SPECIAL 

EDUCATION

Additional Federal 

Actions Could Help 

Address Unique 

Challenges of 

Educating Children in 

Nursing Homes

Report to the Ranking Member, 

Committee on Education and the 

Workforce, House of Representatives

July 2014

GAO-14-585

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-585, a report to the 

Ranking Member, Committee on Education 

and the Workforce, House of Representatives

July 2014

SPECIAL EDUCATION

Additional Federal Actions Could Help Address

Unique Challenges of Educating Children in Nursing 

Homes

Why GAO Did This Study

Although nursing homes typically 

care for elderly or disabled adults, 

some children with disabilities also 

live in these homes. Because these 

children live away from their families, 

they may be less connected to local 

schools and may not receive the 

education benefits to which they are 

entitled. GAO was asked to study the 

delivery of education to children in 

nursing homes. 

GAO examined (1) the 

characteristics of children in nursing 

homes, (2) how such children are 

referred for and receive education,

(3) the challenges in delivering 

services to these children, and (4) 

monitoring of the education of 

children in nursing homes. GAO 

analyzed national nursing home data 

on children, surveyed all state 

special education directors, reviewed

relevant federal laws and 

regulations, and interviewed federal 

officials. GAO also visited nursing 

homes and school districts in three 

states selected to include a large 

percentage (42 percent) of children 

in nursing homes nationwide.

What GAO Recommends

GAO recommends that Education 

develop information sharing 

mechanisms for teachers of these 

children and that Education and HHS 

strengthen their monitoring efforts. 

Education agreed with the first 

recommendation. For the second, 

Education and HHS agreed to further 

collaborate, but expressed concerns 

about creating an oversight structure. 

However, GAO recommends using 

existing means of oversight.

What GAO Found

Children in nursing homes represent a relatively small group of children whose 

medically complex conditions often present unique educational challenges. Of 

the nearly 5,000 school-age children in nursing homes nationwide, about 40 

percent needed a feeding tube for nutrition and one-third needed oxygen therapy 

to help them breathe, according to GAO’s analysis of 2012 data—the most 

recent data available—from the Department of Health and Human Services 

(HHS). Consistent with 2012 data, GAO observed on recent site visits that these 

children also had conditions that affected learning. For example, many children 

GAO observed at the nursing homes were nonverbal and minimally responsive. 

Because of their complex medical needs, these children often stayed in nursing 

homes for long periods of time—about one-third of them for more than a year, 

according to GAO’s analysis of HHS data.

States GAO visited required nursing homes to refer children to school districts for 

educational services, and in nursing homes GAO visited, staff typically 

collaborated with school district officials to help them understand the children’s 

needs. Because of the children’s medical fragility, education services were 

delivered primarily in classrooms at the nursing homes or one-on-one (often

bedside), with a few children transported to local schools. Teachers that GAO 

observed used assistive technology and other methods to aid instruction. 

State and local school officials reported challenges to serving children living in 

nursing homes, including curricula development and teacher training. In GAO’s 

nationwide survey, 31 states indicated having adequate training for teachers was 

a challenge. According to school officials GAO interviewed, teachers may not be 

fully prepared to teach children with profound disabilities, and several teachers 

said they could benefit from the experiences of other teachers about how best to 

serve these children. While the Individuals with Disabilities Education Act (IDEA)

recognizes the importance of information sharing to improve educational results

for children, current technical assistance efforts supported by the Department of 

Education (Education) do not include mechanisms for teachers to share best 

practices about how to serve children with significant cognitive and multiple 

disabilities. Such information sharing about effective approaches and strategies 

could help teachers of children in nursing homes be more fully prepared to 

provide children with education commensurate with their unique needs.

Education and HHS have different, yet complementary, monitoring

responsibilities with respect to children in nursing homes. Education monitors 

state compliance with the IDEA requirement to provide a free appropriate public 

education in the least restrictive environment, and HHS oversees state nursing 

home inspections. Although collaboration between agencies with a common 

interest is a key practice, these agencies do not coordinate their monitoring 

efforts with respect to the education of these children. The relatively small size of 

this population makes it difficult for Education and states to gather information on 

whether these children receive education that meets IDEA requirements. 

Coordinated efforts between the two agencies could help close any potential 

gaps in Education’s monitoring and help ensure that all children in nursing homes 

receive an education.

View GAO-14-585. For more information, 

contact Melissa Emrey-Arras at (617) 788-

0534 or emreyarrasm@gao.gov.
Page i GAO-14-585 Education of Children in Nursing Homes 

Letter 1

Background 4

School-Age Children in Nursing Homes Are a Relatively Small, 

Medically Complex Population Who Often Stay in Homes for 

Long Periods of Time 12

Nursing Homes We Visited Referred Children for Special 

Education and Children Typically Received Educational 

Services On-Site 19

State and Local Officials Cite Challenges in Teaching and Paying 

for Special Education Services for Children in Nursing Homes 27

The Relatively Small, Dispersed Population of Children in Nursing 

Homes Complicates State and Federal Monitoring under IDEA 33

Conclusions 37

Recommendations 37

Agency Comments and Our Evaluation 38

Appendix I Objectives, Scope, and Methodology 41

Appendix II Number of School-Age (6 through 21) Children Living in 

Nursing Homes by State, Calendar Year 2012 47

Appendix III State Performance Report Indicators and Data Collection 

Topics Used by Education to Monitor Compliance with 

Part B of the Individuals with Disabilities Education Act 49

Data Collection Topics for States’ Direct Reporting of Special 

Education Monitoring Data 50

Appendix IV Comments from the Department of Education 51

Appendix V Comments from the Department of Health and Human Services 54

Appendix VI GAO Contact and Staff Acknowledgments 56

Contents
Page ii GAO-14-585 Education of Children in Nursing Homes 

Tables

Table 1: Key Roles of the Department of Education and the 

Centers for Medicare & Medicaid Services with Respect 

to Children in Nursing Homes 6

Table 2: Educational Environment Categories and Definitions 

used by Education in Individuals with Disabilities 

Education Act Monitoring 10

Table 3: Selected Medical Conditions of School-Age Children 

(6 through 21) in Nursing Homes, Calendar Year 2012 15

Table 4: Selected Special Medical Devices and Treatments of 

School-Age Children (6 through 21) in Nursing Homes, 

Calendar Year 2012 16

Table 5: Centers for Medicare & Medicaid Services Select Nursing 

Home Regulations and Guidance on Quality of Life and 

Activities 35

Table 6: Indicators and Definitions Used in State Performance 

Plans and Annual Performance Reports 49

Figures

FIgure 1: Key Federal, State, and Local Responsibilities under the 

Individuals with Disabilities Education Act 9

Figure 2: Total Number of School-Age Children (6 through 21) in 

Nursing Homes by Age Groupings, Calendar Year 2012 13

Figure 3: Distribution of Number of School-Age Children (6 

through 21) in Nursing Homes across States, Calendar 

Year 2012 14

Figure 4: Illustration of How Nursing Homes Assist School Districts 

in Referring Children for Special Education Services in 

the Nursing Homes We Visited 20

Figure 5: Where Children Living in Nursing Homes We Visited 

Receive Educational Services 22

Figure 6: Setting Where Educational Services Are Provided to 

Majority of Children Living in Nursing Homes, According 

to Survey of State Special Education Directors 23

Figure 7: Example of Sensory Box in a Lesson on Seasons for 

Children in Nursing Home We Visited 25

Figure 8: Teaching Challenges to Serving Children Living in 

Nursing Homes, According to Survey of State Special 

Education Directors 28
Page iii GAO-14-585 Education of Children in Nursing Homes 

Figure 9: Challenges Related to Cost and Availability of Special 

Education Service Providers for Children Living in 

Nursing Homes, According to Survey of State Special 

Education Directors 31

Abbreviations

ADA Americans with Disabilities Act

CMS Centers for Medicare & Medicaid Services

HHS Department of Health and Human Services

IDEA Individuals with Disabilities Education Act

IEP Individualized Education Program

MDS Minimum Data Set

SSA Social Security Act

SSI Supplemental Security Income

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Page 1 GAO-14-585 Education of Children in Nursing Homes 

441 G St. N.W.

Washington, DC 20548

July 16, 2014

The Honorable George Miller

Ranking Member

Committee on Education and the Workforce

House of Representatives

Dear Mr. Miller:

Although nursing homes are medical facilities that typically care for 

elderly or disabled adults, a relatively small number of children (less than 

half a percent of nursing home residents) also live in these facilities. 

Children with disabilities who live in nursing homes are a vulnerable 

population about whom little is known. States are required under the 

Individuals with Disabilities Education Act (IDEA), administered by the 

Department of Education (Education), to make available to all children 

with disabilities a free appropriate public education that emphasizes 

special education and related services that, among other things, are 

designed to meet the unique needs of each child.1 The law also requires 

states to ensure that children with disabilities are educated in the least 

restrictive environment, meaning, to the maximum extent appropriate, in 

classes with children who are not disabled.2

 1 20 U.S.C. § 1400(d)(1)(A). Related services are defined as transportation and such 

developmental, corrective, and other supportive services as may be required to assist a 

child with a disability to benefit from special education. Related services also include the 

early identification and assessment of disabling conditions in children. 20 U.S.C. 

§ 1401(26)(A).

Because these children live 

away from their families, and may enter nursing homes from a hospital or 

through a child welfare or health agency, there are concerns that these 

children may not always be connected to the educational system or 

receive the educational services required by IDEA. A September 2012 

Department of Justice (Justice) investigation of children living in Florida 

nursing homes brought attention to the issue of children living in nursing 

2 20 U.S.C. § 1412(a)(5).
Page 2 GAO-14-585 Education of Children in Nursing Homes 

homes.3

In light of these issues, the Ranking Member, House Committee on 

Education and the Workforce, asked for information on the educational 

services provided to children living in nursing homes. We examined (1) 

the characteristics of school-children who live in nursing homes, (2) how 

such children are referred for special education services and how 

services are delivered, (3) the challenges states and localities face in 

delivering special education services to these children in the least 

restrictive environment, and (4) the monitoring of the education of schoolage children in nursing homes.

Although the focus of the Florida investigation was the state’s

compliance with the Americans with Disabilities Act (ADA), the 

investigation noted that many children were offered less than 1 hour per 

day of educational activities, raising questions regarding how Education 

and states ensure that children living in nursing homes are receiving 

educational services required under IDEA.

We used multiple methodologies to address these objectives. To 

determine the characteristics of school-age children living in nursing 

homes, we analyzed administrative data on nursing home residents from 

the Department of Health and Human Services’ (HHS) Minimum Data Set 

(MDS) for calendar year 2012. The MDS is part of the federally mandated 

process for clinical assessment of all residents in Medicare- and 

Medicaid-certified nursing homes. The data set provides demographic 

information about patients residing in Medicare- and Medicaid-certified 

nursing homes as well as information on residents’ overall health and 

functionality. We used the MDS data to analyze the demographics of child 

residents as well as their health and functionality, such as active medical 

diagnoses, medical treatments, and duration of their residence in nursing 

homes. We assessed data reliability by reviewing existing information 

about the data system, conducting electronic testing, and interviewing 

federal and state health care agency officials. We determined that the 

data were sufficiently reliable for the purposes of this report. To obtain 

information on the monitoring of these children’s education and 

 3 The Department of Justice report assessed the state’s compliance with Title II of the 

Americans with Disabilities Act (ADA), as interpreted by the Supreme Court’s decision in 

Olmstead v. L.C., 527 U.S. 581 (1999), which requires public entities to ensure that 

individuals with disabilities receive services in the most integrated setting appropriate to 

their needs. The report found that Florida failed to meet its obligations under Title II of the 

ADA by unnecessarily institutionalizing hundreds of children with disabilities in nursing 

homes. Compliance with the ADA is beyond the scope of this report.
Page 3 GAO-14-585 Education of Children in Nursing Homes 

information about challenges, we conducted a nationwide web-based 

survey of state special education directors from September to December 

2013, and received responses from all 50 states and the District of 

Columbia. In addition, we reviewed relevant federal laws, regulations, and 

guidance and we interviewed federal officials at Education, HHS, and 

Justice. To obtain further information on children’s characteristics and to 

assess educational services and any challenges, we visited three 

states—California, New York, and Texas—that collectively accounted for 

42 percent of all children living in nursing homes in 2011.4 Within these 

states, we visited two or three nursing homes as well as school districts in 

which the nursing homes were located. Our criteria for selecting states 

included the number of school-age children in special education, number 

and percentages of pediatric residents in nursing homes, and geographic 

location. We also selected a mix of nursing homes that serve only 

pediatric patients and those that serve both pediatric and geriatric 

patients. During these visits, we interviewed nursing home administrators 

and social workers, school district officials, special education teachers, 

and parents of children living in nursing homes, and we observed the 

educational instruction for these children. For each state we visited, we 

also interviewed state and local special education officials as well as the 

health agencies responsible for conducting nursing home inspections. In 

visiting nursing homes, we focused on the education of children under 

IDEA, not compliance with the Americans with Disabilities Act, which was 

beyond the scope of this report.5 Finally, using our investigators, we 

posed undercover as the guardian of a child with complex medical 

conditions and called schools, school districts, and nursing homes.6

 4 GAO analysis of 2011 data from the Department of Health and Human Services’ (HHS) 

Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Data Compendium, 

2012, the latest compendium data available.

Our 

goal in making these undercover calls was to explore the kinds of 

responses a parent might receive when trying to obtain information about 

the educational services provided to children who lived in nursing homes. 

5 The Americans with Disabilities Act of 1990 prohibits discrimination against and ensures 

equal opportunity for persons with disabilities in employment, state and local government 

services, public accommodations, commercial facilities, and transportation. The 

Individuals with Disabilities Education Act (IDEA) generally provides funding to states and 

school districts for early intervention and special education and related services for 

children with disabilities.

6 We primarily called nursing homes that we visited as well as selected other nursing 

homes. 
Page 4 GAO-14-585 Education of Children in Nursing Homes 

In particular, we were interested in learning the educational setting 

suggested for the child, as well as the types of educational and related 

services the child might receive in a local school or the nursing home. 

(See app. I for more information on our methodology.)

We conducted this performance audit from March 2013 through July 2014 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. We conducted our related 

investigative work in accordance with standards prescribed by the Council 

of Inspectors General on Integrity and Efficiency.

Although nursing homes are medical facilities that typically care for

elderly or disabled adults, a relatively small number of children also live in 

these facilities. According to the Department of Health and Human 

Services (HHS), children represented less than a half a percent (0.2 

percent) of the more than 1.4 million nursing home residents in the United 

States as of December 31, 2011.7 Medicaid, the joint federal-state 

financing program for health care services for certain low-income 

individuals, is the primary payer for long-term services and supports, 

including nursing home care. Medicaid accounted for about $134 billion, 

or 61 percent, of spending for such long-term care services and supports 

for adults and children in 2012.8

 7 HHS’s Centers for Medicare & Medicaid Services’ Nursing Home Data Compendium, 

2012, which is the most recent data available.

In all states, Medicaid covers the cost of 

8 National Health Policy Forum, The Basics: National Spending for Long-Term Services 

and Supports (LTSS), 2012, (The George Washington University, March 27, 2014). This 

total for long-term care services and supports excludes Medicare payments. Medicare 

generally does not cover long-term care stays in nursing homes, although Medicare may 

cover skilled nursing facility (SNF) care for a limited time after a qualifying hospital 

inpatient stay.

Background

Children in Nursing 

Homes
Page 5 GAO-14-585 Education of Children in Nursing Homes 

nursing facility services for eligible children under age 21.9 To qualify for 

Medicaid coverage for nursing home care, individuals, including children, 

must meet financial and other eligibility criteria. Financial eligibility is 

commonly established by receipt of Supplemental Security Income 

(SSI),10 a federal program that provides cash benefits to low-income blind 

and disabled persons—including adults and children—who meet financial 

eligibility requirements and the program’s definition of disability.11

Education and the Centers for Medicare & Medicaid Services (CMS) 

within HHS both have monitoring and oversight responsibilities pertaining 

to the care of, and services provided to, children in nursing homes. Within 

Education, the Office of Special Education Programs is responsible for 

administering and monitoring IDEA, the primary federal law that

addresses the special education and related service needs of children 

with disabilities, from birth through age 21. In addition, CMS is 

responsible for oversight of the quality of services for residents of 

Medicare- and Medicaid-certified nursing homes. CMS contracts with 

state health agencies to inspect these nursing homes for compliance with 

program requirements laid out in the Social Security Act and in CMS 

regulations. CMS’s protocols for these state surveys assess not only 

nursing homes’ adherence to medical standards, but also quality of life 

standards. Finally, Education is also responsible for enforcing certain civil 

rights laws that could affect the provision of education to children in 

nursing homes.

Many 

children living in nursing homes may receive SSI. Generally, they receive 

no more than $30 a month in SSI benefits, though some states 

supplement that amount.

12

 9 Coverage for children in nursing homes is an optional service under Medicaid, although 

all states provide this service. 

10 Not all Supplemental Security Income (SSI) recipients automatically qualify for 

Medicaid. Under Section 1902(f) of the Social Security Act, a state may use more 

restrictive Medicaid eligibility standards than SSI’s standards, provided the standards are 

no more restrictive than those the state had in place as of January 1, 1972. 42 U.S.C. 

§ 1396a(f)

11 Eligibility may also be established by “spending down” family income on the child’s 

medical costs to meet the state-determined income eligibility limit.

12 The Department of Justice also enforces some civil rights laws that could affect these 

children. Compliance with civil rights laws, such as the Americans with Disabilities Act, is 

beyond the scope of this report. 

Monitoring and Oversight 

of Children in Nursing 

Homes
Page 6 GAO-14-585 Education of Children in Nursing Homes 

Table 1: Key Roles of the Department of Education and the Centers for Medicare & 

Medicaid Services with Respect to Children in Nursing Homes

Agency Responsibilities

Department of Education—Office of 

Special Education Programs

Monitors state compliance with Individuals with 

Disabilities Education Act (IDEA)a

Department of Health and Human 

Services—Centers for Medicare & 

Medicaid Services

for children 

with disabilities in all educational settings

Contracts with states to inspect Medicare- and 

Medicaid-certified nursing homes 

Source: GAO analysis of information provided by the Departments of Education and Health and Human Services. │ GAO-14-585

b

Note: In addition, the Department of Education’s Office for Civil Rights and the Department of 

Justice’s Civil Rights Division play a role in enforcing civil rights laws for education programs.

a Codified at 20 U.S.C. § 1400 et seq.

b The Social Security Act (SSA) establishes requirements that nursing homes must meet in order to 

participate in Medicare and Medicaid, including promoting residents’ quality of life. 42 U.S.C. 

§§ 1395i-3, 1396r.

In 2012, 5.8 million school-age children were served through IDEA. About 

$12.6 billion was appropriated for IDEA for fiscal year 2012. Education 

authorizes grants to states under IDEA, Part B, that enable school 

districts to provide services to students with disabilities aged 3 through 

21.13 Under IDEA, Part D, Education also supports efforts to, among other 

things, disseminate information and provide technical assistance in order 

to improve educational results for children with disabilities.14

An essential component of IDEA is that children with disabilities between 

the ages of 3 and 21 who meet IDEA’s eligibility requirements are entitled 

to a free appropriate public education in the least restrictive 

environment.15

 13 For the purposes of the grants to states program under section 611 of the Individuals 

with Disabilities Education Act (IDEA) (20 U.S.C. § 1411), Education identifies school-age 

children as those ages 6 to 21. Section 619 of IDEA (20 U.S.C. § 1419) authorizes grants 

for preschool programs serving children with disabilities ages three through five. In 

addition, IDEA Part C authorizes Education to provide grants to states for early 

intervention services for infants and toddlers with disabilities (20 U.S.C. §§ 1431-1444), 

but those children are a population broader than those within the scope of this report.

This requirement means that, to the maximum extent 

14 20 U.S.C. §§ 1451(a), 1453(b)(5).

15 In order to receive services under IDEA, a child must have a disability as defined in the 

Act. 20 U.S.C. § 1401(3). 

Special Education under 

IDEA
Page 7 GAO-14-585 Education of Children in Nursing Homes 

appropriate, these children are to be educated with other children who are 

not disabled.16 Further, special classes, separate schooling, or other 

removal of children with disabilities from the regular classroom can occur 

only when the nature or severity of the child’s disability is such that 

education in regular classes with the use of supplementary aids and 

services cannot be achieved satisfactorily. School districts are also 

required to provide a continuum of educational environments, including 

regular classrooms, special classrooms, special schools, and instruction 

in other environments such as residential facilities, home, or hospital 

settings, or correctional facilities.17 Students receive special education 

and related services, such as physical therapy, tailored to their needs 

based on an individualized education program (IEP).18

The first step in providing a free appropriate public education to children 

with disabilities is identifying them. Each state must have in effect policies 

and procedures to ensure that all children with disabilities residing in the 

state who are in need of special education and related services are 

identified, located, and evaluated. These policies and procedures are 

referred to in statute as “Child Find.”

An IEP is a written 

statement developed by a team of educational professionals, parents, 

and interested parties that includes a statement of the child’s present 

levels of academic achievement, goals for progress, and a statement of 

the special education and related services needed to attain those goals.

19

 16 20 U.S.C. § 1412(a)(5)(A). Least restrictive environment is determined individually for 

each child served under IDEA.

School districts are responsible 

under Child Find for identifying students who may have a disability in the 

district by engaging in activities such as distributing informational 

brochures, providing public service announcements, and staffing exhibits 

at community events. School districts are also responsible for evaluating 

children’s educational needs.

17 34 C.F.R. §§ 300.39(a)(1)(i), 300.115(b)(1).

18 In general, related services under IDEA are transportation and those developmental, 

corrective, and other supportive services needed to help a child with a disability to benefit 

from special education. 20 U.S.C. § 1401(26). Related services include speech-language 

pathology services, physical and occupational therapy, and school nurse services, among 

others. 

19 20 U.S.C. § 1412(a)(3). 
Page 8 GAO-14-585 Education of Children in Nursing Homes 

Special education funding is used, among other things, to employ special 

education teachers; related service providers (such as physical or 

occupational therapists); and special education administrators; as well as 

spending on special transportation services and nonpersonnel items 

(such as materials, supplies, and technological supports). As reported in 

2004, expenditures for special education nationwide for the 1999-2000 

school year—the latest national data available—were estimated to be 

about twice the average spent on students without disabilities, and the 

cost of providing services to a child with disabilities tends to escalate for 

children who have multiple disabilities.20 According to a recent report 

about special education in California, the average annual costs of 

educating a student with disabilities were more than double those of a 

nondisabled student in school year 2010-2011—approximately $22,300 

compared to $9,600, and some students require intensive interventions 

that cost notably more than $22,300 per year.21 The 2004 IDEA

reauthorization established high-cost funds—or risk pools—for high-need 

children with disabilities. States that decide to establish such a fund must 

reserve 10 percent of the IDEA funds reserved for other state activities to 

establish and maintain a risk pool to assist school districts serving highneed children.22

Education monitors state compliance with IDEA, including ensuring 

compliance with the requirement to provide students with a free, 

appropriate public education in the least restrictive environment—one of 

three priority areas for Education’s monitoring of IDEA.23

 20American Institutes for Research, Special Education Expenditure Project, What Are We 

Spending on Special Education Services in the United States, 1999-2000?, June 2004. 

The Special Education Expenditure Project reports provide the latest national data 

available on special education spending. 

In turn, states 

(generally state educational agencies) are required to monitor each of 

their school districts for IDEA compliance in both school and out-of-school 

educational environments and to report monitoring data to Education. 

States receive such required data from their school districts (see fig. 1).

21 Mac Taylor, Overview of Special Education in California, California Legislative Analyst’s 

Office, January 3, 2013. www.lao.ca.gov

22 20 U.S.C. § 1411(e)(3).

23 20 U.S.C. § 1416(a)(3). The other two priority areas for monitoring are state exercise of 

general supervisory authority—which includes child find and effective monitoring—and the 

disproportionate representation of racial and ethnic groups in special education and 

related services.

Monitoring States’

Compliance with IDEA
Page 9 GAO-14-585 Education of Children in Nursing Homes 

FIgure 1: Key Federal, State, and Local Responsibilities under the Individuals with 

Disabilities Education Act

a Under IDEA, the Department of Education may determine that a state needs intervention or 

substantial intervention, but we have combined these categories for simplicity.

b In addition to reporting to the Department of Education, states are required to report annually to the 

public on districts’ performance.

Education has two key mechanisms to collect and review information on 

states’ annual performance under IDEA: (1) direct reporting by states of 

detailed IDEA data through Education’s data system and (2) performance 

reports that states submit to Education, providing an overview of state 

performance that year. Through the data system, states report data on 

several topics—such as child counts, educational environment, and 
Page 10 GAO-14-585 Education of Children in Nursing Homes 

discipline—required under the law. 24 In the performance reports, states 

evaluate their IDEA performance against targets they set for each of 17

indicators.25

For both types of reporting, data on the environments in which children 

receive education are a key tool for state and federal monitoring of the 

least restrictive environment requirement under IDEA.

(See app. III for a list of IDEA data collections and 

performance report indicators.) Each year, Education receives these 

IDEA data and performance reports from states.

26

Table 2: Educational Environment Categories and Definitions used by Education in 

Individuals with Disabilities Education Act Monitoring

Educational 

environment categories cover a range of regular classroom and out-ofschool environments (see table 2).

Reporting category

Description of children with disabilities included 

in category

Inside regular classroom 80 

percent or more of the day

Children who receive special education and related 

services inside age-appropriate regular classrooms or 

community-based settings that include individuals with 

and without disabilities for 80 percent or more of the 

school day.

Inside regular classroom 40 

percent to 79 percent of the 

day

Children who receive special education and related 

services inside age-appropriate regular classrooms or 

community-based settings that include individuals with 

and without disabilities for no more than 79 percent but 

no less than 40 percent of the school day.

Inside regular classroom less 

than 40 percent of the day

Children who receive special education and related 

services inside age-appropriate regular classrooms or 

community-based settings that include individuals with 

and without disabilities for less than 40 percent of the 

school day.

 24 20 U.S.C. § 1418(a). States report these data in what is known as the “618 data 

collection,” using the Department of Education’s EDFacts data system. One of the topics 

on which states report data is children’s educational environments. 

25 These 17 indicators are designed to measure state performance on the three IDEA 

priority areas. IDEA requires states to report annually on the state’s performance under 

the state performance plan, which evaluates a state’s efforts to implement the 

requirements and purposes of IDEA and describes how the state will improve 

implementation. 20 U.S.C. § 1416(b). Some, but not all, of the indicators use data also 

included in states’ direct reporting of IDEA data. 

26 Least restrictive environment is determined on an individual basis by each child’s 

individualized education program team. 
Page 11 GAO-14-585 Education of Children in Nursing Homes 

Reporting category

Description of children with disabilities included 

in category

Parentally Placed in Private 

School

Children who have been enrolled by their parents or 

guardians in regular parochial or other private schools 

and whose basic education is paid through private 

resources and who receive special education and

related services at public expense from a local 

educational agency or intermediate educational unit 

under a service plan.

Correctional Facility Children receiving special education and related 

services in short-term detention facilities or correctional 

facilities.

Separate School Children with disabilities receiving special education 

and related services, at public expense, for greater 

than 50 percent of the school day in public or private 

separate day schools for students with disabilities. 

Homebound/Hospital Children receiving special education and related 

services in hospital programs or homebound 

programs. Does not include children whose parents 

have opted to home-school them and who receive 

special education at the public expense.

Residential Facility Children with disabilities receiving special education 

and related services, at public expense, for greater 

than 50 percent of the school day in public or private 

residential facilities, and who live at those facilities. 

Source: Documentation provided by the Department of Education. │ GAO-14-585

Education uses state performance reports and IDEA data—along with 

monitoring visits to states and other information27

 27 Education officials said they have conducted state monitoring visits in some form since 

1977, but conducted what they called verification and continuous improvement visits from 

1999 through 2011. Education is currently undertaking a new monitoring initiative and has 

most recently conducted pilot visits to select states as part of this initiative.

—to determine whether 

the state meets IDEA requirements or whether it needs assistance or 

intervention. Education also examines whether states have appropriate 

procedures in place to monitor school district compliance with IDEA. 

Education is currently undertaking a new initiative called Results-Driven 

Accountability, which is intended to increase focus on educational 

outcomes for students with disabilities. Education began soliciting 
Page 12 GAO-14-585 Education of Children in Nursing Homes 

stakeholder input on this effort in 2012 and states will begin submitting 

performance plans and reports under this new initiative in 2015.

28

Although children in nursing homes represent a relatively small group of 

children, their medically complex conditions make them a unique 

population to educate. While children in nursing homes include children 

as young as infants and toddlers, of all children staying in nursing homes 

at any time during calendar year 2012, about half—nearly 5,000 

children—were school-age children from ages 6 through 21, according to 

our analysis of CMS data.29 School-age children living in nursing homes, 

the focus of this study, accounted for less than half a percent of all 

children with disabilities under IDEA for school year 2011-2012.30

 28 In technical comments provided to GAO on this report, Education officials said that 

under this new initiative, their latest round of state determinations, issued on June 23, 

2014, focused on student outcomes in addition to compliance with requirements in the 

Individuals with Disabilities Education Act. Education will also require states to submit 

State Systematic Improvement Plans beginning in 2015.

There 

29 A total of nearly 10,000 children lived in nursing homes at any time during calendar year 

2012. Of those children, infants and toddlers aged birth to 2 years accounted for nearly 

half, or 4,650, children. Children aged 3 through 5 years accounted for nearly 5 percent, or 

470 of children living in nursing homes in calendar year 2012. These figures are based on 

our analysis of CMS’s Minimum Data Set (MDS) for calendar year 2012. 

30 In the 2011-2012 school year, there were approximately 5.6 million children aged 6 

through 21 years served under IDEA Part B, accounting for nearly 10 percent of children 

in that age group enrolled in school. The number of children served under IDEA is a pointin-time count in school-year 2011-2012, whereas our CMS analysis is an annual 

cumulative total anytime during calendar year 2012.

School-Age Children 

in Nursing Homes Are 

a Relatively Small, 

Medically Complex 

Population Who Often 

Stay in Homes for 

Long Periods of Time

School-Age Children in 

Nursing Homes Are a 

Small, Medically Complex 

Population
Page 13 GAO-14-585 Education of Children in Nursing Homes 

was almost an even split between the number of school-age children in 

nursing homes who were aged 6 through18 years old—the age range 

generally considered as school age—and those who were 19 through 

21.31

Figure 2: Total Number of School-Age Children (6 through 21) in Nursing Homes by 

Age Groupings, Calendar Year 2012

(See fig. 2).

These children were spread out among nursing homes throughout the 

country. In calendar year 2012, eight states had 10 or fewer children 

living in nursing homes, according to our analysis of CMS data. Seven 

states, which tended to have the largest state populations, had more than 

200 children in nursing homes, ranging from 210 in Indiana to 908 

children in California. (See fig. 3.) (For individual state breakouts, see 

app. II.) In all of the nursing homes we visited, staff told us the children 

who lived in their home typically were residents of their state.

 31 We are including children over the age of 18 in this study because services under IDEA 

are generally available to eligible students ages 3 through 21.
Page 14 GAO-14-585 Education of Children in Nursing Homes 

Figure 3: Distribution of Number of School-Age Children (6 through 21) in Nursing 

Homes across States, Calendar Year 2012

School-age children living in nursing homes were often medically fragile 

and had complex, chronic medical conditions, with nearly 71 percent 

having at least two active disease diagnoses, according to our analysis of 

CMS data.32

 32 The data field used in this analysis—”Active Disease Diagnosis”—requires a diagnosis 

documented by a physician (or by a nurse practitioner, physician assistant, or clinical 

nurse specialist if allowable under state licensure laws) in the last 60 days of an 

assessment. Once the diagnosis is identified, it must be determined if the disease is active 

within the last 7 days. Our analysis tested all assessment records for each child to 

determine whether the child had been diagnosed with a disease at any point of time from 

date of admission to a cut-off date of December 31, 2012. 

For example, nearly 37 percent of the children had seizures 

and 21 percent had cerebral palsy, both of which may be caused by brain 

abnormalities and result in conditions that range in severity from 

disabling, to ones that can be controlled with medications and supportive 

treatments. (See table 3.) Nursing home staff described children in the 

homes as having chronic conditions often resulting from genetic 
Page 15 GAO-14-585 Education of Children in Nursing Homes 

disorders, birth trauma, a catastrophic accident, or the onset of a disease 

such as cancer.

Table 3: Selected Medical Conditions of School-Age Children (6 through 21) in 

Nursing Homes, Calendar Year 2012

Medical Conditions

Number of 

Children a Percent of Total

Seizure or Epilepsy: chronic neurological disorder 

characterized by recurrent, unprovoked seizures 

b

1,764 37 

Cerebral Palsy: group of neurological disorders that 

appear in infancy or early childhood and permanently 

affect body movement and muscle coordination 

1,021 21

Respiratory Failure: condition where not enough 

oxygen passes from lungs into blood or if the lungs 

cannot remove carbon dioxide from blood

621 13

Quadriplegia: paralysis of arms and legs 502 10

Comatose: state in which neither arousal 

(wakefulness, alertness) nor awareness exists 

317 7

Traumatic Brain Injury: sudden trauma that causes 

damage to the brain

297 6

Source: GAO analysis of Centers for Medicare & Medicaid Services’ Minimum Data Set 3.0. │ GAO-14-585

a The Individuals with Disabilities Education Act requires that states and school districts make 

available a free appropriate public education to all children with disabilities.

b Percents do not add up to a 100 percent because children could have more than one diagnosis.

In addition, children in nursing homes often needed special treatments or 

procedures to help them breathe and to prevent them from choking. For 

example, 25 percent of the children required the use of a tracheostomy 

tube and 32 percent needed oxygen therapy to help breathe, according to 

our analysis of CMS data.33

 33 A tracheostomy or trach tube is usually placed through the opening of the neck into the 

trachea (windpipe) to provide an airway and to remove secretions from the lungs. A 

tracheotomy may be done if the airway is blocked or because of a condition that makes it 

hard to breathe, such as 

(See table 4.) In nearly all of the nursing 

homes we visited, staff told us that their children had tracheostomy tubes 

and/or needed respiratory care to support breathing, as well as frequent 

suctioning to remove excess fluids and saliva to prevent choking. Staff at 

two nursing homes said that the children are prone to infections, which 

paralysis of the muscles that affect swallowing or severe neck or 

mouth injuries.
Page 16 GAO-14-585 Education of Children in Nursing Homes 

could cause children to be isolated in their room without a roommate and 

require all services to be brought to the room.

Table 4: Selected Special Medical Devices and Treatments of School-Age Children 

(6 through 21) in Nursing Homes, Calendar Year 2012

Special Treatments

Number of 

Children

Percent 

of Total 

Oxygen therapy: continuous or intermittent oxygen 

administered via mask 1,517 32

Suctioning: removal of secretions (phlegm or mucus) or 

drainage from the patient’s airway (trachea) or other part 

of the body 

1,310 27

Tracheostomy Care: cleaning of trach tube used to provide 

an airway to help support breathing and secretion from the 

lungs

1,214 25

Ventilator: a machine used to support breathing by 

providing oxygen to lungs and removing carbon dioxide

681 14

Source: GAO analysis of Centers for Medicare & Medicaid Services’ Minimum Data Set 3.0. │ GAO-14-585

Note: Percents do not add up to a 100 percent because some children require the use of more than 

one medical device or treatment.

Because of their medical conditions, nearly 80 percent of the children 

needed extensive help or were totally dependent in carrying out at least 

one activity of daily living, according to our analysis of CMS data. For 

example, 72 percent could not use the toilet without extensive assistance 

from someone else; 69 percent could not move from one location to 

another (e.g., from bed to standing); and about 69 percent needed 

wheelchairs to move around. Further, 43 percent of the children required 

a feeding tube (such as a gastrostomy tube) to provide food, nutritional 

substances, fluids, or medicine into their bodies.

Compounding their complex medical needs, these children often also had 

conditions that affect learning. For example, about 21 percent of the 

children had at least one condition related to intellectual disability or 

developmental delay, such as Down syndrome; autism; epilepsy; or other 

intellectual disabilities, such as those resulting from other medical 

conditions incurred during pregnancy or birth. Further, many of the 

children also had difficulties communicating. Half of the children had 

difficulties being understood because they could not speak or their words 

were slurred or mumbled, according to our analysis of CMS data. In 
Page 17 GAO-14-585 Education of Children in Nursing Homes 

addition, half of the children also had difficulties understanding others.34

Because of the severity and costliness of their medical needs, children in 

nursing homes are likely to be eligible for Medicaid. In the nursing homes 

we visited, almost all of the children were on Medicaid, according to 

nursing home staff. Several nursing homes told us the children often 

become eligible for Medicaid because their families have low-incomes or 

they have reached the limit for services or number of days under private 

insurance because of the costliness of the child’s medical condition. Staff 

from two nursing homes also told us that the children were generally from 

low-income families and that the families’ income levels, according to one 

nursing home, may have diminished as a result of the child’s medical 

costs. According to nursing home staff in three of the nursing homes we 

visited, some children were also eligible for Supplemental Security 

Income (SSI) payments for their disability.

Many children we observed at the nursing homes were non-verbal; were 

minimally responsive to others; and needed to use hand or arm gestures, 

eye movements, or assistive devices (such as switch buttons) to help 

them communicate. Several nursing home staff told us that it was difficult 

to know if many of the children were absorbing what they were being 

taught because they didn’t show any response.

35

Because of the complexity of their medical needs, these children often 

stayed in nursing homes for long periods of time, although the duration 

varied by child. More than one-third—nearly 1,776 school-age children—

had lived in a nursing home for more than 1 year, according to our 

analysis of CMS data. Of those children, 464 had lived in nursing homes

for more than 4 years. In one nursing home, staff told us the children in 

their facility fell into two categories—children staying for periods of less 

 34 According to the CMS definition, “difficulty understanding others” may be described in 

one of the following ways: (1) misses some part or intent of the message but 

comprehends most conversation; (2) sometimes understands by responding adequately to 

simple, direct communication only; and (3) rarely or never understands. 

35 SSI payments are limited to $30 monthly when a child is in a medical facility where 

health insurance pays for his or her care.

School-Age Children in 

Nursing Homes Often 

Stayed for Extended 

Periods of Time and Level 

of Parental Involvement 

Varied
Page 18 GAO-14-585 Education of Children in Nursing Homes 

than a year and those spending most of their childhood in nursing 

homes.36

In some instances, these children were disconnected from their families, 

while in other instances parents were very involved, with frequent visits to 

and communication with the nursing homes, according to nursing homes 

we visited. Nursing home staff told us that for some parents, their jobs, 

the need to care for other siblings, or language barriers make it difficult to 

regularly visit their child or communicate with the nursing home. Staff at 

one nursing home we visited told us that half of the parents do not visit 

regularly, on holidays, or for major life events. In nearly all of the nursing 

homes, a small number of children were also under the supervision of 

child welfare authorities. According to nursing home staff, in some cases, 

the parents retained their rights to make decisions for their children 

subject to court approval, while in others a social worker represented the 

child’s interests because of parental neglect or abuse. In one nursing 

home, many children were involved with child welfare authorities because 

of previous abuse or neglect. Further, staff from one nursing home told us 

that child protective services may close a case once a child is admitted to 

a nursing home because it is considered a safe location. In other 

instances, parents were very involved in their children’s daily lives. For 

example, nursing home staff described other parents as highly involved 

with their children, either frequently visiting their child and/or regularly 

communicating with the nursing home. For example, in one nursing home 

we visited, the parents of one child visited their child twice a week even 

though they lived out of state. In another nursing home, parents 

organized successfully to keep their children from being relocated to other 

nursing homes because of concerns about how relocation would have 

affected the continuity of care their children received.

 36 According to staff at several nursing homes we visited, school-age children can live in a 

pediatric nursing home or in a mixed geriatric and pediatric nursing home. If children need 

further care after they age out of the pediatric unit (typically at 18 or 21), they may be 

transferred to nursing homes that care for geriatric patients, or remain at their current 

nursing home.
Page 19 GAO-14-585 Education of Children in Nursing Homes 

When a child is admitted to a nursing home, all three states we visited 

had regulations or other guidance requiring nursing homes to refer 

children to the appropriate school districts for educational services,37 and 

nursing home staff we spoke with in those states often collaborated with 

school district officials to notify them about the children and help them 

understand the child’s needs. (See fig. 4.) For example, Texas—which 

has a relatively high number of children in nursing homes—requires 

nursing home staff to notify the school district within 3 days of a child 

being admitted. Texas also requires nursing homes to share with the 

school district the child’s educational history, vision and hearing 

screenings, and educational assessments within 14 days of admission to 

the nursing home. The state further allows nursing home staff to provide 

input into the child’s IEP, which describes special education services the 

child is to receive. The state also requires nursing homes to document 

educational objectives in the child’s nursing home care plan, which 

describes the services the nursing home will provide to maintain the 

resident’s well-being.38

 37 In the three states we visited, written requirements obligated the nursing homes to refer 

pediatric residents to the school district for educational services. In our survey of state 

special education directors, we found that the Child Find requirement under IDEA and the 

responsibility for providing special education services was divided generally evenly among 

the states between the school district where the child’s family resides and the school 

district where the nursing home is located. For example, in New York, the school district in 

which a child’s family resides is responsible, while in California and Texas, responsibility 

lies with the school district in which the nursing home is located. 

California, which has the highest concentration of 

38 Under federal requirements for nursing homes receiving payment under Medicare or 

Medicaid, nursing homes must develop a comprehensive care plan for each resident that 

includes the services necessary for the resident to attain or maintain the highest 

practicable physical, mental, and psychosocial well-being.

Nursing Homes We 

Visited Referred 

Children for Special 

Education and 

Children Typically 

Received Educational 

Services On-Site

Nursing Home Staff on 

Our Site Visits 

Coordinated with School 

Districts to Refer Children 

for Special Education 

Services
Page 20 GAO-14-585 Education of Children in Nursing Homes 

children in nursing homes, also has requirements that the nursing homes 

and school districts collaborate to develop and implement the IEP and 

incorporate the activities identified in the IEP into the child’s care plan. In 

the nursing homes we visited, the social worker on staff typically carried 

out the responsibilities for collaborating with the school districts; and in 

some cases the teacher on-site was also involved in this process. 

Further, some of the nursing home officials we spoke to said that they 

held regular meetings with the teacher to discuss each child’s medical 

needs and care.

Figure 4: Illustration of How Nursing Homes Assist School Districts in Referring 

Children for Special Education Services in the Nursing Homes We Visited

According to officials in the nursing homes we visited, because of their 

medical fragility, children primarily received educational services on-site 

at the nursing homes. (See fig. 5). While instruction was generally 

conducted in classrooms in the nursing homes, some children received 

one-on-one tutoring, often bedside, when the children were too fragile to 

be moved. A child’s physician made the determination as to whether the 

child was too fragile to go to a local school and considered factors such 

as the child’s ventilator dependency, frequency of seizures, tolerance for 

being on a bus and sitting for extended periods of time, and the local 

schools’ capacity to meet the medical needs of the child, according to 

school administrators and nursing home staff. For example, in one 

nursing home, children who had unstable respiratory systems received 

education in the nursing home because they needed to have a respiratory 

therapist nearby. When our undercover investigator inquired about the 

Medical Condition Largely 

Drove Educational Setting 

and Services in Nursing 

Homes Visited
Page 21 GAO-14-585 Education of Children in Nursing Homes 

educational environment for a child living in a nursing home, staff within 

nearly all the nursing homes and school districts explained that the setting 

would depend on the child’s medical stability and individual needs.39

 39 Our investigator made calls to nursing homes and school districts posing as a child’s 

guardian planning to admit the child to a nursing home to inquire about where educational 

services would be delivered and the types of educational services that would be provided.

See appendix I for more information.

These responses corroborated information we heard on site visits about a 

child’s medical fragility determining the setting of the child’s educational 

services. Further, some of the parents we spoke with preferred having 

their child receive education and other services in the nursing home. One 

parent whose child suffered from seizures told us he did not feel 

comfortable having his child away from the medical team at the nursing 

home, while another parent, whose child had previously attended school 

outside the nursing home, said that her child had cried every day at 

school because sitting was painful for him. The child currently receives 

education services in the nursing home. These concerns regarding the 

well-being of children are consistent with our survey findings in which 31 

states considered balancing children’s safety needs while providing 

education in the least restrictive environment a challenge. Some nursing 

homes and school district officials we interviewed said that the school 

district’s capacity to attend to the child’s medical needs while in school 

was also weighed. For example, several nursing home officials said some 

schools do not have staff trained to handle tracheostomy suctioning; in 

contrast, a few school districts we visited had nurses or other staff trained 

to provide for tracheostomy care while children attended school.
Page 22 GAO-14-585 Education of Children in Nursing Homes 

Figure 5: Where Children Living in Nursing Homes We Visited Receive Educational Services

In our survey of state special education directors, officials also reported 

that children in nursing homes primarily receive educational services in 

nursing homes. Specifically, 16 state special education directors indicated 

the majority of children living in nursing homes in their states are 

educated in the nursing homes through individual tutoring or class 

instruction (see fig. 6). Interestingly, however, nearly half (22) of states 

reported that they did not know where such children receive educational 

services, possibly indicating the population of children in nursing homes 

was small and difficult to track at the state level.
Page 23 GAO-14-585 Education of Children in Nursing Homes 

Figure 6: Setting Where Educational Services Are Provided to Majority of Children 

Living in Nursing Homes, According to Survey of State Special Education Directors

Note: States were asked to check one survey response. Six states responded “other” setting, but 

most indicated in their comments that either they do not have children residing in nursing homes or 

the children received educational services across the settings.

A child’s medical fragility also affected the amount of instruction time they 

received, according to several teachers we interviewed. For example, in 

the nursing homes we visited, children who were able to handle 

instruction in a classroom generally received from 1 to 4 hours a day. In 

one of the facilities we visited, school district officials told us the children 

must be able to tolerate sitting for at least 30 minutes in order to 

participate in class instruction. In addition, teachers used some instruction 

time getting the child ready to learn. For example, some teachers said 

that compressing children’s joints and massaging their arms and legs to 

increase blood circulation helped stimulate their brains and prepare them 

for the day’s instruction. Similarly, in some nursing homes, children were 

pulled out of class for IDEA-related services—such as physical, 

occupational, and speech therapies—or providers came into the 

classroom to provide such services during instruction time.40

 40 Under IDEA, related services may be provided to assist a child with a disability to 

benefit from special education. Examples of such services include physical and 

occupational therapy; recreation, including therapeutic recreation; orientation and mobility 

services; and medical services for diagnostic or evaluation purposes. Related services 

also include school health services and school nurse services, social work services in 

schools, and parent counseling and training. 20 U.S.C. § 1401(26), 34 C.F.R. § 300.34(a).

Some 
Page 24 GAO-14-585 Education of Children in Nursing Homes 

teachers also said that many children are unable to be out of bed more 

than a few hours a day and may not be alert for longer periods of time. In 

nearly every nursing home we visited, we observed children who 

appeared to be asleep or had their eyes closed while instruction was 

being delivered. Further, some teachers we spoke with said that nursing 

home staff or teachers regularly check diapers and perform tracheostomy 

suctioning. Children with less tolerance for classroom instruction were 

typically provided with individual tutoring that lasted anywhere from 30 

minutes to 2 hours a day in nursing homes we visited. We also observed 

children receiving individual tutoring because of illnesses, such as the flu. 

In our survey of state directors, 18 reported that their states had a 

minimum number of required hours of instruction for children in nursing 

homes, with the majority requiring between 4 and 10 hours per week. 

Several teachers we interviewed noted they followed the state or local 

requirements for hours of instruction time. For example, children receiving 

educational services through the tutoring program at one nursing home 

received 1 hour or 2 hours depending on their age, per guidance from the 

school district.

According to several teachers and local school administrators, teachers 

had to modify the schools’ curriculum significantly, with emphasis on 

sensory methods for conveying the lessons, because of the children’s 

cognitive and functioning needs. For example, in one nursing home, a 14-

year-old child functioning at a pre-kindergarten instructional level had a 

short-term educational goal of writing five lower-case letters with 

assistance and a long-term educational goal of holding a marker without 

assistance. An 18-year-old child had a short-term educational objective of 

touching the correct color when presented with two choices of color 

cards. Because many of the children were nonverbal and nonresponsive 

or minimally responsive to instruction, teachers we observed used 

sensory and assistive technology to aid instruction.41

 41 Assistive technology is any item, piece of equipment, or product system that is used to 

increase, maintain, or improve functional capabilities of a child with a disability. 

For example, some 

teachers used sensory boxes with objects that corresponded to lessons 

for the children to touch (see fig. 7), and another used multiple sensory 

means to teach eighth-grade earth science (see sidebar 1 for description 

of instruction).
Page 25 GAO-14-585 Education of Children in Nursing Homes 

Figure 7: Example of Sensory Box in a Lesson on Seasons for Children in Nursing 

Home We Visited

1. Example of Classroom Lesson Using Sensory Tools Observed 

at Nursing Facility

As a teacher read a story about rain, she moved around to each child to 

stimulate their senses and simulate actions from the book. For example, 

she:

• sprayed water on their arms or cheeks to simulate rain,

• brushed leaves on children’s arms, and

• turned lights off to simulate night time and played night sounds.

Source: GAO observation of teaching at a nursing home │ GAO-14-585

Note: This lesson was modified from an eighth-grade science curriculum. In earth science, eighthgraders in Texas are expected to learn how interactions in solar, weather, and ocean systems create 

changes in weather patterns and climate. Students are expected to identify how global patterns of 

atmospheric movement influence local weather using weather maps that show high and low 

pressures and fronts, and identify the role of the oceans in the formation of weather systems such as 

hurricanes.
Page 26 GAO-14-585 Education of Children in Nursing Homes 

Several teachers used an adaptive switch, which may look like a button, 

to elicit a response from the children (see sidebar 2 for description) and a 

few special education providers, such as vision or speech therapists, 

used a retinal (eye-gazing) communication device to enable children to 

communicate with their eyes. 

2. Example of Tutoring Using Assistive Technology

The child was sitting in a wheelchair, was nonverbal, and did not move 

his body or eyes. The subject of the lesson was Fall, and the teacher 

described Fall and showed the child pictures of pumpkins and trees. 

The teacher put a picture of a pumpkin into the child’s hand and guided 

the hand to place the picture on a piece of paper (hand-over-hand 

technique in which the teacher guides the child’s hand). To simulate 

Fall weather, the teacher turned a fan on so the child could feel a cool 

breeze on his face. The teacher also placed the child’s hand around an 

adaptive switch, helped him activate the fan, and then asked the child 

to try to turn the fan on himself. A few minutes later, the child held the 

button down on his own, turning the fan on. The teacher repeated this 

activity with a recording of his voice, and after some time, the child 

pushed the switch independently. Each time the child pushed the 

switch, we observed his eyes open very wide, his head move slowly 

one way, and his other arm move slightly. We observed the instruction 

for 25 minutes.

Source: GAO observation of teaching at a nursing home │ GAO-14-585

Some children with relatively higher functional and cognitive capabilities 

received more advanced instruction. In one nursing home, for example, 

the teacher read books aloud to an 18-year-old with the cognitive level of 

a fifth grader, and had the child read back to her.

While most children received education services in the nursing homes, a 

small number of children attended local schools where they were either 

transported by bus or ambulance. Children must not only be medically 

stable, but must also be able to tolerate a longer school day and a 

nonhospital environment—such as normal odors and air quality—as one 

teacher told us. One nursing home administrator said the children must 

be up at 5:30 a.m. to be ready for the buses at 7:30 a.m. The teacher at 

the local school said the bus ride to school can overload the children’s 

senses—as a result, she said, some children are crying when they arrive 

at school while others are asleep. In one local school’s classroom, we 
Page 27 GAO-14-585 Education of Children in Nursing Homes 

observed children from the nursing home who were educated in a selfcontained classroom. We observed them spending time out of their 

wheelchairs in a multi-sensory room. One child was lying on a mat 

exploring lights and chimes. Another child was in a swing as the teacher 

and teacher’s aide swung her back and forth in order to simulate 

movement for the child who could not use her limbs. In another local 

school, we observed a child from the nursing home in a class with other 

children with moderate to severe disabilities listening to the teacher read 

a story aloud.

In our national survey of state special education directors and in 

discussions with teachers and school officials we visited, officials cited 

curricula development and teacher preparation as challenges confronting 

teachers who provide education for children with complex medical needs 

living in nursing homes (see fig. 8).

State and Local 

Officials Cite 

Challenges in 

Teaching and Paying 

for Special Education 

Services for Children 

in Nursing Homes

Officials Cited Developing 

Curriculum and Teacher 

Preparation as Challenges
Page 28 GAO-14-585 Education of Children in Nursing Homes 

Figure 8: Teaching Challenges to Serving Children Living in Nursing Homes, According to Survey of State Special Education 

Directors

Note: A number of states responded “don’t know” to the survey questions on challenges to providing 

special education services to children living in nursing homes, possibly indicating the population of 

children in nursing homes was small and difficult to track at the state level.

For 29 states, developing curricula that effectively fits the needs of these 

students was a challenge, a sentiment echoed by several teachers and 

school administrators we spoke to during our site visits. For example, 

during one of our visits to nursing homes, one teacher with substantial 

teaching experience said that for years she struggled to find curricula that 

fit the needs of children with profound disabilities. Several teachers said 

that it is often difficult to determine what information the children are 

absorbing given the severity of their medical and cognitive impairments. 

Some local education officials questioned whether it would be more 

appropriate to focus instruction on functional life skills, such as learning to 

Developing Curricula
Page 29 GAO-14-585 Education of Children in Nursing Homes 

feed themselves independently, rather than on a grade-level curriculum,42

such as a modified version of algebra. Education is funding efforts to 

develop curriculum resources for teachers of children with the most 

significant cognitive disabilities.43

For 31 states, having adequate training for teachers was a challenge. 

Training and preparation was geared to teaching the broader special 

education population, rather than working with children with profound 

disabilities and complex medical conditions, according to some school

district officials and teachers we interviewed. Further, some school 

officials we interviewed indicated teachers may not be fully prepared to 

teach this unique population, raising questions about the extent to which 

they can provide such children with special education services designed 

to meet the individualized needs of each child. For example, in New York, 

a school official said teachers sometimes arrive at the nursing home 

without sufficient preparation in how to work with the children with 

complex medical and cognitive needs. Likewise, in California, another 

school official said that although their teachers were certified to teach 

children with moderate and severe disabilities, this certification did not 

adequately prepare teachers for teaching children with profound 

Such resources are expected to be 

available by the 2014-2015 school year.

 42 IDEA requires that IEPs include what is needed for the child to make progress toward 

the general education curriculum. 20 U.S.C. § 1414(d)(1)(A)(i)(IV)(bb). The Elementary 

and Secondary Education Act, as amended, requires that children with disabilities be 

included in statewide assessments and requires all students to be measured against 

academic achievement standards established by the states. 20 U.S.C. 

§ 6311(b)(3)(C)(ix)(II). Students with severe cognitive disabilities may be assessed using 

alternate assessments that measure their achievement against grade-level standards or 

alternate academic achievement standards. 34 C.F.R. § 200.6(a)(2). States may include 

the advanced and proficient scores of such students in calculating a state’s adequate 

yearly progress as long as the number based on the alternate standards does not exceed 

1 percent of all students in the grades tested at the state or district level. 34 C.F.R. 

§ 200.13(c).

43 The National Center and State Collaborative, a consortium of 19 states, is currently 

developing a comprehensive system that addresses the curriculum, instruction, and 

assessment needs of students with the most significant cognitive disabilities with grant 

funding from Education. The goal of the collaborative is to ensure that students with the 

most significant cognitive disabilities achieve increasingly higher academic outcomes and 

leave high school ready for postsecondary options. The collaborative has developed 

curriculum and instructional resources based on Common Core State Standards that can 

be used to support that goal. The system is expected to be operational for the 2014-2015 

school year.

Teacher Training
Page 30 GAO-14-585 Education of Children in Nursing Homes 

disabilities they encountered among children living in nursing homes.44

During our site visits, several teachers said they could benefit from the 

experiences of other teachers about how best to serve this population of 

children. Further, on our site visits, some school officials noted that 

teachers of children in nursing homes are isolated and may have few 

opportunities to collaborate with other teachers. For example, one teacher 

said when she began teaching at the nursing home, she visited other 

facilities to observe more experienced teachers; however, because the 

population of children in nursing homes is relatively small and dispersed, 

many teachers may not have opportunities to learn from other teachers. 

IDEA authorizes Education to provide funding for personnel preparation, 

technical assistance, and information sharing,45 and recognizes that 

teachers need information and technical assistance in a timely, 

coordinated, and accessible manner in order to improve educational 

results for children with disabilities.46

According to state and local education officials, paying for costly IDEA 

services and a lack of available providers of special education services 

were key financial challenges to providing educational services in regular 

schools and classrooms—the least restrictive environment—for children 

living in nursing homes (see fig. 9).

However, current technical 

assistance efforts supported by Education do not facilitate the sharing of 

information among teachers of this population. Such information sharing 

about effective approaches and strategies could help teachers of children 

in nursing homes be more prepared to provide these children with 

education commensurate with their unique needs.

 44 The moderate/severe disability specialty area of California’s Education Specialist 

Instruction Credential includes autism, deaf-blindness, moderate to severe mental 

retardation, multiple disabilities, and serious emotional disturbance.

45 IDEA permits such funding to be provided to eligible entities through grants, contracts, 

or cooperative agreements. 20 U.S.C. §§ 1461-63.

46 20 U.S.C. § 1450(10).

Cost of Providing IDEA 

Services Combined with 

Limited Availability of 

Special Education 

Providers Compounded 

Challenges
Page 31 GAO-14-585 Education of Children in Nursing Homes 

Figure 9: Challenges Related to Cost and Availability of Special Education Service Providers for Children Living in Nursing 

Homes, According to Survey of State Special Education Directors

Note: A number of states responded “don’t know” to the survey questions on challenges to providing 

special education services to children living in nursing homes, possibly indicating the population of 

children in nursing homes was small and difficult to track at the state level.

In our survey, 35 states indicated that the high cost of providing IDEArelated services and equipment was a challenge, with nearly half of states 

reporting this as extremely or very challenging.47

 47 IDEA-related equipment could include, for example, audiovisual instructional materials 

and technological aids and devices. 

Further, transporting the 

children to school presented challenges, according to our survey. 

Specifically, 35 states reported it was challenging to have appropriate 

medical care when getting the children to and from school and 30 states 

reported having appropriate vehicles to transport the children as 

challenging. For example, one school district superintendent told us the 

district must obtain buses adapted to transport children in wheel chairs. 
Page 32 GAO-14-585 Education of Children in Nursing Homes 

According to some school officials, school districts in which pediatric 

nursing homes are located may also be responsible for a particularly 

large share of high-cost services because of the large concentrations of 

children with high need in those districts.48 Further, the high costs related 

to serving this population were exacerbated by limited IDEA funding (35 

states) and state or other recent budget cuts to special education (33 

states), according to state special education directors responding to our 

survey.49 Limited funding may compound challenges related to the 

availability of special education teachers and related-service providers, 

which was reported by the majority of special education directors in our 

survey.50 As one school district official told us, it is very difficult to find 

qualified nurses because schools must compete with hospitals and other 

medical facilities yet cannot provide comparable pay. In our survey, 31 

states reported having sufficient numbers of special education teachers 

as a challenge to providing educational services to children living in 

nursing homes, although Education and the states have efforts to address 

teacher shortages.51

 48 In some states, such as in California and Texas, school districts with pediatric nursing 

homes are responsible for providing educational services for any children living in the 

nursing home regardless of whether the child’s family lives in the district.

In addition, staffing shortages caused by limited 

resources, one teacher said, have resulted in fewer teaching aides to help 

serve high-need children in the classrooms. Furthermore, provider 

shortages may be exacerbated in rural areas—a challenge indicated by 

the majority of state special education directors in our survey. To address 

these challenges, some school districts in the states we visited partnered 

to maximize resources for special education services, particularly for 

children with high needs. For example, in Texas, several school districts 

49 States may be able to use Medicaid and IDEA high-cost funds to help cover the high 

costs of these services. To qualify for reimbursement under Medicaid, the service must be 

listed in the child’s IEP, the child must be enrolled in Medicaid, the service received must 

be covered in the state Medicaid plan, and the school district must be authorized by the 

state as a qualified Medicaid provider. Under IDEA, states may reserve 10 percent of the 

IDEA funds reserved for other state activities to establish and maintain a high-cost fund—

or risk pool—to assist school districts serving high-need children. 20 U.S.C. § 1411(e)(3). 

According to Education, 15 states set aside money for high cost funds in fiscal year 2012.

50 Related-service providers include occupational and physical therapists, for example.

51 Special education is considered a high-need teaching field and is on the 2014-2015 

teacher area shortage list for most states, according to Education’s nationwide Teacher 

Shortage Area lists for the 2014-2015 school years. Education and states use the Teacher 

Shortage Area list to highlight teaching fields where there is inadequate supply of teachers 

and to promote these fields to prospective teachers through student loan deferment 

programs and student grants. http://www2.ed.gov/about/offices/list/ope/pol/tsa.doc.
Page 33 GAO-14-585 Education of Children in Nursing Homes 

shared physical and occupational therapists across the districts. One 

large school district in California maintains several pediatricians, nurses, 

and health care assistants on staff, according to school officials, and 

small nearby school districts pay the larger district to access these 

service providers.

Education’s monitoring activities can miss children in nursing homes 

because such children are a relatively small, dispersed population and, as 

a result, special education officials may have limited awareness of them. 

Education monitors state compliance with IDEA, such as reviewing states’

special education data, policies, and monitoring practices. States conduct 

more in-depth monitoring of school districts’ compliance with IDEA. 

However, in our survey, 12 states did not know if their monitoring efforts 

included children educated in nursing homes in the last year, including 

three states that had relatively larger populations of children in nursing 

homes. Furthermore, officials from 11 states commented in our survey 

that they either did not have or were unaware that they had children in 

nursing homes, even though all of these states had children living in 

nursing homes at some point during 2012, according to our analysis of 

CMS data.52

The relatively small size of this population also makes it difficult for 

Education and the states to gather information on this population in order 

to monitor their education. State special education officials may have 

limited awareness of children in nursing homes in part because IDEA 

monitoring data are not set up to specifically track this or other small 

populations of children receiving special education services. Specifically, 

the IDEA data categories on educational environment do not include a 

separate category for children receiving their education in nursing 

homes.

(See app. II.)

53

 52 States commenting that they did not have children in nursing homes were Maryland, 

Minnesota, North Dakota, Oklahoma, Rhode Island, and Vermont. States commenting that 

they were not aware of or did not track such children were Arizona, Georgia, Missouri, 

New Mexico, and South Dakota. Six of these states had fewer than 20 school-age children 

living in nursing homes in 2012, but 2 states had more than 60 such children. CMS data 

do not indicate where these children were receiving education services.

Furthermore, according to our survey, these children are 

53 See table 2 for a full listing of the IDEA educational environment categories and

definitions.

The Relatively Small, 

Dispersed Population 

of Children in Nursing 

Homes Complicates 

State and Federal 

Monitoring under 

IDEA
Page 34 GAO-14-585 Education of Children in Nursing Homes 

reported across several categories for educational environment. 54 As a 

result, this population of school-age children—less than 5,000 overall, 

with some states having 10 children or fewer—is essentially 

indistinguishable in the monitoring data from other children with 

disabilities educated in settings outside of regular schools.55 Similarly, 

children in nursing homes are likely to be missed during the more indepth reviews that states conduct of school districts. According to officials 

in states we visited, state officials review individualized education 

programs (IEP) for selected students within school districts, in one case 

using random sampling to select these students.56

While it is difficult for Education and the states to gather information on 

children in nursing homes under current monitoring efforts, nursing home 

monitoring conducted for HHS’s Centers for Medicare & Medicaid 

Services (CMS) provides more regular and direct access to this group of 

children. As part of its oversight of nursing homes participating in 

Medicare and Medicaid, CMS contracts with state health agencies to 

ensure that the nursing homes comply with federal requirements.

Because this 

population is relatively small, such a sampling method is likely to miss 

these children.

57

 54 In our survey, states reported that their school districts may report students educated in 

nursing homes under the categories Homebound/ Hospital (37 states), Residential Facility 

(23 states), or Separate School (7 states)—or they could report them under one of the 

other categories listed in table 2 (3 states). Nine states also indicated that, within their 

state, different school districts may report these children under different categories. A 

senior Education official told us that states and school districts have the discretion to 

decide which reporting category is most appropriate for reporting these children. 

To do 

this, these state agencies send surveyors to inspect each nursing home—

including those that serve children—about once a year. During these 

inspections, surveyors review the care provided to a sample of nursing 

55 Because some children living in nursing homes attend classes in regular schools, the 

population of children who are educated in nursing homes is smaller than the total number 

reported in figure 2. Children living in nursing homes, but receiving education at a regular 

public school would likely be reported under the IDEA educational environment categories 

“Inside the regular classroom 80 percent or more of the day, 40 to 79 percent of the day, 

or less than 40 percent of the day,” as appropriate. 

56 In three other states, state special education officials also said that they review a 

random sample of student IEPs within the school districts they select for in-depth 

monitoring. We interviewed these state officials in the process of developing our survey. 

57 Nursing homes must comply with these requirements in order to be eligible to 

participate in Medicare and Medicaid.
Page 35 GAO-14-585 Education of Children in Nursing Homes 

home residents. As part of this process, surveyors review residents’ care 

plans, which are required to specify—among other things—objectives for 

meeting residents’ cognitive needs (see table 5). Surveyors also verify 

that nursing homes comply with CMS’s quality of life requirements, which 

include providing activities that promote residents’ cognitive health. 

Although children’s education is not specifically mentioned in CMS 

guidance to state surveyors, care plans for children in nursing homes 

should generally include educational goals, and the required activities for 

these children should include education, according to CMS officials we 

interviewed. CMS officials also said that special education and related 

services would be reasonable goals to include in a child’s care plan.

Table 5: Centers for Medicare & Medicaid Services Select Nursing Home 

Regulations and Guidance on Quality of Life and Activities

Centers for Medicare & Medicaid Services (CMS) requirements

Nursing homes must develop a comprehensive care plan for each resident with 

measurable objectives for meeting the resident’s medical, nursing and mental and 

psychosocial needs that are identified through a comprehensive assessment

Nursing homes must care for residents in a manner that promotes maintenance or

enhancement of each resident’s quality of life, including providing for an ongoing 

program of activities designed to meet the physical, mental, and psychosocial well-being 

of each resident.

a

Activities should promote each resident’s cognitive health and mental status

b

Source: GAO analysis of CMS regulations and guidance documents. │ GAO-14-585

c

a 42 C.F.R. § 483.20(k).

b 42 C.F.R. § 483.15.

c CMS Guidance to Surveyors for Long Term Care Facilities

Although CMS’s purpose in monitoring nursing homes is to ensure their 

compliance with Medicare and Medicaid requirements, the requirements 

for care plans and residents’ quality of life allow for opportunities to 

enhance Education’s oversight of the education of children in nursing 

homes. However, the extent to which state surveyors look at the 

education of children included in their sample of a nursing home’s 

residents varied among the states we reviewed because their 

interpretations of CMS guidance also varied. For instance, in New York 

health agency officials said that surveyors verify that children in nursing 

homes had IEPs in place as part of their inspections for CMS. However, 

in California, health agency officials said surveyors would look to see that 

children were receiving education services only if those services were 

outlined in the child’s care plan, raising the possibility that they would not 

look for such services if education were left out of the care plan. The 
Page 36 GAO-14-585 Education of Children in Nursing Homes 

differing interpretations and practices in these two states indicate the 

potential that in some other states monitoring of children in nursing 

homes may not include verifying that children have IEPs.58

While Education and CMS have different, yet complementary,

responsibilities with respect to children living in nursing homes, officials 

from both agencies told us they have not collaborated in their monitoring 

efforts. For example, the agencies have not coordinated to ensure that 

children in nursing homes have IEPs in place or that state health 

agencies have protocols for contacting education agencies if surveyors 

find that children are not receiving educational services, according to 

Education and CMS officials. In addition, officials in both agencies had 

limited awareness of the other agency’s requirements related to the 

education of this population. For example, while CMS officials told us that 

care plans for children in nursing homes should generally include 

educational goals, they also said they would not necessarily expect this to 

be the case for children who were not alert enough to participate in 

education. IDEA, however, requires that all eligible children with 

disabilities receive special education services.

59

GAO has previously identified key practices that can help enhance 

collaboration among federal agencies with common interests. 

Conversely, a senior 

Education official told us that CMS requirements for promoting residents’

cognitive well-being pertained only to geriatric nursing home residents, 

not to children. However, as previously noted, CMS officials told us these 

requirements also pertain to child residents.

60

 58 New York and California have relatively high numbers of children in nursing homes. In 

other states with only a few children in nursing homes, agencies that conduct nursing 

home inspections may be less likely to consider education or other issues particular to 

child residents.

One such 

key practice is to look for opportunities to address resource needs by 

leveraging each others’ resources to obtain additional benefits that would 

not be available if agencies worked separately. Education is responsible 

59 In practice, on our site visits, some school and nursing home officials reported serving 

children who were in vegetative states or minimally responsive. Examples of educational 

services provided to these children included sensory stimulation and reading or talking to 

them.

60 GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain 

Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: October 21, 

2005), 16.
Page 37 GAO-14-585 Education of Children in Nursing Homes 

for monitoring compliance with the IDEA requirement that states provide 

all children with disabilities with a free appropriate public education in the 

least restrictive environment and has developed a number of mechanisms 

for doing so. In practice, however, it is difficult for these monitoring 

mechanisms to gather information on the low-incidence population of 

children in nursing homes, which is particularly vulnerable and may be at 

risk of not being identified at all for education services. Given CMS’s 

oversight role with respect to nursing homes and their residents, CMS is 

uniquely positioned to help ensure that these children receive education 

services that promote their quality of life. Improved collaboration between 

Education and CMS could help provide additional assurance that children 

in nursing homes receive the educational services to which they are 

entitled under IDEA.

Teachers who serve children with disabilities educated in nursing homes 

face difficult challenges. They typically operate outside of traditional 

school settings and are relatively isolated from other special education 

teachers. In addition, they serve children for whom teaching methods and 

curricula often need significant and individualized modifications to meet 

the children’s unique needs. Education, working with state educational

agencies, could take the lead in developing mechanisms for sharing 

information, including best practices. Such information sharing could help 

teachers who serve this relatively small population of children with 

disabilities be better equipped to effectively manage the varied, complex 

nature of children’s education needs. In addition, the relatively small and 

dispersed nature of the population of children living in nursing homes 

complicates efforts by the states and Education to oversee their 

education. However, CMS’ oversight of state nursing home inspections 

provides an additional opportunity to help Education bridge potential gaps 

in its monitoring of the education of children in nursing homes under 

IDEA. 

1. To enhance the education that children in nursing homes receive and 

to better support the professional development of special education 

teachers who serve these severely disabled children, the Secretary of 

Education should:

develop mechanisms to facilitate information sharing among 

teachers of students in nursing homes. For example, Education 

could facilitate the establishment of a medium, such as a list 

serve, for teachers of these children to share information, 

including best practices, on how to best serve these students.

Conclusions

Recommendations
Page 38 GAO-14-585 Education of Children in Nursing Homes 

2. To provide additional oversight of this vulnerable, low-incident, and 

largely hidden population of children with disabilities living in nursing 

homes, and to minimize potential monitoring gaps, the Secretaries of 

Education and of HHS should:

jointly explore opportunities to use CMS’s existing oversight 

mechanisms of nursing homes to help Education better ensure the 

education of such children. For example, Education and CMS 

could work together to encourage state nursing home surveyors—

as part of their on-site reviews of medical and quality of life 

standards—to confirm that school-age children in nursing homes 

are receiving education services, and, if not, take appropriate 

follow-up steps with the nursing home and school district as 

needed. In another example, Education could offer training to 

enhance relevant CMS employees’ understanding of IDEA 

requirements. Working with Education, CMS could encourage 

state health agencies to share information with state educational 

agencies when surveyors learn of school-age children in nursing 

homes.

We provided a draft copy of this report to the Departments of Education, 

Health and Human Services, and Justice for review and comment. 

Education’s comments are reproduced in appendix IV and HHS’ 

comments are reproduced in appendix V. Justice provided only technical 

comments, which we incorporated as appropriate with the technical 

comments we received from Education.

In its comments, Education agreed with our recommendation on 

information sharing among teachers of children in nursing homes. 

Education also stated that, under IDEA, states and school districts are 

primarily responsible for ensuring that personnel have the necessary 

skills and knowledge. According to the department, Education intends to 

issue guidance for states about providing special education and related 

services to children with disabilities in nursing homes, including 

information on requirements, best practices, and existing resources and 

avenues for information sharing for teachers of these children. 

With regard to our recommendation for Education and HHS to jointly 

explore opportunities to use CMS’s existing oversight of nursing homes, 

Education and HHS agreed that it was important to collaborate, with 

Education noting that working together can produce benefits that may not 

be achieved working separately. Education also stated that Education 

and CMS do coordinate their efforts to better assure the education of 

Agency Comments 

and Our Evaluation
Page 39 GAO-14-585 Education of Children in Nursing Homes 

children in nursing homes, citing in particular Education’s collaboration 

with CMS to help CMS and state and local educational agencies 

understand the requirements for accessing Medicaid to pay for special 

education and related services under IDEA. While such collaboration is 

important, the specific focus of our recommendation pertains to 

monitoring the education of children in nursing homes. Education also 

stated that it does not believe that it is CMS’s responsibility to help verify 

the education of children with disabilities, but rather that of state and local 

educational agencies. We agree that oversight of IDEA compliance is the 

responsibility of Education and the states and have further clarified this 

fact in our report. However, as noted in our draft report, CMS’ oversight of 

nursing homes and its requirements to ensure residents’ quality of life 

uniquely positions it to provide important information to Education and the 

states about the education of children in nursing homes. Such information 

is important because, as we noted in our draft report, Education and 

states’ oversight potentially misses children in nursing homes. In its 

comments, Education further stated that it can best serve children with 

disabilities in nursing homes by helping state and local agencies carry out 

their IDEA responsibilities rather than by creating additional federal 

oversight mechanisms. In recommending that Education leverage CMS’s 

existing, regular nursing home inspections to aid Education in its 

oversight of this relatively small, dispersed population of children, we 

specifically sought to ensure that an additional oversight mechanism 

would not be created. In its comments, HHS said that it conditionally 

concurs with our joint recommendation and will continue to collaborate 

with Education. HHS also stated that monitoring of IDEA compliance 

should not be added to state surveyors’ responsibilities, noting—and we 

agree—that Education has the primary responsibility for monitoring 

compliance with IDEA. Our report points out, however, that looking at 

children’s education is well within nursing home surveyors’ current 

responsibilities, since agency requirements for ensuring child residents’ 

quality of life should include children’s education, according to CMS 

officials responsible for the survey.
Page 40 GAO-14-585 Education of Children in Nursing Homes 

If you or your staff have any questions about this report, please contact 

me at 617-788-0534 or emreyarrasm@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. Other key contributors to this report are listed 

in appendix VI.

Sincerely yours,

Melissa Emrey-Arras

Director, Education, Workforce,

 and Income Security
Appendix I: Objectives, Scope, and 

Methodology

Page 41 GAO-14-585 Education of Children in Nursing Homes 

Our study of the education of children with disabilities in nursing homes 

was framed around four objectives: (1) What are the characteristics of 

school-children who live in nursing homes? (2) How are such children 

referred for special education services and how are services delivered? 

(3) What challenges do states and localities face in delivering special 

education services to these children in the least restrictive environment? 

and (4) How do agencies monitor the education of school-age children in 

nursing homes. To address these objectives, we used a variety of 

methods, including analysis of administrative data on nursing home 

residents; a web-based survey of state special education directors; a 

review of federal laws, regulations, and guidance; interviews with federal 

and other officials; site visits to three states; and investigative telephone 

calls.

To determine the characteristics of school-age children living in nursing 

homes, we obtained and analyzed administrative data from the Centers 

for Medicare & Medicaid Services’ (CMS) Minimum Data Set 3.0 (MDS) 

for calendar year 2012 (January 1, 2012 through December 31, 2012), 

which was the most recent year for which data were available for our 

purposes. These data included information on all children who were in a 

Medicare- and Medicaid-certified nursing home in the United States at 

any point, and for any duration, in calendar year 2012. Medicare- and 

Medicaid-certified nursing homes, including skilled nursing homes, 

provide information annually to CMS on residents’ demographics and 

overall health and functionality through the MDS. We focused our 

analysis on the population of children ages 6 through 21, which is 

consistent with the Individuals with Disabilities Education Act (IDEA) 

reporting requirements for school-age children. We analyzed key 

demographic information as well as information on children’s overall 

health and functionality, such as active medical diagnoses, special 

medical treatments (e.g., tracheostomy care and suctioning), activities of 

daily living (e.g., bed mobility and toileting), speech clarity, and length of 

stay in a nursing home. For measures that reflected the children’s health 

and functionality, we reviewed all assessment records available—not just 

the most recent assessment—for individual children starting from their 

date of admission to a nursing home.1

 1 For example, we reviewed all assessment records for each child to determine whether 

the child had been diagnosed with a disease at any point in time from their date of 

admission to a cut-off date of December 31, 2012. 

Appendix I: Objectives, Scope, and 

Methodology

Analysis of Nursing Home 

Data
Appendix I: Objectives, Scope, and 

Methodology

Page 42 GAO-14-585 Education of Children in Nursing Homes 

For special medical treatments, we limited our analysis to treatments that 

the children had received after their entry into the nursing home. These 

refer to special treatments and procedures the resident performed 

themselves independently or that were performed for them by nursing 

home staff within 14 days of the assessment, according to CMS 

definitions. For activities of daily living, we analyzed the measures in 

which the resident needed extensive help or were totally dependent on 

staff to perform. For speech clarity, we analyzed if the resident had 

unclear speech with slurred or mumbled words or no speech with 

absence of spoken word. To determine the length of time a child was in 

the nursing home, we calculated the total cumulative time, starting from 

the child’s date of admission into a nursing home to the discharge date 

from the current nursing home. If there was no discharge date in the 

child’s record or last assessment as of December 31, 2012, we assumed 

that the child was still in a nursing home.2

To assess the reliability of MDS data, we reviewed relevant CMS 

documentation, including guidance to nursing home staff on data 

collection and reporting, and conducted electronic data testing. We also 

interviewed CMS agency officials about the processes they use to ensure 

the completeness and accuracy of the MDS data that are submitted from 

nursing homes. Many states have established additional MDS 

requirements for Medicare and Medicaid payment and quality monitoring 

purposes. Because of these state reviews, as well as the steps taken by 

CMS officials to ensure the completeness and accuracy of these data, we 

Because discharge dates were 

sometimes missing, some children appeared to be current residents even 

though they had been discharged. To address this limitation, we checked 

whether any assessment had been recorded within the last 120 days for 

residents with no discharge dates. This number of days was selected 

because nursing homes conduct assessments every 90 days, and we 

allowed a few additional days for data to be entered into the MDS system. 

If an assessment had been recorded within the 120 days, then we 

assumed the child still resided in a nursing home. We also consulted with 

an outside expert with extensive experience with using MDS data about 

our approach to calculating length of stays in nursing homes and other 

matters.

 2 Discharge assessments capture a resident’s clinical condition at discharge. When 

discharge assessments are not completed or submitted as required, the true length of 

time in a nursing home is difficult to calculate and may result in children appearing to stay 

in the nursing homes when they have been discharged. 
Appendix I: Objectives, Scope, and 

Methodology

Page 43 GAO-14-585 Education of Children in Nursing Homes 

determined that they were sufficiently reliable for the purposes of this 

report.

To obtain information on state monitoring and challenges, we conducted 

a web-based survey of special education directors in all 50 states and the 

District of Columbia. This survey was in the field from September to 

December 2013. In the survey, we asked states to provide information on 

how they provide educational and related services to children living in 

nursing homes, how they monitor the provision of services to those 

children, the challenges they face in doing so, and guidance states have 

provided to school districts and received from the Department of 

Education related to serving this population. The survey included an 

introductory statement specifying that the survey questions pertained to 

school-age children (ages 6 through 21), that “nursing homes” referred to 

nursing homes and similar medical facilities providing long-term nursing 

care to children with complex medical conditions, and that we were 

interested in children with stays of at least 100 days in these facilities—

not short-term stays for rehabilitation. We received responses from all 50 

states and the District of Columbia, for a 100 percent response rate. We 

reviewed state responses and followed up by telephone and e-mail with 

selected states for additional clarification and context.

The quality of survey data can be affected by nonsampling error, which 

includes variations in how respondents interpret questions, respondents’

willingness to offer accurate responses, and data collection and 

processing errors. To minimize such error, we included the following 

steps in developing the survey and in collecting and analyzing survey 

data: In developing the web-based survey, we pretested draft versions of 

the instrument with special education officials in five states to check the 

clarity of the questions and the flow and layout of the survey. On the basis 

of the pretests, we made revisions to the survey. Further, using a webbased survey and allowing state special education staff to enter their 

responses directly into an electronic instrument created an automatic 

record for each state in a data file and eliminated the errors associated 

with a manual data entry process. In addition, the program used to 

analyze the survey data was independently verified to ensure the 

accuracy of this work. While these steps helped minimize nonsampling 

error, this survey may have been subject to additional error related to the 

low-incidence of children in nursing homes and state officials’ limited 

awareness of these children. As noted in our findings, several state 

officials commented in their survey responses that there are no children in 

nursing homes in their states, or that they are not aware of such children. 

Some of these states noted in their comments that they responded to the 

Survey of State Special 

Education Directors
Appendix I: Objectives, Scope, and 

Methodology

Page 44 GAO-14-585 Education of Children in Nursing Homes 

survey questions based on how they serve children in other out-of-school 

settings, such as hospitals or intermediate care facilities for children with 

intellectual disabilities.

For all four objectives, we reviewed relevant federal laws, regulations, 

and guidance and interviewed federal and state officials and other experts 

regarding children living in nursing homes and educational services for 

these children. We interviewed federal officials from the Office of Special 

Education Programs, the Office of Special Education and Rehabilitative 

Services, and the Office for Civil Rights at the Department of Education.

We also interviewed officials at CMS and Administration on Aging’s LongTerm Care Ombudsman Program at the Department of Health and 

Human Services (HHS), as well as officials from the Disability Rights 

Section, Educational Opportunities Section, and Special Litigation Section 

at the Department of Justice. We interviewed state special education 

officials in California, New York, and Texas and held more limited 

interviews with officials in several other states during our design work and 

survey pretests. In addition, we interviewed researchers, experts, and 

advocates in the fields of special education, disability, and Medicaid 

affiliated with the following organizations: Abt Associates; the Arc National 

Office; Advocates for Justice and Education, Inc. (The Parent Training 

and Information Center for the District of Columbia); Children’s National 

Medical Center in Washington, D.C.; Family Voices; the National Alliance 

for Medicaid in Education, Inc.; the National Association of State Directors 

of Special Education, Inc.; and the National Disability Rights Network.

To learn how school-age children are referred for special education 

services and how such services are delivered, as well as to gather 

additional information about their characteristics and challenges in 

providing services, we conducted site visits to three states—California, 

New York, and Texas—to visit nursing homes and school districts. We 

selected these states on the basis of their comparatively large numbers of 

children residing in nursing homes. Together, these states accounted for 

42 percent of all children living in nursing homes in 2011.3

 3 GAO analysis of 2011 data from the CMS Nursing Home Data Compendium, 2012, the 

latest compendium data available during our design phase. 

We also 

considered the number of students in IDEA in the state as a share of 

national IDEA enrollment and geographic dispersion. Within the three 

selected states, we used state licensing information to identify nursing 

Review of Laws, 

Regulations, and 

Guidance and Interviews 

with Federal Officials

Site Visits
Appendix I: Objectives, Scope, and 

Methodology

Page 45 GAO-14-585 Education of Children in Nursing Homes 

homes with pediatric beds.4

Information we gathered on our site visits represents only the conditions 

present in the states and local areas at the time of our site visits. 

Furthermore, our fieldwork focused on in-depth analysis of only a few 

selected states. On the basis of our site visit information, we cannot 

generalize our findings beyond the states we visited.

We then selected a mix of nursing homes 

that serve only pediatric patients and those that serve both pediatric and 

geriatric patients. In total, we visited seven nursing homes in the three 

states. During these visits, we interviewed nursing home administrators 

and social workers, school district officials, special education teachers 

and, wherever possible, parents of children living in nursing homes. We 

also observed the instruction of children living in the nursing homes both 

in nursing homes and in schools. In order to illustrate the types of goals 

and services outlined in individualized education programs (IEP), we 

obtained a select number of IEPs of children living in the nursing homes 

we visited. All together, we obtained eight IEPs across the three states. 

We did not evaluate the IEPs to determine whether the goals and 

services were appropriate for the child, nor did we determine whether the 

services described in the IEP were actually delivered. At the state level, 

we interviewed by telephone state special education directors as well as 

state health officials responsible for carrying out Medicare and Medicaid 

surveys to learn about state oversight of special education and nursing 

homes respectively. We also reviewed state policies to obtain information 

on state requirements or guidance related to identification, service 

delivery, and monitoring.

In the states we visited, we also investigated how school districts and 

nursing homes portrayed to a parent or guardian the educational setting 

and types of educational services a child might receive when admitted 

into a nursing home. Posing as a guardian of a child with complex 

medical needs who was considering placing the child in the nursing 

home, our undercover investigative staff contacted by telephone 11 

schools, 7 school districts, and 10 nursing homes. During these calls, our 

investigator asked questions about the setting and types of educational 

services the child might receive if admitted to a nursing home. Our calls 

 4 In some locations, we visited sub-acute care facilities and specialty hospitals that 

provide long-term care to school-age children with complex medical conditions. For the 

purposes of this report, we use the term “nursing home” throughout to include such skilled 

nursing facilities. 

Investigative Phone Calls
Appendix I: Objectives, Scope, and 

Methodology

Page 46 GAO-14-585 Education of Children in Nursing Homes 

were primarily made to the entities we visited during our site visits, as well 

as an additional nursing home and school district or school in each of the 

three states in order to investigate these issues with entities we had not 

visited.

We conducted this performance audit from March 2013 through July 2014 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. We conducted our related 

investigative work in accordance with standards prescribed by the Council 

of Inspectors General on Integrity and Efficiency.
Appendix II: Number of School-Age (6 through 

21) Children Living in Nursing Homes by State, 

Calendar Year 2012

Page 47 GAO-14-585 Education of Children in Nursing Homes 

State 

No. of children living in nursing homes in 

calendar year 2012

Alabama

a 

130

Alaska

Arizona

b

117

Arkansas 17

California 908

Colorado

Connecticut

b

47

Delaware 16

District of Columbia

Florida

b 

286

Georgia 38

Hawaii 29

Idaho 12

Illinois 155

Indiana 210

Iowa 89

Kansas 19

Kentucky 123

Louisiana 46

Maine 11

Maryland 70

Massachusetts 140

Michigan 56

Minnesota 37

Mississippi 20

Missouri 62

Montana 14

Nebraska 66

Nevada 42

New Hampshire 35

New Jersey 297

New Mexico 13

New York 595

North Carolina 24

North Dakota

Ohio

b

215

Appendix II: Number of School-Age (6 

through 21) Children Living in Nursing 

Homes by State, Calendar Year 2012
Appendix II: Number of School-Age (6 through 

21) Children Living in Nursing Homes by State, 

Calendar Year 2012

Page 48 GAO-14-585 Education of Children in Nursing Homes 

State 

No. of children living in nursing homes in 

calendar year 2012

Oklahoma

a 

40

Oregon 111

Pennsylvania 102

Rhode Island

South Carolina

b

South Dakota

b

Tennessee

b

36

Texas 236

Utah 60

Vermont

Virginia

b

112

Washington 59

West Virginia 17

Wisconsin 33

Wyoming

Total in the United States

b

4,794

Source: GAO analysis of Center for Medicare and Medicaid Services Minimum Data Set 3.0. │ GAO-14-585

a The number of school-age children (6 through 21) who were in a nursing home in the United States 

at any point, and for any duration, in calendar year 2012 (January 1, 2012 through December 31, 

2012).

b Eight states had 10 or fewer children living in nursing homes in calendar year 2012 including: 

Alaska, District of Columbia, North Dakota, Rhode Island, South Carolina, South Dakota, Vermont, 

and Wyoming.
Appendix III: State Performance Report 

Indicators and Data Collection Topics Used by 

Education to Monitor Compliance with Part B 

of the Individuals with Disabilities Education 

Act

Page 49 GAO-14-585 Education of Children in Nursing Homes 

Table 6: Indicators and Definitions Used in State Performance Plans and Annual Performance Reports

Indicator Definition

1 Percent of youth with individualized education programs (IEP) graduating from high school with a regular diploma.

2 Percent of youth with IEPs dropping out of high school.

3

Participation and performance of children with IEPs on statewide assessments:

A. Percent of the districts with a disability subgroup that meets the state’s minimum “n” size that meet the 

state’s adequate yearly progress targets for the disability subgroup.

B. Participation rate for children with IEPs.

C. Proficiency rate for children with IEPs against grade level, modified and alternate academic achievement 

standards.

4

Rates of suspension and expulsion:

A. Percent of districts that have a significant discrepancy in the rate of suspensions and expulsions of greater 

than 10 days in a school year for children with IEPs; and

B. Percent of districts that have: (a) a significant discrepancy, by race or ethnicity, in the rate of suspensions 

and expulsions of greater than 10 days in a school year for children with IEPs; and (b) policies, procedures 

or practices that contribute to the significant discrepancy and do not comply with requirements relating to the 

development and implementation of IEPs, the use of positive behavioral interventions and supports, and 

procedural safeguards.

5

Percent of children ages 6 through 21 with IEPs served:

A. Inside the regular class 80 percent or more of the day;

B. Inside the regular class less than 40 percent of the day; and

C. In separate schools, residential facilities, or homebound/hospital placements.

6

Percent of children ages 3 through 5 with IEPs attending a:

A. Regular early childhood program and receiving the majority of special education and related services in the 

regular early childhood program; and

A. Separate special education class, separate school or residential facility.

7

Percent of preschool children aged 3 through 5 with IEPs who demonstrate improved:

A. Positive social-emotional skills (including social relationships);

B. Acquisition and use of knowledge and skills (including early language/ communication and early literacy); 

and

C. Use of appropriate behaviors to meet their needs.

8 Percent of parents with a child receiving special education services who report that schools facilitated parent 

involvement as a means of improving services and results for children with disabilities.

9 Percent of districts with disproportionate representation of racial and ethnic groups in special education and related 

services that is the result of inappropriate identification.

10 Percent of districts with disproportionate representation of racial and ethnic groups in specific disability categories 

that is the result of inappropriate identification.

11 Percent of children who were evaluated within 60 days of receiving parental consent for initial evaluation or, if the 

State establishes a timeframe within which the evaluation must be conducted, within that timeframe.

Appendix III: State Performance Report 

Indicators and Data Collection Topics Used 

by Education to Monitor Compliance with 

Part B of the Individuals with Disabilities 

Education Act
Appendix III: State Performance Report 

Indicators and Data Collection Topics Used by 

Education to Monitor Compliance with Part B 

of the Individuals with Disabilities Education 

Act

Page 50 GAO-14-585 Education of Children in Nursing Homes 

Indicator Definition

12 Percent of children referred by Part C prior to age 3, who are found eligible for Part B, and who have an IEP 

developed and implemented by their third birthdays.

13

Percent of youth ages 16 and above with IEPs that include appropriate measurable postsecondary goals that are 

annually updated and based upon an age appropriate transition assessment; transition services, including courses of 

study that will reasonably enable the student to meet those postsecondary goals; and annual IEP goals related to the 

student’s transition service needs. There also must be evidence that the student was invited to the IEP Team meeting 

where transition services are to be discussed and evidence that, if appropriate, a representative of any participating 

agency was invited to the IEP Team meeting with the prior consent of the parent or student who has reached the age 

of majority.

14

Percent of youth who are no longer in secondary school, had IEPs in effect at the time they left school, and were:

A. Enrolled in higher education within 1 year of leaving high school.

B. Enrolled in higher education or competitively employed within 1 year of leaving high school.

C. Enrolled in higher education or in some other postsecondary education or training program; or competitively 

employed or in some other employment within 1 year of leaving high school.

15 Percent of hearing requests that went to resolution sessions that were resolved through resolution session settlement 

agreements.

16 Percent of mediations held that resulted in mediation agreements.

17 The state’s State Performance Plan/ Annual Performance Report includes a State Systemic Improvement Plan that 

meets Education’s requirements.

Source: Information provided by the Department of Education. │ GAO-14-585

Note: This list of indicators was finalized in May 2014. States will submit their first State Performance 

Plans and Annual Performance Reports using this indicator list in February 2015. These indicators 

are the same as those submitted by states in February 2014, with two exceptions: Education 

eliminated two indicators—on state identification and correction of noncompliance and on the 

timeliness and accuracy of state reported data—and replaced them with the indicator on State 

Systemic Improvement Plans.

• Child Count

• Personnel

• Educational Environments

• Exiting Special Education

• Discipline

• Assessment

• Dispute Resolution

• Local Educational Agency Maintenance of Effort Reduction and 

Coordinated Early Intervening Services

Data Collection 

Topics for States’

Direct Reporting of 

Special Education 

Monitoring Data
Appendix IV: Comments from the Department 

of Education

Page 51 GAO-14-585 Education of Children in Nursing Homes 

Appendix IV: Comments from the 

Department of Education
Appendix IV: Comments from the Department 

of Education

Page 52 GAO-14-585 Education of Children in Nursing Homes 
Appendix IV: Comments from the Department 

of Education

Page 53 GAO-14-585 Education of Children in Nursing Homes 
Appendix V: Comments from the Department 

of Health and Human Services

Page 54 GAO-14-585 Education of Children in Nursing Homes 

Appendix V: Comments from the Department 

of Health and Human Services
Appendix V: Comments from the Department 

of Health and Human Services

Page 55 GAO-14-585 Education of Children in Nursing Homes 
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 56 GAO-14-585 Education of Children in Nursing Homes 

Melissa Emrey-Arras (617) 788-0534 or emreyarrasm@gao.gov

In addition to the contact named above, Sherri Doughty (Assistant 

Director), Deborah A. Signer (Analyst-In-Charge), George A. Scott, 

Sheranda Campbell, Lauren Gilbertson, Ethan Levy-Forsythe, Cady S. 

Panetta, and James Rebbe made key contributions to this report. Also 

contributing to this report were Lori Achman, Deborah Bland, Holly Dye, 

Jessica Farb, Jean McSween, Mimi Nguyen, Ramon Rodriguez, James 

Ungvarsky, and Helina Wong.

Appendix VI: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(131240)
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