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entitled 'Nursing Homes: More Reliable Data and Consistent Guidance
Would Improve CMS Oversight of State Complaint Investigations' which
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United States Government Accountability Office:
GAO:
Report to the Ranking Member, Committee on the Judiciary, U.S. Senate:
April 2011:
Nursing Homes:
More Reliable Data and Consistent Guidance Would Improve CMS Oversight
of State Complaint Investigations:
GAO-11-280:
GAO Highlights:
Highlights of GAO-11-280, a report to the Ranking Member, Committee on
the Judiciary, U.S. Senate.
Why GAO Did This Study:
CMS, the agency within HHS that manages Medicare and Medicaid,
contracts with state survey agencies to investigate complaints about
nursing homes from residents, family members, and others. CMS helps
assure the adequacy of state complaint processes by issuing guidance,
monitoring data that state survey agencies enter into CMS’s database,
and annually assessing performance against specific standards.
Concerns have been raised about the timeliness and adequacy of
complaint investigations and CMS’s oversight. GAO examined
(1) complaints received, investigated, and substantiated by state
survey agencies; (2) whether those agencies were meeting CMS
performance standards and other requirements; and (3) the
effectiveness of CMS’s oversight. In addition to analyzing CMS data on
complaints and performance reviews, GAO examined CMS guidance and
conducted interviews with officials from three high- and three low-
performing state survey agencies and their CMS regional offices. GAO
addressed data reliability concerns by reporting only data we
determined to be reliable.
What GAO Found:
CMS’s complaints data showed that state survey agencies received
53,313 complaints about nursing homes in 2009. The number and types of
complaints varied among states. For example, 11 states received 15 or
fewer complaints per 1,000 nursing home residents while 14 states
received more than 45. State survey agencies assess the severity of a
complaint and assign a priority level, which dictates if and when an
investigation must be initiated. About 10 percent of complaints were
prioritized as immediate jeopardy, requiring investigation within 2
working days of receipt, while 45 percent were prioritized as actual
harm-high, requiring investigation within 10 working days of
prioritization. State survey agencies investigated all but 102
complaints that required an investigation. Among investigated
complaints, 19 percent were substantiated and resulted in the citation
of at least one federal deficiency. The percentage of immediate
jeopardy and actual harm-high complaints that were substantiated with
at least one federal deficiency cited was higher if the investigation
was initiated on time.
In CMS’s performance assessment for fiscal year 2009, many state
survey agencies had difficulty meeting some of CMS’s nursing home
complaint standards, most of which also assess performance with regard
to incidents—-specific care issues that nursing homes are required to
report. In particular, 19 state survey agencies had difficulty
investigating actual harm-high complaints and incidents within the
required time frame. However, most states were able to meet other CMS
standards—-timely investigation of immediate jeopardy complaints and
incidents and appropriate prioritization of complaints and incidents.
Although CMS’s performance assessment does not review state survey
agencies’ communication with complainants, CMS does expect the
agencies to convey investigation findings according to CMS guidelines.
GAO found state survey agencies had varied interpretations of those
guidelines, and some provided limited information to complainants.
CMS’s oversight of state survey agencies’ complaint investigation
processes, through its performance standards system and complaints
database, is hampered by data reliability issues. While CMS’s
performance standards are consistent with certain key criteria for
performance measures identified by GAO and other audit agencies,
performance scores are not always reliable, due in part to inadequate
sample sizes and inconsistent interpretation of some standards by CMS
reviewers. In addition, CMS has not made full use of the information
it collects. For example, in part because of data reliability
concerns, CMS does not routinely use data from the complaints database
to calculate certain measures that could enhance its understanding of
agencies’ performance. Although CMS requires state survey agencies
that fail performance standards to develop corrective action plans,
states’ plans do not necessarily address the underlying causes of
performance issues, such as staffing shortages.
What GAO Recommends:
GAO recommends that the CMS Administrator take several steps to
strengthen oversight of complaint investigations, such as improving
the reliability of its complaints database and clarifying guidance for
its state performance standards to assure more consistent
interpretation. HHS generally agreed with our recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-11-280] or key
components. For more information, contact John E. Dicken at (202) 512-
7114 or dickenj@gao.gov.
[End of section]
Contents:
Letter:
Background:
CMS 2009 Data Show that States Received Over 50,000 Nursing Home
Complaints and Substantiated the Complaint and Cited Federal
Deficiencies in 19 Percent of Investigations:
Many State Survey Agencies Had Difficulty Meeting Certain Performance
Standards for Nursing Home Complaint Investigations, but Reported
Taking Steps Intended to Improve Performance:
CMS's Oversight of State Survey Agencies' Complaint Investigation
Processes Is Hampered by Data Reliability Issues, Due in Part to
Inconsistent Interpretation of Performance Standards Among CMS
Reviewers:
Conclusions:
Recommendations:
Agency and Other External Comments:
Appendix I: CMS's State-Level Data on Complaints Received,
Investigated, and Substantiated by State Survey Agencies, 2009:
Appendix II: Performance Scores for Selected Nursing Home Complaint
Performance Standards, Fiscal Year 2009:
Appendix III: Comments from the Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Required Time Frames for Onsite Nursing Home Complaint
Investigations, by Priority Level:
Table 2: Type of Information Entered by State Survey Agencies and
Uploaded to CMS's National Complaints Database, by Step in the
Complaint Process:
Table 3: Nursing Home Complaint Standards that Are Part of CMS's State
Performance Standards System, Fiscal Year 2009:
Table 4: Types of Allegations Associated with Complaints, 2009:
Table 5: Percentage of Investigated Complaints that Were Substantiated
with at least One Federal Deficiency Cited, by Priority Level, 2009:
Table 6: Number of Complaints Received, Number of Nursing Home
Residents, Complaint Rate, and Percentage of Complaints by Priority
Level, 2009:
Table 7: Number of Complaints Requiring Investigation, Investigated,
and Substantiated with at Least One Federal Deficiency Cited, 2009:
Figures:
Figure 1: Number of Nursing Home Complaints Reported by Each State
Survey Agency per 1,000 Nursing Home Residents, 2009:
Figure 2: Excerpt from a Letter Providing Detailed Information about
Investigation Findings:
Figure 3: Excerpts from a Letter Providing Boilerplate Information
about Investigation Findings, in Cases Where Deficiencies Were and
Were Not Cited:
Figure 4: Time Line for State Performance Reviews and Submission of
Corrective Action Plans, Fiscal Year 2009:
Abbreviations:
ACTS: ASPEN Complaints/Incidents Tracking System:
AHFSA: Association of Health Facility Survey Agencies:
ASPEN: Automated Survey Processing Environment:
CASPER: Certification and Survey Provider Enhanced Reporting:
CMS: Centers for Medicare & Medicaid Services:
HHS: Department of Health and Human Services:
PPACA: Patient Protection and Affordable Care Act:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
April 7, 2011:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on the Judiciary:
United States Senate:
Dear Senator Grassley:
The 1.4 million elderly and disabled residents living in nursing homes
are considered a highly vulnerable population. They frequently depend
on others for assistance with basic activities of daily living such as
dressing, eating, or toileting, and some require skilled nursing or
rehabilitative care. The vast majority of nursing homes that care for
these residents participate in Medicare and Medicaid, and in 2009,
nursing homes received about $89 billion in payments from these
programs.[Footnote 1] Ensuring quality of care in these nursing homes
is a joint responsibility of the Centers for Medicare & Medicaid
Services (CMS), within the U.S. Department of Health and Human
Services (HHS), and state survey agencies. Congress and CMS set
federal requirements, and CMS contracts with state survey agencies to
perform both routine inspections of nursing homes, known as standard
surveys, and complaint investigations, among other activities.
Complaint investigations offer a unique opportunity to identify and
correct potential care problems. They can provide more timely alerts
of potential problems than standard surveys and target specific areas
identified by residents, their families, nursing home staff, and
others. In 2009, half of all violations of federal requirements that
resulted in some level of harm to nursing home residents were cited
during complaint investigations. State survey agencies generally
develop their own investigation procedures but must follow certain
federal procedures and time frames for complaints that allege a
violation of federal requirements. State survey agencies also must
provide certain information about their complaint investigations to
CMS through its national complaints database. CMS oversees state
survey agencies in part by assessing their performance on four
standards that pertain to nursing home complaints. These standards are
part of a broader CMS State Performance Standards System.
Members of Congress and others have raised concerns about the
timeliness and adequacy of nursing home complaint investigations, as
well as the manner in which the findings are communicated to
complainants. Concerns have focused not only on state survey agencies'
nursing home complaint investigations, but also on CMS's oversight.
You expressed interest in learning more about these issues.
Specifically, we examined (1) the number and types of complaints CMS's
database showed as received, investigated, and substantiated by state
survey agencies; (2) whether state survey agencies were meeting CMS's
performance standards and complainant communication requirements and
steps taken by the agencies to meet them; and (3) the effectiveness of
CMS's oversight of state survey agencies' complaint investigation
processes.
To describe the number and types of nursing home complaints received,
investigated, and substantiated by state survey agencies, we analyzed
CMS's national complaints data for calendar years 2004 through 2009
for all 50 states and the District of Columbia.[Footnote 2] Because
concerns have focused primarily on complaints, we included only
complaints in our analysis for this objective and excluded facility-
reported incidents, which nursing homes are required to self-report to
state survey agencies.[Footnote 3] In addition, we included only
complaints that alleged a violation of federal requirements.[Footnote
4] To assess the reliability of the complaints data we received from
CMS, we interviewed officials from CMS and state survey agencies about
the quality of the data, reviewed relevant documentation, and examined
the data for reasonableness and internal consistency. In the course of
this assessment, we found some data limitations. Specifically, CMS
officials told us that they have concerns that some state survey
agencies may not have entered all of the complaints they received into
CMS's national database. We therefore consider the number of
complaints in CMS's national data to be a conservative estimate of the
total number of complaints received by state survey agencies. In
addition, we analyzed only those variables that we found to be
reliable. We learned that in some cases, data are missing for certain
variables that state survey agencies are not required to enter into
the database--such as the date on which the state survey agency
acknowledged the complaint--and that state survey agencies interpret
certain variables differently from one another. For example, state
survey agencies have differing interpretations of what it means to
substantiate a complaint. Some state survey agencies limit use of the
term to complaints where at least one deficiency is cited while others
consider complaints to be substantiated if they are confirmed, even if
no deficiencies are cited.[Footnote 5] In this report, we chose to
report data about complaints that were substantiated with at least one
federal deficiency cited, as we believe these data should be more
consistent across states than data on all complaints reported to be
substantiated.[Footnote 6] In addition, the citation of a federal
deficiency demonstrates that the nursing home has failed to meet
federal requirements. After reviewing the possible limitations of the
complaints data, we determined that the data we report were
sufficiently reliable for the purposes of our report.
To determine whether state survey agencies are meeting CMS's standards
and complainant communication requirements and to describe steps they
have taken to meet the requirements, we analyzed scores for two of the
four nursing home complaint performance standards in CMS's State
Performance Standards System for fiscal years 2006 through 2009 for
all 50 states and the District of Columbia. For our analysis, we
reviewed performance on the two standards we considered the most
reliable: (1) prioritization of complaints based on the severity of
the allegations and (2) timeliness of investigations.[Footnote 7]
Although these standards assess state survey agencies' performance
with respect to incidents as well as complaints, we used scores on
these standards as measures of performance with respect to complaints
alone. CMS does not calculate separate scores for complaints.
Moreover, on a national level, complaints considerably outnumber
incidents in CMS's database, and state survey agencies' scores on the
standards are therefore likely to primarily reflect their performance
with respect to complaints.[Footnote 8] We analyzed scores from fiscal
years 2006 through 2009 because CMS reorganized its performance system
in 2006, and the most recent data available at the time of our study
were from fiscal year 2009. Because of changes made in the standards'
requirements and scoring during this time period, we have presented
trend data only when scores were comparable over time. We also
analyzed CMS's national complaints data on the length of time taken by
state survey agencies to investigate complaints in calendar year 2009.
In addition, we reviewed the guidance CMS provided to state survey
agencies and its own regional offices, which are responsible for
evaluating state survey agencies' nursing home complaint processes. We
also conducted structured telephone interviews with CMS regional
office officials in Atlanta, Chicago, and Dallas and state survey
agency officials in Arkansas, Florida, Michigan, Tennessee, Texas, and
Wisconsin.[Footnote 9] We gathered additional perspectives on CMS's
requirements at a membership meeting of the Association of Health
Facility Survey Agencies (AHFSA), the organization that represents
state survey agencies. Finally, we reviewed both templates and samples
of actual letters to complainants provided by the six state survey
agencies in our sample.
To assess the effectiveness of CMS's oversight of state survey
agencies' complaint investigation processes, we drew on information
from our data analyses and interviews, including interviews with
officials at CMS headquarters. We also evaluated the four nursing home
complaint performance standards using key criteria for performance
measures identified by GAO and other audit agencies.[Footnote 10]
These criteria include whether the standards are comprehensive,
limited in number and overlap, practical, balanced, comparable over
time, and reliable. Additionally, to examine the extent to which CMS
has used performance information to promote improvements in state
survey agencies' nursing home complaint investigation processes, we
reviewed information from our interviews and data analyses. We also
reviewed corrective action plans that state survey agencies in our
sample were required to submit for any performance standards they
failed between fiscal years 2006 through 2009.
We conducted our review from January 2010 through April 2011 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 objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
When investigating complaints about nursing homes, state survey
agencies follow state policies and procedures based on CMS
instructions. To oversee state survey agencies' complaint
investigation processes, CMS uses data from its complaints database
and State Performance Standards System.
Complaint Investigation Policies and Procedures:
CMS's State Operations Manual outlines procedures for state survey
agencies' investigation of nursing home complaints. This manual is
based on requirements in statutes and regulations and includes a
detailed protocol for handling complaints and incidents, such as
directions for key parts of the complaints process--intake,
prioritization, investigation, and reporting of results.
Intake. State survey agencies receive complaints via phone calls, e-
mails, or letters. At intake, staff review the information provided by
the complainant and, because each complaint can have more than one
allegation, determine the type(s) of allegations involved, such as
resident abuse or poor quality of care.
Prioritization. Based on the nature of the allegations, staff assign a
priority level to the complaint, which determines if an onsite
investigation is required. Four of the eight priority levels require
an onsite investigation. (See table 1.) For example, investigations
for complaints that allege "immediate jeopardy" to a resident's
health, safety, or life must be started within 2 working days of
receipt, while investigations for complaints that allege a high level
of actual harm ("actual harm-high") to a resident must be started
within 10 working days of prioritization.[Footnote 11]
Table 1: Required Time Frames for Onsite Nursing Home Complaint
Investigations, by Priority Level:
Priority Level: Immediate jeopardy;
Definition: Noncompliance has caused, or is likely to cause, serious
injury, harm, impairment, or death;
Required Time Frame: Onsite investigation must begin within 2 working
days of receipt of the complaint.
Priority Level: Actual harm--high;
Definition: Noncompliance may have caused harm that negatively impacts
the individual's mental, physical, and/or psychosocial status and is
of such consequence to well-being that a rapid response is indicated;
Required Time Frame: Onsite investigation must begin within 10 working
days of prioritization of the complaint.
Priority Level: Actual harm--medium;
Definition: Noncompliance has caused or may cause harm that is of
limited consequence and does not significantly impair the individual's
mental, physical, and/or psychosocial status or function;
Required Time Frame: No deadline specified, but onsite investigation
should be scheduled.
Priority Level: Actual harm--low;
Definition: Noncompliance may have caused physical, mental, and/or
psychosocial discomfort that does not constitute injury or damage;
Required Time Frame: Onsite investigation should be conducted at next
standard survey.
Source: CMS's State Operations Manual.
Note: No onsite investigation is required for complaints assigned any
of the four other priority levels: administrative review/offsite
investigation; referral--immediate; referral--other; or no action
necessary.
[End of table]
Investigation. During the unannounced investigation, state agency
surveyors may conduct a document review and observe nursing home
conditions. Additionally, surveyors interview witnesses, including the
resident about whose care the complaint was filed and other residents
with similar care needs, being careful to protect the anonymity of
those involved in the complaint. Surveyors determine whether the
allegations are substantiated and whether the nursing home should be
cited for any deficiencies (failure to meet federal or state quality
standards), which may be related or unrelated to the complaint
allegations. Deficiencies are categorized according to scope and
severity. Scope refers to the number of residents potentially or
actually affected and has three levels--isolated, pattern, or
widespread. Severity refers to the degree of relative harm and has
four levels--immediate jeopardy (actual or potential for death or
serious injury), actual harm, potential for more than minimal harm, or
potential for minimal harm.
Reporting of Results. After the complaint investigation is completed,
the state survey agency notifies the complainant and the nursing home
of the outcome of the investigation, following guidelines specified in
the State Operations Manual.
CMS Oversight of State Survey Agencies' Complaint Investigation
Processes:
CMS oversees state survey agencies' complaint investigation processes
using its complaints data and State Performance Standards System.
CMS's Complaints Data. As of January 1, 2004, state survey agencies
were required to enter data about all complaints and incidents into
the ACTS--Automated Survey Processing Environment (ASPEN) Complaints/
Incidents Tracking System--database according to guidance provided by
CMS.[Footnote 12] Officials in CMS's headquarters and regional offices
can access all information in ACTS, though the information is stored
on individual state servers. CMS provides guidance to state survey
agencies regarding ACTS database procedures, including what complaint
information states are required to enter. The information is then
uploaded into CMS's national complaints database, which contains a
variety of information about complaints, such as the date of the
alleged event, the name of the nursing home involved, and the source
of the complaint. (See table 2.)
Table 2: Type of Information Entered by State Survey Agencies and
Uploaded to CMS's National Complaints Database, by Step in the
Complaint Process:
Step in complaint process: Intake;
Type of information entered into CMS's complaints database:
* Type of allegation (e.g., abuse, neglect);
* Date and time of the alleged event;
* Name of nursing home involved;
* Mode of reporting the complaint (e.g., phone, letter, e-mail);
* Source of complaint (e.g., resident, family member, friend).
Step in complaint process: Prioritization;
Type of information entered into CMS's complaints database:
* Priority level assigned (e.g., immediate jeopardy, actual harm-high);
* Time frame for conducting investigation.
Step in complaint process: Investigation;
Type of information entered into CMS's complaints database:
* Date investigation was started;
* Date investigation was completed;
* Whether allegations associated with the complaint were substantiated
and whether deficiencies were cited.
Step in complaint process: Reporting of results;
Type of information entered into CMS's complaints database:
* Date complainant was notified of results of investigation.
Source: CMS documents.
[End of table]
State Performance Standards System. CMS's 10 regional offices are
responsible for annually evaluating state survey agencies' nursing
home complaint investigations using four performance standards. (See
table 3.) CMS developed the State Performance Standards System in
fiscal year 2001 to assess whether state survey agencies were meeting
the requirements for the survey and certification program and to
identify areas for improvement.[Footnote 13] In fiscal year 2006, CMS
reorganized the performance standards system, and in the following
years made several revisions to the four nursing home complaint
performance standards. None of the standards focus exclusively on
nursing home complaints. For some standards, the scope of review
includes incidents as well as complaints, facilities other than
nursing homes, or standard surveys as well as complaint
investigations. For all except the timeliness standard, the review is
based on samples rather than the universe of complaints and incidents.
Table 3: Nursing Home Complaint Standards that Are Part of CMS's State
Performance Standards System, Fiscal Year 2009:
Standard: Prioritization of Complaints;
Scope of review: Sample of complaints and incidents about nursing
homes and other types of facilities[A];
Requirements and scoring: Prioritize at least 90 percent of complaints
or incidents at or above the level assigned by CMS reviewers[B].
Standard: Timeliness of Investigations;
Scope of review: All complaints and incidents about nursing homes and
other types of facilities;
Requirements and scoring: Begin investigating within required
timeframes at least 95 percent of complaints and incidents prioritized
as (1) immediate jeopardy[C] or (2) actual harm-high[D].
Standard: Quality of Investigations;
Scope of review: Sample of complaints and incidents about nursing
homes only;
Requirements and scoring: Achieve at least an 85 percent pass rate on
each of 5 requirements:
1. Sufficient sample was chosen to evaluate the complaint or incident;
2. Investigation was conducted at the relevant time (i.e. similar time
of day as the allegation associated with the complaint);
3. Investigator's notes include observations, interviews, and/or
record reviews of each allegation in order to evaluate sufficiently
whether the facility is in compliance with federal requirements;
4. CMS regional office reviewer agrees with the state survey agency's
determination of whether noncompliance exists based on the evidence
collected for each quality of care allegation;
5. If applicable, the complainant was informed of the results of the
investigation.
Standard: Documentation of Deficiencies;
Scope of review: Sample of standard surveys and complaint
investigations (75 and 25 percent, respectively) for nursing homes and
other types of facilities[E];
Requirements and scoring: Achieve at least an 85 percent pass rate on
each of 7 requirements:
1. Each deficient practice statement clearly summarizes the provider's
failures and quantifies the extent of the problem(s) identified;
2. Each person referred to is uniquely identified;
3. Findings support and illustrate the provider's noncompliance;
4. Citation identifies source(s) through which evidence was obtained;
5. Evidence is written in plain language that is clear, concise, and
easily understood;
6. Scope reflects evidence and number of residents who are, or may be,
affected by the deficient practice;
7. Severity rating reflects evidence and actual and/or potential
outcome to residents.
Source: CMS's State Performance Standards System guidance for fiscal
year 2009.
[A] For nursing homes, only complaints that allege violation of a
federal requirement and incidents that require a federal onsite survey
are reviewed.
[B] In fiscal years 2007, 2008, and 2010, CMS's guidance for this
standard specified that if the state survey agency assigned a higher
priority level to a complaint than the CMS regional office, the
complaint should be considered appropriately prioritized. Although
this policy was not specified in the fiscal year 2009 guidance, a CMS
headquarters official told us the omission was an oversight.
[C] Immediate jeopardy is defined as a situation in which the
provider's noncompliance with one or more Medicare or Medicaid
requirements has caused, or is likely to cause, serious injury, harm,
impairment, or death to a resident. For complaints and incidents
assigned this priority level, CMS assesses the timeliness of
investigations involving nursing homes in combination with those
involving other types of facilities.
[D] Actual harm-high is defined as a situation in which the provider's
noncompliance with one or more Medicare or Medicaid requirements may
have caused harm that negatively impacts a resident's mental,
physical, and/or psychosocial status and is of such consequence to the
resident's well-being that a rapid response by the state survey agency
is indicated. For complaints and incidents assigned this priority
level, CMS assesses the timeliness of investigations involving nursing
homes separately from those involving other types of facilities.
[E] The documentation reviewed for this standard is the Statement of
Deficiencies and Plan of Correction (CMS Form 2567). Only those that
cite a deficiency at a scope and severity level indicating potential
for more than minimal harm to residents or higher are evaluated.
[End of table]
Upon completion of the performance evaluation, CMS regional offices
share the results with each respective state survey agency and CMS
headquarters, which in turns shares each state's scores with all of
the other states. State survey agencies that fail performance
standards must submit corrective action plans to their CMS regional
offices, which the regional offices can accept or reject, depending on
whether they believe the state has outlined appropriate steps to
address poor performance. The regional offices use these plans to
follow up with state survey agencies as part of their monitoring
activities.
CMS 2009 Data Show that States Received Over 50,000 Nursing Home
Complaints and Substantiated the Complaint and Cited Federal
Deficiencies in 19 Percent of Investigations:
CMS's national complaints data show that state survey agencies
received over 50,000 complaints about nursing homes in calendar year
2009. The number and types of complaints varied among states. State
survey agencies investigated all but 102 of the complaints that
required an investigation. Among complaints that were investigated and
uploaded to CMS's national database for 2009, 19 percent were
substantiated with at least one federal deficiency cited.[Footnote 14]
According to CMS's National Data, State Survey Agencies Received
53,313 Nursing Home Complaints in 2009:
State survey agencies reported receiving 53,313 complaints about
nursing homes in 2009.[Footnote 15] In 2009, 9 states received fewer
than 100 complaints while 17 states received more than 1,000. Six
states--Illinois, Missouri, New York, Ohio, Texas, and Washington--
accounted for roughly half of all 2009 complaints in CMS's
database.[Footnote 16] Although the number of nursing home residents
has remained relatively stable, the number of complaints received
generally increased by about 1,000 complaints a year from 2004 to
2008. In 2009, the number of complaints dropped by about 5,000.
Complaint Rate. Nationally, in 2009, CMS's database showed a complaint
rate of roughly 38 complaints per 1,000 nursing home residents. The
complaint rate ranged from less than 1 (0.77) in South Dakota to about
137 in Washington. Additionally, 11 states received 15 or fewer
complaints per 1,000 nursing home residents, while 14 states received
more than 45.[Footnote 17] (See figure 1.)
Figure 1: Number of Nursing Home Complaints Reported by Each State
Survey Agency per 1,000 Nursing Home Residents, 2009:
[Refer to PDF for image: illustrated U.S. map]
0 to 15.0 complaints per 1,000 nursing home residents (11 states):
California:
Connecticut:
Hawaii:
Montana:
Nevada:
Minnesota:
New Hampshire:
North Dakota:
Rhode Island:
South Carolina:
South Dakota:
15.1 to 30.0 complaints per 1,000 nursing home residents (15 states):
Alabama:
Alaska:
Colorado:
District of Columbia:
Florida:
Georgia:
Idaho:
Kentucky:
Louisiana:
Massachusetts:
Mississippi:
Pennsylvania:
Tennessee:
Virginia:
Wyoming:
30.1 to 45.0 complaints per 1,000 nursing home residents (11 states):
Indiana:
Iowa:
Maryland:
Michigan:
Nebraska:
New Mexico:
Ohio:
Oregon:
Utah:
West Virginia:
Wisconsin:
45.1 to 60.0 complaints per 1,000 nursing home residents (11 states):
Arizona:
Arkansas:
Delaware:
Illinois:
Kansas:
Maine:
New Jersey:
New York:
North Carolina:
Oklahoma:
Vermont:
Greater than 60.0 complaints per 1,000 nursing home residents (3
states):
Missouri:
Texas:
Washington:
Sources: GAO analysis of CMS data; Map Resources (map).
Note: CMS's database may not include all complaints received by the
state survey agencies because the agencies may not have entered them
into CMS's complaints database. As a result, the data we received from
CMS represent some, but likely not all, of the nursing home complaints
received by state survey agencies.
[End of figure]
Submission of Complaints and Sources. CMS data show that state survey
agencies received three-quarters of complaints in 2009 by phone.
Complaints also were submitted through other means, such as in
writing, through e-mail, or in person. In 2009, complaints were
typically submitted by family members (47 percent), anonymously (19
percent), or by residents (10 percent). Complaints were also submitted
by current nursing home staff or other sources.[Footnote 18]
Prioritization of Complaints. In 2009, among the complaints in CMS's
national data, state survey agencies prioritized most as either actual
harm-high (45 percent) or actual harm-medium (33 percent). Roughly 10
percent of complaints were prioritized as immediate jeopardy and about
4 percent were prioritized as actual harm-low. Approximately 8 percent
of complaints were prioritized at the four lowest levels and did not
require an onsite investigation.[Footnote 19] State survey agencies
varied in the percentage of complaints they prioritized at different
levels. For example, 23 state survey agencies prioritized more than 50
percent of complaints as immediate jeopardy or actual harm-high, while
7 state survey agencies prioritized fewer than 10 percent of
complaints they received at these two levels.
Allegations. Allegations are specific charges within complaints; each
complaint can have multiple allegations. In 2009, according to CMS's
national data, the average number of allegations per complaint was
2.3.[Footnote 20] Allegations that focused on quality of care or
treatment accounted for about 40 percent of all allegations in 2009.
(See table 4.)
Table 4: Types of Allegations Associated with Complaints, 2009:
Type of allegation: Quality of care or treatment;
Percentage of allegations: 40.6%.
Type of allegation: Resident neglect;
Percentage of allegations: 9.3%.
Type of allegation: Violation of resident rights;
Percentage of allegations: 9.3%.
Type of allegation: Physical environment;
Percentage of allegations: 6.1%.
Type of allegation: Resident abuse;
Percentage of allegations: 5.6%.
Type of allegation: Quality of life;
Percentage of allegations: 3.9%.
Type of allegation: Dietary services;
Percentage of allegations: 3.5%.
Type of allegation: Administration/personnel;
Percentage of allegations: 3.2%.
Type of allegation: Admission, transfer, and discharge rights;
Percentage of allegations: 2.7%.
Type of allegation: Nursing services;
Percentage of allegations: 2.4%.
Type of allegation: Accidents;
Percentage of allegations: 2.3%.
Type of allegation: Infection control;
Percentage of allegations: 1.7%.
Type of allegation: Resident assessment;
Percentage of allegations: 1.5%.
Type of allegation: Misappropriation of property;
Percentage of allegations: 1.3%.
Type of allegation: Other[A];
Percentage of allegations: 6.5%.
Source: GAO analysis of CMS data.
[A] The other category includes types of allegations such as injury of
unknown origin, falsification of records and reports, and
rehabilitation services.
[End of table]
CMS National Data Show States Investigated Nearly All Complaints that
Required an Investigation and Cited Deficiencies in 19 Percent of the
Investigations:
CMS data show that in 2009 about 48,900 of the approximately 53,300
complaints received required an investigation and that state survey
agencies investigated all but 102 of those complaints.[Footnote 21]
Among those 102 complaints, 25 percent were prioritized as either
immediate jeopardy or actual harm-high (6 and 19 percent
respectively). The remaining 75 percent were complaints prioritized as
actual harm-medium or actual harm-low.[Footnote 22] The percentage of
complaints investigated from 2004 through 2009 remained relatively
stable even as the number of complaints increased in all years except
2009.
In 2009, an investigation was initiated within CMS's required time
frames for most complaints prioritized as either immediate jeopardy or
actual harm-high. Among immediate jeopardy complaints, an
investigation was initiated within 2 working days of receiving the
complaint for 88 percent of complaints. Among complaints prioritized
as actual harm-high, an investigation was initiated within 10 working
days of prioritization for 72 percent of complaints.[Footnote 23]
Roughly 19 percent of the complaints that were investigated and
uploaded into CMS's complaints database for 2009 were substantiated
with at least one deficiency cited.[Footnote 24] However, there was
considerable variation across states. In 19 states, more than 30
percent of the complaints investigated were substantiated with at
least one deficiency cited, while in 5 states, the proportion was less
than 10 percent. Of the approximately 16,000 nursing homes nationwide,
about 2,800 had one substantiated complaint where at least one
deficiency was cited. In addition, about 1,100 nursing homes had two
such complaints.
The percentage of immediate jeopardy complaints that were
substantiated with at least one deficiency cited was higher than for
complaints prioritized at lower levels in 2009. According to CMS's
complaints database, roughly 26 percent of the immediate jeopardy
complaints that were investigated were substantiated with at least one
deficiency cited. Among complaints prioritized at lower levels, the
percentage was around 21 percent for actual harm-high complaints, 17
percent for actual harm-medium complaints, and 12 percent for actual
harm-low complaints.
In 2009, among the complaints prioritized as immediate jeopardy or
actual harm-high, the percentage substantiated with at least one
deficiency was higher if the investigation was initiated within
required time frames than if it was not. For example, among actual
harm-high complaints that were investigated within 10 working days of
prioritization, 22 percent were substantiated with at least one
federal deficiency cited. (See table 5.) In contrast, among actual
harm-high complaints that were investigated late, the proportion was
17 percent. (Appendix I contains state-level data on complaints
received, investigated, and substantiated by state survey agencies,
according to CMS data.)
Table 5: Percentage of Investigated Complaints that Were Substantiated
with at least One Federal Deficiency Cited, by Priority Level, 2009:
Priority level: Immediate jeopardy;
Required time frame for investigation[A]: Within 2 working days of
receipt of the complaint;
Percentage for complaints that were investigated within the required
time frame[B]: 25.5%;
Percentage for complaints that were not investigated within the
required time frame[C]: 21.7%.
Priority level: Actual harm--high;
Required time frame for investigation[A]: Within 10 working days of
prioritization of the complaint;
Percentage for complaints that were investigated within the required
time frame[B]: 22.2%;
Percentage for complaints that were not investigated within the
required time frame[C]: 16.6%.
Source: GAO analysis of CMS data.
[A] To account for possible state holidays that may have occurred
between when an immediate jeopardy complaint was received and when it
was investigated, we added an additional day to our calculation of
whether these complaints were investigated within the required 2
working days. During its performance review, CMS makes an allowance
for state holidays for immediate jeopardy complaints but not for
actual harm-high complaints.
[B] For immediate jeopardy complaints, investigations were initiated
within the required time frame for 4,515 complaints, but not for 217
complaints. Additionally, we could not determine timeliness of the
investigation for 364 complaints.
[C] For actual harm-high complaints, investigations were initiated
within the required time frame for 17,501 complaints, but not for
5,617 complaints. Additionally, 1,019 complaints were investigated but
did not have a value to determine whether the investigation was
conducted within the required time frame.
[End of table]
Many State Survey Agencies Had Difficulty Meeting Certain Performance
Standards for Nursing Home Complaint Investigations, but Reported
Taking Steps Intended to Improve Performance:
Many state survey agencies did not meet some of CMS's performance
standards for nursing home complaints in fiscal year 2009.[Footnote
25] In particular, 19 state survey agencies had difficulty
investigating complaints and incidents prioritized as actual harm-high
within the required time frame. State survey agencies reported that
they have taken or plan to take steps in four key areas--staffing,
agency restructuring, training and guidance, and monitoring--to meet
CMS's nursing home complaint standards. Although the standards do not
assess state survey agencies' communication with complainants, CMS
does expect agencies to convey investigation findings to complainants
in accordance with CMS's State Operations Manual. We found that
agencies varied in their interpretations of the manual's instructions,
and some provided limited information to complainants.
Many State Survey Agencies Had Difficulty Meeting Certain Nursing Home
Complaint Standards, Particularly for Timely Investigation of Actual
Harm-High Complaints:
More than half of state survey agencies had difficulty meeting certain
CMS performance standards pertaining to nursing home complaints.
[Footnote 26] According to CMS's assessment for fiscal year 2009, 28
state survey agencies failed the timeliness of investigations standard
for either immediate jeopardy or actual harm-high complaints, the
prioritization of complaints standard, or both.
Timeliness of Investigations Standard. CMS's assessment of state
survey agencies' performance found that some had difficulty meeting
the timeliness of investigations standard, which evaluates: (1)
whether an investigation was initiated within 10 working days of
prioritization for actual harm-high complaints and incidents for
nursing homes, and (2) whether an investigation was initiated within 2
working days of receipt for immediate jeopardy complaints and
incidents for nursing homes and other facilities.
[Text box:
Timeliness of investigations: State survey agencies must begin
investigating at least 95 percent of complaints and incidents within
required time frames.
* For actual harm-high complaints and incidents, CMS evaluates
performance for nursing homes separately from that of other facilities.
* For immediate jeopardy complaints and incidents, CMS evaluates
performance for both nursing homes and other types of facilities.
End of text box]
CMS found that in fiscal year 2009, 19 state survey agencies failed to
meet the timeliness of investigations standard for complaints and
incidents prioritized as actual harm-high. This marked an improvement
from fiscal year 2008, when 25 states failed. States' fiscal year 2009
scores varied widely. For example, among states failing this standard,
Louisiana nearly passed with 94.4 percent of actual harm-high
complaints and incidents investigated within the required time frame,
while Michigan's score was 17.3 percent. (For information on all state
survey agencies' performance on this standard, see appendix II.)
According to CMS's national data for calendar year 2009, the 19 states
that failed this standard in fiscal year 2009 accounted for more than
half (52 percent) of all actual harm-high complaints received
nationally.[Footnote 27] In these 19 states, at least 43 percent of
actual harm-high complaint investigations were initiated late, and at
least 33 percent were initiated more than 11 working days late.
[Footnote 28]
Officials from the three state survey agencies in our sample that
failed to meet the timeliness standard for actual harm-high complaints
cited long-standing workload and staffing issues as reasons. More
specifically, officials with the Michigan and Texas survey agencies
said they had difficulty because of staffing shortages and because the
volume of complaints and incidents increased. Tennessee officials
noted that the state has tried to hire the additional staff needed to
investigate the state's backlog of complaints, but has been hampered
by low salaries for surveyor positions as well as a cumbersome state
hiring process.
Nationwide, state survey agencies generally performed better on CMS's
timeliness standard for immediate jeopardy complaints and incidents
than they did for actual harm-high complaints and incidents. In CMS's
assessment for fiscal year 2009, all but nine state survey agencies
passed this standard by initiating investigations within 2 working
days of receipt for at least 95 percent of the immediate jeopardy
complaints and incidents they received about nursing homes and other
facilities. Among the nine state survey agencies that failed this
standard, four had scores at or below 50 percent. As with actual harm-
high complaints and incidents, the two state survey agencies in our
sample that failed the timeliness standard for immediate jeopardy
complaints and incidents--Michigan and Tennessee--cited staffing
shortages or increases in the number of complaints and incidents as
key reasons.
Fourteen state survey agencies that met CMS's timeliness standard for
immediate jeopardy complaints and incidents did not meet the
timeliness standard for actual harm-high complaints and incidents. An
official in one CMS regional office noted that immediate jeopardy
complaints are the highest priority and therefore rightly received the
most attention.
Prioritization of Complaints Standard. CMS's assessment of state
survey agencies' performance found that most agencies (32)
consistently passed this standard for the past four years.
[Text box:
Prioritization of complaints: State survey agencies must appropriately
prioritize at least 90 percent of complaints and incidents. CMS
evaluates performance for nursing homes separately from that of other
facilities.
End of text box]
In CMS's assessment for fiscal year 2009, all but nine state survey
agencies passed this performance standard. Among the nine state survey
agencies that failed this standard in fiscal year 2009, most had
scores between 70 percent and 88 percent.[Footnote 29] (See appendix
II for information on all state survey agencies' performance on this
standard.)
All but one of the six state survey agencies in our sample passed the
prioritization standard in fiscal year 2009. Officials from Tennessee
said that the agency had difficulty meeting this standard because of
personnel changes and because it took time for new management to fully
understand how the agency operates. Officials from the five state
survey agencies in our sample that passed this standard generally
attributed their agencies' performance on the prioritization standard
to staff skills and experience, training, and processes for quality
control. For example, officials from two state survey agencies--
Arkansas and Texas--attributed their states' success, in part, to a
supervisor's or quality assurance specialist's review of the priority
levels assigned by the staff members who received the complaint.
State Survey Agencies Reported Taking Steps Intended to Improve or
Maintain Performance on CMS's Standards:
State survey agencies reported that they have taken or plan to take
steps in four key areas--staffing, agency restructuring, training and
guidance, and monitoring--to either improve or maintain performance on
CMS's nursing home complaint standards.
Staffing. Officials from three of the state survey agencies in our
sample indicated that because staff shortages affected their ability
to meet CMS standards, they had taken steps to increase staffing. For
example, officials of the Michigan survey agency, which repeatedly
failed the timeliness of investigations standard between 2006 and
2009, reported that beginning in fiscal year 2009, the agency was able
to hire additional surveyors and as of June 1, 2010, had eliminated
its backlog of complaints. Tennessee officials indicated that the
agency received state legislature approval in February 2009 to hire
additional surveyors to fill vacant positions. Texas officials also
hired additional surveyors to conduct complaint investigations.
Officials of state survey agencies in our sample that met all or most
of CMS's nursing home complaint standards credited, among other
factors, experienced agency staff. For example, Wisconsin officials
indicated that the agency's ability to meet CMS's standards was partly
due to the quality of the staff hired by the agency--specifically,
some staff members' experience in the regulatory process, as both
health care providers and regulators.
Agency Restructuring. Some state survey agencies restructured
complaint investigation operations to address performance issues,
either consolidating regional offices or creating separate units to
investigate complaints. For example, to provide better statewide
coverage with available staff, the Tennessee survey agency downsized
from three regional offices to two. Arkansas and Texas both
established separate complaint investigation units--in Arkansas's
case, more than 10 years ago--in an effort to better manage large
volumes of complaints.
Officials of state survey agencies that have separate complaint
investigation units cited several advantages to dividing complaint
investigation functions from standard survey functions, including
greater efficiency and flexibility. For example, some officials said
that staff assigned to the complaints unit are able to build
experience and familiarity with the process and thus conduct more
efficient investigations and prepare more accurate reports; likewise,
staff that focus on standard surveys are able to conduct these
inspections more efficiently because they do not have to investigate
complaints at the same time. One official also said that a separate
complaint investigation unit affords managers more flexibility--for
example, by allowing them to more easily change staff members'
assignments from day to day to respond to high priority complaints.
[Footnote 30]
Training and Guidance. Officials of some state survey agencies
attributed their agencies' successful performance on the
prioritization of complaints standard partly to staff training. State
survey agencies also issued guidance, including policy manuals and
standardized forms or templates, to guide staff through the complaint
investigation process. For example, Florida provides staff with a 44-
page manual, with chapters on intake, prioritization, and
investigation of complaints, and created an automated complaint
investigation form that captures information about each allegation in
a complaint, as well as the evidence collected and findings reached
with respect to each.
Monitoring. Among the state survey agencies in our sample that failed
to meet some of CMS's standards, officials indicated that their
agencies had implemented or planned to implement additional monitoring
efforts. For example, Texas officials indicated that the agency
conducts reviews throughout the complaint process. For example, after
a complaint has been prioritized, a quality assurance specialist
reviews the information to ensure that the prioritization was
appropriate. Similarly, officials from Tennessee's survey agency
indicated that the agency planned to increase monitoring. In
particular, the officials indicated that each of the state's regional
offices would track and report quarterly on the timeliness of
investigations for all immediate jeopardy and actual harm-high
complaints. Tennessee officials indicated that surveyors in the
state's regional offices would be immediately alerted when they are
assigned an immediate jeopardy complaint to investigate, something not
always done in the past.
State survey agencies in our sample that generally passed CMS's
performance standards indicated that monitoring programs contributed
to the agencies' success. For example, a Florida official indicated
that a supervisor reviews a sample of complaints received on the
previous day to determine whether they were prioritized appropriately.
Some State Survey Agencies Provide Limited Information to Complainants
about Investigation Findings:
Although the CMS performance standards do not assess whether state
survey agencies are providing sufficient information to complainants
about investigation results, CMS's State Operations Manual indicates
that state survey agencies should provide a written report to
complainants in accordance with certain guidelines specified in the
manual. The manual specifies that the state agency should acknowledge
the complainant's concerns, identify the agency's regulatory authority
to investigate, provide a summary of investigation methods and the
date of the investigation, summarize the investigation findings, and
identify any follow-up action to be taken.
The six state survey agencies in our sample varied in their
interpretations of the manual, particularly the instruction to provide
a summary of the investigation findings. Two of the six agencies
consistently provided detailed information that specifically addressed
complainants' allegations. For example, one sample letter we received
from the Wisconsin survey agency lists four specific allegations made
by the complainant and then describes the agency's finding with
respect to each, including whether a deficiency was cited. (See figure
2 for an excerpt from this letter.) The other state survey agency that
provided detailed information (Michigan) did so by enclosing the
investigation report with the letter, along with the statement of
deficiencies, if any were cited. A Michigan survey agency official
said that staff also make at least one attempt to contact a
complainant by telephone to explain the findings.
Figure 2: Excerpt from a Letter Providing Detailed Information about
Investigation Findings:
[Refer to PDF for image: illustration]
Urinary Tract Infection:
[The resident] had ongoing episodes of nausea and vomiting, low grade
fevers, intermittent or increased confusion, increased weakness and
lethargy, and decreased food and fluid intake. The facility did not
respond to [the resident's] change of condition which resulted in a
urinary tract infection. Federal and state citations were issued.
Source: State of Wisconsin Department of Health Services.
Notes: We redacted the letter to protect the privacy of the resident.
In this report, we refer to citations as deficiencies.
[End of figure]
In contrast, four of the state survey agencies sent complainants only
boilerplate descriptions of the complaint investigation, typically
sending one type of form letter if surveyors cited deficiencies and
another if they did not. For example, in the sample letter we received
from Florida, the survey agency varied the middle paragraph of its
three-paragraph letter depending on whether deficiencies were cited
(see figure 3). An official of this agency said the letter was
intended to let complainants know that the point of an investigation
is to determine a nursing home's compliance with regulations.
Figure 3: Excerpts from a Letter Providing Boilerplate Information
about Investigation Findings, in Cases Where Deficiencies Were and
Were Not Cited:
[Refer to PDF for image: illustration]
The surveyor(s) did find that rules and laws were violated at the time
of our visit. The Agency will take action, since the surveyor
determined the facility was not doing what they were required to do at
the time of the inspection.
Or:
As a result of the complaint inspection, the surveyor(s) did not find
rules or laws were being violated. Since the purpose of a complaint
inspection is to determine if the facility is in compliance with laws
and rules particular to the issues identified in the complaint filed
with us, we take action if our staff determine the facility is not in
compliance with the regulations at the time of our visit. Although
this complaint inspection did not result in a finding of
noncompliance, your concerns will remain part of the file and will be
reviewed as part of future inspections.
Source: Florida Agency for Health Care Administration.
Note: When a state survey agency determines that rules and laws were
violated, the agency cites federal and/or state deficiencies.
[End of figure]
Of the four state survey agencies that provided boilerplate
descriptions of their investigation findings, two told complainants
how to obtain a more detailed report.[Footnote 31] For example, a
sample letter from the Arkansas state survey agency noted that the
agency's report on the deficiencies cited and the nursing home's plan
of correction should be posted in the nursing home. An Arkansas survey
agency official said that complainants could also request a copy of
the investigation report, but that it might be heavily redacted to
protect medical and identifying information.
CMS's Oversight of State Survey Agencies' Complaint Investigation
Processes Is Hampered by Data Reliability Issues, Due in Part to
Inconsistent Interpretation of Performance Standards Among CMS
Reviewers:
CMS's oversight of state survey agencies' complaint investigation
processes, through its performance standards system and complaints
database, is hampered by data reliability issues. While the four
performance standards CMS uses to assess state survey agencies'
processes for investigating nursing home complaints are consistent
with certain key criteria for performance measures identified by GAO
and other audit agencies, the standards have weaknesses in areas
related to other key criteria, particularly data reliability, due in
part to inadequate sample sizes and inconsistent interpretation of
some standards by CMS reviewers. In addition, CMS has not made full
use of the information it collects about state survey agencies'
complaint investigation processes. For example, in part because of
data reliability concerns, CMS does not routinely use data from the
complaints database to calculate certain measures that could enhance
its understanding of state survey agencies' performance. Although CMS
requires state survey agencies that fail performance standards to
develop corrective action plans, these plans do not necessarily
address the underlying causes of performance issues, such as staffing
shortages.
CMS's Performance Standards Are Comprehensive and Limited in Number
and Overlap, but Performance Scores Are Not Always Reliable:
CMS's four nursing home complaint performance standards--(1)
prioritization of complaints, (2) timeliness of investigations, (3)
quality of investigations, and (4) documentation of deficiencies--are
consistent with some, but not all, of the key criteria for performance
measures identified by GAO and other audit agencies. Specific
weaknesses we identified include a lack of comparability over time in
the performance scores and thus an inability to assess trends; a lack
of balance among some standards; and, most critically, a lack of data
reliability, due in part to inadequate sample sizes and varying
interpretations of the standards.
Consistent with key criteria for performance measures, CMS's
performance standards are comprehensive and limited in number and
overlap. Officials of all of the state survey agencies and CMS
regional offices in our sample indicated that they considered the four
nursing home complaint standards comprehensive. Although the
performance standards system does not include standards for certain
steps in the complaint investigation process, such as intake,
officials indicated that the standards cover key steps, which include
prioritizing complaints, scheduling and conducting investigations, and
documenting any deficiencies identified. The standards are also
limited in number and overlap, with each focused on different aspects
of the nursing home complaint process than the others.
Performance trends cannot be easily assessed because scores are not
comparable over time. Because CMS changed the scoring methodologies
for three of the four nursing home complaint standards during the past
4 years, it is not readily apparent from scores on these standards
whether state survey agencies' performance improved or worsened over
that time period. CMS officials generally felt that the changes had
enhanced the standards--in the case of the documentation of
deficiencies and quality of investigations standards, by holding state
survey agencies accountable for meeting all of the underlying
requirements or by highlighting specific areas in need of improvement.
[Footnote 32] Further, they did not identify the lack of trend data as
a major concern. Officials noted that CMS judges state survey
agencies' performance for a given year, not in relation to prior
years, and does not count scores on a standard in the first year after
a significant change in methodology. However, a lack of consistent
trend data makes it more difficult for CMS to assess whether the steps
that it and the states are taking to improve performance on the
nursing home complaint standards are having the desired effect.
The balance among standards may be undermined by how the
prioritization standard is scored. In general, the standards are
balanced, so that the incentives created by one standard are
counterbalanced by the incentives created by other standards. However,
because the prioritization standard requires only that complaints be
assigned a priority level at or above the level assigned by CMS
reviewers, this standard may create an incentive for state survey
agencies to assign higher priority levels than are warranted--which
may jeopardize the timeliness of investigations. As one state survey
agency official pointed out, the staff members who prioritize
complaints may not be responsible for conducting investigations;
consequently, these staff may be more focused on the agency's meeting
the prioritization standard than the timeliness standard and thus err
on the side of caution in prioritizing complaints.[Footnote 33]
According to CMS headquarters officials, the prioritization standard
is scored this way because the agency was most concerned about
complaints being prioritized at too low a level and did not want to
fault state survey agencies for investigating complaints sooner than
necessary. However, officials of two CMS regional offices noted that
assigning complaints too high a priority level can cause misallocation
of resources, as state survey agencies that prioritize complaints at
higher levels than are warranted must investigate these complaints
within shorter time frames than they otherwise would.
Some performance scores are unreliable because of inadequate sample
sizes and varying interpretations of standards among CMS reviewers.
For three of the four CMS performance standards, the samples specified
by CMS are in some cases too small to yield reliable data. Scores on
the prioritization of complaints, quality of investigations, and
documentation of deficiencies standards were generally based on a
sample of 10 to 40 cases (10 percent, up to a maximum of 40). With
samples this small, the margin of error around states' scores on the
prioritization of complaints standard, for example, was as much as 19
percentage points in fiscal year 2009.[Footnote 34] Accordingly, at
least some of the states that received passing marks on this standard
may actually have failed, and at least five of the nine states that
received failing marks may actually have passed.[Footnote 35] Although
the small sample sizes CMS requires make the reviews involved in
certain standards more practical, by reducing the documentation CMS
reviewers must examine, the trade-off is a lack of precision in the
scores for these standards.
Moreover, interpretation of some standards has varied among CMS
reviewers--in terms of both the materials reviewed to assess
performance and how certain requirements were construed by reviewers.
* Materials reviewed. To assess the quality of investigations, some
CMS regional offices reviewed only information surveyors entered into
the complaints database, while other CMS regional offices reviewed
more extensive hard-copy notes from complaint investigations.[Footnote
36] CMS headquarters officials indicated that relying solely on the
information in the complaints database to assess the quality of
investigations was not consistent with federal guidance, stating that
regional office officials should follow the guidance for the standard,
which calls for reviewers to examine a variety of documents, including
surveyor worksheets and investigation notes. They also noted that the
investigation notes are not required data elements in the complaints
database. Some state survey agency officials said that their scores on
this standard have suffered because the investigation notes in the
database do not always provide a complete picture of the agency's
complaint investigations.[Footnote 37]
* How requirements were construed. State survey agency officials we
interviewed also noted differences in how CMS reviewers understood
certain requirements in the standards, particularly in the
documentation of deficiencies standard. For example, officials
described differences in reviewers' interpretations of what it means
to quantify the extent of a deficient practice, one of the
requirements in that standard. One state survey agency official said
that his agency's scores on the standards improved from one half of
the year to the next simply because the CMS staff conducting the
review changed. Officials in one of the CMS regions where all state
survey agencies failed the documentation of deficiencies standard
acknowledged the 100 percent failure rate was at least partially due
to a change in the regional office's review--specifically, regional
managers having issued more explicit instructions to staff about how
to assess states' performance on particular requirements. The
clustering of failing scores on this standard within certain CMS
regions also suggests regional variation in interpretation; in three
regions, all of the state survey agencies failed the documentation of
deficiencies standard in fiscal year 2009, while in the other seven
regions, half or fewer of the state survey agencies failed.[Footnote
38]
Although some CMS regional offices have tried to ensure consistent
interpretation of the standards within their own regions--for example,
by requiring that multiple reviewers concur on any failing marks given
to state survey agencies and encouraging ongoing dialogue about the
standards--some officials we interviewed believe CMS should do more to
ensure consistency across regions. CMS headquarters officials told us
that the agency has issued additional guidance when officials became
aware of a need for clarification, but some CMS regional office
officials said that parts of the guidance need enhancement and that
CMS headquarters should have more staff dedicated to developing
guidance and answering questions from regional office staff. In
addition, some state survey agency officials suggested that CMS
regional offices should have less autonomy in the performance review
process. One official suggested that CMS headquarters should exert
more control over the regional offices with respect to the review
process, and others indicated a need for more "review of the
reviewers"--for example, by having the performance reviews conducted
by each regional office validated by another. Officials of one state
survey agency, noting that state survey agencies can appeal their
performance scores only to the same regional office that conducted
their performance review, suggested that a second regional office
should at least be involved in the appeals process.
CMS Has Not Made Full Use of Performance Information on State Survey
Agencies' Complaint Investigations:
CMS has not made full use of the information it collects about state
survey agencies' complaint investigation processes through its
complaints database and performance standards system. For example, CMS
does not routinely use data from its complaints database to calculate
certain measures that could enhance its understanding of state survey
agencies' performance investigating complaints and has not publicly
reported state survey agencies' scores on the performance standards.
CMS has not made full use of data in the complaints database to
monitor performance. In part because of data reliability concerns, CMS
does not routinely calculate certain measures that could shed
additional light on state survey agencies' performance--such as
substantiation rates or additional measures of the timeliness of
investigations.
* Substantiation rates, if interpreted by state survey agencies in a
consistent manner, could provide insight into the quality of complaint
investigations. Given the many factors that influence these rates,
including whether the complaints have a basis in fact, it would not be
appropriate to require state survey agencies to achieve a particular
rate. However, substantial variation in rates, either among states or
over time, could signal issues with complaint investigations and
prompt further inquiry by CMS. A CMS headquarters official told us
that because some state survey agencies may consider a complaint to be
substantiated even if no federal deficiencies are cited, CMS
headquarters does not systematically monitor substantiation rates and
most CMS regional offices probably do not do so either. The Patient
Protection and Affordable Care Act (PPACA), enacted March 23, 2010,
requires HHS to post on the Nursing Home Compare Web site summary
information on substantiated complaints, including their number, type,
severity and outcome, by March 23, 2011.[Footnote 39] Accordingly, a
CMS official told us that CMS headquarters will issue guidance to
ensure that state survey agencies interpret substantiation in a
consistent manner.
* Additional measures of timeliness--such as the number of days by
which state survey agencies miss the deadlines for some complaint
investigations--could provide CMS with a more comprehensive picture of
performance in this area. We found that some state survey agencies
with similar scores on CMS's timeliness standard for actual harm-high
complaints in fiscal year 2009 had very different backlogs of
complaint investigations. For example, looking at two state survey
agencies with performance scores of 82 and 85 percent--which
indicates, respectively, that 18 and 15 percent of their
investigations were late--we found that 51 percent of one agency's
late investigations were initiated more than 30 days late in calendar
year 2009, compared with 4 percent for the other agency. Currently,
the reliability of timeliness measures such as this is uncertain
because state survey agencies do not necessarily enter all complaints
into CMS's database or prioritize complaints in the same way.
Responsibility for training to address performance issues has
generally been left to CMS regional offices. The CMS regional offices
in our sample have used information from the performance standards
system to identify performance issues, but training designed to
address these issues has generally been undertaken by individual CMS
regional offices and, as a result, has varied in content and scope.
[Footnote 40] Complaint investigation training at the national level
has been limited and was not designed to address specific performance
issues identified during reviews.[Footnote 41] Officials of most of
the state survey agencies in our sample indicated that CMS's training
and guidance was sufficient, but officials of two state survey
agencies noted that their agencies provide any training above the
basic level. One state survey agency official said that CMS should
offer more comprehensive training, including more material on
complaint investigations, so that states are not "sinking or swimming"
on their own and are able to conduct investigations in a more
consistent manner.
PPACA directed HHS to enter into a contract to establish a National
Training Institute to help surveyors develop complaint investigation
skills.[Footnote 42] However, as of March 2011, funds had not yet been
appropriated to implement this provision of the act, and CMS estimates
that it would cost about $12 million to establish the institute. As a
start, CMS has redirected about $1 million from other projects to
initiate a project which will provide instruction on all aspects of
complaint surveys for all facility types, including nursing homes.
Corrective action plans are not timely and may not address the
underlying causes of performance issues. CMS requires state survey
agencies that fail performance standards to submit plans to improve
their performance, but CMS does not require these plans to be
submitted until halfway through the next performance cycle, which
allows little time for corrective actions to take effect before the
next performance review. (See figure 4.) Moreover, despite CMS
regional office input, the plans do not necessarily address the
underlying causes of state survey agencies' failure to meet
performance standards. For example, all three of the state survey
agencies in our sample that failed the timeliness of investigations
standard for immediate jeopardy complaints, actual harm-high
complaints, or both in all 4 fiscal years from 2006 through 2009 cited
staff shortages as a reason, but two of the three submitted at least
one corrective action plan during that period that did not propose
hiring the additional staff needed. CMS regional office officials
indicated that they had accepted such corrective action plans because
the steps the state survey agencies did propose--such as developing a
graphic analysis tool to track performance or implementing additional
central oversight of regional offices--were likely to improve
performance to some extent, and because CMS does not have the
authority to require state survey agencies to hire or reallocate
staff.[Footnote 43] Only one of the CMS regional offices in our sample
reported ever having rejected a corrective action plan, and officials
of one CMS regional office told us they preferred that a corrective
action plan provide a realistic account of what a state survey agency
was going to try to achieve rather than propose actions that the
agency could not carry out.[Footnote 44]
Figure 4: Time Line for State Performance Reviews and Submission of
Corrective Action Plans, Fiscal Year 2009:
[Refer to PDF for image: timeline]
2009 period of performance:
October 1, 2008 through September 30, 2009.
2010 period of performance:
October 1, 2009 through September 30, 2010.
* CMS sends draft 2009 performance reviews to states (February 5,
2010).
* States send comments to CMS (February 19, 2010).
* CMS sends final 2009 performance reviews to states (March 19, 2010).
* States send corrective action plans to CMS (after March 19, 2010).
Source: CMS State Performance Standards System guidance for fiscal
year 2009.
[End of figure]
Some CMS officials view the penalties the agency might impose for
failure to meet nursing home complaint standards as counterproductive
or unrealistic. CMS's regulations provide for penalties to be imposed
on a state survey agency for failure to follow procedures specified by
CMS for complaint investigations, such as reducing funding or
terminating the contract under which the state survey agency conducts
standard surveys and complaint investigations.[Footnote 45] CMS
headquarters officials noted that while CMS has reduced funding to
state survey agencies for failure to meet requirements for standard
surveys, such as statutory time frames, the agency has not done the
same for complaint investigations.[Footnote 46] One official said that
CMS has not done so partly because of concerns about the fairness of
penalizing states for failure to meet standards that may vary from
year to year, as well as concerns that reducing states' funding might
make it even more difficult for them to meet the standards. Some CMS
regional office officials said that reducing state survey agencies'
funding for failure to complete complaint investigations on time made
sense, but others said that taking resources away from the agencies
could be counterproductive, further hampering their ability to carry
out investigations. Although CMS could terminate its contract with a
state survey agency, CMS officials we interviewed indicated that this
was not a realistic option.
CMS has not publicly reported state survey agencies' performance
scores. Public reporting of performance information has been advocated
by GAO and other auditors as a critical step in performance management
because it provides policymakers and the public with information
needed to assess progress and may also serve to motivate agency
managers and staff.[Footnote 47] While CMS has shared state survey
agencies' scores on the performance standards with all of the other
state survey agencies, it has not made the scores available to other
stakeholders, such as residents, family members, or advocates.
According to a CMS headquarters official, some state survey agencies
have made their own scores publicly available, but CMS has not yet
issued any guidance to the states on public disclosure of scores. This
official told us that CMS plans to issue a policy memo affirming state
survey agencies' right to disclose their own scores and is also
considering making all of the scores publicly available, possibly on
CMS's Web site. Although some CMS regional office officials questioned
whether performance reports might too easily be misconstrued by the
public and necessarily gloss over details that would provide a more
nuanced picture of performance, GAO's prior work on performance
management suggests reports can be structured to avoid these potential
pitfalls--for example, by explaining the limitations of the data and
using clearly defined terms and readily understood tables and graphs
to convey information.[Footnote 48]
Conclusions:
In the past decade, CMS has made several efforts to improve the intake
and investigation of nursing home complaints by state survey agencies,
including (1) implementation of a database that not only helps state
survey agencies track complaints but also helps CMS monitor the state
survey agencies' performance and (2) establishment of and refinements
to its performance standards related to nursing home complaints.
However, our review indicates that challenges remain.
CMS's complaint data have limitations. We found that the lack of
consistency in state surveys agencies' use of the database--
particularly in terms of which complaints are entered and how certain
fields are interpreted--undermines the reliability of some of the data
and limits the usefulness of the database as a monitoring tool. CMS
does not routinely use the data to calculate measures such as
substantiation rates that could enhance its understanding of complaint
investigations partly because of concerns about the reliability of the
data.
CMS's performance reviews highlight state workload issues. Although
state survey agencies generally prioritized nursing home complaints in
accordance with CMS's performance standard, we found that many
agencies had difficulty managing a heavy workload of actual harm-high
complaints. In 2009, state survey agencies prioritized 45 percent of
the more than 53,000 nursing home complaints they received as actual-
harm high, which requires initiation of an investigation within 10
working days of prioritization. In fiscal year 2009, 19 state survey
agencies failed to meet the CMS timeliness standard for these
complaints. Staffing shortages and heavy workloads were cited as key
reasons by survey agency officials we interviewed whose states had
failed this standard. CMS's policy for scoring the prioritization
standard may contribute to these workload issues by creating an
incentive for the agency staff who prioritize complaints to assign
higher priority levels than are warranted. While CMS is correct in
asserting that prioritizing complaints at too high a level is
preferable to the reverse, this practice can have a significant impact
on state survey agencies' workload and thus on their ability to meet
requirements for timely investigations. Additionally, CMS data for
2009 showed that, among investigated complaints prioritized as either
immediate jeopardy or actual harm-high, the percentage substantiated
with at least one federal deficiency cited was higher if the
investigation was initiated within required time frames than if it was
not. Though many factors can affect whether complaints are
substantiated, including whether there is evidence to support them,
considerable variation in substantiation rates, among the states or
over time, could indicate potential concerns with state survey
agencies' complaint investigations.
Some performance standards scores are unreliable due to small samples
and varying interpretations of requirements. CMS has also made efforts
to refine its performance standards for nursing home complaints.
However, as with the complaints data, scores on some standards are
unreliable, because of inadequate sample sizes and varying
interpretations of the standards by the CMS regional office officials
who conduct the performance reviews. While we recognize that CMS may
have opted for small samples for some standards in order to limit the
amount of documentation reviewers must examine each year, sample sizes
could be increased without increasing reviewers' workloads if
performance on certain standards--those that require document review--
were assessed less frequently than once a year. Less frequent reviews
could also help address the issue of state survey agencies receiving
their final scores and submitting their corrective action plans so far
into the next performance cycle that little time remains for them to
improve their performance. The credibility of the scores could be
further enhanced by ensuring that the standards are consistently
interpreted by the CMS regional offices. Clarifying CMS guidance could
help in this regard as well as in ensuring that state survey agencies
understand their responsibilities with respect to each aspect of the
complaint investigation process, including the manner in which
investigation results are communicated to complainants.
CMS is considering making state survey agencies' scores on the
performance standards publicly available. While we support such a
step, we believe that it is important to consider the reliability of
data, as well as its comparability over time, when deciding which
scores to publish. For such performance reports to be useful to the
public, they should also include meaningful trend data that reflect
agencies' actual progress over time, as well as a clear explanation of
the limitations of the data.
Recommendations:
To ensure that information entered into CMS's complaints database is
reliable and consistent, we recommend that the Administrator of CMS:
* Identify issues with data quality and clarify guidance to states
about how particular fields in the database should be interpreted,
such as what it means to substantiate a complaint.
To strengthen CMS's assessment of state survey agencies' performance
in the management of nursing home complaints, we recommend that the
Administrator of CMS take the following three actions:
* Conduct additional monitoring of state performance using information
from CMS's complaints database, such as additional timeliness measures.
* Assess state survey agencies' performance in certain areas--
specifically, documentation of deficiencies, prioritization of
complaints, and quality of investigations--less frequently than once a
year.
* Assure greater consistency in assessments by identifying differences
in interpretation of the performance standards and clarifying guidance
to state survey agencies and CMS regional offices.
To strengthen and increase accountability of state survey agencies'
management of the nursing home complaints process, we recommend that
the Administrator of CMS take the following three actions:
* Clarify guidance to the state survey agencies about the minimum
information that should be conveyed to complainants at the close of an
investigation.
* Provide guidance encouraging state survey agencies to prioritize
complaints at the level that is warranted, not above that level.
* Implement CMS's proposed plans to publish state survey agencies'
scores but limit publication to those performance standards that CMS
considers the most reliable and clear.
Agency and Other External Comments:
We received written comments on a draft of this report from HHS and
from the Association of Health Facility Survey Agencies (AHFSA), the
organization that represents state survey agencies.
HHS Comments:
HHS provided written comments, which are reproduced in appendix III.
HHS generally concurred with all of our recommendations. With respect
to our first recommendation, HHS agreed that CMS should take steps to
ensure that information entered into the agency's complaints database
is reliable and consistent. HHS said that CMS will convene a
workgroup--including staff from CMS headquarters, CMS regional
offices, and state survey agencies--to address data quality issues.
HHS also agreed that CMS needs to strengthen its assessment of state
survey agencies' performance in the management of nursing home
complaints. HHS said that CMS's planned workgroup will review the
three specific actions we recommended and identify ways to strengthen
the agency's oversight process. Finally, HHS agreed that CMS needs to
strengthen and increase accountability of state survey agencies'
management of the nursing home complaints process. Regarding the
specific actions we recommended, HHS said that CMS will provide
increased guidance to states regarding the minimum information that
must be conveyed to complainants at the close of an investigation and
provide clarification and guidance to ensure that complaints are
prioritized at the appropriate level. With respect to our
recommendation that CMS publish state survey agencies' scores on
certain nursing home complaint performance standards, HHS said that
CMS will work with state officials and others to identify key
information about state survey agencies' performance that would be of
public value. HHS also provided technical comments, which we
incorporated as appropriate.
AHFSA Comments:
AHFSA emphasized the critical importance of enforcing federal and
state survey and certification standards and noted that in many
states, complaint systems have significant connections to state and
local licensing and enforcement activities, which are outside CMS's
jurisdiction. AHFSA noted that several of the policy and operational
issues raised in our report create challenges for states. These
include lack of clarity about what it means to substantiate a
complaint and lack of timely notification to the states of any changes
in CMS's performance standards for nursing home complaints. AHFSA also
commented that CMS's guidance on prioritizing complaints could be
improved but questioned whether many states were prioritizing
complaints at a higher level than is warranted in order to meet CMS's
prioritization standard. In addition, AHFSA said that the complaint
system is the primary safety net for vulnerable nursing home residents
and therefore suggested that states should err on the side of caution
when prioritizing complaints in order to better protect residents.
AHFSA also provided some state-specific comments, which we
incorporated as appropriate.
As agreed with your office, 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 to the
Secretary of Health and Human Services, the Administrator of the
Centers for Medicare & Medicaid Services, and other interested
parties. In addition, the report will be available at no charge on the
GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or at dickenj@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made key contributions
to this report are listed in appendix IV.
Sincerely yours,
Signed by:
John E. Dicken:
Director, Health Care:
[End of section]
Appendix I: CMS's State-Level Data on Complaints Received,
Investigated, and Substantiated by State Survey Agencies, 2009:
This appendix provides additional information on the number of
complaints received, investigated, and substantiated by all 50 state
survey agencies and the survey agency for the District of Columbia for
2009 based on complaints in Centers for Medicare & Medicaid Services'
(CMS) national complaints database. We included only complaints and
excluded facility-reported incidents, which nursing homes are required
to self-report to state survey agencies. Additionally, we included
only complaints that alleged a violation of federal
requirements.[Footnote 49] In the course of our work, we found some
limitations to the data we obtained, including that state survey
agencies interpret certain variables, such as substantiation,
differently from one another and that data are missing for certain
variables, such as the date on which the state survey agency
acknowledged the complaint. Additionally, we learned that CMS's
national database may not include all complaints because the state
survey agencies may not have entered all of the complaints they
received. Because of the data limitations we found, we included in our
analysis only those variables that we found to be reliable, and we
consider the number of complaints from CMS's national complaints
database to be a conservative estimate of the total number of
complaints received by state survey agencies.
Table 6: Number of Complaints Received, Number of Nursing Home
Residents, Complaint Rate, and Percentage of Complaints by Priority
Level, 2009:
State: Alabama;
Number of complaints received: 384;
Number of nursing home residents: 23,290;
Rate of complaints per 1,000 nursing home residents: 16.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 40%;
Actual harm-high: 26%;
Actual harm-medium: 0;
Actual harm-low: 29%;
Other[B]: 4%.
State: Alaska;
Number of complaints received: 14;
Number of nursing home residents: 632;
Rate of complaints per 1,000 nursing home residents: 22.2;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 0;
Actual harm-medium: 71%;
Actual harm-low: 14%;
Other[B]: 14%.
State: Arizona;
Number of complaints received: 548;
Number of nursing home residents: 11,870;
Rate of complaints per 1,000 nursing home residents: 46.2;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 2%;
Actual harm-high: 69%;
Actual harm-medium: 17%;
Actual harm-low: 1%;
Other[B]: 11%.
State: Arkansas;
Number of complaints received: 810;
Number of nursing home residents: 17,879;
Rate of complaints per 1,000 nursing home residents: 45.3;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 5%;
Actual harm-high: 63%;
Actual harm-medium: 30%;
Actual harm-low: 2%;
Other[B]: 0.
State: California;
Number of complaints received: 902;
Number of nursing home residents: 103,239;
Rate of complaints per 1,000 nursing home residents: 8.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 7%;
Actual harm-high: 49%;
Actual harm-medium: 37%;
Actual harm-low: 2%;
Other[B]: 5%.
State: Colorado;
Number of complaints received: 368;
Number of nursing home residents: 16,419;
Rate of complaints per 1,000 nursing home residents: 22.4;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 2%;
Actual harm-high: 55%;
Actual harm-medium: 43%;
Actual harm-low: 0;
Other[B]: 0.
State: Connecticut;
Number of complaints received: 312;
Number of nursing home residents: 26,324;
Rate of complaints per 1,000 nursing home residents: 11.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 7%;
Actual harm-medium: 72%;
Actual harm-low: 4%;
Other[B]: 17%.
State: Delaware;
Number of complaints received: 205;
Number of nursing home residents: 4,244;
Rate of complaints per 1,000 nursing home residents: 48.3;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 13%;
Actual harm-medium: 59%;
Actual harm-low: 24%;
Other[B]: 4%.
State: District of Columbia;
Number of complaints received: 45;
Number of nursing home residents: 2,518;
Rate of complaints per 1,000 nursing home residents: 17.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 18%;
Actual harm-medium: 71%;
Actual harm-low: 4%;
Other[B]: 7%.
State: Florida;
Number of complaints received: 1,760;
Number of nursing home residents: 71,819;
Rate of complaints per 1,000 nursing home residents: 24.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 5%;
Actual harm-high: 44%;
Actual harm-medium: 51%;
Actual harm-low: 0;
Other[B]: 0.
State: Georgia;
Number of complaints received: 1,025;
Number of nursing home residents: 34,983;
Rate of complaints per 1,000 nursing home residents: 29.3;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 7%;
Actual harm-high: 80%;
Actual harm-medium: 11%;
Actual harm-low: 0;
Other[B]: 2.
State: Hawaii;
Number of complaints received: 12;
Number of nursing home residents: 3,850;
Rate of complaints per 1,000 nursing home residents: 3.1;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 8%;
Actual harm-medium: 33%;
Actual harm-low: 58%;
Other[B]: 0.
State: Idaho;
Number of complaints received: 117;
Number of nursing home residents: 4,362;
Rate of complaints per 1,000 nursing home residents: 26.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 4%;
Actual harm-high: 27%;
Actual harm-medium: 63%;
Actual harm-low: 1%;
Other[B]: 4%.
State: Illinois;
Number of complaints received: 4,316;
Number of nursing home residents: 76,168;
Rate of complaints per 1,000 nursing home residents: 56.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 2%;
Actual harm-high: 53%;
Actual harm-medium: 45%;
Actual harm-low: 0;
Other[B]: 0.
State: Indiana;
Number of complaints received: 1,616;
Number of nursing home residents: 39,590;
Rate of complaints per 1,000 nursing home residents: 40.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 4%;
Actual harm-high: 42%;
Actual harm-medium: 52%;
Actual harm-low: 1%;
Other[B]: 0.
State: Iowa;
Number of complaints received: 785;
Number of nursing home residents: 26,069;
Rate of complaints per 1,000 nursing home residents: 30.1;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 1%;
Actual harm-high: 60%;
Actual harm-medium: 37%;
Actual harm-low: 0;
Other[B]: 2%.
State: Kansas;
Number of complaints received: 1,010;
Number of nursing home residents: 19,175;
Rate of complaints per 1,000 nursing home residents: 52.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 5%;
Actual harm-high: 15%;
Actual harm-medium: 52%;
Actual harm-low: 8%;
Other[B]: 20%.
State: Kentucky;
Number of complaints received: 599;
Number of nursing home residents: 23,334;
Rate of complaints per 1,000 nursing home residents: 25.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 12%;
Actual harm-high: 76%;
Actual harm-medium: 12%;
Actual harm-low: 0;
Other[B]: 0.
State: Louisiana;
Number of complaints received: 674;
Number of nursing home residents: 25,548;
Rate of complaints per 1,000 nursing home residents: 26.4;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 26%;
Actual harm-high: 54%;
Actual harm-medium: 10%;
Actual harm-low: 2%;
Other[B]: 7%.
State: Maine;
Number of complaints received: 320;
Number of nursing home residents: 6,444;
Rate of complaints per 1,000 nursing home residents: 49.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 13%;
Actual harm-high: 65%;
Actual harm-medium: 13%;
Actual harm-low: 2%;
Other[B]: 7%.
State: Maryland;
Number of complaints received: 1,060;
Number of nursing home residents: 25,007;
Rate of complaints per 1,000 nursing home residents: 42.4;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 68%;
Actual harm-medium: 25%;
Actual harm-low: 4%;
Other[B]: 2%.
State: Massachusetts;
Number of complaints received: 778;
Number of nursing home residents: 43,352;
Rate of complaints per 1,000 nursing home residents: 18.0;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 60%;
Actual harm-medium: 1%;
Actual harm-low: 0;
Other[B]: 39%.
State: Michigan;
Number of complaints received: 1,239;
Number of nursing home residents: 40,214;
Rate of complaints per 1,000 nursing home residents: 30.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 6%;
Actual harm-high: 87%;
Actual harm-medium: 3%;
Actual harm-low: 0;
Other[B]: 5%.
State: Minnesota;
Number of complaints received: 440;
Number of nursing home residents: 30,085;
Rate of complaints per 1,000 nursing home residents: 14.6;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 3%;
Actual harm-high: 38%;
Actual harm-medium: 3%;
Actual harm-low: 15%;
Other[B]: 41%.
State: Mississippi;
Number of complaints received: 293;
Number of nursing home residents: 16,349;
Rate of complaints per 1,000 nursing home residents: 17.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 5%;
Actual harm-high: 85%;
Actual harm-medium: 10%;
Actual harm-low: 0;
Other[B]: 0.
State: Missouri;
Number of complaints received: 3,770;
Number of nursing home residents: 38,447;
Rate of complaints per 1,000 nursing home residents: 98.1;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 7%;
Actual harm-high: 44%;
Actual harm-medium: 39%;
Actual harm-low: 4%;
Other[B]: 6%.
State: Montana;
Number of complaints received: 70;
Number of nursing home residents: 5,034;
Rate of complaints per 1,000 nursing home residents: 13.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 3%;
Actual harm-high: 10%;
Actual harm-medium: 40%;
Actual harm-low: 40%;
Other[B]: 7%.
State: Nebraska;
Number of complaints received: 442;
Number of nursing home residents: 12,802;
Rate of complaints per 1,000 nursing home residents: 34.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 5%;
Actual harm-high: 19%;
Actual harm-medium: 38%;
Actual harm-low: 19%;
Other[B]: 19%.
State: Nevada;
Number of complaints received: 67;
Number of nursing home residents: 4,732;
Rate of complaints per 1,000 nursing home residents: 14.2;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 1%;
Actual harm-high: 42%;
Actual harm-medium: 37%;
Actual harm-low: 4%;
Other[B]: 15%.
State: New Hampshire;
Number of complaints received: 81;
Number of nursing home residents: 6,913;
Rate of complaints per 1,000 nursing home residents: 11.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 5%;
Actual harm-medium: 60%;
Actual harm-low: 10%;
Other[B]: 25%.
State: New Jersey;
Number of complaints received: 2,103;
Number of nursing home residents: 45,826;
Rate of complaints per 1,000 nursing home residents: 45.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 5%;
Actual harm-medium: 56%;
Actual harm-low: 9%;
Other[B]: 30%.
State: New Mexico;
Number of complaints received: 218;
Number of nursing home residents: 5,694;
Rate of complaints per 1,000 nursing home residents: 38.3;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 3%;
Actual harm-high: 24%;
Actual harm-medium: 0;
Actual harm-low: 72%;
Other[B]: 1%.
State: New York;
Number of complaints received: 5,064;
Number of nursing home residents: 110,412;
Rate of complaints per 1,000 nursing home residents: 45.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 3%;
Actual harm-high: 34%;
Actual harm-medium: 19%;
Actual harm-low: 8%;
Other[B]: 37%.
State: North Carolina;
Number of complaints received: 1,982;
Number of nursing home residents: 37,626;
Rate of complaints per 1,000 nursing home residents: 52.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 8%;
Actual harm-high: 32%;
Actual harm-medium: 41%;
Actual harm-low: 12%;
Other[B]: 8%.
State: North Dakota;
Number of complaints received: 32;
Number of nursing home residents: 5,776;
Rate of complaints per 1,000 nursing home residents: 5.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 3%;
Actual harm-medium: 84%;
Actual harm-low: 13%;
Other[B]: 0.
State: Ohio;
Number of complaints received: 2,900;
Number of nursing home residents: 79,963;
Rate of complaints per 1,000 nursing home residents: 36.3;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 6%;
Actual harm-high: 51%;
Actual harm-medium: 35%;
Actual harm-low: 3%;
Other[B]: 4%.
State: Oklahoma;
Number of complaints received: 1,083;
Number of nursing home residents: 19,842;
Rate of complaints per 1,000 nursing home residents: 54.6;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 10%;
Actual harm-high: 33%;
Actual harm-medium: 55%;
Actual harm-low: 0;
Other[B]: 2%.
State: Oregon;
Number of complaints received: 259;
Number of nursing home residents: 7,724;
Rate of complaints per 1,000 nursing home residents: 33.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 85%;
Actual harm-medium: 2%;
Actual harm-low: 5%;
Other[B]: 9%.
State: Pennsylvania;
Number of complaints received: 1,771;
Number of nursing home residents: 80,840;
Rate of complaints per 1,000 nursing home residents: 21.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 99%;
Actual harm-high: 1%;
Actual harm-medium: 0;
Actual harm-low: 0;
Other[B]: 0.
State: Rhode Island;
Number of complaints received: 114;
Number of nursing home residents: 8,026;
Rate of complaints per 1,000 nursing home residents: 14.2;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 1%;
Actual harm-medium: 5%;
Actual harm-low: 81%;
Other[B]: 13%.
State: South Carolina;
Number of complaints received: 178;
Number of nursing home residents: 17,092;
Rate of complaints per 1,000 nursing home residents: 10.4;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 10%;
Actual harm-high: 81%;
Actual harm-medium: 3%;
Actual harm-low: 0;
Other[B]: 6%.
State: South Dakota;
Number of complaints received: 5;
Number of nursing home residents: 6,498;
Rate of complaints per 1,000 nursing home residents: 0.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 20%;
Actual harm-medium: 80%;
Actual harm-low: 0;
Other[B]: 0.
State: Tennessee;
Number of complaints received: 925;
Number of nursing home residents: 32,232;
Rate of complaints per 1,000 nursing home residents: 28.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 22%;
Actual harm-high: 55%;
Actual harm-medium: 18%;
Actual harm-low: 4%;
Other[B]: 0.
State: Texas;
Number of complaints received: 7,730;
Number of nursing home residents: 91,239;
Rate of complaints per 1,000 nursing home residents: 84.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 12%;
Actual harm-high: 57%;
Actual harm-medium: 31%;
Actual harm-low: 0;
Other[B]: 1%.
State: Utah;
Number of complaints received: 180;
Number of nursing home residents: 5,326;
Rate of complaints per 1,000 nursing home residents: 33.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 11%;
Actual harm-high: 16%;
Actual harm-medium: 60%;
Actual harm-low: 11%;
Other[B]: 3%.
State: Vermont;
Number of complaints received: 175;
Number of nursing home residents: 2,955;
Rate of complaints per 1,000 nursing home residents: 59.2;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 9%;
Actual harm-high: 29%;
Actual harm-medium: 46%;
Actual harm-low: 3%;
Other[B]: 13%.
State: Virginia;
Number of complaints received: 523;
Number of nursing home residents: 28,335;
Rate of complaints per 1,000 nursing home residents: 18.5;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 0;
Actual harm-high: 13%;
Actual harm-medium: 84%;
Actual harm-low: 2%;
Other[B]: 1%.
State: Washington;
Number of complaints received: 2,521;
Number of nursing home residents: 18,415;
Rate of complaints per 1,000 nursing home residents: 136.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 6%;
Actual harm-high: 66%;
Actual harm-medium: 28%;
Actual harm-low: 0;
Other[B]: 0.
State: West Virginia;
Number of complaints received: 371;
Number of nursing home residents: 9,584;
Rate of complaints per 1,000 nursing home residents: 38.7;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 2%;
Actual harm-high: 41%;
Actual harm-medium: 49%;
Actual harm-low: 1%;
Other[B]: 7%.
State: Wisconsin;
Number of complaints received: 1,060;
Number of nursing home residents: 31,757;
Rate of complaints per 1,000 nursing home residents: 33.4;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 6%;
Actual harm-high: 21%;
Actual harm-medium: 73%;
Actual harm-low: 1%;
Other[B]: 0.
State: Wyoming;
Number of complaints received: 57;
Number of nursing home residents: 2,394;
Rate of complaints per 1,000 nursing home residents: 23.8;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 2%;
Actual harm-high: 14%;
Actual harm-medium: 32%;
Actual harm-low: 32%;
Other[B]: 21%.
State: Total;
Number of complaints received: 53,313;
Number of nursing home residents: 1,408,248;
Rate of complaints per 1,000 nursing home residents: 37.9;
Percentage of complaints, by priority level[A]:
Immediate jeopardy: 10%;
Actual harm-high: 45%;
Actual harm-medium: 33%;
Actual harm-low: 4%;
Other[B]: 8%.
Source: CMS's complaints database.
Note: As previously noted, CMS's national data may not include all
complaints received by the state survey agencies, because the agencies
may not have entered them. As a result, the data we received from CMS
represent some, but likely not all, of the nursing home complaints
received by state survey agencies.
[A] Percentages may not add to 100 due to rounding.
[B] This category includes complaints that were assigned any of the
four other priority levels: administrative review/offsite
investigation, referral--immediate, referral--other, or no action
necessary or that did not have data on priority level.
[End of table]
Table 7: Number of Complaints Requiring Investigation, Investigated,
and Substantiated with at Least One Federal Deficiency Cited, 2009:
State: Alabama;
Number of complaints that required an investigation[A]: 367;
Number of complaints where an investigation was completed: 354;
Number of complaints that were substantiated with at least one federal
deficiency cited: 92;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 26.0%.
State: Alaska;
Number of complaints that required an investigation[A]: 12;
Number of complaints where an investigation was completed: 12;
Number of complaints that were substantiated with at least one federal
deficiency cited: 1;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 8.3%.
State: Arizona;
Number of complaints that required an investigation[A]: 487;
Number of complaints where an investigation was completed: 483;
Number of complaints that were substantiated with at least one federal
deficiency cited: 190;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 39.3%.
State: Arkansas;
Number of complaints that required an investigation[A]: 809;
Number of complaints where an investigation was completed: 809;
Number of complaints that were substantiated with at least one federal
deficiency cited: 235;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 29.1%.
State: California;
Number of complaints that required an investigation[A]: 858;
Number of complaints where an investigation was completed: 858;
Number of complaints that were substantiated with at least one federal
deficiency cited: 116;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 13.5%.
State: Colorado;
Number of complaints that required an investigation[A]: 368;
Number of complaints where an investigation was completed: 359;
Number of complaints that were substantiated with at least one federal
deficiency cited: 140;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 39.0%.
State: Connecticut;
Number of complaints that required an investigation[A]: 260;
Number of complaints where an investigation was completed: 256;
Number of complaints that were substantiated with at least one federal
deficiency cited: 142;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 55.5%.
State: Delaware;
Number of complaints that required an investigation[A]: 196;
Number of complaints where an investigation was completed: 190;
Number of complaints that were substantiated with at least one federal
deficiency cited: 65;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 34.2%.
State: District of Columbia;
Number of complaints that required an investigation[A]: 42;
Number of complaints where an investigation was completed: 42;
Number of complaints that were substantiated with at least one federal
deficiency cited: 14;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 33.3%.
State: Florida;
Number of complaints that required an investigation[A]: 1,759;
Number of complaints where an investigation was completed: 1,757;
Number of complaints that were substantiated with at least one federal
deficiency cited: 387;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 22.0%.
State: Georgia;
Number of complaints that required an investigation[A]: 1,006;
Number of complaints where an investigation was completed: 1,006;
Number of complaints that were substantiated with at least one federal
deficiency cited: 140;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 13.9%.
State: Hawaii;
Number of complaints that required an investigation[A]: 12;
Number of complaints where an investigation was completed: 5;
Number of complaints that were substantiated with at least one federal
deficiency cited: 2;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 40.0%.
State: Idaho;
Number of complaints that required an investigation[A]: 112;
Number of complaints where an investigation was completed: 112;
Number of complaints that were substantiated with at least one federal
deficiency cited: 51;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 45.5%.
State: Illinois;
Number of complaints that required an investigation[A]: 4,300;
Number of complaints where an investigation was completed: 4,296;
Number of complaints that were substantiated with at least one federal
deficiency cited: 1,108;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 25.8%.
State: Indiana;
Number of complaints that required an investigation[A]: 1,616;
Number of complaints where an investigation was completed: 1,616;
Number of complaints that were substantiated with at least one federal
deficiency cited: 494;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 30.6%.
State: Iowa;
Number of complaints that required an investigation[A]: 767;
Number of complaints where an investigation was completed: 767;
Number of complaints that were substantiated with at least one federal
deficiency cited: 262;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 34.2%.
State: Kansas;
Number of complaints that required an investigation[A]: 812;
Number of complaints where an investigation was completed: 811;
Number of complaints that were substantiated with at least one federal
deficiency cited: 214;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 26.4%.
State: Kentucky;
Number of complaints that required an investigation[A]: 599;
Number of complaints where an investigation was completed: 599;
Number of complaints that were substantiated with at least one federal
deficiency cited: 153;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 25.5%.
State: Louisiana;
Number of complaints that required an investigation[A]: 626;
Number of complaints where an investigation was completed: 626;
Number of complaints that were substantiated with at least one federal
deficiency cited: 252;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 40.3%.
State: Maine;
Number of complaints that required an investigation[A]: 299;
Number of complaints where an investigation was completed: 297;
Number of complaints that were substantiated with at least one federal
deficiency cited: 32;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 10.8%.
State: Maryland;
Number of complaints that required an investigation[A]: 1,034;
Number of complaints where an investigation was completed: 1,031;
Number of complaints that were substantiated with at least one federal
deficiency cited: 178;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 17.3%.
State: Massachusetts;
Number of complaints that required an investigation[A]: 472;
Number of complaints where an investigation was completed: 472;
Number of complaints that were substantiated with at least one federal
deficiency cited: 92;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 19.5%.
State: Michigan;
Number of complaints that required an investigation[A]: 1,181;
Number of complaints where an investigation was completed: 1,181;
Number of complaints that were substantiated with at least one federal
deficiency cited: 320;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 27.1%.
State: Minnesota;
Number of complaints that required an investigation[A]: 259;
Number of complaints where an investigation was completed: 252;
Number of complaints that were substantiated with at least one federal
deficiency cited: 25;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 9.9%.
State: Mississippi;
Number of complaints that required an investigation[A]: 293;
Number of complaints where an investigation was completed: 293;
Number of complaints that were substantiated with at least one federal
deficiency cited: 40;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 13.7%.
State: Missouri;
Number of complaints that required an investigation[A]: 3,539;
Number of complaints where an investigation was completed: 3,537;
Number of complaints that were substantiated with at least one federal
deficiency cited: 431;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 12.2%.
State: Montana;
Number of complaints that required an investigation[A]: 65;
Number of complaints where an investigation was completed: 64;
Number of complaints that were substantiated with at least one federal
deficiency cited: 26;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 40.6%.
State: Nebraska;
Number of complaints that required an investigation[A]: 356;
Number of complaints where an investigation was completed: 354;
Number of complaints that were substantiated with at least one federal
deficiency cited: 112;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 31.6%.
State: Nevada;
Number of complaints that required an investigation[A]: 57;
Number of complaints where an investigation was completed: 57;
Number of complaints that were substantiated with at least one federal
deficiency cited: 20;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 35.1%.
State: New Hampshire;
Number of complaints that required an investigation[A]: 61;
Number of complaints where an investigation was completed: 61;
Number of complaints that were substantiated with at least one federal
deficiency cited: 11;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 18.0%.
State: New Jersey;
Number of complaints that required an investigation[A]: 1,470;
Number of complaints where an investigation was completed: 1,468;
Number of complaints that were substantiated with at least one federal
deficiency cited: 231;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 15.7%.
State: New Mexico;
Number of complaints that required an investigation[A]: 216;
Number of complaints where an investigation was completed: 216;
Number of complaints that were substantiated with at least one federal
deficiency cited: 36;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 16.7%.
State: New York;
Number of complaints that required an investigation[A]: 3,188;
Number of complaints where an investigation was completed: 3,179;
Number of complaints that were substantiated with at least one federal
deficiency cited: 273;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 8.6%.
State: North Carolina;
Number of complaints that required an investigation[A]: 1,826;
Number of complaints where an investigation was completed: 1,825;
Number of complaints that were substantiated with at least one federal
deficiency cited: 281;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 15.4%.
State: North Dakota;
Number of complaints that required an investigation[A]: 32;
Number of complaints where an investigation was completed: 32;
Number of complaints that were substantiated with at least one federal
deficiency cited: 11;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 34.4%.
State: Ohio;
Number of complaints that required an investigation[A]: 2,785;
Number of complaints where an investigation was completed: 2,783;
Number of complaints that were substantiated with at least one federal
deficiency cited: 613;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 22.0%.
State: Oklahoma;
Number of complaints that required an investigation[A]: 1,061;
Number of complaints where an investigation was completed: 1,061;
Number of complaints that were substantiated with at least one federal
deficiency cited: 337;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 31.8%.
State: Oregon;
Number of complaints that required an investigation[A]: 236;
Number of complaints where an investigation was completed: 236;
Number of complaints that were substantiated with at least one federal
deficiency cited: 77;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 32.6%.
State: Pennsylvania;
Number of complaints that required an investigation[A]: 1,769;
Number of complaints where an investigation was completed: 1,767;
Number of complaints that were substantiated with at least one federal
deficiency cited: 379;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 21.5%.
State: Rhode Island;
Number of complaints that required an investigation[A]: 99;
Number of complaints where an investigation was completed: 99;
Number of complaints that were substantiated with at least one federal
deficiency cited: 5;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 5.1%.
State: South Carolina;
Number of complaints that required an investigation[A]: 168;
Number of complaints where an investigation was completed: 168;
Number of complaints that were substantiated with at least one federal
deficiency cited: 39;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 23.2%.
State: South Dakota;
Number of complaints that required an investigation[A]: 5;
Number of complaints where an investigation was completed: 5;
Number of complaints that were substantiated with at least one federal
deficiency cited: 3;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 60.0%.
State: Tennessee;
Number of complaints that required an investigation[A]: 922;
Number of complaints where an investigation was completed: 914;
Number of complaints that were substantiated with at least one federal
deficiency cited: 119;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 13.0%.
State: Texas;
Number of complaints that required an investigation[A]: 7,683;
Number of complaints where an investigation was completed: 7,678;
Number of complaints that were substantiated with at least one federal
deficiency cited: 666;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 8.7%.
State: Utah;
Number of complaints that required an investigation[A]: 174;
Number of complaints where an investigation was completed: 174;
Number of complaints that were substantiated with at least one federal
deficiency cited: 43;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 24.7%.
State: Vermont;
Number of complaints that required an investigation[A]: 153;
Number of complaints where an investigation was completed: 153;
Number of complaints that were substantiated with at least one federal
deficiency cited: 28;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 18.3%.
State: Virginia;
Number of complaints that required an investigation[A]: 517;
Number of complaints where an investigation was completed: 515;
Number of complaints that were substantiated with at least one federal
deficiency cited: 129;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 25.1%.
State: Washington;
Number of complaints that required an investigation[A]: 2,521;
Number of complaints where an investigation was completed: 2,519;
Number of complaints that were substantiated with at least one federal
deficiency cited: 423;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 16.8%.
State: West Virginia;
Number of complaints that required an investigation[A]: 345;
Number of complaints where an investigation was completed: 343;
Number of complaints that were substantiated with at least one federal
deficiency cited: 103;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 30.0%.
State: Wisconsin;
Number of complaints that required an investigation[A]: 1,059;
Number of complaints where an investigation was completed: 1,059;
Number of complaints that were substantiated with at least one federal
deficiency cited: 323;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 30.5%.
State: Wyoming;
Number of complaints that required an investigation[A]: 45;
Number of complaints where an investigation was completed: 45;
Number of complaints that were substantiated with at least one federal
deficiency cited: 12;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 26.7%.
State: Total;
Number of complaints that required an investigation[A]: 48,898;
Number of complaints where an investigation was completed: 48,796;
Number of complaints that were substantiated with at least one federal
deficiency cited: 9,476;
Percentage of complaints that were substantiated with at least one
federal deficiency cited: 19.4%.
[End of table]
Source: CMS's complaints database.
[A] Our analysis of complaints investigated and substantiated is
limited to the number of complaints that were entered into CMS's
database.
[End of section]
Appendix II:Performance Scores for Selected Nursing Home Complaint
Performance Standards, Fiscal Year 2009:
Alabama;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Alaska;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Arizona;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 31.2%.
Arkansas;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
California;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 85.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Colorado;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 93.8%;
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Connecticut;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 92.0%.
Delaware;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
District of Columbia;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Florida;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Georgia;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Hawaii;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 70.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 0.0%;
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 50.0%.
Idaho;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Illinois;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 84.5%.
Indiana;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Iowa;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Kansas;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Kentucky;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 89.8%;
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Louisiana;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 88.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 94.4%.
Maine;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 73.0%.
Maryland;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 50.0%;
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 59.5%.
Massachusetts;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 0.0%;
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Michigan;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 64.3%;
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 17.3%.
Minnesota;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 60.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 87.5%;
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Mississippi;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 83.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Missouri;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Montana;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 50.0%.
Nebraska;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Nevada;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 78.8%.
New Hampshire;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
New Jersey;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
New Mexico;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 72.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
New York;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 81.9%.
North Carolina;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
North Dakota;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Ohio;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 77.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Oklahoma;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 56.0%.
Oregon;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 93.0%.
Pennsylvania[A];
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 21.4%;
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Rhode Island;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 84.0%.
South Carolina;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 62.6%.
South Dakota;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Tennessee;
Prioritization of complaints: Pass or fail: Fail;
Passing score = 90%: Score: 83.0%;
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 41.9%;
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 47.8%.
Texas;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 36.0%.
Utah;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Vermont;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Fail;
Passing score = 95%: Score: 77.0%;
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 69.0%.
Virginia;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Fail;
Passing score = 95%: Score: 32.5%.
Washington;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
West Virginia;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Wisconsin;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Wyoming;
Prioritization of complaints: Pass or fail: Pass;
Passing score = 90%: Score: [Empty];
Timeliness of immediate jeopardy investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty];
Timeliness of actual harm-high investigations: Pass or fail: Pass;
Passing score = 95%: Score: [Empty].
Source: CMS data.
Pass: passed performance standard.
Fail: failed performance standard.
An [Empty] in the score column indicates that the state received a
passing score (at least 90 percent for the prioritization of
complaints standard and at least 95 percent for the timeliness of
investigation standards for immediate jeopardy and actual harm-high
complaints).
[A] Pennsylvania officials reported that the state did not pass the
prioritization of complaints standard because it required all
complaint investigations to be initiated within 48 hours and survey
agency staff therefore assigned a priority level of immediate jeopardy
to nearly all complaints. Because CMS guidance on this standard was
not clear in fiscal year 2009, the CMS regional office that assessed
Pennsylvania's performance considered complaints assigned a priority
level higher than warranted to be inappropriately prioritized and
therefore gave the state a failing score on this standard.
[End of table]
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
Department Of Health & Human Services:
Office of the Assistant Secretary for Legislation:
Washington, D.C. 20201:
March 23, 2011:
John Dicken:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Mr. Dicken:
Attached are comments on the U.S. Government Accountability Office's
(GAO) draft report entitled: "Nursing Homes: More Reliable Data and
Consistent Guidance Would Improve CMS Oversight of State Complaint
Investigations" (GA0-11-280).
The Department appreciates the opportunity to review this report prior
to publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health and Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled,
"Nursing Homes: More Reliable Data And Consistent Guidance Would
Improve CMS Oversight of State Complaint Investigations" (GAO-11-280):
The Department appreciates the opportunity to review and comment on
this draft report.
GAO Recommendation No. 1:
To assure that information entered into CMS's complaints database is
reliable and consistent, we recommend that the Administrator of CMS:
* Identify issues with data quality and clarify guidance to States
about how particular fields in the database should be interpreted,
such as what it means to substantiate a complaint.
Centers for Medicare & Medicaid Services' (CMS) Response:
We agree with this recommendation. CMS will establish and convene a
complaints workgroup which will include CMS Central Office, Regional
Offices and State Survey Agency staff. The purpose of the workgroup
will be to better understand the current systems in various States and
regions that are impacting data quality, and the lack of consistency
regarding substantiating a complaint. The workgroup will be tasked to:
* Develop further baseline information useful to the analysis of
issues relative to complaint investigation and enforcement of
deficiency remediation;
* Review, analyze and identify recommendations for standardizing the
process for oversight of the complaint investigations.
GAO Recommendation No. 2:
To strengthen CMS's assessment of State survey agencies' performance
in the management of nursing home complaints, we recommend that the
Administrator of CMS take the following three actions:
* Conduct additional monitoring of State performance using information
from CMS's complaints database, such as additional timeliness measures;
* Assess State survey agencies' performance in certain areas—-
specifically, documentation of deficiencies, prioritization of
complaints, and quality of investigations-—less frequently than once a
year; and;
* Assure greater consistency in assessments by identifying differences
in interpretation of the performance standards and clarifying guidance
to State survey agencies and CMS regional offices.
CMS Response:
We agree with this recommendation and with the need for greater
overall consistency throughout the survey process. As such, CMS will
continue to examine options for utilizing complaints as well as other
data sources more effectively to ensure greater consistency.
CMS will convene the aforementioned workgroup, however, to review the
three actions identified above. The workgroup will be used to analyze,
identify and develop recommendations for conducting a standardized
quality Federal oversight process for complaint investigations.
The workgroup would identify, based upon suggested criteria and
specifications, how CMS could most effectively implement quality
monitoring.
GAO Recommendation No. 3:
To strengthen and increase accountability of State survey agencies'
management of the nursing home complaints process, we recommend that
the Administrator of CMS take the following three actions:
* Clarify guidance to the State survey agencies about the minimum
information that should be conveyed to complainants at the close of an
investigation;
* Provide guidance encouraging State survey agencies to prioritize
complaints at the level that is warranted, not above that level; and;
* Implement CMS's proposed plans to publish State survey agencies'
scores but limit publication to those performance standards that CMS
considers the most reliable and clear.
CMS Response:
We agree with this recommendation. In order to implement these
recommendations, CMS will:
* Provide increased guidance to States regarding the minimum
information that must be conveyed to complainants at the close of an
investigation; and;
* Provide clarification and guidance for assuring that complaints are
prioritized at the appropriate level.
We will work with States and others in identifying the key information
regarding State performance that will be of public value.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
John E. Dicken (202) 512-7114 or dickenj@gao.gov:
Acknowledgments:
In addition to the contact name above, Walter Ochinko, Assistant
Director; Jennie Apter; Shaunessye Curry; Christie Enders; Nancy
Fasciano; Dan Lee; Lisa Motley; Matthew Rae; and Jessica Smith made
key contributions to this report.
[End of section]
Related GAO Products:
Nursing Homes: Complexity of Private Investment Purchases Demonstrates
Need for CMS to Improve the Usability and Completeness of Ownership
Data. [hyperlink, http://www.gao.gov/products/GAO-10-710]. Washington,
D.C.: September 30, 2010.
Poorly Performing Nursing Homes: Special Focus Facilities Are Often
Improving, but CMS's Program Could Be Strengthened. [hyperlink,
http://www.gao.gov/products/GAO-10-197]. Washington, D.C.: March 19,
2010.
Nursing Homes: Addressing the Factors Underlying Understatement of
Serious Care Problems Requires Sustained CMS and State Commitment.
[hyperlink, http://www.gao.gov/products/GAO-10-70]. Washington, D.C.:
November 24, 2009.
Nursing Homes: Opportunities Exist to Facilitate the Use of the
Temporary Management Sanction. [hyperlink,
http://www.gao.gov/products/GAO-10-37R]. Washington, D.C.: November
20, 2009.
Nursing Homes: CMS's Special Focus Facility Methodology Should Better
Target the Most Poorly Performing Homes, Which Tended to Be Chain
Affiliated and For-Profit. [hyperlink,
http://www.gao.gov/products/GAO-09-689]. Washington, D.C.: August 28,
2009.
Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine
Its Approach for Funding State Oversight of Health Care Facilities.
[hyperlink, http://www.gao.gov/products/GAO-09-64]. Washington, D.C.:
February 13, 2009.
Nursing Homes: Federal Monitoring Surveys Demonstrate Continued
Understatement of Serious Care Problems and CMS Oversight Weaknesses.
[hyperlink, http://www.gao.gov/products/GAO-08-517]. Washington, D.C.:
May 9, 2008.
Nursing Home Reform: Continued Attention Is Needed to Improve Quality
of Care in Small but Significant Share of Homes. [hyperlink,
http://www.gao.gov/products/GAO-07-794T]. Washington, D.C.: May 2,
2007.
Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
Deterred Some Homes from Repeatedly Harming Residents. [hyperlink,
http://www.gao.gov/products/GAO-07-241]. Washington, D.C.: March 26,
2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety. [hyperlink,
http://www.gao.gov/products/GAO-06-117]. Washington, D.C.: December
28, 2005.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. [hyperlink,
http://www.gao.gov/products/GAO-03-561]. Washington, D.C.: July 15,
2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. [hyperlink,
http://www.gao.gov/products/GAO-03-187]. Washington, D.C.: October 31,
2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. [hyperlink,
http://www.gao.gov/products/GAO-02-279]. Washington, D.C.: February
15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-197]. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-6]. Washington, D.C.: November
4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-154R]. Washington, D.C.:
August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing
Homes Has Merit. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157]. Washington, D.C.: June
30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-80]. Washington, D.C.: March
22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46]. Washington, D.C.: March
18, 1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-98-202]. Washington, D.C.: July
27, 1998.
[End of section]
Footnotes:
[1] Medicare is the federal health care financing program for elderly
and certain disabled individuals. Medicaid is the joint federal-state
health care financing program for certain categories of low-income
individuals. According to CMS's Office of the Actuary, combined
Medicare and Medicaid payments for nursing home care in both
freestanding and hospital-based nursing homes were about $89 billion
in calendar year 2009.
[2] State survey agency staff enter information about complaints into
the Automated Survey Processing Environment (ASPEN) Complaints/
Incidents Tracking System (ACTS) and upload certain complaint
information from ACTS to CMS's national Certification and Survey
Provider Enhanced Reporting (CASPER) database. We obtained the data we
analyzed from CASPER; we refer to these data as CMS's national
complaints data.
[3] Facility-reported incidents involve any suspected mistreatment,
abuse, neglect, or misappropriation of resident property. Throughout
this report, we refer to facility-reported incidents simply as
incidents.
[4] State survey agencies also investigate allegations that state
requirements were violated; however, we did not include those
complaints in our analysis.
[5] For example, if surveyors confirm that a resident has a pressure
sore as alleged in a complaint, some state survey agencies would
consider the complaint to be substantiated even if the sore was
acquired through no fault of the nursing home and was being treated
appropriately by the home.
[6] Although surveyors can cite a nursing home for an unrelated
deficiency found during a complaint investigation, the data we
obtained from CMS included only data on deficiencies related to the
complaint. Information about federal deficiencies cited during
complaint investigations that were unrelated to the complaint is
stored in a separate CMS database.
[7] We determined these standards were most reliable because the
scoring methodologies were objective, raised relatively few concerns
on the part of the state survey agency officials we interviewed, or
both.
[8] In addition, CMS officials told us that including incidents in
performance assessments should not greatly affect states' scores, as
state survey agency staff probably do not make a distinction between
complaints and incidents when prioritizing or investigating them.
[9] We chose a judgmental sample of six states and the three CMS
regional offices that oversee them based on state survey agencies'
performance on the four performance standards that pertain to nursing
home complaints. Specifically, we selected pairs of states--one that
performed well on the standards and another that performed poorly--in
regions where there were states in each category.
[10] The other audit agencies include the Office of the Auditor
General of Canada and the Office of the Inspector General of the U.S.
Environmental Protection Agency.
[11] No onsite investigation is required for complaints assigned any
of the four other priority levels: administrative review/offsite
investigation; referral--immediate; referral--other; or no action
necessary.
[12] Two states--Washington and Pennsylvania--were granted waivers
from implementing ACTS on January 1, 2004, and were simply required to
provide summary information on complaints to CMS. Washington did not
begin using ACTS until January 1, 2006, and Pennsylvania did not do so
until April 1, 2009.
[13] In addition to complaints, the system assesses state survey
agencies' performance in other areas, such as enforcement actions.
[14] CMS considers complaints substantiated when the investigation
determines that at least one allegation occurred. Federal deficiencies
are cited when the nursing home has failed to meet federal quality
standards. Some state survey agencies have differing interpretations
of what constitutes a substantiated complaint. As a result, we chose
to report data about complaints that were substantiated with at least
one federal deficiency cited as we believe these data to be more
consistent across states than data on all complaints reported to be
substantiated. In our analysis, we did not include cited state
deficiencies and hereafter use the term deficiencies to refer to
federal deficiencies.
[15] As previously noted, data are for complaints that allege a
violation of federal requirements. Additionally, CMS's national data
may not include all complaints received by the state survey agencies,
because the agencies may not have entered them into CMS's complaints
database. As a result, the data we received from CMS represent some,
but likely not all, of the nursing home complaints received by state
survey agencies.
[16] The population of nursing home residents in these six states
represented about 30 percent of all nursing home residents in 2009.
[17] One possible reason for some of the differences in complaint
rates among states may be the extent to which the state survey
agencies enter complaints into CMS's database.
[18] The other sources included other state agencies, ombudsmen,
former staff, friends, physicians, and other health providers.
[19] These four levels were administrative review/offsite
investigation, referral--immediate, referral--other, and no action
necessary.
[20] Most complaints had one allegation (44 percent), two allegations
(23 percent), or three allegations (15 percent). Ninety-eight percent
of all complaints had seven or fewer allegations.
[21] According to CMS data, approximately 4,400 complaints did not
require an onsite investigation either because the complaint was
referred to another agency, because only an offsite investigation/
administrative review was necessary, or because no further action was
needed.
[22] An investigation had not been conducted for these complaints at
the time of our analysis. However, CMS does not require that an
investigation be initiated within a certain time frame for actual harm-
medium complaints, only that one be scheduled. Additionally, for
complaints prioritized as actual harm-low, CMS requires that the
complaint be investigated at the next onsite survey of the nursing
home involved in the complaint.
[23] To account for possible state holidays that may have occurred
between when an immediate jeopardy complaint was received and when it
was investigated, we added an additional day to our calculation of
whether these complaints were investigated within the required 2
working days. During its performance review, CMS makes an allowance
for state holidays for immediate jeopardy complaints but not for
actual harm-high complaints.
[24] The majority of allegations associated with investigated
complaints were unsubstantiated because of lack of evidence.
[25] As previously noted, we chose to present CMS's assessment of
state survey agencies' performance for the two standards--timeliness
of investigations and prioritization of complaints--for which we had
data that were sufficiently reliable for our purposes.
[26] As previously noted, these standards assess performance with
respect to both complaints and facility-reported incidents for nursing
homes, as well as other facilities. We refer to these standards as
nursing home complaint standards.
[27] National complaints data that we received from CMS were for
calendar year 2009. Data we received from CMS about state survey
agencies' performance on the nursing home complaint standards were
fiscal year data and are referenced as such.
[28] The percent calculation for the timeliness of complaint
investigations includes those complaints where the investigation was
required but not completed but excludes those complaints where the
data to determine timeliness of the investigation were missing.
[29] The scores indicate the percentage of complaints and incidents to
which the state survey agencies assigned a priority level that was
deemed appropriate by CMS reviewers. In fiscal years 2007, 2008, and
2010, CMS's guidance for the prioritization of complaints standard
specified that if the state survey agency assigned a higher priority
level to a complaint than the CMS regional office, the complaint
should be considered appropriately prioritized. Although this policy
was not specified in the fiscal year 2009 guidance, a CMS headquarters
official told us the omission was an oversight. However, at least one
CMS regional office was unaware of this and therefore considered
complaints that were assigned a higher priority level than was
warranted to be inappropriately prioritized.
[30] In contrast, an official of one state survey agency that
eliminated its separate complaint investigation unit said that having
that same staff conduct both standard surveys and complaint
investigations affords more flexibility and takes best advantage of
surveyors' familiarity with the facilities they inspect on a regular
basis.
[31] All of the letters also included contact information and some
explicitly invited complainants to call if they had questions about
the information provided, but only one (Michigan) provided
instructions for requesting a hearing in the event complainants were
dissatisfied with the agency's findings.
[32] Before the change in the scoring methodology for the
documentation of deficiencies and quality of investigations standards,
a state survey agency that scored below the overall performance
threshold for a standard on one or more requirements could still pass
the standard by scoring above the threshold on other requirements.
[33] This state (Alabama) had the second highest percentage of
complaints prioritized as immediate jeopardy in 2009 (40 percent,
compared with a national average of 10 percent) but was still able to
meet the timeliness of investigation standard for these complaints in
fiscal year 2009; the state's relatively low complaint rate of 17
complaints per 1,000 nursing home residents, compared with a national
average of 38 per 1,000, may have been a factor. Nineteen states that
passed the prioritization of complaints standard failed the timeliness
of investigations standard for actual harm-high complaints, immediate
jeopardy complaints, or both.
[34] This margin of error is based on a 95 percent confidence interval
around the states' scores.
[35] We are unable to determine the number of states with passing
scores that may actually have failed because the score sheet we
received from CMS indicates only that these states passed and does not
provide the percentage of cases that met the standard's requirements.
For one of the states that failed, the sample size in the data we
received is obviously in error.
[36] CMS officials from one regional office that we were told reviewed
only information in the complaints database said that the regional
office allowed states to submit additional information, including hard-
copy material, to dispute any negative preliminary marks in their
draft performance reports. However, officials from two states in the
region said either that they were not aware of this policy and
therefore had never submitted such material or that the regional
office had accepted only materials in the complaints database in such
disputes. As a result of our inquiries, the CMS regional office
clarified its policy during a conference call with states in the
region in January 2011.
[37] CMS headquarters officials acknowledged that some CMS regional
offices may rely on the investigation notes in the CMS database
because they lack the resources for more extensive reviews that may
involve travel to state agencies.
[38] In addition, as previously noted, the interpretation of the
prioritization of complaints standard varied among CMS regional
offices in fiscal year 2009, with some regional office reviewers
considering complaints prioritized above the level they would have
assigned to be appropriately prioritized while others considered such
complaints to be inappropriately prioritized.
[39] See Pub. L. No. 111-148, § 6103(a) and (b), 124 Stat. 119, 704-08
(2010) (to be codified at 42 U.S.C. §§ 1395i-3(i) and 1396r(i)). CMS
currently posts on the Nursing Home Compare Web site information about
specific deficiencies cited at nursing homes during complaint
investigations in addition to those cited during standard surveys.
[40] All three of the CMS regional offices in our sample reported
conducting training related to the nursing home complaint performance
standards. Some of the training--which included presentations at
regional meetings, Webinars, and sessions at individual state survey
agencies--was designed to address specific knowledge gaps identified
during performance reviews. For example, officials of one CMS regional
office told us that concerns about the high failure rate for the
quality of investigations standard had prompted them to dedicate part
of a regional meeting to training on survey planning, documentation,
and other issues raised by this standard.
[41] For example, national level training may occur through CMS
headquarters survey training Web site, which offers online courses,
archived Webcasts, and other resources. CMS headquarters officials
said they have addressed some of these performance issues by providing
guidance to state survey agencies, including a tool to assist with the
intake and prioritization of nursing home complaints. One CMS official
also noted that materials for CMS's basic training for nursing home
surveyors are updated partly based on information about training needs
gleaned through interaction with state survey agencies and CMS
regional offices, which may in turn reflect concerns raised by
performance reviews.
[42] See Pub. L. No. 111-148, § 6703(b)(1), 124 Stat. 119, 798-99
(2010).
[43] While CMS temporarily increased funding to some state survey
agencies in our sample so they could hire additional staff, a CMS
official told us that some state survey agencies are unable to use
temporary increases in funding to increase staffing.
[44] Officials said they have not had to reject corrective action
plans in part because their office had consulted with state survey
agencies before the plans were submitted.
[45] See 42 C.F.R. §§ 488.318, 488.320 (2010).
[46] State survey agencies that do not comply with statutorily set
time lines for standard surveys are assessed a nondelivery deduction
on the following fiscal year's federal funding allocation, which is
equal to 75 percent of the estimated cost of the uncompleted nursing
home or home health agency surveys, not to exceed 2 percent of the
state's overall survey and certification budget.
[47] GAO, Executive Guide: Effectively Implementing the Government
Performance and Results Act, [hyperlink,
http://www.gao.gov/products/GAO/GGD-96-118] (Washington, D.C.: June
1996), 34-35. U.S. Environmental Protection Agency, Office of
Inspector General, EPA Performance Measures Do Not Effectively Track
Compliance Outcomes (2006-P-00006) (Washington, D.C.: Dec. 15, 2005),
3.
[48] [hyperlink, http://www.gao.gov/products/GAO/GGD-96-118], 35.
[49] State survey agencies also investigate allegations that state
requirements were violated; however, we did not include those
complaints in our analysis. As a result, our analysis of the number of
complaints received may not fully portray state survey agencies'
complaints workload.
[End of section]
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