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CMS Should Take Further Action To Address States With Poor Performance in Conducting Nursing Home Surveys


CMS oversees how State survey agencies (States) conduct surveys of nursing homes to assess the homes' compliance with Federal requirements. Recent work by OIG has found problems with performance by some States, which raise questions about the effectiveness of CMS oversight of State performance in conducting nursing home surveys, and the ability of CMS to hold States accountable when problems arise.


We analyzed CMS oversight of 52 States (including Puerto Rico and the District of Columbia) during FYs 2015-2018 to identify. We conducted interviews with CMS staff at the central office and 10 regional offices during February and March 2020, to learn how they work with States to address serious problems with survey performance and any challenges that States may face. We also collected and analyzed documents from CMS about State performance and CMS imposition of remedies and sanctions on States with poor performance.


Just over half of States-28 of 52-failed to meet the same performance measure or measures in three or four consecutive years during FYs 2015-2018. States most commonly missed performance measures related to survey timeliness, which CMS and States often attributed to staffing shortages. Ten percent of States' corrective action plans were missing from CMS files and many others lacked substantive detail. In addition to corrective action plans, CMS relied on other remedies, such as training and technical assistance, to help States improve performance.

Although CMS sometimes imposed financial penalties when States failed to meet the timeliness requirement for surveys, it frequently offset these penalties with one-time funding adjustments. CMS rarely imposed formal sanctions and has never initiated action to terminate any of its agreements with States for conducting surveys.


We recommend that CMS: (1) actively monitor States' corrective action plans, (2) establish guidelines for progressive enforcement actions, (3) engage with senior State officials earlier and more frequently to address problems, and (4) revise the State Operations Manual to reflect current CMS oversight practices. CMS concurred with these recommendations. We also recommend that CMS: (5) disseminate the results of State performance reviews more widely. In response, CMS stated that its current practices already fulfill the recommendation. We revised the recommendation to clarify the new and expanded dissemination of results we are recommending.