Long-Term Care Hospitals:

CMS Oversight Is Limited and Should Be Strengthened

GAO-11-810, Sep 15, 2011

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Allegations about quality-of-care problems have raised questions about the oversight of long-term care hospitals (LTCH), which provide care to individuals with multiple acute or chronic conditions. Medicare pays for about 80 percent of LTCH patient care. To ensure compliance with federal quality standards, accrediting organizations (AO) and state survey agencies under contract with the Centers for Medicare & Medicaid Services (CMS) conduct routine and complaint surveys. One AO, The Joint Commission (TJC), surveys most LTCHs. In a November 2010 report, GAO compared oversight of LTCHs to that of other facilities. In this report, GAO examined the extent to which CMS collects data about LTCHs' quality of care and oversees LTCH survey activities. To do this work, GAO analyzed CMS data on the results of LTCH surveys and discussed oversight activities with both CMS and AO officials. GAO assessed the reliability of the survey data and took steps to ensure that the data presented were reliable.

CMS collects some data on the quality of care at LTCHs, but the data are limited for several reasons. First, CMS does not have detailed data on the results of surveys conducted by TJC prior to 2009 and has limited data on current surveys because TJC did not begin submitting detailed data to CMS until July 2009. CMS does have prior year and current survey data for state-surveyed LTCHs--about 16 percent of LTCHs. In addition, current survey results in CMS's databases may be incomplete because these databases do not always accurately identify (1) the organization responsible for surveying each LTCH and (2) whether a facility is, in fact, an LTCH. As of fiscal year 2010, CMS data showed a total of 447 LTCHs, but GAO identified 18 LTCHs incorrectly categorized in one CMS database as having been surveyed by state survey agencies. GAO also found 56 LTCHs either misidentified as acute care hospitals or missing from another CMS database that contains information on LTCHs surveyed by accrediting organizations. Second, CMS does not currently collect data on quality measures--information used to evaluate how health care is delivered--from LTCHs because, unlike other types of hospitals, LTCHs are not yet required to report them. The Patient Protection and Affordable Care Act enacted in 2010 requires LTCHs to report quality measures by 2014. CMS's oversight of state survey agency and AO survey activities of LTCHs is limited. Two of CMS's three oversight approaches do not focus on LTCHs specifically, but on hospitals in general. First, CMS established performance measures--expectations regarding survey activities or the reporting of survey results--for survey organizations, but reports the results of its assessments for hospitals in general rather than for LTCHs specifically. Second, state survey agencies conduct surveys annually in AO-accredited hospitals--known as validation surveys--to assess the effectiveness of the AO surveys, but have not systematically included some LTCHs in the sample of hospitals subject to validation surveys. Additional validation surveys are done based on complaints. State survey agencies conducted more than 1,000 validation surveys over a 5-year period based on complaints in LTCHs that had been surveyed by TJC. CMS does not refer such complaints to TJC for investigation. As a result, TJC conducted few complaint surveys. Although CMS has instructed its regional offices to provide TJC with the results of these surveys, GAO found that these data were not always shared. CMS's third oversight approach--collection and analysis of data on the results of survey organizations' activities--has not utilized all the available data to identify problems that may require further investigation. GAO identified several potential areas where the data may assist CMS in more effectively overseeing survey activities at LTCHs, such as how effectively states triage and conduct complaint validation surveys. GAO recommends that CMS strengthen its oversight of LTCHs by improving available data on quality of care and by improving oversight of LTCH survey activities. HHS concurred with all of the recommendations. TJC agreed with most of them, but disagreed with the value of state oversight surveys of AO-surveyed LTCHs. We continue to believe that such surveys are an important part of CMS oversight of LTCH survey activities.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: In order to improve CMS's oversight of survey activities at LTCHs, the Administrator of CMS should explore differences in survey workload and in the resources survey organizations devote to LTCH surveys in order to (1) identify areas for efficiencies, and (2) determine whether the workload associated with complaint validation surveys could be more equitably shared with TJC.

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

    Status: Open

    Comments: In its response to our report, CMS concurred with this recommendation and stated that it intends to explore the differences in survey workload and resource allocation while working with regional offices to clarify the policy for triaging complaint surveys at AO-surveyed LTCHs and referring certain complaints to the AOs. In August 2012, CMS told us that it is currently examining differences is survey workload and resource allocation and clarifying the policy for triaging complaint surveys at AO-surveyed LTCHs and referring certain complaints to the appropriate AO. CMS told us these efforts should be completed in 2013.

    Recommendation: In order to improve CMS's oversight of survey activities at LTCHs, the Administrator of CMS should conduct traditional validation surveys at a sample of LTCHs each fiscal year and include an LTCH disparity rate in its annual financial report to Congress.

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

    Status: Open

    Comments: In its response to our report, CMS concurred with this recommendation and stated that it intends to explore an option to increase its traditional validation survey sample that would permit LTCHs to be included in the sample. In August 2012, CMS partially implemented this recommendation by including LTCHs in its annual sample of traditional validation surveys. CMS told us that it intends to use the results of the LTCH traditional validation surveys to calculate an LTCH-specific disparity rate, which it will include in its annual reports to Congress beginning in 2013.

    Recommendation: In order to improve the data available on the quality of care at LTCHs, the Administrator of CMS should improve information sharing with TJC regarding complaint validation survey results for TJC-surveyed LTCHs, such as ensuring that all survey findings are shared in a timely fashion.

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

    Status: Open

    Comments: In its response to our report, CMS concurred with this recommendation and stated that it intends to reinforce the existing CMS policy on sharing information with accrediting organizations and work with regional officers to enhance compliance. In August 2012, CMS told us that it is working on revisions to the State Operations Manual that will reinforce CMS's policy on sharing information, including sharing survey findings, with accreditation organizations in a timely fashion. CMS told us that these revisions will be finalized in fiscal year 2013

    Recommendation: In order to improve the data available on the quality of care at LTCHs, the Administrator of CMS should improve the accuracy of the databases that track LTCH survey results by (1) working with AOs and state survey agencies to develop a complete and accurate list of the LTCHs that they each survey and an approach to ensuring that the list is updated in a timely manner, and (2) expanding the On-line Survey, Certification, and Reporting system (OSCAR) database to include the results of all LTCH surveys, such as those conducted by TJC, which are currently stored in the separate Accrediting Organization System for Storing User Recorded Experiences (ASSURE) database.

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

    Status: Open

    Comments: In its response to our report, CMS concurred with this recommendation and stated it had plans to further increase the accuracy of its database. In 2012, CMS partially implemented this recommendation by a) implementing quarterly monitoring of The Joint Commission's data to ensure previously identified inaccuracies were corrected, and b) issuing two memos aimed at ensuring timely and accurate updates. The first memo, issued in December 2011, CMS outlined the AOs role in following up their data when it does not match the corresponding data in CMS's national database. The second memo, issued in February 2012, outlined state survey agencies' role in following up on AO-submitted data that does not match the corresponding data in CMS's national database for LTCHs located in their state or region. As of August 2012, CMS had not expanded the OSCAR database to include the results of all LTCHs, including those which are currently stored in a separate ASSURE database. CMS told us it plans to move the ASSURE database to a secure, web-enabled platform which will allow ASSURE data to be accessed alongside data from its other databases during fiscal year 2013.

    Recommendation: In order to improve CMS's oversight of survey activities at LTCHs, the Administrator of CMS should develop a plan to use available data on survey activities to hold survey organizations accountable for conducting surveys consistent with CMS requirements for evaluating the quality of care provided by LTCHs.

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

    Status: Open

    Comments: In its response to our report, CMS concurred with this recommendation and stated that it intends to review the available data to determine to what extent it can be used to develop additional AO performance measure for evaluating quality of care at LTCHs. In August 2011, CMS told us that it is analyzing data collected from mid-cycle surveys conducted on a sample of LTCHs and acute care hospitals and that it is considering how it will address any problems indicated by the results.