Testimony 

Before the Committee on Finance, 

U.S. Senate

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 10:00 a.m. 

Thursday, July 17, 2003 NURSING HOMES 

Prevalence of Serious 

Quality Problems Remains 

Unacceptably High, Despite 

Some Decline 

Statement of William J. Scanlon 

Director—Health Care Issues 

GAO-03-1016T 
The magnitude of documented serious deficiencies that harmed nursing 

home residents remains unacceptably high, despite some decline. For the 

most recent period reviewed, one in five nursing homes nationwide (about 

3,500 homes) had serious deficiencies that caused residents actual harm or 

placed them in immediate jeopardy. Moreover, GAO found significant 

understatement of care problems that should have been classified as actual 

harm or higher—serious avoidable pressure sores, severe weight loss, and 

multiple falls resulting in broken bones and other injuries—for a sample of 

homes with a history of harming residents. Several factors contributed to 

such understatement, including confusion about the definition of harm; 

inadequate state review of surveys to identify potential understatement; 

large numbers of inexperienced state surveyors; and a continuing problem 

with survey timing being predictable to nursing homes. States continue to 

have difficulty identifying and responding in a timely fashion to public 

complaints alleging actual harm—delays state officials attributed to an 

increase in the volume of complaints and to insufficient staff. Although 

federal enforcement policy was strengthened in January 2000 by requiring 

state survey agencies to refer for immediate sanction homes that had a 

pattern of harming residents, many states did not fully comply with this new 

requirement, significantly undermining the policy’s intended deterrent effect. 

While CMS has increased its oversight of state survey and complaint 

investigation activities, continued attention is required to help ensure 

compliance with federal requirements. In October 2000, the agency 

implemented new annual performance reviews to measure state 

performance in seven areas, including the timeliness of survey and 

complaint investigations and the proper documentation of survey findings. 

The first round of results, however, did not produce information enabling the 

agency to identify and initiate needed improvements. For example, some 

regional office summary reports provided too little information to determine 

if a state did not meet a particular standard by a wide or a narrow margin—

information that could help CMS to judge the seriousness of problems 

identified and target remedial interventions. Rather than relying on its 

regional offices, CMS plans to more centrally manage future state 

performance reviews to improve consistency and to help ensure that the 

results of those reviews could be used to more readily identify serious 

problems. Finally, implementation has been significantly delayed for three 

federal initiatives that are critical to reducing the variation evident in the 

state survey process in categorizing the seriousness of deficiencies and 

investigating complaints. These delayed initiatives were intended to 

strengthen the methodology for conducting surveys, improve surveyor 

guidance for determining the scope and severity of deficiencies, and increase 

standardization in state complaint investigation processes. 

Since 1998, the Congress and 

Administration have focused 

considerable attention on 

improving the quality of care in the 

nation’s nursing homes, which 

provide care for about 1.7 million 

elderly and disabled residents in 

about 17,000 homes. GAO has 

earlier reported on serious 

weaknesses in processes for 

conducting routine state 

inspections (surveys) of nursing 

homes and complaint 

investigations, ensuring that homes 

with identified deficiencies correct 

the problems without recurrence, 

and providing consistent federal 

oversight of state survey activities 

to ensure that nursing homes 

comply with federal quality 

standards. 

GAO was asked to update its work 

on these issues and to testify on its 

findings, as reported in Nursing 

Home Quality: Prevalence of 

Serious Problems, While 

Declining, Reinforces Importance 

of Enhanced Oversight, GAO-03-

561 (July 15, 2003). In commenting 

on this report, the Centers for 

Medicare & Medicaid Services 

(CMS) generally concurred with 

the recommendations to address 

survey and oversight weaknesses. 

In this testimony, GAO addresses 

(1) the prevalence of serious 

nursing home quality problems 

nationwide, (2) factors contributing 

to continuing weaknesses in states’ 

survey, complaint, and 

enforcement activities, and (3) the 

status of key federal efforts to 

oversee state survey agency 

performance and improve quality. 

www.gao.gov/cgi-bin/getrpt?GAO-03-1016T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen on (202) 512-7118. 

Highlights of GAO-03-1016T, a testimony 

before the Committee on Finance, U.S. 

Senate 

July 17, 2003

NURSING HOMES

Prevalence of Serious Quality Problems 

Remains Unacceptably High, Despite 

Some Decline 
Page 1 GAO-03-1016T 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you address the quality of care provided 

to the nation’s 1.7 million nursing home residents, a highly vulnerable 

population of elderly and disabled individuals. The federal government 

plays a major role in ensuring nursing home quality and in financing 

nursing home care. Medicare and Medicaid paid the nation’s 

approximately 17,000 homes an estimated $42 billion in 2002 to care for 

beneficiaries. More specifically, Medicaid pays for care provided to about 

two-thirds of all nursing home residents nationwide. In addition, the 

Department of Veterans Affairs contracts with many of these same nursing 

homes to provide long-term care to veterans at a cost of more than $250 

million in fiscal year 2002. In 1998, the Senate Special Committee on Aging 

held a hearing to address nursing home care problems in California. 

Troubled by our findings of poor care in that state’s homes and weak 

federal oversight in general, the Committee held additional hearings on 

nursing home quality nationwide in 1999 and 2000. In response to 

congressional oversight and our recommendations, the Administration has 

taken actions intended to address many of the weaknesses we identified. 

These weaknesses included: 

• periodic state inspections, known as surveys, that understated the extent 

of serious care problems due to procedural weaknesses; 

• considerable delays that occurred in states investigating complaints by 

residents, family members or friends, and nursing home staff alleging 

actual harm to residents; 

• federal enforcement policies that did not ensure that identified 

deficiencies were addressed and remained corrected; and 

• federal oversight of state survey activities that was often inconsistent 

across states and limited in scope and effectiveness. 

In September 2000, we reported on progress made in addressing these 

weaknesses and concluded that the success of the Administration’s 

actions to improve nursing home quality required sustained federal and 

state commitment to reach their full potential. My remarks today will 

address federal and state progress made since our September 2000 report 

and testimony, focusing in particular on (1) the prevalence of serious 

nursing home quality problems, (2) factors contributing to continuing 

weaknesses in states’ survey, complaint, and enforcement activities, and 

(3) the status of key federal efforts to oversee state survey agency 
Page 2 GAO-03-1016T 

performance and improve quality. My remarks are based on our report 

being released today that addresses these issues in greater detail.1

In summary, the magnitude of serious deficiencies that harmed nursing 

home residents remains unacceptably high, despite some decline. For the 

most recent period we reviewed, one in five of all nursing homes 

nationwide (about 3,500 homes) had serious deficiencies that caused 

residents actual harm or placed them in immediate jeopardy. Moreover, 

we found significant understatement of care problems that should have 

been classified as actual harm or higher—serious avoidable pressure 

sores, severe weight loss, and multiple falls resulting in broken bones and 

other injuries—for a sample of homes with a history of harming residents. 

We identified several factors that contributed to such understatement, 

including confusion about the definition of harm; inadequate state 

supervisory review of surveys to identify potential understatement; large 

numbers of inexperienced state surveyors; and a continuing, significant 

problem with survey timing being predictable to nursing homes. States 

also continue to have difficulty identifying and responding in a timely 

fashion to complaints alleging actual harm—delays that state officials 

attributed to an increase in the volume of complaints and to insufficient 

staff. Although federal enforcement policy was strengthened in January 

2000 by requiring state survey agencies to refer for immediate sanction 

homes that had a pattern of harming residents, we found that many states 

did not fully comply with this new requirement. States failed to refer 

hundreds of homes for immediate sanction, significantly undermining the 

policy’s intended deterrent effect. 

While the Centers for Medicare & Medicaid Services (CMS) has increased 

its oversight of state survey and complaint investigation activities, 

continued attention is required to help ensure compliance with federal 

requirements.2

 In October 2000, the agency implemented new annual 

performance reviews to measure state performance in seven areas, 

including the timeliness of survey and complaint investigations and the 

proper documentation of survey findings. The first round of results, 

 1

U.S. General Accounting Office, Nursing Home Quality: Prevalence of Serious Problems, 

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

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

2

Effective July 1, 2001, the name of the Health Care Financing Administration (HCFA) was 

changed to the Centers for Medicare & Medicaid Services. In this testimony we continue to 

refer to HCFA where our findings apply to the organizational structure and operations 

associated with that name. 
Page 3 GAO-03-1016T 

however, did not produce information enabling the agency to identify and 

initiate needed improvements. For example, some regional office summary 

reports provided too little information to determine if a state agency did 

not meet a particular standard by a wide or a narrow margin—information 

that could help CMS to judge the seriousness of problems identified and 

target remedial actions. Rather than relying on its regional offices, CMS 

plans to more centrally manage future state performance reviews to 

improve consistency and to help ensure that the results of those reviews 

could be used to more readily identify serious problems. Finally, 

implementation has been significantly delayed for three federal initiatives 

that are critical to reducing the variation evident in the state survey 

process in categorizing the seriousness of deficiencies and investigating 

complaints. These delayed initiatives were intended to strengthen the 

methodology for conducting surveys, improve surveyor guidance for 

determining the scope and severity of deficiencies, and increase 

standardization in state complaint investigation processes. In our view, 

finalizing and implementing these initiatives as quickly as possible would 

help bring more clarity and consistency to the process for assessing and 

improving the quality of care provided to the nation’s nursing home 

residents. 

Oversight of nursing homes is a shared federal and state responsibility. 

CMS is the federal agency that manages Medicare and Medicaid and 

oversees compliance with federal nursing home quality standards. On the 

basis of statutory requirements, CMS defines standards that nursing homes 

must meet to participate in the Medicare and Medicaid programs and 

contracts with states to certify that homes meet these standards through 

annual inspections and complaint investigations. The “annual” inspection, 

called a survey, which must be conducted on average every 12 months and 

no less than every 15 months at each home, entails a team of state 

surveyors spending several days in the home to determine whether care 

and services meet the assessed needs of the residents. CMS establishes 

specific protocols, or investigative procedures, for state surveyors to use 

in conducting these comprehensive surveys. In contrast, complaint 

investigations, also conducted by state surveyors within certain federal 

guidelines and time frames, typically target a single area in response to a 

complaint filed against a home by a resident, the resident’s family or 

friends, or nursing home employees. Quality-of-care problems identified 

during either standard surveys or complaint investigations are classified in 

1 of 12 categories according to their scope (the number of residents 

potentially or actually affected) and their severity (potential for or 

occurrence of harm to residents). 

Background 
Page 4 GAO-03-1016T 

Ensuring that documented deficiencies are corrected is likewise a shared 

responsibility. CMS is responsible for enforcement actions involving 

homes with Medicare or dual Medicare and Medicaid certification—about 

86 percent of all homes. States are responsible for enforcing standards in 

homes with Medicaid-only certification—about 14 percent of the total. 

Enforcement actions can involve, among other things, requiring corrective 

action plans, imposing monetary fines, denying the home Medicare and 

Medicaid payments for new admissions until corrections are in place, and, 

ultimately, terminating the home from participation in these programs. 

Sanctions are imposed by CMS on the basis of state referrals. States may 

also use their state licensure authority to impose state sanctions. 

CMS is also responsible for overseeing each state survey agency’s 

performance in ensuring quality of care in its nursing homes. One of its 

primary oversight tools is the federal monitoring survey, which is required 

annually for at least 5 percent of all Medicare- and Medicaid-certified 

nursing homes. Federal monitoring surveys can be either comparative or 

observational. A 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. Roughly 85 percent of federal surveys are observational. 

Based on prior work, we have concluded that the comparative survey is 

the more effective of the two federal monitoring surveys for assessing 

state agencies’ abilities to identify serious deficiencies in nursing homes 

and have recommended that more priority be given to them. A new federal 

oversight tool, state performance reviews, implemented in October 2000, 

measures state survey agency performance against seven standards, 

including statutory requirements regarding survey frequency, requirements 

for documenting deficiencies, and timeliness of complaint investigations. 

These reviews replaced state self-reporting of their compliance with 

federal requirements. CMS also maintains a central database—the On-Line 

Survey, Certification, and Reporting (OSCAR) system—that compiles, 

among other information, the results of every state survey conducted at 

Medicare- and Medicaid-certified facilities nationwide. 
Page 5 GAO-03-1016T 

State survey data indicate that the proportion of nursing homes with 

serious quality problems remains unacceptably high, despite a decline in 

such reported problems since mid-2000. For an 18-month period ending in 

January 2002, 20 percent of nursing homes (about 3,500) were cited for 

deficiencies involving actual harm or immediate jeopardy to residents. 

This share is down from 29 percent (about 5,000 homes) for the previous 

period.3

 (Appendix I provides trend data on the percentage of nursing 

homes cited for serious deficiencies for all 50 states and the District of 

Columbia.) Despite this decline, there is still considerable variation in the 

proportion of homes cited for such serious deficiencies, ranging from 

about 7 percent in Wisconsin to about 50 percent in Connecticut. 

Federal comparative surveys completed during a recent 21-month period 

found actual harm or higher-level deficiencies in about 10 percent fewer 

homes where state surveyors found no such deficiencies, compared to an 

earlier period. Fewer discrepancies between federal and state surveys 

suggest that state surveyors’ performance in documenting serious 

deficiencies has improved. However, the magnitude of the state surveyors’ 

understatement of quality problems remains a serious issue. From June 

2000 through February 2002, federal surveyors conducting comparative 

surveys found examples of actual harm deficiencies in about one fifth of 

homes that states had judged to be deficiency free. For example, federal 

surveyors found that a home had failed to prevent pressure sores, failed to 

consistently monitor pressure sores when they did develop, and failed to 

notify the physician promptly so that proper treatment could be started. 

These federal surveyors noted that inadequate monitoring of pressure 

sores was a problem during the state’s survey that should have been found 

and cited. CMS plans to hire a contractor to perform approximately 170 

additional comparative surveys each year, bringing the annual total to 330, 

including those conducted by CMS surveyors.4

 We continue to believe that 

comparative surveys are the most effective technique for assessing state 

 3

We analyzed OSCAR data for surveys performed from January 1, 1999, through July 10, 

2000, and from July 11, 2000, through January 31, 2002, and entered into OSCAR as of June 

24, 2002. Immediate jeopardy involves situations with actual or potential for death/serious 

injury. 

4

Contractor proposals are due to CMS on July 19, 2003. 

Magnitude of 

Problems Remains 

Cause for Concern, 

Even Though Fewer 

Serious Nursing 

Home Quality 

Problems Were 

Reported 
Page 6 GAO-03-1016T 

agencies’ ability to identify serious deficiencies in nursing homes because 

they constitute an independent evaluation of the state survey.5

Beyond the continuing high prevalence of actual harm or immediate 

jeopardy deficiencies, we found a disturbing understatement of actual 

harm or higher deficiencies in a sample of surveys that were conducted 

since July 2000 at homes with a history of harming residents but whose 

current surveys indicated no actual harm deficiencies. Overall, 39 percent 

of 76 surveys we reviewed had documented problems that should have 

been classified as actual harm: serious, avoidable pressure sores; severe 

weight loss; and multiple falls resulting in broken bones and other injuries. 

We were unable to assess whether the scope and severity of other 

deficiencies in our sample of surveys were also understated because of 

weaknesses in how those deficiencies were documented. 

Despite increased attention in recent years, widespread weaknesses 

persist in state survey, complaint investigation, and enforcement activities. 

In our view, this reflects not necessarily a lack of effort but rather the 

magnitude of the challenge in effecting important and consistent systemic 

change across all states. We identified several factors that contributed to 

these weaknesses and the understatement of survey deficiencies, 

including confusion over the definition of actual harm. Moreover, many 

state complaint investigation systems still have timeliness problems and 

some states did not comply with HCFA’s policy to refer to the agency for 

immediate sanction those nursing homes that showed a pattern of harming 

residents, resulting in hundreds of nursing homes not appropriately 

referred for action. 

 5

In prior work completed on veterans’ care in nursing homes, we recommended that the VA 

consider contracting with CMS to conduct these comparative surveys in order to better 

assess the quality of state data that are used in placing veterans in nursing homes. See U.S. 

General Accounting Office, VA Long-Term Care: Oversight of Community Nursing 

Homes Needs Strengthening, GAO-01-768 (Washington, D.C.: July 27, 2001). VA has not 

contracted with CMS to conduct comparative surveys but is beginning to discuss the issue 

with CMS. 

Weaknesses Persist in 

State Survey, 

Complaint, and 

Enforcement 

Activities 
Page 7 GAO-03-1016T 

We identified several factors at the state level that contributed to the 

understatement of serious quality-of-care problems. State survey agency 

officials expressed confusion about the definitions of “actual harm” and 

“immediate jeopardy,” which may contribute to the variability in 

identifying deficiencies among states. Several states’ comments on our 

draft report underscored how the lack of clear and consistent CMS 

guidance on these definitions may have contributed to such confusion. For 

example, supplementary guidance provided to one state by its CMS 

regional office on how to assess the severity of a newly developing 

pressure sore was inconsistent with CMS’s definition of actual harm. 

Other factors that have contributed to the understatement of actual harm 

include lack of adequate state supervisory review of survey findings, large 

numbers of inexperienced surveyors, and continued survey predictability. 

While most of the 16 states we contacted had processes for supervisory 

review of deficiencies cited at the actual harm level and higher, half did 

not have similar processes to help ensure that the scope and severity of 

less serious deficiencies were not understated.6

 According to state 

officials, the large number of inexperienced surveyors, which ranged from 

25 percent to 70 percent in 27 states and the District of Columbia and is 

due to high attrition and hiring limitations, has also had a negative impact 

on the quality of surveys. In addition, our analysis of OSCAR data 

indicated that the timing of about one-third of the most recent state 

surveys nationwide remained predictable—a slight reduction from homes’ 

prior surveys, about 38 percent of which were predictable. Predictable 

surveys can allow quality-of-care problems to go undetected because 

homes, if they choose to do so, may conceal certain problems such as 

understaffing. 

CMS’s 2001 review of a sample of complaints in all states demonstrated 

that many states were not complying with CMS complaint investigation 

timeliness requirements. Specifically, 12 states were not investigating all 

immediate jeopardy complaints within the required 2 workdays, and 42 

states were not complying with the new requirement established in 1999 to 

 6

Officials explained the focus on actual harm or higher-level deficiencies by noting that the 

potential for sanctions increased the likelihood that the deficiencies would be challenged 

by the nursing home and perhaps appealed in an administrative hearing. 

Confusion about Definition 

of Harm and Other Factors 

Contribute to 

Underreporting of Care 

Problems 

Many State Complaint 

Investigation Systems Still 

Have Timeliness Problems 

and Other Weaknesses 
Page 8 GAO-03-1016T 

investigate actual harm complaints within 10 days.7 Some states attributed 

the timeliness problem to an increase in the number of complaints and to 

insufficient staff. CMS also found that the triaging of complaints to 

determine how quickly to investigate each complaint was inadequate in 

some states. A CMS-sponsored study of the states’ complaint practices 

also raised concerns about state approaches to accepting and investigating 

complaints. For example, 15 states did not provide toll-free hotlines to 

facilitate the filing of complaints and the majority of states lacked 

adequate systems for managing complaints. To address the latter problem, 

CMS planned to implement a new complaint tracking system nationwide 

in October 2002, but as of today, the system is still being tested and its 

implementation date is uncertain. 

State survey agencies did not refer a significant number of cases where 

nursing homes were found to have a pattern of harming residents to CMS 

for immediate sanction as required by CMS policy, significantly 

undermining the policy’s intended deterrent effect. Our earlier work found 

that nursing homes tended to “yo-yo” in and out of compliance, in part 

because HCFA rarely imposed sanctions on homes with a pattern of 

deficiencies that harmed residents.8

 In response, the agency required that, 

as of January 2000, homes found to have harmed residents on successive 

standard surveys be referred to it for immediate sanction.9

 While most 

states did not forward at least some cases that should have been referred 

under this policy, four states accounted for over half of the 700 nursing 

 7

In March 1999, we reported that inadequate state complaint intake and investigation 

practices in states we reviewed had too often resulted in extensive delays in investigating 

serious complaints. As a result of our findings, HCFA began requiring states to investigate 

complaints that allege actual harm, but do not rise to the level of immediate jeopardy, 

within 10 working days. U.S. General Accounting Office, Nursing Homes: Complaint 

Investigation Processes Often Inadequate to Protect Residents, GAO/HEHS-99-80

(Washington, D.C.: Mar. 22, 1999). 

8

See GAO/HEHS-99-46. 

9

This policy was implemented in two stages, and our analysis focused on implementation of 

the second stage beginning in January 2000. As of September 1998, HCFA required states to 

refer homes that had a pattern of harming a significant number of residents or placed 

residents at high risk of death or serious injury. Effective January 14, 2000, HCFA expanded 

this policy by requiring state survey agencies to refer for immediate sanction homes that 

had harmed residents on successive surveys. States are now required to deny a grace 

period to correct deficiencies without sanction to homes that are assessed one or more 

deficiencies at the actual harm level or above in each of two surveys within a survey cycle. 

A survey cycle is two successive standard surveys and any intervening survey, such as a 

complaint investigation. 

Substantial Number of 

Nursing Homes Were Not 

Referred to CMS for 

Immediate Sanctions 
Page 9 GAO-03-1016T 

homes not referred. One of these states did not fully implement the new 

CMS policy until mid-2002 and another state implemented its own version 

of the policy through September 2002, resulting in relatively few referrals. 

In most other states, the failure to refer cases resulted from a 

misunderstanding of the policy by both some states and CMS regional 

offices and, in some states, from the lack of an adequate system for 

tracking a home’s survey history to determine if it met the policy’s criteria. 

While CMS has instituted a more systematic oversight process of state 

survey and complaint activities by initiating annual state performance 

reviews, CMS officials acknowledged that the effectiveness of the reviews 

could be improved. Major areas needing improvement as a result of the 

fiscal year 2001 review include (1) distinguishing between minor and 

major problems, (2) evaluating how well states document deficiencies, and 

(3) ensuring consistency in how regions conduct reviews. Data limitations, 

particularly involving complaints, and inconsistent use of periodic 

monitoring reports also hampered the effectiveness of state performance 

reviews. For subsequent reviews, CMS plans to more centrally manage the 

process to improve consistency and to help ensure that future reviews 

distinguish serious from minor problems. 

Implementation has been significantly delayed for three federal initiatives 

that are critical to reducing the subjectivity in the state survey process for 

identifying deficiencies and determining the seriousness of complaints. 

These delayed initiatives were intended to strengthen the methodology for 

conducting surveys, improve surveyor guidance for determining the scope 

and severity of deficiencies, and increase standardization in state 

complaint investigation processes. 

• Strengthening the survey methodology. Because surveyors often 

missed significant care problems due to weaknesses in the survey process, 

HCFA contracted in 1998 for the development of a revised survey 

methodology. The agency’s contractor has proposed a two-phase survey 

process. In the first phase, surveyors would initially identify potential care 

problems using data generated off-site prior to the start of the survey and 

additional, standardized information collected on-site. During the second 

phase, surveyors would conduct an onsite investigation to confirm and 

document the care deficiencies initially identified. Compared to the 

current survey process, the revised methodology under development is 

designed to more systematically target potential problems at a home and 

give surveyors new tools to more adequately document care outcomes and 

conduct onsite investigations. In April 2003, a CMS official told us that the 

CMS Oversight of 

State Survey 

Activities Requires 

Further Strengthening 
Page 10 GAO-03-1016T 

agency lacked adequate funding to complete testing and implementation 

of the revised methodology under development for almost 5 years. 

Through September 2003, CMS will have committed about $4.7 million to 

this effort. While CMS did not address the lack of adequate funding in its 

comments on our draft report, a CMS official subsequently told us that 

about $508,000 has now been slated for additional field testing. This 

amount, however, has not yet been approved. Not funding the additional 

field testing could jeopardize the entire initiative, in which a substantial 

investment has already been made. 

• Developing clearer guidance for surveyors. Recognizing 

inconsistencies in how the scope and severity of deficiencies are cited 

across states, in October 2000, HCFA began developing more structured 

guidance for surveyors, including survey investigative protocols for 

assessing specific deficiencies. The intent of this initiative is to enable 

surveyors to better (1) identify specific deficiencies, (2) investigate 

whether a deficiency is the result of poor care, and (3) document the level 

of harm resulting from a home’s identified deficient care practices. Delays 

have occurred, and the first such guidance to be completed—pressure 

sores—has not yet been released. 

• Developing additional state guidance for investigating complaints. 

Despite initiation of a complaint improvement project in 1999, CMS has 

not yet developed detailed guidance for states to help improve their 

complaint investigation systems. CMS received its contractor’s report in 

June 2002, and indicated agreement with the report’s conclusion that 

reforming the complaint system is urgently needed to achieve a more 

standardized, consistent, and effective process. CMS told us that it plans to 

issue new guidance to the states in late fiscal year 2003—about 4 years 

after the complaint improvement project initiative was launched. 

As we reported in September 2000, continued federal and state attention is 

required to ensure necessary improvements in the quality of care provided 

to the nation’s vulnerable nursing home residents. The proportion of 

homes reported to have harmed residents is still unacceptably high, 

despite the reported decline in the incidence of such problems. This 

decline is consistent with the concerted congressional, federal, and state 

attention focused on addressing quality of care problems. Despite these 

efforts, however, CMS needs to continue its efforts to better ensure 

consistent compliance with federal quality requirements. Several areas 

that require CMS’s ongoing attention include: (1) developing more 

structured guidance for surveyors to address inconsistencies in how the 

scope and severity of deficiencies are cited across states, (2) finalizing and 

Conclusions 
Page 11 GAO-03-1016T 

implementing the survey methodology redesign intended to make the 

survey process more systematic, (3) implementing a nationwide complaint 

tracking system and providing states additional complaint investigation 

guidance, and (4) refining the newly established state agency performance 

standard reviews to ensure that states are held accountable for ensuring 

that nursing homes comply with federal nursing home quality standards. 

Some of these efforts have been underway for several years, with CMS 

consistently extending their estimated completion and implementation 

dates. The need to come to closure on these initiatives is clear. The report 

on which this testimony is based contained several new recommendations 

for needed CMS actions on these issues; CMS generally concurred with 

our recommendations.10 We believe that effective and timely 

implementation of planned improvements in each of these areas is critical 

to ensuring better quality care for the nation’s 1.7 million vulnerable 

nursing home residents. 

Mr. Chairman and Members of the Committee, this concludes my prepared 

statement. I will be happy to answer any questions you may have. 

For further information about this testimony, please contact Kathryn G. 

Allen at (202) 512-7118 or Walter Ochinko at (202) 512-7157. Jack Brennan, 

Patricia A. Jones, and Dean Mohs also made key contributions to this 

statement. 

 10GAO-03-561. 

Contact and Staff 

Acknowledgments 
Page 12 GAO-03-1016T 

Number of homes surveyed 

Percentage of homes cited for 

actual harm or immediate 

jeopardy Percentage point differencea

State 1/97-6/98 1/99-7/00 7/00-1/02 1/97-6/98 1/99-7/00 7/00-1/02 

1/97-6/98 and 

1/99-7/00 

1/99-7/00 and 

7/00-1/02

Alabama 227 225 228 51.1 42.2 18.4 -8.9 -23.8

Alaska 16 15 15 37.5 20.0 33.3 -17.5 13.3

Arizona 163 142 147 17.2 33.8 8.8 16.6 -25.0

Arkansas 285 273 267 14.7 37.7 27.3 23.0 -10.4

California 1,435 1,400 1,348 28.2 29.1 9.3 0.9 -19.9

Colorado 234 227 225 11.1 15.4 26.2 4.3 10.8

Connecticut 263 262 259 52.9 48.5 49.4 -4.4 0.9

Delaware 44 42 42 45.5 52.4 14.3 6.9 -38.1

District of Columbia 24 20 21 12.5 10.0 33.3 -2.5 23.3

Florida 730 753 742 36.3 20.8 20.1 -15.5 -0.8

Georgia 371 368 370 17.8 22.6 20.5 4.8 -2.0

Hawaii 45 47 46 24.4 25.5 15.2 1.1 -10.3

Idaho 86 83 84 55.8 54.2 31.0 -1.6 -23.3

Illinois 899 900 881 29.8 29.3 15.4 -0.5 -13.9

Indiana 602 590 573 40.5 45.3 26.2 4.8 -19.1

Iowa 525 492 494 39.2 19.3 9.9 -19.9 -9.4

Kansas 445 410 400 47.0 37.1 29.0 -9.9 -8.1

Kentucky 318 312 306 28.6 28.8 25.2 0.2 -3.7

Louisiana 433 387 367 12.7 19.9 23.4 7.2 3.5

Maine 135 126 124 7.4 10.3 9.7 2.9 -0.6

Maryland 258 242 248 19.0 25.6 20.2 6.6 -5.5

Massachusetts 576 542 512 24.0 33.0 22.9 9.0 -10.2

Michigan 451 449 441 43.7 42.1 24.7 -1.6 -17.4

Minnesota 446 439 431 29.6 31.7 18.8 2.1 -12.9

Mississippi 218 202 219 24.8 33.2 19.6 8.4 -13.5

Missouri 595 584 569 21.0 22.3 10.2 1.3 -12.1

Montana 106 104 103 38.7 37.5 25.2 -1.2 -12.3

Nebraska 263 242 243 32.3 26.0 18.9 -6.3 -7.1

Nevada 49 52 51 40.8 32.7 9.8 -8.1 -22.9

New Hampshire 86 83 79 30.2 37.3 21.5 7.1 -15.8

New Jersey 377 359 366 13.0 24.5 22.4 11.5 -2.1

New Mexico 88 82 82 11.4 31.7 17.1 20.3 -14.6

New York 662 668 671 13.3 32.2 32.3 18.9 0.2

North Carolina 407 414 419 31.0 40.8 30.1 9.8 -10.7

North Dakota 88 89 88 55.7 21.3 28.4 -34.4 7.1

Ohio 1,043 1,047 1,029 31.2 29.0 23.7 -2.2 -5.3

Oklahoma 463 432 394 8.4 16.7 20.6 8.3 3.9

Oregon 171 158 152 43.9 47.5 33.6 3.6 -13.9

Pennsylvania 811 788 764 29.3 32.2 11.6 2.9 -20.6

Appendix I: Trends in The Proportion of 

Nursing Homes Cited for Actual Harm or 

Immediate Jeopardy Deficiencies, 1999-2002 
Page 13 GAO-03-1016T 

Number of homes surveyed 

Percentage of homes cited for 

actual harm or immediate 

jeopardy Percentage point differencea

State 1/97-6/98 1/99-7/00 7/00-1/02 1/97-6/98 1/99-7/00 7/00-1/02 

1/97-6/98 and 

1/99-7/00 

1/99-7/00 and 

7/00-1/02

Rhode Island 102 99 99 11.8 12.1 10.1 0.3 -2.0

South Carolina 175 178 180 28.6 28.7 17.8 0.1 -10.9

South Dakota 124 112 114 40.3 24.1 30.7 -16.2 6.6

Tennessee 361 354 377 11.1 26.0 16.7 14.9 -9.3

Texas 1,381 1,336 1,275 22.2 26.9 25.5 4.7 -1.5

Utah 98 95 95 15.3 15.8 15.8 0.5 0.0

Vermont 45 46 45 20.0 15.2 17.8 -4.8 2.6

Virginia 279 287 285 24.7 19.9 11.6 -4.8 -8.3

Washington 288 279 275 63.2 54.1 38.5 -9.1 -15.6

West Virginia 130 147 143 12.3 15.6 14.0 3.3 -1.7

Wisconsin 438 428 421 17.1 14.0 7.1 -3.1 -6.9

Wyoming 38 41 40 28.9 43.9 22.5 15.0 -21.4

Nation 17,897 17,452 17,149 27.7 29.3 20.5 1.6 -8.8

Source: GAO analysis of OSCAR data as of June 24, 2002. 

a

Differences are based on numbers before rounding. 
Page 14 GAO-03-1016T 

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. 

VA Long-Term Care: Oversight of Community Nursing Homes Needs 

Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001. 

Nursing Homes: Success of Quality Initiatives Requires Sustained 

Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.: 

September 28, 2000. 

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 Homes: HCFA Should Strengthen Its Oversight of State Agencies 

to Better Ensure Quality of Care. GAO/T-HEHS-00-27. 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: HCFA Initiatives to Improve Care Are Under Way but 

Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington, 

D.C.: June 30, 1999. 

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing 

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

Related GAO Products 
Page 15 GAO-03-1016T 

Nursing Homes: Complaint Investigation Processes in Maryland. 

GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999. 

Nursing Homes: Complaint Investigation Processes Often Inadequate to 

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

Nursing Homes: Stronger Complaint and Enforcement Practices Needed 

to Better Ensure Adequate Care. GAO/T-HEHS-99-89. 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: Federal and State Oversight Inadequate to 

Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS98-219. Washington, D.C.: July 28, 1998. 

California Nursing Homes: Care Problems Persist Despite Federal and 

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

(290310) 
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