Nursing Home Quality:

Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight

GAO-03-561: Published: Jul 15, 2003. Publicly Released: Jul 17, 2003.

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Since July 1998, GAO has reported numerous times on nursing home quality-of-care issues and identified significant weaknesses in federal and state oversight. GAO was asked to assess the extent of the progress made in improving the quality of care provided by nursing homes to vulnerable elderly and disabled individuals, including (1) trends in measured nursing home quality, (2) state responses to previously identified weaknesses in their survey, complaint, and enforcement activities, and (3) the status of oversight and quality improvement efforts by the Centers for Medicare & Medicaid Services (CMS).

The proportion of nursing homes with serious quality problems remains unacceptably high, despite a decline in the incidence of such reported problems. Actual harm or more serious deficiencies were cited for 20 percent or about 3,500 nursing homes during an 18-month period ending January 2002, compared to 29 percent for an earlier period. Fewer discrepancies between federal and state surveys of the same homes suggests that state surveyors are doing a better job of documenting serious deficiencies and that the decline in serious quality problems is potentially real. Despite these improvements, the continuing prevalence of and state surveyor understatement of actual harm deficiencies is disturbing. For example, 39 percent of 76 state surveys from homes with a history of quality-of-care problems--but whose current survey found no actual harm deficiencies--had documented problems that should have been classified as actual harm or higher, such as serious, avoidable pressure sores. Weaknesses persist in state survey, complaint, and enforcement activities. According to CMS and states, several factors contribute to the understatement of serious quality problems, including poor investigation and documentation of deficiencies, limited quality assurance systems, and a large number of inexperienced surveyors in some states. In addition, GAO found that about one-third of the most recent state surveys nationwide remained predictable in their timing, allowing homes to conceal problems if they chose to do so. Considerable state variation remains regarding the ease of filing a complaint, the appropriateness of the investigation priorities, and the timeliness of investigations. Some states attributed timeliness problems to inadequate staff and an increase in the number of complaints. Although the agency strengthened enforcement policy by requiring states to refer for immediate sanction homes that had repeatedly harmed residents, GAO found that states failed to refer a substantial number of such homes, significantly undermining the policy's intended deterrent effect. CMS oversight of state survey activities has improved but requires continued attention to help ensure compliance with federal requirements. While CMS strengthened oversight by initiating annual state performance reviews, officials acknowledged that the reviews' effectiveness could be improved. For the initial fiscal year 2001 review, officials said they lacked the capability to systematically distinguish between minor lapses and more serious problems that required intervention. CMS oversight is also hampered by continuing database limitations, the inability of some CMS regions to use available data to monitor state activities, and inadequate oversight in areas such as survey predictability and state referral of homes for enforcement. Three key CMS initiatives have been significantly delayed--strengthening the survey methodology, improving surveyor guidance for determining the scope and severity of deficiencies, and producing greater standardization in state complaint processes. These initiatives are critical to reducing the subjectivity evident in current state survey and complaint activities.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In fiscal year 2004, CMS completed two actions that improve guidance to states for conducting investigations of complaints. In the first action, effective January 2004, in conjunction with the nationwide implementation of its new complaint tracking system, CMS provided detailed direction and guidance to the states for managing complaint investigations for numerous types of providers, including nursing homes. This guidance targets, among other things, the issue of prioritizing complaints, particularly those alleging harm to residents. The second action, effective in June 2004, was the publication on the Internet of an updated chapter of CMS's State Operations Manual that consolidates complaint investigation procedures for numerous types of providers.

    Recommendation: To better ensure that state survey and complaint activities adequately address quality-of-care problems, the Administrator of CMS should finalize the development of guidance to states for their complaint investigation processes and ensure that it addresses key weaknesses, including the prioritization of complaints for investigation, particularly those alleging harm to residents; the handling of facility self-reported incidents; and the use of appropriate complaint investigation practices.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Not Implemented

    Comments: In September 2004, a cognizant CMS official advised GAO that CMS had taken no action with respect to the issue of requiring states to have a quality assurance process focusing on reviewing survey reports below the level of actual harm to assess the appropriateness of the scope and severity cited, and has no plans to do so.

    Recommendation: To better ensure that state survey and complaint activities adequately address quality-of-care problems, the Administrator of CMS should require states to have a quality assurance process that includes, at a minimum, a review of a sample of survey reports below the level of actual harm (less than G level) to assess the appropriateness of the scope and severity cited and to help reduce instances of understated quality-of-care problems.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Implemented

    Comments: In addition, CMS developed the new Quality Indicator Survey (QIS) to improve the consistency and efficiency of state surveys and provide a more reliable assessment of quality. As of August 2009, it has started implementing the QIS in eleven states: Connecticut, Florida, Kansas, Louisiana, Maryland, Minnesota, New Mexico, North Carolina, Ohio, Washington and West Virginia, and prioritized the remaining 39 states, District of Columbia, Puerto Rico and Virgin Islands for QIS implementation. The QIS uses an expanded sample and structured interviews with residents in a two-stage process. State surveyors are guided through the QIS process using customized software on tablet personal computers. In stage 1, a large resident sample is drawn and relevant data from on- and off-site sources is analyzed to develop a set of quality-of-care indicators, which will be compared to national benchmarks. Stage 2 systematically investigates potential quality-of-care concerns identified in stage 1 CMS concluded a five-state demonstration project of the QIS in 2007 and has since released the QIS evaluation. Based on the QIS evaluation, CMS has identified several areas for improvement such as increasing the specificity and usability of investigative guidelines and evaluating how well the new methodology accurately identifies the areas in which there are potential quality problems. In addition, CMS articulated that future QIS development efforts should concentrate on improving survey consistency and giving supervisors more tools to assess performance of surveyor teams.

    Recommendation: To strengthen the ability of the nursing home survey process to identify and address problems that affect the quality of care, the Administrator of CMS should finalize the development, testing, and implementation of a more rigorous survey methodology, including guidance for surveyors in documenting deficiencies at the appropriate level of scope and severity.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Closed - Not Implemented

    Comments: A cognizant CMS official advised GAO in September 2004, that CMS had taken no specific action on this recommendation and has no current plans to do so.

    Recommendation: To better ensure that states comply with statutory, regulatory, and other CMS nursing home requirements designed to protect resident health and safety, the Administrator of CMS should further refine annual state performance reviews so that they (1) consistently distinguish between systemic problems and less serious issues regarding state performance, (2) analyze trends in the proportion of homes that harm residents, (3) assess state compliance with the immediate sanctions policy for homes with a pattern of harming residents, and (4) analyze the predictability of state surveys.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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