homes[A]: 133;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 21.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 6.0; Percentage point
difference, 4/9/02 and 7/8/05: -15.0.
State: Louisiana;
Number of homes[A]: 288;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 19.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 5.9; Percentage point
difference, 4/9/02 and 7/8/05: -13.1.
State: Tennessee;
Number of homes[A]: 326;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 6.2; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 5.2; Percentage point
difference, 4/9/02 and 7/8/05: -1.0.
State: Minnesota;
Number of homes[A]: 408;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 4.4; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 4.7; Percentage point
difference, 4/9/02 and 7/8/05: 0.3.
State: West Virginia;
Number of homes[A]: 129;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 8.7; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 3.9; Percentage point
difference, 4/9/02 and 7/8/05: -4.8.
State: Arkansas;
Number of homes[A]: 235;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 27.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 3.8; Percentage point
difference, 4/9/02 and 7/8/05: -23.8.
State: Utah;
Number of homes[A]: 87;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 1.1; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 3.4; Percentage point
difference, 4/9/02 and 7/8/05: 2.3.
State: Connecticut;
Number of homes[A]: 245;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 15.8; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 2.9; Percentage point
difference, 4/9/02 and 7/8/05: -12.9.
State: Ohio;
Number of homes[A]: 960;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 3.0; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 2.2; Percentage point
difference, 4/9/02 and 7/8/05: -0.8.
State: Mississippi;
Number of homes[A]: 201;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 2.1; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 2.0; Percentage point
difference, 4/9/02 and 7/8/05: -0.1.
State: Oklahoma;
Number of homes[A]: 333;
Percentage of homes surveyed within 15 days of 1-year anniversary of
prior survey: 4/9/02: 0.6; Percentage of homes surveyed within 15 days
of 1-year anniversary of prior survey: 7/8/05: 1.8; Percentage point
difference, 4/9/02 and 7/8/05: 1.2.
Source: GAO analysis of OSCAR data.
Note: The term states includes the 50 states and the District of
Columbia.
[A] Represents the number of nursing homes with a prior and a current
survey as of July 8, 2005.
[End of table]
[End of section]
Appendix IV: Percentage of State Nursing Home Surveyors with 2-Years'
Experience or Less, 2002 and 2005:
Increase:
State: Arizona;
2002: 20;
2005: 53;
Percentage point change: 33.
State: Colorado;
2002: 24;
2005: 53;
Percentage point change: 29.
State: Alaska;
2002: 29;
2005: 57;
Percentage point change: 28.
State: Illinois;
2002: 5;
2005: 25;
Percentage point change: 20.
State: Rhode Island;
2002: 9;
2005: 23;
Percentage point change: 14.
State: North Carolina;
2002: 33;
2005: 44;
Percentage point change: 11.
State: Ohio;
2002: 17;
2005: 21;
Percentage point change: 4.
State: Virginia;
2002: 21;
2005: 25;
Percentage point change: 4.
State: Florida;
2002: 55;
2005: 57;
Percentage point change: 2.
State: Arkansas;
2002: 33;
2005: 33;
Percentage point change: 0.
Decrease:
State: Indiana;
2002: 20;
2005: 18;
Percentage point change: -2.
State: New Jersey;
2002: 30;
2005: 26;
Percentage point change: -4.
State: Oregon;
2002: 34;
2005: 29;
Percentage point change: -5.
State: Texas;
2002: 32;
2005: 26;
Percentage point change: -6.
State: Wisconsin;
2002: 25;
2005: 19;
Percentage point change: -6.
State: Nebraska;
2002: 29;
2005: 20;
Percentage point change: -9.
State: Alabama;
2002: 48;
2005: 38;
Percentage point change: -10.
State: Georgia;
2002: 51;
2005: 35;
Percentage point change: -16.
State: Tennessee;
2002: 45;
2005: 28;
Percentage point change: -17.
State: New York;
2002: 40;
2005: 18;
Percentage point change: -22.
State: Washington;
2002: 54;
2005: 26;
Percentage point change: -28.
State: Louisiana;
2002: 48;
2005: 19;
Percentage point change: -29.
State: Maryland;
2002: 70;
2005: 14;
Percentage point change: -56.
State: South Carolina;
2002: [A];
2005: 52;
Percentage point change: N/A.
State: Vermont;
2002: [A];
2005: 38;
Percentage point change: N/A.
Source: State survey agency responses to July 2002 GAO questions, and
updates obtained from AHFSA in July 2005.
Note: The term states includes the 50 states and the District of
Columbia.
[A] This state did not respond to our 2002 questions about surveyor
experience.
[End of table]
[End of section]
Appendix V: Comments from the Centers for Medicare & Medicaid Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES: Centers for Medicare & Medicaid
Services: Administrator:
Washington, DC 20201:
NOV 25 2005:
TO: Kathryn G. Allen:
Director, Health Care:
FROM: (Signed by) Mark B. McClellan, M.D., Ph.D.: Administrator:
SUBJECT: GAO Draft Report: "Despite Increased Oversight, Challenges
Remain in Ensuring High-Quality Care and Resident Safety," GAO-06-117:
The title to this GAO report succinctly expresses a dual message with
which we fully concur: there has been significant improvement in
federal oversight of nursing homes, while important challenges remain.
We appreciate the considerable time and expertise the GAO has invested
in identifying key oversight challenges and in contributing, from 1998
through 2005, ideas that helped strengthen the federal and state
quality assurance systems for the nation's nursing homes.
We also appreciate the opportunity to comment on a few important
indicators of progress, such as improved frequency of nursing home
surveys (99.4% surveyed within the previous 15 months), a 45% increase
in complaints investigated, more fire-safety protections and oversight,
fewer serious deficiencies in nursing homes overall, and at least a 17%
decline in serious deficiencies missed by state survey agencies (from
1999-2004). We conclude with observations about future challenges.
Improvements in Oversight:
Improvement in nursing home oversight is illustrated by the progress
toward 100% completion of full nursing home surveys at least once every
15 months (from 96.3 in 1999 to 99.4% in 2004). This graph portrays the
consistent march toward 100% fulfillment of our commitment to ensure
that all nursing homes have an objective, on-site review every 15
months.
% NH Surveys Completed Every 15 Months:
[See PDF for image]
[End of figure]
Prompt and effective investigation of resident complaints has been
another key focus of our improvement effort in recent years.
From 1999 to 2004 the number of completed complaint investigations
increased from 32,422 to 47,124. This 45 increase in completed
complaint investigations is shown in the following graph. The graph
illustrates both stronger performance and added commitment to be as
responsive as possible to nursing home residents and their families.
# Complaint Surveys, 1999-2004:
[See PDF for image]
[End of figure]
Fire-safety assumed a higher priority after the nursing home fires in
Tennessee and Connecticut in 2003. Those fires indicated that the
downward trend toward fewer fires might not continue without added
impetus. Through greater oversight, in 2004 we identified about 7,800
more fire-safety deficiencies compared with 2003 (a 20% increase).
Most recently, in 2005 we promulgated a new rule that required all
nursing homes to have smoke detectors in unsprinklered areas, including
hallways and residents' rooms. We also increased by 17-fold (from 41 to
732) the number of CMS validation surveys ("comparative life-safety
code surveys") in which we check on the adequacy of each state's fire-
safety inspections.
Fire Safety-# Cited Deficiencies 2001-2004:
[See PDF for image]
[End of figure]
A new "State Performance Standards System (SPSS)" has been expanded and
strengthened each year since it was initially piloted in 2000. We
initiated a "Special Focus Facility (SFF)" regimen in which surveyors
visit more frequently those nursing homes that are judged to be most at
risk of quality breakdowns. When SFF nursing homes improve, those homes
are removed from the list. SFF nursing homes that do not show
improvement have a higher chance of being terminated from the Medicare
and Medicaid program under the new protocols. In 2005 we expanded the
number of such nursing homes by 30% and strengthened the enforcement
consequences for nursing homes that fail to improve significantly.
Critical improvements in the information and tracking system used by
surveyors will increase the effectiveness of surveys and remedial
action. The "Aspen Complaint Tracking System (ACTS)" was implemented in
FY 2004. It provides an automated medium in which to record and track
the progress of every federally-required complaint investigation. The
"Aspen Enforcement Manager (AEM)," was implemented in FY 2005. The
system will improve the application and management of enforcement
actions (e.g., denial of payment, state monitoring, directed plans of
correction, civil money penalties, temporary management, termination).
The CMS Web site ("Nursing Home Compare") provides consumers, families,
and others with key information about every nursing home. It includes
quality measure data, as well as deficiencies identified through the
survey process. The "Nursing Home Compare" website remains one of the
most frequently-used CMS Web sites, with over 1.6 million page-views by
the public each year. We continue to take steps to make publicly
reported data as reliable and accurate as possible under current
authority. For example, this year CMS instituted back-end edits of
staffing data to help identify suspect data. We return such suspect
data to the state survey agencies for confirmation or correction. We
are further improving consumer information on the CMS website by
posting information about past non-compliance. A finding of past non-
compliance occurs when a nursing home was out of compliance with
federal requirements but corrected the problem prior to the most recent
survey or complaint investigation. The new information will identify
the specific deficiencies that gave rise to the past non-compliance.
Through the Quality Improvement Organizations (QIOs) we have made a
strong investment in providing technical assistance to help nursing
homes improve their care. Beginning August 2005 all QIOs are charged
with working with nursing homes to achieve progress in four areas:
pressure sores, physical restraints, pain management, and depression.
We also inaugurated a "Collaborative Focus Facility CFF" initiative in
which state survey agencies refer (for QIO assistance) certain nursing
homes judged to have significant and persistent quality challenges.
Results from the first (pilot) year of the CFF are quite promising: the
42 nursing homes agreeing to work with their QIO (in 18 states)
successfully reduced their prevalence of pressure ulcers in high risk
residents by almost 20%, reduced the use of daily restraints by 27%,
and reduced the incidence of "serious survey deficiencies" (see
paragraph below) by 24%. Building on the success of the pilot program,
the CFF will be expanded with the new QIO 8th scope of work contract
that began in August 2005.
Percentage of Nursing Homes Nationwide with Serious Deficiencies,
January 1999 through January 2005:
[See PDF for image]
[End of figure]
Oversight and regulatory improvements documented in the GAO report have
contributed to an improved quality picture for the nation's nursing
homes. For example, Figure 1 in the GAO report shows a consistent
decline in the percentage of nursing homes nationwide with serious 5.0
deficiencies. [NOTE 1]
NOTE:
[1] "Serious deficiencies" in this context means deficiencies in which
there is actual harm to one or more residents. The decrease occurred
despite an increase in monitoring for fire-safety code violations.
While noting the overall decrease in nursing home deficiencies
nationwide, GAO expressed concern that state survey agencies sometimes
understate the seriousness of deficiencies, or fail to cite them at
all. We also remain concerned about possible understatement or omission
of serious deficiencies by state survey agencies. But we do not believe
that the trend of fewer deficiencies in nursing homes is due to this
problem. That is, we do not believe that the understatement is
worsening.
In its report, the GAO seeks to address the question of whether state
survey agencies are getting better or worse in identifying
deficiencies. It does so by comparing CMS findings with state agency
findings. CMS conducts two types of "validation surveys" to check on
the accuracy of state surveys. The first, a "comparative" validation
survey, involves a CMS survey team conducting a full survey within 60
days after the state survey. The second type of validation survey is
"observational." In an observational validation one or more federal
surveyors accompany the state team. The federal surveyors observe both
(a) conditions in the nursing home and (b) the state team's survey
process. The two types of validation surveys offer different
advantages, so CMS uses both.
In the GAO analysis, the data are restricted to the "comparative
validation" surveys. The comparatives represent 15-20% of the
validation checks that CMS conducts to assess the adequacy of the state
surveys. The remaining 80-85% are "observational validation surveys."
Comparison of GAO and CMS Percentages of Federal Surveys with Serious
Deficiencies' Not Identified in State Surveys:
[See PDF for image]
[End of figure]
The graph on the right first shows the GAO data line (taken from Figure
2 in the GAO report). It shows the percentage of deficiencies missed by
state surveyors but identified by federal surveyors. The data line runs
from 34% in 1999 and declines to 28% in 2004. While GAO acknowledges
that there is a trend showing fewer deficiencies missed by state
surveyors, GAO calls our attention to the increase between 2002 and
2004. We believe the increase between 2002 and 2004 is an artifact of
the limited data used.
To investigate the trend when all the data are used, CMS added (to the
GAO graph above) a second line showing the trend from 2002-2004 when
both "comparative" and "observational" validation surveys are used. The
second line shows that the percentage of serious deficiencies missed by
state surveys (when we use all the data) is remaining relatively
constant (moving from 23% to 24% from 2002-2004), rather than
worsening.
Some states are improving in their ability to identify deficiencies,
while some other states are failing to improve. We are increasingly
focused on those states whose performance is not up to par. In fact,
for one of the five states selected by GAO as indicative of the
problem, we withheld $1.6 million from the state's 2005 Medicare survey
budget until an appropriate corrective action plan was developed.
Future CMS actions will promote further resolution in those states that
appear to be missing a significant number of deficiencies identified by
federal surveyors.
Consistency in how States conduct surveys is also being addressed
through improved training for surveyors and the development of an
improved survey process. The new "Quality Improvement Survey (QIS)" is
being pilot-tested and evaluated in 2006. The system uses quality data
to highlight, in advance, the areas in which there are more likely to
be quality problems in a particular nursing home. The survey process is
loaded onto a tablet personal computer to improve productivity and to
augment the amount of information readily available to the surveyor on-
site. The QIS offers a standardized approach designed to increase
surveyor consistency and effectiveness.
Adopting a Comprehensive Approach:
A new, internal Long Term Care (LTC) Task Force was initiated in
December 2004 to coordinate nursing home improvement efforts throughout
CMS. It functions as a subcommittee to the Administrator's Quality.
Council. The LTC Task Force published a 2005 Nursing Home Action Plan
in December 2004. The Nursing Home Action Plan summarizes our
comprehensive strategy and consists of 32 separate initiatives in four
inter-related and coordinated approaches. It describes in detail CMS
commitments to improving quality in nursing homes. A copy of the
Nursing Home Action Plan can be found at
http://www.cms.hhs.gov/qualityy/nhgi/NHActionPlan.pdf. The Action Plan
organized CMS actions into four "pillars of progress:"
Consumer Awareness and Action: Providing consumers and families with
more information to enable them to use both the federal survey system
and the power of the marketplace more effectively. Enhanced assurance
that complaints will be investigated by federal or state surveyors,
more information on the CMS website (NH Compare), development of
enhanced public reporting on pressure ulcers, and the early stages of
developing a staffing measure are examples.
Standards, Survey and Certification: Additional quality standards
(e.g., for fire safety), increased monitoring and follow-through by
surveyors are examples.
Technical Assistance: The new QIO contract, for example, augments the
technical assistance being provided to nursing homes.
Partnering: Quality is best assured when all parts and all actors in
the health care system collaborate to fulfill the common goal. In
particular, we greatly strengthened the coordination between state
survey agencies and the QIOs. For example, when CMS strengthened the
survey agencies' "Special Focus Facility (SFF)" effort, we inaugurated
a companion "Collaborative Focus Facility (CFF) " initiative with the
QIOs. In the "CFF" initiative, state survey agencies refer for QIO
assistance certain nursing homes judged to have significant quality
challenges. The success of this pilot has led to a national rollout in
the latest contract with the QIOs. Each QIO will be required to work
with a subset of these poor performing nursing homes as part of their
contract.
In 2006 we expect to pilot test, via a demonstration, an additional
area of endeavor: making the payment system more sensitive to
variations in quality. Known by various phrases (e.g., "value-based
purchasing" or "pay for performance"), the theory is that we ought to
use and coordinate all available means to carry forward the quality
mandate. The payment system is an important leverage point by which
quality may be promoted. The 2006 Nursing Home Action Plan is under
development now. It will include a plan for value-based purchasing
demonstration, making a total of five (5) "pillars of progress" in the
Action Plan.
While the progress from 1998-2005 documented by the GAO is comprised
predominantly of improvements in the survey and certification process,
we believe that future progress will require even more alignment of all
parts of the health care system, and improvements in every aspect.
Challenges:
As the GAO noted, the total number of providers that participate in
Medicare and/or Medicaid is increasing. This trend enlarges the overall
survey and certification workload for both state and CMS regional
offices. Providers subject to survey & certification include not only
nursing homes, but hospitals, home health agencies, dialysis
facilities, hospices, intermediate care facilities for the mentally
retarded (ICFs-MR), ambulatory surgical centers, and others. This graph
illustrates the total cumulative effect of increased numbers of all
types of regulated providers.
Medicare S&C Total Facilities FY 2000-2007:
[See PDF for image]
[End of figure]
The combination of (a) more providers and (b) fewer resources poses a
significant challenge that will exceed many of the issues upon which
the GAO has focused in the past.
We expect resources to be significantly constrained for some time. In
2005, for example, Medicare funding appropriated by Congress for survey
and certification was $11.7 million below the President's budget
request. State budgets (for Medicaid surveys) remain very limited. And
as the GAO well observed, state survey agencies continue to struggle
from the effects of state hiring freezes and the difficulties in
recruiting and retaining professional staff.
These trends could likely cause some erosion of the gains already made,
particularly the gains from increased survey frequency and the 45%
increase in complaints investigated (2004 compared with 1999). As the
GAO noted, we also recently increased CMS oversight of states through
more comparative health surveys (which the GAO has recommended). The
improvement was accomplished partly through a national contractor. As a
result of the 2005 budget limitations, however, the contract that
helped increase the number of nursing home comparative health surveys
will no longer be supported. More states have resorted to bundling
complaint investigations together so as to investigate multiple
complaints in one visit. Such bundling will affect the timeliness of
the complaint investigations, as well as the total number conducted.
Implementation of the new "Quality Improvement Survey (QIS)" will be
much slower than we desired due to the cost implications of new
computers needed in most states, as well as the training challenge.
Survey predictability will possibly increase since it is so directly
connected with funding. The adequacy of surveyor training will be
severely challenged. As we seek to preserve nursing home oversight
within resource constraints, there will be some trade-offs to make with
surveys for other types of regulated providers, such as hospitals,
hospices, ambulatory surgical centers, dialysis facilities, and home
health agencies. The frequency of surveys and complaint investigations
for such non-long term care providers will likely decrease.
To counteract some of these forces we are redoubling efforts to
increase productivity. We will reexamine CMS policies with a determine
the value added compared with the cost. We will enlarge the scope of
the state performance standards and seek to focus as much as possible
on substantive issues. We will continue to prioritize survey activities
and coordinate with other actors in the health care system to promote
the best possible outcomes. Fuel efficiency improvement must be another
focal point. Survey agencies represent one of the larger transportation-
dependent agencies in state and federal governments. The recent 20-60%
increase in the cost of fuel creates a diversion of resources away from
other important functions. Increases in fuel economy, improved on-site
transportation planning, and strategic investments will be vital.
The future will require that we respond to new challenges as well as
those previously identified. Enhanced emergency preparedness is one
such imperative. Recent experiences from Hurricanes Katrina and Rita
point to the need for more robust preparedness planning. Such planning
must more effectively take into account the type of community-wide
health care crisis that occurs when all major types of interdependent
health care providers (e.g. hospitals, nursing homes, home health
agencies) are all simultaneously and severely affected by a common
cascade of adverse events.
We greatly appreciate the comprehensive approach represented in this
GAO report. Greater challenges ahead require a keen sense of priorities
among the competing activities and enhancements that are theoretically
possible while working within the available programmatic resources.
Together with our own Nursing Home Action Plan posted on our website,
the GAO report offers an excellent overview of many of the initiatives
underway.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Kathryn G. Allen, (202) 512-7118 or allenk@gao.gov:
Acknowledgments:
In addition to the contact named above, Walter Ochinko, Assistant
Director; Jack Brennan; Joanne Jee; Elizabeth T. Morrison; and Christal
Stone made key contributions to this report.
[End of section]
Related GAO Products:
Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in
State and Federal Oversight of Quality of Care. GAO-05-78. Washington,
D.C.: November 12, 2004.
Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal
Standards and Oversight. GAO-04-660. Washington D.C.: July 16, 2004.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. GAO-03-561. Washington,
D.C.: July 15, 2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. GAO-03-187. Washington, D.C.:
October 31, 2002.
Nursing Homes: Quality of Care More Related to Staffing than Spending.
GAO-02-431R. Washington, D.C.: June 13, 2002.
Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-
02-312. Washington, D.C.: March 1, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. GAO-02-279. Washington, D.C.:
February 15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September
28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4,
1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,
D.C.: August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18,
1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.
FOOTNOTES
[1] Medicare is the federal health care program for elderly and
disabled people. In addition to other health and long-term care
services, Medicare covers up to 100 days of nursing home care following
a hospital stay. Medicaid is the joint federal-state health care
financing program for certain categories of low-income individuals.
Medicaid also pays for long-term care services, including nursing home
care. Data for 2003 are the most recent data available.
[2] See Related GAO Products at the end of this report.
[3] Prior to July 2001, CMS was known as the Health Care Financing
Administration. Throughout this report, we refer to the agency as CMS,
even when describing initiatives taken prior to its name change.
[4] http://www.medicare.gov/NHCompare/home.asp.
[5] In this report, we use the term "states" to include the 50 states
and the District of Columbia.
[6] In addition to nursing homes, CMS and state survey agencies are
responsible for oversight of other Medicare and Medicaid providers such
as home health agencies, intermediate care facilities for the mentally
retarded, accredited and nonaccredited hospitals, end-stage renal
dialysis facilities, ambulatory surgical centers, rural health clinics,
outpatient physical therapy centers, hospices, portable x-ray
suppliers, comprehensive outpatient rehabilitation facilities, and
Community Mental Health Centers.
[7] CMS generally interprets these requirements to permit a statewide
average interval of 12.9 months and a maximum interval of 15.9 months
for each home.
[8] CMS requires nursing homes to meet applicable provisions of the
fire safety standards developed by the National Fire Protection
Association (NFPA), of which CMS is a member. NFPA is a nonprofit
membership organization that develops and advocates scientifically
based consensus standards on fire, building, and electrical safety.
[9] In the time period prior to CMS's implementation of its quality
initiatives (January 1, 1997, through June 30, 1998), the proportion of
homes nationwide with actual harm or higher-level deficiencies was 27.7
percent. However, this report focuses on trend data following CMS's
July 1998 announcement of the initiatives. In our September 2000 report
on CMS's quality initiatives, we compared trends in nursing home
deficiency citations for two time periods--one before (January 1, 1997,
through June 30, 1998) and one after (January 1, 1999, through July 10,
2000) the implementation of the nursing home initiatives. Since our
2000 report, we have updated this trend analysis for three time
periods: July 11, 2000, through January 31, 2002; February 1, 2002,
through July 10, 2003; and July 11, 2003, through January 31, 2005.
[10] For example, a deficiency noted in a federal survey could involve
a resident who was not in the nursing home at the time of the state
survey but was admitted between the state and the federal surveys.
[11] The decline in serious deficiencies ranged from a low of 14.3
percentage points in Texas to a high of 23 percentage points in
California and New York (see app. II).
[12] CMS has independently identified shortcomings in areas such as
survey processes and consumer information and has developed initiatives
to address these problems.
[13] Under contract with CMS, 39 Quality Improvement Organizations
(QIO) (formerly known as Peer Review Organizations) help to ensure the
quality of care delivered to Medicare beneficiaries in each state.
Prior to 2002, QIO's work focused on care delivered in acute care
settings such as hospitals.
[14] Quality indicators, the result of a CMS-funded contract, are based
on nursing home resident assessment information--MDS--which is data on
each resident that homes are required to report periodically to CMS.
Quality indicators are derived from nursing homes' assessments of
residents and are used to rank a facility in 24 areas compared with
other nursing homes in the state.
[15] On-site sources include observations, interviews, and records
review. An example of an off-site data source is the MDS.
[16] The pilot states are California, Connecticut, Kansas, Louisiana,
and Ohio.
[17] Prior to this contract, surveyor protocols were developed by CMS,
with comments from stakeholder groups, but the development process did
not include an expert panel.
[18] Investigative protocols are being developed for accidents and
supervision, quality assurance, resident activities programs,
psychosocial severity, safe food handling/nutrition, pharmacy
services/unnecessary drugs, and end-of-life/pain management issues.
[19] For example, a CMS official informed us that the language,
"limited consequences to the resident," which is used in the current
definition of actual harm, confused states because it was vague and
that states formed their own interpretations of the language. The draft
revised definition eliminates this language.
[20] CMS disagreed with a portion of our predictability recommendation
that suggested segmenting the standard survey into more than one review
to provide more opportunities for surveyors to observe problematic
homes. CMS disagreed because of concerns that segmenting the survey
would reduce the effectiveness and increase the cost of surveys.
[21] CMS instructed the states to avoid, if possible, scheduling a
home's survey for the same month as the one in which the home's
previous standard survey was conducted.
[22] According to CMS, states consider 9 months to 15 months from the
last standard survey as the window for completing standard surveys
because it yields a 12-month average. CMS and states acknowledged that
states sometimes fall behind in conducting surveys and homes are not
surveyed until near or after the 15-month time frame. Thus, to maintain
an average survey interval of 12 months, more surveys would need to
occur within 9 months of the last standard survey.
[23] ASPEN stands for the Automated Survey Processing Environment.
ASPEN is used by CMS central office, regional offices, and state survey
agencies for tracking surveys and survey findings. ASPEN comprises
multiple modules such as the ASPEN Enforcement Manager and the ASPEN
Complaints and Incidents Tracking System.
[24] Prior to this new requirement, federal guidelines required only
that complaints alleging immediate jeopardy to residents be
investigated within 2 workdays. For all other complaints, states could
establish their own investigative time frame.
[25] MFCUs have authority to investigate the physical and sexual abuse
of nursing home residents, in addition to investigating fraud and abuse
in the Medicaid program. Typically, MFCUs are an investigative
component of the state's Office of the Attorney General but may be
located in other agencies, such as the state police, instead. Forty-
eight states have a MFCU.
[26] In 2002, CMS informed us that the posters were developed, but have
not yet been printed or distributed. According to a CMS official, the
agency's focus on higher-priority activities has contributed to the
delay.
[27] Results for 2005 were not available at the time we conducted our
work for this report.
[28] We did not evaluate the effectiveness of the complaint tracking
system.
[29] CMS requires state survey agencies to investigate allegations of
nursing home resident abuse, which can be submitted by residents,
family members, friends, physicians, and nursing home staff, within 2
days of learning of the allegation, but does not impose a deadline for
completing the investigation. After the state survey agency has made an
initial determination, the nurse aide may request an appeal within 30
days. Hearings may not be held for several months, and decisions are
not always immediate.
[30] The Background Check Pilot Program was mandated by Section 307 of
the Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (Pub. L. No. 108-173, 117 Stat. 2066, 2257.) CMS issued grant
solicitation letters to states in July 2004 and made grants in January
2005.
[31] States are now required to deny a grace period to homes that are
assessed one or more deficiencies at the actual harm level or above (G
through L on CMS's scope and severity grid) in each of two successive
surveys within a survey cycle. A survey cycle is two successive
standard surveys and any intervening survey, such as a complaint
investigation.
[32] Substandard quality of care is defined as deficiencies cited at
the F level of scope and severity in certain care areas--quality of
life, quality of care, and resident behavior and facility practices.
[33] Before readmitting a terminated nursing home to Medicare, CMS
requires the home to address the situation that led to termination and
provide reasonable assurance that it will not recur. To give this
assurance, a home is required to have two surveys not more than 6
months apart, each of which shows the problem to be corrected. The
reasonable assurance period is the time between these two surveys.
[34] From 2000 to 2004, CMS used a nationwide summary of the 10
regional office enforcement databases known as the Long Term Care
Enforcement Tracking System.
[35] We did not evaluate the performance of the ASPEN Enforcement
Manager for this report.
[36] In the Special Focus Facility Program, state survey agencies
conduct enhanced monitoring of nursing homes with histories of
providing poor care.
[37] The revised special focus facility selection methodology addressed
criticisms about the original state selection process from state survey
agencies, including that the process did not account for state size or
number of nursing homes, and used insufficient performance data in
selecting homes. Alaska is not required to select special focus
facilities.
[38] CMS's guidance to states describes the factors to be considered
when determining the amount of a civil money penalty.
[39] The assumption is that the nursing home identified and corrected
this earlier care problem.
[40] CMS is statutorily required to conduct federal monitoring surveys
in at least 5 percent of the surveyed nursing homes in each state each
year, with a minimum of 5 facilities in each state. As of January 2005,
there were 16,146 nursing homes, which would require 807 federal
monitoring surveys. Until 1992, all federal monitoring surveys were
comparative. In part because comparative surveys were resource
intensive, CMS began to rely more heavily on observational surveys,
which require a smaller number of federal surveyors.
[41] During fiscal years 1999 and 2000, CMS required a minimum of one
comparative survey to be completed yearly in the 20 states having fewer
than 200 nursing homes, two in the 24 states that had from 200 to 599
homes, and three in the 7 states that had 600 or more homes.
[42] Since fiscal year 2001, CMS has expanded the scope of state
performance reviews to include seven additional Medicare and Medicaid
providers, such as hospitals and renal dialysis facilities, in addition
to nursing homes.
[43] The 11 elements are (1) the citation has the full regulatory
reference; (2) evidence supports determination of noncompliance at the
cited regulation; (3) each deficient practice statement clearly
summarizes the provider/supplier failure(s) and quantifies a relevant
extent; (4) the scope accurately reflects the evidence and the
residents who are, or may be, affected by the deficient practice; (5)
the severity rating in nursing homes or the condition, standard, or
element level cited reflects the evidence and the actual and/or
potential outcomes to beneficiaries; (6) each person referred to is
uniquely identified; (7) the observations, interviews, and record
reviews support the deficient practice statement and illustrate the
entity's noncompliance; (8) descriptions of observation of
provider/supplier practice include date, time, duration, and location;
(9) descriptions of interviews include dates and times and who was
interviewed; (10) record review includes date of entry and exact title
of record, and verifies lack of additional records with a knowledgeable
person; and (11) evidence is written in plain language that is clear,
concise, and easily understood.
[44] CMS was unable to score the standard in fiscal year 2001 because
the standard was too complicated. The standard consisted of 33 elements
in fiscal year 2001 but was reduced to 7 elements for the subsequent 2
fiscal years. In fiscal year 2004, the number of elements was increased
to 11.
[45] Examples include reports on pending nursing home terminations
(weekly), data entry timeliness (quarterly), tallies of state surveys
that find homes deficiency-free (semiannually), and analyses of the
most frequently cited deficiencies by states (annually).
[46] The MDS, which is prepared periodically for each nursing home
resident, contributes to multiple functions, including establishing
patient care plans, assisting with quality oversight, and setting
nursing home payments that account for variation in resident care
needs.
[47] This limited on-site presence was also inconsistent with a
recommendation in a 2001 report CMS commissioned regarding the benefits
of on-site reviews in detecting MDS accuracy problems and with the view
of 9 of the 10 states with separate MDS review programs that an on-site
presence at a significant number of their nursing homes is central to
their review efforts.
[48] Such a shift in focus would include (1) taking full advantage of
the periodic on-site visits already conducted at every nursing home
nationwide through its routine survey process; (2) ensuring that the
federal MDS review process is designed and sufficient to consistently
assess the performance of all states' reviews for MDS accuracy; and (3)
providing additional guidance, training, and other technical assistance
to states as needed to facilitate their efforts.
[49] Although the focus of the prior data assessment and verification
contract was MDS accuracy reviews, the contract also included an
examination of issues of interest to other CMS components that
sponsored the contract. For example, the contractor examined facility
assessment data on Medicare beneficiaries who received home health
services.
[50] While on-site, the contractor had access to a broader range of
information gleaned from observation, interviews with residents and
staff, and reassessments of residents. During the 3-1/2 years of the
data assessment and verification contract, 69 on-site reviews were
completed, less than the 200 anticipated in 2001 and less than the
revised goal of 100 on-site reviews. According to the contractor's
report, the highest discrepancy rates identified during the 69 on-site
reviews of 617 assessments included the number of medications (50
percent discrepancy rate) and pain management (10 percent discrepancy
rate).
[51] The November 2002 roll-out of quality indicator data included a
combined total of 10 chronic care and post-acute-care quality
indicators. Chronic care quality indicators included decline in
activities of daily living, pressure sores (with facility-level
adjustment), pressure sores (without facility-level adjustment),
inadequate pain management, physical restraints used daily, and
infections. Post-acute-care quality indicators included failure to
improve and manage delirium (with facility-level adjustment), failure
to improve and manage delirium (without facility-level adjustment),
inadequate pain management, improvement in walking, and
rehospitalizations.
[52] The National Quality Forum is a nonprofit organization created to
develop and implement a national strategy for health care quality
measurement and reporting. It has broad participation from government
and private entities as well as all sectors of the health care
industry.
[53] The Web site reports the nursing staff hours per resident per day
and certified nurse aides per resident per day.
[54] The National Quality Forum has discussed expanding staffing data
to include these and other issues such as use of nonnursing staff to
provide care, use of part-time and contract nurses, and the tenure of
the director of nursing and the administrator.
[55] In smaller states, QIOs worked with at least 10 nursing homes.
[56] An evaluation of the pilot program reported on the results of the
pilot program; however, the evaluation was conducted by the same QIO
responsible for facilitating the pilot program.
[57] Best practices have been collected from organizations including
the American Medical Directors Association, University of Iowa
Geriatric Nursing Center, Association of Rehabilitation Nurses,
American Diabetes Association, National Kidney and Urologic Diseases
Information Clearinghouse, Feinberg School of Medicine (Northwestern
University), American Academy of Neurology, American Society of
Consultant Pharmacists, United Ostomy Association, and the Centers for
Disease Control and Prevention.
[58] To update federal fire safety standards, CMS issues notice and
solicits comments on the proposed new standards in the Federal
Register, reviews public comments, and publishes a final version of the
standards with an effective date. This process of adopting NFPA's 2000
standards in 2003 took CMS about 16 months.
[59] After the 2003 nursing home fire in Hartford, Connecticut, the
state passed a law requiring all nursing homes to install sprinklers
not later than July 1, 2005 (Conn. Spec. Acts 03-3, §92.) In 2005, the
state extended the effective date to July 31, 2006 (Conn. Pub. Acts 05-
187.) Florida enacted a law in June 2005 that requires nursing homes in
the state to be protected with automatic sprinklers by December 31,
2010. A loan guarantee program would be available in Florida because of
concern about the cost impact of retrofitting on homes (Fla. Laws Ch.
2005-234).
[60] This includes about 1 percent of homes whose sprinkler status is
unknown.
[61] According to CMS and state officials, the first year for a new
surveyor is essentially a training period with low productivity. It
takes as long as 3 years for a surveyor to gain sufficient knowledge,
experience, and confidence to perform the job well.
[62] As a result of the recession that began in 2001, states
experienced growing budget pressures and experienced significant budget
shortfalls from fiscal years 2003 through 2005. Although budget
pressures diminished at the end of fiscal year 2004, many states
projected budget shortfalls in fiscal year 2005.
[63] The Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 created the new Medicare prescription drug benefit, which will
offer Medicare beneficiaries outpatient prescription drug coverage
(Pub. L. No. 108-173, §101, 117 Stat. 2066, 2071-2152 (adding §§ 1860D-
1-1860D-42 to the Social Security Act, codified at 42 U.S.C. §§ 1395w-
101-1395w-152)). On January 28, 2005, CMS issued the final regulations
implementing the Medicare prescription drug benefit.
[64] This increase includes a substantial increase in the number of end-
stage renal disease facilities and ambulatory surgical centers.
[65] The federal government funds 100 percent of costs associated with
certifying that nursing homes meet Medicare requirements and 75 percent
of the costs associated with Medicaid standards.
[66] The time frames for home health agency surveys are also
established by statute.
[67] CMS has identified four priority tiers for ranking state workload.
CMS's guidance to states for formulating budgets puts standard surveys
in Tier I, the highest tier, and puts complaints and initial surveys in
Tiers II and III, respectively.
[68] As stated earlier, CMS set aside some fiscal year 2006 funds for
conducting fire safety comparative surveys.
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