California Nursing Homes: Care Problems Persist Despite Federal and State Oversight

On January 1, 1999, HCFA issued instructions to state survey agencies directing them to begin some of their surveys on evenings and weekends, to vary the sequencing of surveys in a geographical area to avoid alerting others that the surveyors are in the area, and to vary the month in which surveys are conducted for a specific survey. However, HCFA disagreed with GAO's suggestion to segment the standard annual survey into more than one review throughout a 12-to 15-month period and, therefore, did not implement the recommendation. HCFA stated that segmenting the survey will render it ineffective and that, as the survey is designed, it functions best as a whole and cannot effectively be divided into smaller parts that can be conducted independently at different times.

In response to our recommendation, 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, CMS 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.

HCFA implemented this recommendation in two stages. In September 1998, it modified its policy to require that states refer for immediate imposition of a sanction on any nursing home with a pattern of harming a significant number of residents on successive surveys (levels H and above on HCFA's scope and severity grid). Effective December 15, 1999, HCFA expanded this policy to include deficiencies that harmed only one or a small number of residents (level G deficiencies) on two successive surveys.

HCFA responded to the recommendation by sending an August 20, 1998 memorandum to its regional offices and state survey agencies, strengthening its revisit policy. HCFA now requires that if a home is found to have serious violations during a survey, the home must correct all its violations and any new violations found during a revisit, until it comes into full compliance with federal standards. These homes will no longer be allowed to self-report resumed compliance.