Nursing Homes: Better Oversight Needed to Protect Residents from Abuse
Released: 2019-11-14T00:00:00

Letter

Improved CMS Oversight Is Needed to Better Protect Residents from Abuse

In our June 2019 report, we found that, while abuse deficiencies cited in nursing homes were relatively rare from 2013 through 2017, they became more frequent during that time, with the largest increase in severe cases. Specifically, abuse deficiencies comprised less than 1 percent of the total deficiencies in each of the years we examined, which is likely conservative. Abuse in nursing homes is often underreported by residents, family, staff, and the state survey agency, according to CMS officials and stakeholders we interviewed. However, abuse deficiencies more than doubled—from 430 in 2013 to 875 in 2017—over the 5-year period. (See appendix II.) In addition, abuse deficiencies cited in 2017 were more likely to be categorized at the highest levels of severity— deficiencies causing actual harm to residents or putting residents in immediate jeopardy—than they were in 2013. In light of the increased number and severity of abuse deficiencies, it is imperative that CMS have strong nursing home oversight in place to protect residents from abuse; however, we found oversight gaps that may limit the agency’s ability to do so. Specifically, we found that CMS: (1) cannot readily access data on the type of abuse or type of perpetrator, (2) has not provided guidance on what information nursing homes should include in facility-reported incidents, and (3) has numerous gaps in its referral process that can result in delayed and missed referrals to law enforcement.

Information on Abuse and Perpetrator Types Is Not Readily Available

In our June 2019 report, we found that CMS’s data do not allow for the type of abuse or perpetrator to be readily identified by the agency. Specifically, CMS does not require the state survey agencies to record abuse and perpetrator type and, when this information is recorded, it cannot be easily analyzed by CMS. Therefore, we reviewed a representative sample of 400 CMS narrative descriptions—written by state surveyors—associated with abuse deficiencies cited in 2016 and 2017 to identify the most common types of abuse and perpetrators. From this review, we found that physical abuse (46 percent) and mental/verbal abuse (44 percent) occurred most often in nursing homes, followed by sexual abuse (18 percent). Furthermore, staff, which includes those working in any part of the nursing home, were more often the perpetrators (58 percent) of abuse in deficiency narratives, followed by resident perpetrators (30 percent) and other types of perpetrators (2 percent). (See appendix III for examples from our abuse deficiency narrative review.)

CMS officials told us they have not conducted a systematic review to gather information on abuse and perpetrator type. Further, based on professional experience, literature, and ad hoc analyses of deficiency narrative descriptions, CMS officials told us they believe the majority of abuse is committed by nursing home residents and that physical and sexual abuse were the most common types. This understanding does not align with our findings on the most common types of abuse and perpetrators represented in CMS’s data on deficiencies cited as abuse. Without the systematic collection and monitoring of specific abuse and perpetrator data, CMS lacks key information and, therefore, cannot take actions—such as tailoring prevention and investigation activities—to address the most prevalent types of abuse or perpetrators. To address this, we recommended that CMS require state survey agencies to report abuse and perpetrator type in CMS’s databases for deficiency, complaint, and facility-reported incident data and that CMS systematically assess trends in these data. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented the recommendation.

Facility-Reported Incidents Lack Key Information

Despite federal law requiring nursing homes to self-report allegations of abuse and covered individuals to report reasonable suspicions of crimes against residents, in June 2019 we reported that CMS had not provided guidance to nursing homes on what information they should include in facility-reported incidents, contributing to a lack of information for state survey agencies and delays in their investigations. Specifically, officials from each of the five state survey agencies told us that the documentation they receive from nursing homes for facility-reported incidents can lack key information that affects their ability to triage incidents and determine whether an investigation should occur and, if so, how soon. For example, officials from two state survey agencies we interviewed said they sometimes have to conduct significant follow-up with the nursing homes to obtain the information they need to prioritize the incident for investigation—follow-up that delays and potentially negatively affects investigations. Incomplete incident reports from nursing homes are particularly problematic given that nearly half of abuse deficiencies cited between 2013 and 2017 were identified through facility-reported incidents, which is dramatically different than the approximately 5 percent of all types of deficiencies that were identified in this manner. Therefore, facility-reported incidents play a unique and significant role in identifying abuse deficiencies in nursing homes, making it critical that incident reports provided by nursing homes include the information necessary for state survey agencies to prioritize and investigate. To address this issue, we recommended that CMS develop and disseminate guidance— including a standardized form—to all state survey agencies on the information nursing homes and covered individuals should include on facility-reported incidents. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented the recommendation.

Gaps Exist in CMS Process for State Survey Agency Referrals to Law Enforcement and MFCUs

In June 2019, we identified gaps in CMS’s process for referring incidents of abuse to law enforcement and, if appropriate, to MFCUs. These gaps may limit CMS’s ability to ensure that nursing homes meet federal requirements for residents to be free from abuse. Specifically, we identified issues related to (1) referring abuse to law enforcement in a timely manner, (2) tracking abuse referrals, (3) defining what it means to substantiate an allegation of abuse—that is, the determination by the state survey agency that evidence supports the abuse allegation, and (4) sharing information with law enforcement. We made recommendations that CMS address each of these four gaps in the referral process, and HHS concurred with each recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented these recommendations.

One of the gaps in CMS’s process is related to referring abuse to law enforcement in a timely manner. For example, law enforcement investigations can be significantly delayed because CMS requires a state survey agency to make referrals to law enforcement only after abuse is substantiated—a process that can often take weeks or months. Officials from one law enforcement agency and two MFCUs we interviewed told us the delay in receiving referrals limits their ability to collect evidence and prosecute cases—for example, bedding associated with potential sexual abuse may have been washed, and a victim’s wounds may have healed. As such, we recommended that CMS require state survey agencies to immediately refer to law enforcement any reasonable suspicion of a crime against a resident. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented this recommendation.

In conclusion, while nursing home abuse is relatively rare, our June 2019 report shows that abuse deficiencies cited in nursing homes are becoming more frequent, with the largest increase in severe cases. It is imperative that CMS have more complete and readily available information on abuse to improve its oversight of nursing homes. It is also essential that CMS require state survey agencies to immediately report incidents to law enforcement if they have a reasonable suspicion that a crime against a resident has occurred in order to ensure a prompt investigation of these incidents.

Chairman Neal, Ranking Member Brady, and Members of the Committee, this concludes GAO’s statement for the record.

GAO Contact and Staff Acknowledgments

For further information about this statement, please contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. In addition to the contact named above, key contributors to this statement were Karin Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-in-Charge) and Summar C. Corley. Also contributing to the underlying report for this statement were Luke Baron, Julianne Flowers, Laurie Pachter, Vikki Porter, Kathryn Richter, and Jennifer Whitworth.

Appendix I: Summary of GAO Reports on the Health and Welfare of the Elderly

We have issued a number of reports reviewing the health and welfare of the elderly in multiple settings. For example, since January 2015, we have issued reports on the incidence of abuse in nursing homes and what is known about the incidence of abuse in assisted living facilities. Reports often included key recommendations. (See table 1.)

Appendix II: Severity of Abuse Deficiencies Cited in Nursing Homes, 2013 through 2017

Appendix II: Severity of Abuse Deficiencies Cited in Nursing Homes, 2013 through 2017 CMS restructured its deficiency code system beginning on November 28, 2017. Due to these coding changes, we did not analyze CMS data cited by surveyors after the implementation of that change.

Percentages may not add to 100 due to rounding.

Appendix III: Examples from a Representative Sample of Nursing Home Abuse Deficiency Narratives, 2016-2017

Related GAO Reports

Elder Abuse: Federal Requirements for Oversight in Nursing Homes and Assisted Living Facilities Differ. GAO-19-599. Washington, D.C.: August 19, 2019.

Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse. GAO-19-433. Washington, D.C.: June 13, 2019.

Elder Justice: Goals and Outcome Measures Would Provide DOJ with Clear Direction and a Means to Assess Its Efforts. GAO-19-365. Washington, D.C.: June 7, 2019.

Management Report: CMS Needs to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations That Persisted in Oregon for at Least 15 Years. GAO-19-313R. Washington, D.C.: April 15, 2019.

Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed. GAO-18-179. Washington, D.C.: January 5, 2018.

Medicaid Managed Care: CMS Should Improve Oversight of Access and Quality in States’ Long-Term Services and Supports Programs. GAO-17- 632. Washington, D.C.: August 14, 2017.

Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs. GAO-17-28. Washington, D.C.: November 23, 2016.

Nursing Homes: Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System. GAO-17-61. Washington, D.C.: November 18, 2016.

Elder Abuse: The Extent of Abuse by Guardians is Unknown, but Some Measures Exist to Help Protect Older Adults. GAO-17-33. Washington, D.C.: November 16, 2016.

Skilled Nursing Facilities: CMS Should Improve Accessibility and Reliability of Expenditure Data. GAO-16-700. Washington, D.C.: September 7, 2016.

Nursing Home Quality: CMS Should Continue to Improve Data and Oversight. GAO-16-33. Washington, D.C.: October 30, 2015.

Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings. GAO-15-211. Washington, D.C.: January 30, 2015.

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