Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse
Fast Facts
To protect vulnerable nursing home residents from abuse, the Centers for Medicare & Medicaid Services (CMS) contracts with state agencies—known as survey agencies—that can cite nursing homes for incidents of abuse.
Abuse citations doubled from 2013-2017. We reviewed a 2016-2017 sample of narratives substantiating abuse citations and determined that physical and mental/verbal abuse were more common than sexual abuse, and that perpetrators were often staff.
CMS can't readily access this information, which it could use to improve its oversight by focusing on the most prevalent problems. Our recommendations address this and other issues we found.
Nursing Home Abuse by Type and Perpetrator among the Sample of Narratives in Our Review
Bar chart showing physical and mental/verbal abuse and staff perpetrators most common
Highlights
What GAO Found
The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents. GAO analysis of CMS data found that, while relatively rare, abuse deficiencies cited in nursing homes more than doubled, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. GAO also reviewed a representative sample of abuse deficiency narratives from 2016 through 2017. Physical and mental/verbal abuse occurred most often in nursing homes, followed by sexual abuse, and staff were more often the perpetrators of the abuse deficiencies cited. CMS cannot readily access information on abuse or perpetrator type in its data and, therefore, lacks key information critical to taking appropriate actions.
GAO Analysis of a Representative Sample of CMS Nursing Home Abuse Deficiency Narratives, 2016-2017
Note: Percentages do not add to 100 because some narratives had multiple types of abuse, were missing or incomplete, or were not consistent with CMS's definition of abuse.
GAO also found gaps in CMS oversight, including:
Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement.
Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all of the state survey agencies in GAO's review said the facility-reported incidents can lack information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.
Why GAO Did This Study
Nursing homes provide care to about 1.4 million nursing home residents—a vulnerable population of elderly and disabled individuals. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs.
GAO was asked to review abuse of residents in nursing homes. Among other objectives, this report: (1) determines the trends and types of abuse in recent years, and (2) evaluates CMS oversight intended to ensure residents are free from abuse.
GAO reviewed CMS's policies, analyzed CMS data on abuse deficiencies from 2013 through 2017, the most recent data at the time of our review, and interviewed officials from CMS and state survey agencies in five states, as well as other key stakeholders in those states such as ombudsmen and law enforcement officials. The states were selected for variation in factors such as number of nursing homes and role of other state agencies in abuse investigations.
Recommendations
GAO is making six recommendations, including that CMS: require state survey agencies to submit data on abuse and perpetrator type; require state survey agencies to immediately refer to law enforcement any suspicion of a crime; and develop guidance on what abuse information nursing homes should self-report. HHS concurred with all of GAO's recommendations and identified actions it will take to implement them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services |
Priority Rec.
The administrator of CMS should require that abuse and perpetrator type be submitted by state survey agencies in CMS's databases for deficiency, complaint, and facility-reported incident data, and that CMS systematically assess trends in these data. (Recommendation 1) |
HHS concurred with this recommendation. In February 2020, HHS said CMS is developing the ability to review survey trends related to alleged perpetrator and alleged abuse types and aims to implement this recommendation by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. As of February 2022, HHS had not reported any additional actions taken to address this recommendation. In October 2022, CMS issued updated guidance to state survey agencies that requires surveyors to enter the abuse and perpetrator type into CMS's deficiencies database. CMS officials said the agency is monitoring trends in abuse deficiencies and reviewing the types of perpetrators. However, as of February 2024, CMS did not require that state surveyors enter the abuse or perpetrator type for complaint and facility-reported incident data.
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| Centers for Medicare & Medicaid Services | The administrator of CMS should 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. (Recommendation 2) |
HHS concurred with this recommendation. In February 2020, HHS said CMS will list the elements that all nursing homes should report to state agencies and aims to implement this recommendation by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. In October 2022, CMS issued updated guidance to state survey agencies that included a sample standardized form on the information nursing homes and covered individuals should include on facility-reported incidents.
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| Centers for Medicare & Medicaid Services |
Priority Rec.
The administrator of CMS should require state survey agencies to immediately refer complaints and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units (MFCU)) if they have a reasonable suspicion that a crime against a resident has occurred when the complaint is received. (Recommendation 3) |
HHS concurred with this recommendation. In February 2020, HHS said CMS will require state survey agencies to immediately refer complaints upon receipt and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units) if they have a reasonable suspicion that a crime against a resident has occurred and aims to implement this requirement by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. As of February 2022, HHS had not reported any additional actions taken to address this recommendation. In October 2022, CMS issued updated guidance that requires state survey agency officials to immediately make referrals to law enforcement if they have a reasonable suspicion that a crime against a resident has occurred and if it has not already been reported.
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| Centers for Medicare & Medicaid Services | The administrator of CMS should conduct oversight of state survey agencies to ensure referrals of complaints, surveys, and substantiated incidents with reasonable suspicion of a crime are referred to law enforcement (and, when applicable, to MFCUs) in a timely fashion. (Recommendation 4) |
HHS concurred with this recommendation. In February 2020, HHS said CMS will revise guidance to ensure state survey agencies will investigate and track incidents of abuse and neglect and report substantiated findings to local law enforcement. CMS aims to implement this recommendation by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. As of February 2022, HHS had not reported any additional actions taken to address this recommendation. In October 2022, CMS issued guidance that requires state survey agency officials to enter data into CMS's complaint and facility-reported incident database for any referrals made to law enforcement. It also provides more details about the deficiency code state surveyors should use if, while conducting a survey, they suspect that a crime has occurred but that law enforcement has not been notified. This guidance also instructs state survey agencies to immediately report the suspected crime to law enforcement. In April 2023, CMS officials confirmed they are monitoring state survey agencies to ensure that timely referrals of suspected crimes are made to law enforcement.
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| Centers for Medicare & Medicaid Services | The administrator of CMS should develop guidance for state survey agencies clarifying that allegations verified by evidence should be substantiated and reported to law enforcement and state registries in cases where citing a federal deficiency may not be appropriate. (Recommendation 5) |
HHS concurred with this recommendation. In February 2020, HHS said CMS will provide clarification to the state survey agencies regarding the definition of substantiated and when cases need to be referred to law enforcement. CMS aims to implement this recommendation by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. In October 2022, CMS issued updated guidance that removes the term "substantiated" from state survey agency guidance and notes that the role of the surveyor is not to validate whether the events contained in the allegation had occurred, but is to determine whether the nursing home is in compliance with federal requirements.
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| Centers for Medicare & Medicaid Services | The administrator of CMS should provide guidance on what information should be contained in the referral of abuse allegations to law enforcement. (Recommendation 6) |
HHS concurred with this recommendation. In February 2020, HHS said it will provide guidance to state agencies and nursing homes on identifying and reporting potential abuse and neglect of residents and will develop a list of standardized elements that should be included when reporting an abuse allegation to law enforcement. HHS aims to implement this recommendation by July 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. In October 2022, CMS issued updated guidance that instructs nursing homes to provide as much information as possible at the time of the submission of the report so that state agencies can initiate action necessary to oversee the protection of nursing home residents. CMS also issued a sample form for this initial reporting with examples of information that should be reported. CMS's guidance says that, if a crime is suspected, state survey agencies must immediately forward the information from this initial report to law enforcement.
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