Accessible Version

NURSING HOME 

QUALITY

CMS Should Continue 

to Improve Data and 

Oversight

Report to Congressional Requesters

October 2015

GAO-16-33

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-16-33, a report to 

congressional requesters

October 2015

NURSING HOME QUALITY

CMS Should Continue to Improve Data and Oversight

Why GAO Did This Study

To help ensure nursing home residents 

receive quality care, CMS, an agency 

within the Department of Health and 

Human Services (HHS), defines quality 

standards homes must meet to 

participate in the Medicare and 

Medicaid programs. To monitor 

compliance with these standards, CMS 

enters into agreements with state 

survey agencies to conduct on-site 

surveys of the state’s homes and also 

collects other data on nursing home 

quality. CMS and others have reported 

some potential improvements in 

nursing home quality. 

GAO was asked to study these trends. 

This report examines (1) the extent to 

which reported nursing home quality 

has changed in recent years and the 

factors that may have affected any 

observed changes, and (2) how CMS 

oversight activities have changed in 

recent years. GAO analyzed four sets 

of CMS quality data—deficiencies cited 

on standard surveys (2005-2014), 

consumer complaints (2005-2014), 

staffing levels (2009-2014), and a subset of clinical quality measures (2011-

2014)—at both national and state 

levels. We also reviewed relevant 

documents, including CMS guidance 

and Standards for Internal Control in 

the Federal Government, and 

interviewed CMS and state agency 

officials at 5 states selected on factors 

such as size. 

What GAO Recommends

GAO recommends, among other 

things, that CMS implement a clear 

plan for ongoing auditing of selfreported data and establish a process 

for monitoring oversight modifications 

to better assess their effects. HHS 

agreed with GAO’s recommendations.

What GAO Found

In recent years, trends in four key sets of data that give insight into nursing home 

quality show mixed results, and data issues complicate the ability to assess 

quality trends. Nationally, one of the four data sets—consumer complaints—

suggests that consumers’ concerns over quality have increased, while the other 

three data sets—deficiencies, staffing levels, and clinical quality measures—

indicate potential improvement in nursing home quality. For example, the 

average number of consumer complaints reported per home increased by 21 

percent from 2005-2014, indicating a potential decrease in quality. Conversely, 

the number of serious deficiencies identified per home with an on-site survey, 

referred to as a standard survey, decreased by 41 percent over the same period, 

indicating potential improvement. The Centers for Medicare & Medicaid Services’ 

(CMS) ability to use available data to assess nursing home quality is complicated 

by various issues with these data, which make it difficult to determine whether 

observed trends reflect actual changes in quality, data issues, or both. For 

example, clinical quality measures use data that are self-reported by nursing 

homes, and while CMS has begun auditing the self-reported data, it does not 

have clear plans to continue. Federal internal control standards require agencies 

to monitor performance data to assess the quality of performance over time.

Consumer Complaints and Serious Deficiencies, 2005 - 2014 

In recent years, CMS has made numerous modifications to its nursing home 

oversight activities, but has not monitored the potential effect of these 

modifications on nursing home quality oversight. Some of the modifications have 

expanded or added new oversight activities, while others have reduced existing 

oversight activities. According to CMS, some of the reductions to oversight 

activities are in response to an increase in oversight responsibilities and limited 

number of staff and financial resources. However, CMS has not monitored how 

the modifications might affect CMS’s ability to assess nursing home quality. For 

example, CMS reduced the number of nursing homes participating in the Special 

Focus Facility program—which provides additional oversight of homes with a 

history of poor performance—from 152 in 2013 to 62 in 2014. State survey 

agency officials who conduct surveys for CMS also made modifications which 

could have either a positive or negative effect on oversight, but CMS does not 

have an effective mechanism for monitoring. Federal internal control standards 

require ongoing monitoring as a part of normal program operations; without this 

monitoring, CMS cannot ensure that any modifications in oversight do not 

adversely affect its ability to assess nursing home quality.

View GAO-16-33. For more information, 

contact Linda Kohn at (202) 512-7114 or 

kohnl@gao.gov.
Letter 1

Page i GAO-16-33 Nursing Home Quality

Background 4

Nursing Home Quality Data Show Mixed Results, Although Data 

Issues Complicate Ability to Assess Quality Trends 10

CMS Has Modified Oversight Activities, But Has Not Monitored 

Potential Effect on Nursing Home Quality Oversight 22

Conclusions 26

Recommendations 27

Agency Comments 27

Appendix I: Additional Detail on Analysis 30

Appendix II: State Quality Data Trends in Recent Years 33

Appendix III: Summary of Key Nursing Home Oversight Changes CMS Made from 2005 through 2014 39

Appendix IV: Comments from the Department of Health and Human Services 43

Appendix V: GAO Contact and Staff Acknowledgments 47

Appendix VI: Accessible Data 48

Agency Comment Letter 48

Data Tables 52

Tables

Table 1: Categories of Deficiencies Identified during Nursing 

Home Surveys Based on Scope and Severity 8

Table 2: Examples of Data Issues in Nursing Home Quality Data 16

Table 3: Serious Deficiencies and Consumer Complaints, by 

State, 2005 and 2014 33

Table 4: Nurse Staffing Hours, by State, 2009 and 2014 35

Table 5: Percentage Change in Selected Clinical Quality 

Measures, by State, 2011 - 2014 37

Table 6: CMS-Defined Categories of Oversight and Examples of 

Key Oversight Changes Cited by Agency, 2005 through 

201439

Data Table for Highlights Figure: Consumer Complaints and 

Serious Deficiencies, 2005 - 2014 52

Data Table for Figure 1: Number of Consumer Complaints 

Reported Per Nursing Home, 2005-2014 52

Contents
Data Table for Figure 2: Number of Serious Deficiencies Cited Per 

Nursing Home Receiving Standard Surveys, 2005-2014 52

Data Table for Figure 3: Average Number of Total Nurse Staffing 

Hours, 2009-2014 53

Data Table for Figure 4: Selected Quality Measure Scores, 2011-

201453

Data Table for Figure 5: Examples in Selected States of Data 

Issues that May Have Affected Complaint and Deficiency 

Data, 2005 – 2014 53

Figures

Page ii GAO-16-33 Nursing Home Quality

Figure 1: Number of Consumer Complaints Reported Per Nursing 

Home, 2005-2014 11

Figure 2: Number of Serious Deficiencies Cited Per Nursing Home 

Receiving Standard Surveys, 2005-2014 12

Figure 3: Average Number of Total Nurse Staffing Hours, 2009-

2014 13

Figure 4: Selected Quality Measure Scores, 2011-2014 14

Figure 5: Examples in Selected States of Data Issues that May 

Have Affected Complaint and Deficiency Data, 2005 –

2014 19

Abbreviations

CMS Centers for Medicare & Medicaid Services

GPRA Government Performance and Results Act of 1993

HHS Department of Health and Human Services

IMPACT Act Improving Medicare Post-Acute Care Transformation Act

of 2014

OBRA ’87 Omnibus Budget Reconciliation Act of 1987 

PAMA Protecting Access to Medicare Act of 2014 

PPACA Patient Protection and Affordable Care Act 

QIO Quality Improvement Organization 

QIS Quality Indicator Survey 

SFF Special Focus Facility

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-16-33 Nursing Home Quality

441 G St. N.W.

Washington, DC 20548

October 30, 2015

Congressional Requesters

Nationwide, approximately 15,800 nursing homes provide care to about 

1.4 million nursing home residents—a population of elderly and disabled 

individuals. To help ensure that this population receives quality care, the 

Centers for Medicare & Medicaid Services (CMS), an agency within the 

Department of Health and Human Services (HHS), defines the quality 

standards that nursing homes must meet in order to participate in the 

Medicare and Medicaid programs. To monitor compliance with these 

standards, CMS enters into agreements with agencies in each state 

government—known as state survey agencies—to conduct required 

surveys, or evaluations, of the state’s nursing homes.

For many years we and the HHS Office of the Inspector General have 

reported on problems in nursing home quality and on weaknesses in 

CMS’s oversight. For example, in multiple reports dating back to the 

1990s, we have identified weaknesses in federal and state activities 

designed to correct quality problems in nursing homes. CMS and state 

survey agencies have made some changes in how they conduct oversight 

of nursing home quality, and some potential improvements in nursing 

home quality have been reported in recent years; for example, CMS has 

reported a decrease in the percentage of homes that, as part of the 

survey process, were cited for serious health deficiencies from 2006 to 

2012.1In addition, CMS and others have reported on improvements in 

specific nursing home clinical measures such as reductions in the use of

physical restraints, which can be a sign of improved quality of care.2 The 

characteristics of nursing home residents have also shifted in recent 

years; for example, some studies have described a growing number of 

nursing home residents with acute medical needs and examined the 

 

1CMS, Nursing Home Data Compendium 2013 Edition. 

2See for example, CMS, Nursing Home Data Compendium 2013 Edition and J. Engberg, 

N.G. Castle, and D. McCaffrey, “Physical Restraint Initiation in Nursing Homes and 

Subsequent Resident Health,” The Gerontologist, Vol. 48, No. 4 (2008). 

Letter
potential impact of these patient characteristics on nursing home quality 

data.

Page 2 GAO-16-33 Nursing Home Quality

3

Policymakers and others have questions about whether changes in 

reported nursing home quality represent actual improvements in quality 

or, for example, may be the result of changes in how oversight is 

performed. In light of these questions, you asked us to provide 

information on the quality of care in nursing homes and to study whether 

changes in quality are due to improvements in quality or to changes in

oversight. This report examines:

1. the extent to which reported nursing home quality has changed in 

recent years and the factors that may have affected any observed 

changes; and

2. how CMS oversight activities have changed in recent years.

To examine the extent to which reported nursing home quality has 

changed in recent years and the factors that may have affected any 

observed changes, we analyzed four key sets of quality data from CMS. 

Each of these four key sets of data provide an important perspective on 

quality and together can give a multi-dimensional view of potential 

changes in nursing home quality over time. The four sets of data are: (1) 

data on deficiencies cited during standard surveys conducted by state 

survey agencies on all nursing homes from 2005-2014; (2) data on 

complaints submitted by nursing home residents, families, state nursing 

home ombudsmen, and others from 2005-2014; (3) data on nurse staffing 

levels from 2009-2014; and (4) data from 2011-2014 on nursing homes’ 

performance on a sub-set of CMS’s clinical nursing home quality 

measures derived from standardized clinical assessments of all nursing 

 

3See for example, V. Mor, et al, “Changes in the Quality of Nursing Homes in the U.S.: A 

Review and Data Update,” August 2009.
home residents.

Page 3 GAO-16-33 Nursing Home Quality

4 We analyzed the four sets of data at both the national 

and state level for the time periods identified above, which represent the 

most recent data available for a ten-year period or its closest equivalent. 

At the national level we collected and analyzed data for all 50 states and 

Washington, D.C.5 At the state level we selected five states to focus our 

review—California, Florida, Massachusetts, Michigan, and West 

Virginia—based on factors such as variation in geographic region, size 

(number of nursing homes), and state performance standard scores. We 

reviewed documents (such as CMS’s Nursing Home Data Compendium 

and a CMS regional office’s annual report) and interviewed officials from 

CMS central office, CMS regional offices, and state survey agencies for 

the five selected states on the results of our data analysis. We assessed 

the reliability of each of the four sets of data and determined that they 

were sufficiently reliable, for purposes of describing trends, through 

interviews with knowledgeable CMS officials, reviews of supporting 

documentation, and comparisons with other published data. (For more 

detail on our data analysis, see Appendix I.) In our report we describe 

various issues associated with these data. We also reviewed relevant 

published literature, interviewed officials from nursing home consumer 

and provider groups, and interviewed nursing home researchers who 

have published studies on nursing home quality. As part of our review, we 

examined whether the data used by CMS to assess nursing home quality 

are consistent with federal standards for internal control as well as 

 

4CMS currently tracks data for 18 clinical quality measures. Out of these 18 quality 

measures, we selected 8 to include in our analysis based on factors such as endorsement 

by the National Quality Forum and data reliability. Six of the 8 measures are used by CMS 

for long-stay residents—the percentage of residents who report moderate to severe pain; 

the percentage of high-risk residents with pressure ulcers; the percentage of residents 

who lose too much weight; the percentage of residents who were physically restrained; 

the percentage of residents experiencing one or more falls with major injury; and the 

percentage of residents who received antipsychotic medication. The remaining 2 

measures are used for short-stay residents—the percentage of residents who report 

moderate to severe pain and the percentage of residents with pressure ulcers that are 

new or worsening. The long-stay quality measures are for residents with equal to or 

greater than 101 cumulative days in the nursing home, and the short-stay measures are 

for residents with less than or equal to 100 cumulative days in the nursing home. 

5For the purposes of this report, we include Washington, D.C. when we refer to data for 

states. 
leading practices identified by GAO for the effective implementation of the 

Government Performance and Results Act of 1993 (GPRA).

Page 4 GAO-16-33 Nursing Home Quality

6

To examine how CMS’s oversight activities have changed in recent years 

we reviewed relevant documents (such as CMS’s State Operations 

Manual, Nursing Home Action Plan, Survey & Certification memos, and 

Mission & Priority Documents) and interviewed CMS central office 

officials (such as officials from CMS’s Survey & Certification Group). We 

also reviewed relevant documents and interviewed officials from the five 

selected states and from the states’ corresponding CMS regional offices 

regarding the officials’ efforts to oversee nursing home quality. As part of 

our review, we examined whether CMS’s oversight of nursing home 

quality is consistent with federal standards for internal control.7

We conducted this performance audit from December 2014 to October 

2015 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.

Titles XVIII and XIX of the Social Security Act, as amended, establish 

minimum requirements nursing homes must meet to participate in the 

Medicare and Medicaid programs, respectively, with key legislative 

provisions enacted below.8

 

6GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: Nov. 1999). Internal control is synonymous with management control 

and comprises the plans, methods, and procedures used to meet missions, goals, and 

objectives. GAO, Executive Guide: Effectively Implementing the Government Performance 

and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1996).

7GAO/AIMD-00-21.3.1.

8These parts of the Social Security Act and their implementing regulations use the terms 

“skilled nursing facility” (Medicare) and “nursing facility” (Medicaid), instead of the term 

nursing home. For the purposes of this report, we use the term nursing home to refer to 

both skilled nursing facilities and nursing facilities. 

Background

Federal Legislation
· The Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) included 

wide-ranging reforms.

Page 5 GAO-16-33 Nursing Home Quality

9 For example, the law revised the care 

requirements providers must meet in order to participate in the 

Medicare or Medicaid programs, modified the survey process, 

introduced additional enforcement actions, and required nursing 

homes to periodically assess the health of nursing home residents. 

OBRA ‘87 is considered largely responsible for the quality 

environment under which nursing homes operate.

· In 2010, Title VI of the Patient Protection and Affordable Care Act 

(PPACA) added additional federal and state oversight and 

enforcement requirements. Specifically, PPACA requires CMS to 

establish a national system to collect and report payroll data on nurse 

staffing hours and develop a standardized complaint form. It also 

requires states to establish a complaint resolution process.10

· The Protecting Access to Medicare Act of 2014 (PAMA) requires CMS 

to establish a value-based purchasing program, which will increase or 

reduce Medicare payments to nursing homes based on an 

assessment of their performance against quality measures related to 

rates of hospital readmissions.11 Under this program, lowerperforming nursing homes will receive lower incentive payments 

compared to better-performing peers, or they may receive a reduction 

to their Medicare payment rate.12 CMS is required to implement the 

program starting in fiscal year 2019.

 

9Pub. L. No. 100-203, Title IV, Subtitle C, 101 Stat. 1330 (Dec. 22, 1987).

10Pub. L. No. 111-148, Title VI, Subtitle B, §§ 6105-06, 124 Stat. 119, 711-13 (March 23, 

2015). PPACA also requires CMS to include additional information on its Nursing Home 

Compare website, including staffing information, links to state websites with information 

regarding state surveys and certification programs, links to state inspection reports, and 

summary information on the number, type, severity, and outcome of substantiated 

complaints against nursing homes. Id. § 6103. PPACA further requires CMS to redesign 

certain Medicare cost reports. Id. § 6104. The Act also requires nursing homes to disclose 

to CMS details concerning their ownership, management, and organizational structure, 

and to establish compliance and ethics programs, consistent with regulations established 

by CMS. Id. §§ 6101-02.

11Pub. L. No. 113-93, Title II, § 215, 128 Stat. 1040, 1048 (April 1, 2014). 

12PAMA requires the establishment of the Skilled Nursing Facility Readmissions Quality 

Measure, to be used in the Skilled Nursing Facility value-based purchasing program. Pub. 

L. No. 113-93, § 215(a). According to CMS, the agency is in the process of developing this 

measure and expects to begin publicly reporting on it in fiscal year 2017. This 

readmissions quality measure will estimate the risk-standardized rate of all-cause, 

unplanned, hospital readmissions for Skilled Nursing Facility Medicare beneficiaries within 

30 days of their prior proximal short-stay acute hospital discharge.
· Finally, the Improving Medicare Post-Acute Care Transformation Act 

of 2014 (the IMPACT Act) requires the standardization of certain 

types of Medicare data across multiple health care settings, including 

long term care hospitals, home health agencies, inpatient 

rehabilitation facilities, and nursing homes.

Page 6 GAO-16-33 Nursing Home Quality

13 For example, the 

IMPACT Act requires the reporting to CMS of standardized patient 

assessment data so that information can be used to help facilitate 

coordinated care and improve Medicare beneficiary outcomes.

Oversight of nursing homes is a shared federal-state responsibility, with 

specific activities occurring at the national, regional, and state levels 

performed by the entities listed below.

· CMS central office. At the national level, CMS central office oversees 

the federal quality standards nursing homes must meet to participate 

in the Medicare and Medicaid programs. The office also establishes 

the responsibilities of CMS’s regional offices and state survey 

agencies in ensuring that federal quality standards for nursing homes 

are met. For example, the office issues guidance on how regional and 

state entities should assess compliance with federal nursing home 

standards.

· CMS regional offices. CMS’s 10 regional offices oversee state 

activities and report back to CMS central office the results of their 

efforts. Specifically, each year regional offices are required to conduct 

federal monitoring surveys in at least five percent of each state’s 

nursing homes surveyed by the state to assess the adequacy of 

surveys conducted by state survey agencies.14 Regional offices also 

use the State Performance Standards System to evaluate state 

surveyors’ performance on factors such as the frequency and quality 

of state surveys.

· State survey agencies. Under agreement with CMS, a state survey 

agency in each state assesses whether nursing homes meet CMS’s 

standards, allowing them to participate in the Medicare and Medicaid 

programs. State survey agencies assess nursing homes using 

standard surveys and the statewide average between standard 

 

13Pub. L. No. 113-185, § 2, 128 Stat. 1952 (Oct. 6, 2014). 

1442 U.S.C. §§ 1395i-3(g)(3)(B), 1396r(g)(3)(B) . 

Oversight of Nursing 

Homes
surveys may not exceed one year. State survey agencies also 

conduct complaint investigations as needed. These investigations 

generally focus on a specific allegation regarding resident care or 

safety made by residents, families, ombudsmen, or others.

CMS collects data on nursing home quality through a number of sources, 

including annual standard surveys and complaint investigations, as well 

as other sources such as staffing data and clinical quality measures. The 

four key sources that we use in this report are described below.

· Standard surveys. By law, every nursing home receiving Medicare or 

Medicaid payment must undergo a standard survey not less 

frequently than once every 15 months, with a statewide average 

frequency of once every 12 months.

Page 7 GAO-16-33 Nursing Home Quality

15 During a standard survey, 

teams of state surveyors conduct a comprehensive on-site evaluation 

of compliance with federal quality standards.

· In 2005, CMS launched a new survey process called the Quality 

Indicator Survey (QIS), designed to improve the accuracy and 

consistency of standard surveys and the documentation of 

deficiencies. Though the QIS is similar to the traditional survey 

processes used for standard surveys, the QIS is electronic rather 

than paper-based and draws on a random sample of residents for 

closer analysis, as opposed to a sample hand-picked by the 

surveyor. As of late 2014, 23 states had transitioned completely to 

QIS, while 3 states were using a mixture of QIS and traditional 

surveys.

· Deficiencies in nursing home care identified during standard 

surveys are classified into 1 of 12 categories, each designated 

with a different letter, according to scope—the number of 

residents potentially affected—and severity—the potential for or 

occurrence of harm to residents.16 (See table 1.)

 

1542 U.S.C. §§ 1395i-3(g)(2)(A)(iii)(I); 1396r(g)(2)(A)(iii)(I); 42 C.F.R. Part 488, Subpart E.

16Reviews of deficiencies often focus on deficiencies at the severity levels of actual harm 

(caused harm to resident) and immediate jeopardy (risk of death or serious injury) 

because of the significance of these deficiencies. Throughout this report, we refer to 

deficiencies identified as causing actual harm or immediate jeopardy as “serious” 

deficiencies. 

Nursing Home Quality 

Data
Table 1: Categories of Deficiencies Identified during Nursing Home Surveys Based 

Page 8 GAO-16-33 Nursing Home Quality

on Scope and Severity

Scope

Severity Isolated Pattern Widespread

Potential for minimal harmaA B C

Potential for more than minimal harm D E F

Actual harm G H I

Immediate jeopardybJ K L

Source: CMS. | GAO-16-33

aNursing home is considered to be in “substantial compliance.”

bActual or potential for death / serious injury.

For most deficiencies, a home is required to prepare a plan of 

correction, and, depending on the severity of the deficiency, 

surveyors may conduct a revisit to ensure that the nursing home 

has implemented its plan and corrected the deficiency. The scope 

and severity of a deficiency determine the enforcement actions—

such as requiring training for staff, imposing monetary fines, 

temporary management changes, or termination from the 

Medicare and Medicaid programs—that CMS may impose on a 

nursing home.

· Complaint investigations. Nursing homes are also surveyed on an 

as-needed basis with complaint investigations. Complaints can be 

filed with state survey agencies by residents, families, ombudsmen, 

or others acting on a resident’s behalf. During a complaint 

investigation, state surveyors conduct a focused evaluation of the 

nursing home’s compliance with a specific federal quality standard. 

CMS sets guidelines state survey agencies should follow when 

recording, investigating, and resolving complaints.

· Staffing data. Nurse staffing levels are considered a key component 

of nursing home quality. Higher nurse staffing levels—particularly 

registered nurse staffing levels—are typically linked with higher 

quality nursing home care. CMS currently tracks nurse staffing data in 

nursing homes.

· Clinical quality measures. Nursing homes are required to provide 

data on certain clinical quality measures—such as pressure ulcers—

for all residents to CMS. CMS currently tracks data for 18 clinical 

quality measures.
Nursing homes with consistently poor performance can be selected for 

the Special Focus Facility (SFF) program, which requires more frequent 

surveys.

Page 9 GAO-16-33 Nursing Home Quality

17 To select nursing homes for the SFF program, CMS scores the 

relative performance of nursing homes and identifies the poorest 

performing homes in each state as candidates. State survey agencies 

then work with CMS to choose some of the candidates to participate; 

homes that are selected receive more intensive oversight, including more 

frequent surveys. According to CMS guidance, SFF nursing homes that 

fail to significantly improve after three standard surveys, or about 18 

months, may be involuntarily terminated from Medicare and Medicaid. 

Originally created by CMS in 1998, the SFF program is now statutorily 

required under PPACA; CMS is now mandated to conduct its SFF 

program for homes that have “substantially failed” to meet applicable 

requirements of the Social Security Act, and must conduct surveys of 

each facility in the program no less than once every six months.

CMS publicly reports a summary of each nursing home’s quality data on 

its Nursing Home Compare website using a five-star quality rating.18 The 

Five-Star Quality Rating System assigns each nursing home an overall 

rating and three component ratings—surveys (standard and complaint), 

staffing, and quality measures—based on the extent to which the nursing 

home meets CMS’s quality standards and other measures.19 CMS also 

works to influence nursing home quality through specific quality 

improvement efforts—such as the agency’s effort to improve dementia 

care—and through Quality Improvement Organizations (QIOs).20 CMS 

contracts with QIOs to help nursing homes address quality problems such 

 

17For more information on the SFF program, see GAO, Poorly Performing Nursing 

Homes: Special Focus Facilities Are Often Improving, but CMS’s Program Could Be 

Strengthened, GAO-10-197 (Washington, D.C.: Mar. 19, 2010).

18For more information on Nursing Home Compare, see GAO, Health Care Transparency: 

Actions Needed to Improve Cost and Quality Information for Consumers, GAO-15-11

(Washington, D.C.: Oct. 20, 2014).

19As of February 2015, CMS uses a subset of 11 of its 18 clinical quality measures in 

calculating each nursing home’s Five-Star rating for quality measures. All but one of the 

quality measures we selected for our analysis are included in CMS’s Five-Star calculation. 

For more information on the Five-Star System, see GAO, Nursing Homes: CMS Needs 

Milestones and Timelines to Ensure Goals for the Five-Star Quality Rating System Are 

Met, GAO-12-390 (Washington, D.C.: Mar. 23, 2012).

20For more information on QIOs, see GAO, Nursing Homes: Federal Action Needed to 

Improve Targeting and Evaluation of Assistance by Quality Improvement Organizations, 

GAO-07-373 (Washington, D.C.: May 29, 2007).
as pressure ulcers. Nursing homes’ participation in QIO efforts is 

voluntary.

In recent years, trends in four key sets of data that give insight into 

nursing home quality show mixed results. Specifically, one of the four 

data sets suggests that consumers’ concerns over nursing home quality 

have increased, which may indicate a potential decrease in quality, while 

the other three sets of data may indicate potential improvement in nursing 

home quality. However, data issues complicate the ability to assess 

trends in nursing home quality over time.

Page 10 GAO-16-33 Nursing Home Quality

Nationally, in recent years, one of four data sets—number of consumer 

complaints—demonstrated a potential decrease in nursing home quality, 

while the other three data sets—serious deficiencies cited on standard 

surveys, staffing data, and selected clinical quality measures—

demonstrated potential quality improvement.

Consumer complaints: From 2005 through 2014, the average number 

of consumer complaints reported per nursing home increased nationally 

from 3.2 to 3.9, a 21 percent increase over the 10-year period. After an 

initial increase, the number of complaints decreased from 2008 through 

2011 and then again increased through 2014. (See fig. 1.) Specifically, 

52,411 complaints were reported in 2005 and 61,466 complaints were 

reported in 2014. At the state level, 30 states had increases in the 

number of complaints per home, with increases of more than 50 percent 

in 11 of those states, and 21 states had decreases in the number of 

complaints per home, with decreases of more than 50 percent in 4 of 

those states. (See Appendix II for data for all states.)

Nursing Home Quality 

Data Show Mixed 

Results, Although 

Data Issues 

Complicate Ability to 

Assess Quality 

Trends

Data on Nursing Home 

Quality Show Mixed 

Results
Figure 1: Number of Consumer Complaints Reported Per Nursing Home, 2005-2014

Page 11 GAO-16-33 Nursing Home Quality

Deficiencies cited on standard surveys: From 2005 through 2014, the 

number of serious deficiencies—deficiencies that at a minimum caused 

harm to the resident—cited per nursing home surveyed decreased 

nationally from 0.35 to 0.21, a 41 percent decline over the 10-year period. 

(See fig. 2.) Specifically, 4,840 serious deficiencies were cited during 

surveys for 13,800 nursing homes in 2005, and 2,660 serious deficiencies 

were cited during surveys for 12,759 nursing homes in 2014. At the state 

level, we also found a decreasing trend in 36 of the states, and an 

increasing trend in the remaining 15 states.
Figure 2: Number of Serious Deficiencies Cited Per Nursing Home Receiving 

Page 12 GAO-16-33 Nursing Home Quality

Standard Surveys, 2005-2014

Nurse staffing: From 2009 through 2014, the average total nurse hours 

per resident per day—a measure of registered nurse, licensed practical 

nurse, and nurse assistant hours—increased nationally from 4.2 to 4.6, a 

9.0 percent increase over the 6-year period. (See fig. 3.) In addition, the 

average registered nurse hours per resident per day also increased over 

the same time period from 0.5 to 0.8, a 51.2 percent increase. 

Furthermore, the average total nurse hours per resident per day 

increased in all but one state, and the average registered nurse hours per 

resident per day increased in all states. Studies suggest that higher levels 

of nurse staffing—particularly registered nurse staffing—can result in 

higher quality of nursing home care.
Figure 3: Average Number of Total Nurse Staffing Hours, 2009-2014

Page 13 GAO-16-33 Nursing Home Quality

Selected quality measures: From 2011 through 2014, nationwide 

nursing homes’ scores on all eight of our selected quality measures 

improved, at least somewhat, by showing decreases in the number of 

reported quality problems, such as falls resulting in major injury. The rate 

of decline varied greatly by quality measure. For example, the percentage 

of long-stay residents with too much weight loss decreased 1.3 percent 

over the 4-year period, while the percentage of short-stay residents with 

new or worsening pressure ulcers decreased 52.2 percent. (See fig. 4.) 

Similar trends were seen at the state level for most of the quality 

measures, although two of the quality measures—long-stay residents with 

too much weight loss and long-stay residents experiencing one or more 

falls with major injury—had more state-level differences in trends.
Figure 4: Selected Quality Measure Scores, 2011-2014

Page 14 GAO-16-33 Nursing Home Quality

Note: The long-stay quality measures are for residents with equal to or greater than 101 cumulative

days in the nursing home, and the short-stay measures are for residents with less than or equal to 

100 cumulative days in the nursing home.
In our analysis we also attempted to identify trends across the four data 

sets at the nursing home level. Specifically, we examined the data to 

determine whether there were nursing homes that consistently performed 

poorly across the four data sets over the time periods we reviewed. We 

identified 416 homes nationwide with consistently poor performance. 

These homes were located in 36 states; the remaining 15 states did not 

have any of the consistently poorly performing homes. Of the 416 homes, 

71 (17 percent) were included in the SFF program at some point between 

2005 and 2014. The number of consistently poorly performing homes is 

greater than the number of SFFs allotted in 2015—416 homes and 85 

homes, respectively. As will be discussed, the number of nursing homes 

included in the SFF program is affected by budget resources, according 

to CMS. We also attempted to identify commonalities among homes that 

consistently performed poorly compared to homes that performed well 

across the four data sets and found that the poorest performing homes 

were more likely to be for-profit or large homes (greater than 100 beds) 

compared to homes that performed well; our analysis did not reveal a link 

between performance and urban or rural location.

Page 15 GAO-16-33 Nursing Home Quality

21

CMS’s ability to use available data to assess nursing home quality trends 

is complicated by various issues with these data. Specifically, each of the 

four key sets of nursing home data we analyzed have issues that make it 

difficult to determine whether observed trends reflect actual changes in 

quality, data issues, or a combination of both. (See table 2 for examples 

of these issues). Under federal internal control standards, agencies 

should monitor performance data to assess the quality of performance 

over time, and CMS’s ability to do so is hindered by these data issues.22

Furthermore, according to GPRA leading practices identified by GAO, 

agencies should ensure that data are complete, accurate, and consistent 

 

21These results were consistent with our analysis in a 2009 report. In that report, we 

estimated that 580 of the nursing homes in the United States could be considered the 

most poorly performing and that the poorest performing homes were more likely to be forprofit or large homes compared to homes that performed well. The methodology we used 

for that estimate was different and relied generally on deficiencies cited during standard 

surveys and complaint investigations. See GAO, Nursing Homes: CMS’s Special Focus 

Facility Methodology Should Better Target the Most Poorly Performing Homes, Which 

Tended to Be Chain Affiliated and For-Profit, GAO-09-689 (Washington, D.C.: Aug. 28, 

2009).

22GAO/AIMD-00-21.3.1.

Data Issues Complicate 

Ability to Assess Quality 

Trends
enough to document performance and support decision making.

Page 16 GAO-16-33 Nursing Home Quality

23 In the 

discussion that follows table 2, we describe in more detail the data issues 

that exist in each of the four key data sets CMS uses to assess the quality 

of nursing home care.

Table 2: Examples of Data Issues in Nursing Home Quality Data

Quality data type Data issue

Consumer complaints · State variation in recording of complaints

Deficiencies cited on 

standard surveys

· Multiple survey types—some states use QIS and some 

use traditional survey methodology for standard surveys

· State survey agency challenges in completing standard 

surveys

Nurse staffing · Self-reported by nursing homes

Selected quality 

measures

· Self-reported by nursing homes

Source: GAO analysis of CMS information. | GAO-16-33

Consumer complaints: Although the average number of consumer 

complaints reported per nursing home increased between 2005 and 

2014, it is unclear to what extent this can be attributed to a change in 

quality or to state variation in the recording of complaints. State survey 

agency officials from the states we interviewed with dramatic increases in 

the average number of consumer complaints per nursing home over the 

10-year period—California and Michigan—both explained that changes in 

how they recorded complaints into CMS’s complaint tracking system 

could in part account for the jump in reported complaints. In addition, 

officials at one state survey agency explained that the increase in 

complaints could also reflect state-level efforts to provide consumers with 

more user-friendly options for filing complaints, such as via email. In April 

2011, we found differences in how states record and track complaints and 

made recommendations to CMS to clarify guidance to states.24 CMS 

concurred with the recommendations. As of July 2015, CMS had not fully 

addressed these recommendations; however, the agency had taken 

some steps. For example, CMS officials reported that the agency was in 

the early stages of a planned multi-year review of its business practices, 

 

23GAO/GGD-96-118.

24See GAO, Nursing Homes: More Reliable Data and Consistent Guidance Would 

Improve CMS Oversight of State Complaint Investigations, GAO-11-280 (Washington, 

D.C.: April 7, 2011). 
including those related to nursing home complaint investigations, and 

would provide clarification to states, as needed. Also in 2011, CMS 

created a standardized complaint form, as required by PPACA, and made 

it available to states and consumers on its website. Use of the form is 

voluntary, but it provides consistent information to consumers wishing to 

file complaints and facilitates their ability to compose and file complaints 

with appropriate supporting information.

Deficiencies cited on standard surveys: Although the decline in the 

number of serious deficiencies cited on standard surveys between 2005 

and 2014 may indicate an improvement in quality, it may also be 

attributed to inconsistencies in measurement. One reason these 

measurement inconsistencies occur is the use of both traditional paperbased surveys and QIS electronic surveys, which, for example, have 

different methodologies for selecting residents for closer analysis during 

the survey. This use of multiple survey types complicates the ability to 

compare the results of standard surveys nationally. As of late 2014, 23 

states used QIS surveys, 25 states used traditional, and 3 states used 

both. An internal CMS review that analyzed survey data from 2012 to 

2014 found that states using traditional surveys cited a slightly higher rate 

of severe deficiencies than states using the QIS methodology. Some 

regional offices and state survey agencies we spoke with noted that QIS 

results in fewer deficiencies cited, especially for more serious deficiencies 

and deficiencies related to quality of care.

Page 17 GAO-16-33 Nursing Home Quality

25 As a result, the decreasing 

trend of serious deficiencies cited on standard surveys could be the result 

of an expanding use of QIS surveys over the same time period, rather 

than an improvement in the quality of nursing homes. Officials at one 

state survey agency suggested that this change in the number of 

deficiencies cited on QIS surveys could be attributed to the way that the 

QIS process guides surveyors through a structured investigation.

Another reason for measurement inconsistencies is that state survey 

agencies face challenges in completing standard surveys, particularly in 

states where there are less experienced surveyors or surveyors with very 

heavy workloads, according to CMS and state survey agency officials. 

CMS officials said these challenges led to reduced state survey agency 

 

25Federal quality standards, which CMS and state survey agencies use when conducting 

surveys and complaint investigations, focus on the delivery of care, resident outcomes, 

and facility concerns. These quality standards are grouped into 15 categories, such as 

quality of care, quality of life, resident rights, and resident behavior and facility practices. 
capacity to conduct surveys, which could contribute to the decrease in the 

number of deficiencies cited on standard surveys. According to CMS 

officials, the recession had the significant and lasting effect of reducing 

some state survey agencies’ ability to complete high quality standard 

surveys, in part because it caused them to rely on smaller and less 

experienced workforces to conduct surveys. Officials from one of the 

state survey agencies we interviewed said an increasingly heavy survey 

workload distributed among a limited number of surveyors could have 

contributed to the decrease in deficiencies cited on standard surveys in 

that state. In addition, CMS officials found that the number of hours 

surveyors spent completing standard surveys has increased as the 

number of deficiencies cited has decreased, which they said suggests 

that state survey agencies are relying on newer, less experienced staff to 

conduct surveys. Finally, in 2012 and 2013, CMS central office notified 

two state survey agencies that their performance was persistently 

substandard, and that if the state survey agencies did not improve, then 

CMS may terminate its agreement with them to oversee nursing home 

quality in their states.

CMS has taken some steps to address the inconsistencies in 

measurement for deficiencies cited on standard surveys, and, according 

to CMS officials, continues to work on addressing inconsistencies. 

Regarding the different survey methodologies, CMS suspended further 

implementation of QIS in 2012 to address issues such as deficiency 

patterns, software compatibility, the time required to complete QIS, and 

surveyor training. States already using QIS continued to do so, but other 

states continued to do traditional paper-based surveys. In May 2015 CMS 

acknowledged the challenges created by operating two survey types. 

CMS officials told us they plan to develop a hybrid model of the QIS and 

traditional surveys, with the long-term goal of moving all states to this 

hybrid model. However, CMS officials said dates for developing and 

implementing the new hybrid model have not been set. CMS officials also 

commented on the challenges faced by state survey agencies in 

completing standard surveys, and have documented that some level of 

variation across states may always exist, but that its systems, such as 

national training and state performance standards, are intended to 

improve consistency and limit the variation.

Information gathered from the five states we interviewed suggests how 

some of the data issues for complaints and deficiencies may be affecting 

the trends in quality data within these states. Specifically, figure 5 below 

illustrates this potential effect on the trends in the number of consumer 

Page 18 GAO-16-33 Nursing Home Quality
complaints reported and the number of serious deficiencies cited on 

standard surveys.

Figure 5: Examples in Selected States of Data Issues that May Have Affected Complaint and Deficiency Data, 2005 – 2014

Page 19 GAO-16-33 Nursing Home Quality

aNo relevant examples of data issues that may have affected complaint and deficiency data.
b

The economic recession began in December 2007 and ended in June 2009.

Nurse staffing: Although CMS data show that the average total nurse 

hours per resident day increased from 2009 through 2014, CMS does not 

have assurances that these data are accurate. CMS uses data on nurse 

staffing hours that are self-reported by the nursing homes, but the agency 

does not regularly audit these data to ensure their accuracy. CMS has 

conducted little auditing of staffing data outside of when state survey 

agency surveyors are on-site for inspections, and as a result may be less 

likely to identify intentional or unintentional inaccuracies in the selfreported data.

Page 20 GAO-16-33 Nursing Home Quality

26 Many of the regional office and state survey agency 

officials we spoke with expressed concern over the self-reported nature of 

these data, noting that it may be easy to misrepresent nurse staff hours. 

For instance, one state survey agency stated that nursing home residents 

would sometimes tell surveyors that the high numbers of staff on site 

during the survey were not normally present and other regional office and 

state survey agency officials noted that some homes will “staff up” when 

expecting a standard survey in order to make their staffing levels look 

better.

Although provisions in PPACA required nursing homes to submit staffing 

information based on payroll and other verifiable and auditable data in a 

uniform format by March 2012, CMS did not develop a system to begin 

collecting data by that date. According to CMS officials, CMS did not 

receive funding to develop the electronic payroll-based data system until 

the IMPACT Act, enacted in October 2014, provided the necessary multiyear funding. In April 2015 CMS issued a memo outlining a plan to begin

collecting staffing data through its payroll-based system on a voluntary 

basis beginning October 2015 and on a mandatory basis beginning July 

2016. In August 2015, CMS issued a final rule confirming this timetable 

for implementation. According to CMS, the new payroll-based staffing 

data system will allow homes to directly upload payroll data or to 

manually enter the required information. CMS indicated that the system 

will allow staffing and census information to be collected on a regular and 

more frequent basis than under the previous method. In addition, CMS 

expects the system to be auditable to check accuracy. However, as of 

 

26In 2015, CMS included an assessment of the staffing levels of selected nursing homes 

in an audit of another data set. The goal of the assessment was to verify the self-reported 

data reported during the standard survey and identify the staffing levels at a different point 

in the year. 
August 2015, CMS had not developed an audit plan and said that it was 

too soon in the implementation of the new system to do so. While 

updating the method for collecting staffing data could improve data 

quality, it is still necessary to audit the data to ensure accuracy.

Selected quality measures: Although nursing homes generally improved 

their performance on the eight selected quality measures we reviewed, it 

is unclear to what extent this can be attributed to a change in quality or 

possible inaccuracies in self-reported data. As previously noted, these 

improvements indicate a reduction in reported quality problems at nursing 

homes from 2011 through 2014. However, like the nurse staffing data 

used by CMS, data on nursing homes’ performance on these measures 

are self-reported by nursing homes, and until 2014 CMS conducted little 

to no auditing of these data to ensure their accuracy. As a result, CMS 

has no assurance that nursing homes’ reported performance on these 

measures are accurate improvements. Some regional office and state 

survey agency officials told us that public reporting may provide an 

incentive for nursing homes to make quality improvements on these 

measures. However, some officials noted that nursing homes may 

change how they collect and report data on the measures, leading to 

improvements in measures without corresponding improvements in actual 

quality.

CMS has begun taking steps to help mitigate the problem with selfreported data by starting to audit the data through focused surveys. For 

the surveys, CMS selected a sample of nursing homes in each state for 

state survey agency surveyors to evaluate whether the self-reported

quality data matches the residents’ medical records. CMS guidance 

states that data inaccuracies found during the focused surveys can result 

in deficiency citations to the nursing homes. These new surveys were 

piloted in 2014 for a sample of five homes in each of the five states and 

the pilot found some inconsistencies between self-reported data and 

residents’ medical records. In 2015, CMS expanded the focused surveys 

to include some homes in each state. According to agency officials, the 

2015 focused surveys will be completed by the end of the fiscal year. 

CMS officials stated that they intend to continue the focused surveys 

nationwide in 2016. The agency did not state firm plans after 2016, so it is 

uncertain whether the necessary auditing will continue.

Collectively, these data issues have broader implications related to 

nursing home quality trends, including potential effects on the quality 

benchmarks CMS sets, consumers’ decisions about which nursing home 

to select, and Medicare payments to the homes. Specifically, CMS 

Page 21 GAO-16-33 Nursing Home Quality
established benchmarks for some of its quality data through its Five-Star 

Rating System, which indicates the specific staffing levels and quality 

measure scores a home needs to receive each star rating. In addition, 

consumers can use the Five-Star ratings to help determine which nursing 

home to use. Therefore, underlying problems with the data may affect the 

benchmarks a nursing home uses to assess its quality performance, the 

ratings a home receives, and the home a consumer selects. Furthermore, 

data used by CMS to assess quality measures are also used when 

determining Medicare payments to nursing homes, so data issues—and 

CMS’s internal controls related to the data—could affect the accuracy of 

payments. Moreover, the use of quality data for payment purposes will 

expand in fiscal year 2019 when a nursing home value-based purchasing 

program will be implemented, which will increase or reduce Medicare 

payments to nursing homes based on certain quality measures.

In recent years CMS has made numerous modifications to its nursing 

home oversight activities. Some of these modifications expanded or 

added new oversight activities. For example, as previously described, 

CMS has introduced, evaluated, and, ultimately, suspended additional 

implementation of the QIS survey methodology to additional states; 

begun implementing the PPACA requirement to collect and report data on 

nurse staffing hours; and begun implementing a process for auditing 

quality measure data. In addition, CMS has also expanded the number of 

tools available to state surveyors when investigating medication-related 

adverse events, increased the amount of nursing home quality data

available to the public, and created new trainings for surveyors on 

unnecessary medication usage. (A summary of key oversight 

modifications CMS has made can be found in Appendix III.)

Other modifications have reduced existing oversight activities. For 

example, CMS has made modifications to the federal monitoring survey 

program and the Special Focus Facility program.

· Federal monitoring surveys: CMS has reduced the scope of the 

federal monitoring surveys regional offices use to evaluate state 

surveyors’ skills in assessing nursing home quality. CMS requires 

regional offices to complete federal monitoring surveys in at least 5 

percent of nursing homes surveyed by the state each year. Before 

2013, CMS required that 80 percent of these federal monitoring 

surveys be standard surveys—the most comprehensive type—which 

cover a broad range of quality issues within a nursing home. The 

remaining 20 percent of surveys were permitted to be either revisit or 

Page 22 GAO-16-33 Nursing Home Quality

CMS Has Modified 

Oversight Activities, 

But Has Not 

Monitored Potential 

Effect on Nursing 

Home Quality 

Oversight
complaint surveys, which are more narrow in scope. These surveys 

focus on a particular deficiency cited on a previous survey or a 

specific care issue for which a complaint was reported, respectively, 

and are also less-resource intensive as they take less surveyor time 

to complete than standard surveys. Starting in 2013, CMS required 

fewer federal monitoring surveys to be standard surveys and allowed 

more monitoring surveys to be revisits and complaint investigations.

· Special Focus Facilities: CMS has reduced the number of nursing 

homes participating in the SFF program. Nursing homes placed in the 

SFF program receive additional oversight because of the homes’ 

history of poor performance. For example, instead of being surveyed 

at least once every 15 months, SFF homes are surveyed at least once 

every 6 months. If homes do not improve the quality of their care, 

CMS can terminate their participation in Medicare and Medicaid. In 

2013, CMS began to reduce the number of homes in the program by 

instructing states to terminate homes that had been in the program for 

18 months without improvement and not to select replacements for 

these homes or homes that left the program by improving their 

performance. As we have previously reported, between 2013 and 

2014, the number of nursing homes in the SFF program dropped by 

more than half—from 152 to 62.

Page 23 GAO-16-33 Nursing Home Quality

27 In 2014, CMS began the process of 

re-building the number of facilities in the SFF program; however, 

according to CMS officials, the process will be slow (as of July 2015 

there were 85 SFF homes).

According to CMS officials, these reductions in the scope of CMS’s 

nursing home oversight activities were made in order to help the agency 

meet its increasing responsibilities with its limited resources. Specifically, 

CMS officials said that increasing oversight responsibilities, such as those 

required by PPACA, and a limited number of staff and financial resources 

at the central, regional, and state levels required the agency to evaluate 

its activities and reduce the scope of some activities. For example, CMS 

officials noted that reductions to the SFF program were made, 

specifically, as a result of the decrease in CMS’s budget under the 

Budget Control Act of 2011.

 

27GAO, 2013 Sequestration: Selected Federal Agencies Reduced Some Services and 

Investments, While Taking Short-Term Actions to Mitigate Effects, GAO-14-452

(Washington, D.C.: May 28, 2014).
The effect of CMS’s modifications in nursing home oversight activities is 

uncertain but could potentially be significant, especially because the 

modifications included reductions to activities that CMS considers 

essential to oversight. For example, by reducing the scope of federal 

monitoring surveys, CMS may be decreasing its ability to monitor state 

survey agencies—which is essential because they are one of CMS’s 

primary tools for assessing nursing home quality, and a lack of effective 

state oversight could, for example, lead to understatement of care 

problems. Similarly, by reducing the number of nursing homes in the SFF 

program, CMS may be limiting its ability to monitor nursing homes with 

poor performance. As previously noted, we found—both in our analysis 

for this report and in a prior report—that the number of homes with poor 

performance exceeds the number of homes included in the SFF program; 

a difference that is made even greater with the reduction to the SFF 

program.

Page 24 GAO-16-33 Nursing Home Quality

28

CMS officials said a variety of factors, including a review of statutory 

requirements, were considered prior to making modifications; however, 

the agency is not monitoring how the modifications might affect CMS’s 

ability to assess nursing home quality. Therefore, the agency is not able 

to determine whether the modifications are the most effective use of its 

limited resources for assessing nursing home quality. Under federal 

internal control standards, ongoing monitoring should occur in the course 

of normal program operations.29 When discussing the potential effects of 

the modifications, CMS officials acknowledged the potential for adverse 

impacts on their ability to oversee nursing home quality.

Just as CMS’s central office has made modifications to its nursing home 

oversight activities, regional offices and state survey agencies have made 

modifications to some of their own nursing home oversight activities—

both expansions and reductions. For example, state survey agency 

officials we interviewed from one of the states indicated that partly 

because of resource constraints, the state had reduced the number of 

standard surveys until the frequency between surveys for many nursing 

homes reached 36 months—instead of the required frequency of once 

every 15 months. Also, state survey agency officials from another state 

said that in part due to political changes at the state level their state 

 

28GAO-09-689.

29GAO/AMID-00-21.3.1.
survey agency modified its regulatory philosophy towards nursing homes; 

in speaking about this shift officials from the state survey agency noted 

that the modification resulted in state survey agency surveyors 

emphasizing more of a partner role with nursing homes rather than acting 

as a strict regulator.

Other officials described modifications that could be helpful to share with 

other regional offices and state survey agencies. For example, officials 

from one regional office described how they share staff with other 

regional offices in order to complete oversight activities—such as federal 

monitoring surveys—within required timelines. In addition, these regional 

office officials develop an annual report that includes oversight data for 

their region, which could be a useful template for other regions, 

particularly as officials from another regional office expressed the need 

for greater data analysis in their office. Given the tight resource 

environment, regional offices and state survey agencies could benefit 

from adopting strategies that other agencies have used to successfully 

meet their nursing home oversight requirements in an efficient and 

effective manner.

However, while CMS’s central office has some ways of collecting 

information from regional offices and state survey agencies, the agency 

does not have a national approach for routinely collecting such 

information on modifications to nursing home oversight activities—

whether positive or negative. CMS’s state performance standard system, 

which is intended to identify whether a state survey agency is generally 

compliant with CMS’s oversight requirements, may elicit isolated 

information on negative modifications when asking state survey agencies 

to explain poor performance. However, as currently designed, it does not 

routinely collect information on state survey agency modifications that 

could negatively impact nursing home oversight or provide examples of 

best practices. As a result, CMS does not have enough information to 

respond to state survey agency modifications—and make adjustments 

where needed—in an ongoing or timely manner. As we previously noted, 

under federal internal control standards, ongoing monitoring should occur 

in the course of normal program operations.

Page 25 GAO-16-33 Nursing Home Quality

30

 

30GAO/AMID-00-21.3.1. 
CMS collects several types of data that give some insight into the quality 

of nursing homes, and these data show mixed results. However, these 

data could provide a clearer picture of nursing home quality if some 

underlying problems with the data are corrected. CMS is in the process of 

taking steps to address some of these problems—such as the rollout of 

focused surveys to evaluate the data used in quality measures and plans 

to use and audit payroll data rather than self-reported data to determine 

nursing home staffing levels. If properly implemented, completion of these 

steps—as well as pursuing other, longer-term plans such as the eventual 

standardization of the survey methodology across all states—has the 

potential to make nursing home quality data more comparable and 

accurate, allowing more effective tracking of nursing home quality trends. 

However, without specific timeframes with milestones to track 

implementation of a standardized survey methodology and clear ongoing 

audit plans, it is unclear whether these important steps will occur. Federal 

internal control standards require agencies to monitor performance data 

to assess the quality of performance over time, and CMS’s ability to do so 

is hindered by data issues. Timely completion of these actions is 

particularly important because Medicare payments to nursing homes will 

be dependent on quality data, through the implementation of the value 

based purchasing program, starting in fiscal year 2019.

In addition to problems with the data used to measure nursing home 

quality, according to CMS officials, the agency faces the challenge of 

conducting effective oversight of nursing home quality with its limited 

resources, while meeting all of its oversight requirements. CMS has made 

modifications to some activities it considered essential to its oversight, 

without knowing whether the modifications have affected the agency’s 

ability to assess nursing home quality. Further, some modifications made 

by CMS regional offices and state survey agencies to their own nursing 

home oversight activities could adversely affect the CMS central office’s 

ability to oversee nursing home quality, while other modifications could be 

effective strategies that could be adopted more widely among regional 

offices and state survey agencies. Consistent with federal internal control 

standards, establishing an effective process for monitoring modifications 

of essential oversight activities made at the CMS central office, CMS 

regional office, and state survey agency levels—whether positive or 

negative—could allow CMS to better understand the effects these 

modifications may have on nursing home quality and make improvements 

to its own oversight.

Page 26 GAO-16-33 Nursing Home Quality

Conclusions
To improve the measurement of nursing home quality, the Administrator 

of CMS should take the following two actions:

· Establish specific timeframes, including milestones to track progress, 

for the development and implementation of a standardized survey 

methodology across all states.

· Establish and implement a clear plan for ongoing auditing to ensure 

reliability of data self-reported by nursing homes, including payrollbased staffing data and data used to calculate clinical quality 

measures.

To help ensure modifications of CMS’s oversight activities do not 

adversely affect the agency’s ability to assess nursing home quality and 

that effective modifications are adopted more widely, the Administrator of 

CMS should establish a process for monitoring modifications of essential 

oversight activities made at the CMS central office, CMS regional office, 

and state survey agency levels to better understand the effects on 

nursing home quality oversight.

We provided a draft of this report to HHS for its review and comment. 

HHS provided written comments, which are reprinted in appendix IV. In its 

written comments, HHS described its efforts to improve nursing home 

quality. HHS also concurred with the report’s three recommendations. To 

address our first recommendation, HHS stated that it would set 

timeframes and milestones for the development and implementation of a 

standardized survey methodology. To address our second 

recommendation, HHS stated that it would continue to work to address 

the reliability of self-reported data by, for example, continuing through 

fiscal year 2017 the auditing of clinical quality measures data, which 

began in fiscal year 2015. As we describe in this report, ongoing auditing 

of self-reported data is important for ensuring data accuracy; as a result, 

whenever self-reported data are used for understanding nursing home 

quality—including the new electronic payroll system for collecting staffing 

data and data used to calculate clinical quality measures—our 

recommendation indicates that HHS should plan for and conduct audits in 

a continuing manner. To address our third recommendation, HHS stated 

that it would review its monitoring of key oversight activities and make 

adjustments as indicated. HHS also provided technical comments, which 

we incorporated into the final version of this report as appropriate.

Page 27 GAO-16-33 Nursing Home Quality

Recommendations

Agency Comments
As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution of it until 30 days from its 

date. At that time, we will send copies to the Secretary of Health and 

Human Services. In addition, the report will be available at no charge on 

the GAO website at http://www.gao.gov.

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

me at (202) 512-7114 or kohnl@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix IV.

Linda T. Kohn

Director, Health Care

Page 28 GAO-16-33 Nursing Home Quality
List of Requesters

The Honorable Ron Wyden

Ranking Member

Committee on Finance

United States Senate

The Honorable Frank Pallone, Jr.

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Sander M. Levin

Ranking Member

Committee on Ways and Means

House of Representatives

The Honorable Jim McDermott

Ranking Member

Subcommittee on Health

Committee on Ways and Means

House of Representatives

The Honorable Janice Schakowsky

House of Representatives

Page 29 GAO-16-33 Nursing Home Quality
Appendix I: Additional Detail on Analysis

This appendix describes our scope and methodology for examining the 

extent to which reported nursing home quality has changed in recent 

years and the factors that may have affected any observed changes. For 

this examination, we analyzed four sets of quality data from the Centers 

for Medicare & Medicaid Services (CMS). Each set of data provide an 

important perspective on quality and together can give a multidimensional view of potential changes in nursing home quality over time.

We analyzed the four sets of data at both the national and state level for 

the time periods identified below, which represent the most recent data 

available for a ten-year period or its closest equivalent. At the national 

level we collected and analyzed data for all 50 states and Washington, 

D.C. At the state level we selected five states to focus our review—

California, Florida, Massachusetts, Michigan, and West Virginia—based 

on factors such as variation in geographic region, size (number of nursing 

homes), and state performance standard scores.

Deficiencies cited on standard surveys. To identify trends in the 

number of serious deficiencies—deficiencies at the actual harm or 

immediate jeopardy levels—cited during nursing home standard surveys, 

we analyzed data from CMS’s Certification and Survey Provider 

Enhanced Reports system for years 2005 through 2014. Specifically, we 

calculated the number of serious deficiencies cited during standard 

surveys in each year.

Consumer complaints. To identify trends in the number of consumer 

complaints regarding resident care or safety reported by residents, 

families, ombudsmen, or others, we analyzed data from CMS’s 

Automated Survey Processing Environment Complaint/Incident Tracking 

System.

Page 30 GAO-16-33 Nursing Home Quality

1 Specifically, we calculated the total number of complaints 

reported—not substantiated—for all nursing homes for years 2005 

through 2014.

Nurse staffing. To identify trends in nurse staffing data, specifically the 

number of nursing hours per resident day, we analyzed data from CMS’s 

Certification and Survey Provider Enhanced Reports. Specifically, we 

collected quarterly staffing data on the nursing hours per resident day for 

 

1We did not include facility reported incidents—incidents that nursing homes report to 

state survey agencies and that are also recorded in the Automated Survey Processing 

Environment Complaint/Incident Tracking System—in this analysis. 

Appendix I: Additional Detail on Analysis
Appendix I: Additional Detail on Analysis

years 2009 through 2014, calculated an average nurse staffing level, and 

used CMS’s formula to create adjusted nurse staffing levels.

Page 31 GAO-16-33 Nursing Home Quality

2

Clinical quality measures. To identify trends in clinical quality measures, 

we analyzed data from CMS’s Minimum Data Set—the data set 

containing the standardized clinical assessments nursing homes 

complete for all residents and report to CMS—for years 2011 through 

2014.3 We selected eight CMS quality measures to include in our analysis 

based on factors such as endorsement by the National Quality Forum and 

data reliability. Six of the eight measures are used by CMS for long-stay 

residents—the percentage of residents who report moderate to severe 

pain; the percentage of high-risk residents with pressure ulcers; the 

percentage of residents who lose too much weight; the percentage of 

residents who were physically restrained; the percentage of residents 

experiencing one or more falls with major injury; and the percentage of 

residents who received antipsychotic medication—and the remaining two 

measures are used for short-stay residents—the percentage of residents 

who report moderate to severe pain and the percentage of residents with 

pressure ulcers that are new or worsening. To create an annual score for 

each quality measure we averaged quarterly data.

Analysis across four data sets. For each of the four data sets, we 

ranked nursing homes by quartile and identified those at the upper 

quartile (worst performing) and lower quartile (best performing) for each 

year. We then counted the number of years each home fell into the upper 

or lower quartile for each quality measure to identify homes with 

consistently poor or good performance. We then identified homes with 

poor or good performance across all data sets. We also received a list 

from CMS of all Special Focus Facilities (SFF) for 2005 through 2014 to 

identify how many of the poor performers were or had been in the SFF 

program. Finally, we attempted to identify any commonalities among 

homes that consistently performed poorly compared to homes that 

 

2

In 2009 CMS modified its method of determining nursing home staffing. Previously, CMS 

simply used the staff information each home reported during its standard survey. 

However, staffing needs vary depending on the needs of the residents in the nursing 

homes. So, in 2009, CMS introduced a calculation to adjust the staffing information 

reported by the severity and resource needs of the residents in each nursing home. 

Therefore, adjusted staffing information is not available prior to 2009.

3

In 2010 CMS implemented significant changes in its Minimum Data Set clinical 

assessments, which limit the ability to compare data after 2010 with earlier years’ data.
Appendix I: Additional Detail on Analysis

performed well across the four data sets; for example, using Certification 

and Survey Provider Enhanced Reports files for each home, we 

examined bed size, non-profit or for-profit status, and urban or rural 

location (using zip codes and the Health Resources and Services 

Administration’s Area Resource File).

We assessed the reliability of each of the four sets of data and 

determined that they were sufficiently reliable for purposes of describing 

trends through interviews with knowledgeable CMS officials, reviews of 

supporting documentation, and comparisons with other published data.

Page 32 GAO-16-33 Nursing Home Quality
Appendix II: State Quality Data Trends in 

Recent Years

Tables 3-5 provide state-level data for each of the four data sets. 

Specifically, Table 3 provides deficiencies cited on standard surveys and 

consumer complaint data, Table 4 provides nurse staffing data, and Table 

5 provides selected quality measure data.

Table 3: Serious Deficiencies and Consumer Complaints, by State, 2005 and 2014 

Page 33 GAO-16-33 Nursing Home Quality

Average number of serious deficiencies per 

nursing home cited on standard surveys

Average number of consumer complaints per 

nursing home

2005 2014

Percentage 

change 2005 2014

Percentage 

change

AK 0.08 0.50 500.0% 0.6 1.3 107.4%

AL 0.48 0.07 -85.3 2.6 1.2 -52.8

AR 0.57 0.11 -80.4 3.3 3.1 -8.3

AZ 0.44 0.39 -13.3 5.3 9.3 75.4

CA 0.16 0.10 -37.5 1.1 5.0 353.5

CO 0.77 0.30 -60.5 1.9 1.7 -9.7

CT 0.82 0.40 -50.7 1.3 1.6 20.4

DC 0.45 0.53 17.6 1.9 3.6 88.4

DE 0.34 0.10 -72.1 4.5 3.2 -28.4

FL 0.08 0.09 15.7 2.6 3.4 29.4

GA 0.53 0.20 -62.1 3.3 3.1 -7.9

HI 0.00 0.24 —

a

0.2 0.5 133.3

IA 0.14 0.15 12.3 1.8 1.7 -3.3

ID 0.81 0.58 -28.2 1.4 1.2 -20.1

IL 0.29 0.21 -28.3 5.2 5.9 14.2

IN 0.58 0.16 -72.3 3.2 3.3 1.6

KS 0.90 0.31 -64.9 2.9 2.7 -6.9

KY 0.20 0.32 54.4 2.6 2.3 -9.1

LA 0.52 0.04 -91.9 2.6 2.0 -21

MA 0.47 0.30 -35.9 0.9 1.1 16.8

MD 0.08 0.14 68.1 5.7 6.1 5.9

ME 0.15 0.06 -59.6 2.6 2.9 12.9

MI 0.42 0.23 -45.9 2.4 5.8 137.7

MN 0.30 0.11 -63.4 1.6 1.1 -33.7

MO 0.29 0.12 -58.8 6.6 7.9 19.4

MS 0.37 0.21 -43.2 1.3 1.4 12.9

MT 0.33 0.26 -20.1 0.9 0.8 -7.1

NC 0.42 0.18 -56.9 4.9 4.9 0.1

Appendix II: State Quality Data Trends in 

Recent Years
Appendix II: State Quality Data Trends in 

Recent Years

Page 34 GAO-16-33 Nursing Home Quality

Average number of serious deficiencies per 

nursing home cited on standard surveys

Average number of consumer complaints per 

nursing home

2005 2014

Percentage 

change 2005 2014

Percentage 

change

ND 0.41 0.51 25.0 0.2 0.6 183.3

NE 0.25 0.23 -6.2 1.8 2.8 51.6

NH 0.58 0.02 -96.6 1.1 2.8 149.0

NJ 0.37 0.19 -47.9 6.4 3.9 -39.0

NM 0.79 0.94 19.0 14.6 0.7 -94.9

NV 0.29 0.40 36.7 14.3 3.9 -72.5

NY 0.32 0.13 -61.0 5.9 7.2 23.6

OH 0.19 0.11 -44.1 2.6 2.9 10.6

OK 0.47 0.40 -15.7 2.7 4.1 49.7

OR 0.64 0.15 -76.2 2.7 2.4 -11.5

PA 0.22 0.14 -35.7 0.0 2.4 —

a

RI 0.18 0.02 -88.8 4.9 4.3 -11.4

SC 0.63 0.25 -61.3 0.8 1.1 45.3

SD 0.33 0.40 22.4 0.0 0.7 —

a

TN 0.40 0.43 7.3 3.3 2.0 -38.6

TX 0.33 0.30 -9.1 7.0 7.2 3.1

UT 0.50 0.40 -20.5 3.7 1.6 -56.0

VA 0.33 0.29 -11.8 2.9 1.6 -43.9

VT 0.58 0.23 -59.9 3.3 4.0 18.9

WA 0.52 0.13 -75.5 2.3 8.9 287.6

WI 0.35 0.38 10.3 2.1 2.7 26.2

WV 0.17 0.32 89.3 2.4 1.7 -25.7

WY 0.11 0.40 260.0 2.2 3.6 60.9

National 0.35 0.21 -40.6 3.2 3.9 21.0

Source: GAO analysis of CMS data. | GAO-16-33

aA percentage change cannot be calculated when the original value is zero.
Appendix II: State Quality Data Trends in 

Recent Years

Table 4: Nurse Staffing Hours, by State, 2009 and 2014

Page 35 GAO-16-33 Nursing Home Quality

Total nurse staffing hours per 

resident per daya

Total registered nurse staffing hours per 

resident per day

2009 2014

Percentage 

change 2009 2014

Percentage 

change

AK 8.2 8.3 1.2% 2.3 2.5 8.3%

AL 4.5 5.0 11.3 0.4 0.7 73.4

AR 4.7 5.2 10.6 0.4 0.6 56.2

AZ 4.3 4.9 15.1 0.5 0.9 76.4

CA 4.4 5.0 12.3 0.5 0.8 60.8

CO 4.4 4.8 9.6 0.7 1.1 51.0

CT 4.4 4.7 6.5 0.7 1.0 38.1

DC 5.3 5.9 10.4 0.8 1.3 65.9

DE 5.1 5.4 5.8 0.9 1.3 48.5

FL 4.7 4.9 4.6 0.4 0.7 67.2

GA 3.8 4.1 8.1 0.3 0.5 64.3

HI 4.8 6.1 26.6 1.1 1.8 65.9

IA 4.0 4.6 15.9 0.6 1.0 54.7

ID 5.3 5.3 1.2 0.7 1.1 48.4

IL 4.0 4.3 8.8 0.6 0.9 44.5

IN 4.0 4.5 12.6 0.5 0.8 77.1

KS 4.4 5.0 13.7 0.6 0.9 52.3

KY 4.3 4.6 5.1 0.5 0.8 48.6

LA 4.0 4.3 8.5 0.3 0.5 38.3

MA 4.3 4.7 9.3 0.7 1.0 49.7

MD 4.2 4.7 12.2 0.5 0.9 71.0

ME 4.6 4.9 8.0 0.8 1.2 46.8

MI 4.2 4.7 12.1 0.5 0.8 61.1

MN 4.1 4.6 12.4 0.6 0.9 63.5

MO 4.4 4.9 10.4 0.4 0.7 56.7

MS 4.5 4.7 5.2 0.5 0.8 50.5

MT 4.6 5.0 8.0 0.8 1.2 50.3

NC 4.2 4.5 5.1 0.5 0.7 32.4

ND 4.9 5.3 8.2 0.7 1.0 38.7

NE 4.6 5.0 8.4 0.6 0.9 44.3

NH 4.7 4.9 3.6 0.8 1.1 38.7

NJ 4.0 4.4 11.8 0.6 0.9 55.4

NM 4.0 3.8 -4.9 0.6 0.7 23.7
Appendix II: State Quality Data Trends in 

Recent Years

Page 36 GAO-16-33 Nursing Home Quality

Total nurse staffing hours per 

resident per daya

Total registered nurse staffing hours per 

resident per day

2009 2014

Percentage 

change 2009 2014

Percentage 

change

NV 4.4 4.5 3.1 0.7 1.0 33.4

NY 4.0 4.2 7.1 0.5 0.7 32.7

OH 4.0 4.2 5.4 0.5 0.7 44.0

OK 4.6 4.8 5.3 0.4 0.5 32.6

OR 4.7 5.1 8.6 0.7 0.9 34.4

PA 3.8 4.2 10.6 0.5 0.8 46.9

RI 4.1 4.4 6.6 0.7 1.0 45.3

SC 4.4 4.9 11.5 0.5 0.9 67.8

SD 4.0 4.4 9.7 0.7 1.0 38.3

TN 3.9 4.3 12.6 0.4 0.7 59.6

TX 4.1 4.2 3.6 0.4 0.5 40.4

UT 4.5 4.6 3.1 0.8 1.1 48.3

VA 4.2 4.7 12.1 0.5 0.8 61.0

VT 4.2 4.7 10.6 0.6 1.0 59.2

WA 4.3 4.7 11.2 0.6 1.1 69.6

WI 4.1 4.6 13.0 0.6 1.0 61.9

WV 4.1 4.4 6.7 0.5 0.8 44.2

WY 4.5 4.7 2.8 0.8 1.1 32.3

National 4.2 4.6 9.0 0.5 0.8 51.2

Source: GAO analysis of CMS data. | GAO-16-33

Note: We used adjusted nurse staffing hours for all analyses.

a

Total nurse staffing hours is a measure of registered nurse, licensed practical nurse, and nurse 

assistant hours.
Appendix II: State Quality Data Trends in 

Recent Years

Table 5: Percentage Change in Selected Clinical Quality Measures, by State, 2011 - 2014

Page 37 GAO-16-33 Nursing Home Quality

Percentage change

Long-stay 

residents 

who selfreport 

moderate to 

severe pain

Long-stay 

high-risk 

residents 

with 

pressure 

ulcers

Long-stay 

residents 

who lose 

too much 

weight

Long-stay 

residents 

who were 

physically 

restrained

Long-stay 

residents 

with one or 

more falls 

resulting in 

major injury

Long-stay 

residents 

who received 

antipsychotic 

medication

Short-stay 

residents 

who selfreport 

moderate to 

severe pain

Short-stay 

residents 

with new or 

worsened 

pressure 

ulcers

AK -32.7% 24.6% 11.9% -9.0% -7.4% -30.6% 23.9% 17.0%

AL -39.5 -12.5 6.5 -24.8 -1.5 -17.8 -17.4 -50.6

AR -41.2 -19.9 4.5 -57.3 -1.8 -17.0 -14.3 -49.4

AZ -43.5 -23.6 -8.1 -56.3 -12.1 -20.4 -25.8 -57.3

CA -47.4 -17.8 2.9 -58.5 -7.8 -27.3 -31.7 -57.2

CO -29.7 -21.5 -8.1 -58.9 -10.5 -14.8 -20.0 -58.9

CT -36.7 -15.9 -2.5 -36.2 -4.2 -21.5 -15.5 -47.6

DC -45.1 -11.9 -8.8 -55.1 -44.7 -22.9 -37.4 -60.7

DE -30.7 -17.9 -1.1 -54.3 22.6 -28.1 -17.3 -33.6

FL -44.1 -10.0 -1.6 -47.4 -10.6 -12.6 -26.0 -58.9

GA -38.1 -8.2 -0.8 -42.4 -5.3 -27.8 -20.3 -53.0

HI -28.0 -23.4 2.7 -43.4 -21.5 -9.2 -20.5 -67.8

IA -31.8 -8.2 0.1 -47.7 -13.1 -11.0 -8.6 -35.9

ID -43.2 -32.7 -16.9 -43.1 17.5 -26.5 -30.1 -68.1

IL -34.7 -18.7 -6.9 -55.8 -7.2 -8.3 -16.9 -52.6

IN -33.6 -12.8 6.2 -46.1 -8.0 -16.8 -14.6 -46.1

KS -26.9 -14.3 6.4 -16.3 -4.5 -15.8 -12.5 -56.6

KY -34.7 -9.8 -2.2 -39.2 6.6 -17.2 -13.9 -49.2

LA -40.2 -16.4 6.1 -52.3 -6.2 -12.9 -14.4 -52.3

MA -33.3 -19.1 -4.7 -40.8 -6.9 -21.3 -13.4 -47.8

MD -31.0 -12.3 0.0 -43.2 -14.5 -17.3 -14.7 -50.2

ME -32.6 -14.7 -6.7 -38.2 9.0 -23.6 -8.1 -51.0

MI -35.6 -12.9 0.1 -42.1 -7.2 -13.9 -19.6 -55.0

MN -28.9 -8.6 -3.8 -42.5 -4.0 -17.4 -6.4 -53.1

MO -38.0 -20.6 -6.7 -56.6 -6.3 -14.4 -18.8 -52.3

MS -29.9 -5.3 14.7 -27.1 -10.9 -12.2 -10.8 -53.4

MT -31.0 -3.2 -4.5 -45.7 -10.2 -16.1 -15.9 -28.7

NC -34.9 -7.9 5.6 -48.9 -3.0 -27.3 -18.1 -49.8

ND -30.9 -23.8 -10.8 -57.6 -9.6 -13.6 -15.9 -48.6

NE -33.5 -13.3 -6.0 -58.4 -8.4 -1.8 -16.6 -48.7

NH -27.2 -21.1 4.7 -39.8 -4.0 -23.2 -16.3 -45.7
Appendix II: State Quality Data Trends in 

Recent Years

Page 38 GAO-16-33 Nursing Home Quality

Percentage change

Long-stay 

residents 

who selfreport 

moderate to 

severe pain

Long-stay 

high-risk 

residents 

with 

pressure 

ulcers

Long-stay 

residents 

who lose 

too much 

weight

Long-stay 

residents 

who were 

physically 

restrained

Long-stay 

residents 

with one or 

more falls 

resulting in 

major injury

Long-stay 

residents 

who received 

antipsychotic 

medication

Short-stay 

residents 

who selfreport 

moderate to 

severe pain

Short-stay 

residents 

with new or 

worsened 

pressure 

ulcers

NJ -48.1 -20.2 -4.8 -37.3 -13.3 -16.4 -27.8 -54.8

NM -37.4 -20.0 -13.4 -72.3 -3.6 -20.1 -19.9 -42.7

NV -22.7 -20.0 -14.9 -48.9 -13.6 -6.5 -25.5 -56.2

NY -36.3 -11.2 -2.6 -30.7 -12.1 -15.7 -21.8 -52.3

OH -46.1 -15.8 -4.0 -57.8 -2.8 -13.5 -23.6 -52.5

OK -33.9 0.2 14.1 -54.4 -0.8 -18.8 -14.2 -48.5

OR -30.6 -11.7 -4.5 -68.8 1.2 -11.9 -12.9 -45.7

PA -31.2 -17.5 -2.6 -43.6 -1.7 -17.4 -11.8 -50.0

RI -33.2 -15.9 -2.9 -78.7 -15.2 -27.4 -14.5 -30.4

SC -38.8 -16.1 -3.7 -42.0 -6.4 -26.1 -23.3 -46.7

SD -34.8 -13.4 -1.4 -51.3 2.3 -17.4 -1.8 -61.9

TN -45.9 -18.3 -0.9 -44.9 1.9 -22.4 -18.6 -57.2

TX -33.0 -10.5 -4.4 -46.8 -7.4 -9.1 -18.2 -54.4

UT -50.2 -24.4 -6.5 -49.6 -6.4 -19.5 -32.7 -56.0

VA -33.3 -15.8 -3.2 -32.5 -9.8 -17.1 -14.0 -57.5

VT -29.0 -15.2 2.1 -84.5 -3.5 -27.0 -8.7 -66.0

WA -36.1 -10.6 -10.1 -18.2 -8.6 -17.4 -23.6 -48.5

WI -27.2 -15.3 -2.5 -32.9 -0.7 -17.3 -10.2 -52.5

WV -37.6 -22.9 3.0 -29.7 7.2 -19.1 -12.2 -61.1

WY -38.6 -27.8 -4.8 -52.6 -12.9 -8.5 -14.5 -50.8

National -36.9 -14.1 -1.3 -47.9 -5.7 -16.6 -19.0 -52.2

Source: GAO analysis of CMS data. | GAO-16-33

Note: The long-stay quality measures are for residents with equal to or greater than 101 cumulative 

days in the nursing home, and the short-stay measures are for residents with less than or equal to 

100 cumulative days in the nursing home.
Appendix III: Summary of Key Nursing Home 

Oversight Changes CMS Made from 2005 

through 2014

CMS divides its nursing home activities into six dimensions—with the 

agency considering four of these dimensions “essential” and two “highly 

advisable”. In recent years, CMS has made adjustments to oversight 

activities within all dimensions.

Table 6: CMS-Defined Categories of Oversight and Examples of Key Oversight Changes Cited by Agency, 2005 through 2014

Page 39 GAO-16-33 Nursing Home Quality

Dimensions of 

oversight Dimension description Examples of key changes in recent years

Essential 

Surveys and complaint 

investigations

Oversight of state survey agencies 

and CMS regional offices conducting 

standard surveys, revisit surveys, 

federal monitoring surveys, and 

complaint investigations.

· In 2005, CMS provided states with guidance on complaint 

prioritization using the Automated Survey Processing 

Environment Complaint/Incident Tracking System, which it 

began implementing in 2004.

· In 2005, CMS introduced the Quality Indicator Survey (QIS) to 

improve the consistency and accuracy of surveys. Citing 

resource constraints and program evaluation results, CMS 

suspended additional implementation of QIS in 2012.

· In 2006, CMS redesigned its state performance standards 

system to include measures on the quality of surveys and 

enforcement actions taken by states in addition to the 

frequency of surveys.

· Starting in 2013, CMS reduced the number of standard surveys 

that regional offices needed to complete in order to meet the 

federal monitoring survey requirements.

· Starting in 2013, CMS hired contractors to assist regional office 

staff in meeting some of their oversight responsibilities, such as 

completing federal monitoring surveys.

· CMS revised surveyor guidance in several areas, including: 

unnecessary medication usage (2006 and 2013), infection 

control (2010), and feeding tubes (2012).

Standards Standards outlining basic public 

expectations for quality and safety. 

· In 2011, CMS issued guidance to state survey agencies 

regarding the Patient Protection and Affordable Care Act 

(PPACA) requirement that nursing homes and other long term 

care facilities report reasonable suspicion of a crime against a 

resident or a patient of the facility.

· In 2011, CMS published regulations implementing additional 

requirements for civil monetary penalties.

· In 2013, CMS ended the five year phase-in of the requirement 

for all long term care facilities to have automatic sprinklers. 

Facilities may apply for an extension of the deadline for up to 

three years.

· In 2013, CMS published regulations regarding requirements for 

facility closure.

· In 2015, per the Improving Medicare Post-Acute Care 

Transformation Act of 2014 (IMPACT Act), CMS published a 

final rule implementing a new quality reporting program for 

nursing homes under Medicare.

· In July 2015, per PPACA, CMS published a proposed rule that 

Appendix III: Summary of Key Nursing Home

Oversight Changes CMS Made from 2005

through 2014
Appendix III: Summary of Key Nursing Home 

Oversight Changes CMS Made from 2005 

through 2014

Page 40 GAO-16-33 Nursing Home Quality

Dimensions of 

oversight Dimension description Examples of key changes in recent years

would revise the requirements that long term care facilities 

must meet to participate in the Medicare and Medicaid 

programs, including requirements for compliance and ethics 

programs, dementia management and abuse prevention 

training for nurses’ aides, and quality assurance and 

performance improvement programs. In addition, revisions to 

the discharge planning requirements were proposed to 

implement the discharge planning requirements mandated by 

the IMPACT Act

· In July 2015, per PPACA, CMS published a proposed rule that 

would require facilities to establish policies and procedures to 

ensure compliance with the Elder Justice Act, which requires 

reporting of reasonable suspicion of a crime against a resident 

or anyone receiving care from a nursing home.

Remediation and 

Enforcement

The timely remediation of 

deficiencies; deterrence of abuse, 

neglect, and poor quality; and the 

prevention of reoccurring adverse 

events through systematic 

improvements. 

· Starting in 2007, CMS began using systems improvement 

agreements as a way for nursing homes to acquire the 

appropriate expertise and implement quality assurance and 

performance improvement practices in order to improve quality 

of care before being terminated from Medicare.

· In 2011, per PPACA, CMS began publicly reporting 

enforcement information on the Nursing Home Compare 

website.

· In 2013, CMS began reducing the number of facilities in the 

Special Focus Facility program by advising states to complete 

final surveys for facilities not showing signs of improvement 

and not to enroll new facilities into the program. The program 

targets consistently poor performing facilities for increased 

survey frequency and quality improvement.

· In 2013, CMS implemented the civil monetary penalty tool and 

required all regional offices to use the tool to help promote 

consistent application of penalties.

Education and training Education of surveyors and providers 

to promote adherence to standards, 

quality improvement, competency, 

and consistency.

· In 2006, CMS provided training to regional office and state 

survey agency staff on guidance related to unnecessary 

medications. In 2013, CMS provided additional training to state 

survey agency staff.

· In 2007, CMS provided facilities with emergency preparedness 

tools and checklists. In 2014, CMS updated the emergency 

preparedness checklist.

· In 2012, CMS established the National Partnership to Improve 

Dementia Care to address the issue of high use of 

antipsychotic medications in the nursing home population, 

especially among residents with dementia. As part of the 

partnership, CMS updated its guidance to surveyors on 

identifying deficient practices related to dementia care and 

antipsychotic medication use in 2013. In addition, CMS 

released three mandatory trainings for surveyors in 2013 

focusing on dementia care and antipsychotic medications and 

distributed training materials on dementia care to all nursing 

homes in the country.

· In 2013, per PPACA, CMS published guidance to assist 
Appendix III: Summary of Key Nursing Home 

Oversight Changes CMS Made from 2005 

through 2014

Page 41 GAO-16-33 Nursing Home Quality

Dimensions of 

oversight Dimension description Examples of key changes in recent years

nursing homes in meeting regulatory requirements related to 

quality assurance and performance improvement.

· In 2015, CMS developed the Adverse Drug Event Trigger Tool 

to assist surveyors in investigating preventable medication 

related adverse events, and evaluate whether or not nursing 

homes have systems in place to prevent them. CMS also is 

piloting a focused survey on medication safety systems in 

response to the 2014 Department of Health & Human Services’ 

Office of the Inspector General’s report “A Call to Action –

Adverse Events in Nursing Homes: National Incidence Among 

Medicare Beneficiaries”.

Highly advisable

Quality measurement Measuring discrete aspects of care 

through a continuous stream of 

performance information. 

· In 2009, CMS worked on improving pressure ulcer rates 

through its contracts with Quality Improvement Organizations, 

and published a list of 4,000 nursing homes that have a higher 

than expected pressure ulcer rate.

· Starting in 2008, CMS incorporated data on in-dwelling 

catheter use into the Five-Star Quality Rating System.

· In 2010, CMS implemented changes intended to improve and 

increase efficiency of data reports for its Minimum Data Set 

clinical assessments.

· In 2011 and 2014, CMS added a quality improvement measure 

to the Quality Improvement Organizations’ statement of work 

focusing on reducing the number of beneficiaries that are using 

anti-psychotic drugs and are prescribed potentially 

inappropriate medications.

· In 2011, CMS added a measure to the Quality Improvement 

Organizations’ statement of work to reduce the use of physical 

restraints in beneficiaries in long-stay nursing homes.

· In 2012, CMS conducted an environmental scan of state 

survey agencies to determine how current nursing home 

healthcare acquired infection programs operate and identify 

best practices.

· In 2014, CMS implemented a pilot of its Minimum Data Set 

focused survey. The purpose of the pilot was to assess coding 

practices and identify discrepancies between data in the 

Minimum Data Set and medical records. CMS expanded the 

surveys nationwide in 2015.

· In 2015, per PPACA, CMS began developing a process for 

collecting staffing data through its payroll-based system. CMS 

plans to collect data on a voluntary basis beginning in October 

2015 and on a mandatory basis beginning July 2016.

Alignment and 

partnering

Alignment of strategies, partnering 

with stakeholders, and use of market 

forces to promote quality. 

· In 2008, CMS released the Five-Star Quality Rating System to 

publicly report nursing home performance based on survey 

performance, select quality measures, and staffing levels. In 

2015, CMS changed the Five-Star Quality Rating System to 

include two additional quality measures, adjust staffing 

algorithms, and raise performance expectations.
Appendix III: Summary of Key Nursing Home 

Oversight Changes CMS Made from 2005 

through 2014

Page 42 GAO-16-33 Nursing Home Quality

Dimensions of 

oversight Dimension description Examples of key changes in recent years

· In 2011, per PPACA, CMS added enforcement and complaint 

data to the Nursing Home Compare website.

· In 2012, CMS established the National Partnership to Improve 

Dementia Care to address the issue of high use of 

antipsychotic medications in the nursing home population, 

especially among residents with dementia. The partnership 

includes Quality Improvement Organizations, state survey 

agencies, patients, and providers.

In 2012, antipsychotic use among short and long-stay residents 

measures were added to the Nursing Home Compare website 

and in 2015 were added to the Five-Star Quality Rating 

System.

Source: GAO analysis of CMS information. | GAO-16-33
Appendix IV: Comments from the Department 

of Health and Human Services

Page 43 GAO-16-33 Nursing Home Quality

Appendix IV: Comments from the 

Department of Health and Human Services
Appendix IV: Comments from the Department 

of Health and Human Services

Page 44 GAO-16-33 Nursing Home Quality
Appendix IV: Comments from the Department 

of Health and Human Services

Page 45 GAO-16-33 Nursing Home Quality
Appendix IV: Comments from the Department 

of Health and Human Services

Page 46 GAO-16-33 Nursing Home Quality
Appendix V: GAO Contact and Staff 

Acknowledgments

Linda T. Kohn (202) 512-7114 or kohnl@gao.gov

In addition to the contact name above, Will Simerl, Assistant Director; 

Wesley Dunn, Julianne Flowers, Krister Friday, Q. Akbar Husain, Kathryn 

Richter, Helen Sauer, and Karin Wallestad made key contributions to the 

report.

Page 47 GAO-16-33 Nursing Home Quality

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments

(291249)
Appendix VI: Accessible Data

Page 48 GAO-16-33 Nursing Home Quality

Linda Kohn

Director , 

Health Care

U.S. Government Accountability Office 

441 G Street NW

Washington , DC 20548 

Dear Ms. Kohn:

Attached are comments on the U.S. Government Accountability Office's 

(GAO) report entitled,

"Nursing Home Quality: CMS Should Continue to Improve Data and 

Oversight" (GA0-16-33). The Department appreciates the opportunity to 

review this report prior to publication.

Sincerely,

Jim Esquea

Assistant Secretary for Legislation

Attachment

GENERAL COMMENTS OF THE DEPARTMENT OF HEALTH AND 

HUMAN SERVICES (HHS) ON THE GOVERNMENT ACCOUNTABILITY 

Appendix VI: Accessible Data

Agency Comment 

Letter

Text of Appendix IV: 

Comments from the 

Department of Health and 

Human Services

Page 1

Page 2
Appendix VI: Accessible Data

OFFICE'S DRAFT REPORT ENTITLED: NURSING HOME QUALITY: 

CMS SHOULD CONTINUE TO IMPROVE DATA AND OVERSIGHT 

(GA0-16-33)

The Department of Health and Human Services (HHS) appreciates the 

opportunity to review and comment on the Government Accountability 

Office's (GAO) draft report on nursing home quality. HHS is committed to 

promoting nursing home safety and quality improvement.

HHS conducts initial and ongoing inspections of all nursing home facilities 

participating in the Medicare and Medicaid programs, which play a critical 

role in monitoring nursing home compliance with Federal and State 

requirements. Federal and State surveyors conduct on-site surveys of 

certified nursing homes on average every 12 months to confirm basic 

levels of quality and safety for beneficiaries. HHS has undertaken many 

initiatives over the past several years to improve the effectiveness of the 

annual nursing home surveys, as well as to improve the data collection on 

nursing home compliance .

To improve the accuracy and consistency of standard surveys and the 

documentation of deficiencies, HHS tested a new survey process in 2005 

called the Quality Indicator Survey (QIS). HHS has evaluated both the 

traditional survey and the QIS processes to identify, in both quantitative 

and qualitative terms, the strengths and limitations of each survey 

process. HHS is developing a plan for improving the efficiency and 

effectiveness of the survey process, using data collected and input from 

stakeholders.

HHS has also improved the way that data are captured from its oversight 

of nursing home compliance. HHS has provided an increasing array of 

understandable information on Medicare and Medicaid participating 

nursing homes that can be readily accessed by the public. For example, 

enhancements to the Centers for Medicare and Medicaid Services (CMS) 

Nursing Home Compare website, a consumer information website, 

include the Five-Star Quality Rating System, information on administrative 

enforcement actions and complaint investigations, and publicizing the 

names of nursing homes in the Special Focus Facility (SFF) initiative. 

HHS has also taken steps to verify the accuracy of self-reported data, 

through focused surveys conducted on a targeted sample of facilities. 

HHS recently expanded its pilot-project nationwide to assess differences 

in self-reported data and patients ' medical records. In addition, to 

improve accuracy of reported staffing levels and types, HHS will soon 

Page 49 GAO-16-33 Nursing Home Quality
Appendix VI: Accessible Data

begin electronic collection of staffing data that is verifiable through the 

nursing home's payroll-based system.

HHS works among stakeholders to improve the quality and safety of 

nursing homes including State Survey Agencies (SAs), Quality 

Improvement Organizations (QIOs), and other public and private partners. 

HHS has worked closely with these groups to reduce the use of physical 

restraints and overprescribing of antipsychotic medications as well as 

reduce the prevalence of pressure ulcers. In many areas HHS has made 

great strides in improving nursing home care and is committed to further 

improvements by mobilizing a broad array of activities both in HHS and 

among stakeholders.

HHS appreciates GAO's effo1is on this issue and will continue to improve 

data quality and oversight of nursing homes moving forward. GAO's 

recommendations and HHS' responses are below.

GAO Recommendation

The GAO recommends that in order to improve the measurement of 

nursing home quality the Administrator of the CMS should establish 

specific timeframes, including milestones to track progress, for the 

development and implementation of a standardized survey methodology 

across all states.

HHS Response

HHS concurs with GAO's recommendation . HHS is in the process of 

establishing timeframes and milestones for the development and 

implementation of a standardized survey methodology. HHS has recently 

issued a proposed rule seeking input to revise Medicare and Medicaid 

Requirements for Participation for long-term care facilities (nursing 

homes), which would change the specific requirements that would be 

reviewed through a standardized survey process.

GAO Recommendation

The GAO recommends that in order to improve the measurement of 

nursing home quality, the Administrator of the CMS should establish and 

implement a clear plan for ongoing auditing to ensure reliability of data 

self-reported by nursing homes, including payroll-based staffing data and 

data used to calculate clinical quality measures.

Page 50 GAO-16-33 Nursing Home Quality

Page 3
Appendix VI: Accessible Data

HHS Response

HHS concurs with GAO's recommendation and is already addressing 

reliability of self-reported nursing home data. HHS issued a final rule 

requiring nursing homes to electronically submit direct care staffing 

information based on payroll and other verifiable and auditable data 

starting July 2016. In addition, in FY2014, HHS piloted in five states a 

short-term focused survey to assess a nursing home's resident 

assessment coding practices and its relationship to resident care in 

nursing homes. In FY2015, CMS expanded the focused surveys to all 

states and added a review of nursing home staffing to those surveys. In 

these onsite inspections, surveyors examine available evidence (such as 

medical records), observe a sample of residents, and interview staff to 

assess the adequacy and accuracy of the resident assessments and 

information reported by the nursing home. HHS plans to continue with a 

targeted national sample of focused surveys in FY2016 and FY2017.

GAO Recommendation

The GAO recommends that in order to help ensure modifications of 

CMS's oversight activities do not adversely affect the agency's ability to 

assess nursing home quality and that effective modifications are adopted 

more widely, the Admi nistrator of the CMS should establish a process for 

monitoring modifications of essential oversight activities made at the CMS 

central office, CMS regional office, and state survey agency levels to 

better understand the effects on nursi ng home quality oversight.

HHS Response

HHS concurs with GAO's recommendati on. HHS has several systems 

and processes in place to monitor key oversight activities. HHS will 

review these processes and make program adjustments as indicated.

Federal Monitoring Surveys (FMS) for both standard and complaint/revisit 

surveys allow HHS to evaluate the effectiveness of state agencies 

performing work on HHS' behalf. HHS is developing FMS protocols to 

allow for more direct engagement with state surveyors during these 

reviews and flexibility to focus on quality issues specific to a particular 

state. These efforts will result in discrete measurable pre- and postintervention results that allow for a more comprehensive monitoring of 

both state and nursing home performance over time and can be applied 

to other states experiencing similar issues. HHS will continue to review 

Page 51 GAO-16-33 Nursing Home Quality

Page 4
Appendix VI: Accessible Data

the efficacy of the FMS process through monitoring of state FMS 

performance scores.

Further , development of national productivity measures compiled by HHS 

will allow HHS to better monitor state performance through the tracking of 

enforcement and certification activities. This reporting will allow for both 

specific and comparative analysis across regions of enforcement and

oversight trends and concerns.

Data Table for Highlights Figure: Consumer Complaints and Serious Deficiencies, 

Page 52 GAO-16-33 Nursing Home Quality

2005 - 2014

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of 

Consumer 

Complaints

3.2 3.5 3.6 3.7 3.4 3.3 3.2 3.6 3.6 3.9

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of 

serious 

deficiencies

.35 .4 .38 .36 .29 .25 .24 .21 .2 .21

Data Table for Figure 1: Number of Consumer Complaints Reported Per Nursing 

Home, 2005-2014

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of 

Consumer 

Complaints

3.2 3.5 3.6 3.7 3.4 3.3 3.2 3.6 3.6 3.9

Data Table for Figure 2: Number of Serious Deficiencies Cited Per Nursing Home 

Receiving Standard Surveys, 2005-2014

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of 

serious 

deficiencies

.35 .4 .38 .36 .29 .25 .24 .21 .2 .21

Data Tables
Appendix VI: Accessible Data

Data Table for Figure 3: Average Number of Total Nurse Staffing Hours, 2009-2014

Page 53 GAO-16-33 Nursing Home Quality

2009 2010 2011 2012 2013 2014

Number of hours per resident per day 4.2 4.2 4.3 4.4 4.6 4.6

Data Table for Figure 4: Selected Quality Measure Scores, 2011-2014

2011 2012 2013 2014

Residents Who Report Moderate to Severe Pain (longstay)13 11.1 8.9 8.4

High-Risk Residents With Pressure Ulcers (long-stay) 6.6 6.2 5.8 5.6

Residents Who Lose Too Much Weight (long-stay) 7.3 7.4 7.5 7.2

Residents Who Were Physically Restrained (long-stay) 2.1 1.8 1.3 1.1

Residents Experiencing One or More Falls with Major 

Injury (long-stay)

3.6 3.5 3.4 3.4

Residents Who Received an Antipsychotic Medication 

(long-stay)

23.1 22.3 19.9 19

Residents Who Report Moderate to Severe Pain (shortstay)24 22.7 20.3 20

Residents With Pressure Ulcers That Are New or 

Worsened (short-stay)

2 1.5 1.1 1

Data Table for Figure 5: Examples in Selected States of Data Issues that May Have 

Affected Complaint and Deficiency Data, 2005 – 2014

Complaints

STATE 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

CA 1.1 1.7 2.1 2.1 .7 .5 .2 4. 4.3 5.

FL 2.6 3. 3. 2.9 2.6 2.6 3.2 3.4 3.6 3.4

MA .9 1.1 1. 1.7 1.8 1.6 1.3 1. 1. 1.1

MI 2.4 2.7 2.9 2.9 2.9 3.2 3.3 3.8 4.9 5.8

WV 2.4 2.4 2.3 2.7 2.9 2.7 2.8 2.1 2.2 1.7

Deficiencies

STATE 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

CA .16 .33 .23 .24 .18 .16 .11 .09 .1 .1

FL .08 .17 .15 .16 .12 .15 .09 .08 .06 .09

MA .47 .76 .52 .45 .33 .37 .36 .4 .47 .3
Appendix VI: Accessible Data

Page 54 GAO-16-33 Nursing Home Quality

STATE 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

MI .42 .5 .62 .39 .36 .28 .42 .26 .22 .23

WV .17 .17 .36 .21 .2 .72 .71 .31 .21 .32
The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and 

policies; and provides analyses, recommendations, and other assistance 

to help Congress make informed oversight, policy, and funding decisions. 

GAO’s commitment to good government is reflected in its core values of 

accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no 

cost is through GAO’s website (http://www.gao.gov). Each weekday 

afternoon, GAO posts on its website newly released reports, testimony, 

and correspondence. To have GAO e-mail you a list of newly posted 

products, go to http://www.gao.gov and select “E-mail Updates.”

The price of each GAO publication reflects GAO’s actual cost of 

production and distribution and depends on the number of pages in the 

publication and whether the publication is printed in color or black and 

white. Pricing and ordering information is posted on GAO’s website, 

http://www.gao.gov/ordering.htm. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 

TDD (202) 512-2537.

Orders may be paid for using American Express, Discover Card, 

MasterCard, Visa, check, or money order. Call for additional information.

Connect with GAO on Facebook, Flickr, Twitter, and YouTube.

Subscribe to our RSS Feeds or E-mail Updates. 

Listen to our Podcasts and read The Watchblog.

Visit GAO on the web at www.gao.gov.

Contact:

Website: http://www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470

Katherine Siggerud, Managing Director, siggerudk@gao.gov, (202) 512-

4400, U.S. Government Accountability Office, 441 G Street NW, Room 

7125, Washington, DC 20548

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548

GAO’s Mission

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Phone

Connect with GAO

To Report Fraud, 

Waste, and Abuse in 

Federal Programs

Congressional 

Relations

Public Affairs

PleasrintoRecyldPapr.