Testimony Before the  
United States Senate Special Committee on Aging 
 
 
 
 
Residents at Risk: The Strained Nursing Home Inspection  
System and the Need to Improve Oversight  
 
Testimony of 
Erin Bliss 
Assistant Inspector General  
Office of Evaluation and Inspections 
Office of Inspector General 
Department of Health and Human Services 
 
 
 
 
 
May 18, 2023 
9:30 a.m. 
366 Dirksen Senate Office Building 
     
   
 
Testimony of Erin Bliss 
Assistant Inspector General for Evaluation and Inspections 
Department of Health and Human Services, Office of Inspector General  
Good morning, Chair Casey, Ranking Member Braun, and distinguished Members of the Senate 
Special Committee on Aging.  I am Erin Bliss, Assistant Inspector General for Evaluation and 
Inspections at the Department of Health and Human Services (HHS), Office of Inspector General 
(OIG).  Thank you for inviting me to testify today regarding strains on the nursing home 
inspection system and the need to improve oversight to better protect nursing home residents.   
I appreciate this opportunity to discuss one of the most consequential issues in health care today: 
ensuring safe, quality care for people in the Nations nursing homes.  Many nursing homes 
provide excellent care.  But through decades of OIG work, we have found that people in nursing 
homes are too often subjected to poor quality care and unsafe conditions.  Improving nursing 
home care for those who need it is Inspector General Grimms top priority.   
My testimony focuses on the roles and performance of State Survey Agencies (State Agencies) 
in overseeing more than 15,000 nursing homes nationally.  While the responsibility for providing 
high-quality, safe care lies first and foremost with the nursing homes themselves, State Agencies 
provide critical, frontline oversight of nursing homes.  State Agencies are the eyes and ears to 
conditions in nursing homes that millions of people and their families experience, and are the 
only Government entities regularly entering nursing homes to assess their operations. 
I will provide brief context on the vital roles of State Agencies in overseeing nursing homes and 
then focus on concerns OIG has raised about State Agency performance and Centers for 
Medicare & Medicaid Services (CMS) oversight of State Agencies, challenges State Agencies 
face in fulfilling their responsibilities, and OIGs recommendations for improvements. 
KEY TAKEAWAYS 
  State Agencies have not consistently fulfilled their responsibilities for overseeing the 
quality and safety of nursing home care, which puts residents at risk.  
 
  State Agencies point to key challengesparticularly staffing shortagesthat limit their 
ability to meet their oversight responsibilities. 
 
  CMS has struggled to improve performance by State Agencies that have repeatedly 
fallen short.  
 
  Sustained commitment and efforts by CMS, State Agencies, and others are critical to 
ensuring nursing home quality and safety for millions of Americans. 
 
2  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
STATE AGENCIES ARE ON THE FRONT LINES FOR PROTECTING NURSING HOME 
RESIDENTS FROM SUBSTANDARD CARE AND UNSAFE CONDITIONS 
State Agencies responsibilities for overseeing nursing homes are vast, touching millions of lives 
and involving billions of dollars.  Federal and State expenditures to nursing homes through 
Medicare and Medicaid totaled $94 billion in 2022 ($56 billion under Medicaid and $38 billion 
under Medicare).1  According to CMS data in July 2022, approximately 1.2 million people 
resided in more than 15,000 certified nursing homes.2   
State Agencies have specific responsibilities aimed at ensuring that nursing homes meet 
Federal standards for quality and safety. 
Conducting Standard Surveys.  CMS requires State Agencies to conduct onsite standard 
surveys (i.e., inspections) of nursing homes on average every 12 months, with no facility going 
more than 15 months without a standard survey.  These surveys are comprehensive assessments 
of nursing homes compliance with Federal health and safety standards set by CMS.3 
Assessing and Responding to Complaints.  State Agencies receive, track, and respond to 
complaints about nursing homes.  They assess incoming complaints and assign severity levels 
based on the degree of harm or potential harm associated with an alleged problem.  State 
Agencies must investigate the most serious complaints on site within 3 business days (for the 
highest level known as immediate jeopardy) or in 15 to 18 business days (for the next highest 
level, known as high priority).  These investigations are also called complaint surveys.  State 
Long-Term Care Ombudsmen, who advocate for nursing home residents and their families and 
do not have oversight responsibilities, can also receive complaints about nursing homes and can 
work to help resolve these complaints.  With a residents consent, an ombudsman may refer a 
complaint to a State Agency for investigation. 
Citing and Following Up on Deficiencies.  When a State Agency finds (e.g., through a standard 
survey or a complaint survey) that a nursing home has failed to meet one or more quality or 
 
1 These figures are based on an OIG analysis of CMS claims data for calendar year 2022; accessed May 3, 2023.  Amounts 
include payments to nursing homes and exclude payments to other providers (such as physicians) for services to nursing home 
residents.   
2 Kaiser Family Foundation (KFF), KFF analysis of CMS Care Compare data, Total Number of Residents in Certified Nursing 
Facilities, July 2022, accessed at Total Number of Residents in Certified Nursing Facilities | KFF on May 14, 2023.  
3 In response to the COVID-19 pandemic, CMS temporarily suspended annual standard surveys in March 2020 and introduced a 
new, focused infection control survey.  On June 1, 2020, CMS directed States to conduct focused infection control surveys for all 
nursing homes and, at a States discretion, to continue surveys for the most serious complaints.  On August 17, 2020, CMS 
further directed States to conduct standard surveys as soon as they had the appropriate resources to do so.  (See CMS, Suspension 
of Survey Activities, Ref: QSO-20-12-All, March 4, 2020; CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, 
March 20, 2020; CMS, Revised COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control 
Deficiencies, and Quality Improvement Activities in Nursing Homes, Ref: QSO-20-31-All (rescinded as of March 30, 2023); 
CMS, Enforcement Cases Held During Prioritization Period and Revised Survey Prioritization, Ref: QSO-20-35-All, 
August 17, 2020).   
 
3  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
safety standards, the State cites the nursing home with applicable deficiencies and rates the 
severity of the deficiencies.  The State Agency then obtains and reviews plans of correction from 
the nursing home and must verify that the nursing home corrects its deficiencies (for all but the 
least severe categories).  CMS provides timeframes for State Agencies to cite and follow up on 
deficiencies.4 
CMS provides funding to and oversight of State Agencies. 
State Agency oversight of nursing homes is jointly funded by CMS and the States.  According to 
HHS, CMSs survey and certification budget to support State Agency operations has remained 
relatively flat between fiscal years (FYs) 2015 and 2023 at roughly $400 million annually.5  
Congress appropriated about $100 million in supplemental funds to cover costs for 
COVID-19-related survey and certification activities through the Coronavirus Aid, Relief, and 
Economic Security (CARES) Act.6  The HHS FY 2024 budget requests $566 million for survey 
and certification, and cites continuing problems with poor, substandard care leading to 
preventable harm for nursing home residents and increases in complaints about nursing homes 
requiring surveys.7    
CMS oversees State Agency performance of responsibilities including conducting surveys, 
handling complaints, and citing and following up on deficiencies.  CMS uses the State 
Performance Standards System to evaluate whether State Agencies are meeting obligations and 
to identify areas for improvement.8  CMS considers a States performance to be inadequate 
 
4 This process varies by the scope and severity of the deficiency.  For most deficiencies (not including immediate jeopardy), State 
Agencies have 10 working days to send a nursing home a statement of deficiencies.  A nursing home then has 10 calendar days 
from receiving the statement of deficiencies from a State Agency to submit plans of correction.  Generally, State Agencies have 
60 days from the date of a survey to revisit a nursing home to verify compliance. 
5 See HHS, FY 2024 Budget in Brief, pp. 115-16, accessed at https://www.hhs.gov/sites/default/files/fy-2024-budget-in-
brief.pdf on May 3, 2023, and HHS, CMS FY 2024 Justification of Estimates for Appropriations Committees, pp. 69-73, 
accessed at https://www.cms.gov/files/document/cms-fy-2024-congressional-justification-estimates-appropriations-
committees.pdf-0 on May 3, 2023. 
6 CARES Act, P.L. No. 116-136, Division B, Emergency Appropriations for Coronavirus Health Response and Agency 
Operations, Title VIII (March 27, 2020).  
7 HHS, FY 2024 Budget in Brief, pp. 115-16, accessed at https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf 
on May 3, 2023.  
8 42 CFR  488.320(a); CMS State Operations Manual (SOM), Pub. No. 100-07, Ch. 8Standards and Certification (Rev. 1, 05-
21-04); Accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c08pdf.pdf on May 
14, 2023.  
 
4  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
when the State does not meet a specified performance threshold.9  When CMS determines that 
State performance is inadequate, it may impose one or more remedies or sanctions on the State.10   
Longstanding, persistent problems in nursing homes make State Agency oversight crucial 
for the safety and well-being of residents.   
The importance of State Agencies roles in identifying and correcting poor care by nursing 
homes cannot be overstated in light of the longstanding and persistent problems that affect 
resident health and safety.  Although many nursing homes provide excellent care and are diligent 
in protecting their residents, an alarming number of nursing home residents are subject to 
low-quality care and unsafe conditions.   
Decades of OIG oversight and enforcement have revealed persistent, entrenched problems in 
nursing homes ranging from preventable harm to residents to failed emergency preparedness, 
understaffing, and cases of abuse and neglect, among others.  The COVID-19 pandemic and its 
devastating impact on nursing home residents brought to the forefront known and new nursing 
home challenges, including staffing shortages and poor infection control.   
STATE AGENCIES HAVE NOT CONSISTENTLY FULFILLED THEIR RESPONSIBILITIES 
FOR OVERSEEING THE QUALITY AND SAFETY OF NURSING HOME CARE, WHICH 
PUTS RESIDENTS AT RISK. 
OIG and CMS have identified a variety of shortfalls among some State Agencies in performance 
of their responsibilities for protecting nursing home residents health and safety.  
Many States repeatedly failed to conduct timely standard and complaint surveys. 
OIG analyzed CMSs performance metrics for State Agencies from 2015 to 2018.  We found that 
the most common recurring performance deficiencies identified by CMS were associated with 
timeliness of standard and complaint surveys.  In each of those years, between 20 and 29 States 
failed to meet the performance threshold of investigating 95 percent of high priority complaints 
within 10 business days.11  From 2015 to 2018, between 12 and 28 States each year failed to 
meet the performance threshold of conducting standard surveys within 15.9 months for each 
 
 
9 CMS SOM, Pub. No. 100-07, Ch. 8Standards and Certification, Section 8000F (Rev. 1, 05-21-04); CMS response to OIG 
informational questions on August 30, 2019; and CMS, FY 2018 State Performance Standards System Guidance, Admin Info: 
18-02-ALL, October 17, 2017.   
10 Sections 1819(g)(3)(C) and 1919(g)(3)(C) of the Social Security Act; 42 CFR  488.320; CMS, SOM, Pub. No. 100-07, Ch. 
8Standards and Certification, Section 8000G (Rev. 1, 05-21-04). 
11 During that time period, CMS required States to investigate high priority complaints onsite within 10 business days.  CMS 
recently changed that requirement.  Effective October 2022, States need to investigate these complaints on site within 15 business 
days on average, not to exceed 18 business days for any high priority complaint.  See Medicare State Operations Manual. 
 
 
5  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
nursing home or a Statewide average interval of 12.9 months.12  When State Agencies miss these 
performance measures, poor care or safety risks for residents may go undetected and 
unaddressed. 
OIG also evaluated State Agency timeliness in conducting onsite investigations of serious 
complaints (i.e., immediate jeopardy and high priority complaints) from 2011 to 2018, and our 
findings raise concerns.13  Serious complaints typically include allegations concerning health and 
safety, such as allegations of residents left sitting in urine and feces, preventable infections, or 
verbal and physical abuse, among others.  We found that in 2018, States were late in 
investigating 13 percent of immediate jeopardy (the most serious) complaints and were late in 
investigating 19 percent of high priority (the second most serious) complaints.  Furthermore, 10 
States did not meet the timeliness threshold for high priority complaints for 8 consecutive years, 
from 2011 through 2018.  
State Agencies have sometimes fallen short in identifying risks to nursing home residents. 
OIGs work has raised questions about the effectiveness of State Agencies in identifying certain 
problems in nursing homes.    
Infection Control.  OIG has raised serious concerns about the effectiveness of the State Agency 
survey process in uncovering infection control problems during the first year of the COVID-19 
pandemic.  We identified more than 1,300 nursing homes that experienced extremely high 
infection rates75 percent or more of their Medicare beneficiariesduring COVID-19 surge 
periods in the spring and fall of 2020.  More than half54 percentof the nursing homes with 
extremely high infection rates were not cited with an infection control deficiency during any    
 
12 OIG, CMS Should Take Further Action To Address States With Poor Performance Conducting Nursing Home Surveys, 
OEI-06-19-00460, January 2022, accessed at  CMS Should Take Further Action To Address States With Poor Performance in 
Conducting Nursing Home Surveys on April 27, 2023.   
13 OIG, States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016
2018, September 2020, OEI-01-19-00421, accessed at States Continued To Fall Short in Meeting Required Timeframes for 
Investigating Nursing Home Complaints: 20162018 on April 19, 2023. 
 
6  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
standard survey, complaint survey, or targeted infection control survey in 2020, despite virtually 
all of these facilities having had multiple surveys during that year.14, 15 
Life Safety and Emergency Preparedness.  Beginning in 2018, OIG audited 154 nursing homes 
across 8 States to assess the facilities compliance with CMSs life safety and emergency 
preparedness requirements, which were updated in 2016.16  Across these 8 States, we found more 
than 1,000 areas of noncompliance with life safety requirements (e.g., requirements for building 
exits, and fire and carbon monoxide detectors) and more than 1,000 areas of noncompliance with 
emergency preparedness requirements (e.g., requirements for emergency supplies, evacuations, 
and emergency communications).  As a result, residents were at increased risk of injury or death 
during a fire or other emergency in 150 of the 154 nursing homes included in our review.  OIG 
determined that inadequate oversight by State Agencies was one of multiple factors contributing 
to these deficiencies.17 
State Agencies have not always verified that nursing homes have corrected cited 
deficiencies, as required. 
Through a series of reports, OIG determined that seven of nine State Agencies reviewed did not 
always verify nursing home correction of deficiencies.  The deficiencies ranged in scope and 
severity, and included improper restraining of residents and failing to provide necessary care and 
services for managing diabetes, among others.  Furthermore, for the less serious deficiencies, six 
of the seven State Agencies without further evidence or followup simply accepted the nursing 
homes correction plans as confirming compliance.18  Without proper verification that nursing 
homes are correcting their deficiencies, residents may be at risk.   
 
14 CMS temporarily suspended annual standard surveys in late March 2020 and introduced a new, focused infection control 
survey.  On June 1, 2020, CMS directed States to conduct focused infection control surveys for all nursing homes and, at the 
States discretion, to continue surveys for the most serious complaints.  On August 17, 2020, CMS further directed States to 
conduct standard surveys as soon as they had the appropriate resources to do so.  (See CMS, Suspension of Survey Activities, Ref: 
QSO-20-12-All, March 4, 2020; CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 20, 2020; CMS, Revised 
COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control Deficiencies, and Quality 
Improvement Activities in Nursing Homes, Ref: QSO-20-31-All (rescinded as of March 30, 2023); CMS, Enforcement Cases 
Held During Prioritization Period and Revised Survey Prioritization, Ref: QSO-20-35-All, August 17, 2020).  
15 OIG, Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of 
the COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491, accessed at 
https://oig.hhs.gov/oei/reports/OEI-02-20-00491.pdf on May 5, 2023.  
16 Except for one State, these audits were conducted prior to the COVID-19 pandemic and CMSs 2019 updated infection control 
requirements.  Accordingly, these audits did not focus on infectious disease preparedness.  
17 OIG, Audits of Nursing Home Life Safety and Emergency Preparedness in Eight States Identified Noncompliance With 
Federal Requirements and Opportunities for the Centers for Medicare & Medicaid Services to Improve Resident, Visitor, and 
Staff Safety, A-02-21-01010, July 2022, accessed at https://oig.hhs.gov/oas/reports/region2/22101010.asp on April 20, 2023.  
18 OIG, CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs To Be Improved To Help 
Ensure the Health and Safety of Nursing Home Residents, February 2019, A-09-18-02000, accessed at 
https://oig.hhs.gov/oas/reports/region9/91802000.pdf on April 20, 2023. 
 
7  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
STATE AGENCIES POINT TO KEY CHALLENGESPARTICULARLY STAFFING 
SHORTAGESTHAT LIMIT THEIR ABILITY TO MEET THEIR OVERSIGHT 
RESPONSIBILITIES.  
For State Agency performance problems, especially timeliness problems, CMS and State 
Agencies have pointed to staffing shortages as a root cause.  
CMS and State Agencies have reported that staffing shortages are a driving factor in States 
performance shortfalls, particularly with respect to timeliness of surveys.  Staffing concerns 
reported by State Agencies commonly centered on the inability to attract and retain surveyors 
(who are typically nurses), and some State Agencies pointed to long hours and not being able to 
offer salaries that are high enough to compete in local markets.  CMS staff from one region noted 
that many of the staffing shortages occur in States with widespread nurse shortages, and that 
these States have difficulty attracting and retaining nurses to conduct surveys.  In one State, 15 of 
47 surveyor positions were vacant.19  Not surprisingly, State Agencies reported to OIG that the 
COVID-19 pandemic exacerbated longstanding challenges in maintaining sufficient staffing 
levels.20   
CMS and State Agencies have also linked performance challenges to increased workloads.  In 
our report on the timeliness of State Agency complaint surveys, OIG documented that the rate of 
incoming complaints grew from 2015 to 2018, and about half of the complaints were serious 
enough to require that State Agencies investigate promptly.  CMS reported to us that the increase 
in nursing home complaints over the years has remained a challenge for CMS and States because 
resources to investigate these complaints have not kept up.21  The HHS FY 2024 budget request 
stated that in recent years State Agencies conducted more than 10,000 additional complaint 
surveys compared to 2015, marking a 19 percent increase.22   
 
 
19 OIG, CMS Should Take Further Action To Address States With Poor Performance Conducting Nursing Home Surveys, 
OEI-06-19-00460, January 2022, accessed at CMS Should Take Further Action To Address States With Poor Performance in 
Conducting Nursing Home Surveys on April 27, 2023.   
20 OIG, Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020, December 2020, 
OEI-01-20-00430, accessed at Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23May 30, 2020 
(hhs.gov) on April 25, 2023.  
21 OIG, States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016
2018, OEI-01-19-00421, September 2020, accessed at States Continued To Fall Short in Meeting Required Timeframes for 
Investigating Nursing Home Complaints: 20162018 on April 27, 2023.  
22 HHS, FY 2024 Budget in Brief, p. 115, accessed at https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf on 
May 3, 2023. 
 
8  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
The COVID-19 pandemic drove substantial backlogs of standard surveys that persist in 
many States. 
In early 2020 and in light of the unprecedented pandemic, CMS directed State Agencies to 
temporarily suspend standard surveys and shift their resources to conduct more limited focused 
infection control surveys and investigations of serious complaints.  Starting on March 23, 2020, 
State Agencies conducted shorter onsite surveys as opposed to the standard surveys that 
comprehensively cover nursing home quality and safety operations.   
Prior to the suspension, State agencies were required to conduct a standard survey for each 
nursing home at least once every 15 months.  By late June 2020, 8 percent of nursing homes had 
gone at least 16 months without a standard survey, and State Agencies were growing concerned 
about how they would eventually work through mounting backlogs.23  In August 2020, CMS 
called on States to resume their standard surveys if they had the resources to do so.  By May 31, 
2021, the backlog of standard surveys had grown substantially: 71 percent of nursing homes had 
gone at least 16 months without a standard survey.24  According to CMSs publicly available 
data as of May 7, 2023, that backlog stood at 28 percent of nursing homes nationwide going at 
least 16 months without a standard survey.  By State, the backlogs range from less than 1 percent 
to as high as 87 percent, with Kentucky and Maryland each facing a backlog of 80 percent or 
greater.25 
CMS HAS STRUGGLED TO IMPROVE PERFORMANCE BY STATE AGENCIES THAT 
HAVE REPEATEDLY FALLEN SHORT.  
The persistence of State Agency performance problems over time raises questions about how 
effectively CMS is able to drive improvements.  CMS has relied primarily on corrective action 
plans, training, and informal communication to improve State Agency performance.  But these 
tools did not always resolve problems.  CMS has raised concerns about having few practical 
options for addressing intractable problems in some States.26 
 
 
23 OIG, Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23May 30, 2020, December 2020, 
OEI-01-20-00430, accessed at Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23May 30, 2020 
(hhs.gov) on April 25, 2023. 
24 OIG, Addendum: States Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 
Pandemic, August 2021, OEI-01-20-00431, accessed at States Backlogs of Standard Surveys of Nursing Homes Grew 
Substantially During the COVID-19 Pandemic on April 20, 2023. 
25 Calculated at S&C QCOR, accessed on May 7, 2023. 
26 OIG, CMS Should Take Further Action To Address States With Poor Performance in Conducting Nursing Home Surveys, 
OEI-06-19-00460, January 2022, accessed at CMS Should Take Further Action To Address States With Poor Performance in 
Conducting Nursing Home Surveys on April 27, 2023.   
 
9  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
OIG work raises concerns about how effectively CMS is using corrective action plans. 
CMS has commonly relied upon State Agencies to address their performance problems by 
developing corrective action plans, but OIG has found that those corrective action plans are 
sometimes insufficient to address performance.  In a review spanning 2015 to 2018, plans for 
12 States were missing from CMS files.  When plans were available for our review, we found 
that State Agencies often failed to include substantive details about which actions would address 
the performance problem.  For example, one State Agency indicated it would work to achieve 
100 percent without providing further detail in each of three corrective action plans responding 
to three missed performance measures.  In other States, corrective action plans were nearly 
identical to plans submitted for the previous year, which raises concern that either the plan was 
insufficient to address the problem or that the original plan was not fully implemented. 
CMS has used other remedies, but many of these have limitations. 
We found that CMS also used other remedies to address State Agency performance.  Some 
examples include training, technical assistance, close communications, and allocating funding as 
States meet performance goals, a process called benchmarking.  Among these examples, 
benchmarking to provide incentives for performance improvement appears to hold some 
promise.  Limits in documenting training, assistance, and communications make it hard to 
determine their effectiveness.  Other types of remedies included a few cases in which CMS used 
third-party contractors to support State Agencies struggling with performance; however, CMS 
reported to us that limited funding means only one to three States will typically receive this kind 
of support in a year.  
CMS can also impose financial penalties, but this approach can compound the strains associated 
with increased workloads and staffing shortages.  CMS has the authority to terminate its 
agreement, in whole or in part, with any State Agency for performance concerns;27 it considers 
this to be the option of last resort.  Terminating an agreement with a State Agency could lead to 
significant gaps in the oversight of nursing homes in that State.  
Finally, CMS reported to OIG that in three cases, CMS escalated to senior State officialsin one 
case to a Governor and in the others to a State health department directorits concerns about 
State Agency performance and that this elevated attention led to some improvements.28    
 
 
27 Under 42 CFR  488.320(d)(5), for all survey inadequacies in Medicare facilities CMS may initiate action to terminate the 
1864 agreement with the State, either in whole or in part.  
28 OIG, CMS Should Take Further Action To Address States With Poor Performance in Conducting Nursing Home Surveys, 
January 2022, OEI-06-19-00460, accessed at CMS Should Take Further Action To Address States With Poor Performance in 
Conducting Nursing Home Surveys on April 25, 2023. 
 
10  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
CMSs processes for reviewing State survey results reported on the Care Compare website 
were inadequate, resulting in some inaccurate information for consumers.  
In 2023, an OIG audit found that CMSs processes for reviewing State survey results reported on 
its Care Compare website were inadequate.  Care Compare is a resource with information about 
health care providers to help consumers make informed health care decisions.  It provides 
information for each Medicare- and Medicaid-certified nursing home in the country, including 
results of recent surveys by State Agencies.  An estimated two-thirds of nursing homes had one 
or more deficiencies related to health, fire safety, and emergency preparedness identified during 
State Agency surveys that were inaccurately reported on Care Compare.  CMS looked into the 
circumstances of some of the inaccuracies we identified.  CMS determined that human error by 
surveyors entering the data had caused some of them and that systems errors had cause some 
others.29    
SUSTAINED COMMITMENT AND EFFORTS BY CMS, STATE AGENCIES, AND OTHERS 
ARE CRITICAL TO ENSURING NURSING HOME QUALITY AND SAFETY FOR MILLIONS 
OF AMERICANS.  
Supporting a robust and effective survey process is crucial to the health and safety of nursing 
home residents.  State agencies are on the front lines for determining whether nursing homes 
meet standards, investigating complaints, identifying deficiencies in nursing home care or 
conditions, and validating that deficiencies are corrected.  Delays in responding to complaints or 
conducting comprehensive inspections and unaddressed nursing home deficiencies can put 
residents at great risk of harm.   
OIG has made numerous recommendations to CMS to address specific shortcomings of State 
Agency oversight identified in our evaluations and audits.  CMS has implemented some, and 
others remain open.  We continue to call on CMS to work with urgency in implementing 
recommendations, including the following:  
  Address State Agency Timeliness Problems More Effectively.  CMS should engage earlier 
and more frequently with high-level State officials on serious or recurring performance 
shortfalls (most commonly survey timeliness), disseminate results of State performance 
reviews more widely, and actively monitor State Agency corrective action plans and other 
remedies to focus on making the remedies specific and outcome-oriented.  CMS should also 
identify new approaches to address States that consistently fail to meet the required 
timeframes for investigating the most serious nursing home complaints, one of the most 
 
29 OIG, CMS Did Not Accurately Report on Care Compare One or More Deficiencies Related to Health, Fire Safety, and 
Emergency Preparedness for an Estimated Two-Thirds of Nursing Homes, April 2023, A-09-20-02007, accessed at 
https://oig.hhs.gov/oas/reports/region9/92002007.pdf on April 20, 2023. 
 
11  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
persistent and widespread problems.  Furthermore, CMS should work with State Agencies on 
a plan to more frequently survey nursing homes with repeat deficiencies.
 
   
 
  Strengthen Oversight of Nursing Home Risk Areas.  These areas include:  
o  Infection Control.  CMS should improve how surveys identify infection control risks and 
strengthen guidance on assessing the scope and severity of those risks.   
o  Life Safety.  CMS should work with State Agencies to require standardized life safety 
training for nursing home staff.   
o  Leveraging Data to Target Risks.  OIG has also encouraged CMS efforts to leverage data 
to analyze risks and target CMS and State agency oversight efforts in ways that are most 
likely to uncover problems in nursing home care.  For example, CMS has implemented 
an OIG recommendation to provide State Agencies with certain nursing home staffing 
data to help States target specific nursing homes for weekend inspections.30  OIG has also 
recommended that CMS use data to identify nursing homes associated with a higher use 
of psychotropic drugs and focus oversight on nursing homes with trends that may signal 
inappropriate use.31   
 
  Better Ensure That State Agencies Verify Nursing Home Corrections of Deficiencies.  
CMS should improve guidance to State Agencies on verifying nursing home corrections of 
deficiencies and documentation to support verification. 
 
  Improve the Accuracy of Deficiency Data in Care Compare.  CMS should strengthen its 
processes for reviewing State Agency survey results reported on Care Compare by requiring 
State Agencies to verify that deficiencies shown across CMSs systems are accurate, 
providing technical assistance and additional training to State Agencies that are not following 
procedures for reporting deficiencies, and requiring quality assurance checks to ensure 
accurate reporting. 
 
 
 
 
 
30 OIG, CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More, March 2021, OEI-04-18-
00451, accessed at CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More on May 3, 2023. 
31 OIG, Long-Term Trends of Psychotropic Drug Use in Nursing Homes, November 2022, OEI-07-20-00500, accessed at 
Long-Term Trends of Psychotropic Drug Use in Nursing Homes on April 26, 2023.  
 
 
12  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
OIG is committed to and is investing in improving quality of care and safety for nursing 
home residents.   
This is the top priority of Inspector General Grimm, and OIG is building a nursing home strategy 
that targets problems with care, safety, and oversight.  OIGs PRO strategy centers on 
initiatives in three key areas:  
1.  Performance.  Understanding why poorly performing nursing homes fail and why good ones 
succeed. 
2.  Residents First.  Ensuring that nursing homes prioritize quality of care and quality of life for 
residents. 
3.  Oversight.  Ensuring that CMS and State Agencies detect and remedy problems quickly and 
effectively. 
OIG is investing substantial resources into our oversight and enforcement work to drive better 
outcomes for nursing home residents.  We have 26 audits and evaluations underway focused on 
nursing homes, and we have released 19 reports related to nursing home since January 2021.32  
We also prioritize nursing home cases on the enforcement side.  For example, OIG works in 
partnership with the Department of Justice on False Claims Act cases, including two recent cases 
involving allegations of materially substandard care by nursing home providers.  The San Miguel 
Villa case in California involved allegations of overuse of psychotropic drugs, excessive falls, 
resident-to-resident altercations, and other serious mental and physical harm to residents.  The 
Saratoga Center case in New York involved allegations of worthless nursing home care and 
misrepresentations in order to obtain operating certificates.  As part of the Saratoga Center 
settlement, OIG excluded culpable individuals and entities from participation in Federal health 
care programs.   
However, while more needs to be done, OIGs investments in this critical work are constrained 
by our resources.  With a FY 2023 enacted budget of $432.5 million, OIG has about 2 cents to 
oversee every $100 in HHS spending.  With current resources, we cannot keep up with the level 
of threats to HHS programs, nursing home residents and other patients, and taxpayer dollars.  
Every day, we make difficult choices on which cases we can and cant investigate, and which 
new audits and evaluations we can and cant start.  There are many areas of critical concern that 
we are not able to address each year.  The increased funding for Medicare and Medicaid 
oversight and enforcement in the Presidents FY 2024 Budget Request would significantly 
expand OIGs ability to conduct consequential oversight and enforcement, including to improve 
nursing homes for the people who need them and ensure that taxpayer dollars are being well 
spent on high-quality, safe nursing home care.  
 
32 Some of these audits and evaluations underway may produce more than one final report. 
 
13  Senate Special Committee on Aging                                                                                                          
May 18, 2023 
   
 
Conclusion 
Nursing home residents deserve and should expect high-quality care and safe living conditions.  
The persistence and seriousness of quality and safety problems in many nursing homes demands 
urgent attention and sustained action by stakeholders across Federal and State Governments, 
including program officials, Congress, and oversight entities, as well as the nursing home 
industry and care providers.  My testimony today focuses on one critical component of the safety 
system designed to protect nursing home residents: the State Agency survey process.  OIG is 
committed to driving positive change to strengthen this safety system as well as other aspects of 
nursing home performance, resident well-being, and oversight.  Nursing home care is a deeply 
challenging enterprise.  But with dedicated attention and action, nursing homes can be made 
better for residents who need them. 
Thank you for your ongoing leadership in this area and for affording OIG the opportunity to 
testify and discuss with you this vitally important topic.  I am happy to answer questions. 
 
 
14  Senate Special Committee on Aging                                                                                                          
May 18, 2023