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GAO-11-130R: 

United States Government Accountability Office: 
Washington, DC 20548: 

November 30, 2010: 

The Honorable Max Baucus: 
Chairman: 
The Honorable Charles E. Grassley: Ranking Member: 
Committee on Finance: 
United States Senate: 

Subject: Long-Term Care Hospitals: Differences in Their Oversight 
Compared to Other Types of Hospitals and Nursing Homes: 

This report formally transmits our briefing slides highlighting 
differences in the oversight of long term care hospitals (LTCH), other 
types of hospitals, and nursing homes (see enclosure I). The slides 
are a partial response to your request letter and were used to brief 
your staff on November 29, 2010. We provided a draft of this report to 
the Department of Health and Human Services (BHS) and to The Joint 
Commission (TJC)-—an accrediting organization that oversees the 
majority of LTCHs. BHS's comments, which indicated that the briefing 
slides were a welcome resource, are reproduced in appendix III of the 
slides. We also received technical comments from BHS and TJC, which we 
incorporated as appropriate. 

We will address your questions about the types of quality and patient 
safety information collected on LTCHs by the Centers for Medicare & 
Medicaid Services (CMS) and the coordination among oversight 
organizations in a subsequent report. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to the Secretary of BHS, the Administrator of CMS, and relevant 
congressional committees. In addition, the report will be available at 
no charge on the GAO Website at [hyperlink, http://www.gao.gov]. 

If you or your staffs have any questions regarding this report, please 
contact me at (202) 512-7114 or kohnl@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. Key contributors to this report were 
Walter Ochinko, Assistant Director; Sarah Harvey; Kristin Helfer 
Koester; Elizabeth T. Morrison; Phillip J. Stadler; and Jennifer 
Whitworth. 

Signed by: 

Linda T. Kohn: 
Director, Health Care: 

Enclosure: 

[End of section] 

Enclosure I: Long-Term Care Hospitals: Differences in Their Oversight 
Compared to Other Types of Hospitals and Nursing Homes: 

Briefing for Staff of Committee on Finance United States Senate: 

November 29, 2010: 

Overview: 
* Introduction; 
* Objective; 
* Scope and Methodology; 
* Background; 
* Results; 
* Summary of Differences in Oversight among LTCHs, Other Hospitals, 
and Nursing Homes; 
* Agency Comments. 

Overview: 

* Appendix I: CMS's 23 Hospital Conditions of Participation. 

* Appendix II: TJC's17 Categories of Hospital Standards. 

* Appendix III: Comments from HHS. 

Introduction: 

Long-term care hospitals (LTCH) provide acute and post acute care to 
clinically complex individuals who have multiple acute or chronic 
conditions and need care for relatively extended periods—more than 25 
days, on average.[A] 

* Unlike LTCHs, other types of hospitals, such as acute-care hospitals 
(ACH), do not have length of stay requirements for Medicare payment.[B] 

* Most LTCH patients are transferred from an intensive or critical 
care unit of an ACH. 

[A] The Social Security Act permits certain LTCHs to maintain an 
average length of stay of more than 20 days. See 42 U.S.C. 
§1395ww(d)(1)(B)(iv)(II). 

[B] Medicare is the federal health insurance program for people aged 
65 and older, certain individuals with disabilities, and individuals 
with end-stage renal disease. Among other things, Medicare covers 
inpatient hospital stays and physician services. 

In fiscal year (FY) 2009, about 7 percent of hospitals were LTCHs, up 
from 4.5 percent in FY 2001. 

* Changes in the Medicare payment system, among other factors, 
contributed to the increase in the number of LTCHs. 

* After growth in the number of LTCHs, Congress placed a moratorium on 
the establishment of new LTCHs and on increases in bed size for 
existing LTCHs, with limited exceptions, beginning in 2007.[A] 

Medicare payments to LTCHs: 

* Medicare paid about $5 billion in FY 2009 for care provided in 434 
LTCHs for about 140,000 discharges—an average of more than $32,000 per 
discharge.[B] 

* Following a 2010 article in The New York Times, you expressed 
concern about the oversight of and quality of care provided in 
LTCHs.[C] 

[A] The Medicare, Medicaid, and SCRIP Extension Act of 2007, Pub. L. 
No. 110-173, § 114(d), 121 Stat. 2492, 2503-04. 

[B] According to CMS, there were 439 LTCHs as of November 2010. 

[C] Alex Berenson, "Long-Term Care Hospitals Face Little Scrutiny," 
The New York Times, February 10, 2010. 

Objective: 

Our briefing focuses on the oversight of LTCHs and how it differs from 
the oversight at other types of hospitals and nursing homes. 

Scope and Methodology: 

To describe oversight of LTCHs, other types of hospitals—ACHs, 
psychiatric hospitals, and rehabilitation hospitals—and nursing 
homes.[A] 

* We reviewed documents and interviewed officials from: 

- The Centers for Medicare & Medicaid Services (CMS), which contracts 
with state survey agencies to survey hospitals, nursing homes, and 
other facility types that participate in the Medicare and Medicaid 
programs;[B] and; 

- The Joint Commission (TJC), an accreditation organization (AO) that 
surveys most hospitals, including most LTCHs. 

* We analyzed data from CMS on FY 2009 survey activities, facility 
characteristics, and sanctions applied to these facilities from FY 
2005 through FY 2009. 

- We obtained data on these FYs from CMS's Providing Data Quickly 
(PDQ) Website, which we downloaded on September 14, 2010.[C] 

* We analyzed data from TJC on FY 2009 survey activities and 
accreditation actions applied to these types of hospitals from FY 2007 
through FY 2009. 

[A] We compared LTCHs to psychiatric hospitals and rehabilitation 
hospitals because these hospitals often provide post acute care. We 
included ACHs because LTCH patients are transferred from an ACH. Some 
ACHs have psychiatric and rehabilitation units, which are excluded 
from the inpatient prospective payment system (IPPS), that provide 
services similar to psychiatric or rehabilitation hospitals; they have 
the same CMS identification number as the ACH in which they are 
located and are considered part of the ACH. Throughout these slides, 
we use all types of hospitals" to refer to LTCHs, ACHs, and 
psychiatric and rehabilitation hospitals. We included information on 
hospitals and nursing homes from all 50 states, the District of 
Columbia, and 5 territories—American Samoa, Guam, Puerto Rico, the 
Commonwealth of the Northern Mariana Islands, and the United States 
Virgin Islands. 

[B] Medicaid is the joint federal-state health care financing program 
for certain categories of low-income individuals. 

[C] PDQ was created for use by CMS and state survey agencies and 
provides data on survey activities. PDQ is updated weekly. 

Data Limitations: 

We excluded critical access hospitals, children's hospitals, and 
cancer hospitals because they generally do not provide post acute care 
services. 

We generally excluded two of the three AOs that accredit hospitals 
from our analysis—the American Osteopathic Association and Det Norske 
Veritas Healthcare, Inc.—because combined they surveyed 2 percent of 
LTCHs in 2009; however, we interviewed officials at these AOs to 
understand their accreditation policies. 

We generally used FY 2009 data for our analyses because FY 2009 was 
the most recent year for which complete data were available; these 
data included information on any facility that operated during FY 2009. 

To ensure the reliability of the data we analyzed, we interviewed CMS 
and TJC officials, reviewed CMS and TJC documentation, and traced a 
selection of CMS records to verify internal consistency. Based on the 
information obtained from CMS and TJC, we determined that the data 
were sufficiently reliable for the purposes of this report. 

We conducted this performance audit from July 2010 through November 
2010 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objective. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objective. 

Background: Types of Hospitals: 

ACHs: Provide general, short-term care for a broad range of medical 
conditions and provide diagnostic or therapeutic services, surgery, 
and limited rehabilitation services. 
* Medicare pays for ACH services using the inpatient prospective 
payment system (IPPS). IPPS rates are based on the average costs per 
case for each diagnosis. 

While all hospitals are expected to treat individuals who require an 
acute level of care, some may also specialize in post acute care. 
Other types of hospitals (excluded from the IPPS)[A] that may 
specialize in post acute care include: 

* LTCHs: Provide acute and post acute care for relatively extended 
periods of time, such as for individuals requiring ventilator care. 

* Psychiatric hospitals: Provide clinical psychiatric services to 
patients with mental illness. 

* Rehabilitation hospitals: Provide intensive rehabilitation to 
patients recovering from medical conditions. 

[A] These facilities are paid under prospective payment systems that 
are specific to each facility type. 

Background: Hospital Categories: 

Freestanding Hospitals: 

* Are self-contained hospitals, not located in or on the campus of 
another hospital. 

* Are identified with a unique CMS identification number.[A] 

Hospitals within Hospitals (HwH): 

* Are located in a building used by another hospital—known as the host 
hospital—or in one or more separate buildings located on the same 
campus as another hospital. 

* Must be licensed and operate separately from the host hospital, 
maintain a separate board and administrative structure, and have 
separate medical staff to be excluded from IPPS. 

* Are identified with a unique CMS identification number. 

* According to CMS officials, approximately half of LTCHs are HwHs. 

- Other types of hospitals—-including psychiatric and rehabilitation 
hospitals-—can also be HwHs, but CMS officials told us that this is 
less common. 

[A] Hospitals that separately participate in the Medicare program are 
assigned a unique identification number by CMS, called the CMS 
Certification Number. 

Background: Nursing Homes: 

* Provide skilled nursing, rehabilitation, and/or custodial care to 
elderly and disabled individuals. 

- Medicare covers up to 100 days of skilled nursing home care 
following a hospital stay. 

- Medicaid covers nursing home stays for certain low-income 
individuals. 

- Combined Medicare and Medicaid payments for nursing home services in 
2008 were about $82 billion—with a federal share of $58 billion—which 
represented about 45 percent of total U.S. nursing home 
expenditures.[A] 

* Can be freestanding or located within hospitals.[B] 

* Ninety percent provide services for both Medicare and Medicaid 
patients; of the remaining 10 percent, half accept Medicare patients 
only and half accept Medicaid patients only. 

[A] FY 2008 data were the most recent data available at the tine we 
did our work. 

[B] Freestanding and hospital-based nursing homes are considered to be 
independent facilities and are identified with unique CMS 
identification numbers. 

Background: Differences in Hospital and Nursing Home Ownership: 

Fifty-eight percent of LTCHs are for-profit. 

* Thirty-one percent of LTCHs are owned by two for-profit chains. 

- Select Medical Corporation owns 18 percent of LTCHs. 

- Kindred Healthcare owns 13 percent of LTCHs. 

In contrast, 27 percent of all types of hospitals are for-profit. 

Table: Differences in Hospital Ownership, FY 2009: 

Number (percentage) of hospitals: 

For-profit: 
LTCHs: 252 (58%); 
ACHs[A]: 764 (21%); 
Psychiatric hospitals: 154 (30%); 
Rehabilitation hospitals: 139 (61%); 
Total: 1,309 (27%). 

Nonprofit: 
LTCHs: 150 (34%); 
ACHs[A]: 2,185 (60%); 
Psychiatric hospitals: 136 (26%); 
Rehabilitation hospitals: 80 (35%); 
Total: 2,551 (53%). 

Government: 
LTCHs: 32 (7%); 
ACHs[A]: 706 (19%); 
Psychiatric hospitals: 224 (44%); 
Rehabilitation hospitals: 10 (4%); 
Total: 972 (20%). 

Total: 
LTCHs: 434 (100%)[B]; 
ACHs[A]: 3,655 (100%); 
Psychiatric hospitals: 514 (100%); 
Rehabilitation hospitals: 229 (100%); 
Total: 4,832 (100%). 

Source: GAO analysis of CMS data. 

Note: Numbers do not always sum to 100 percent because of rounding. 

[A] Some ACHs have IPPS-excluded psychiatric and rehabilitation units 
that provide services similar to those of psychiatric and 
rehabilitation hospitals, but these units have the same CMS 
identification number as the ACH in which they are located. 

[B] According to CMS, there were 439 LTCHs as of November 2010. 

[End of table] 

Table: Differences in Nursing Home Ownership, FY 2009: 

The majority (68 percent) of nursing homes are for-profit. 

Number (percentage) of nursing homes: 

For-profit: 
Freestanding: 10,655 (72%); 
Hospital-based: 152 (13%); 
Total nursing homes, by type of ownership: 10,807 (68%). 

Nonprofit: 
Freestanding: 3,453 (23%); 
Hospital-based: 730 (62%); 
Total nursing homes, by type of ownership: 4,183 (26%). 

Government: 
Freestanding: 640 (4%); 
Hospital-based: 293 (25%); 
Total nursing homes, by type of ownership: 933 (6%). 

Total nursing homes: 
Freestanding: 14,748 (100%); 
Hospital-based: 1,175 (100%); 
Total nursing homes, by type of ownership: 15,923 (100%). 

Source: GAO analysis of CMS data. 

Note: Numbers do not always sum to 100 percent because of rounding. 

[End of table] 

Geographic Distribution of LTCHs, ACHs, and Nursing Homes: 

LTCHs are not evenly distributed across the nation (see next slide). 

* Four states-—ME, NH, VT, WY—-do not have LTCHs. 

* One state—-TX-—has 76 LTCHs (18 percent of LTCHs). 

* Patients who can be treated by LTCHs may instead receive care in 
ACHs, other types of hospitals, or nursing homes. 

In contrast, every state has ACHs and nursing homes, although 
distribution patterns vary (i.e., rural vs. urban).[A] 

[A] Additionally, two U.S. territories do not have nursing homes—
American Samoa and the Commonwealth of the Northern Mariana Islands. 

Figure: Geographic Distribution of LTCHs: 

[Refer to PDF for image: illustrated U.S. map] 

Sources: GAO analysis of CMS data; Map Resources (map). 

[End of figure] 

Results: 

There are differences in the oversight of LTCHs, other types of 
hospitals, and nursing homes. These differences exist in four areas: 

* Medicare and Medicaid participation requirements. 

* Quality standards. 

* Surveys. 

* Enforcement of quality standards. 

Medicare and Medicaid Participation Requirements: 

Hospitals (All Types) and Nursing Homes: 

Hospitals All Types: 

* Must demonstrate compliance, through unannounced on-site surveys, 
with Medicare quality standards established by CMS called Conditions 
of Participation (COP). 

- AOs conduct on-site surveys using standards that CMS has deemed to 
be at least equivalent to the COPs. 

Nursing Homes: 

* Must demonstrate compliance, through unannounced on-site surveys, 
with Medicare and Medicaid nursing home quality standards that focus 
on the delivery of care, resident outcomes, and facility conditions. 

Surveys for hospitals and nursing homes may be either: 

* Routine-—conducted at specific intervals or; 

* Complaint-—conducted in response to allegations of quality problems 
made by families, patients, health care workers, or others. 

Hospitals have a choice of being surveyed either by state survey 
agencies or AOs; nursing homes can only be surveyed by state survey 
agencies because no AOs are currently approved to survey them.[A] 

* For hospitals and nursing homes, surveys by state survey agencies 
result in their certification to participate in Medicare and/or 
Medicaid. 

* For hospitals, surveys by AOs result in facility accreditation, 
which CMS accepts as a basis for facility certification for Medicare 
participation. 

Facilities that fail to meet CMS or AO standards may be sanctioned, 
may lose accreditation, or both. 

[A] AOs charge a fee for accreditation; state survey agency surveys 
are generally funded by Medicare. 

Table: State- and Accreditation-Organization-Surveyed Hospitals and 
Nursing Homes, FY 2009: 

Number (percentage) of facilities: 

State-surveyed: 
Hospital: LTCHs: 90 (21%); 
Hospital: ACHs[A]: 508 (14%); 
Hospital: Psychiatric hospitals: 108 (21%); 
Hospital: Rehabilitation hospitals: 37 (16%); 
Total Hospitals: 743 (15%); 
Nursing homes: 15,923 (100%). 

AO-surveyed[B]: 
Hospital: LTCHs: 334 (79%); 
Hospital: ACHs[A]: 3,147 (86%); 
Hospital: Psychiatric hospitals: 406 (79%); 
Hospital: Rehabilitation hospitals: 192 (84%)
Total Hospitals: 4,089 (85%)
Nursing homes: N/A. 

Total: 
Hospital: LTCHs: 434[C] (100%); 
Hospital: ACHs[A]: 3,655 (100%); 
Hospital: Psychiatric hospitals: 514 (100%); 
Hospital: Rehabilitation hospitals: 229 (100%); 
Total Hospitals: 4,832 (100%); 
Nursing homes: 15,923(100%). 

Source: GAO analysis of CMS data. 

[A] Some ACHs have IPPS-excluded psychiatric and rehabilitation units 
that provide services similar to those of psychiatric and 
rehabilitation hospitals, but these units have the same CMS 
identification number as the ACH in which they are located. 

[B] These numbers include hospitals that were accredited by TJC, Det 
Norske Veritas Healthcare, Inc., and the American Osteopathic 
Association. In FY 2009, hospitals accredited by TJC accounted for 
over 95 percent of accredited hospitals. 

[C] According to CMS, there were 439 LTCHs as of November 2010. 

[End of table] 

Quality Standards: Hospital COPs and Standards: 

CMS has 74 standards organized under 23 COPs, including categories 
such as Medical Staff, Infection Control, and Emergency Services (see 
appendix l).[A] 

* COPs were created in 1966 and significantly revised in 1986. 

* CMS has since updated the COPs several times on a variety of topics, 
including Patients' Rights. 

* In August 2010, CMS adopted an update to the Rehabilitation and 
Respiratory Services COPs. 

* Additionally, since 2000 CMS has been updating the guidance used to 
interpret and apply these standards. 

TJC's standards are organized into 17 categories, such as Medication 
Management and Leadership (see appendix II). 

* TJC last updated its standards in 2010. 

[A] Hospitals that provide certain specialized services may be 
required to meet additional COPs. For example, hospitals that provide 
transplant services must also meet the 13 COPs governing transplant 
services. 

In addition, TJC: 

* Measures hospitals against its National Patient Safety Goals, which 
are intended to promote specific improvements in patient safety. 

* Requires hospitals to complete and submit annual self-assessments of 
compliance with standards. 

* Requires hospitals to submit data for selected measures of clinical 
performance. 

LTCHs are surveyed by state survey agencies and AOs using the same 
standards that are applied to ACHs; there are no additional survey 
standards or patient care requirements that are specific to LTCHs. 

Psychiatric hospitals and rehabilitation hospitals are surveyed using 
the same standards that are applied to ACHs, but must meet additional 
standards.[A] 

* Psychiatric hospitals must meet two additional COPs: 

- Adequate staffing of qualified mental health professionals, and; 

- Medical record requirements that stress the psychiatric components 
of the evaluation(s) and treatment(s) provided. 

* Rehabilitation hospitals must: 

- Comply with IPPS exclusion requirements for inpatient rehabilitation 
facilities. 

[A] Surveys for these additional standards are not conducted by AOs. 
Most surveys of the additional psychiatric hospital COPs are conducted 
by CMS contractors with psychiatric expertise. IPPS-excluded 
psychiatric and rehabilitation units within ACHs must meet additional 
standards similar to those for psychiatric and rehabilitation 
hospitals. These units meet the additional standards primarily through 
self-attestation. In addition, state survey agencies survey a small 
sample of the units annually to validate compliance. 

According to CMS, the agency is developing LTCH-specific regulations 
in the hospital COPs in response to requirements in the Medicare, 
Medicaid, and SCHIP Extension Act of 2007. 

* CMS officials told us that the changes to the COPs may reflect the 
patient admission and discharge process, staffing requirements, and 
the level of patient care. 

* Estimated release for public comment is in May 2011, with the final 
rule expected to be issued in May 2012. 

* TJC officials also reported that they are developing standards 
specific to LTCHs. 

CMS will ensure that the LTCH-specific standards developed by TJC and 
other AOs are at least equivalent to those developed by CMS. 

Quality Standards: Nursing Home Standards: 

CMS has about 200 nursing home standards, such as preventing avoidable 
pressure sores, weight loss, and accidents. The standards are grouped 
into 15 categories, including quality of life, resident assessment, 
quality of care, and administration. 

* Uniform standards for Medicare and Medicaid were created in 1987. 

* Since 2000, CMS has been updating the guidance used to interpret and 
apply these standards. 

Surveys: Frequency of Routine Surveys-—Hospitals (All Types): 

According to CMS policy, all state-surveyed hospitals are to be 
surveyed every 3 years, on average, with an interval not to exceed 5 
years.[A] 

* From 25 to 33 percent of psychiatric hospitals are to be surveyed 
annually for their two additional COPs. 

* Rehabilitation hospitals must attest annually to meeting IPPS 
exclusion criteria. 

TJC-surveyed hospitals are to be surveyed every 3 years, but to ensure 
that surveys are unannounced, the interval between surveys ranges from 
18 months to 39 months.[B] 

* According to CMS policy, AOs are required to conduct surveys every 3 
years, on average. 

Survey schedules are established when a hospital enters the Medicare 
program. 

* Because HwHs are independently licensed and operated, their schedule 
is not necessarily tied to the host hospital's survey schedule. 

[A] We have previously found that not all hospitals are surveyed 
within the maximum survey interval of 5 years. See GAO, Medicare and 
Medicaid Participating Facilities: CMS Needs to Reexamine Its Approach 
for Funding State Oversight of Health Care Faculties, GAO-09-64 
(Washington, D.C.: Feb. 13, 2009). 

[B] Effective January 1, 2011, TJC's survey interval will range from 
18 months to 36 months. 

Surveys: Frequency of Routine Surveys-—Nursing Homes: 

Nursing homes are to be surveyed every 12 months, on average, with an 
interval not to exceed 15 months. 

The nursing home survey interval is a statutory requirement.[A] 

[A] See 42 U.S.C. § 1395i-3(g)(2)(A)(iii)(I), § 1396r(g)(2)(A)(iii)(I). 

Table: Percentage of Hospitals and Nursing Homes That Had Routine 
Surveys, Based on Their Respective Survey Intervals: 

State-surveyed[A]: 
Hospitals (FY 2007 through 2009): LTCHs: 63%; 
Hospitals (FY 2007 through 2009): ACHs: 87%; 
Hospitals (FY 2007 through 2009): Psychiatric hospitals: 79%; 
Hospitals (FY 2007 through 2009): Rehabilitation hospitals: 54%; 
Nursing homes (FY 2009): 99%. 

TJC-surveyed: 
Hospitals (FY 2007 through 2009): LTCHs: 100%[B]; 
Hospitals (FY 2007 through 2009): ACHs: 100%; 
Hospitals (FY 2007 through 2009): Psychiatric hospitals: 100%[B]; 
Hospitals (FY 2007 through 2009): Rehabilitation hospitals: 100%[B]; 
Nursing homes (FY 2009): N/A. 

Source: GAO analysis of CMS data and TJC data. 

[A] State-surveyed hospitals are generally surveyed every 3 to 5 
years; nursing homes are surveyed every year, on average. 

[B] In these years, 100 percent of hospitals were surveyed, but a few 
hospitals received more than one survey during the 3-year period. To 
ensure that TJC surveys are unannounced, the survey interval ranges 
from 18 months to 39 months. 

[End of table] 

Surveys: Complaint Surveys-—Hospitals (All Types): 

State survey agencies may conduct complaint surveys for allegations 
made against state-surveyed hospitals. 

* State survey agencies conduct an on-site survey to evaluate 
compliance with the COP(s) and standard(s) related to the complaint. 

* If surveyors find a hospital is out of compliance with one or more 
COPs during a complaint survey, the survey may be expanded to include 
all Medicare COPs. 

State survey agencies' complaint surveys for allegations involving AO-
surveyed hospitals require CMS regional office authorization. 

* CMS may place the hospital under the state's jurisdiction until it 
returns to compliance with the COP(s). 

TJC may conduct complaint surveys when it receives complaints against 
hospitals it accredits. 

* TJC conducts an on-site survey to evaluate compliance with the 
standard(s) related to the complaint, but the survey may be expanded 
if warranted. 

* If a TJC complaint survey finds a hospital is out of compliance with 
one or more TJC standard(s) that are equivalent to CMS's COP(s), TJC 
conducts an on-site follow-up survey within 45 days. 

Surveys: Complaint Surveys-—Nursing Homes: 

State survey agencies are to conduct all nursing home complaint 
surveys, which focus on specific allegations, and may be expanded to 
examine all Medicare and Medicaid standards. 

Table: Number of Hospital and Nursing Home Complaint Surveys 
Conducted, FY 2009: 

State-survey-agency-conducted complaint surveys: 

State-surveyed:
Hospitals: LTCHs: 70; 
Hospitals: ACHs: 483; 
Hospitals: Psychiatric hospitals: 67; 
Hospitals: Rehabilitation hospitals: 10; 
Nursing homes: 47,160. 

TJC-surveyed[A]: 
Hospitals: LTCHs: 234; 
Hospitals: ACHs: 4,195; 
Hospitals: Psychiatric hospitals: 304; 
Hospitals: Rehabilitation hospitals: 70; 
Nursing homes: N/A. 

TJC-conducted complaint surveys: 

TJC-surveyed: 
Hospitals: LTCHs: 14; 
Hospitals: ACHs: 177; 
Hospitals: Psychiatric hospitals: 38; 
Hospitals: Rehabilitation hospitals: 5; 
Nursing homes: N/A. 

Source: GAO analysis of CMS data and TJC data. 

[A] State survey agencies may investigate complaints against hospitals 
that are surveyed by TJC. 

[End of table] 

Enforcement of Quality Standards: State-Surveyed Hospitals-—All Types: 

State survey agencies may cite COP- and standard-level deficiencies on 
routine or complaint surveys. 

* COP-level deficiencies are more serious and can jeopardize or 
adversely affect the health of a patient if they recur or are not 
resolved. 

* Standard-level deficiencies are less serious and may not adversely 
affect the health of patients. 

Hospitals, including LTCHs, must prepare corrective action plans for 
both types of deficiencies. 

* For COP-level deficiencies, the state survey agency may return to 
the facility to ensure that the deficiencies have been corrected prior 
to the facility's next survey. 

State-surveyed hospitals that are unable to correct COP-level 
deficiencies may be terminated from the Medicare program. 

Survey findings are not available on CMS's Website for any type of 
hospital. 

Enforcement of Quality Standards: Accreditation-Organization-Surveyed 
Hospitals—-All Types: 

TJC cites two types of requirements for improvement (RFI) for 
hospitals found out of compliance with its standards on routine or 
complaint surveys: 

* Direct RFIs: Cited when compliance issues are directly tied to 
quality, such as pain. 

* Indirect RFIs: Cited when compliance issues are indirectly related 
to quality, such as hospital leadership. 

Hospitals must document corrective actions to demonstrate that they 
have returned to compliance within 45 days for direct RFIs and within 
60 days for indirect RFIs. 

* Hospitals may be resurveyed by TJC to verify the implementation of 
the corrective actions. 

TJC officials said they use the term RFI instead of deficiency because 
they consider the survey process to be an opportunity to consult with 
and educate hospitals about quality-of-care issues. 

A hospital that does not correct all of its RFIs within the required 
time frames may receive[A]. 

* Conditional accreditation: The hospital is not in substantial 
compliance with applicable TJC standards; the hospital must remedy 
identified problem areas by submitting a plan of correction and be 
resurveyed, or; 

* Preliminary denial of accreditation: The hospital has an immediate 
threat to health or safety for patients or has failed to resolve the 
requirements of a conditional accreditation, but the appeal process 
may result in a decision other than denial of accreditation. 

A hospital may be denied accreditation if it has exhausted all review 
and appeal opportunities, failed to pay the accreditation fee, or 
refused to allow a survey. 

CMS may subsequently terminate hospitals that lose their accreditation 
from the Medicare program. 

A hospital's final accreditation decision is posted on TJC's Website. 
According to TJC officials, findings of noncompliance with the 
standards evaluated during the survey are available on the Website 
only if the hospital received conditional or preliminary denial of 
accreditation. 

[A] Effective January 1, 2011, TJC plans to change the titles of these 
categories. 

Enforcement of Quality Standards: Nursing Homes: 

Deficiencies identified by state survey agencies during routine or 
complaint surveys are classified according to: 

* Scope: the number of affected residents, and; 

* Severity: four levels, ranging from minimal harm to immediate 
jeopardy. 

Plans of correction are required for all deficiencies at the more than 
minimal harm level. 

* State survey agencies revisit facilities to ensure correction of 
serious deficiencies. 

Generally, CMS imposes sanctions (enforcement actions) for serious 
deficiencies. 

* Nursing homes may be terminated from the Medicare and Medicaid 
programs but may also receive intermediate sanctions such as denial of 
payment or civil money penalties. 

* Past compliance with CMS standards is considered when determining 
severity of sanctions. 

* In FY 2009, CMS data showed that state survey agencies used 
intermediate sanctions in about 17 percent of all nursing homes. 

The deficiencies cited during nursing home surveys are available on 
CMS's Website.[A] 

[A] See Nursing Home Compare, [hyperlink, 
http://www.medicare.gov/NHcompare] (accessed Sept. 29, 2010). 

Table: Hospitals and Nursing Homes Terminated from Medicare, FY 2005 
through FY 2009[A]: 

Number (percentage) terminated: 

State-surveyed: 
Hospitals: LTCHs: 2 (2.5%). 
Hospitals: ACHs: 7 (1.3%). 
Hospitals: Psychiatric hospitals: 2 (2.1%). 
Hospitals: Rehabilitation hospitals: 0 (0%). 
Nursing homes: 88 (0.6%). 

TJC-surveyed: 
Hospitals: LTCHs: 0 (0%); 
Hospitals: ACHs: 3 (0.1%); 
Hospitals: Psychiatric hospitals: 4 (1.0%); 
Hospitals: Rehabilitation hospitals: 1 (0.5%); 
Nursing homes: N/A. 

Source: GAO analysis of CMS data. 

[A] Hospitals and nursing homes may voluntarily choose to terminate 
their participation in the Medicare program for a number of reasons 
including merger or change of ownership. We have excluded these 
facilities from our analysis. 

[End of table] 

Summary of Differences in Oversight among LTCHs, Other Hospitals, and 
Nursing Homes: 

Although some aspects of the oversight of LTCHs are similar to those 
of other types of hospitals and nursing homes, there are more aspects 
in which the oversight differs. 

Similarities: 

* All facility types must meet certain minimum quality requirements in 
order to participate in the Medicare and Medicaid programs. 

* Compliance for all facility types is determined during unannounced, 
on-site surveys. 

Differences: 

* While LTCHs are assessed using the same standards that are applied 
to ACHs, other types of hospitals have additional standards or patient 
care requirements that are specific to their facility type; nursing 
homes also have a specific set of standards that reflect the 
characteristics of the population served. 

* LTCHs and other types of hospitals may choose to be surveyed by AOs 
or state survey agencies, and most choose the former; in contrast, 
nursing homes are only surveyed by state survey agencies because no 
AOs are currently approved to survey them. 

* The interval between surveys for LTCHs surveyed by state survey 
agencies may be longer than the interval for AO-surveyed LTCHs; 
nursing homes are surveyed more frequently than all types of 
hospitals, including LTCHs. 

* Survey findings for LTCHs and other types of hospitals are not 
always publicly available, but nursing home deficiencies are always 
published on CMS's Nursing Home Compare Website. 

* The only sanction that may be imposed upon any type of hospital is 
termination from the Medicare and Medicaid programs; nursing homes may 
receive a variety of sanctions when they fail to meet federal quality 
standards. 

Agency Comments: 

We provided a draft of these briefing slides to the Department of 
Health and Human Services (HHS) and TJC for comment, and HHS provided 
CMS's response (see app. III). CMS noted that it is in the process of 
developing a LTCH-specific regulation within the hospital COPs in 
response to requirements in the Medicare, Medicaid, and SCHIP 
Extension Act of 2007. CMS also noted that the briefing slides were a 
welcome resource for highlighting the statutory and other differences 
in how the agency exercises oversight of these types of health care 
facilities. Both CMS and TJC provided technical comments, which we 
incorporated as appropriate. 

Appendix I: CMS's 23 Hospital COPs: 

Table: COPs reviewed by state survey agencies: 

1. Anesthesia Services: 
If anesthesia services are provided, they must be well organized and 
directed by a qualified doctor of medicine or osteopathy. The service 
is responsible for all anesthesia administered. 

2. Compliance with Federal, State, and Local Laws: 
The hospital must comply with applicable federal laws on patient 
health and safety and state and local laws on hospital and personnel 
licensing. 

3. Discharge Planning: 
A hospital must have a discharge planning process applicable to all 
patients. Policies and procedures must be in writing. 

4. Emergency Services: 
If emergency services are provided, they must be organized under the 
direction of a qualified member of the medical staff and have adequate 
medical and nursing personnel qualified in emergency care to meet the 
needs anticipated by the facility. 

5. Food and Dietetic Services: 
Dietary services must be organized, directed, and staffed by qualified 
personnel. Contracted services must meet certain requirements. 

6. Governing Body: 
The hospital must have a legally responsible governing body or persons 
charged with the responsibilities of a governing body. 

7. Infection Control: 
A hospital's sanitary environment must avoid sources and transmission 
of infections and communicable diseases. It must have an active 
program to prevent, control, and investigate infections and 
communicable diseases. 

8. Laboratory Services: 
The hospital must maintain, or have available, adequate laboratory 
services. 

9. Medical Record Services: 
A hospital must have a medical record service that has administrative 
responsibility for medical records. 

10. Medical Staff: 
A hospital must have an organized medical staff that abides by bylaws 
approved by the governing body and is responsible for the quality of 
patient medical care. 

11. Nuclear Medicine Services: 
If nuclear medicine services are provided, they must meet the needs of 
the patients in accordance with acceptable standards of practice. 

12. Nursing Services: 
An organized nursing service must provide 24-hour nursing services 
that are supervised or furnished by registered nurses. 

13. Organ, Tissue, and Eye Procurement: 
The hospital must have and implement written protocols on procurement, 
have adequate organ transplant policies, and meet the 13 COPs 
governing transplant services if transplants are performed in the 
hospital. 

14. Outpatient Services: 
If outpatient services are provided, they must meet patient needs 
consistent with acceptable standards of practice. 

15. Patients' Rights: 
A hospital must protect and promote each patient's rights. 

16. Pharmaceutical Services: 
The hospital must have pharmaceutical services that meet patient needs. 

17. Physical Environment: 
Hospital construction, arrangements, and maintenance must ensure 
patient safety and provide diagnostic and treatment facilities and 
special hospital services appropriate to community needs. 

18. Quality Assessment and Performance Improvement Program: 
A hospital must have an effective, hospitalwide quality assurance 
program. 

19. Radiologic Services: 
The hospital must maintain, or have available, diagnostic radiologic 
services. Therapeutic services provided must meet professionally 
approved standards for safety and personnel qualifications. 

20. Rehabilitation Services: 
If rehabilitation, physical therapy, occupational therapy, audiology 
or speech pathology services are provided, they must be organized and 
staffed to ensure the health and safety of patients. 

21. Respiratory Care Services: 
If respiratory services are provided, they must meet patient needs in 
accordance with acceptable standards of practice. 

22. Surgical Services: 
If surgical services are provided, they must be well organized and 
provided in accordance with acceptable standards of practice. 
Outpatient services must be consistent with inpatient care quality in 
accordance with the complexity of services offered. 

23. Utilization Review: 
Utilization review plans must provide for review of the services that 
a hospital and its medical staff provide to Medicare and Medicaid 
patients. 

Source: GAO summary of CMS's hospital COPs. 

[End of table] 

Appendix II: TJC's 17 Categories of Hospital Standards: 

Table: Standards reviewed by TJC: 

1. Environment of Care: 
The hospital must manage risks to its environment, including safety 
and security, hazardous materials and waste, medical equipment, 
utility systems, and fire. This standard also requires hospitals 
establish a safe, functional environment. The hospital is required to 
monitor and make improvements to the environment based on its analysis 
of environment of care issues. 

2. Emergency Management: 
The hospital is required to develop a written emergency operations 
plan that includes how it will communicate, manage security and 
safety, and manage patients during emergencies. The hospital also 
evaluates the effectiveness of its emergency management plan. 

3. Human Resources: 
The hospital is required to establish and verify staff qualifications, 
orient staff, and provide staff with training to support hospital 
care, treatment, and services. The hospital is required to assess 
staff competence and performance on a regular basis. 

4. Infection Prevention and Control: 
The hospital must establish a systematic infection prevention and 
control program. The systematic approach to infection prevention and 
control includes requirements to plan, implement, and evaluate the 
program. 

5. Information Management: 
The hospital must establish a plan for managing information and 
maintaining the security of the health information. The requirements 
include planning for continuity of information management processes in 
the event of any interruptions. 

6. Leadership: 
The hospital is required to have a leadership structure to support 
operations and develop a culture of safety and quality. The 
requirements include leadership's responsibilities regarding 
relationships, communications, and systems performance and operations. 

7. Life Safety: 
The hospital is required to design and manage its physical environment 
to prevent fires and protect individuals in the event of fires. 

8. Medication Management: 
The hospital is required to safely, clearly, and appropriately manage 
the medication it procures, dispenses, administers, and monitors and 
reduce the potential for medication errors. The hospital is required 
to evaluate its medication management processes and take action on 
improvement opportunities. 

9. Medical Staff: 
The medical staff and governing body of the hospital must provide 
oversight of the quality of care, treatment, and services delivered by 
the hospital's practitioners. The hospital uses a process to determine 
the competency of practitioners by collecting, verifying, and 
evaluating data relevant to the practitioners' professional 
performance. The hospital evaluates practitioner performance on an 
ongoing basis. 

10. National Patient Safety Goals: 
The hospital's patient safety goals include improving the accuracy of 
patient identification, effectiveness of caregiver communication, and 
safety of using medications. 

11. Nursing: 
The hospital is required to employ a qualified nurse executive to 
establish guidelines and direct the hospital's nursing services, 
policies, and procedures and delivery of care, treatment, and 
services. The nurse executive functions at the senior leadership level. 

12. Provision of Care, Treatment, and Services: 
The hospital is required to accept, provide, and coordinate safe, 
interdisciplinary care, treatment, and services for all patients if it 
is able to meet their needs. 

13. Performance Improvement: 
The hospital is required to collect and analyze data to monitor and 
continually improve performance. The hospital uses data to implement 
performance improvement activities and monitors the effectiveness of 
these activities. 

14. Record of Care, Treatment, and Services: 
The hospital is required to maintain and audit complete, timely, 
authentic, and accurate medical records for each patient. 

15. Rights and Responsibilities of the Individual: 
The hospital must respect protect, and promote patients' rights. 

16. Transplant Safety: 
The hospital is required to develop and implement policies and 
procedures for organ and tissue donation and procurement. 

17. Waived Testing: 
The hospital is required to have current, approved, and readily 
available policies and procedures for waived testing. 

Source: GAO summary of TJC's hospital standards. 

[End of table] 

Appendix III: Comments from the Department of Health and Human 
Services: 

Department Of Health and Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 6, 2010: 

Linda T. Kohn: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Kohn: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft briefing slides entitled: "Differences in the Oversight of 
Long-Term Care Hospitals, Other Types of Hospitals, and Nursing Homes" 
(Job Code 290871). The Department appreciates the opportunity to 
review this correspondence before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The U.S. Department Of Health And Human Services 
(HHS) On The Government Accountability Office's (GAO) Draft Briefing 
Slides Entitled: "Differences In The Oversight Of Long-Term. Care 
Hospitals, Other Types Of Hospitals, And Nursing Homes (Job Code 
290871): 

The Centers for Medicare & Medicaid Services (CMS) appreciates the 
opportunity to review and comment on the subject draft report. We have 
included a number of technical6omments which we hope will facilitate 
an accurate overview of certain data on hospitals and nursing homes as 
well as of CMS' oversight mechanisms for the different types of 
facilities. We are committed to providing vigorous oversight of all 
types of hospitals and nursing homes in order to ensure that, patients 
and residents receive safe, high quality care. 

Long-term care hospitals (LTCHs) are a type of hospital that 
participates in the Medicare program and which provides acute care to 
clinically complex patients whose length of stay exceeds 25 days on 
average. Currently there are 439 LTCHs participating in the Medicare 
program, in order to be paid under the Medicare LTCH prospective 
payment system, hospitals must Satisfy a number of specific 
requirements based on the Medicare payment regulations. In addition, 
like all other hospitals, LTCHs must comply with the hospital health 
and safety standards as a condition of participation;in the Medicare 
program. The CMS is also in the process of developing LTCH-specific 
regulations within the hospital conditions of participation, 
consistent with the requirements for LTCHs found in the Medicare, 
Medicaid, and State Children's Health Insurance Program (SCHIP) 
Extension Act of 2007. Location of these provisions in the conditions 
of participation will allow enforcement through Federal surveys or 
surveys by Medicare-approved hospital accreditation programs. We 
believe that this will strengthen CMS' oversight of the quality of 
care in LTCH facilities. 

The GAO's draft briefing slides, Differences in the Oversight of Long 
Term Care Hospitals, Other Types of Hospitals, and Nursing Homes, job 
code 290871, provides a welcome resource for highlighting the 
statutory and other differences in the manner in which CMS, exercises 
oversight of these various types of health care facilities. This 
report makes no recommendations. 

[End of briefing slides] 

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