Background Oversight of nursing homes is a shared federal-state responsibility, with  CMS central and regional offices overseeing activities completed by state  survey agencies. Specifically, CMS central office (1) oversees the federal  quality standards nursing homes must meet to participate in the Medicare  and Medicaid programs and (2) establishes the responsibilities of CMS’s  regional offices and state survey agencies to ensure federal quality  standards for nursing homes are met. CMS regional offices oversee state  activities and report results back to CMS central office. Specifically,  regional offices are required to conduct annual federal monitoring surveys  to assess the adequacy of surveys conducted by state survey agencies.  CMS regional offices also evaluate state surveyors’ performance on  factors such as the frequency and quality of state surveys. Finally, in each  state, under agreement with CMS, a state survey agency assesses  whether nursing homes meet CMS’s standards by conducting regular  surveys and investigations of complaints regarding resident care or  safety, as needed. CMS collects data on nursing home quality through annual standard  surveys and complaint investigations, as well as other sources, such as  staffing data and clinical quality measures. Standard surveys. By law, every nursing home receiving Medicare or  Medicaid payment must undergo a standard survey during which  teams of state surveyors conduct a comprehensive on-site evaluation  of compliance with federal quality standards. Nursing homes with  consistently poor performance can be selected for the Special Focus  Facility (SFF) program, which requires more intensive oversight,  including more frequent surveys. Complaint investigations. Nursing homes also are surveyed on an  as-needed basis with investigations of consumer complaints. These  complaints can be filed with state survey agencies by residents,  families, ombudsmen, or others acting on a resident’s behalf. During  an investigation, state surveyors evaluate the nursing home’s  compliance with a specific federal quality standard. Staffing data. Nurse staffing levels are considered a key component  of nursing home quality and are often measured in total nurse hours  per resident day. Higher nurse staffing levels are typically linked with  higher quality nursing home care. Clinical quality measures. Nursing homes are required to provide  data on certain clinical quality measures—such as the incidence of  pressure ulcers—for all residents to CMS. CMS currently tracks data  for 18 clinical quality measures. CMS publicly reports a summary of each nursing home’s quality data on  its Nursing Home Compare website using a five-star quality rating. The  Five-Star Quality Rating System assigns each nursing home an overall  rating and three component ratings—surveys (standard and complaint),  staffing, and quality measures—based on the extent to which the nursing  home meets CMS’s quality standards and other measures. In a 2016  report, we found that CMS did not have a systematic process for  prioritizing recommended changes to improve its Nursing Home Compare  website and that several factors limited the ability of CMS’s Five-Star  Quality Rating System to help consumers understand nursing home  quality and choose a home. We recommended that CMS establish a  process to evaluate and prioritize website improvements and add  explanatory information about the Five-Star System to Nursing Home  Compare.  HHS agreed and in 2018 completed actions on these  recommendations, but has not yet acted on the other recommendations,  including providing national comparison information that we maintain are  important to help enable consumers to understand nursing home quality  and make distinctions between nursing homes. Nursing Home Quality  Data Show Mixed  Results, Although  Data Issues  Complicate Ability to  Assess Quality  Trends  Data on Nursing Home  Quality Showed Mixed  Results In our October 2015 report examining trend data that give insight into  nursing home quality, we found that four key data sets showed mixed  results, and data issues complicated the ability to assess quality trends. Nationally, one of the four data sets—consumer complaints—suggested  consumers’ concerns over nursing home quality increased from 2005 to  2014. However, the other three data sets—deficiencies, staffing levels,  and clinical quality measures—indicated potential improvement in nursing  home quality (see Table 1). Specifically, we found consumer  complaints—which can originate from residents, families, ombudsmen, or  others acting on a resident’s behalf—had a 21 percent increase from  2005 to 2014. In contrast, nurse staffing levels increased 9 percent from  2009 to 2014 and selected quality measure scores showed decreases in  the number of reported quality problems, such as falls resulting in major  injury from 2011 to 2014. In addition, we identified 416 homes in 36 states that had consistently  poor performance across the four data sets we examined. Of the 416  homes, 71 (17 percent) were included in the Special Focus Facility (SFF)  program at some point between 2005 and 2014. Data Issues Complicated  CMS’s Ability to Assess  Quality Trends In our October 2015 report, we found CMS’s ability to use available data  to assess nursing home quality trends was complicated by various issues  with these data, which made it difficult to determine whether observed  trends reflect actual changes in quality, data issues, or both. CMS has  taken some actions to address these data complications, however, more  work is needed. Consumer complaints: The average number of consumer complaints  reported per nursing home increased in the 10 years of data we  examined, although it is unclear to what extent this can be attributed to a  change in quality or to state variation in the recording of complaints.  Some state survey agency officials explained that changes in how they  recorded complaints into CMS’s complaint tracking system could in part  account for the jump in reported complaints. In addition, officials at one  state survey agency explained the increase in complaints could also  reflect state-level efforts to provide consumers with more user-friendly  options for filing complaints. Similarly, in April 2011, we found differences  in how states record and track complaints. Deficiencies cited on standard surveys: The decline in the number of  serious deficiencies—deficiencies that at a minimum caused a harm to  the resident—in the data we examined may have indicated an  improvement in quality, although it may also be attributed to  inconsistencies in measurement. For example, the use of multiple survey  types, such as both traditional paper-based surveys and electronic  surveys, to conduct the standard survey that every nursing home  receiving Medicare or Medicaid payment must undergo complicates the  ability to compare the results of these surveys nationally. In our October  2015 report, we recommended CMS implement the same survey  methodology across all states; HHS agreed with this recommendation  and in November 2017 completed its national implementation of this  electronic survey methodology. Nurse staffing: CMS data showed the average total nurse hours per  resident day increased from 2009 through 2014, although CMS did not  have assurance these data were accurate. Many of the regional office  and state survey agency officials we spoke with expressed concern over  the self-reported nature of these data, noting that it may be easy to  misrepresent nurse staff hours. At the time of our 2015 report, CMS was  in the process of implementing a system to collect staffing information  based on payroll and other verifiable data and has now completed that  implementation, as required by law. We recommended in 2015 that CMS  establish and implement a clear plan for ongoing auditing of its staffing  data and other quality data. HHS agreed with this recommendation and in  July 2018 CMS provided us with documentation that it was conducting  regular audits of this new nurse staffing data. According to CMS, facilities  experienced challenges submitting complete and accurate data in the  early stages, however, as of April 2018 the agency has begun relying on  the payroll data to calculate the staffing measures that it posts in Nursing  Home Compare and uses in the Five-Star Quality Rating System. Selected quality measures: Nursing homes generally improved their  performance on the eight selected quality measures we reviewed,  although it is unclear to what extent this can be attributed to a change in  quality or possible inaccuracies in self-reported data. Like the nurse  staffing data used by CMS, data on nursing homes’ performance on these  measures were self-reported, and until 2014 CMS conducted little to no  auditing of these data to ensure their accuracy. In our 2015 report, we  found CMS had begun taking steps to help mitigate the problem with self- reported data by starting to audit the data in 2015; however, the agency  did not have clear plans to continue the audits beyond 2016. As such, in  our recommendation we indicated the need for ongoing auditing of data  used to calculate clinical quality measures. As of August 2018, CMS has  not provided us a plan for ongoing auditing of its clinical quality measures  and we continue to believe that CMS should establish and carry out such  a plan. Collectively, these data issues have broader implications related to  nursing home quality trends, including potential effects on the quality  benchmarks CMS sets and consumers’ decisions about which nursing  home to select. Furthermore, data used by CMS to assess quality  measures are also used when determining Medicare payments to nursing  homes, so data issues—and CMS’s internal controls related to the data— could affect the accuracy of payments. Moreover, the use of quality data  for payment purposes will expand in fiscal year 2019 when a nursing  home value-based purchasing program will be implemented, which will  increase or reduce Medicare payments to nursing homes based on  certain quality measures. CMS Had Modified  Oversight Activities by  2015, But Had Not  Monitored Potential  Effect on Nursing  Home Quality  Oversight Our 2015 report found that CMS had made numerous modifications to its  nursing home oversight activities in recent years, but had not monitored  the potential effect of these modifications on nursing home quality  oversight. Some of these modifications expanded or added new oversight  activities—for example, CMS expanded the number of tools available to  state surveyors when investigating medication-related adverse events,  increased the amount of nursing home quality data available to the public,  and created new trainings for surveyors on unnecessary medication  usage. However, other modifications reduced existing oversight  activities. In 2015, we highlighted modifications that reduced two existing oversight  activities—the federal monitoring survey program and the SFF program. Federal monitoring surveys: CMS reduced the scope of the federal  monitoring surveys regional offices use to evaluate state surveyors’  skills in assessing nursing home quality. CMS requires regional  offices to complete federal monitoring surveys in at least 5 percent of  nursing homes surveyed by the state each year. Starting in 2013,  CMS required fewer federal monitoring surveys to be standard  surveys and allowed more monitoring surveys to be the narrower  scoped and less-resource intensive revisits and complaint  investigations. Special Focus Facilities: CMS reduced the number of nursing  homes participating in the SFF program. In 2013, CMS began to  reduce the number of homes in the program by instructing states to  terminate homes that had been in the program for 18 months without  improvement from participating in Medicare and Medicaid. As we  have previously reported, between 2013 and 2014, the number of  nursing homes in the SFF program dropped by more than half—from  152 to 62. In 2014, CMS began the process of re-building the number  of facilities in the SFF program; however, according to CMS officials,  the process would be slow, and as of August 2018 there were 85  SFFs. In 2015, CMS said some of the reductions to oversight activities were in  response to an increase in oversight responsibilities and limited number  of staff and financial resources. Specifically, CMS officials said increasing  oversight responsibilities and a limited number of staff and financial  resources at the central, regional, and state levels required the agency to  evaluate its activities and reduce the scope of some activities. In the  October 2015 report, we recommended CMS monitor oversight  modifications to better assess their effects; HHS agreed with the  recommendation and told us they are beginning to take steps to address  this issue. We maintain the importance of monitoring to help CMS better  understand how its oversight modifications affect nursing home quality  and to improve its oversight given limited resources. Chairman Harper, Ranking Member DeGette, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you may have at this time. 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 testimony. In addition to the contact named above,  key contributors to this statement were Karin Wallestad (Assistant  Director), Sam Amrhein, Summar Corley, Pam Dooley, Will Simerl, and  Jennifer Whitworth. Appendix I: Related  GAO Reports 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. 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. Health Care Transparency: Actions Needed to Improve Cost and Quality  Information for Consumers. GAO-15-11. Washington, D.C.: October 20,  2014. Nursing Homes: More Reliable Data and Consistent Guidance Would  Improve CMS Oversight of State Complaint Investigations. GAO-11-280.  Washington, D.C.: April 7, 2011. Nursing Homes: Complexity of Private Investment Purchases  Demonstrates Need for CMS to Improve the Usability and Completeness  of Ownership Data. GAO-10-710. Washington, D.C.: September 30,  2010. Poorly Performing Nursing Homes: Special Focus Facilities Are Often  Improving, but CMS’s Program Could Be Strengthened. GAO-10-197.  Washington, D.C.: March 19, 2010. Nursing Homes: Addressing the Factors Underlying Understatement of  Serious Care Problems Requires Sustained CMS and State Commitment.  GAO-10-70. Washington, D.C.: November 24, 2009. Nursing Homes: Opportunities Exist to Facilitate the Use of the  Temporary Management Sanction. GAO-10-37R. Washington, D.C.:  November 20, 2009. Nursing Homes: CMS’s Special Focus Facility Methodology Should Better  Target the Most Poorly Performing Homes, Which Tended to Be Chain  Affiliated and For-Profit. GAO-09-689. Washington, D.C.: August 28,  2009. Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine  Its Approach for Funding State Oversight of Health Care Facilities.  GAO-09-64. Washington, D.C.: February 13, 2009. Nursing Homes: Federal Monitoring Surveys Demonstrate Continued  Understatement of Serious Care Problems and CMS Oversight  Weaknesses. GAO-08-517. Washington, D.C.: May 9, 2008. Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not  Deterred Some Homes from Repeatedly Harming Residents.  GAO-07-241. Washington, D.C.: March 26, 2007. Nursing Homes: Complaint Investigation Processes Often Inadequate to  Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22,  1999. California Nursing Homes: Care Problems Persist Despite Federal and  State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998. This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.
Approximately 15,600 nursing homes participating in the Medicare and Medicaid programs provide care to 1.4 million residents—a population of elderly and disabled individuals. To help ensure nursing home residents receive quality care, CMS defines quality standards that homes must meet to participate in the Medicare and Medicaid programs. To monitor compliance with these standards, CMS enters into agreements with state survey agencies to conduct on-site surveys of the state's homes and also collects other data on nursing home quality. Although CMS and others have reported some potential improvements in nursing home quality, questions have been raised about nursing home quality and weaknesses in CMS oversight. This statement summarizes GAO's October 2015 report, GAO-16-33 . Specifically, it describes (1) trends in nursing home quality through 2014, and (2) changes CMS had made to its oversight activities as of October 2015. It also includes the status of GAO's recommendations associated with these findings. GAO recently obtained information from CMS officials about steps they have taken to implement the 2015 GAO recommendations. GAO's October 2015 report found mixed results in nursing home quality based on its analysis of trends reflected in key sources of quality data that the Centers for Medicare & Medicaid Services (CMS) collects. An increase in reported consumer complaints suggested that consumers' concerns about nursing home quality increased. In contrast, trends in care deficiencies, nurse staffing levels, and clinical quality measures indicated potential improvement in nursing home quality. GAO also found that data issues complicated CMS's ability to assess nursing home quality trends. For example: CMS allowed states to use different survey methodologies to measure deficiencies in nursing home care, which complicates the ability to make comparisons nationwide. GAO recommended that CMS implement a standardized survey methodology across states, and in November 2017 CMS completed national implementation. CMS did not regularly audit selected quality data including nurse staffing and clinical data (for example, on residents with pressure ulcers) to ensure their accuracy. GAO recommended CMS implement a plan for ongoing auditing of quality data. The agency concurred with this recommendation and has been conducting regular audits of nurse staffing data but does not have a plan to audit other quality data on a continuing basis. GAO continues to believe that regular audits are needed to ensure the accuracy and comparability of nursing home quality data. GAO's October 2015 report found that CMS had made numerous modifications to its nursing home oversight activities. However, CMS had not monitored how the modifications might affect its ability to assess nursing home quality. GAO found that some modifications expanded or added new activities—such as creating new training for state surveyors on unnecessary medication usage—while others reduced existing activities. For example, CMS reduced the number of nursing homes participating in the Special Focus Facility program—which provides additional oversight of certain homes with a history of poor performance—by over half from 2013 to 2014. CMS officials told GAO that some of the reductions to oversight activities were in response to an increase in oversight responsibilities and a limited number of staff and financial resources. To help ensure modifications do not adversely affect CMS's ability to assess nursing home quality, GAO recommended that CMS monitor modifications of essential oversight activities to better understand the effects on nursing home quality oversight. CMS concurred with this recommendation and told us it has begun to take steps to address it. Such monitoring is important for CMS to better understand how its oversight modifications affect nursing home quality and to improve its oversight given limited resources.