Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline
Published: 2003-07-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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  performance and improve quality. My remarks are based on our report  being released today that addresses these issues in greater detail.
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. 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 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.
subsections: section_title: Background
paragraphs: 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).
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.
section_title: Magnitude of Problems Remains Cause for Concern, Even Though Fewer Serious Nursing Home Quality Problems Were Reported
paragraphs: 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. (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. We continue to believe that  comparative surveys are the most effective technique for assessing state  agencies’ ability to identify serious deficiencies in nursing homes because  they constitute an independent evaluation of the state survey.
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.
section_title: Weaknesses Persist in State Survey, Complaint, and Enforcement Activities
paragraphs: 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.
subsections: section_title: Confusion about Definition of Harm and Other Factors Contribute to Underreporting of Care Problems
paragraphs: 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. 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.
section_title: Many State Complaint Investigation Systems Still Have Timeliness Problems and Other Weaknesses
paragraphs: 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  investigate actual harm complaints within 10 days. 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.
section_title: Substantial Number of Nursing Homes Were Not Referred to CMS for Immediate Sanctions
paragraphs: 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. 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. 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  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.
section_title: CMS Oversight of State Survey Activities Requires Further Strengthening
paragraphs: 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  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.
section_title: Conclusions
paragraphs: 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  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. 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.
section_title: Contact and Staff Acknowledgments
paragraphs: 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.
section_title: Appendix I: Trends in The Proportion of Nursing Homes Cited for Actual Harm or Immediate Jeopardy Deficiencies, 1999-2002
section_title: Related GAO Products
paragraphs: 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.
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-HEHS- 98-219. 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.
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