United States Government Accountability Office

GAO Testimony 

Before the Special Committee on Aging, 

U.S. Senate

NURSING HOME REFORM

Continued Attention Is 

Needed to Improve Quality 

of Care in Small but 

Significant Share of Homes 

Statement of Kathryn G. Allen 

Director, Health Care 

For Release on Delivery

Expected at 10:30 a.m. EDT 

Wednesday, May 2, 2007

 

GAO-07-794T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2, 2007

NURSING HOME REFORM 

Continued Attention Is Needed to 

Improve Quality of Care in Small but 

Significant Share of Homes 

Highlights of GAO-07-794T, a testimony 

before the Special Committee on Aging, 

U.S. Senate 

With the Omnibus Budget

Reconciliation Act of 1987

(OBRA ’87), Congress responded to 

growing concerns about the quality 

of care that nursing home residents

received by requiring reforms in 

the federal certification and 

oversight of nursing homes. These 

reforms included revising care

requirements that homes must 

meet to participate in the Medicare

or Medicaid programs, modifying 

the survey process for certifying a 

home’s compliance with federal 

standards, and introducing

additional sanctions and 

decertification procedures for 

noncompliant homes. 

GAO’s testimony addresses its 

work in evaluating the quality of 

nursing home care and the

enforcement and oversight 

functions intended to ensure highquality care, the progress made in

each of these areas since the 

passage of OBRA ‘87, and the 

challenges that remain. 

GAO’s testimony is based on its

prior work; analysis of data from

the Centers for Medicare & 

Medicaid Services’ (CMS) On-Line

Survey, Certification, and 

Reporting system (OSCAR), which 

compiles the results of state

nursing home surveys; and 

evaluation of federal comparative 

surveys for selected states (2005-

2007). Federal comparative surveys 

are conducted at nursing homes 

recently surveyed by each state to

assess the adequacy of the state’s 

surveys. 

The reforms of OBRA ’87 and subsequent efforts by CMS and the nursing 

home industry to improve the quality of nursing home care have focused on 

resident outcomes, yet a small but significant share of nursing homes 

nationwide continue to experience quality-of-care problems. In fiscal year

2006, almost one in five nursing homes was cited for serious deficiencies, 

those that caused actual harm or placed residents in immediate jeopardy. 

While this rate has fluctuated over the last 7 years, GAO has found persistent 

variation in the proportion of homes with serious deficiencies across states. 

In addition, although the understatement of serious deficiencies—that is, 

when federal surveyors identified deficiencies that were missed by state 

surveyors—has declined since 2004 in states GAO reviewed, it has continued 

at varying levels. 

CMS has strengthened its enforcement capabilities since OBRA ’87 in order 

to better ensure that nursing homes achieve and maintain high-quality care, 

but several key initiatives require refinement. CMS has implemented 

additional sanctions authorized in the legislation, established an immediate 

sanctions policy for homes found to repeatedly harm residents, and 

developed a new enforcement management data system. However, the

immediate sanctions policy is complex and appears to have induced only 

temporary compliance in some homes with a history of repeated

noncompliance. Furthermore, CMS’s new data system’s components are not 

integrated and national reporting capabilities are incomplete, which hamper 

CMS’s ability to track and monitor enforcement. 

CMS oversight of nursing home quality has increased significantly, but CMS 

initiatives continue to compete for staff and financial resources. Attention to 

oversight has led to greater demand on limited resources, and to queues and 

delays in certain key initiatives. For example, a new survey methodology has 

been in development for over 8 years and resource constraints threaten the 

planned expansion of this methodology beyond the initial demonstration 

states. 

Significant attention from the Special Committee on Aging, the Institute of 

Medicine, and others served as a catalyst to focus national attention on 

nursing home quality issues, culminating in the nursing home reform 

provisions of OBRA ’87. In response to many GAO recommendations and at 

its own initiative, CMS has taken many important steps; however, the task of 

ensuring high-quality nursing home care for all residents is not complete. In 

order to guarantee that all nursing home residents receive high-quality care, 

it is important to maintain the momentum begun by the reforms of OBRA ’87 

and continue to focus national attention on those homes that cause actual 

harm to vulnerable residents. www.gao.gov/cgi-bin/getrpt?GAO-07-794T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118 or allenk@gao.gov. 
Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you acknowledge the 20th anniversary of

the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87), 

which contained nursing home reform provisions. In March 1986, the 

National Academy of Sciences’ Institute of Medicine (IOM) released a 

report concluding that quality of care and quality of life in many nursing 

homes were not satisfactory, despite the existence of government 

regulation, and that more effective government regulation could 

substantially improve nursing home quality.1

 In July 1987, we issued a 

report recommending that Congress pass legislation that would strengthen 

enforcement of federal nursing home requirements, consistent with the 

IOM’s recommendations.2

 Largely in response to these reports, Congress 

passed the nursing home reform provisions of OBRA ‘87, which was 

significant in that it changed the focus of quality standards from a home’s 

capability to provide care to its actual delivery of care and resident 

outcomes. OBRA ‘87 directed the Health Care Financing Administration, 

now known as the Centers for Medicare & Medicaid Services (CMS), to 

reform its certification and oversight of nursing homes for Medicare and

Medicaid, which includes surveys to ensure the quality of resident care,

complaint investigations, and remedies and penalties for nursing homes 

not in compliance with federal standards.3

The nation’s 1.5 million nursing home residents are a highly vulnerable 

population of elderly and disabled individuals for whom remaining at 

home is no longer feasible. With the aging of the baby boom generation,

the number of individuals needing nursing home care and the associated 

costs are expected to increase dramatically. Combined Medicare and

Medicaid payments for nursing home services were about $72.7 billion in 

2005, including a federal share of about $49 billion. The federal 

 1

See Institute of Medicine, National Academy of Sciences, Improving the Quality of Care

in Nursing Homes (Washington, D.C.: March 1986). 

2

GAO, Medicare and Medicaid: Stronger Enforcement of Nursing Home Requirements 

Needed, GAO/HRD-87-113 (Washington, D.C.: July 22, 1987). 

3

Prior to July 2001, CMS was known as the Health Care Financing Administration. 

Throughout this testimony, we refer to the agency as CMS, even when describing initiatives

taken prior to its name change. Medicare is the federal health care program for elderly and 

disabled people. Medicare may cover up to 100 days of skilled nursing home care following 

a hospital stay. Medicaid is the joint federal-state health care financing program for certain 

categories of low-income individuals. Medicaid also pays for long-term care services, 

including nursing home care. 

Page 1 GAO-07-794T
government plays a key role in ensuring that nursing home residents 

receive appropriate care by setting quality-of-care, quality-of-life, and life 

safety requirements that nursing homes must meet to participate in the

Medicare and Medicaid programs and by contracting with states to 

routinely inspect homes and conduct complaint investigations.

4

 To 

encourage compliance with these requirements, Congress has authorized 

certain enforcement actions. 

Since this Committee requested us to investigate California nursing homes 

in 1997, we have reported to Congress and testified numerous times on the 

quality of resident care, identified significant weaknesses in federal and

state activities designed to detect and correct quality problems in nursing 

homes, and made many recommendations to improve the survey process

and federal oversight of nursing home quality.5

 In response to our 

recommendations as well as needed improvements CMS identified in its 

own self-assessment in 1998, CMS announced a set of initiatives intended 

to address many of these weaknesses. Over time, CMS has refined and

expanded these initiatives in order to continue to improve nursing home 

quality. 

My remarks today will focus on GAO’s work in evaluating the quality of 

nursing home care and the enforcement and oversight functions intended 

to ensure high-quality care.6

 I will address the progress made in these three 

areas since OBRA ‘87, as well as the challenges that remain. This 

statement is based primarily on prior GAO work. In addition, we 

interviewed CMS officials; analyzed data from CMS’s On-Line Survey, 

Certification, and Reporting system (OSCAR), which compiles the results 

of state nursing home surveys; and evaluated the results of federal 

comparative surveys for selected states for the period January 2005 

through March 2007. Federal comparative surveys are conducted at 

nursing homes recently surveyed by each state to assess the adequacy of 

the state’s surveys. We considered these data sufficiently reliable for our 

purposes. We discussed the highlights of this statement including our new 

 4

In this report, we use the term states to include the 50 states and the District of Columbia. 

5

Related GAO products are included at the end of this statement. See appendix I for 

recommendations GAO has made, related CMS initiatives, and the implementation status of 

these initiatives. 

6

OBRA ‘87 included other requirements pertaining to nursing homes, such as staffing, 

services, and specific rights of residents, including privacy, restricted use of physical or 

chemical restraints, and voicing of grievances, but GAO has not examined these issues. 

Page 2 GAO-07-794T
analyses with CMS officials, and they provided us additional information, 

which we incorporated as appropriate. We conducted our work from 

March through April 2007 in accordance with generally accepted 

government auditing standards. 

In summary, despite the reforms of OBRA ‘87 and subsequent efforts by 

CMS and the nursing home industry to improve the quality of nursing 

home care, a small but significant share of nursing homes nationwide 

continues to experience quality-of-care problems. In 2006, one in five 

nursing homes nationwide was cited for serious deficiencies—those 

deficiencies that cause actual harm or place residents in immediate 

jeopardy. While this rate has fluctuated over the last 7 years, we have 

regularly found (1) significant variation across states in their citation of 

serious deficiencies, indicating inconsistencies in states’ assessments of 

quality of care and (2) understatement of these deficiencies—when 

deficiencies are found on federal comparative surveys but not cited on 

corresponding state surveys. Among the five large states we reviewed—

California, Florida, New York, Ohio, and Texas—understatement of 

serious deficiencies has declined from 18 percent prior to December 2004

to 11 percent for the most recent time period ending in March 2007, but 

understatement has continued at varying levels. 

Since the passage of OBRA ‘87, CMS has strengthened its enforcement 

capabilities—for example, by implementing sanctions authorized in the 

legislation, establishing an immediate sanctions policy for nursing homes 

found to repeatedly harm residents, and developing a new enforcement 

management data system—but several key initiatives require refinement. 

The immediate sanctions policy is complex and appears to have induced 

only temporary compliance in certain nursing homes with histories of 

repeated noncompliance. In addition, the term “immediate sanctions” 

policy is misleading because it requires only that homes be notified 

immediately of CMS’s intent to implement sanctions, not that sanctions be

implemented immediately. Furthermore, when a sanction, such as a denial 

of payment for new admissions (DPNA), is implemented, there is a lag 

time between when the deficiency citation occurs and the effective date of

the sanction. Finally, although CMS has developed a new data system, the 

system’s components are not integrated and the national reporting 

capabilities are incomplete, hampering the agency’s ability to track and 

monitor enforcement. 

CMS oversight of nursing home quality and state surveys has increased 

since OBRA ‘87, but certain key initiatives continue to compete for 

resources. To increase its oversight of quality of care in nursing homes, 

Page 3 GAO-07-794T
CMS has focused its resources and attention in areas such as prompt 

investigation of complaints and allegations of abuse, more frequent federal 

comparative surveys, stronger fire safety standards, and upgrades to data

systems. However, this increased emphasis on nursing home oversight 

coupled with growth in the number of Medicare and Medicaid providers 

has caused greater demand on limited resources, which, in turn, has led to

queues and delays in certain key initiatives. For example, the 

implementation of a new survey methodology, the Quality Indicator 

Survey (QIS), has been in development for over 8 years and resource 

constraints threaten the planned expansion of this methodology beyond 

the initial five demonstration states. 

Significant attention from the Special Committee on Aging, the Institute of 

Medicine, and others served as a catalyst to focus national attention on 

nursing home quality issues, culminating in the nursing home reform 

provisions of OBRA ‘87. Since then, in response to many GAO 

recommendations and at its own initiative, CMS has taken many important 

steps to respond in a timelier, more rigorous, more consistent manner to 

identified problems. Nevertheless, the task of ensuring high-quality 

nursing home care is still not complete. To guarantee that all nursing home 

residents receive high-quality care, it is important to maintain the 

momentum begun by the reforms of OBRA ‘87 and continue to focus 

national attention on those homes that cause actual harm to vulnerable 

residents. 

Titles XVIII and XIX of the Social Security Act establish minimum 

requirements that all nursing homes must meet to participate in the 

Medicare and Medicaid programs, respectively. With the passage of OBRA 

‘87, Congress responded to growing concerns about the quality of care that 

nursing home residents received by requiring major reforms in the federal

regulation of nursing homes. Among other things, these reforms revised 

care requirements that facilities must meet to participate in the Medicare 

or Medicaid programs, modified the survey process for certifying a home’s

compliance with federal standards, and introduced additional sanctions 

and decertification procedures for homes that fail to meet federal 

standards. Following OBRA ‘87, CMS published a series of regulations and 

transmittals to implement the changes. Key implementation actions have 

included the following: In October 1990, CMS implemented new survey 

standards; in July 1995, it established enforcement actions for nursing 

homes found to be out of compliance; and it enhanced oversight through 

more rigorous federal monitoring surveys beginning in October 1998 and 

annual state performance reviews in fiscal year 2001. CMS has continued 

Background 

Page 4 GAO-07-794T
to revise and refine many of these actions since their initial 

implementation. 

Survey Process Every nursing home receiving Medicare or Medicaid payment must 

undergo a standard survey not less than once every 15 months, and the 

statewide average interval for these surveys must not exceed 12 months.7

During a standard survey, separate teams of surveyors conduct a 

comprehensive assessment of federal quality-of-care and life safety 

requirements. In contrast, complaint investigations, also conducted by

surveyors, generally focus on a specific allegation regarding resident care 

or safety.8

The quality-of-care component of a survey focuses on determining 

whether (1) the care and services provided meet the assessed needs of the

residents and (2) the home is providing adequate quality care, including

preventing avoidable pressure sores, weight loss, and accidents. Nursing 

homes that participate in Medicare and Medicaid are required to 

periodically assess residents’ care needs in 17 areas, such as mood and 

behavior, physical functioning, and skin conditions, in order to develop an

appropriate plan of care. Such resident assessment data are known as the 

minimum data set (MDS). To assess the care provided by a nursing home, 

surveyors select a sample of residents and (1) review data derived from 

the residents’ MDS assessments and medical records; (2) interview nursing 

home staff, residents, and family members; and (3) observe care provided

to residents during the course of the survey. CMS establishes specific 

investigative protocols for state survey teams—generally consisting of 

registered nurses, social workers, dieticians, and other specialists—to use 

in conducting surveys. These procedural instructions are intended to make

the on-site surveys thorough and consistent across states. 

 7

CMS generally interprets these requirements to permit a statewide average interval of 

12.9 months and a maximum interval of 15.9 months for each home. In addition to nursing 

homes, CMS and state survey agencies are responsible for oversight of other Medicare and

Medicaid providers such as home health agencies, intermediate care facilities for the 

mentally retarded, accredited and nonaccredited hospitals, end-stage renal dialysis

facilities, ambulatory surgical centers, rural health clinics, outpatient physical therapy

centers, hospices, portable x-ray suppliers, comprehensive outpatient rehabilitation 

facilities, and Community Mental Health Centers.

8

CMS contracts with state survey agencies to conduct surveys and complaint 

investigations. 

Page 5 GAO-07-794T
The life safety component of a survey focuses on a home’s compliance 

with federal fire safety requirements for health care facilities.9

 The fire

safety requirements cover 18 categories, ranging from building 

construction to furnishings. Most states use fire safety specialists within 

the same department as the state survey agency to conduct fire safety 

inspections, but some states contract with their state fire marshal’s office.

Complaint investigations provide an opportunity for state surveyors to 

intervene promptly if problems arise between standard surveys. 

Complaints may be filed against a home by a resident, the resident’s 

family, or a nursing home employee either verbally, via a complaint 

hotline, or in writing. Surveyors generally follow state procedures when 

investigating complaints but must comply with certain federal guidelines 

and time frames. In cases involving resident abuse, such as pushing, 

slapping, beating, or otherwise assaulting a resident by individuals to 

whom their care has been entrusted, state survey agencies may notify state 

or local law enforcement agencies that can initiate criminal investigations.

States must maintain a registry of qualified nurse aides, the primary 

caregivers in nursing homes, that includes any findings that an aide has 

been responsible for abuse, neglect, or theft of a resident’s property. The 

inclusion of such a finding constitutes a ban on nursing home 

employment. 

Effective July 1995, CMS established a classification system for 

deficiencies identified during either standard surveys or complaint 

investigations. Deficiencies are classified in 1 of 12 categories according to 

their scope (i.e., the number of residents potentially or actually affected) 

and their severity. An A-level deficiency is the least serious and is isolated

in scope, while an L-level deficiency is the most serious and is considered 

to be widespread in the nursing home (see table 1). States are required to 

enter information about surveys and complaint investigations, including 

the scope and severity of deficiencies identified, in CMS’s OSCAR 

database. 

 9

CMS requires nursing homes to meet applicable provisions of the fire safety standards 

developed by the National Fire Protection Association (NFPA), of which CMS is a member. 

NFPA is a nonprofit membership organization that develops and advocates scientifically 

based consensus standards on fire, building, and electrical safety. 

Page 6 GAO-07-794T
Table 1: Scope and Severity of Deficiencies Identified during Nursing Home 

Surveys 

Scope

Severity Isolated Pattern Widespread

Immediate jeopardyaJ K L

Actual harm G H I 

Potential for more than minimal harm D E F

Potential for minimal harmbA B C

Source: CMS. 

a

Actual or potential for death/serious injury. 

b

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

Enforcement In an effort to better ensure that nursing homes achieve and maintain 

compliance with the new survey standards, OBRA ‘87 expanded the range 

of enforcement sanctions. Prior to OBRA ‘87, the only sanctions available 

were terminations from Medicare or Medicaid or, under certain

circumstances, DPNAs. OBRA ‘87 added several new alternative sanctions, 

such as civil money penalties (CMP) and requiring training for staff 

providing care to residents, and expanded the types of deficiencies that 

could result in DPNAs. To implement OBRA ‘87, CMS published 

enforcement regulations, effective July 1995. According to these 

regulations, the scope and severity of a deficiency determine the 

applicable sanctions. CMS imposes sanctions on homes with Medicare or

dual Medicare and Medicaid certification on the basis of state referrals.10

CMS normally accepts a state’s recommendation for sanctions but can 

modify it. 

Effective January 2000, CMS required states to refer for immediate 

sanction homes found to have harmed one or a small number of residents 

or to have a pattern of harming or exposing residents to actual harm or 

potential death or serious injury (G-level or higher deficiencies on the 

agency’s scope and severity grid) on successive surveys. This is known as 

the double G immediate sanctions policy. Additionally, in January 1999, 

 10Ensuring that documented deficiencies are corrected is a shared federal-state 

responsibility. States are responsible for enforcing standards in homes with Medicaid-only 

certification—about 14 percent of homes. They may use the federal sanctions or rely on

their own state licensure authority and nursing home sanctions. 

Page 7 GAO-07-794T
CMS launched the Special Focus Facility program. This initiative was 

intended to increase the oversight of homes with a history of providing 

poor care. When CMS established this program, it instructed each state to

select two homes for enhanced monitoring. For these homes, states are to

conduct surveys at 6-month intervals rather than annually. In December 

2004, CMS expanded this program to require immediate sanctions for 

those homes that fail to significantly improve their performance from one 

survey to the next and termination for homes with no significant 

improvement after three surveys over an 18-month period.11

Unlike other sanctions, CMPs do not require a notification period before 

they go into effect. However, if a nursing home appeals the deficiency, by 

statute, payment of the CMP—whether received directly from the home or 

withheld from the home’s Medicare and Medicaid payments—is deferred 

until the appeal is resolved.12 In contrast to CMPs, other sanctions, 

including DPNAs, cannot go into effect until homes have been provided a 

notice period of at least 15 days, according to CMS regulations; the notice 

period is shortened to 2 days in the case of immediate jeopardy. Although

nursing homes can be terminated involuntarily from participation in 

Medicare and Medicaid, which can result in a home’s closure, termination 

is used infrequently.13

Oversight CMS is responsible for overseeing each state survey agency’s performance 

in ensuring quality of care in nursing homes participating in Medicare or 

Medicaid. Its primary oversight tools are (1) statutorily required federal

monitoring surveys and (2) annual state performance reviews. Pursuant to 

OBRA ‘87, CMS is required to conduct annual monitoring surveys in at 

least 5 percent of the state-surveyed Medicare and Medicaid nursing 

homes in each state, with a minimum of five facilities in each state. These 

federal monitoring surveys can be either comparative or observational. A 

 11As of December 2004, Alaska is not required to select Special Focus Facilities, because 

there were fewer than 21 nursing homes in the state at that time. 

12If efforts to collect the CMP directly from the home fail, Medicare and Medicaid payments

are withheld. 

13Homes also can choose to close voluntarily, but we do not consider voluntary closure to

be a sanction. When a home is terminated, it loses any income from Medicare and 

Medicaid, which accounted for about 40 percent of nursing home payments in 2004.

Residents who receive support through Medicare or Medicaid must be moved to other 

facilities. However, a terminated home generally can apply for reinstatement if it corrects 

its deficiencies. 

Page 8 GAO-07-794T
comparative survey involves a federal survey team conducting a complete, 

independent survey of a home within 2 months of the completion of a 

state’s survey in order to compare and contrast the findings. In an 

observational survey, one or more federal surveyors accompany a state 

survey team to a nursing home to observe the team’s performance. State 

performance reviews measure state survey agency compliance with seven 

standards: timeliness of the survey, documentation of survey results, 

quality of state agency investigations and decision making, timeliness of 

enforcement actions, budget analysis, timeliness and quality of complaint 

investigations, and timeliness and accuracy of data entry. These reviews 

replaced state self-reporting of their compliance with federal 

requirements. 

A small but significant proportion of nursing homes nationwide continue

to experience quality-of-care problems—as evidenced by the almost 1 in 5 

nursing homes nationwide that were cited for serious deficiencies in 

2006—despite the reforms of OBRA ‘87 and subsequent efforts by CMS 

and the nursing home industry to improve the quality of nursing home 

care. Although there has been an overall decline in the numbers of nursing 

homes found to have serious deficiencies since fiscal year 2000, variation

among states in the proportion of homes with serious deficiencies 

indicates state survey agencies are not consistently conducting surveys. 

Challenges associated with the recruitment and retention of state 

surveyors, combined with increased surveyor workloads, can affect survey

consistency. In addition, federal comparative surveys conducted after 

state surveys found more serious quality-of-care problems than were cited 

by state surveyors. Although understatement of serious deficiencies 

identified by federal surveyors in five states has declined since 2004, 

understatement continues at varying levels across these states. 

Quality of Care 

Remains a Problem 

for a Small but 

Significant Proportion 

of Nursing Homes 

Nationwide 

CMS data indicate an overall decline in reported serious deficiencies from

fiscal year 2000 through 2006. The proportion of nursing homes 

nationwide cited with serious deficiencies declined from 28 percent in 

fiscal year 2000 to a low of 16 percent in 2004, and then increased to 

19 percent in fiscal year 2006 (see fig. 1). 

Page 9 GAO-07-794T
Figure 1: Percentage of Nursing Homes Nationwide with Serious Deficiencies, 

Fiscal Years 2000-2006 

Percentage

Source: GAO analysis of OSCAR data.

Fiscal year

28

23

20

18

16

17

19

0

5

10

15

20

25

30

2000 2001 2002 2003 2004 2005 2006

Despite this national trend, significant interstate variation in the 

proportion of homes with serious deficiencies indicates that states 

conduct surveys inconsistently. (App. II shows the percentage of homes,

by state, cited for serious deficiencies in standard surveys across a 7-year 

period.). In fiscal year 2006, 6 states identified serious deficiencies in 

30 percent or more of homes surveyed, 16 states found such deficiencies 

in 20 to 30 percent of homes, 22 found these deficiencies in 10 to 

19 percent of homes, and 7 found these deficiencies in less than 10 percent 

of homes. For example, in fiscal year 2006, the percentage of nursing 

homes cited for serious deficiencies ranged from a low of approximately 

2 percent in one state to a high of almost 51 percent in another state. 

The inconsistency of state survey findings may reflect challenges in 

recruiting and retaining state surveyors and increasing state surveyor 

workloads. We reported in 2005 that, according to state survey agency 

officials, it is difficult to retain surveyors and fill vacancies because state 

Page 10 GAO-07-794T
survey agency salaries are rarely competitive with the private sector.14

Moreover, the first year for a new surveyor is essentially a training period 

with low productivity. It can take as long as 3 years for a surveyor to gain 

sufficient knowledge, experience, and confidence to perform the job well. 

We also reported that limited experience levels of state surveyors resulting 

from high turnover rates was a contributing factor to (1) variability in 

citing actual harm or higher-level deficiencies and (2) understatement of 

such deficiencies. In addition, the implementation of CMS’s nursing home 

initiatives has increased state survey agencies’ workload. States are now 

required to conduct on-site revisits to ensure serious deficiencies have 

been corrected, promptly investigate complaints alleging actual harm onsite, and initiate off-hour standard surveys in addition to quality-of-care 

surveys. As a result, surveyor presence in nursing homes has increased 

and surveyor work hours have effectively been expanded to weekends, 

evenings, and early mornings. 

In addition, data from federal comparative surveys indicate that quality-ofcare problems remain for a significant proportion of nursing homes. In 

fiscal year 2006, 28 percent of federal comparative surveys found more 

serious deficiencies than did state quality-of-care surveys. Since 2002,

federal surveyors have found serious deficiencies in 21 percent or more of 

comparative surveys that were not cited in corresponding state quality-ofcare surveys (see fig. 2). However, some serious deficiencies found by 

federal, but not state surveyors, may not have existed at the time the state 

survey occurred.15

 14GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring 

High-Quality Care and Resident Safety, GAO-06-117 (Washington, D.C.: Dec. 28, 2005). 

15For example, a deficiency noted in a federal survey could involve a resident who was not 

in the nursing home at the time of the state survey. 

Page 11 GAO-07-794T
Figure 2: Percentage of Federal Comparative Surveys That Noted Serious

Deficiencies Not Identified in State Surveys 

0

5

10

15

20

25

30

2002 2003 2004 2005 2006

Percentage

Source: GAO analysis of OSCAR data.

Fiscal year

28 28

21

25

22

In December 2005, we reported on understatement of serious deficiencies

in five states—California, Florida, New York, Ohio, and Texas—from 

March 2002 through December 2004.16 We selected these states for our 

analysis because the percentage of their state surveys that cited serious 

deficiencies decreased significantly from January 1999 through January 

2005.

17 Our analysis of more recent data from these states showed that 

understatement of serious deficiencies continues at varying levels. 

Altogether, we examined 139 federal comparative surveys conducted from

March 2002 through March 2007 in the five states. Understatement of 

serious deficiencies decreased from 18 percent for federal comparative 

surveys during the original time period to 11 percent for federal 

comparative surveys during the period January 2005 through March 2007.

 16GAO-06-117. CMS requires its federal surveyors to specifically identify which deficiencies 

state surveyors missed during the state survey. 

17These declines in serious deficiencies were 14.3 percentage points for Texas, 

15.4 percentage points for Florida, 17.4 percentage points for Ohio, 22.8 percentage points 

for California, and 23.0 percentage points for New York. 

Page 12 GAO-07-794T
Federal comparative surveys for Florida and Ohio for this most recent 

time period found that state surveys had not missed any serious 

deficiencies; however, since 2004 all five states experienced increases in 

the percentage of homes cited with serious deficiencies on state surveys 

(see app. II). Understatement of serious deficiencies varied across these 

five states, as the percentage of serious missed deficiencies ranged from a 

low of 4 percent in Ohio to a high of 26 percent in New York during the 5-

year period March 2002 to March 2007. Figure 3 summarizes our analysis 

by state, from March 2002 through March 2007.

Page 13 GAO-07-794T
Figure 3: Federal Comparative Surveys in Five States That Identified Serious

Deficiencies Missed by State Surveys, March 2002-March 2007 

0

1

2

3

4

5

6

Missed deficiencies 1/2005–3/2007

Missed deficiencies 3/2002–12/2004

Texas 

(n = 31)

Ohiob

(n = 23)

New Yorkb

(n = 19)

Florida

(n = 21)

Californiaa

(n = 45)

Federal comparative surveys

Source: GAO analysis of federal comparative surveys for five years.

States

4 4

2

1

2

1

3 3

Notes: The total number of federal comparative surveys conducted in each state for the 5-year 

period, March 2002 to March 2007, is listed in parentheses following the name of the state. The 

percentage of federal comparative surveys that noted serious deficiencies missed by state surveyors 

in each state was California, 11 percent; Florida, 19 percent; New York, 26 percent; Ohio, 4 percent; 

and Texas, 16 percent. 

a

On two comparative surveys, federal surveyors did not provide information on whether any of the 

deficiencies they identified existed at the time of the state survey; therefore, this number may be 

understated. 

b

On one comparative survey, federal surveyors did not provide information on whether any of the 

deficiencies they identified existed at the time of the state survey; therefore, this number may be 

understated. 

Page 14 GAO-07-794T
CMS has strengthened its enforcement capabilities since OBRA ‘87 by, for 

example, implementing additional sanctions and an immediate sanctions 

policy for nursing homes found to repeatedly harm residents and 

developing a new enforcement management data system; however, several 

key initiatives require refinement. The immediate sanctions policy is 

complex and appears to have induced only temporary compliance in

certain nursing homes with histories of repeated noncompliance. The term

“immediate sanctions” is misleading because the policy requires only that 

homes be notified immediately of CMS’s intent to implement sanctions, 

not that sanctions must be implemented immediately. Furthermore, when 

a sanction is implemented, there is a lag time between when the deficiency

citation occurs and the sanction’s effective date. In addition to the 

immediate sanctions policy, CMS has taken other steps that are intended

to address enforcement weaknesses, but their effectiveness remains 

unclear. Finally, although CMS has developed a new data system, the 

system’s components are not integrated and the national reporting 

capabilities are incomplete, hampering the agency’s ability to track and 

monitor enforcement. 

CMS Has 

Strengthened Its 

Enforcement 

Capabilities, although 

Key Initiatives Still 

Need Refinement 

Despite Changes in 

Federal Enforcement 

Policy, Immediate 

Sanctions Do Not Always 

Deter Noncompliance and 

Often Are Not Immediate 

Despite CMS’s efforts to strengthen federal enforcement policy, it has not 

deterred some homes from repeatedly harming residents. Effective 

January 2000, CMS implemented its double G immediate sanctions policy. 

The policy is complex and does not always appear to deter 

noncompliance, nor are the sanctions always implemented immediately. 

We recently reported that the immediate sanctions policy’s complex rules, 

and the exceptions they include, allowed homes to escape immediate 

sanctions even if they repeatedly harmed residents.18 CMS acknowledged 

that the complexity of the policy may be an inherent limitation and 

indicated that it intends to either strengthen the policy or replace it with a 

policy that achieves similar goals through alternative methods. 

In addition to the complexity of the policy, it does not appear to always 

deter noncompliance. We recently reported that our review of 63 homes 

with prior serious quality problems in four states indicated that sanctions 

may have induced only temporary compliance in these homes because 

surveyors found that many of the homes with implemented sanctions were 

 18GAO, Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred

Some Homes from Repeatedly Harming Residents, GAO-07-241 (Washington, D.C.:

Mar. 26, 2007). 

Page 15 GAO-07-794T
again out of compliance on subsequent surveys.19 From fiscal year 2000 

through 2005, 31 of these 63 homes cycled in and out of compliance more 

than once, harming residents, even after sanctions had been implemented, 

including 8 homes that did so seven times or more. During this same time

period, 27 of the 63 homes were cited 69 times for deficiencies that 

warranted immediate sanctions, but 15 of these cases did not result in 

immediate sanctions.20

We also recently reported that the term “immediate sanctions” is 

misleading because the policy is silent on how quickly sanctions should be 

implemented and there is a lag time between the state’s identification of 

deficiencies during the survey and when the sanction (i.e., a CMP or 

DPNA) is implemented (i.e., when it goes into effect). The immediate 

sanctions policy requires that sanctions be imposed immediately. A 

sanction is considered imposed when a home is notified of CMS’s intent to 

implement a sanction—15 days from the date of the notice. If during the 

15-day notice period the nursing home corrects the deficiencies, no 

sanction is implemented. Thus, nursing homes have a de facto grace 

period. In addition, there is a lag time between the state’s identification of

deficiencies and the implementation of a sanction. CMS implemented 

about 68 percent of the DPNAs for double Gs among the homes we 

reviewed during fiscal year 2000 through 2005 more than 30 days after the

survey.21 In contrast, CMPs can go into effect as early as the first day the 

home was out of compliance, even if that date is prior to the survey date 

because, unlike DPNAs, CMPs do not require a notice period. About 

98 percent of CMPs imposed for double Gs took effect on or before the 

survey date. However, the deterrent effect of CMPs was diluted because

CMS imposed CMPs at the lower end of the allowable range for the homes 

we reviewed. For example, the median per day CMP amount imposed for 

 19GAO-07-241. In this report, we analyzed federal sanctions from fiscal year 2000 through 

2005 against 63 nursing homes with a history of harming residents and whose prior 

compliance and enforcement histories formed the basis for the conclusions in our March 

1999 report. The homes were located in California, Michigan, Pennsylvania, and Texas. 

20In 2003, we reported that we found over 700 cases that should have been referred for 

immediate sanctions but were not, from January 2000 through March 2002. See GAO, 

Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces

Importance of Enhanced Oversight, GAO-03-561 (Washington, D.C.: July 15, 2003). 

21CMPs and DPNAs accounted for 80 percent of federal sanctions from fiscal year 2000 

through 2005. The majority of federal sanctions implemented during this time period—

about 54 percent—were CMPs. During this time period, DPNAs and terminations

accounted for about 26 percent and less than 1 percent of federal sanctions, respectively.

Page 16 GAO-07-794T
deficiencies that do not cause immediate jeopardy to residents was $500 in 

fiscal year 2000 through 2002 and $350 in fiscal year 2003 through 2005; the 

allowable range is $50 to $3,000 per day. 

Although CMPs can be implemented closer to the date of survey than 

DPNAs, the immediacy and the effect of CMPs may be diminished by 

(1) the significant time that can pass between the citation of deficiencies 

on a survey and the home’s payment of the CMP and (2) the low amounts 

imposed, as described earlier. By statute, payment of CMPs is delayed 

until appeals are exhausted. For example, one home we reviewed did not 

pay its CMP of $21,600 until more than 2 years after a February 2003 

survey had cited a G-level deficiency. This citation was a repeat deficiency:

less than a month earlier, the home had received another G-level 

deficiency in the same quality-of-care area. This finding is consistent with 

a 2005 report from the Department of Health and Human Services’ (HHS) 

Office of Inspector General that found that the collection of CMPs in 

appealed cases takes an average of 420 days—a 110 percent increase in 

time over nonappealed cases—and “consequently, nursing homes are 

insulated from the repercussions of enforcement by well over a year.”22

CMS has taken additional steps intended to improve enforcement of 

nursing home quality requirements; however, the extent to which—or 

when—these initiatives will address enforcement weaknesses remains 

unclear. First, to ensure greater consistency in CMP amounts proposed by 

states and imposed by regions, CMS, in conjunction with state survey 

agencies, developed a grid that provides guidance for states and regions. 

The CMP grid lists ranges for minimum CMP amounts while allowing for 

flexibility to adjust the penalties for factors such as the deficiency’s scope 

and severity, the care areas where the deficiency was cited, and a home’s 

past history of noncompliance. In August 2006, CMS completed the 

regional office pilot of its CMP grid but had not completed its analysis of 

the pilot as of April 2007. CMS plans to disseminate the final grid to states 

soon.23 Second, in December 2004, CMS expanded the Special Focus 

Facility program from about 100 homes to include about 135 homes. CMS 

also modified the program by requiring immediate sanctions for those 

homes that failed to significantly improve their performance from one 

 22See HHS, Office of Inspector General, Nursing Home Enforcement: The Use of Civil 

Money Penalties, OEI-06-02-00720 (April 2005). 

23Use of the CMP grid would be optional to provide states flexibility to tailor sanctions to 

specific circumstances. 

Page 17 GAO-07-794T
survey to the next and by requiring termination for homes with no 

significant improvement after three surveys over an 18-month period. 

According to CMS, 11 Special Focus Facilities were terminated in fiscal 

year 2005 and 7 were terminated in fiscal year 2006. Despite the expansion 

of the program, many homes that could benefit from enhanced oversight

and enforcement are still excluded from the program. For example, of the 

63 homes with prior serious quality problems that we recently reviewed, 

only 2 were designated Special Focus Facilities in 2005, and the number 

increased to 4 in 2006. 

While CMS Collects 

Valuable Enforcement 

Data, Its Enforcement 

Monitoring Data Systems 

Need Improvement 

In March 1999, we reported that CMS lacked a system for effectively 

integrating enforcement data nationwide and that the lack of such a 

system weakened oversight. Since 1999, CMS has made progress 

developing such a system—ASPEN Enforcement Manager (AEM)—and, 

since October 1, 2004, CMS has used AEM to collect state and regional 

data on sanctions and improve communications between state survey 

agencies and CMS regional offices. CMS expects that the data collected in 

AEM will enable states, CMS regional offices, and the CMS central office 

to more easily track and evaluate sanctions against nursing homes as well 

as respond to emerging issues. Developed by CMS’s central office 

primarily for use by states and regions, AEM is one of many modules of a 

broader data collection system called ASPEN. However, the ASPEN 

modules—and other data systems related to enforcement such as the 

financial management system for tracking CMP collections—are 

fragmented and lack automated interfaces with each other. As a result, 

enforcement officials must pull discrete bits of data from the various 

systems and manually combine the data to develop a full enforcement 

picture. 

Furthermore, CMS has not defined a plan for using the AEM data to inform 

the tracking and monitoring of enforcement through national enforcement 

reports. While CMS is developing a few such reports, it has not developed 

a concrete plan and timeline for producing a full set of reports that use the 

AEM data to help assess the effectiveness of sanctions and its 

enforcement policies. In addition, while the full complement of 

enforcement data being recorded by the states and regional offices in AEM 

is now being uploaded to CMS’s national system, CMS does not intend to 

upload any historical data, which could greatly enhance enforcement 

monitoring efforts. Finally, AEM has quality control weaknesses, such as 

the lack of systematic quality control mechanisms to ensure accuracy of 

data entry. 

Page 18 GAO-07-794T
CMS officials told us they will continue to develop and implement 

enhancements to AEM to expand its capabilities over the next several 

years. However, until CMS develops a plan for integrating the fragmented 

systems and for using AEM data—along with other data the agency 

collects—efficient and effective tracking and monitoring of enforcement 

will continue to be hampered. As a result, CMS will have difficulty 

assessing the effectiveness of sanctions and its enforcement policies.24

CMS oversight of nursing home quality and state surveys has increased 

significantly through several efforts, but CMS initiatives for nursing home 

quality oversight continue to compete with each other, as well as with 

other CMS programs, for staff and financial resources. Since OBRA ‘87 

required CMS to annually conduct federal monitoring surveys for a sample 

of nursing homes to test the adequacy of state surveys, CMS has developed 

a number of initiatives to strengthen its oversight. These initiatives have

increased federal surveyors’ workload and the demand for resources. 

Greater demand on limited resources has led to queues and delays in 

certain key initiatives. In particular, the implementation of three key 

initiatives—the new Quality Indicator Survey (QIS), investigative protocols 

for quality-of-care problems, and an increase in the number of federal 

quality-of-care comparative surveys—was delayed because they compete 

for priority with other CMS projects. 

CMS Has 

Strengthened 

Oversight, although 

Competing Priorities 

Impede Certain Key 

Initiatives 

Intensity of Federal Efforts 

Has Increased Significantly 

CMS has used both federal monitoring surveys and annual state 

performance reviews to increase its oversight of quality of care in nursing 

homes. Through these two mechanisms it has focused its resources and 

attention on (1) prompt investigation of complaints and allegations of 

abuse, (2) more frequent and timely federal comparative surveys, 

(3) stronger fire safety standards, and (4) upgrades to data systems. 

To ensure that complaints and allegations of abuse are investigated and 

addressed in accordance with OBRA ‘87, CMS has issued guidance and

taken other steps. CMS guidance issued since 1999 has helped strengthen 

state procedures for investigating complaints. For example, CMS 

instructed states to investigate complaints alleging harm to a resident 

Complaint Investigations 

 24We recently recommended that the Administrator of CMS undertake a number of steps to

strengthen enforcement capabilities. CMS generally concurred with our recommendations, 

although it pointed out some resource constraints to implementing certain ones. See 

GAO-07-241. 

Page 19 GAO-07-794T
within 10 workdays; previously states could establish their own time 

frames for complaints at this level of severity. In addition, CMS guidance 

to states in 2002 and 2004 clarified policies on reporting abuse, including

requiring notification of local law enforcement and Medicaid Fraud 

Control Units, establishing time frames, and citing abuse on surveys. 

CMS has taken three additional steps to improve its oversight of state 

complaint investigations, including allegations of abuse. First, in its annual 

state performance reviews implemented in 2002, it required that federal 

surveyors review a sample of complaints in each state.25 These reviews 

were done to determine whether states (1) properly categorized 

complaints in terms of how quickly they should be investigated, 

(2) investigated complaints within the time specified, and (3) properly 

included the results of the investigations in CMS’s database. Second, in

January 2004, CMS implemented a new national automated complaint 

tracking system, the ASPEN Complaints and Incidents Tracking System. 

The lack of a national complaint reporting system had hindered CMS’s and 

states’ ability to adequately track the status of complaint investigations 

and CMS’s ability to maintain a full compliance history on each nursing 

home. Third, in November 2004, CMS requested state survey agency

directors to self-assess their states’ compliance with federal requirements 

for maintaining and operating nurse aide registries. CMS has not issued a 

formal report of findings from these assessments, but in 2005 we reported 

that CMS officials noted that resource constraints have impeded states’ 

compliance with certain federal requirements.26 As a part of this effort, 

CMS is also conducting a Background Check Pilot Program. The pilot 

program will test the effectiveness of state and national fingerprint-based 

background checks on employees of long-term care facilities, including 

nursing homes.27

CMS has increased the number of federal comparative surveys for both 

quality of care and fire safety and decreased the time between the end of

the state survey and the start of the federal comparative surveys. These 

improvements allow CMS to better distinguish between serious problems 

Federal Comparative Surveys 

 25Annual state performance reviews were established in fiscal year 2001 and fully 

implemented in fiscal year 2002. 

26GAO-06-117. 

27Pilot programs have been phased in from fall 2005 through September 2007 in seven 

states—Alaska, Idaho, Illinois, Michigan, Nevada, New Mexico, and Wisconsin. An

independent evaluation is expected in spring 2008. 

Page 20 GAO-07-794T
missed by state surveyors and changes in the home that occurred after the 

state survey. The number of comparative quality-of-care surveys 

nationwide per year increased from about 10 surveys a year during the 

24-month period prior to October 1998 to about 160 per year for fiscal 

years 2005 and 2006.28 The number of fire safety comparative surveys 

increased as well from 40 in fiscal year 2003 to 536 in fiscal year 2006. In 

addition, the average elapsed time between state and comparative qualityof-care surveys has decreased from 33 calendar days for the 64 

comparative surveys we reviewed in 1999 to 26 days for all federal 

comparative surveys completed through fiscal year 2006. 

In addition to conducting more frequent federal comparative surveys for 

fire safety, CMS has strengthened fire safety standards. In response to a 

recommendation in our July 2004 report to strengthen fire safety 

standards,29 CMS issued a final rule in September 2006 requiring 

nonsprinklered nursing homes to install battery-powered smoke detectors 

in resident rooms and common areas.30 In addition, CMS has issued a 

proposed rule that would require all nursing homes to be equipped with 

sprinkler systems and, after reviewing public comment, intends to publish 

a final version of the rule and stipulate an effective date for all homes to 

comply.31

Fire Safety Standards 

CMS has pursued important upgrades to data systems, expanded 

dissemination of data and information, and addressed accuracy issues in 

the MDS in addition to implementing complaint and enforcement systems. 

One such upgrade increased state and federal surveyors’ access to OSCAR 

data. CMS now uses OSCAR data to produce periodic reports to monitor 

both state and federal survey performance. Some reports, such as survey

timeliness, are used during state performance reviews, while others are 

intended to help identify problems or inconsistencies in state survey 

Upgrades to Data Systems 

 28As of fiscal year 2006, there were about 16,000 nursing homes which would require over 

800 federal monitoring surveys. Since 1992 when all federal monitoring surveys were 

comparative, CMS has begun to rely more heavily on observational surveys, which require

a smaller number of federal surveyors. In fiscal year 2006, roughly 77 percent of federal

monitoring surveys were observational. 

29GAO, Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal 

Standards and Oversight, GAO-04-660 (Washington D.C.: July 16, 2004). 

3071 Fed. Reg. 55326 (Sept. 22, 2006) (codified in pertinent part at 42 C.F.R. §483.70). CMS 

began surveying nursing homes’ compliance with the new requirement in May 2006. 

3171 Fed. Reg. 62957 (Oct. 27, 2006) (to be codified at 42 C.F.R. §483.70). 

Page 21 GAO-07-794T
activities and the need for intervention. In addition, CMS created a Webaccessible software program called Providing Data Quickly (PDQ) that 

allows regional offices and state survey agencies easier access to standard 

OSCAR reports, including one that identifies the homes that have 

repeatedly harmed residents and meet the criteria for imposition of 

immediate sanctions. 

Since launching its Nursing Home Compare Web site in 1998, CMS has 

expanded its dissemination of information to the public on individual 

nursing homes participating in Medicare or Medicaid.32 In addition to data 

on any deficiencies identified during standard surveys, the Web site now 

includes data on the results of complaint investigations, information on 

nursing home staffing levels, and quality measures, such as the percentage 

of residents with pressure sores. On the basis of our recommendations, 

CMS is now reporting fire safety deficiencies on the Web site, including 

information on whether a home has automatic sprinklers to suppress a 

fire, and may include information on impending sanctions in the future. 

However, CMS continues to address ongoing problems with the accuracy

and reliability of some of the underlying data. For example, CMS has 

evaluated the validity of quality measures and staffing information it 

makes available on the Web, and it has removed or excluded questionable 

data. 

In addition to building the quality measures reported on Nursing Home 

Compare, the MDS data are the basis for patient care plans, adjusting 

Medicare nursing home payments as well as Medicaid payments in some 

states, and assisting with quality oversight. Thus the accuracy of the MDS 

has implications for the identification of quality problems and the level of 

nursing home payments. OBRA ‘87 required nursing homes that participate 

in the Medicare and Medicaid programs to perform periodic resident 

assessments; these resident assessments are known as the MDS. In 

February 2002, we assessed federal government efforts to ensure the 

accuracy of the MDS data.33 We reported that on-site reviews of MDS data 

that compared the MDS to supporting documentation were a very effective 

method of assessing the accuracy of the data. However, CMS’s efforts to 

ensure the accuracy of the underlying MDS data were too reliant on offsite reviews, which were limited to documentation reviews or data 

 32http://www.medicare.gov/NHCompare/home.asp. 

33GAO, Nursing Homes: Federal Efforts to Monitor Resident Assessment Data Should

Complement State Activities, GAO-02-279 (Washington, D.C.: Feb. 15, 2002). 

Page 22 GAO-07-794T
analysis. To ensure the accuracy of the MDS, CMS signed a new contract 

for on-site reviews in September 2005; these reviews are ongoing. 

Competing Priorities 

Impede Certain Key CMS 

Initiatives 

CMS initiatives for nursing home quality oversight continue to compete 

with each other, as well as with other CMS programs, for staff and 

financial resources. Greater nursing home oversight and growth in the 

number of Medicare and Medicaid providers has created increased 

demand for staff and financial resources. Greater demand on limited 

resources has led to queues and delays in key initiatives. Three key 

initiatives—the new Quality Indicator Survey (QIS), investigative protocols 

for quality-of-care problems, and an increase in the number of federal 

quality-of-care comparative surveys—were delayed because they compete 

for priority with other CMS projects. 

The implementation of the QIS, in process for over 8 years, continues to 

encounter delays because of a lack of resources. The QIS is a two-stage, 

data-driven, structured survey process intended to systematically target 

potential problems at nursing homes by using an expanded sample and 

structured interviews to help surveyors better assess the scope of any 

identified deficiencies. CMS is currently concluding a five-state

demonstration of the QIS system. A preliminary evaluation by CMS 

indicates that surveyors have spent less time in homes that are performing 

well, deficiency citations were linked to more defensible documentation, 

and serious deficiencies were more frequently cited in some 

demonstration states. However, CMS officials recently reported that 

resource constraints in fiscal year 2007 threaten the planned expansion of 

this process beyond the five demonstration states. Although 13 states 

applied to transition to QIS, resource limitations may prevent this 

expansion. In addition, at least $2 million is needed over 2 years to develop

a production quality software package for the QIS. 

Since hiring a contractor in 2001 to facilitate convening expert panels for 

the development and review of new investigative protocols, CMS has 

implemented eight sets of investigative protocols. In December 2005, we

reported that these investigative protocols provided surveyors with 

detailed interpretive guidance and ensured greater rigor in on-site 

investigations of specific quality-of-care areas, such as pressure sores, 

incontinence, and medical director qualifications. However, the issuance 

of additional protocols was slowed because of lengthy consultation with 

experts and prolonged delays related to internal disagreement over the 

structure of the process. Instead, it has returned to the traditional revision

process even though agency staff believes that the expert panel process 

Page 23 GAO-07-794T
produced a high-quality product. Since issuing several protocols in 2006, 

CMS has plans to issue two additional protocols.

Although CMS hired a contractor in 2003 to further increase the number of 

federal quality-of-care comparative surveys, it stopped funding this 

initiative in fiscal year 2006. The agency reallocated the funds to help state 

survey agencies meet the increased workload resulting from growth in the 

number of other Medicare providers. 

About 20 years ago, significant attention from the Special Committee on 

Aging, the Institute of Medicine, and others served as a catalyst to focus 

national attention on nursing home quality issues, culminating in the 

nursing home reform provisions of OBRA ‘87. Beginning in 1998, the 

Committee again served as a catalyst to focus national attention on the 

fact that the task was not complete; through a series of hearings, it held 

the various stakeholders publicly accountable for the substandard care 

reported in a small but significant share of nursing homes nationwide. 

Since then, in response to many GAO recommendations and on its own 

initiative, CMS has taken many important steps and invested resources to 

respond in a timelier, more rigorous, and more consistent manner to 

identified problems and improve its oversight process for the care of 

vulnerable nursing home residents. This is admittedly no small 

undertaking, given the large number and diversity of stakeholders and 

caregivers involved at the federal, state, and provider levels. Nevertheless, 

despite the passage of time and the level of investment and effort, the 

work begun after OBRA ‘87 is still not complete. It is important to continue 

to focus national attention on and ensure public accountability for homes 

that harm residents. With these ongoing efforts, the momentum of earlier 

initiatives can be sustained and perhaps even enhanced and the quality of

care for nursing home residents can be secured, as intended by Congress 

when it passed this legislation. 

Concluding 

Observations 

Mr. Chairman, this concludes my prepared remarks. I would be pleased to 

respond to any questions that you or other Members of the Committee 

may have. 

Page 24 GAO-07-794T
For future contacts regarding this testimony, please contact Kathryn G. 

Allen at (202) 512-7118 or at allenk@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this testimony. Walter Ochinko, Assistant Director; Kaycee M. 

Glavich; Leslie V. Gordon; K. Nicole Haeberle; Daniel Lee; and Elizabeth T. 

Morrison made key contributions to this statement. 

GAO Contact and 

Acknowledgments 

Page 25 GAO-07-794T
Page 26 GAO-07-794T

Table 2 summarizes our recommendations from 11 reports on nursing 

home quality and safety, issued from July 1998 through March 2007; CMS’s 

actions to address weaknesses we identified; and the implementation 

status of CMS’s initiatives as of April 2007. The recommendations are 

grouped into four categories—surveys, complaints, enforcement, and 

oversight. If a report contained recommendations related to more than one 

category, the report appears more than once in the table. For each report, 

the first two numbers identify the fiscal year in which the report was 

issued. For example, HEHS-98-202 was released in 1998. The Related GAO 

Products section at the end of this statement contains the full citation for 

each report. Of our 42 recommendations, CMS has fully implemented 18, 

implemented only parts of 7, is taking steps to implement 10, and declined

to implement 7. 

Table 2: Implementation Status of CMS’s Initiatives Responding to GAO’s Nursing Home Quality and Safety 

Recommendations, July 1998 through April 2007 

GAO report 

number GAO recommendation CMS initiative

Implementation 

status

Surveys

GAO/HEHS-98-202 1. Stagger or otherwise vary the scheduling of 

standard surveys to effectively reduce the 

predictability of surveyors’ visits. The 

variation could include segmenting the 

standard survey into more than one review 

throughout the 12- to 15-month period, 

which would provide more opportunities for 

surveyors to observe problematic homes 

and initiate broader reviews when 

warranted. 

CMS took several steps to reduce survey 

predictability, but some state surveys remain

predictable. 

• In 1999, CMS instructed state survey 

agencies to (1) conduct 10 percent of 

surveys on evenings and weekends, 

(2) vary the sequencing of surveys in a 

geographical area to avoid alerting other 

homes that the surveyors are in the area, 

(3) vary the scheduling of surveys by day of 

the week, and (4) avoid scheduling surveys 

for the same month as a home’s prior 

survey. 

• In 2004, CMS provided states with an 

automated scheduling and tracking system 

(AST) to assist in scheduling surveys. CMS 

officials told us that AST can be used to 

address survey predictability. States 

appeared to be unaware of this feature and 

use of AST is optional. 

• CMS disagreed with and did not implement 

the recommendation to segment the 

standard survey into more than one review 

throughout the 12- to 15-month period. 

◑

Appendix I: Prior GAO Recommendations, 

Related CMS Initiatives, and Implementation 

Status 
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

2. Revise federal survey procedures to 

instruct surveyors to take stratified random 

samples of resident cases and review 

sufficient numbers and types of resident 

cases so that surveyors can better detect 

problems and assess their prevalence. 

CMS has been developing a revised survey 

methodology since 1998. A pilot test of the 

new methodology began in the fall of 2005. 

Implementation could begin in mid-2007. 

}

GAO-03-561 3. Finalize the development, testing, and 

implementation of a more rigorous survey 

methodology, including investigative 

protocols that provide guidance to 

surveyors in documenting deficiencies at 

the appropriate scope and severity level. 

See CMS action in response to

recommendation to revise federal survey 

procedures (recommendation #2 above). 

CMS began revising surveyors’ investigative 

protocols in October 2000. Eight protocols 

have been issued, and two additional 

protocols are under development. Due to 

issues with interpretation, CMS is no longer 

planning to issue definitions of actual harm 

and immediate jeopardy outside of the 

regulations. 

}

4. Require states to have a quality assurance 

process that includes, at a minimum, a 

review of a sample of survey reports below 

the level of actual harm to assess the 

appropriateness of the scope and severity 

cited and to help reduce instances of 

understated quality-of-care problems. 

CMS has no plans to implement this 

recommendation, indicating that regular 

workload and priorities take precedence over

it. 

9

GAO-05-78 5. Hold homes accountable for all past 

noncompliance resulting in harm to 

residents, not just care problems deemed

to be egregious, and develop an approach 

for citing such past noncompliance in a 

manner that clearly identifies the specific 

nature of the care problem both in the 

OSCAR database and on CMS’s Nursing

Home Compare Web site. 

CMS revised its definition of past 

noncompliance. While CMS has not ruled out 

placing enforcement information on its 

Nursing Home Compare Web site in the 

future, CMS officials told us that resource 

constraints limit the agency’s ability to do so 

at the current time. 

}

Complaints 

GAO/HEHS-99-80 6. Develop additional standards for the 

prompt investigation of serious complaints 

alleging situations that may harm residents 

but are categorized as less than immediate 

jeopardy. These standards should include 

maximum allowable time frames for 

investigating serious complaints and for 

complaints that may be deferred until the 

next scheduled annual survey. States may 

continue to set priority levels and time 

frames that are more stringent than these 

federal standards. 

In October 1999, CMS issued a policy letter 

stating that complaints alleging harm must be 

investigated within 10 days. 

In January 2004, CMS provided detailed 

direction and guidance to states for managing 

complaint investigations for numerous types

of providers, including nursing homes. 

In June 2004, CMS made available updated

guidance on the Internet that consolidates 

complaint investigation procedures for 

numerous types of providers.

z

Page 27 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

7. Strengthen federal oversight of state 

complaint investigations, including 

monitoring states’ practices regarding 

priority-setting, on-site investigation, and 

timely reporting of serious health and safety 

complaints. 

In 2000, CMS began requiring its regional 

offices to perform yearly assessments of 

states’ complaint investigations as part of 

annual state performance reviews. 

z

GAO-03-561 8. Finalize the development of guidance to 

states for their complaint investigation 

processes and ensure that it addresses key 

weaknesses, including the prioritization of 

complaints for investigation, particularly 

those alleging harm to residents; the 

handling of facility self-reported incidents; 

and the use of appropriate complaint 

investigation practices. 

In January 2004, CMS provided detailed 

direction and guidance to states for managing 

complaint investigations for numerous types

of providers, including nursing homes. 

In June 2004, CMS made available updated

guidance on the Internet that consolidates 

complaint investigation procedures for 

numerous types of providers.

z

GAO-02-312 9. Ensure that state survey agencies 

immediately notify local law enforcement 

agencies or Medicaid Fraud Control Units 

when nursing homes report allegations of 

resident physical or sexual abuse or when 

the survey agency has confirmed 

complaints of alleged abuse. 

In 2002, CMS issued a memorandum to the 

regional offices and state survey agencies 

emphasizing its policy for preventing abuse in

nursing homes and for promptly reporting it to 

the appropriate agencies when it occurs. 

CMS determined it does not have the legal 

authority to require state survey agencies to 

report suspected physical and sexual abuse

of nursing home residents. 

◑

10. Accelerate the agency's education 

campaign on reporting nursing home abuse 

by (1) distributing its new poster with clearly 

displayed complaint telephone numbers 

and (2) requiring state survey agencies to 

ensure that these numbers are prominently 

listed in local telephone directories. 

In 2002, CMS released a memorandum to 

regional offices and state agencies that 

addresses displaying complaint telephone 

numbers. CMS asked all state agencies to 

review how their telephone number is listed in

the local directory and asked them to ensure

that their complaint telephone numbers are 

prominently listed. 

In 2007, CMS officials told us that it has not 

and is not likely to release the poster. 

◑

11. Systematically assess state policies and 

practices for complying with the federal

requirement to prohibit employment of 

individuals convicted of abusing nursing 

home residents and, if necessary, develop 

more specific guidance to ensure 

compliance. 

CMS is conducting a Background Check Pilot

Program in several states, as required by the

Medicare Prescription Drug, Improvement, 

and Modernization Act of 2003. The pilot is 

expected to run through September 2007 and

will be followed by an independent evaluation.

The final study is targeted for submission by 

spring of 2008. 

}

Page 28 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

12. Clarify the definition of abuse and 

otherwise ensure that states apply that 

definition consistently and appropriately. 

In 2002, CMS released a memorandum to its 

regional offices and state survey agency 

directors clarifying its definition of abuse and

instructing them to report suspected abuse to 

law enforcement authorities and, if 

appropriate, to the state's Medicaid Fraud 

Control Unit.a

 

z

13. Shorten the state survey agencies' time 

frames for determining whether to include 

findings of abuse in nurse aide registry 

files. 

CMS informed GAO that federal regulations 

specify that if an investigation finds an 

individual has neglected or abused a resident 

or misappropriated resident property, the state 

must report the findings in writing within 10

working days to the nurse aide registry. 

However, CMS stated it does not specify a 

time frame for completion of such 

investigations due to concerns that a time limit 

could compromise complaint investigations in 

some instances. 

◑

Enforcement 

GAO/HEHS-98-202 14. Require that for problem homes with 

recurring serious violations, state surveyors 

substantiate, by means of an on-site revisit, 

every report to CMS of a home’s resumed 

compliance status. 

In 1998, CMS issued guidance to regional 

offices and state survey agencies 

strengthening its revisit policy by requiring onsite revisits until all serious deficiencies are 

corrected. Homes are no longer permitted to 

self-report resumed compliance. 

z

15. Eliminate the grace period for homes cited 

for repeated serious violations and impose 

sanctions promptly, as permitted under 

existing regulations. 

CMS phased in implementation of its double

G policy from September 1998 through 

January 2000. 

z

GAO/HEHS-99-46 16. Improve the effectiveness of civil 

monetary penalties: The Administrator 

should continue to take those steps 

necessary to shorten the delay in 

adjudicating appeals, including monitoring 

progress made in reducing the backlog of 

appeals. 

As requested by HHS, Congress approved 

increased funding and staffing levels for the 

Departmental Appeals Board in fiscal years 

1999 and 2000. 

z

17. Strengthen the use and effect of 

termination: 

◑

• Continue Medicare and Medicaid payments 

beyond the termination date only if the 

home and state Medicaid agency are 

making reasonable efforts to transfer 

residents to other homes or alternative 

modes of care. 

CMS conducted a study and concluded that it 

was not practical to establish rules to address

this problem. 

Page 29 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

• Ensure that reasonable assurance periods 

associated with reinstating terminated 

homes are of sufficient duration to 

effectively demonstrate that the reason for 

termination has been resolved and will not 

recur. 

CMS added examples to the reasonable 

assurance guidance in 2000, but declined to 

lengthen the reasonable assurance period. 

• Strengthen the use and effect of 

termination: Revise existing policies so that 

the pretermination history of a home is 

considered in taking a subsequent 

enforcement action. 

In 2000, CMS revised its guidance so that 

pretermination history of a home is considered 

in taking subsequent enforcement actions. 

18. Improve the referral process: The 

Administrator should revise CMS guidance 

so that states refer homes to CMS for 

possible sanction (such as civil monetary 

penalties) if they have been cited for a 

deficiency that contributed to a resident’s 

death. 

In 2000, CMS revised its guidance to require

states to refer homes for possible sanction if

they had been cited for a deficiency that 

contributed to a resident’s death. 

z

19. Reassess and revise the immediate 

sanctions policy to ensure that it 

accomplishes the following: 

CMS acknowledged that the complexity of its 

immediate sanctions policy may be an 

inherent limitation and indicated that it intends

to either strengthen the policy or replace it 

with a policy that achieves similar goals 

through alternative methods. 

• Reduce the lag time between citation of a 

double G and the implementation of a 

sanction. 

CMS agreed to reduce the lag time between

citation and implementation of a double G

immediate sanction by limiting the prospective 

effective date for DPNAs to no more than 30 

to 60 days. 

• Prevent nursing homes that repeatedly 

harm residents or place them in immediate 

jeopardy from escaping sanctions. 

CMS indicated it will remove the limitation in

the double G policy on applying an additional 

sanction simply because a nursing home has 

not completed corrections to a deficiency that 

gave rise to a previous sanction. 

GAO-07-241 

• Hold states accountable for reporting in 

federal data systems serious deficiencies 

identified during complaint investigations so 

that all complaint findings are considered in 

determining when immediate sanctions are 

warranted. 

CMS agreed to collect additional information

on complaints for which data are not reported

in federal data systems. 

}

20. Strengthen the deterrent effect of 

available sanctions and ensure that 

sanctions are used to their fullest potential: 

}

• Ensure the consistency of CMPs by issuing 

guidance, such as the standardized CMP 

grid piloted during 2006. 

CMS agreed to issue a CMP analytic tool, or 

grid, and to provide states with further 

guidance on discretionary DPNAs and 

terminations. 

Page 30 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

• Increase use of discretionary DPNAs to 

help ensure the speedier implementation of 

appropriate sanctions. 

CMS indicated it will issue further guidance for 

states on factors to be considered in

determining whether a discretionary DPNA is 

imposed or a termination date is set earlier 

than the time periods required by law 

• Strengthen the criteria for terminating 

homes with a history of serious, repeated 

noncompliance by limiting the extension of 

termination dates, increasing the use of 

discretionary terminations, and exploring 

alternative thresholds for termination, such 

as the cumulative duration of 

noncompliance.

CMS stated it will work with states, consumer

organizations, stakeholders, and others to 

design proposals for a better combination of 

enforcement actions for homes with repeated

quality-of-care deficiencies. 

21. Develop an administrative process under 

which CMPs would be paid—or Medicare 

and Medicaid payments in equivalent 

amounts would be withheld—prior to 

exhaustion of appeals and seek legislation

for the implementation of this process, as 

appropriate. 

CMS agreed to seek legislative authority to 

collect CMPs prior to the exhaustion of 

appeals. 

}

22. Further expand the Special Focus Facility 

program with enhanced enforcement 

requirements to include all homes that 

meet a threshold to qualify as poorly 

performing homes. 

CMS agreed with the concept of expanding 

the Special Focus Facility program to include

all homes that meet a threshold qualifying 

them as poorly performing homes, but said it

lacks the resources needed for this 

expansion. CMS also identified other 

initiatives it will implement to improve the 

program. 

}

23. Improve the effectiveness of the new 

enforcement data system: 

}

• Develop the enforcement-related data 

systems’ abilities to interface with each 

other in order to improve the tracking and 

monitoring of enforcement. 

CMS agreed to study the feasibility of linking 

the separate data systems used for 

enforcement; however, it indicated that 

available resources may limit further action. 

• Expedite the development of national 

enforcement reports and a concrete plan 

for using the reports. 

CMS agreed to study the feasibility of 

developing national standard enforcement 

reports, but stated that further action on these

reports may be limited by resource availability. 

• Develop and institute a system of quality 

checks to ensure the accuracy and integrity 

of AEM data. 

CMS agreed to develop and implement a 

system of quality checks to ensure the 

accuracy of its data systems, including AEM. 

24. Expand CMS’s Nursing Home Compare 

Web site to include implemented sanctions 

and homes subjected to immediate 

sanctions. 

CMS proposed reporting implemented

sanctions only for poorly performing homes 

that meet an undefined threshold—this is not 

fully responsive to our recommendation. 

◑

Page 31 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

Oversight

GAO/HEHS-99-46 25. Develop better management information

systems. The Administrator should 

enhance OSCAR or develop some other 

information system that can be used by 

both by the states and CMS to integrate the 

results of complaint investigations, track the 

status and history of deficiencies, and 

monitor enforcement actions. 

CMS has implemented new national 

enforcement and complaint tracking systems 

but has delayed its replacement of the 

OSCAR data system until 2009 as a result of

funding cuts and CMS focus on other 

initiatives. 

}

GAO/HEHS-99-80 26. Require that the substantiated results of 

complaint investigations be included in 

federal data systems or be accessible by 

federal officials. 

In January 2004, CMS’s new ASPEN 

Complaint Tracking system was implemented

nationwide. 

z

GAO/HEHS-00-6 27. Improve the scope and rigor of CMS’s 

oversight process: 

z

• Increase the proportion of federal 

monitoring surveys conducted as 

comparative surveys to ensure that a 

sufficient number are completed in each 

state to assess whether the state 

appropriately identifies serious deficiencies.

CMS has significantly increased the number 

of quality-of-care comparative surveys. In 

fiscal year 2006, however, the agency will no

longer contract for additional quality-of-care 

comparative surveys because of funding 

constraints. 

• Ensure that comparative surveys are 

initiated closer to the time the state agency 

completes the home’s annual standard 

survey. 

To better ensure that conditions in a nursing 

home have not changed since the state 

survey, CMS regional offices reduced the 

average time between the state survey and 

the initiation of a federal comparative survey 

from 33 days in 1999 to 26 days by 2004. 

• Require regions to provide more timely 

written feedback to the states after the 

completion of federal monitoring surveys. 

CMS instructed the regions to report the 

results of federal monitoring surveys to states 

on a monthly basis. 

• Improve the data system for observational 

surveys so that it is an effective 

management tool for CMS to properly 

assess the findings of observational 

surveys. 

CMS developed a separate database 

accessible to all regional offices that includes 

the results of observational surveys. 

Beginning in fiscal year 2002, CMS added 

data on the results of comparative surveys. 

28. Improve the consistency in how CMS 

holds state survey agencies accountable by 

standardizing procedures for selecting state 

surveys and conducting federal monitoring 

surveys: 

◑

• Ensure that the regions target surveys for 

review that will provide a comprehensive 

assessment of state surveyor performance.

CMS did not implement our recommendation

to select individual state surveys for federal 

review in a manner that ensures its regional 

offices observe as many state surveyors as 

possible. 

Page 32 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

• Require federal surveyors to include as 

many of the same residents as possible in 

their comparative survey sample as the 

state included in its sample (where CMS 

surveyors have determined that the state 

sample selection process was appropriate).

In October 2002, CMS instructed federal

surveyors to select at least half of those 

residents selected by the state surveyors for

their resident sample. 

29. Further explore the feasibility of 

appropriate alternative remedies or 

sanctions for those states that prove unable 

or unwilling to meet CMS’s performance 

standards. 

In December 1999, CMS adopted new state 

sanctions. In fiscal year 2005, CMS began to 

tie survey agency funding increases to the 

timely conduct of standard surveys, a step 

that we believe offers a strong incentive for 

improved compliance. 

z

GAO/HEHS-02-279 30. Review the adequacy of current state 

efforts to ensure the accuracy of minimum 

data set (MDS) data, and provide, where 

necessary, additional guidance, training, 

and technical assistance. 

CMS disagreed with and did not implement 

this recommendation. 

9

31. Monitor the adequacy of state MDS 

accuracy activities on an ongoing basis, 

such as through the use of the established 

federal comparative survey process. 

CMS disagreed with and did not implement 

this recommendation. 

9

32. Provide guidance to state agencies and 

nursing homes that sufficient evidentiary 

documentation to support the full MDS 

assessment be included in residents' 

medical records. 

CMS disagreed with and did not implement 

this recommendation. 

9

GAO-03-187 33. Delay the implementation of nationwide 

reporting of quality indicators until there is 

greater assurance that the quality 

indicators are appropriate for public 

reporting—including the validity of the 

indicators selected and the use of an 

appropriate risk-adjustment methodology—

based on input from the National Quality 

Forum and other experts and, if necessary, 

additional analysis and testing. 

CMS disagreed with and did not implement 

this recommendation. 

9

34. Delay the implementation of nationwide 

reporting of quality indicators until a more

thorough evaluation of the pilot is 

completed to help improve the initiative's 

effectiveness, including an assessment of 

the presentation of information on the Web 

site and the resources needed to assist 

consumers' use of the information. 

CMS disagreed with and did not implement 

this recommendation. 

9

Page 33 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

GAO-03-561 35. Further refine annual state performance 

reviews so that they (1) consistently 

distinguish between systemic problems and 

less serious issues regarding state 

performance, (2) analyze trends in the 

proportion of homes that harm residents, 

(3) assess state compliance with the 

immediate sanctions policy for homes with 

a pattern of harming residents, and (4) 

analyze the predictability of state surveys. 

CMS did not implement this recommendation 

because it believes that the state performance

standards take into account statutory and 

nonstatutory performance standards. 

9

GAO-04-660 36. Ensure that CMS regional offices fully 

comply with the statutory requirement to 

conduct annual federal monitoring surveys 

by including an assessment of the fire 

safety component of states' standard 

surveys, with an emphasis on 

unsprinklered homes. 

CMS’s evaluation of state surveyors’ 

performance now routinely includes fire safety 

as part of the statutory requirement to 

annually conduct federal monitoring surveys 

in at least 5 percent of surveyed nursing 

homes in each state. 

z

37. Ensure that data on sprinkler coverage in 

nursing homes are consistently obtained 

and reflected in the CMS database. 

CMS now obtains the sprinkler status of over 

99 percent of nursing homes during routine 

surveys and inputs this information into 

OSCAR. 

z

38. Until sprinkler coverage data are routinely 

available in CMS's database, work with 

state survey agencies to identify the extent 

to which each nursing home is sprinklered 

or not sprinklered. 

See CMS action in response to

recommendation for ensuring that data on 

sprinkler coverage in nursing homes are 

consistently obtained (recommendation #37 

above). 

z

39. On an expedited basis, review all waivers 

and Fire Safety Evaluation System (FSES) 

assessments for homes that are not fully 

sprinklered to determine their

appropriateness.b

CMS has completed reviews of all waiver 

requests and FSES assessments and noted 

that the number of homes using FSES 

dropped significantly as a result of the review. 

z

40. Make information on fire safety

deficiencies available to the public via the 

Nursing Home Compare Web site, 

including information on whether a home 

has automatic sprinklers. 

This information was made available on the 

Nursing Home Compare Web site as of 

October 2006. 

z

41. Work with the National Fire Protection 

Association to strengthen fire safety 

standards for unsprinklered nursing homes, 

such as requiring smoke detectors in 

resident rooms, exploring the feasibility of 

requiring sprinklers in all nursing homes, 

and developing a strategy for financing 

such requirements. 

CMS issued regulations effective May 24, 

2005, requiring nursing facilities to install 

smoke detectors in resident rooms and public 

areas if they do not have a sprinkler system 

installed throughout the facility or a hard-wired 

smoke detection system in those areas. 

Facilities were given 1 year, until May 24, 

2006, to comply with this requirement. In 

addition, the National Fire Protection 

Association approved a revision to the 2006 

Life Safety Code which requires the 

installation of automatic sprinkler systems in 

all existing facilities. 

z

Page 34 GAO-07-794T
GAO report 

number GAO recommendation CMS initiative

Implementation 

status

42. Ensure that thorough investigations are 

conducted following multiple-death nursing 

home fires so that fire safety standards can 

be reevaluated and modified where 

appropriate. 

CMS developed and issued a standardized

procedure to ensure that both state survey 

agencies and its own staff take appropriate 

action to investigate fires that result in serious 

injury or death.

z

(z) Fully implemented our recommendation 

(◑) Implemented only part of our recommendation and no further steps are planned 

(}) Taking steps to implement our recommendation 

(9) Did not implement our recommendation 

Source: GAO analysis of CMS’s responses to our recommendations.

a

In 1999, CMS had required the use of an investigative protocol on abuse prohibition during every 

standard survey. The protocol’s objective is to determine if the facility has developed and 

operationalized policies and procedures that prohibit abuse, neglect, involuntary seclusion, and 

misappropriation of resident property. 

b

As an alternative to correcting or receiving a waiver for deficiencies identified on a standard survey, a 

home may undergo an assessment using the Fire Safety Evaluation System. The system provides a

means for nursing homes to meet the fire safety objectives of CMS’s standards without necessarily 

being in full compliance with every standard. 

Page 35 GAO-07-794T
Page 36 GAO-07-794T

In order to identify trends in the percentage of nursing homes cited with 

actual harm or immediate jeopardy deficiencies, we analyzed data from 

CMS’s OSCAR database for fiscal years 2000 through 2006 (see table 3). 

Because surveys are conducted at least every 15 months (with a required 

12-month statewide average), it is possible that a home was surveyed 

twice in any time period. To avoid double counting of homes, we included 

only homes’ most recent survey from each period.

Table 3: Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy, by State, Fiscal Years 2000-2006 

 Fiscal year 

State 

Number of 

homes 2006 2000 2001 2002 2003 2004 2005 2006

Alabama 231 35.5 23.0 12.7 18.1 15.6 23.1 24.2

Alaska 15 28.6 26.7 26.7 0.0 0.0 0.0 26.7

Arizona 135 24.2 12.6 7.3 6.6 9.4 9.9 24.8

Arkansas 245 38.1 27.7 22.3 24.7 19.5 15.9 14.5

California 1,304 24.1 10.9 5.1 3.7 6.1 8.0 14.1

Colorado 215 20.4 26.4 32.7 20.9 25.9 40.4 44.8

Connecticut 245 41.9 51.6 45.8 43.1 54.4 44.2 50.8

Delaware 44 47.5 14.6 10.8 5.3 15.0 35.7 36.8

District of Columbia 20 17.7 28.6 30.0 41.2 40.0 30.0 25.0

Florida 688 22.8 20.2 14.9 10.2 7.8 4.2 9.1

Georgia 371 19.5 21.0 23.7 24.6 16.6 18.0 15.9

Hawaii 48 23.8 14.3 21.2 12.1 22.9 2.8 2.1

Idaho 80 51.4 29.7 39.2 31.9 27.3 38.4 47.8

Illinois 816 28.4 19.2 15.3 18.3 15.1 15.7 21.7

Indiana 526 45.0 29.4 23.2 19.7 24.1 28.3 33.4

Iowa 466 14.7 12.0 8.0 9.1 11.8 11.2 11.7

Kansas 361 37.9 30.7 32.9 26.5 30.3 34.9 38.3

Kentucky 298 26.8 29.1 23.2 26.1 14.6 7.7 11.4

Louisiana 307 21.8 29.9 21.7 16.2 12.0 15.4 15.8

Maine 114 11.1 13.9 6.6 11.1 12.8 7.0 9.8

Maryland 235 22.4 16.5 26.1 15.4 17.8 7.6 7.6

Massachusetts 456 29.1 24.4 24.6 25.9 16.7 22.6 20.9

Michigan 429 42.8 24.5 29.7 26.9 22.9 22.9 29.7

Minnesota 404 30.4 17.3 22.3 18.3 14.3 14.4 18.8

Mississippi 207 33.0 19.8 18.7 16.0 18.9 18.1 9.4

Missouri 526 19.8 13.0 15.6 12.5 11.7 15.4 15.6

Appendix II: Percentage of Nursing Homes 

Cited for Actual Harm or Immediate 

Jeopardy during Standard Surveys 
Montana 97 33.3 29.7 12.0 20.0 18.0 17.9 16.7

Nebraska 229 19.2 21.1 20.1 14.8 15.3 14.4 25.7

Nevada 47 34.8 14.6 11.9 9.1 17.5 19.6 21.3

New Hampshire 83 37.8 31.1 29.4 24.1 25.6 26.3 22.9

New Jersey 363 25.5 27.8 18.8 10.5 13.5 18.2 15.5

New Mexico 75 23.7 16.9 14.9 21.3 24.3 29.4 25.0

New York 658 33.8 37.1 34.2 15.2 11.0 14.0 18.5

North Carolina 424 43.6 35.8 25.6 29.0 21.1 18.5 17.2

North Dakota 83 25.9 28.7 17.9 12.4 13.6 17.7 21.7

Ohio 980 26.6 27.3 25.4 19.1 11.4 13.8 14.6

Oklahoma 359 19.3 21.3 22.0 26.3 13.9 23.2 20.1

Oregon 142 45.5 32.6 23.7 20.3 15.9 19.8 18.6

Pennsylvania 724 30.3 19.2 13.5 17.2 19.5 15.2 13.6

Rhode Island 90 14.3 12.9 5.6 6.7 9.3 9.5 4.5

South Carolina 178 26.4 17.2 19.8 29.6 32.7 24.8 17.1

South Dakota 111 27.1 26.7 26.8 32.1 21.6 12.8 21.7

Tennessee 332 28.2 20.2 20.7 21.8 22.9 17.3 12.5

Texas 1,175 29.7 30.5 22.4 18.0 12.0 16.2 18.3

Utah 93 19.5 14.1 25.6 19.0 11.1 8.4 17.9

Vermont 41 22.5 18.2 15.0 10.0 19.5 23.7 13.5

Virginia 281 19.2 14.3 11.6 13.7 10.2 15.5 15.8

Washington 247 46.9 38.3 37.0 30.9 28.1 27.2 24.1

West Virginia 132 12.1 17.7 20.4 12.7 9.8 15.0 9.7

Wisconsin 403 15.8 15.6 11.2 10.9 13.1 18.2 23.0

Wyoming 39 52.8 32.4 25.0 22.9 17.1 11.8 16.2

Nation 16,172 28.4 23.3 20.2 17.8 15.7 16.8 18.9

Source: GAO analysis of OSCAR and PDQ data. 

Page 37 GAO-07-794T
Page 38 GAO-07-794T

Related GAO Products 

Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not 

Deterred Some Homes from Repeatedly Harming Residents. GAO-07-241. 

Washington, D.C.: March 26, 2007. 

Nursing Homes: Despite Increased Oversight, Challenges Remain in 

Ensuring High-Quality Care and Resident Safety. GAO-06-117. 

Washington, D.C.: December 28, 2005. 

Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses 

in State and Federal Oversight of Quality of Care. GAO-05-78. 

Washington, D.C.: November 12, 2004. 

Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in 

Federal Standards and Oversight. GAO-04-660. Washington D.C.: 

July 16, 2004.

Nursing Home Quality: Prevalence of Serious Problems, While 

Declining, Reinforces Importance of Enhanced Oversight. GAO-03-561. 

Washington, D.C.: July 15, 2003. 

Nursing Homes: Public Reporting of Quality Indicators Has Merit, but 

National Implementation Is Premature. GAO-03-187. Washington, D.C.: 

October 31, 2002. 

Nursing Homes: Quality of Care More Related to Staffing than Spending. 

GAO-02-431R. Washington, D.C.: June 13, 2002. 

Nursing Homes: More Can Be Done to Protect Residents from Abuse. 

GAO-02-312. Washington, D.C.: March 1, 2002. 

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data 

Should Complement State Activities. GAO-02-279. Washington, D.C.: 

February 15, 2002. 

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of 

the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: 

September 28, 2000. 

Nursing Home Care: Enhanced HCFA Oversight of State Programs 

Would Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: 

November 4, 1999. 
Nursing Home Oversight: Industry Examples Do Not Demonstrate That 

Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, 

D.C.: August 13, 1999. 

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing 

Homes Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999. 

Nursing Homes: Complaint Investigation Processes Often Inadequate to 

Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999. 

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of 

Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: 

March 18, 1999. 

California Nursing Homes: Care Problems Persist Despite Federal and

State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998. 

(290628) Page 39 GAO-07-794T
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