Medicare Home Health Agencies: Weaknesses in Federal and State Oversight Mask Potential Quality Issues
GAO-02-382
Published: Jul 19, 2002. Publicly Released: Jul 19, 2002.
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Highlights
The 6,900 Home Health Agencies (HHAs) that serve Medicare beneficiaries must meet federal requirements, known as conditions of participation (COP), to ensure that they have the appropriate staff, are following the plan of care specified by a physician, maintain medical records to document the care provided, and periodically reassess each patient's condition. Although nationwide surveys done at HHAs since 1998 have identified a small proportion of agencies with serious deficiencies, the extent of the problem may be understated, and dangerous situations affecting home health patients may occur more often than documented. Shortcomings in the survey process and inconsistencies in state surveys make it difficult to assess the quality of care delivered and may mask potential problems. The ability to lodge complaints about an HHA and have them resolved promptly is important to protecting patient health and safety. HHA oversight by the Centers for Medicare and Medicaid Services (CMS) has been too limited to identify the problems GAO found in the survey process. CMS does not review state compliance with requirements for conducting HHA surveys, such as whether HHAs with COP-level deficiencies are surveyed annually rather than every 3 years or whether minimum patient visit and medical record review samples are adhered to.
Recommendations
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| Given the significant delay in implementing intermediate sanctions for HHAs, Congress may wish to consider giving CMS a new deadline for issuing the necessary implementing regulations. | Congress has not taken action on this issue. GAO will continue to monitor Congressional activity on this issue. 2006 Update: We are closing this recommendation because we do not believe that Congress will act on our suggestion. However, according to the Director of CMS's Survey and Certification Division, CMS may issue an NPR for intermediate sanctions before the end of 2006. | |
| To better ensure that state surveys comply with statutory, regulatory, and other CMS requirements, Congress may wish to consider requiring CMS to conduct federal monitoring surveys of HHAs, with priority given to comparative surveys. | Congress has not taken action on this issue. GAO will continue to monitor Congressional activity on this issue. 2006 Update: We closed this recommendation because it had become apparent that Congress would not act on our suggestion. |
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | To strengthen the ability of the HHA survey process to identify and address problems that affect the quality of care, the Administrator of CMS should develop more specific branch oversight criteria and procedures for states and assign unique identification numbers for each HHA branch office to enable CMS to track survey results and facilitate its own branch oversight. | As of January 1, 2004, CMS assigned a branch identification number to every home health agency branch and entered the number into its OSCAR and ASPEN survey and certification data systems. In addition, CMS is developing branch outcome reports using OASIS data. The reports will allow surveyors to target their investigations of care practices on those branches with poor clinical outcomes. Before the reports can be used, CMS needs to (1) collect at least 12 months of patient assessment data to generate the branch outcome reports, (2) overcome potential data validity issues involving branches serving a small number of patients and branches serving the same patient, and (3) determine how to...
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| Centers for Medicare & Medicaid Services | To strengthen the ability of the HHA survey process to identify and address problems that affect the quality of care, the Administrator of CMS should develop more specific guidance and training for distinguishing between COP-level and lesser deficiencies and for improving the consistency across states in documenting deficiencies. | CMS conducted several training sessions for state home health agency surveyors in fiscal year 2003 and the training for home health surveyors has been enhanced to focus surveyors' attention on consistently identifying and documenting standard and condition-level deficiencies. In addition, CMS is in the process of convening a panel of home health agency survey experts to develop surveyor guidelines to improve the consistency of citing both standard and condition-level deficiencies. The panel is currently evaluating possible formats for such guidelines, e.g., a worksheet for guiding and documenting decision processes. The guidelines will be pilot tested during 2005 and CMS hopes to...
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| Centers for Medicare & Medicaid Services | To strengthen the ability of the HHA survey process to identify and address problems that affect the quality of care, the Administrator of CMS should improve the adequacy of the sampling process, such as increasing the size of the sample medical records and patient visits, to better determine the prevalence of quality-of-care problems. | Effective May 1, 2003, CMS instructed home health surveyors to begin using enhanced protocols to identify specific records and "at risk" patients for review during surveys. A scoring metric for identifying home health agencies with problematic outcomes is under development and will be tested in early 2005. August 2007 Update: CMS still plans to include guidance to surveyors on increasing the sample size in guidelines developed by a contractor. However, the guidelines are still under review and have not yet been issued. We need to check back with CMS next year. August 2007 Update: Guidance to surveyors that includes sampling has been developed by a contractor but has still not been...
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| Centers for Medicare & Medicaid Services | To strengthen the ability of the HHA survey process to identify and address problems that affect the quality of care, the Administrator of CMS should ensure that resources are adequate for states to fully comply with the requirement to survey all HHAs at least once every 36 months and certain HHAs more frequently. | August 2007 update: CMS revised and simplified its policy on HHA survey frequency. For example, it eliminated the requirement to survey new home health agencies within a year of their initial certification. These changes rendered our recommendation moot and the recommendation is being closed as not implemented. CMS restructured its fiscal year 2004 budget call letter to highlight that states must perform all statutorily required surveys, including home health surveys at least once every 36 months. CMS's fiscal year 2005 budget call letter reiterates this legal requirement. As the agency enhances the home health survey process, it intends to request the necessary resources to ensure...
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| Centers for Medicare & Medicaid Services | To ensure that the complaint process adequately addresses quality-of-care problems, the Administrator of CMS should ensure that states eliminate barriers to filing complaints by improving the accessibility and effectiveness of hotlines and by not requiring complaints to be filed in writing. |
Effective June 1, 2004, CMS published a new chapter of its State Operations Manual that consolidates procedures for reporting and investigating complaints, including those filed against home health agencies. This new guidance specifies that complaints do not have to be in writing.
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| Centers for Medicare & Medicaid Services | To ensure that the complaint process adequately addresses quality-of-care problems, the Administrator of CMS should monitor states' responsiveness to complaints, including developing assurances that serious allegations are promptly investigated and resolved. | CMS has taken steps to improve states' ability to properly identify and prioritize home health complaints in need of investigation. For example, CMS issued guidance in November 2003, which covers (1) complaint intake and triage procedures and (2) priority definitions and investigation requirements. Effective June 1, 2004, CMS revised the complaint chapter of its State Operations Manual by consolidating procedures for investigating complaints into a single document. In addition, CMS implemented an annual state performance standard in which it determines whether states are investigating all home health complaints alleging immediate jeopardy to resident and/or patient health and safety...
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| Centers for Medicare & Medicaid Services | To ensure that the complaint process adequately addresses quality-of-care problems, the Administrator of CMS should provide technical assistance to states as appropriate to develop consistently effective complaint tracking systems. | In January 2004, CMS implemented its new complaint tracking system nationwide. The new system, called the ASPEN Complaints/Incidents Tracking System (ACTS), is intended to improve the management and oversight of complaints by allowing states to create electronic intake records and update them as necessary. The system allows CMS and states to track complainants' allegations, investigations of complaints, referrals made to other investigating bodies, and how complaints are ultimately resolved. CMS has also taken steps to improve the consistency of how states track Medicare home health complaints. For example, during 2003, CMS conducted a web and satellite broadcast and issued guidelines on...
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| Centers for Medicare & Medicaid Services | To ensure that states comply with home health statutory, regulatory, and other CMS requirements designed to protect health and safety, the Administrator of CMS should adopt comprehensive state performance standards for HHAs, such as holding states accountable for (1) performing HHA surveys based on CMS's variable 12- to 36-month survey schedule and (2) improving the timeliness and reliability of states' Online Survey, Certification, and Reporting System (OSCAR) data entry. |
CMS has incorporated home health agency (HHA) criterion into its annual state performance standards. Thus, CMS now routinely evaluates states on the (1) timeliness of HHA surveys, (2) adequacy in which surveyors document survey findings, (3) timeliness of correcting condition-level deficiencies, and (4) timeliness and quality of complaint investigations.
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| Centers for Medicare & Medicaid Services | To ensure that states comply with home health statutory, regulatory, and other CMS requirements designed to protect health and safety, the Administrator of CMS should use OSCAR and other means to monitor and assess state survey performance on an ongoing basis. | CMS has created a web-based data reporting system, known as PDQ (Providing Data Quickly), which accumulates and stores data related to a variety of home health agency survey activities. The home health agency reports available on PDQ for CMS and all 50 states and the District of Columbia include (1) detailed demographic information for active, new, and terminated providers, including those with branch locations; (2) provider-specific and summary data for home health agencies scheduled to be surveyed as prescribed by CMS's 4- to 36-month survey cycle, including those that are overdue; and (3) detailed deficiency information, including the number and percentage of recertification and...
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