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Last Updated: 07-29-2022
Nursing homes are intended to be places of comfort and healing. More than 1.4 million individuals live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation. Most nursing homes in the United States are certified to serve as both skilled nursing facilities, which provide a clinically managed recovery period after a person's illness or injury, and long-term care facilities that deliver health care and services a resident needs for mental or physical conditions not rising to the level of skilled nursing care.
Decades of OIG work on nursing homes has uncovered widespread challenges in providing safe, high-quality care. Our audits, evaluations, and investigations have raised concerns regarding staffing levels, background checks for employees, reporting of adverse events experienced by residents, and other issues.
Proper nursing home care requires a partnership involving Federal, State, and local entities, the provider community, residents, and their families. To protect residents, OIG continually assesses nursing home performance and oversight, monitors the impact of program changes, and uses our enforcement tools to address misconduct. Key goals in OIG nursing home oversight are below.
Protect Residents from Fraud, Abuse, and Neglect and Promote Quality of Care
Nursing homes should be environments that are free of harm. However, criminal and civil enforcement actions involving OIG have uncovered misconduct and grossly substandard care in nursing homes. Bad actors perpetrate criminal activity that targets nursing home residents. In other cases, substandard care can result in harm such as costly medical injury, unsafe conditions, and abuse and neglect of residents.
OIG investigates potential violations to hold accountable those who victimize residents of nursing homes. Patient neglect and inadequate care by nursing facilities is a recurring challenge that OIG works with the Department of Justice to address in False Claims Act cases.
Promote Emergency Preparedness and Response Efforts
Nursing home residents and their families rely on facility administrators to plan and execute appropriate procedures during emergency events such as emerging infectious disease outbreaks, natural disasters, and life safety threats. Noncompliance with preparedness requirements and plans can place residents at increased risk of injury or death during an emergency.
In 2020, OIG quickly pivoted to new work to help protect nursing home residents during the pandemic. These individuals are particularly vulnerable to infectious diseases, such as COVID-19, due to their age and underlying medical conditions.
Strengthen Frontline Oversight
State survey agencies are on the front lines for ensuing nursing home quality and safety. States conduct on-site surveys at nursing facilities to evaluate the care they provide and respond to allegations of noncompliance with Federal requirements from residents, their families, staff, and others.
OIG reports have identified shortcomings in State agencies' effectiveness and recommended improvements to strengthen this safety system for nursing home residents.
Support Federal Monitoring of Nursing Homes to Mitigate Risks to Residents
HHS' Centers for Medicare and Medicaid Services (CMS) has an essential, ongoing responsibility to oversee nursing homes and shares with State agencies the responsibility for ensuring that nursing homes meet Federal requirements for quality and safety. CMS oversees the State process for certifying nursing homes and provides guidance to States regarding the survey process.
OIG examines risks to residents' well-being and recommends ways for CMS to better monitor and mitigate these risks. This work often includes assessments of how CMS is—or could be—leveraging data more effectively for oversight and to make risks more transparent to consumers.
The Office of Evaluation and Inspections conducts national evaluations of HHS programs from a broad, issue-based perspective. The evaluations incorporate practical recommendations and focus on preventing fraud, waste or abuse and encourage efficiency and effectiveness in HHS programs. The most recent nursing home-related evaluations are listed below.
- CMS Should Take Further Action To Address States With Poor Performance in Conducting Nursing Home Surveys
- Facility-Initiated Discharges in Nursing Homes Require Further Attention
- States' Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic
- COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020
- CMS Could Improve the Data It Uses To Monitor Antipsychotic Drugs in Nursing Homes
- CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More
- Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
- States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018
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- National Background Check Program for Long Term Care Providers: Assessment of State Programs Concluded in 2019
- Some Nursing Homes' Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased
The Office of Audit Services conducts independent audits of HHS programs and/or HHS grantees and contractors. These audits examine the performance of HHS programs and/or grantees in carrying out their responsibilities and provide independent assessments of HHS programs and operations. These audits help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. The most recent nursing home-related audits are listed below.
- Certain Nursing Homes May Not Have Complied With Federal Requirements for Infection Prevention and Control and Emergency Preparedness
- Audits of Nursing Home Life Safety and Emergency Preparedness in Eight States Identified Noncompliance With Federal Requirements and Opportunities for the Centers for Medicare & Medicaid Services to Improve Resident, Visitor, and Staff Safety
- An Estimated 91 Percent of Nursing Home Staff Nationwide Received the Required COVID-19 Vaccine Doses, and an Estimated 56 Percent of Staff Nationwide Received a Booster Dose
- Posthospital Skilled Nursing Facility Care Provided to Dually Eligible Beneficiaries in Indiana Generally Met Medicare Level-of-Care Requirements
- CMS's COVID-19 Data Included Required Information From the Vast Majority of Nursing Homes, but CMS Could Take Actions To Improve Completeness and Accuracy of the Data
- California Did Not Ensure That Nursing Facilities Always Reported Incidents of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Prioritize Allegations Properly
- Georgia Generally Ensured That Nursing Facilities Reported Allegations of Potential Abuse or Neglect of Medicaid Beneficiaries and Prioritized Allegations Timely
- Florida Did Not Ensure That Nursing Facilities Always Reported Allegations of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Assess, Prioritize, or Investigate Reported Incidents
- Iowa Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
- North Carolina Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
View Reports in Progress
During the COVID-19 pandemic, OIG has identified a spike in the number of reports alleging elder harm and neglect. Also, of great concern is the rise in the number of bad actors preying on Medicare and Medicaid beneficiaries during the public health crisis. In response, our Office of Investigations launched an initiative to raise awareness of fraud and abuse in elder care settings. Learn about Operation CARE.
OIG annually publishes the top unimplemented recommendations that, in our agency's view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and public health and safety if implemented. Recommendations concerning nursing homes that were unimplemented as of October 2021 appear in the table below. Find all top unimplemented recommendations of 2021 here.
OIG annually identifies top management and performance challenges HHS faces as it strives to fulfill its mission. View challenges regarding nursing homes.
Recommendation Relevant Reports
To ensure that nursing homes are implementing actions to prevent the spread of COVID-19 and that they are protecting residents, CMS should assess the results of infection control surveys of nursing homes and revise surveys as appropriate, as well as clarify expectations for States to complete backlogs of standard surveys and high priority complaint surveys that were suspended in the early months of the pandemic.
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020
OEI-01-20-00430 (December 2020)
CMS should take actions to ensure that incidents of potential abuse or neglect of Medicare and Medicaid beneficiaries are identified and reported.
Medicaid Data Can Be Used To Identify Instances of Potential Child Abuse or Neglect
A-01-19-00001 (July 2020)
Safeguards Must Be Strengthened To Protect Medicare Hospice Beneficiaries From Harm
OEI-02-17-00021 (July 2019)
CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect
A-01-17-00513 (June 2019)
Recommendation Relevant Reports
CMS should analyze the potential impacts of counting time spent as an outpatient toward the 3-night requirement for skilled nursing facility services so that beneficiaries receiving similar hospital care have similar access to these services.
Vulnerabilities Remain Under Medicare's 2-Midnight Hospital Policy
OEI-02-15-00020 (December 2016)
CMS should reevaluate the Inpatient Rehabilitation Facility (IRF) payment system, which could include seeking legislative authority to make any changes necessary to more closely align IRF payment rates and costs.
Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements
A-01-15-00500 (September 2018)