Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety
Published: 2005-12-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Since 1998, GAO has issued numerous reports on nursing home quality and safety that identified significant weaknesses in federal and state oversight. Under contract with the Centers for Medicare & Medicaid Services (CMS), states conduct annual nursing home inspections, known as surveys, to assess compliance with federal quality and safety requirements. States also investigate complaints filed by family members or others in between annual surveys. When state surveys find serious deficiencies, CMS may impose sanctions to encourage compliance with federal requirements. GAO was asked to assess CMS's progress since 1998 in addressing oversight weaknesses. GAO (1) reviewed the trends in nursing home quality from 1999 through January 2005, (2) evaluated the extent to which CMS's initiatives have addressed survey and oversight problems identified by GAO and CMS, and (3) identified key challenges to continued progress in ensuring resident health and safety. GAO reviewed federal data on the results of state nursing home surveys and federal surveys assessing state performance; conducted additional analyses in five states with large numbers of nursing homes; reviewed the status of its prior recommendations; and identified key workforce and workload issues confronting CMS and states.
section_title: What GAO Found
paragraphs: CMS's nursing home survey data show a significant decline in the proportion of nursing homes with serious quality problems since 1999, but this trend masks two important and continuing issues: inconsistency in how states conduct surveys and understatement of serious quality problems. Inconsistency in states' surveys is demonstrated by wide interstate variability in the proportion of homes found to have serious deficiencies--for example, about 6 percent in one state and about 54 percent in another. Continued understatement of serious deficiencies is shown by the increase in discrepancies between federal and state surveys of the same homes from 2002 through 2004, despite an overall decline in such discrepancies from October 1998 through December 2004. In five large states that had a significant decline in serious deficiencies, federal surveyors concluded that from 8 percent to 33 percent of the comparative surveys identified serious deficiencies that state surveyors had missed. This finding is consistent with earlier GAO work showing that state surveyors missed serious care problems. These two issues underscore the importance of CMS initiatives to improve the consistency and rigor of nursing home surveys. CMS has addressed many survey and oversight shortcomings, but it is still developing or has not yet implemented several key initiatives, particularly those intended to improve the consistency of the survey process. Key steps CMS has taken include (1) revising the survey methodology, (2) issuing states additional guidance to strengthen complaint investigations, (3) implementing immediate sanctions for homes cited for repeat serious violations, and (4) strengthening oversight by conducting assessments of state survey activities. Some CMS initiatives, however, either have shortcomings impairing their effectiveness or have not effectively targeted problems GAO and CMS identified. For example, CMS has not fully addressed issues with the accuracy and reliability of the data underlying consumer information published on its Web site. The key challenges CMS, states, and nursing homes face in their efforts to further improve nursing home quality and safety include (1) the cost to older homes to be retrofit with automatic sprinklers to help reduce the loss of life in the event of a fire, (2) continuing problems with hiring and retaining qualified surveyors, and (3) an expanded workload due to increased oversight, identification of additional initiatives that compete for staff and financial resources, and growth in the number of Medicare and Medicaid providers. Despite CMS's increased nursing home oversight, its continued attention and commitment are warranted in order to maintain the momentum of its efforts to date and to better ensure high-quality care and safety for nursing home residents. CMS generally concurred with the report's findings. CMS noted several areas of progress in nursing home quality and identified remaining challenges to conducting nursing home survey and oversight activities.

section_title: Letter
paragraphs: Numerous congressional hearings since July 1998 have focused attention  on the need to improve the care and safety of the nation’s 1.5 million  nursing home residents, a highly vulnerable population of elderly and  disabled individuals for whom remaining at home is no longer feasible.  Many nursing home residents require help with feeding, toileting,  grooming, or other routine activities of daily living; are cognitively  impaired; or have chronic health care conditions such as heart disease.  Some individuals with chronic conditions are long-term residents of  nursing homes, while others enter nursing homes for a short period, such  as after a hospitalization. With the aging of the baby boom generation, the  number of individuals needing nursing home care is expected to increase  in size dramatically. Combined Medicare and Medicaid payments for  nursing home services were about $65 billion in 2003, including a federal  share of about $43 billion.
In a series of reports, we have identified significant weaknesses in federal  and state activities designed to detect and correct quality and safety  problems at nursing homes. Our key findings included the following:    A small but unacceptable proportion of nursing homes repeatedly caused  actual harm to residents, such as worsening pressure sores or untreated  weight loss, or placed residents at risk of death or serious injury.
The results of state inspections, known as surveys, understated the extent  of serious quality-of-care and fire safety problems, reflecting weaknesses  in the survey methodology and an inconsistent application of federal  standards.
Serious complaints by residents, family members, or staff alleging harm to  residents remained uninvestigated for weeks or months, and delays in the  reporting of abuse allegations compromised the quality of available  evidence, hindering investigations.
When serious deficiencies were identified, federal and state enforcement  policies did not ensure that the deficiencies were addressed and remained  corrected.
Federal mechanisms for overseeing state monitoring of nursing home  quality and safety were limited in their scope and effectiveness.
The Centers for Medicare & Medicaid Services (CMS)—the federal agency  responsible for managing the Medicare and Medicaid programs, as well as  overseeing compliance with federal nursing home standards—announced  a set of initiatives intended to address many of the weaknesses we  identified in July 1998 as well as needed improvements CMS identified in  its own self-assessment. Over time, CMS has refined and expanded these  initiatives, including launching a Web site—Nursing Home Compare—that  has progressively increased the data available to the public about the care  provided by nursing homes. You asked us to review the progress made by  CMS since 1998 in addressing quality and safety problems in the nation’s  nursing homes. In response to your request, we (1) reviewed the trends in  nursing home quality by analyzing nursing home survey results,   (2) evaluated the extent to which CMS’s initiatives have addressed survey  and oversight shortcomings identified by us and CMS, and (3) identified  key remaining challenges to continued progress in ensuring resident  health and safety.
To assess trends in nursing home quality, we analyzed data from the  federal On-Line Survey, Certification, and Reporting system (OSCAR),  which compiles the results of state nursing home surveys; we focused on  trend data since CMS announced its nursing home initiatives. We have  used OSCAR data since 1997 to track trends in the proportion of homes  found to have harmed residents or placed them at risk of immediate  jeopardy. To better understand the trends identified through our OSCAR  analysis, we evaluated the results of federal comparative surveys for all  states for the period March 2002 through December 2004 and compared  the results for two other time periods—October 1998 through May 2000  and June 2000 through February 2002. Federal comparative surveys are  conducted at nursing homes recently surveyed by the state to assess the  adequacy of the state surveys. We judgmentally selected five large states— California, Florida, New York, Ohio, and Texas—for additional analysis  based on the change in the proportion of homes cited with serious  deficiencies, geographic representation, and the number of nursing homes.  These five states account for almost 30 percent of the nation’s nursing  homes. CMS officials generally recognize OSCAR data to be reliable. We  have used OSCAR data in prior work to examine nursing home quality  issues and we updated certain data for this report. Throughout the course  of our work, we discussed our analysis of OSCAR data with CMS officials  at both the central office and the regional offices to ensure that the data  accurately reflected state nursing home survey activities. We determined  that these data were accurate for our purposes.
To evaluate the extent to which survey and oversight shortcomings we  identified had been addressed by CMS’s initiatives, we reviewed the status  of our recommendations, and updated our understanding of the initiatives  by analyzing relevant documentation and discussing their implementation  status with CMS officials (see app. I). We also discussed with CMS officials  the initiatives implemented as a result of CMS’s self-assessment of needed  improvements. We focused on four areas: surveys, complaints,  enforcement, and oversight. We discussed the preliminary findings from  our OSCAR data trend analysis with CMS and state survey agency officials.  To assess the remaining challenges to continued improvement of nursing  home oversight, we identified through interviews with CMS and state  survey agency officials key workforce and workload issues that confront  states and CMS in protecting the health and safety of nursing home  residents. We also contacted officials at the Association of Health Facility  Survey Agencies (AHFSA) to update information on surveyor turnover and  retention issues. We conducted our review from May through December  2005 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: Oversight of nursing homes is a shared federal-state responsibility. Based  on statutory requirements, CMS defines standards that nursing homes  must meet to participate in the Medicare and Medicaid programs and  contracts with states to assess whether homes meet these standards  through annual surveys and complaint investigations. A range of  statutorily defined sanctions is available to CMS and the states to help  ensure that homes maintain compliance with federal quality requirements.  CMS also is responsible for monitoring the adequacy of state survey  activities.
subsections: section_title: Standard Surveys and Complaint Investigations
paragraphs: 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.  During a standard survey, separate teams of surveyors conduct a  comprehensive assessment of federal quality-of-care and fire safety  requirements. In contrast, complaint investigations generally focus on a  specific allegation regarding resident care or safety.
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  RNs, 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.
The fire safety component of a survey focuses on a home’s compliance  with federal standards for health care facilities. The fire safety standards  cover 18 categories ranging from building construction to furnishings.  Examples of specific requirements include the use of fire- or smoke- resistant construction materials, the installation and testing of fire alarms  and smoke detectors, and the development and routine testing of a fire  emergency plan. Most states use fire safety specialists within the same  department as the state survey agency to conduct fire safety inspections,  but about one-third of 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.
Deficiencies identified during either standard surveys or complaint  investigations 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.
section_title: Enforcement Policy
paragraphs: Ensuring that documented deficiencies are corrected is a shared federal- state responsibility. CMS imposes sanctions on homes with Medicare or  dual Medicare and Medicaid certification on the basis of state referrals.  CMS normally accepts a state’s recommendation for sanctions but can  modify it. The scope and severity of a deficiency determine the applicable  sanctions, which can involve, among other things, requiring training for  staff providing care to residents, imposing money fines, denying the home  Medicare and Medicaid payments for new admissions, and terminating the  home from participation in these programs. 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.
section_title: Oversight
paragraphs: 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 statutorily required federal  monitoring surveys conducted annually in at least 5 percent of the state- surveyed Medicare and Medicaid nursing homes in each state and annual  state performance reviews. 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 81 percent of the approximately 800  federal monitoring surveys are observational. Performance reviews  examine state survey agency compliance with seven standards:   (1) timeliness of the survey, (2) documentation of survey results,   (3) quality of state agency investigations and decision making,   (4) timeliness of adverse action procedures, (5) budget analysis,   (6) timeliness and quality of complaint investigations, and (7) timeliness  and accuracy of data entry.
section_title: Available Data Show Significant Overall Decrease in Serious Quality Problems but Indicate Continued Inconsistency and Understatement in State Findings
paragraphs: CMS’s nursing home survey data show a significant decrease in serious  quality problems in recent years, but other information indicates that this  trend masks two important and continuing issues: inconsistency in how  states conduct surveys and understatement of serious quality problems.  OSCAR data continue to show wide interstate variability in the proportion  of homes found to have serious deficiencies, suggesting inconsistency in  states’ interpretation and application of federal regulations. We previously  reported that confusion about the definition of actual harm contributed to  inconsistency and understatement in state surveys. Moreover, although  federal comparative surveys conducted from October 1998 through  December 2004 showed a decline in the proportion of serious deficiencies  that were not identified by state surveys, this overall trend masks a more  recent increase from 2002 through 2004 in federally identified  understatement of serious deficiencies. In five large states we examined  with a significant decline in the proportion of homes found to have  harmed residents, federal comparative surveys found that a significant  proportion of state surveys had missed serious deficiencies, that is, state  surveyors either failed to cite the deficiencies altogether or cited them at  too low a level of scope and severity.
From January 1999 through January 2005, the proportion of nursing homes  nationwide with actual harm or immediate jeopardy deficiencies declined  from about 29 percent to about 16 percent. Figure 1 shows the proportion  of homes nationwide with these deficiencies for four consecutive time  periods from January 1999 through January 2005. During the 6-year time  period, 41 states had a decline in serious deficiencies ranging from about 5  to about 36 percentage points (see app. II).
The nationwide data show a decline in nursing homes cited for serious  deficiencies; however, the data obscure the continued significant  interstate variation in the proportion of homes with serious deficiencies,  which suggests inconsistency in how states conduct surveys. Table 2  shows that while 10 states identified serious deficiencies in less than   10 percent of the homes surveyed, 15 states found similar deficiencies in  more than 20 percent of homes surveyed from July 2003 through January  2005. For example, during that period California identified actual harm  and immediate jeopardy deficiencies in about 6 percent of the state’s  nursing homes, while Connecticut found such deficiencies in  approximately 54 percent of its facilities. Since January 1999, the  proportion of homes with serious deficiencies had declined nearly   23 percentage points in California but increased by about 6 percentage  points in Connecticut.
We discussed the decline in serious deficiencies in the five large states we  examined with state survey agency officials and officials from the  responsible CMS regional offices. Officials in four of the five states  believed that there had been some improvement in nursing home quality.  CMS regional office officials, however, were concerned about the  magnitude of the decline in serious deficiencies in two states—Texas and  California. The Texas state survey agency noted both some improvement  in quality as well as a significant number of inexperienced surveyors who  it believed were hesitant in citing actual harm. The San Francisco regional  office and state survey agency officials acknowledged that confusion by  state surveyors as to what constituted actual harm had contributed to the  decline in California. The regional office staff discussed this issue with  California survey agency officials and believed that training combined with  the CMS inquiries might have contributed to a recent increase in actual  harm deficiency citations.
The overall decline in the proportion of federal comparative surveys  nationwide that noted serious deficiencies not identified by state  surveyors across the three time periods we examined masks a reversal of  this trend in the most recent time period analyzed, suggesting ongoing  understatement of deficiencies. The time periods analyzed were October  1998 through May 2000, June 2000 through February 2002, and March 2002  through December 2004. From October 1998 through February 2002, the  proportion of federal comparative surveys nationwide that noted serious  deficiencies that were not identified by state surveyors declined from   34 percent to 22 percent (see fig. 2). However, federal surveys conducted  from March 2002 through December 2004 that found serious deficiencies  not identified by state surveyors increased from 22 percent to 28 percent.  In addition, our work in the five states we examined demonstrates  continued understatement by state surveyors of serious deficiencies that  cause actual harm or immediate jeopardy.
Because some serious deficiencies found by federal, but not state,  surveyors may not have existed at the time of the state survey, CMS  requires its regional offices to specifically identify on worksheets which  deficiencies state surveyors had missed during the state survey. We  analyzed CMS regional office worksheets for 73 comparative surveys in  five large states—California, Florida, New York, Ohio, and Texas—with a  significant decline in serious deficiencies from January 1999 through  January 2005. Overall, 18 percent of these federal comparative surveys  identified at least one serious deficiency missed by state surveyors,  ranging from a low of 8 percent in Ohio to a high of 33 percent in Florida  (see table 3). Table 3 also shows that in comparative surveys noting  serious deficiencies that state surveyors missed, from one to seven serious  deficiencies were missed. Federal surveyors’ findings of understatement of  serious deficiencies are consistent with our own work. Our July 2003  report analyzed state surveys of homes with a history of harming residents  but whose most current survey identified quality-of-care problems at  below the level of harm; we concluded that about 40 percent of the 76  homes we analyzed had harmed residents, including instances of severe  weight loss; multiple falls resulting in broken bones and other injuries; and  serious, avoidable pressure sores. Similarly, our November 2004 report on  Arkansas nursing home deaths found numerous instances of serious,  understated quality-of-care problems.
Our prior reports identified five factors that we believe contribute to  inconsistency and the understatement of deficiencies by state surveyors:  (1) weaknesses in CMS’s survey methodology; (2) confusion about the  definition of actual harm; (3) predictability of surveys, which allows  homes to conceal problems if they so desire; (4) inadequate quality  assurance processes at the state level to help detect understatement in the  scope and severity of deficiencies; and (5) inexperienced state surveyors  due to retention problems. CMS has initiatives under way to revise the  survey methodology and address the confusion about what constitutes  harm, and it has taken some steps to reduce survey predictability.  However, CMS did not implement the recommendation in our July 2003  report to strengthen the ability of state quality assurance processes to  detect understatement. While it agreed with the intent of our  recommendation, CMS indicated that its state performance standards  initiative already incorporated this concept. The status of these initiatives  and state workforce issues are discussed in the following section.
section_title: CMS Has Addressed Many Shortcomings in Survey and Oversight Activities, but Work Continues on Some Key Initiatives
paragraphs: CMS has addressed many shortcomings in nursing home survey and  oversight activities both in response to our recommendations and as a  result of its own assessment of needed improvements, but it is still  working on key initiatives that have not yet been implemented. Appendix  I provides a complete listing of our previous recommendations and the  implementation status of CMS initiatives taken in response. Examples of  CMS’s initiatives to address shortcomings include (1) revising the survey  methodology, (2) issuing states additional guidance to strengthen  complaint investigations, (3) implementing immediate sanctions for homes  cited for repeat serious violations, and (4) strengthening oversight by  conducting assessments of state survey activities. CMS also has published  information on its Web site about nursing home quality and has engaged  independent quality organizations to work with nursing homes to improve  quality. Despite CMS’s initiatives in four distinct areas—surveys,  complaints, enforcement, and oversight—some initiatives either have not  effectively targeted the problems we identified or have shortcomings that  impair their effectiveness.
subsections: section_title: Surveys: Key Initiatives Are under Development, but Most Have Not Yet Been Implemented
paragraphs: Several CMS initiatives are intended to address shortcomings in the survey  process, but most of these initiatives are in the developmental stage and  have not yet been implemented. In addition, despite CMS’s efforts to make  scheduling of surveys less predictable, many remain predictable. (See  table 4).
In response to our 1998 recommendation to improve the rigor of the  survey methodology to help ensure that surveyors do not miss significant  care problems, CMS took some interim steps and launched a longer-term  initiative. As interim steps, CMS instructed state survey agencies in 1999 to  (1) increase the sample of residents reviewed during surveys and   (2) review available quality indicator information on the care provided to a  home’s residents before actually visiting the home. By using the quality  indicators, which are essentially numeric warning signs of the prevalence  of care problems, to select a preliminary sample of residents before the  on-site review, surveyors are better prepared to target their surveys and to  identify potential care problems. Surveyors augment the preliminary  sample with additional resident cases once they arrive in the home.
For the longer term, CMS awarded a contract in 1998 to revise the  methodology used to survey nursing homes, and the agency plans to pilot  this new methodology in the fall 2005. Under development for 7 years, the  proposed two-stage, data-driven Quality Indicator Survey (QIS) is intended  to systematically target potential problems at nursing homes. Its expanded  sample should help surveyors better assess the scope of any deficiencies  identified. In stage 1, a large resident sample will be drawn and relevant  data from on- and off-site sources will be analyzed to develop a set of  quality-of-care indicators, which will be compared to national  benchmarks. Stage 2 will systematically investigate potential quality-of- care concerns identified in stage 1. In June 2005, CMS selected five states  to pilot test the new survey methodology. The QIS pilot test will begin  during the fall 2005, with a final evaluation of the pilot due in the fall 2006.  The evaluation will examine the QIS’s cost-effectiveness, focusing on the  time and surveyor team size required under QIS compared to the current  survey methodology, and on the QIS’s impact on deficiency citations. In  developing the QIS, CMS has attempted to prevent increases in the time  required to complete surveys. Depending on evaluation findings and any  subsequent streamlining of the QIS, national implementation could begin  in mid-2007.
subsections: section_title: Investigative Protocols
paragraphs: Since 2001, CMS has been developing surveyor investigative protocols to  ensure greater rigor in on-site investigations of specific quality-of-care  areas. We recommended in July 2003 that CMS finalize the development of  these important protocols; however, CMS is still working on this initiative.  In 2001, CMS hired a contractor to facilitate the convening of expert  panels for the development and review of these protocols. In November  2004, more than 1 year later than scheduled, CMS implemented a protocol  on pressure sores. Since then, CMS has implemented protocols in two  other areas—incontinence and medical director qualifications and  responsibilities. The protocols provide detailed interpretive guidelines and  severity guidance. Protocols in seven more areas are under development,  with an issuance target of fall 2005.
section_title: Definitions of Actual Harm and Immediate Jeopardy
paragraphs: To promote increased consistency among states in deficiency citations, a  work group of CMS central office, regional office, and state survey agency  staff was convened in early 2005 to clarify the definitions of actual harm  and immediate jeopardy. Our July 2003 report noted that confusion about  the definitions contributed to the understatement of serious deficiencies.
According to CMS, the 2005 draft revised definition of actual harm  attempts to clarify the existing definition by eliminating confusing  language and identifying indicators and examples of actual harm. The  draft revised definition of immediate jeopardy is intended to provide  additional guidance on documenting whether deficiencies are at the  immediate jeopardy severity level, including criteria for identifying  whether immediate jeopardy exists, and updates examples of immediate  jeopardy. A CMS official indicated that the draft revised definition of  immediate jeopardy stresses that action must be taken at once to prevent  harm. As of August 2005, CMS had no target issuance date for the revised  definitions.
section_title: Additional Survey Initiatives
paragraphs: CMS is implementing two additional survey initiatives—developing  guidance to ensure surveyors are able to report concerns to CMS regional  offices and studying surveyors’ use of photographic evidence.
To address anecdotal reports that surveyors are sometimes asked to  overlook or downgrade survey findings, CMS has issued and is obtaining  state comments on draft guidance to ensure that surveyors can cite survey  findings without such inappropriate pressure. Currently, surveyors report  concerns to the state survey agency. CMS officials indicated that the draft  guidance tries to (1) establish a nonthreatening option for voicing  concerns to CMS regional office staff without overburdening the regional  offices with additional investigations and (2) give CMS a way to identify  any patterns of problems. Implementation of this effort is anticipated in  late 2005.
CMS also contracted for a study of the use of photographic evidence by  surveyors to support survey findings. In our 2004 report on Arkansas  nursing home deaths, we reported that photographs taken by coroners  provided key evidence supporting neglect of nursing home residents and  the existence of serious, avoidable care problems. The goal of CMS’s study  is to identify issues and develop training materials related to surveyors’  use of photographic evidence. This study began in the summer 2005, with  final training materials to be issued in the summer 2006.
section_title: Survey Predictability
paragraphs: In 1998, we reported that nursing homes could mask certain deficiencies if  they chose to because of survey predictability. CMS responded by  directing states to (1) avoid scheduling a home’s survey for the same  month of the year as the home’s previous standard survey and (2) begin at  least 10 percent of standard surveys outside the normal workday (either  on weekends, early in the morning, or late in the evening). However, our  current analysis showed that a significant proportion of state nursing  home surveys remain predictable. We consider surveys to be predictable if  they are conducted within 15 days of the anniversary of a home’s prior  survey. From 2002 to 2005, the proportion of predictable surveys  increased from 13 percent to 14.5 percent (see app. III). Overall, 29 states  had an increase in survey predictability. As shown in table 5, as of July  2005, from 10 percent to over 50 percent of current nursing home surveys  in 35 states were conducted within 15 days of the anniversary of a home’s  last standard survey. CMS officials stated that avoiding surveys close to  the 12-month anniversary of a home’s prior survey, while meeting the  requirements that surveys occur not less than once every 15 months and  maintaining a statewide average interval of 12 months, could require  increased funding because more surveys would need to be accomplished  within the first 9 months after a survey. However, CMS noted that states  are not currently funded to conduct surveys within the first 9 months after  the previous survey. CMS officials also told us that CMS had introduced  the ASPEN Scheduling and Tracking (AST) module for its central and  regional offices and the states in February 2004 as a tool to reduce survey  predictability; however, state officials we spoke with about AST were  unfamiliar with its survey predictability features.
section_title: Complaint Investigations: CMS Has Strengthened State Guidance and Oversight and Is Continuing to Address Problems Involving Allegations of Abuse
paragraphs: CMS has completed certain initiatives to ensure that quality problems  found during complaint investigations are promptly addressed and has  taken steps to address weaknesses in the notification and investigation of  abuse in nursing homes. CMS is continuing work on (1) ensuring state  compliance with federal nurse aide registry requirements and (2) assessing  the effectiveness of conducting employee background checks. (See table  6).
CMS guidance issued since 1999 has helped to strengthen state procedures  for investigating complaints. In 1999, we reported that complaints alleging  that nursing home residents were being harmed were not being  investigated for weeks or months in several states and recommended that  CMS develop additional standards for the prompt investigation of serious  complaints alleging situations that may harm residents but are categorized  as less than immediate jeopardy. CMS promptly instructed states to  investigate complaints alleging harm to a resident within 10 workdays of  receiving the complaint and later specified that investigations of these  complaints be conducted on-site at the nursing home. During 1999, CMS  developed and issued guidance intended to help states identify complaints  that allege harm to residents. Also in 1999, CMS hired a contractor to study  and recommend improvements to state complaint practices. CMS used the  findings of this study to develop more detailed guidance for states to help  improve the effectiveness of complaint investigations. In 2004, CMS issued  this guidance to states, which further clarified the 1999 instructions on  identifying actual harm.
In March 2002, we recommended that CMS ensure that state survey  agencies immediately notify local law enforcement agencies or Medicaid  Fraud Control Units (MFCU) of allegations or confirmed complaints of  abuse. In response, CMS issued a March 2002 letter to CMS regional  offices and state survey agencies clarifying its policies on abuse reporting  time frames, requirements for reporting to local law enforcement and/or  the MFCU, displaying complaint telephone numbers, and citing abuse on  surveys. CMS issued additional guidance in December 2004 clarifying  nursing home reporting requirements and definitions for alleged  violations, including mistreatment, neglect, abuse, injuries of unknown  source, and misappropriation of resident property. CMS has not, however,  implemented our March 2002 recommendation to accelerate the agency’s  campaign to increase public awareness of nursing home abuse through the  development and distribution of posters that are to be prominently  displayed in nursing homes, and other materials.
subsections: section_title: Complaint Oversight
paragraphs: CMS has taken three important steps to improve its oversight of state  complaint investigations, including allegations of abuse. First, it required  in its annual state performance review, which was established in fiscal  year 2001 and fully implemented in fiscal year 2002, that federal surveyors  review a sample of complaints in each state to determine whether states  properly categorize complaints (i.e., determine how quickly they should be  investigated), investigate complaints within the time specified, and  properly include the results of investigations in CMS’s database. Our  March 1999 report on complaints had recommended that CMS strengthen  its oversight in these areas. During its 2004 review of state performance,  CMS identified 5 states that did not meet the standard for properly  categorizing complaints and 13 states that did not conduct timely  investigations of all complaints alleging immediate jeopardy to residents;  however, 11 of the 13 states missed the requirement by a small margin.  States failing state performance review standards are asked to submit a  corrective action plan to CMS.
Second, in January 2004, CMS implemented a new national automated  complaint tracking system, the ASPEN Complaints and Incidents Tracking  System. Our March 1999 report on enforcement noted that the lack of a  national complaint reporting system hindered CMS’s and states’ ability to  adequately track the status of complaint investigations as well as CMS’s  ability to maintain a full compliance history on each nursing home. To  address these concerns, we recommended the development of a better  management information system. One goal of CMS’s new management  information system is to standardize reported complaints so that analysis  can be conducted across all states. This system is intended to provide CMS  with an effective tool for overseeing and managing state complaint  investigations.
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, to which states are  required to report substantiated findings of abuse, neglect, or theft of  nursing home residents’ property by nurse aides. CMS has not issued a  formal report of findings from the state self-assessment, but CMS officials  noted that as a result of resource constraints some states reported having  difficulty maintaining compliance with certain federal requirements, such  as (1) timely entry by state survey staff of information in nurse aide  registries and (2) state notification to nursing homes employing nurse  aides found guilty of abuse at another facility. In our March 2002 report,  we recommended that CMS shorten the state survey agencies’ time frames  for determining whether to include findings of abuse in the nurse aide  registry. Annotations to nurse aide registries are made after final  determinations that abuse occurred, which entail completion of the state’s  investigation as well as adjudication of any appeals. Until the final  determination, residents may continue to be exposed to aides who are  allegedly abusive. CMS noted that while most of the time frames are  defined in regulation, it can review the time frames when regulatory  changes are considered. No changes to the regulations had been made as  of August 2005.
As part of its third effort, CMS also is conducting a Background Check  Pilot Program. Our March 2002 report recommended an assessment of  state policies and practices for complying with federal requirements  prohibiting employment of individuals convicted of abusing nursing home  residents. 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. Pilot programs in seven states— Alaska, Idaho, Illinois, Michigan, Nevada, New Mexico, and Wisconsin— will be phased in from fall 2005 through September 2007. An independent  evaluation is planned.
section_title: Enforcement: CMS Has Strengthened the Potential Deterrent Effect of Sanctions and Has Other Initiatives Under Way
paragraphs: CMS significantly strengthened the potential deterrent effect of  enforcement actions by requiring immediate sanctions for homes found to  have a pattern of harming residents. Moreover, CMS continues to develop  new policies and to clarify existing ones in order to strengthen  enforcement activities and encourage nursing home compliance with  federal requirements. (See table 7).
Responding to our July 1998 recommendation to eliminate grace periods  for homes cited for repeat serious violations, CMS began a two-stage  phase-in of a new enforcement policy. In the first stage, effective  September 1998, CMS required states to refer for immediate sanction  homes found to have a pattern of harming residents or of exposing them to  actual harm or potential death or serious injury (H-level deficiencies and  above on CMS’s scope and severity grid). Effective January 2000, CMS  expanded this policy, requiring referral of homes found to have harmed  one or a small number of residents (G-level deficiencies) on successive  standard surveys. In response to our 2003 finding that states failed to  refer a substantial number of homes that met the criteria for the  immediate sanctions, CMS initiated oversight of state compliance with this  policy. To conduct this oversight, CMS analyzed deficiency data for 2000  through 2003 to identify potential instances of homes that should have  been but were not referred for immediate sanctions. In ongoing work, we  are assessing the impact and implementation of the immediate sanctions  policy.
subsections: section_title: Additional Enforcement Policy Issues
paragraphs: Based on recommendations in our July 1998 report and our March 1999  report on enforcement, CMS has addressed weaknesses in its policies in  three areas: nursing homes’ correction of deficiencies, the nursing home  appeals process, and the enforcement data tracking system.
CMS now requires on-site follow-up, referred to as a revisit, of homes with  substandard quality of care or actual harm or higher-level deficiencies  until the state verifies correction of each deficiency cited. Our 1998  report found that CMS’s policy of allowing nursing homes to self-report  resumed compliance was sometimes inappropriately applied to homes  with deficiencies in the immediate jeopardy category or that were found to  have substandard quality of care. We recommended that CMS require that  for homes with recurring serious violations, state surveyors substantiate  resumed compliance by means of an on-site revisit. CMS also has issued  additional guidance on the “reasonable assurance period” during which  terminated homes must demonstrate that they have corrected the  deficiencies that led to their terminations. This guidance provided  additional examples of reasonable assurance decisions.
CMS and the Department of Health and Human Services (HHS) requested  and received funding and staffing increases for the HHS Departmental  Appeals Board in fiscal years 1999 and 2000 to address our March 1999  finding that the growing backlog of appeals hampered the effectiveness of  civil money penalties by delaying their collection. The Board is responsible  for adjudicating the appeals. By August 2003, the backlog of appeals of  civil money penalties had been significantly reduced.
CMS implemented the automated ASPEN Enforcement Manager on  October 1, 2004, to facilitate tracking of enforcement actions. Prior to  implementing this system, CMS had no centralized system for tracking or  managing federal and state enforcement actions. The ASPEN  Enforcement Manager is intended to provide real-time entry and tracking  of enforcement actions, issue monitoring alerts, generate enforcement  letters, and facilitate analysis of enforcement patterns. CMS expects that  ASPEN Enforcement Manager data will enable states, CMS regional  offices, and the CMS central office to more easily track and evaluate  nursing home performance and compliance status as well as respond to  emerging issues. In ongoing work, we are assessing whether data from the  ASPEN Enforcement Manager can be used to analyze nursing homes’  deficiency and enforcement histories.
section_title: Special Focus Facility Program
paragraphs: In December 2004, CMS revised the method for selecting nursing homes  for the Special Focus Facility Program to ensure that the most poorly  performing homes were included in the program and to strengthen  enforcement for those nursing homes with an ongoing pattern of  substandard care. For this program, first initiated in January 1999, states  were directed to select two nursing homes to be special focus facilities,  conduct two standard surveys each year in the special focus facilities, and  submit monthly status reports on the selected homes. The revised  guidance directs states to select, from an expanded list of facilities, a  minimum of up to six nursing homes, depending on the number of nursing  homes in the state; the revised guidance gives states the option to select  more than the minimum. States are also given the flexibility to remove  from the list homes that have made significant improvements.  Enforcement authority over special focus facilities has been strengthened  so that while homes are in the Special Focus Facility Program, immediate  sanctions must be imposed if homes fail to significantly improve  performance from one survey to the next; termination from participation  in Medicare and Medicaid is required for homes with no significant  improvement in 18 months and three surveys.
section_title: Civil Money Penalties
paragraphs: In April 2004, CMS launched a Civil Money Penalty Improvement Project  to improve its ability to track and collect civil money penalties in an effort  to make them a more effective enforcement tool. CMS mapped out the  current process for tracking and collecting civil money penalties to  identify weaknesses and developed draft guidance with detailed policies  and procedures for addressing areas identified as needing improvement,  with a target release date of fall 2005. Also planned are enhancements to  the Civil Money Penalty Tracking System, CMS’s information system for  civil money penalties. The enhancements are intended to streamline the  system, improve its reporting capabilities, and improve its compatibility  with the enforcement monitoring system. The system’s changes are  planned to occur through 2005 and 2006.
Also in 2004, CMS, in conjunction with various state survey agencies,  began developing a civil money penalty grid—an optional guideline for use  by states and CMS regional offices to help ensure greater consistency  across states in the amounts of civil money penalties recommended. The  grid is expected to provide ranges for minimum civil money penalties for  deficiencies, while allowing for flexibility to adjust the penalties on the  basis of factors such as the severity of an identified deficiency, the care  areas in which deficiencies were cited, and past history of  noncompliance. The target issuance date for a draft grid was August  2005.
section_title: Past Noncompliance Policy
paragraphs: In October 2005, CMS issued a revised past noncompliance policy that   (1) clarifies how to address recently identified past deficiencies,   (2) further defines “past noncompliance,” (3) eliminates the use of the  term “egregious,” and (4) clarifies the methods for determining whether  past noncompliance has been corrected. Past noncompliance occurs when  a current survey reveals no deficiencies but determines that an egregious  violation of federal standards occurred in the past and was not identified  during an earlier survey. In November 2004, we reported that CMS’s past  noncompliance policy was ambiguous. The policy did not define what  constituted an egregious violation or relate egregious violations to its  scope and severity grid. Moreover, the policy did not hold homes  accountable for negligence associated with resident deaths unless current  residents are experiencing the same quality-of-care problems and it  obscures the nature of care problems. CMS’s revised policy responds to  our recommendation and holds homes accountable for all past  noncompliance resulting in harm to residents. We also recommended that  past noncompliance citations identify the specific nature of the care  problem in the OSCAR database and on the Nursing Home Compare Web  site. In 2007, CMS plans to enhance the information on the Nursing Home  Compare Web site to include the specific nature of the past  noncompliance. According to CMS officials, the delay is related to the  implementation of higher priority initiatives by the agency. Currently, the  Web site only indicates whether there were instances of past  noncompliance and does not identify the nature of the care deficiency.
section_title: Oversight: Intensity and Scope of Federal Efforts Has Increased Significantly, but Work Remains
paragraphs: CMS has significantly improved the intensity and scope of its oversight  activities and has made significant improvements both in its data systems  and in its analysis and use of the data it collects on survey activities. The  effectiveness of several of these oversight initiatives, however, is uneven,  and more work remains to be done. (See table 8).
In response to recommendations in our November 1999 and July 2004  reports, CMS has (1) significantly increased the number of federal  comparative surveys both for quality of care and fire safety and   (2) decreased the time between the end of the state survey and the start of  the federal survey for quality-of-care comparative surveys, allowing CMS  to better distinguish between serious problems missed by state surveyors  and changes in a home that occurred after the state survey. We found  earlier that CMS was making negligible use of comparative surveys, its  most effective tool for assessing a state survey agency’s ability to identify  serious quality-of-care and fire safety deficiencies in a nursing home, to  fulfill its 5 percent monitoring mandate. Only 21 quality-of-care  comparative surveys were conducted from November 1996 through  October 1998. Our 2004 fire safety report found that CMS had conducted  only 40 fire safety comparative surveys in fiscal year 2003, ranging from 4  in some states to none in others.
Since 2001, CMS has required its regional offices to complete at least two  quality-of-care comparative surveys per state per year, but federal  surveyors have been exceeding this minimum threshold. During the  period March 1, 2002, through December 31, 2004, CMS completed 424  comparative surveys, about 140 per year. In addition, the average elapsed  time between state and comparative surveys has decreased from 33  calendar days for the 64 comparative surveys we reviewed in 1999 to 26  calendar days for the 424 surveys completed through 2004.
CMS planned to further increase the number of comparative surveys by  contracting in the fall of 2003 for 170 quality-of-care comparative surveys  in addition to those conducted by federal surveyors. However, an increase  in the number of quality-of-care comparative surveys is unlikely because  of delays in contractor readiness and the addition of fire safety  comparative surveys to the contract. CMS had expected to have a  sufficient number of contract surveyors trained and available to start  surveys by the winter of 2005, but it took longer than anticipated to train  the new surveyors. In addition, CMS modified the contract to include fire  safety comparative surveys. In fiscal year 2005, the contractor conducted  34 quality-of-care comparative surveys and 250 fire safety comparative  surveys. Together, the contractor and CMS regional offices conducted a  total of 859 fire safety comparative surveys in fiscal year 2005. CMS also is  using the contract surveyors to augment federal survey teams. According  to CMS, it will use contract funds carried over from earlier years to  conduct quality-of-care comparative surveys during fiscal year 2006, and  will only use fiscal year 2006 funds to conduct fire safety comparative  surveys.
subsections: section_title: Smoke Detectors in Homes without Sprinklers
paragraphs: In response to a recommendation in our July 2004 report to strengthen fire  safety standards, CMS published an interim final rule in March 2005  requiring nonsprinklered nursing homes to install battery-powered smoke  detectors in resident rooms and common areas, including resident dining,  activity, and meeting rooms. Previously, federal standards required smoke  detectors in (1) corridors or resident rooms only in homes built after 1981  and (2) nonsprinklered resident rooms containing furniture brought from  the resident’s home. We reported that the lack of smoke detectors in  resident rooms may delay staff response and fire department notification,  which in turn may increase the number of nursing home fire-related  fatalities. CMS will begin surveying nursing homes’ compliance with the  new requirement in May 2006.
section_title: Assessments of State Survey Activities
paragraphs: In October 2000, CMS regional offices began conducting on-site state  performance reviews to assess compliance with federal standards.  Previously, CMS permitted states to evaluate and report on their own  performance against a number of standards, a technique that essentially  allowed states to write their own report cards because CMS did not  independently validate information provided by the states. In fiscal year  2005, CMS began to tie funding increases for state survey agencies to one  of the seven performance standards—the timely conduct of standard  surveys—time frames that are established in federal statute.
Nevertheless, in our current analysis of the standard that is intended to  measure the supportability of survey findings, we found that three key  issues we identified in July 2003 still exist. First, distinctions in state  performance were hard to identify because, while some states have  consistently met the standard for documentation of deficiencies, federal  comparative surveys completed during essentially the same time frame  found that surveyors in these states frequently missed serious deficiencies.  Second, CMS regional offices were inconsistent in conducting state  performance reviews. For fiscal year 2004, five states nationwide did not  meet this standard, but three of the five states were in one CMS region.  Third, the standard for assessing the supportability of deficiencies is  composed of 11 elements that mix major and minor issues. Although CMS  has simplified the standard for assessing the supportability of deficiencies,  we believe that many of the elements reviewed remain essentially  administrative in nature rather than substantive. Of the elements that  make up the standard, only 2 assess the appropriateness of the cited scope  and severity; the remaining elements assess such issues as how the  deficiency is written, including avoiding the use of the passive voice. We  do not believe that this standard is sufficiently focused on identifying  understatement.
CMS did not implement our July 2003 recommendation that it require  states to review a sample of deficiencies cited at or below the level of  actual harm in order to detect understatement because, according to CMS,  the state performance review of the supportability of deficiencies already  accomplished this objective. In discussing our current findings regarding  the standard intended to measure the supportability of survey findings,  CMS officials agreed that (1) measuring the quality of state surveys, one  goal of reviewing the supportability of deficiencies, was particularly  challenging because there is no one agreed-upon way to measure quality;  and (2) some standards are complex, contributing to consistency  problems.
In developing this report, we also noted two additional problems with the  state performance reviews that were not previously reported. First, in its  fiscal year 2004 review, CMS began combining state performance review  results across the different provider types, such as nursing homes and  home health agencies, for which states have oversight responsibility. For  example, CMS calculates one overall state score on the supportability of  deficiencies across provider types, rather than issuing provider-specific  scores. One CMS region suggested that because nursing homes are  generally surveyed by a unique pool of surveyors, combining results in this  manner limits the usefulness of the feedback to state survey agencies.  Second, CMS provides feedback to states regarding their performance  each year, but it does not publicly report the results. Doing so would  appear to be consistent with CMS’s stated philosophy of sharing  information with the public to help improve nursing home quality.
section_title: Data Systems and Analysis
paragraphs: CMS has pursued important upgrades in the system used to track the  results of state survey activities and has increased its analysis of OSCAR  and other data to improve oversight by CMS central and regional offices  and state survey agencies. Examples include the following:  In 2000, CMS began to produce 19 periodic reports to monitor both state  and regional office 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 activities and the  need for intervention.  In 2001, 2002, and 2005 CMS published a “Nursing Home Data  Compendium,” which includes detailed tables and figures on nursing  homes, resident demographics, resident clinical characteristics, and  survey results.  In 2004, CMS commissioned a series of “White Papers” on topics ranging  from enforcement to resource issues. The goal was to stimulate discussion  among key stakeholders and generate ideas for “next steps” to help  mitigate problems. The reports, authored by CMS and state survey agency  staff, relied on data analysis from OSCAR and other CMS databases.  In 2004, CMS prepared an internal study on enforcement trends since the  imposition of the immediate sanctions policy using data from the  Enforcement Tracking System.  In 2005, CMS unveiled a Web site for use by regional offices and state  survey agencies that generates a series of standard reports through a  software program called Providing Data Quickly; this software permits  easier access to the data contained in OSCAR. One such report identifies  homes that have repeatedly harmed residents and meet the criteria for  imposition of immediate sanctions.
CMS indicated that it is continuing to make progress in redesigning the  OSCAR system. In our March 1999 report on enforcement, we  recommended that the agency develop an improved management  information system that would help it to track the status and history of  deficiencies, integrate the results of complaint investigations, and monitor  enforcement actions. Although the target implementation date for the  redesigned system has slipped from 2005 to 2008, depending on competing  priorities and available funding, CMS has implemented two key  components of the redesigned system—a complaint tracking system and a  system to track the status of enforcement actions. Both systems are  intended to provide CMS with critical management capabilities that it  previously lacked.
section_title: Sharing Data with the Public
paragraphs: Using market forces to help drive quality improvement is an important  CMS objective behind sharing data with the public on nursing home  quality. Since CMS launched Nursing Home Compare in 1998, the agency  has progressively expanded the information available on this Web site. In  addition to data on the 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 indicators, such  as the percentage of residents with pressure sores. However, CMS  continues to address ongoing problems with the accuracy and reliability of  the underlying data, such as the MDS, quality indicators, and nurse staffing  levels.
In February 2002, we concluded that CMS efforts to ensure the accuracy of  the underlying MDS data used to calculate the quality indicators (1) relied  too much on off- site review activities by its contractor and (2) anticipated  on-site reviews in only 10 percent of its data accuracy assessments,  representing fewer than 200 of the nation’s nursing homes. CMS did not  concur with our recommendation that it reorient its review program to  complement ongoing state MDS accuracy efforts as a more effective and  efficient way to ensure MDS data accuracy. CMS commented that its  efforts already provided adequate oversight of state activities and  complemented state efforts. In April 2005, CMS ended work under its data  assessment and verification contract because of cost concerns, but signed  a new contract in September 2005 that focuses on on-site reviews of MDS  accuracy. According to CMS officials, the on-site reviews were more  effective in identifying discrepancies because the reviewers were able to  find more information on-site that conflicted with the nursing homes’  assessments.
In November 2002, CMS began reporting on its Web site quality indicator  data for each nursing home nationwide that participates in Medicare and  Medicaid, even though our October 2002 report concluded that such  reporting was premature given serious questions about the sufficiency of  CMS efforts to validate the quality indicators and improve the accuracy of  the underlying data. CMS disagreed with our recommendation to  postpone its scheduled November 2002 public reporting of the data until  these problems were addressed. Since 2002, however, CMS has taken  steps to address the questions we raised about the validity of quality  indicators. For example, CMS dropped certain quality indicators that it  found were not sufficiently reliable for public reporting, such as the  facility-adjusted profile prevalence of pressure sores. In addition, CMS  worked with the National Quality Forum to address measurement  problems with the pressure sore quality indicator by developing separate  indicators for short- and long-term nursing home residents; these new  indicators were added to the Web site in January 2004. A weight loss  quality indicator also was developed and added to the Web site in  November 2004. Our October 2002 report had noted the potential for  consumer confusion in interpreting and using quality indicator data. CMS  conducted consumer testing of new language and displays on Nursing  Home Compare during the summer of 2004.
Although nursing home staffing data have been available on the Nursing  Home Compare Web site since June 2000, a CMS official told us that the  agency has been aware of problems with these self-reported data since the  late 1990s. This official stressed that, despite problems, they were the  only available data on nursing home staffing. Examples of erroneously  reported data include facilities with no nurse staffing hours or hours equal  to thousands of residents per day. In addition, the staffing data do not  address important issues such as turnover or retention. As a temporary  fix, CMS developed edits that examine staffing ratios to determine  whether any facility falls above or below certain thresholds and, effective  July 2005, temporarily excluded the questionable staffing data from  Nursing Home Compare until they can be corrected or confirmed. To  address this issue, CMS is considering a proposal for a new system that  relies on nursing home payroll data. If approved, such a system could take  3 to 4 years to implement because of the need to solicit and consider  public comment and to develop software to transmit the staffing data.
section_title: Quality Improvement Organizations
paragraphs: CMS’s initiative to include quality indicator data on its Nursing Home  Compare Web site also established a new role for Quality Improvement  Organizations (QIO) with regard to nursing homes. From 2002 through  2005, QIOs worked intensively with at least 10 percent of nursing homes in  each state to improve quality. Although we have not evaluated QIO  nursing home quality improvement activities, CMS’s preliminary analyses  indicate that the QIO program has helped to reduce the use of daily  physical restraints, increased management and treatment of pain, and  reduced the incidence of delirium among post-acute-care residents.  However, less progress has been made in decreasing the prevalence of  pressure sores, according to CMS’s analyses. In August 2004, the QIO and  state survey agency in 18 states launched a new pilot program. Working  together, they identified from one to five nursing homes per state that had  significant quality problems. The QIO then worked with these homes to  help them redesign their clinical practices. According to CMS, the results  of this pilot indicated that these historically “troubled” nursing homes had  dramatically improved their clinical quality and decreased their quality-of- care survey deficiencies. In 2005, the QIOs’ role with nursing homes was  extended for an additional 3 years, and QIOs will continue to focus on  statewide improvement in four areas—pressure sores, physical restraints,  pain management, and depression. In addition, QIOs will help nursing  homes set individual targets for quality improvement, implement and  document process-related clinical care, and assist in the development of a  more resident-focused care model. QIO expenditures on nursing home  quality improvement for the period of August 2002 through July 2008 are  expected to total about $216 million.
section_title: Coordination and Dissemination of Best Practices
paragraphs: CMS has taken certain actions to maximize the experience and resources  of state survey agencies as well as the CMS central and regional offices to  improve nursing home oversight. Specifically, in 2004, CMS convened an  internal Long-Term Care Task Force and charged it with providing  guidance on and coordinating long-term care efforts within CMS and  included representation across the agency’s divisions and the regional  offices. Also in 2004, CMS began an effort to collect and disseminate  nursing home survey and certification best practices developed by  professional associations, universities, and federal agencies. Through the  best practices effort, CMS plans to share successful strategies used by  states and regional offices in a broad range of issues affecting survey and  certification of nursing homes, such as surveyor recruitment and  complaint intake. A contractor will identify, research, and document best  practices, which CMS plans to post on its Web site. One of the issues the  best practices effort will address is surveyor recruitment initiatives  underway in states. As of August 2005, these best practices had not been  published on the CMS Web site.
section_title: Resource and Workload Issues Pose Key Challenges to Further Improving Nursing Home Quality and Safety
paragraphs: CMS, states, and nursing homes face a number of key challenges in their  efforts to further improve nursing home quality and safety, including   (1) the cost of retrofitting older nursing homes with automatic sprinklers,  a potentially costly requirement that has a demonstrated ability to prevent  deaths in the event of a fire; (2) continuing problems in hiring and  retaining qualified surveyors, a factor that states indicated can contribute  to variability in the citation of serious deficiencies; and (3) an increasing  federal and state survey workload due to increased oversight, the  identification over time of additional initiatives, and growth in the number  of Medicare and Medicaid providers that must be surveyed, including  expected growth in nursing homes. The increased workload has created  competition for both staff and financial resources and required the  establishment of priorities, which may have contributed to delays in  developing and implementing several key quality initiatives, such as the  implementation of a more rigorous survey methodology.
subsections: section_title: Cost Could Delay Retrofitting of Older Nursing Homes with Sprinklers
paragraphs: Although the substantial loss of life in two 2003 nursing home fires could  have been reduced or eliminated by the presence of properly functioning  automatic sprinkler systems, cost has been an impediment to CMS’s  requiring them for all homes nationwide. Newly constructed homes must  incorporate sprinkler systems; however, older homes constructed with  noncombustible materials that have a certain minimum ability to resist fire  are not required to install sprinklers. We previously reported that cost has  been a barrier to requiring sprinklers for all older nursing homes. In July  2005, the National Fire Protection Association (NFPA) voted to require  retrofitting of older homes with sprinklers, a requirement that will become  a part of the 2006 edition of the NFPA code. Anticipating this action, CMS  indicated that it has been developing a notice of proposed rule making, the  first step in adopting the NFPA requirement for all homes that serve  Medicare and Medicaid beneficiaries. A CMS official stated that the agency  plans to issue the notice in March 2006 and after reviewing public  comments, it will publish a final version of the rule and stipulate an  effective date for homes to come into compliance.
One issue that remains unresolved is how much time older homes will be  given to install sprinklers. As we reported in 2004, industry officials  believe that a transition period must be considered for homes to come into  compliance and to determine how to pay for the cost of installing  sprinklers. Rather than proposing a phase-in period, the proposed rule  will request input on how much time homes should be given to come into  compliance with the requirement. According to CMS, a longer phase-in  period could help alleviate concerns about the cost of retrofitting homes  with sprinklers. Based on our recommendation, CMS collected data on the  sprinkler status of homes nationwide and found that about 21 percent of  nursing homes are unsprinklered or partially sprinklered. Although CMS  has not completed its cost analysis, the agency believes that the costs  associated with the retrofit will be less than the industry’s $1 billion  estimate.
section_title: States Continue to Have Problems in Hiring and Retaining Surveyors
paragraphs: The hiring and retention of surveyors, particularly RNs, remains a major,  frequently discussed issue among state survey agency directors, according  to an AHFSA official, the association that represents state survey agency  directors. In July 2003, we reported that the limited experience level of  state surveyors because of a high turnover rate was a contributing factor  to (1) variability in citing actual harm or higher-level deficiencies and   (2) understatement of such deficiencies. In more than half of the 42 states  that responded to our inquiry, from 30 percent to more than 50 percent of  surveyors had 2 years’ experience or less, as of July 2002. Twenty-five  states responded to our request for updated information on surveyor  workforce issues as of July 2005.
Of 23 states that provided data in both 2002 and 2005, 13 reported an  improvement in 2005 (i.e., a decline in the proportion of inexperienced  surveyors); 9 indicated that the situation had worsened (e.g., an increase  in the proportion of inexperienced surveyors); and 1 state reported no  change (see app. IV). As of July 2005, however, 20 percent or more of  surveyors in 20 of the 25 states had 2 years’ experience or less (see table  9). Surveyor vacancy rates in the 25 states ranged from about 3 percent in  Tennessee to 31 percent in Alabama and Florida; overall, 15 states had  double-digit vacancy rates. Officials in 18 states believed that  inexperienced surveyors contributed to interstate variability in the citation  of serious deficiencies. One state survey agency indicated that staff  attrition resulted in a workforce of less experienced surveyors who  demonstrated a hesitance to cite actual harm and contributed to  understatement. State survey agency officials in several states, however,  suggested that the problem for less-experienced surveyors was not  identifying harm but rather investigating and documenting the  circumstances that led to the harm, including facility culpability, a skill  that surveyors develop as they gain more experience.
Because state survey agency salaries are rarely competitive with the  private sector, state survey agencies told us that it is difficult to retain  surveyors and to fill vacancies. RNs, a major component of states’  surveyor workforce, are in high demand and short supply, according to  AHFSA. Furthermore, 9 states responding to our July 2005 inquiry  indicated that state civil service requirements can make it more difficult to  fill vacancies. Several of the 9 states characterized the hiring process as  either cumbersome or time-consuming, or both, and 1 state noted that the  process takes close to 9 months. Two states reported that they had to  select candidates to interview from a certified list. One of the states  indicated that the certified list often contained unqualified applicants,  while the other state noted that some of the applicants were not the “best  fit.” Of the 25 states, 21 indicated that they had implemented initiatives to  help retain surveyors. The most popular retention strategies were to  increase starting salaries and to implement flexible surveyor work  schedules. For example, New York instituted a locality pay differential for  New York City. While 5 of the 25 states indicated that they had a state- imposed hiring freeze, 1 state reported that budget pressures prevented it  from taking steps to improve retention rates. A continuing problem cited  by AHFSA is that federal funds are distributed late in the fiscal year, which  does not tie into state budget cycles for approving additional positions.  This problem may be particularly acute in the 5 states that reported having  a hiring freeze.
section_title: Workload Issues and Competing Priorities Pose Challenges for CMS and States
paragraphs: CMS and states have experienced increased survey workloads due to the  greater intensity of nursing home oversight, the increasing number of  initiatives, and growth in the number of Medicare and Medicaid providers  requiring oversight. This workload growth required the prioritization of  initiatives that, in some cases, has resulted in implementation delays for  some key initiatives. The consensus-building process necessary to bring  initiatives to fruition also has contributed to some delays. The initiatives  likely will continue to compete for priority with other CMS programs,  posing a challenge for efforts to further improve nursing home quality and  safety.
subsections: section_title: Increased Workload Has Contributed to Delays
paragraphs: Greater nursing home oversight has increased demand on both CMS and  state survey agency resources, causing delays for some key initiatives.  CMS’s increased workload is evident in the labor-intensive state  performance reviews. Since their introduction in October 2000, the  reviews have been gradually expanded from nursing homes to several  other Medicare and Medicaid providers, such as home health agencies and  hospitals. CMS also has significantly increased the number of federal  quality-of-care and fire safety comparative surveys. Such surveys are more  labor-intensive than the alternative type of federal monitoring surveys,  known as observational surveys, because they require an entire federal  survey team rather than a smaller number of federal surveyors. The agency  also has committed considerable resources to developing new data  systems for complaints and enforcement actions while simultaneously  increasing its use of available data to further improve federal and state  oversight. Despite the increased workload, CMS implemented survey staff  reductions of 5 percent in regional offices and 3 percent in its central  office in January 2004. As of August 2005, these staff reductions have  remained in effect.
As state survey agency workloads grew with the implementation of the  initiatives, they also experienced resource pressures. States are now  required to conduct on-site revisits to ensure serious deficiencies have  been corrected, investigate complaints alleging actual harm on-site and do  so more promptly, and initiate off-hour standard surveys. Thus, surveyors’  presence in nursing homes has increased and surveyors’ work hours have  effectively been expanded to weekends, evenings, and early mornings. The  requirement to impose immediate sanctions on homes that repeatedly  harm residents also has had a workload impact because in the past a grace  period allowed homes to correct deficiencies before the sanctions went  into effect. The imposition of immediate sanctions requires states to track,  which some states do manually, the homes that must be referred for  immediate sanctions and requires CMS and states to act to impose  recommended sanctions that in the past would have been rescinded  because the homes could have corrected the deficiencies during a grace  period. While states’ budget pressures appear to be easing, many state  survey agencies reported hiring freezes, staff vacancies, or high turnover  as of July 2002 when all of these initiatives had already been fully  implemented.
The number of initiatives that CMS has implemented on its own has  grown, further increasing its workload. For example, CMS added quality  indicator data to its Nursing Home Compare Web site and has involved  QIOs in helping nursing homes to improve quality of care. In addition,  CMS created a task force to develop guidance intended to improve  consistency across states in the imposition of civil money penalties.
The number of nursing home initiatives simultaneously under  development or being implemented as well as other CMS responsibilities,  such as preparing to implement the new Medicare prescription drug  benefit in January 2006, have necessitated the establishment of priorities  and led to delays and queues. CMS assigned some initiatives, such as the  development and public reporting of quality indicators, a high priority and  implemented them swiftly despite issues related to their validity and the  quality of the underlying data—problems that CMS is still working to  address. In contrast, the revision of the survey process has encountered  delays because of funding shortfalls and has been in process for 7 years.  For example, initial testing of the new methodology in 2002 and 2003 was  limited, even though CMS had already invested $4.7 million in its  development from initiation in 1999 through September 2003. A pilot test  of the new methodology is scheduled to begin in the fall 2005; depending  on the results of the testing, implementation could begin in mid-2007.  Although CMS attaches a high priority to enhancing the information  available to the public on nursing home quality and safety, adding  information on past noncompliance and the fire safety status of nursing  homes are in a queue behind the programming required to implement  higher-priority projects. There is also a regulatory queue, with other,  higher-priority regulations ahead of the notice of proposed rule making to  require retrofitting of nursing homes with automatic sprinklers.
Delays in implementing the nursing home initiatives are also attributable  to CMS’s need to be responsive to stakeholder input. Appropriately, CMS  seeks input from various stakeholders such as states, regional offices, the  nursing home industry, and resident advocates. For example, CMS sought  input from experts in developing investigative protocols for surveyors.  Due to this lengthy consultative process, combined with the prolonged  delays stemming from internal disagreement over the structure of the  process during the initial stages, CMS has only implemented two  investigative protocols since 2001. Likewise, implementation of the ASPEN  Complaint Tracking System was delayed because during the system’s pilot  test, several states indicated their belief that their existing systems were  superior and opposed the idea of either abandoning these systems or  maintaining separate systems.
section_title: Number of Providers Subject to Surveys Is Growing
paragraphs: Both the overall growth in providers and the anticipated growth in nursing  homes pose additional workload challenges for CMS and states. In  addition to nursing homes, CMS and states are responsible for surveys of  other Medicare and Medicaid providers, such as home health agencies and  hospitals. The number of these providers grew from 39,651 in October  2000 to 45,375 in January 2005, approximately 14 percent. While the  number of nursing homes has decreased slightly during the same period,  from 17,012 to 16,146, the rate of decline has slowed; and as the baby  boom generation ages, increasing the number of elderly needing long-term  care services, the number of nursing homes is expected to grow to meet  the demand. In 2000, 35.1 million people were aged 65 or older. This  number is expected to grow to about 54.7 million by 2020.
Nursing home survey activities consume the majority of state survey  budgets and resources. Nursing homes make up about 31 percent of  Medicare and Medicaid providers, but account for 73 percent of the  federal budget for oversight of such providers. The funding for nursing  home surveys is disproportionate because the time frames for standard  nursing home surveys are statutory. For those survey requirements not in  statute, CMS determines the survey time frames; these surveys are  therefore a lower priority. Even among nursing home survey activities,  however, annual standard surveys are considered a higher priority than  complaint surveys or initial surveys for which the statute does not dictate  specific time frames. CMS and state survey agency officials recognize  that CMS may have shifted its focus and resources to nursing homes at the  expense of adequate oversight of other providers serving Medicare and  Medicaid beneficiaries, and some states contend that the focus on nursing  home standard surveys has hampered their ability to investigate nursing  home complaints within mandated time frames. For example, according to  a California state survey agency official, California law mandates that all  nursing home resident complaints, not just complaints alleging actual  harm, be investigated within 10 days. Likewise, an official from the  Pennsylvania state survey agency stated that in Pennsylvania, all  complaints must be investigated within 48 hours. California survey agency  officials have told us that a complaint alleging a care problem deserves a  higher priority than a standard survey, which may or may not identify  deficiencies.
section_title: Key Nursing Home Initiatives Continue to Compete for Priority
paragraphs: According to CMS officials, key nursing home initiatives continue to  compete for priority with other CMS projects. Examples of nursing home  initiatives that have been affected include revision and testing of the new  survey methodology, continued development of the investigative protocols  that surveyors use to investigate care problems, and an increase in the  number of quality-of-care comparative surveys.
Revised survey methodology. CMS officials have indicated that  nationwide implementation of the revised survey methodology could be  affected if its use requires additional survey time or a greater number of  surveyors to conduct each survey. The pilot test of the new methodology,  scheduled for 2005 and 2006, includes an examination of steps to  streamline the revised process, if necessary. Cost considerations limited  the pilot of the new methodology to fewer states than the 20 that  volunteered.
Investigative protocols for quality-of-care problems. Only three sets  of investigative protocols had been implemented as of November 2005,  and it is unclear whether the contractor’s assessment of the protocols’  effectiveness can be completed before the contract ends in 2006.  Furthermore, unless the contract for the investigative protocols is re-bid,  CMS expects to return to the traditional revision process even though  agency staff believe that the expert panel process used under the contract  produced a high-quality product.
Federal comparative surveys. CMS hired a contractor in 2003 to further  increase the number of federal quality-of-care comparative surveys, but  dropped funding for quality-of-care comparative surveys from the fiscal  year 2006 contract. The agency reallocated the funds to help state survey  agencies meet the increased survey workload resulting from growth in the  number of other Medicare providers.
section_title: Concluding Observations
paragraphs: CMS has focused considerable attention since 1998 on addressing  weaknesses in state and federal oversight activities in order to better care  for and protect nursing home residents. The agency has implemented  many important improvements in the areas of surveys, complaints,  enforcement, and oversight, such as taking steps to address survey  predictability, issuing additional guidance to ensure timely on-site  investigations of complaints alleging harm to residents, implementing an  immediate sanctions policy to eliminate grace periods for homes cited for  repeat serious violations, and strengthening oversight by conducting  assessments of state survey activities. However, some key activities are  still in process. For example, CMS’s effort to revise the survey  methodology has been underway for 7 years. Given the pivotal role played  by surveys in helping to ensure that nursing home residents receive high- quality care, the development and implementation of a more rigorous  survey methodology is one of the most important contributions CMS can  make to addressing oversight weaknesses. Certain other initiatives, such  as sharing data with the public in an effort to use market forces to drive  quality improvement, also remain in process. Since launching Nursing  Home Compare in 1998, CMS has been aware of accuracy and reliability  issues with the underlying data and began changing its approach to data  integrity in 2005. The agency is working to address issues concerning data  on nursing home staffing that compelled it to temporarily exclude  questionable data from its Web site in July 2005 until its accuracy can be  verified. Because consumers use these data to make decisions about  nursing home care, ensuring the accuracy, reliability, and timeliness of  nursing home quality data is critical. Even with CMS’s increased efforts to  improve nursing home quality, the agency’s continued attention and  commitment to these efforts is essential in order to maintain and build  upon the momentum of its accomplishments to date.
section_title: Agency and State Comments and Our Evaluation
paragraphs: We provided CMS a draft of this report for review. CMS generally  concurred with our findings, noting that progress has been made in many  areas such as surveys and complaint investigations, oversight activities,  and citation of serious deficiencies, but that challenges remain. (CMS’s  comments are reproduced in app. V.) CMS also provided technical  comments, which we included in the report as appropriate. We also  provided the five states we contacted an opportunity to review the portion  of the draft focused on trends in nursing home quality. California, Florida,  Ohio, New York, and Texas provided written comments. California’s  comments focused on clarifying its experience seeking CMS guidance on  the definition of actual harm, but did not state whether it agreed with our  findings. Ohio commented that our report’s findings related to continued  inconsistency and understatement of serious deficiencies by state  surveyors did not apply to its state survey agency. New York stated that  including a more detailed description of states’ efforts to improve nursing  home quality would provide a more balanced view of the reasons for the  decline in serious deficiencies. Florida and Texas generally concurred, but  Texas did not provide specific comments. CMS and states’ specific  comments focused primarily on four issues: understatement of serious  deficiencies, the definition of actual harm, data availability, and challenges  to conducting nursing home survey and oversight activities.
CMS commented that it remains concerned about the possible  understatement or omission of serious deficiencies, but that it did not  believe that understatement caused the decline in serious nursing home  deficiencies or that understatement was worsening. CMS noted its efforts  to work with states that fail to improve their ability to identify deficiencies  such as withholding funding increases until corrective action plans are  developed. Florida, New York, and Ohio similarly commented that efforts  such as their states’ quality improvement initiatives, regulatory changes to  improve nursing home operations, and engagement of the provider  community have contributed to the decline.
CMS suggested that including the results of observational surveys in our  analysis of the percentage of federal surveys that found serious  deficiencies missed by states would show that the percentage remained  relatively constant from 2002 to 2004 rather than increasing. As we noted  in our 1999 report, however, comparative surveys are more effective than  observational surveys in identifying serious deficiencies missed by state  surveyors because they are the only oversight tool that provides an  independent federal survey where results can be compared to those of the  state. Observational surveys can serve as an effective training tool for state  surveyors but, in our view, they do not accurately represent typical state  surveyor performance due to the likelihood that state surveyors modify  their performance when they are aware that they are being observed by  federal surveyors.
Florida and Ohio noted that in addition to comparative surveys, CMS  conducted many observational surveys during the time period studied.  Ohio disagreed that our analysis of federal comparative surveys suggests  that nursing home surveyors in Ohio missed serious deficiencies, citing its  combined performance ratings for observational and comparative surveys.  New York commented that federal comparative surveys often do not  include the same resident sample used in the state survey and that only  looking at comparative surveys provides a narrow analysis of state survey  quality. New York suggested a more detailed analysis of comparative  survey data and consideration of state performance review results. We  note that, in 2002, CMS directed federal surveyors to include at least   50 percent of the residents included in the state survey sample. We also  acknowledge that CMS is conducting state performance reviews as part of  its oversight of state survey activities, but note that the reviews have  shortcomings as described in our July 2003 report. Florida noted that our  analysis of federal comparative surveys that identified missed serious  deficiencies is based on limited data. We acknowledge that our analysis is  based on a small number of surveys, but note that it includes the full  universe of comparative surveys conducted from March 2002 through  December 2004 in the five states we reviewed.
The range of comments from states reinforces the need for CMS to clarify  the definition of actual harm, as it plans to do. California noted that while  some of its state surveyors were confused about the definition of actual  harm, after discussions with CMS from 1998 through 2004, the survey  agency and CMS are now in agreement on the definition of actual harm.  New York stated that confusion about the definition of actual harm has  been reduced. Ohio noted that its state surveyors are not confused by the  definition of actual harm, but that states have not received clear and  specific guidance from CMS. Florida agreed that clearer guidance would  be useful.
CMS indicated that it is taking steps to improve the reliability and  accuracy of publicly reported data by identifying suspect data and posting  more detailed information about past noncompliance. As we state in our  report, we believe that consumers should have timely and accurate data to  inform their decisions regarding nursing home care.
CMS commented that the workload issues described in this report present  challenges beyond those we have previously reported. CMS stated that  continued constraint of resources could “likely cause some erosion of the  gains already made” in the survey and oversight activities to date. To  address the challenges it faces, CMS plans to increase efforts to improve  productivity, determine the cost and value of policies, focus state  performance standards on substantive issues, prioritize survey activities,  coordinate with stakeholders, address increasing fuel costs, and enhance  emergency preparedness. California, Florida, New York, and Ohio  reiterated the staffing challenges they have experienced and the steps they  have taken to address them, some of which are described in this report.  Despite these efforts, California indicated that its staffing challenges have  negatively impacted the investigative process. While we recognize the  challenges CMS and states face, we continue to believe that maintaining  the momentum developed over the last several years on key CMS  initiatives, such as the development of the revised survey methodology  (i.e., Quality Indicator Survey), is critical to addressing nursing home  survey and oversight weaknesses.
As arranged with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies of this report to the  Administrator of the Centers for Medicare & Medicaid Services and  appropriate congressional committees. We also will make copies available  at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-7118 or allenk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix VI.
section_title: Appendix I: Prior GAO Recommendations, Related CMS Initiatives, and Implementation Status
paragraphs: Table 10 summarizes our recommendations from 14 reports on nursing  home quality and safety, issued from July 1998 through November 2004;  CMS’s actions to address weaknesses we identified; and the  implementation status of CMS’s initiatives. 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 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 report contains the full citation for each report.  Of our 36 recommendations, CMS has fully implemented 13, implemented  only parts of 3, is taking steps to implement 13, and declined to implement  7.
section_title: Appendix II: Percentage of Nursing Homes Cited for Actual Harm or Immediate Jeopardy during Standard Surveys
paragraphs: In order to identify trends in the proportion of nursing homes cited with  actual harm or immediate jeopardy deficiencies, we analyzed data from  CMS’s OSCAR database for four time periods: (1) January 1, 1999, through  July 10, 2000; (2) July 11, 2000, through January 31, 2002; (3) February 1,  2002, through July 10, 2003; and (4) July 11, 2003, through January 31,  2005. 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 time period.
section_title: Appendix III: Percentage of Homes Surveyed Within 15 Days of the 1-Year Anniversary of Prior Survey
paragraphs: In order to determine the predictability of nursing home surveys, we  analyzed data from CMS’s OSCAR database for a home’s current survey as  of April 9, 2002, and as of July 8, 2005 (see table 12). We considered  surveys to be predictable if homes were surveyed within 15 days of the   1-year anniversary of their prior survey.
section_title: Appendix IV: Percentage of State Nursing Home Surveyors with 2-Years’ Experience or Less, 2002 and 2005
paragraphs: Appendix IV: Percentage of State Nursing  Home Surveyors with 2-Years’ Experience or  Less, 2002 and 2005 This state did not respond to our 2002 questions about surveyor experience.
section_title: Appendix V: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Walter Ochinko, Assistant  Director; Jack Brennan; Joanne Jee; Elizabeth T. Morrison; and Christal  Stone made key contributions to this report.
section_title: Related GAO Products
paragraphs: 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.