Testimony Before the United States House of Representatives 
Committee on Energy and Commerce 
Subcommittee on Oversight and Investigations 
Examining Federal Efforts to Ensure Quality of Care 
and Resident Safety in Nursing Homes  
Testimony of: 
Ruth Ann Dorrill 
Regional Inspector General 
Office of Inspector General  
U.S. Department of Health and Human Services 
September 6, 2018 
10:15 a.m. 
Location: 2322 Rayburn House Office Building  Testimony of: 
Ruth Ann Dorrill 
Regional Inspector General 
   Office of Inspector General, U.S. Department of Health and Human Services 
 
Good morning, Chairman Harper, Ranking Member DeGette, and other distinguished 
Members of the Subcommittee on Oversight and Investigations.  Thank you for the opportunity 
to appear before you to discuss one of the most consequential issues in health care today:  
ensuring safe, quality care for residents in the Nations nursing homes.  
KEY TAKEAWAYS 
High-quality nursing homes can deliver enormous benefit as places of comfort and 
healing.  For Medicare beneficiaries, nursing homes provide a clinically managed recovery 
period after illness and injury that can make the difference between more good years ahead or a 
downward spiral.  For long-term-care residents and their families, often insured through 
Medicaid, nursing homes can provide responsible and much-needed care to those in fragile 
health.   
Many nursing homes provide excellent care and are diligent in protecting their residents.  
But an alarming number of residents are subject to costly medical harm, unsafe conditions, and 
abuse and neglect, much of it preventable with better practices and oversight. 
Nursing home care is a critical component of the continuum of care.  Quality and safety 
of care in nursing homes affect the provision and cost of care in other settings.  With an aging 
population and heightened focus on value-driven care, it is increasingly critical that Federal and 
State funds are used to purchase safe, high-quality care for vulnerable elderly and disabled 
patients.   
Decades of OIG work on nursing homes has uncovered widespread problems in 
providing safe, high-quality care and reporting problems when they occur.  We found that one in 
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  three Medicare residents in skilled nursing facilities experienced harm from the care provided, 
and half of these harm events were preventable.  In addition, nursing homes affected by disasters, 
such as hurricanes, often struggle to execute emergency plans and protect residents.  We have 
also raised concerns about failures to report potential cases of abuse and neglect.  Criminal and 
civil enforcement actions have uncovered misconduct and grossly substandard care.  State 
Agencies play a crucial role in ensuring quality and safety in nursing homes.  However, OIG has 
found mixed results in these agencies attention to nursing home deficiency corrections and 
complaints.     
Addressing the challenge of improving nursing home safety and quality of care requires 
strong leadership by CMS and serious, sustained commitment and effort by CMS, States, and the 
provider community.  
My testimony today will focus on significant OIG findings and recommendations regarding 
nursing home quality and safety in three key areas:  
  Harm to residents in nursing homes 
  Nursing home emergency preparedness 
  State Agency enforcement  
OVERVIEW OF ACCOUNTABILITY FOR NURSING HOME CARE AND OVERSIGHT 
According to CMS, Federal expenditures on nursing home care totaled $73 billion in 
2016, including $44 billion for Medicaid long-term care and $29 billion for Medicare post-acute 
and other skilled care.  Most nursing homes are certified to serve as both long-term-care facilities 
and skilled nursing facilities (SNFs).  Long-term-care facilities provide health-related care and 
services needed as a result of a mental or physical condition and may serve beneficiaries whose 
condition may not rise to the level of needing skilled nursing care.  SNFs provide skilled nursing 
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  care and rehabilitation services for residents who require such care because of injury, disability, 
or illness, typically following a hospital stay.  Meeting the needs of these two different 
populations, long-term care and skilled post-acute care, can complicate the effective 
management of facilities, and make oversight more challenging. 
CMS and States share responsibility for ensuring that nursing homes meet Federal 
requirements for quality and safety.  State Agencies are required by CMS to conduct a survey 
(inspection) of nursing homes at least every 15 months to certify each facilitys compliance.  
CMS oversees the State certification process and provides guidance regarding the survey process 
in its State Operations Manual (SOM) and Interpretive Guidelines.   
When State Agencies identify deficiencies during their surveys, nursing homes must 
submit correction plans, and State Agencies must verify that the facility corrected its 
deficiencies.  CMS and State Medicaid agencies may also take enforcement actions to address 
nursing home deficiencies, including imposing civil monetary penalties or terminating the 
nursing home from the Medicare Program, among other actions, as appropriate.  
OIG WORK ADDRESSING HARM TO RESIDENTS IN NURSING HOMES 
OIG found that that one in three SNF residents experienced adverse events during their 
nursing home stays, including infections, pressure ulcers, and misuse of medication.   
 
In a nation-wide review, OIG found that one-third of residents in SNFs experienced harm 
from the care provided in the nursing homes and more than half of the harm (adverse events) 
were preventable had the facilities provided better care.  This report was one in a decade-long 
OIG series regarding adverse events in various healthcare settings, including hospitals.   
The adverse events OIG identified in nursing homes resulted in a range of harmful 
outcomes for residents, including extended stays in the SNF, transfers to hospital emergency 
departments, and the need for life-sustaining intervention.  For 6 percent of the adverse events, 
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  the harm contributed to residents death.  Over half of the residents who experienced harm 
returned to a hospital for treatment, incurring millions of dollars in additional Medicare 
expenditures.1  
Some adverse events involved medical errors such as supplying incorrect medication, but 
most preventable harm resulted from daily substandard care, such as inadequate resident 
monitoring and failure or delay of necessary care.  For these adverse events, residents and 
families may not know that they were harmed, thinking instead that the residents suffering and 
decline were the result of their illness or conditions and inevitable.  Nursing home staff also 
failed to identify harm in some cases; for example, a number of adverse events started with 
dehydration, which can quickly result in kidney damage.  One nursing home resident died of 
cardiac arrest after progressive kidney failure that was not detected until the resident was 
awaiting discharge from the SNF.    
Most nursing home residents who died or were harmed from adverse events had multiple, 
complex co-morbidities that made their care challenging.  We found a wide range of adverse 
events not typically associated with nursing home care, such as internal bleeding due to 
medication.  While some events are widely recognized as risks for patients in nursing homes, 
such as falls and pressure ulcers, fewer nursing home staff may be aware of the risks posed by 
aspiration and blood clots, both of which harmed numerous patients in our study sample.  In our 
review of CMS and other guidance, we noted a tendency to focus narrowly on a subset of the 
most extreme harm events, many of which are rare, while missing the broad range of possible, 
more common harms that cause patient declines.  
                                                           
1 OIG, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries (OEI-06-11-00370), issued 
February 2014.  For this evaluation, OIG contracted with physicians who were experts in SNF care, surgery, cardiology, and 
infectious disease to conduct an extensive medical review of SNF stays.  
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  What is needed is a shift in thinking about the care provided in nursing homes.  Our work 
identifying adverse events in nursing homes and other settings showed that nursing home 
residents often had care needs similar to patients in hospitals, with residents sometimes seriously 
ill and impaired.  The hospital community has focused keenly on patient safety and, while still 
experiencing high harm rates in some categories, has made substantial changes in the provision 
of patient care and safety systems.  Sustained improvements in nursing homes will require a 
cultural shift that recognizes clinical harm and elevates reduction of harm as a priority for 
nursing home care.   
The foundation of OIGs recommendations to reduce harm is that CMS (and the Agency 
for Healthcare Research and Quality) raise awareness of adverse events in nursing homes (and 
other post-acute-care settings) with the same methods used to promote hospital safety.  
Broadening these and other patient safety improvement efforts to include the nursing home 
environment would ensure that safe care practices promoted in acute care hospitals extend to the 
critical periods of post-acute recovery and long-term care.  
To address the high rate of harm in nursing homes, OIG made two recommendations to 
CMS: (1) provide guidance to nursing homes about detecting and reducing harm to be included 
in facility Quality Assurance and Performance Improvement programs, and (2) instruct State 
Agencies to review facility practices for identifying and reducing adverse events, and link related 
deficiencies specifically to resident safety practices.  OIG determined that CMS fully 
implemented these recommendations on adverse events in SNFs as of August 2018.  It is too 
early to assess the effectiveness of CMSs actions in changing practices, but they hold promise 
for improving quality of care and reducing adverse events for nursing home residents.   
   
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  Meaningful improvement will rest on diligent execution by CMS and States, and 
continued evaluation of the effectiveness of these changes.      
OIG has raised concerns about failure to report allegations or potential cases of abuse and 
neglect of nursing home residents. 
 
It is both required and expected that nursing homes will report allegations of abuse or 
neglect to law enforcement or other appropriate agencies to ensure resident safety and protect 
victims of crimes.  However, OIG has documented serious deficiencies in reporting of abuse and 
neglect of nursing home patients dating back several years and continuing in our recent and 
ongoing work.  OIG found that, in 2012, nearly one in four nursing facilities did not have 
policies for reporting allegations of abuse or neglect and the subsequent results of an 
investigation, and facilities reported only half of allegations and investigation results as federally 
required.2  In response to OIG recommendations that CMS ensure nursing homes maintain 
policies for reporting allegations of abuse or neglect and report allegations in a timely manner, 
CMS revised the SOM in 2017 to instruct State Agency surveyors to assess facility policies and 
practices.  
Yet concerns about unreported abuse and neglect remain.  OIG reviewed hospital 
emergency room records from 2015 and 2016 for SNF residents sent to hospitals whose injuries 
may have been the result of potential abuse or neglect in the SNF.  In preliminary work, OIG 
found 134 such incidents across 33 States.  We further found that many of these incidents may 
not have been reported to law enforcement.  Pending completion of the full review, OIG alerted 
CMS that it had inadequate procedures to ensure that incidents of potential abuse and neglect at 
                                                           
2 OIG, Nursing Facilities' Compliance with Federal Regulations for Reporting Allegations of Abuse or Neglect (OEI-
07-13-00010), issued in August 2014.  
 
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  SNFs are properly identified and reported.3  OIG made immediate suggestions for improvement, 
including that CMS analyze Medicare claims (including matching claims for emergency room 
services to claims for SNF services) to identify incidents of potential abuse and neglect and take 
specific steps to enhance its ability to impose civil monetary penalties for reporting failures.   
OIG investigations and enforcement cases illustrate that nursing home harm can involve 
conduct by individual bad actors, as well facility and chain-wide conduct 
 
OIG investigates potential criminal conduct and pursues enforcement actions to hold 
accountable those who victimize residents of nursing homes.  In some cases, this involves 
criminal activity by bad actors.  For example, in 2018, the owner of a long-term-care facility was 
convicted of engaging in the physical and emotional abuse of one of its residents, following an 
investigation by OIG and our law enforcement partners.     
In other cases, facility-wide or chain-wide grossly substandard care can harm patients.  
Such cases may result in civil False Claims Act resolutions or administrative actions, such as 
exclusion.  Patient neglect, often due to understaffing, is a recurring issue in False Claims Act 
cases.  Other allegations that commonly arise in these cases include overmedication of nursing 
home residents, which may lead to falls and fractures; failure to follow physicians orders; and 
failure to provide a habitable living environment, with concerns including mold and roof leaks.   
NURSING HOME EMERGENCY PREPAREDNESS 
Despite enhanced guidance from CMS, nursing homes hit by disaster often struggle to 
execute emergency plans and protect residents.  
 
Nursing home residents and their families rely on facility administrators to plan and 
execute appropriate procedures during disasters.  Through years of visiting nursing homes after 
                                                           
3 OIG, Early Alert: The Centers for Medicare & Medicaid Services Has Inadequate Procedures to Ensure That 
Incidents of Potential Abuse or Neglect at SNFs Are Identified and Reported in Accordance With Applicable 
Requirements (A-01-17-00504), issued in August 2017. 
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  disasters, we have learned that facilities may ostensibly meet CMS guidelines prior to the 
disaster, but at the time of crisis fail to follow requirements and prior planning.  
In 2006, following Hurricanes Katrina, Rita, and others, OIG found that 94 percent of the 
Nations nursing homes met Federal regulations for emergency plans.  In visiting 20 nursing 
homes affected by hurricanes, however, we found that these plans were often not practical or up 
to date, and that during the crisis many administrators did not know how to navigate CMS 
guidelines and instructions from local authorities, and they often did not have adequate supplies, 
staffing, or transportation in place to care for residents.  These findings indicated that State 
Agency reviews of emergency plans were insufficient, and that the plans themselves were often 
not useful.4  In a followup study by OIG in 2012, after CMS had revised its guidance to include a 
suggested checklist for preparedness, we visited nursing homes affected by a range of disasters 
and found that only half had plans that included the checklist items.5 
For nursing homes that continued to operate without adequate emergency planning, the 
omissions were often a matter of common sense and the consequences for residents extreme. 
One nursing home that flooded during a storm had no plan for responding to floods, despite 
residing in a flood plain.  Other homes evacuated residents to facilities far away and without 
sufficient tracking or methods to ensure residents traveled with personal equipment and supplies, 
such as wheelchairs and medication.  Administrators from most nursing homes that OIG studied 
reported that residents experienced deteriorating health conditions, skin issues, and falls resulting 
in serious injury.  This occurred in nursing homes that evacuated and those that sheltered in 
place.  In some cases of evacuation, residents poor conditions necessitated hospitalization.  
                                                           
4 OIG, Nursing Home Emergency Preparedness and Response during Recent Hurricanes (OEI-06-06-00020), issued August 2006.  
5 OIG, Gaps Continue To Exist in Nursing Home Preparedness and Response After Disasters (OEI-06-09-00270), issued April 2012. 
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  Reports of nursing homes performance in the aftermath of the 2017 hurricanesincluding 
failures to evacuate residents or to provide safe sheltering in placeraise continued questions 
about the adequacy of emergency plans and their proper execution.  
OIG recommended that CMS require facilities to create effective emergency plans and 
take other specific actions in preparing for emergencies, such as improving staff training and 
communication with local authorities.  In 2016, CMS revised its emergency preparedness 
requirements for nursing homes and other healthcare facilities that participate in Medicare and 
Medicaid, to include specific provisions for planning, training, and communication.  State 
Agencies began assessing compliance for these provisions in November 2017.  OIG will 
continue to monitor these important provisions.   
STATE AGENCY ENFORCEMENT 
State Agencies play a critical role in ensuring the quality and safety of nursing homes, and 
OIG has found mixed results in State Agency attention to nursing home deficiencies. 
  
From 2015 to 2018, OIG completed audits of nine States to determine whether the State 
Agency took appropriate steps to verify that nursing facilities had corrected identified 
deficiencies.  OIG found that State Agencies in seven of nine States were not meeting 
requirements to verify correction of deficiencies.6  Lack of verification was evident in both 
serious and minor deficiencies.  For example, surveyors found that a nursing home failed to 
provide a resident oxygen per physician orders; the corrective action plan included additional 
training for nursing staff.  Yet the State Agency was unable to confirm that the staff involved 
attended the training.  
                                                           
6 OIGs State audits included Arizona (A-09-16-02013), Florida (A-04-17-08052), Kansas (A-07-1703218), Missouri (A-07-16-
03217), Nebraska (A-07-17-03224), New York (A-02-15-01024), North Carolina (A-04-17-02500), Oregon (A-09-16-02007), and 
Washington (A-09-13-02039). 
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  OIG also found that one of the nine States reviewed did not conduct standard surveys for 
approximately 40 percent of nursing homes within the required 15 months.  For seven States that 
did not meet requirements, OIG recommended that State Agencies improve verification 
processes, update internal systems, and for the one State, develop a correction plan to ensure the 
State conducts timely surveys.  OIG found that the remaining two States were in full compliance.  
Four of the States with recommendations implemented them, including the State not performing 
timely surveys.  Recommendations for three of the States remain outstanding, including two 
States that received our audit reports only within the last few months.  
Other OIG findings indicated that State Agency oversight of SNFs was not sufficient to 
ensure that SNFs developed and followed care and discharge plans for residents, as required.  
These care and discharge plans can be the linchpin of effective SNF care, helping to ensure that 
residents receive needed care, protecting residents from receiving unnecessary care, and assisting 
them in securing home- and community-based care and personal care services that can prevent 
them from re-entering the SNF or a hospital. 
OIG made extensive recommendations to CMS that the agency address this problem from 
multiple vantage points: (1) strengthen the regulations on care and discharge planning,  
(2) provide guidance to SNFs to improve planning, (3) increase surveyor efforts to identify 
problems, (4) link payments to meeting quality-of-care requirements, and (5) follow up on the 
SNFs that failed to meet requirements.7  In June 2018, OIG determined that CMS had fully 
implemented these recommendations.  We will continue to monitor the extent to which CMSs 
and State Agencies actions resolve the problems and improve care. 
State Agencies serve as front-line responders to address health and safety complaints in 
                                                           
7 OIG, Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Requirements (OEI-02-09-00201), issued 
February 2013.  
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  nursing homes.  State Agencies are responsible for onsite investigations of serious complaints of 
abuse and neglect.  OIG work in 2017 found that a few states fell short in timely investigations 
of the two most serious categories of complaints:  immediate jeopardy and high priority.8  
NEXT STEPS TO IMPROVE NURSING HOME QUALITY AND SAFETY 
Sustained commitment by CMS and continued collaboration among HHS, States, 
providers, and residents and their families will be critical to ensuring quality and safety. 
 
Quality nursing home care requires a partnership between a large and diverse group of 
Federal, State, and local entities.  Residents and their families are also critical stakeholders.  As 
the Federal agency charged with oversight of nursing home compliance and performance, CMS 
must demonstrate strong leadership of this group.  Effective collaboration will narrow gaps, 
provide better information and insight, and give greater assurance to residents and their families 
that they will receive high-quality care.  
As an example, following the 2011 OIG report Medicare Atypical Antipsychotic Drug 
Claims for Elderly Nursing Home Residents, CMS led an effort across HHS to correct improper 
drug prescribing and use in nursing homes.  OIG found that 83 percent of atypical antipsychotic 
drug claims were for elderly nursing home residents not diagnosed with a condition for which 
the Food and Drug Administration (FDA) had approved antipsychotic medications.  This 
supported a theory long held by residents advocates that nursing homes used atypical 
antipsychotic medications for off-label indications, with the purpose of controlling undesirable 
behavior. Both CMS and FDA took action to make changes to regulations and guidance, and 
CMS formed a public-private effort, the National Partnership to Improve Dementia Care in 
Nursing Homes, to engage providers, advocates, and families.  Subsequent CMS data show 
                                                           
8 OIG, A Few States Fell Short in Timely Investigations of the Most Serious Nursing Home Complaints: 2011-2015 (OEI-01-16-
00330), issued September 2017.  
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  substantial reductions in the use of these drugs among nursing home residents.  Given the 
number of stakeholders involved and the urgency of the problems, this type of public-private 
partnership would be useful for CMS to foster improvements across nursing home care.   
Further, it is critical that States remain active participants in the Federal-State partnership 
needed to oversee nursing homes.  States are on the front line in surveying nursing homes, 
identifying deficiencies, and verifying corrections.  States play an essential enforcement role 
when residents are victims of abuse and neglect.  States active participation in ensuring that 
nursing homes are providing safe, high-quality care is essential to improving patient outcomes 
and reducing adverse events. 
To protect nursing home residents, OIG will continue to assess CMS oversight and nursing 
home and State Agency performance, monitor the impact of program changes, and use our 
enforcement tools to address misconduct.  
 
Nursing home residents deserve and should expect high-quality care and to be safe from 
abuse and neglect.  OIG will continue to monitor whether CMSs recent actions to improve 
safety and quality produce the intended positive outcomes.  Moreover, OIG will follow up on its 
findings and recommendations to State Agencies to strengthen the effectiveness of their efforts.   
OIG has upcoming work that will assess multiple dimensions of nursing home quality 
and safety to protect beneficiaries.  These audits and evaluations follow up on past findings and 
recommendations, and examine new areas, such as nursing home compliance with new Life and 
Safety Code requirements, assessment of the accuracy and use of new nursing home staffing 
data, and the extent to which State Agencies investigate involuntary resident transfers and 
discharges.  
Allegations involving patient harm remain a top OIG enforcement priority.  OIG will 
continue to investigate potential criminal conduct and pursue administrative actions to hold 
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  accountable those who victimize residents of nursing homes.  In resolving False Claims Act 
cases, OIG may enter into quality of care corporate integrity agreements (CIAs) with nursing 
homes or chains that require actions to improve quality of care and safety.  OIG is currently 
monitoring quality of care CIAs covering more than 200 nursing homes.  OIG also collaborates 
closely with the 50 State Medicaid Fraud Control Units (MFCUs) that often have primary 
responsibility for enforcement of cases of abuse and neglect in nursing homes. 
CALL TO ACTION 
To provide guidance, support, and oversight of this industry is a grave and vitally 
important responsibility.  Government policies and leadership, Federal and State, can 
substantially affect residents experience and outcomes.  The problems I present today are not 
new, and they may seem daunting and intractable given the challenges and complexities of 
nursing home care.  But change is possible, and essential.  Nursing home care will always be a 
deeply challenging enterprise, but with dedicated attention and focus, CMS, States, and providers 
can do better.   
While CMS has taken steps to create a framework for correcting problems of resident 
harm and risk, all progress will be in the execution of that framework and the performance of 
CMS, States, and providers.  CMS must stay alert to the impact of policies and practices and 
promote meaningful, sustainable change.  OIG is committed to working with CMS as it takes 
action to address problems identified by our work, the Government Accountability Office, and 
others.   
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. 
 
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