Intro -- Contents -- Preface -- Chapter 1 -- Examining Federal Efforts to Ensure Quality of Care and Resident Safety in Nursing Homes* -- Opening Statement of Hon. Gregg Harper, A Representative in Congress from the State of Mississippi -- Prepared Statement of Hon. Gregg Harper -- Opening Statement of Hon. Diana Degette, A Representative in Congress from the State of Colorado -- Opening Statement of Hon. Greg Walden, A Representative in Congress from the State of Oregon -- Prepared Statement of Hon. Greg Walden, Opening Statement of Hon. Frank Pallone, Jr., a Representative in Congress from the State of New Jersey -- Statement of Kate Goodrich -- Quality and Safety Oversight -- Addressing Suspected Abuse and Neglect in Nursing Homes -- National Partnership to Improve Dementia Care in Nursing Homes -- Ensuring Quality of Care by Putting Patients Over Paperwork -- Promoting Transparency, Rewarding Quality, and Encouraging Competition -- Skilled Nursing Facility Quality Reporting Program and Value-Based Purchasing Program -- Nursing Home Compare Five-Star Quality Rating System, Tracking Nursing Home Staffing Data -- Moving Forward -- Statement of Ruth Ann Dorrill -- Key Takeaways -- Overview of Accountability for Nursing Home Care and Oversight -- OIG Work Addressing harm to Residents in Nursing Homes -- OIG Found that that One in Three SNF Residents Experienced Adverse Events during Their Nursing Home Stays, Including Infections, Pressure Ulcers, and Misuse of Medication -- OIG has Raised Concerns about Failure to Report Allegations or potential Cases of Abuse and Neglect of Nursing Home Residents, OIG Investigations and Enforcement Cases Illustrate That Nursing Home Harm Can Involve Conduct by Individual Bad Actors, as Well Facility and Chain-Wide Conduct -- Nursing Home Emergency Preparedness -- Despite Enhanced Guidance from CMS, Nursing Homes Hit by Disaster Often Struggle to Execute Emergency Plans and Protect Residents -- State Agency Enforcement -- State Agencies Play a Critical Role in Ensuring the Quality and Safety of Nursing Homes, and OIG has Found Mixed Results in State Agency Attention to Nursing Home Deficiencies -- Next Steps to Improve Nursing Home Quality and Safety, and Sustained Commitment by CMS and Continued Collaboration among HHS, States, Providers, and Residents and Their Families will be Critical to Ensuring Quality and Safety -- To Protect Nursing Home Residents, OIG Will Continue to Assess CMS Oversight and Nursing Home and State Agency Performance, Monitor the Impact of Program Changes, and Use our Enforcement Tools to Address Misconduct -- Call to Action -- Statement of John Dicken -- Nursing Home Quality: Continued Improvements Needed in CMS's Data and Oversight -- Why GAO Did This Study -- What GAO Found -- Background
