State inspectors often overlook serious deficiencies, including life-threatening conditions, in the nation's nursing homes, Congressional investigators say in a new report.

In the report, the investigators, from the Government Accountability Office, questioned data used by the Bush administration in arguing that its policies have fostered "significant improvements" in the nation's nursing homes. Nursing homes must meet federal standards to participate in Medicaid and Medicare. Homes are inspected by state employees working under contract to the federal government.

Much of the apparent improvement has resulted from the fact that those state inspectors "missed serious deficiencies" or understated their severity, the accountability office said.The Congressional investigators found pervasive understatement of "serious deficiencies that cause actual harm or immediate jeopardy to patients." The harm includes severe weight loss, "multiple falls resulting in broken bones and other injuries, and serious, avoidable pressure sores," the report said. The deficiencies included fire safety violations.

The top Medicare official, Dr. Mark B. McClellan, said that he too was "concerned about possible understatement or omission of serious deficiencies" by state inspectors.Over all, Dr. McClellan said, the quality of nursing home care has improved in the last five years. But, he said, these gains are in jeopardy because Congress has not provided enough money and state budgets for this purpose are "very limited."Dr. McClellan said the Bush administration wanted to link payment of nursing homes to the quality of care they provide. He said he expected to test such a "pay for performance" system this year.

Medicaid, the federal-state program for low-income people, covers two-thirds of the nation's 1.6 million nursing home residents. Together, Medicaid and Medicare spend more than $67 billion a year on nursing home care.The study was requested by Senators Charles E. Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin. "If state surveyors are missing serious deficiencies in the quality of care, then the federal government has not yet achieved the necessary level of improvement in oversight of the inspection process," said Mr. Grassley, who is chairman of the Finance Committee.
In its report, the Government Accountability Office made these points:
States often take weeks or months to start investigating reports of harm to nursing home residents. These reports come from patients and their relatives and from nursing home employees.Some useful information on nursing home quality is available at a federal Web site, but much of the data is inaccurate or unreliable.The timing of inspections is highly predictable. This "allows homes to conceal problems if they so desire."

Concerns about cost have delayed the installation of automatic sprinkler systems in older nursing homes. More than 20 percent of homes lack such fire protection devices. The industry wants the government to help pay the installation costs, estimated at $1 billion. Dr. McClellan said the proportion of nursing homes cited for serious deficiencies had declined sharply, to 16 percent last year from 29 percent in 1999. 

The Government Accountability Office found great variation from state to state, and it suggested that inspectors were more rigorous in some states. From 2003 to 2005, the report said, California cited 6 percent of its nursing homes for serious violations, while Connecticut cited 54 percent of its homes.Senator Kohl said, "There are too many inconsistencies in what is deemed a deficiency from state to state."The accountability office said that some inspectors were confused about the meaning of "actual harm." As a result, it said, the same conditions are sometimes viewed as a violation of federal rules in one state but not in others.

Texas reported a big decline in serious deficiencies over the last five years. But one reason, the report said, is that Texas had "a significant number of inexperienced surveyors" who were hesitant to cite nursing homes for major violations.The Bush administration said that, by some measures, the regulation of nursing homes had improved. For example, it said, inspectors investigated 47,124 complaints in 2004, reflecting an increase of 45 percent over the number investigated in 1999. Moreover, Dr. McClellan said, inspectors have paid more attention to fire safety since 31 people died in nursing home fires in Connecticut and Tennessee in 2003. Inspectors identified 47,456 fire-safety violations in 2004, an increase of 20 percent over the previous year.

Federal employees visit about 5 percent of the nation's 17,000 nursing homes each year to validate the findings of state inspectors. In 28 percent of these visits from 2002 to 2004, the federal agents found serious problems not detected by state inspectors. This proportion has increased in recent years, from 22 percent in 2000 to 2001.