begin a second panel we have mr david zimmerman who is the director of the center for health services research analysis at the university of wisconsin madison dr andrew kramer who is professor of medicine head of colorado division mary jane corrine who is chair of the american healthcare association's advancing excellence campaign will wait for you who is the former nursing home worker and president of pennsylvania service employees international union as you know it's a policy of this subcommittee to take all testimony under oath please be advised that witnesses have the right under the rules of the house to be represented by counsel do any of you wish to be represented by counsel during your testimony and onesies be shaking their heads no i'll take it as a no they're from asking a pretty please rise raise your right hand take  members shimkus and honorable members of the subcommittee i thank you for the opportunity to testify today i'm the president of health care pennsylvania and i'm here today speaking on behalf of sci use one point nine million members including one hundred fifty thousand nursing home workers nearly thirty five years ago i began my working life as a nursing assistant in a large public nursing home even today i can remember my first day on the job the challenge providing quality compassionate care and support for the frail elderly residents intrusted to me i've seen a great deal of progress since that time but i'm here today out of a great concern about our ability to continue that progress a new player has entered the nursing home world private equity firms sci u is deeply concerned that the private equity business model which seeks to make extreme profit while operate at the expense will operate at the expense of nursing home residents their families caregivers and taxpayers buyout firms operate behind a veil of secrecy that allows them to conceal virtually all aspects of their business from regulators and affected stakeholders others have testified today and at other congressional hearings about the tragedies that occur too often in nursing homes these tragedies will only continue because federal laws and regulations have failed to keep pace with the trends in nursing home ownership and financing which are placing many homes in financial jeopardy while making it increasingly difficult to hold them accountable for patient care problems the industry has moved towards increasingly complex corporate structures and highly leveraged buyouts for example last year the carlyle group completed a six point six billion dollar leveraged buyout of manor care it remains unclear how carlisle manor care will service such high debt without some effect on care plain common sense suggests that there's is reason to be worried about cost cutting pressure at a company that's just taken on almost five point five billion in new debt are we really to believe carlyle's investment plan for man or care is to drive a profitable company deeply into the red and not cut costs of which staffing is one of the largest to keep its investment profitable there is a real concern that nursing homes involved in highly leveraged buyouts will cut staffing to pay off debt this raises concern both about the safety of residents and about the value taxpayers are getting from medicare and medicaid dollars in addition to the concern of inadequate staffing there is a fundamental lack of transparency in the nursing home industry nursing homes today employee ownership structures that obscure who is actually responsible for decisions that impact the quality of care in the facility buyout firms set up  sometimes or hundreds of entities involved to run their nursing homes and avoid liability often separating the real estate asset holdings from the operations such diffuse structures become even more complex when employed by large chains which may create multiple layers of corporate shields that stand between the ultimate parent company and the facility level elsie's nursing home chains have used such structures in the past to frustrate efforts by regulators to hold parent companies accountable for the care provided in their facilities and to obscure transactions and self dealing between related parties c m a c m s has previously testified that they do not know who owns all nursing homes in this country this despite the fact that the nursing home industry receives seventy five billion dollars a year from medicare and medicaid how can congress accept this twenty years ago it was at the urging of courageous reformers like chairman dangle and pennsylvania's republican senator the late john heinz that congress passed landmark nursing home reform legislation the real question before us whether congress will show the political urge today to once again passed significant nursing home reform in february senators grassley and cole introduced the bipartisan bill s twenty six forty one the nursing home transparency and improvement act and representative stark  indicated that though introduced similar legislation soon congress will likely pass a medicare bill this year the senate is currently negotiating legislation which means there's an opportunity to attach s twenty six forty one a no cost bill and i invite the industry to work with us to pass as twenty six forty one we commend many in the industry who have recognized the need for greater transparency however the for profit industry appears to be blocking this legislation we stand ready to work with them but if they choose to continue lobbying against this bill then i urge congress to stand up to the industry pressure and stand with the vulnerable seniors who count on their members of congress to represent their interests hearings are not enough your constituents want to take real action and not simply talk about the problem taxpayers trust that medicare and medicaid dollars will go toward providing seniors with quality care they deserve and will not become profit at the expense of nursing home residents congress must exercise its overthe oversight authority to ensure that medicare and medicaid dollars are spent as intended to provide high quality care we must not fail to protect our seniors and we cannot allow the bad actors in the for profit nursing home industry to continue to let our seniors down and block attempts to pass meaningful reform with s twenty for your opening statement sir good afternoon mr chairman as a fellow yooper that would be dollar bay michigan i'm especially pleased to be here this afternoon my name zimmerman i'm a professor of health systems engineering at the university of wisconsin madison and i'm the director of the center for health systems research and analysis at u w madison i'm also the president of the long term care institute a nonprofit organization created to assist in the monitoring of quality of nursing home care in organizations with corporate integrity agreements with the office of the inspector general within the department of health and human services as researchers and monitors are clinicians and analysts have conducted visits to more than one thousand nurses in homes in the past eight years we have observed or participated in more than one hundred quality improvement meetings including more than thirty such sessions at the corporate level of organizations i have spoken to at least fifteen corporate boards or board committees and met with individual board members about quality of care issues so we have been observing and analyzing the care of nursing home residents and the systems that govern this care from the bridge from the bedside to the boardroom what are some of the things we have learned from this rich field experience one thing that is very clear from our experience is that there is tremendous variation in the quality of care by facility by unit and area of care within a facility by district and region and across nursing home corporations as a whole even the best performing organizations have pockets of mediocrity and performance and even in the worst performing organizations there are facilities that deliver good care it is this inconsistency that represents one of the most difficult challenges to overcome and yet it also represents a significant opportunity to take a systems approach to improving nursing home quality of care frankly another thing that comes out loud and clear f morefield experience is that there is an arguable need for transparency in the provision of nursing home care others have spoken to this issue and frankly i'm astonished that it still is even a subject of debate what else have we learned well we have some pretty solid pulmonary evidence that monitoring has had a positive impact on improvement in regulatory outcomes at least for the national and regional corporations that have been the subject of our work in our analysis the initial findings are also quite positive in terms of the effect of monitoring on reducing excessive rates of resident functional and clinical impairment in addition we have substantial anecdotal i don't know whether it's including feedback from the providers themselves that monitoring has had a productive impact on their quality assurance and quality improvement initiatives how does monitoring help we believe the presence of monitors and monitoring activities has elevated the importance of the internal compliance function within the organization themselves and it is difficult to exaggerate the importance of this having a more important and a more prominent compliance function within the within the facility and the organization not only improves the quality of care but imbues the organization with an enhanced culture of quality by making compliance a more visible and integral part of the leadership and management of the organization our experience has been that this increased presence and in visibility as well as the existence of a more direct line of communication between compliance and top leadership including the board can lead directly to improved care and it can help put quality of care on an equal footing with financial stewardship within the organization another advantage of the monitoring process is that can it it can help to expand the quality assurance function beyond individual facilities to levels of organization that can more effectively make things happen to implement quality initiatives initiatives and help to sustain them throughout the organization another important contribution and one which we stress greatly in all of our work is the emphasis on systems of care and quality assurance at all levels of the organization probably the single most important insight from our monitoring work has been the importance of developing and sustaining effective systems of care which along with good policies and procedures can promote more consistent care across units facilities districts and regions of organizations too often we find that such consistency is lacking and it was through continuous interaction with the organization including at the top levels that this commitment to consistency and capability to bring about consistency was achieved a critical corollary point in it is is that implementing and sustaining good systems of care and quality assurance demands loyalty to what we have come to refer to as the v word validation to many times we have found that those responsible for the oversight of quality unmonitored organizations would accept without validation assurances of compliance with policy or that care protocols were being carried out as documented or reported yet validation did not confirm that this was true when quality assurance efforts include valid validation that what was said what was happening what was said was happening was indeed happening consistently then care improved markedly validation must be a fundamental part of any effective quality oversight function or any quality initiative that the industry or the regulatory community undertakes this of course includes validation of staffing levels and staff co so in conclusion we believe that the internal compliance function is absolutely essential to meaningful quality improvement and quality assurance it can work side by side with the regulatory community to bring about lasting quality of care for nursing home residents thank you thank you you're going to find in dollar bay dr kramer your opening please sir good afternoon mr chairman shimkus members of the committee i'm a physician and a professor of medicine and health policy and about ten years ago i was over the way at in the hart building and gave testimony similar to this before the senate special committee on aging and chairman grassley asked me at that point how come the methods i use in research are not currently being used in the survey process because i had testified about all sorts of problems with subjectivity and inconsistency in the survey process and my response was that i didn't know and then in one nine hundred ninety eight they began the  development contract in that and dr zimmermann act and i worked together on some they had early development on q i s so ten years later where are we well we still have very good nursing homes out there we've got good nursing homes out there we've got not so good ones and we've got poor ones and the problem is that today you still can't tell from the information that publicly reported or the information in the survey process which nursing homes fall in which categories you can't tell you know i can't even tell from the information published out there and that's a serious problem we have enforcement problems because we don't have a system that people are confident about and i've shown that in some recent case study work and we don't even have a national standard that's widely distributed that says this is quality and you better meet but we are making some progress and we're making some progress in six states that are now implement have now implemented the quality indicator service i want to tell you a little bit about the progress we've made because i think it's very porton for today's discussion and c m s is moving towards wider rollout of that national rollout of q i s but it's very very slow so q i asked what's the difference here with  s takes much larger samples of residents and facilities people who are residing there in new admissions and as somebody said earlier they talked in the q o s survey you talk to the residents you talk to forty of them you ask them questions you ask them you know do you have a choice about when you get up in the morning you ask them whether they have oral pain you find out if they've you find out about their nutrition you ask them all sorts of questions you make structured observations you pull information from records you pull weights out of charts you ask them if they're on a weight loss program you use that information there's one hundred sixty two indicators that are used in the first two days of q i s that book that cover the code of regulations and that's what the q o s is based on is regulations the regulations so this is the process there's another piece about the process it's very very exciting the data it's very structured very data driven and so at the end you can audit what surveyors are doing with all that information and in june we're actually training the the regional office oversight people to use that same information on their oversight projects so let's talk for a minute about what the impacts of us have been well first of all the surveys you look at the surveys in the states has been over seven hundred surveys that are q o s has over two hundred fifty people trained in doing q i asked what's going out there so the surveyors eighty plus percent of them said they would never go back to the traditional process now there's those that don't like this imposed structure because it is more structured deficiencies were finding deficiencies that were in the code or regulations that never showed up before the fishing season dental health oral pain because we ask people about oral pain there's programs in in a couple of the q o s states that are being led now by the associations by the americal dental and merican dental association to actually start providing oral health care inside nursing facilities hospitalization is one  targets quality of life choices the kinds of things the culture change movement has embraced q i s because of the importance of those areas so there's there's another issue about consistency another impact and consistency there was when i first went to one of these states a group of providers came up to me and i was presenting about q o s and a group of providers came up to me and they said dr we're getting a huge increase in efficiencies in our district office guess what this was a district office that had a long history of low deficiencies because the process was not consistent there's been one more impact and that's on providers providers have started to embrace and use these tools of q o s for quality improvement a bad q i s survey they use the tools and they move in that direction and so so the question next is why has it taken ten years to get this out in six states and i'm going to wrap up with those points first of all development development took many many years we had to build all sorts of systems under c m s contract to make this happen and so there was a lot of great deal development work there was an evaluation that took extra time twice as long as it was expected and that slowed things down secondly everybody criticizes the survey process but there is reluctance to change this or lock since everywhere and it's been been a big effort to work together at this stage there is a core group in c m s of about eight people that have been very strong advocates of to us but it has taken some time and now they are strong strong the advocate and then the final issues budget fifteen states applied to be q i s days after the first word came out one of them was chosen minnesota at that point the others what they didn't have a budget to roll it out and that is the been the biggest problem the budget has been uncertain the commitment to it has been uncertain the budget commitment is beyond certain and so basically it would take twenty million dollars one time to roll q o s out in every one of the other states over the next several years and that's the one recommendation i would have to make thank you thank you mr pruitt your opening pl success and remaining challenges we face in ensuring quality nursing home care for nearly forty years my family owned company has been providing professional health care services throughout the southeast where nearly eight thousand employees we touched lives of more than eighteen thousand individuals daily and we have a long standing tradition of quality and a commitment to caring i am proud of the advances of our profession has made in delivering high quality care and we remain committed to sustaining these gains in the future when demand for care will dramatically increase data tracked by c m s clearly illustrates improvements in patients out outcomes increase and overall direct care staffing levels and significant decreases in quality of care survey deficiencies in our nation's skilled nursing facilities positive trends are also evidence by initiatives including quality forests in the advancing excellence in america's nursing home campaign which are having a significant significant impact on the quality of care provided the advancing excellence campaign is a coordinated initiative among abiders caregivers consumers c m s and others that promotes quality and encourages best practices and evidence based processes this voluntary initiative is working and outcomes and processes are improving we remain committed to building upon quality improvements into the future twenty one years ago passage of over eighty seven brought forth significant changes in our approach to patient care today we are in danger of abandoning the abandoning the original intent of over eighty seven in favor of a regulatory system that defines quality and context is often measured by fines and violations whether than quality of care quality of life as is route was originally intended we believe that a reform and effective survey process here to embody three guiding principles survey should be fair accurate and consistent they should protect the health and safety of the res and they should focus on requiring improvement and problems in our areas we must revamp the system ensure the quality of life isn't the size consistent with intent of over eighty seven we know the vast majority of nursing homes provide high quality compassionate care that patients and their families want and deserve however we must recognize there is a very small fraction of the sill of these that do not meet these high standards of quality care there should be in sense rather than current distance new operators to take over troubled facilities and improve the care of the patients u h s pruitt has a history of parchin facilities that have had trouble survey record and turning them into top tier performing nursing facilities we have been successful  working with the regulatory agencies in georgia north carolina and south carolina to improve the quality of care delivered to those that we serve i am proud of our organizations ability to improve underperforming facilities and make them a better pay place for our patients however these efforts do not come without risk or difficulties last year we purchased a facility in monks corner south carolina this was a facility with the s s designation which needed six significant investment to reform it into a better environment that embraces the constructs of culture change implements advances including information technologies and has increased staffing levels prior to our purchase this facility would have been issued to medicare notice of terminations and efforts were underway to relocate more than one hundred thirty patients further the center was one of the first to enter into a settlement agreement with c m s upon transfer of ownership this agreement was renamed  systems improvement agreement i believe that this type of agreement is a model for government provider close collaboration to improve care and underperforming nursing centers before purchase we presented a performance improvement plan to c m s in the south carolina department of health and environmental control both regulatory agencies offer valuable feedback on the past performance of the facility and the likely effect of innes of our plan to address past performance deficiencies our team ho periodic briefings with both agencies these briefings are honest and open and a focus on each even outcomes that will benefit patient care while i'm the first in that the facility is still far from perfect we are proud of our efforts and the outcomes we have seen investment to improve the facility however we have still not been approved for medicare certification and thus have not received any medicare payments for the improved care and services we continue to provide we know that encouraging the purchase of troubled facilities can help patient care but there remain significant barriers with the current change of ownership process to be recognized and changed there are a waste improve the regulatory process and ensure that current safeguards are adequate and appropriate one inherent flaw with the current survey process is incredibly subjective by nature this is because the review relies upon individual interpretation there is however one system that has been mentioned that shows promise in reducing the human interpretation and subjectivity the quality indicator survey we applaud c m s this latest attempt to minimize human variability although it is too early to draw conclusions on q i s h c a is cautiously optimistic that the process will help correct some of the inadequacies of the current system why i've provided a more thorough list of recommendations for a smarter oversight system in my written statement some ideas include congress to establish a pilot program in a few states that would require funds collected through civil monetary penalties to be put back into the system to improve quality care congress great a national commission that includes all long term care stakeholders to best determine what information would provide assistance to consumers and how it should be made available encourage the posting of more complete staffing data on nursing home compare we also urge congress to pass the long term care quality and modernization act of two thousand and seven we are proud of the advances we have made in delivering high quality long term care and we remain committed to staying in these gains in the years and decades to come thank you for the opportunity to offer these i'm here to testify in my own behalf as an expert in this field besides having been a nursing home physician and having had a father in a nursing home from nine hundred eighty seven to one thousand nine hundred two i was a director for survey and certification for new york state i've also been privileged to be a member of the national commission on quality long term care which was chaired by former senator bob kerrey and former house speaker newt gingrich currently i'm an assistant vice president the commonwealth fund where i direct a program to improve nursing home quality and i have the honor to be this year's chair of the steering committee for advancing excellence which if i may comment is actually an independent coalition of stakeholder groups and is really not sponsored by any one given organization this advancing excellence so far has overseen forty three percent of the nursing homes in the country as participants i'd like to thank you chairman stupak and also ranking member shimkus and every member of the committee for conducting these hearings today since recent events have brought to light important issues with the nursing home oversight system and how quality may be achieved in the nation's nursing homes i'd like to tell you about some of the positive changes that have been occurring in that continue to spread i believe that survey and foresman is a critically important undertaking because it really sets a floor of what we expect all her nursing should be doing i also think it should be easy to find out where the buck really stops when there are problems so that they can be fixed expeditiously and permanently however while i agree that our current survey system of oversight could and should be improved i don't think we should rely on the regulatory process to improve quality of care alone and we certainly shouldn't ask our surveyor to become consultants to the industry there are other ways government can help improve nursing homes for example washington state has a quality assurance nurse program as a separate and distinct unit from its survey agency in addition the federally supported quality improvement organization program could be charged to help nursing homes come into compliance after survey and continue to work collaboratively with voluntary it's such as happening now with two initiatives which i'd like to tell you about briefly one is the first is called culture change it's a grassroots movement which began about fifteen years ago when a number of people suddenly tapped into over eighty seven's potential to promote resident centered care and to really try to turn or sink comes into homes picture a nursing home where you can stay up to watch the end of the ballgame you can get yourself a midnight snack and then your help to bed by somebody who actually knows you and all your little quirks this is light years away from business as usual but it is something that is happening more and pleasurable whether you stay in a nursing home for five days or whether you stay there for five hundred days findings from a recent national survey of nursing home supported by the commonwealth fund show that over half the facilities in the field say that they are either doing to try to make themselves more resident centered or that their leadership is committed to the principles of resident centered care and that they will begin shortly likewise the survey found that adopters are beginning to see a positive impact on their bottom line  improvement organization programs a scope of work borrowed from the culture change movement to target things like how to retain staff and ways to help staff really get to know their residents and to test residents satisfaction this boosted industry interest across the industry in residence centered care at the same time c m s is office of survey and certification has been trying to ensure that the survey process itself not become a barrier to innovation the other positive development is advancing excellence which several of you here have mentioned today this effort is less than two years old the campaign's national steering committee which as i said i do chair is made up of an unprecedented coalition of thirty organizations including provider associations health professionals unions consumer advocacy groups and representatives from c m s the collaborative spirit of the group itself deserves be counted as one of its most noteworthy accomplishments the campaign has been very successful so far it's open to all nursing homes not just those an association it also seeks support and participation from consumers and frontline staff were tracking the clinical goals and results already show that it's working participant homes are improving at a faster rate for the clinical goals than homes which have not yet joined forty nine state level networks have been established that are very efficient ways to get good ideas out there and provide technical assistance to homes one one web in our call that we had we had over ten percent of the industry actually on that call to hear about evidence best evidence based ways to improve performance in taking care of pressure alters in addition i'd like to conclude my remarks by observing that there are a number of steps congress could take that would really support current voluntary efforts while at the same time improving transparency and the regulatory process they include the c m s website nursing home compare include information on multiple staffing characteristics and the rate of consistent assignment and also perhaps whether or not a nursing home is participating and in the advancing excellence also a should be charged with developing payment methods that would reward nursing homes part as participating in the campaign or achieving results on the doctor and resident centered care practices also see him a should be encouraged to continue to make long term care long term commitments to supporting advancing excellence in similar efforts at quality improvement perhaps also we should direct c m s to funding conducted demonstration to pilot other ways to provide technical assistance that could be linked to the survey process but not be provided by the survey agency and lastly that c m s be directed to continue to vigorously pursue its work on using resident put to improve the assessment the care planning and the survey findings another report shows only about a quarter of the deficiencies practices are detected by the surveyors and it was that well the that report was based on going in and using the methods that are used in the quality indicator survey concurrently with surveys and it was done in twenty six the philippines and one of the things that was very evident is that without the structure of something like quality indicators survey the surveyors are faced with this regulations that they're trying to interpret they have interpretive guidance to figure out how to do this and there's no structure to fall and in the end the documentation that comes out of it is not strong enough for them to compile and  in the q i s and the structure that was used in these case studies it's a much more methodical repeatable replicable process you get q o s and then you have the other current where they do the surveys to get the current way of doing surveys as i've heard from mr pruitt dr korn and others that it's basically more subjective than yes that's what the case study showed and that is that the in can system c then depending on the well the enforcement is the you know the next next step but enforcement actually can get watered down if you don't have really clear evidence of the problem and good documentation and the problem is that the current process as it's structured they invest a lot of resources in it but because that structure is not there they don't get the information that's needed in all cases when the key again that c m s commissioned an evaluation that was completed in december and the reason why that you know the reason why that's not been released i don't know why that's not really are there any independent conducted surveys that document superiority of the q us over the current survey system independent and that show that it works better than the current system we have ok so the evidence we have the case studies are one example of it where we actually went in and use q i s methods and then the surveyors use the traditional process and you could and they were pretty dramatic difference the other evidence is what you hear from the surveyors they all say it's more consistent more objective and that's why the states are lining up to do it and in it what's very interesting is that there's another group that's starting to support it and it's the provider community because they also find it more more objective even though there's more deficiencies in q hi s and in different areas and into new areas there's support there and there's some cotton growing converts in that area dr corn mentioned the   it is not integrated with that advancing excellence activity because it's just not the national system yet it could be integrated it could be fully integrated and broaden that initiative so that you could target the full range code regulations instead of more narrowly targeted as you mentioned twenty million dollars to get the other states into it where those states are first selected as the pilot states or you talk about nation that we could do it nationally for twenty million dollars the pilot states  there's three more being being done and with twenty million dollars it could be rolled out to every state in the country and dr zimmermann you mentioned your group looked at a thousand nurses in homes is it fair to say that  regulatory framework is not equipped to address the contemporary challenges posed by chain ownership that we heard about in the earlier panel well i think i think that  agencies that actually carry out the surveys are the state survey agencies their state agencies and to my knowledge there has been very little thus far and i'm not privy to a lot of the information within c m s so i would defer to administrate or wins on this but my to my knowledge there hasn't been a lot of activity that that enables survey agencies to cross state lines and so if you have  a corporation that has facilities across of variety of states or regions it is somewhat difficult within that regulatory community to be able to do this that is one issue the other issue  is that i think that the internal compliance function within the within corporations as well as looking at the systems of care is some things that that the regulatory process right now is not that equipped to do that's not to say that there's not a prominent role for it but i think it has limitations and in terms of looking at systemic changes that can be brought about as as we look at these private equity firms i think said more in fifty percent of nursing homes now are owned by private equity firms i got the distinct impression in earlier panels that all the nursing home administrators who would be there when the surveys are going on would like to do the right thing but who they turn to to get the resources to do it or to make those policy decisions in your surveys that you see the nursing home that was locally or privately owned as opposed to those that are part of a chain a private equity firm well we certainly saw the phenomenon of of facility leadership wanting to engage in more resources or this phenomenon was not universal but we saw quite a bit of it i don't i'm not prepared to say that that was systematically different between private equity firms and other organizations number one and number two it's also true that in some cases the reversed phenomenon took place which is that there were district and regional folks within a corporation that wanted to engage in quality initiatives and there was some resistance so this is this is a complicated problem one last question i'll turn to mr shimkus dr kramer you said twenty million for full funding the national rollout of the y also said in this tree is now supporting the us has there been in this gush about maybe having industry help provide some that twenty million to roll out the program i haven't been privy to those discussions services and care it's just if you if you can get funded you might help you you know people have to caution if being is sometimes cautious and but i also have observed i think all of us who've had loved ones have heard the change in in care and the continual care as i mentioned before and i think the continuum care probably can help those who are moved moving to this continuum of care are probably more i shouldn't just be generalizing but it's our own experiences as members of congress we we don't and nursing facilities we visit all these different aspects and what industries doing on its own and there was a percentage of forty three percent dr coren mentioned forty three percent of participants in the debate is how do you get you know for how do you get the fifty s that the fifty seven percent to get two hundred percent and do you do it regulatory and then the debate if you have the information then  follow up the latter if it's if is if it's voluntary then were the the ability of government to step in so one chance that question i think i want to go to mr de broom for hopefully a segue into it after i get how do we get the other fifty seven percent to be involved what the advancing excellence campaign has been a tremendous success and as was mentioned it is two years old and during that time we have seen participation dramatically increase from my own organizations experience all of our facilities participate in advancing excellence the american healthcare association has publicly stated that it encourages all members participate in the campaign one of the ongoing industry efforts as we are collecting quality statistics about our members and where their deficiencies and practices we're offering resources to help them improve before i go to mr or mrs him and how does the advancing this program affect the internal compliance issues that you discussed or does it does it not is there a connection there we've got two or three different things going in different directions  well i don't i don't think they're completely independent at all i think that the advancing excellence campaign is really an initiative a quality improvement initiative that has taken on  importance throughout the industry and i think that's very important it can be very complimentary to internal compliance functions frankly internal compliance is just good management and so if you are engaged in good management you're going to look for quality improvement programs as well i would suggest that what we need to do as any good manager would do is to make sure that we validate that what we are being told in terms of some of the outcomes in terms of some of the processes is happening as we are told it is happening and i'm not suggesting that we need to do that because we don't automatically believe somebody but it's just good oversight and management to make sure that we that we validate these quality improvement efforts so i think they can be very letteri and what's the number nursing homes that are involved in internal compliance issues well i'm aware i'm not sure i have this correct but i think that with respect to the corporate integrity agreements there probably are anywhere from  a thousand nursing homes to twelve hundred nursing homes that have that have been part of corporate integrity agreements with the with the office of the inspector general that the oh i g also has corporate compliance agreements with probably another thousand i would bet but at any rate so that would represent a little over ten percent of the industry the mandatory versus voluntary would have a voluntary i'm not actually that familiar with the voluntary ones because we we don't get involved as as outside monitors in this process so i would have to defer to actually mr morris who was on the previous in the spirit you have a compliance program we have a voluntary composite before purchase of the moncks corner facility we were not required to have a compliance program and once we purchased up its military they wanted us to maintain the quality of care compliance program that was eight months ago prior to that since two thousand and two we've had a voluntary compliance program that is extremely effective with an organization we've used it to improve quality ensure that we are in compliance with all federal laws and regulations and how does that help you i mean you said it helps how we have a corporate compliance officer  also trained in six sigma he has a staff to analyze our data when there are issues we identify him internally and disclose them when necessary to government authorities this being pro active we're able to catch problems industry working on its own the state still has a major role to play with licensing and and attorney general and as we saw in the connecticut issue that there was a problem identify and there was a couple steps that had failed within the state my issue is how much we're going to relook at this we also have to look at the ability of the states to to carry their share of the load as far as laws on the books to help us in this process of segue maybe some where this information into that arena  would you agree no i absolutely agree i think states you know obviously play a major role i think i agree that you know voluntary programs are very important that you know in  fact the the advancing excellence program is a program that we as a union are very involved in and support and you know i think that the questions you're asking go right to the heart of the issue here which is that you know there are many of the providers most of the providers that that are union represents are very good providers that you know that do volunteer and do you know very good work to comply the problem is with those who don't and you know as mr morris testified earlier you know based on recent surveys and information that's available if twenty percent of the nursing homes in this country are actually putting nursing home residents at risk by not being involved in these voluntary programs and not complying you know that's one point five million residents and nursing homes that's three hundred thousand people and that's really i think what the right you know what regulation is needed for us to hold those providers accountable and i think you know i just again i'll just end up by saying because of the way the industry has changed in rural small town america they're still probably in the model of care from twenty twenty five years ago where they haven't done this expansion or or capital because the numbers are there not to and it's going to be interesting to see how we segue because they just can't they're needed but that's why i'm have no plans to run for the united states senate i want to touch on a couple of issues from a serious standpoint now sorry because i've actually spent more time in a nursing home the last year than i would have liked my brother was nearly killed in a motorcycle accident in august my mother in law actually just passed away this morning and so there are some real life issues i think many of us  deal with and have questions with and some of them frankly are the stupid regulations that are on the books today and i wish i could have been here for earlier part of the panel but i was unable to my brother's case he's now fortunately mostly recovered went into a veteran's nursing home which was terrific except that there's a regulation that says you can't put up the little bar there on the side of the bed because it's considered a restraint so you know what they did they lower the bed as far as they could to the floor and put a plastic mat out with a sensor so when he would roll out of the bed he'd roll onto a mat because there's a regulation or a law that says oh no you can't restrain somebody like that i mean that's pretty darn stupid out there and i just wonder if we all talk in these terms of a you know quality assurance and yet he idea i want to get to the real life problems that you all are dealing with and that we as family members deal with and then i read about the the issue here is the state inspectors apparently aren't doing their jobs and i'm wondering do we need a new law or do we just need to bring the states up short and say do your job do the inspection report back the other issue and i know this came up in earlier discussion about access to ownership i was a licensee of the federal communications commission for more than twenty years we had to file annual ownership reports and i believe those are available on the internet how hard is this with today's technology to do that and if there's a change in ownership you're required to file or you don't get paid it's real simple and so it just strikes me there are some of these things  that don't make a lot of sense and i've seen you know really good treatment and i've seen some real bonehead mistakes my mother in law was glucose intolerant allergic to wheat to morning in the same week they tried to feed her cream of wheat for breakfast and ground up pills that were time release because she was having trouble swallowing you know so you see we ended up hiring private care to be in the room to make sure those things didn't happen so i mean i've seen all sides in this industry i've also seen when my mother was was in her final years was a decade or more ago that the staff was so burdened with the paperwork requirements of government that they didn't have time to do the care they were trained to do and so i don't want to see us go to the point where we just add a whole new layer rules and regulations some of which is i've said don't make any sense to me as a you know a lay person here i've talked to a nursing home manages some homes that deal specifically with those who have mental deficiencies and they're required on the rules in this particular state not my own that all those people have access to anything anybody else has access to and he said you know that means if we have drain cleaner that they can get access to it we can't lock it up and then i mean it just makes no there's some commonsense things here we cannot micromanage we have to have responsible people and then we have to have quality assurance programs that insuring that commonsense piece can any of you explain to me why we would have a rule on the books that says if somebody is rolling out of bed repeatedly you can't have one of those bars you put up like you do if you have a baby is there are cases where you need to you know where there's some these truly at risk and there's no other way but some form of a system for for helping them preventing falls but there's all sorts of ways of doing that and the trick is how do you apply these regulations in individual cases and and that's why you need a structured process you mention that you don't think the surveyors are doing their job it no i'm telling you what's in the in the press reports here and it was you know the thing about the surveyors is i don't think in the current process they have the tools always to do the jobs and help them work through the decision process in order to apply those very regulations because those running the operation no if i do anything i'm going to get sued or i'm going to get you know fine tell me then why they couldn't put or i could i was going to go put the bar up on the bed i mean every hospital bed at one it doesn't it doesn't have the impact that everybody thinks i strangled themselves in side rails they have seen cases in which people have climbed over the side where else because they were in danger of falling and they could get over the  design strengths that would keep somebody from her falling out of bed without having it beside rail some of which can kill people so i think that's what dr kramer is saying there is common sense that needs to be provided and  the application of the rule is with with that which is blind to the context in which is being applied is is agreed to be that's the bad that and yet the and yet there are ways in which we can do this without having to put somebody in in the kind of jeopardy that we've just discussed so yes there is a solution to your problem and everyone and everyone these things have a risk and of course they do with them and so you've the application of all these regulations has to be done with care and side rails turns out to be a reasonable regulation the issue is to approach it and make sure that people that the restraints is a quality measured that we do measure on a periodic basis but all of the quality measures need to be example for instance high risk pressure old sources and one of the advancing excellence initiatives that is publicly tracked what is an issue with this indicator is that you don't count the indicator on the national nissho assessment so if i met a patient with a high risk pressure all sir on day five when i do my initial assessment that doesn't count against me but if i haven't healed that pressure old within by the fourteen day assessment it goes on my record as a deficient practice and you measure that in terms of quality indicators believes we need to examine quality good discussions mr pruitt going to go into the nursing home business and with these private equity firms moving in there if you take a nursing home how much should i be a expect on return on my investment is there a rule of thumb that you look at there is no real rule of i can only speak to how we look at the silty when we look at parties and one we look at the long term value that it can create and a lot of it has to do with our social mission as well as how we feel that will fit into our model of care which also involves community services so we look at a center by center basis we plug in the staffing levels that we would provide which typically is more than the seller provided and we look at our ability to operate that center and achieve the type of care we want to achieve the private equity firms  bruyne mentioned they've got a five point five billion dollar return i got to make up and you buy a number of centers as you said there has to be some kind of expected return on it why you wouldn't do it and especially private equity firms who are in the business of making money so i'm just a little bothered with that let me ask this question the advancing excellence does it costs more to implement it or is it common sense things you should be in your make up for deficiencies elsewhere within the home and then you eliminate those deficiencies so in the long run it's profitable what events in excellence has allowed us to do is concentrate our resources and moving certain indicators in my opinion it does not cost more to employment the initiative in fact it saves money on the back if we can identify problems and as industry share best practices we are more than likely to decrease the cost of care if we can prevent a ro wound it's going to be cheaper than if we have to treat it wasn't sure and i believe advancing excellence encourages us to do what is right in the first place where they're not they're going to want more centers come into your quality we're advancing excellence we're at forty three percent i think mr shimkus that what the other fifty seven percent how do we get in there well remember we've only been doing this now for less than two years and it is a voluntary effort and i don't think you'll ever get one hundred percent of people to volunteer for something like this but what we're hoping to do is we're hoping to reach out to people and start to show the advantages of improvement of mr prewitt said one of the things one of our targets is trying to increase staff or tension the costs to a nursing home of high staff turnover is profound and here's a way that you can both improve quality and save costs and we're trying to show those kinds of things so that we have people come into the campaign and kind of  join it we're going to continue it we're looking to use our local area networks to continue to recruit so so basically your quality program your quality advancing excellence i'm sorry well while there can be some beneficial said it's easier to prevent the open wound as opposed to treat it that's the incentive to write better quality care maybe cut down your costs but there's nothing mandatory there's no one forced in it  participate and i think this is just too much hassle and i drop out there's no mechanism or no punishment for doing that is a no this is a completely voluntary campaign ok and so it has that limitation as well as that advantage she felt like she didn't get enough information about the quality of care that was provided by that center that her husband was at and she said if there's one thing she wanted to see was more comprehensive  report or patient information before you put your loved one in a nursing home or center any problem with that like identifying who the owners are what's your rights before you enter into center do it either dr corn or anyone else want to comment on that i think that one of the big problems first of all is that as we know the nursing home compare site just has a very limited amount of information and a lot more could be put on there in order to help people make the decision but i think we should also realize that discharge planners and most people who end up in nursing homes come from a hospital don't tell people to go look at it so one of the things we've got to do is work collaboratively with the hospital side to ensure that people know where to go to get information on line information we're suggesting that be done in our food and drug bill that we're moving on so someone you know where to go to have that information as the ownership what's the quality assurance or advancing excellence if they're a member of that program or not just trying to get more information on line that the appropriate i think would be critical i had to choose a nursing home for my father and while i was able to go to nursing home care because i knew about it all right this chart planner didn't tell me about it it provided enough information that i knew what nursing homes were in his area and i could start to narrow my search but it certainly didn't provide enough information to be able to go and say i know this one's a good one and this one isn't so you have no objection to an online program or something the universal database nationwide mr proust chairman one other point about this is that sure they don't go to  doctors are and i'm sure that the issue to other points about the nursing or comparing that information first of all we actually were engaged in a project that was funded by the commonwealth fund  to engage folks in using some of this information using the data on the quality indicators and the deficiencies etc it turned out that one of the most difficult groups to engage in this process was hospital discharge planners and it's not clear even to this day why it was somewhat difficult to get them to be engaged but i think in fact they probably had other a lot of other things to do and felt that they might have had sufficient information so we have to make sure that those professionals who are responsible for for the reference to nursing homes are going to be using this information secondly i think one of the opportunities we're really missing in this information is that it's not just the selection of the nursing home that means that you can use this information because as several of you have mentioned in several panel members frankly the selection of a nursing home is very limited it's extremely limited in rural areas there just isn't there just aren't that many options and and you have a very traumatic situation what i'm talking about is using this information after the selection to make sure that you can monitor how well the nursing home is taking care of your mother which i think would suggest a somewhat different way of putting the  on our indicators many of which are the same as the events in excellence campaign the american health care association supports transparency but i urge the committee to be careful that we don't restrict capital in our profession in our industry we are serving our patients and our residents and outdated buildings many of which were built in the sixty's and seventy's if we disclose all relationships we may discourage banks which lend our corporation money and have really no say so in our operations from investing in our industry corporations fine someone is in charge of making decisions about that facility who is it that's who we need to know so the blood and can do their job without having to go to litigation which i would just like to say that i concur with the notion of transparency in that there ought to be much more information available to residents and to discharge planners and people making these decisions one of the things i think we need to keep working on is the breadth of that information and again i come back to q i ask because of the bratz th covers quality of life issues in a full range of the regulatory areas it turns out that a lot of times the issues that are most important to residents things like self determination somebody waking you up at five in the morning versus getting up things that dr karn talked about that information is not very available and there are some very important things that we need to make available and i think we can do that with a much broader array of information than we currently provide people did you know did not comment about the q i asked evaluation report and i should just tell you something about it since i do know about it and they are going to probably talk about in the release of one of the relay reasons it hasn't been released is that it is  somewhat inconclusive it took a long time to do they actually only went on ten q i asked surveys and to their own claims they indicate that  qualify these findings by noting that comparisons between q i s and standard surveys were limited by sample size thus the data we provide are best used for survey improvement purposes rather than to inform decisions about what type of process so they ended up with a very modest study that didn't actually wasn't actually conclusive and and and didn't really address the consistency issue as well as it should and so i know there's a there's a lot that needs to be done i'm going to i don't really have a lot more but i do want to follow up may not have the answer but it's my understanding that the hospitals actually provide more information which is the  irony behind this is that hospitals understand you have to provide more information then you have the discharge planner who's who's not really requiring or helping hospital so the whole aspect of you would you would hope if you're concerned about the patients in the wellness that the discharge panel would would would want to go in  well i'm not sure why they would not want to know i think that the i think that there hasn't been a really an organized way of providing the information etc but frankly one of the transition of care between settings is is to put it bluntly one of the scariest aspects of our care problem right now with the elderly it is it is abysmally bad in terms of the transfer of information from the acute care setting to just about any other setting whether it's home care whether it's skilled nursing facilities whether  it's a hospice whether it's a long term acute care hospital etc in my testimony i said the following which i can repeat very quickly if you'll permit me if we are truly to accomplish the goal of giving our elderly citizens the care they so richly deserve then we need to expand our focus to include the other care providers settings that feed into skilled nursing facilities in particular this must include greater scrutiny of acute care hospitals whose discharge practices have placed enormous pressures on skilled nursing facilities because some times they will discharge folks before they are ready to be discharged and sometimes the  inadequately adequately prepared to provide the complex care needed by elderly patients we have some hospitals that have a program called an ace program acute care for the elderly about forty hospitals around the country have this program but often they don't and frankly that's not their business i mean that that that is not as we say in economics their comparative advantage and so i think we have to be very careful to make sure that this setting transfer is handled more carefully than it is now and i appreciate those comments and it is kind of scary and scary for families to as they're trying to move people through the process in some hospitals in southern illinois because of the way just regular health care is changed from patient to outpatient they have beds and they have segue into skilled nursing facilities so i facility where you have limited choices i would think and i'll go check with my local providers that's not a big problem because you're just going from really one wing of the hospital to another but i just want to make a comment on the i would think if i was a provider and i had a my own quality assurance program or the advancing excellence is something i'd be advertising in thrown information out as dr simon said i mean this is an aspect of where you can get a competitive advantage as people are looking for quality care but this whole resident centered care which we all know as we all want to be individuals we w individuals in education planning we don't we segment of groups that's it costs a lot more what we're what we're finding at least what we found from the survey that we just conducted was that in fact there seems to be a positive effect on the bottom line and it might be a program that you know costs before it saves but ultimately as you start to empower staff is used to make them in charge of their own residence and make it a better job you have lower turnover you have happier residents you have higher occupancy rates you have fewer lawsuits you're not being do survey i mean there are huge advantages to to really individualizing the care and taking care of those people and it's really trying to get people to understand that not only is it a good way to do business but it's the right way to do business and i would i would concur with her you know the problem is not a cost issue to start doing resident centered culture change care the issue has more to do with the focus of our whole regulatory system and our whole quality of care system quality of life has not been part of that focus for a long time and and in the amount of reliance on what residents and families tell you and what you observe and whether you go into rome's and observe certain key things has not really been the focus and and it's starting to become the focus and and it needs to be the focus of the regulatory process and the quality improvement process out there i would say as a provider there are aspects of residents in our care which i absolutely do not cost more it's  instead of a way of changing the how you operate a building for instance traditionally nursing homes and many of our state regulations require higher staffing on the first just so many of our patients don't wish to be bathed or have their activities of daily living performed on the first ship they may have done that traditionally at night so as an operator as we have more consistent staffing across all shifts is a reallocation of re sources and then becomes more outcome driven more customer satisfaction driven unnecessarily regulatory driven i thank you very much mr chairman since i have no more questions for this panel i don't want to segue into the high cost of energy for health care delivery but that's a debate for another time i'm always willing to have that debate with you in the residence punkers medical care facility which you probably know empowers area has opened a couple of these residents and i was there two weeks ago as they cut the ribbon in all this and it was really interesting that these were probably some  severely injured people but they were so excited and they did one a year earlier supposed to be their second one and i asked about the cost in the initial cost to build the building new and special features there's a cost there when the long run happier staff is happier in the quality of life that you speak of was much greater so i think there's a lot of good things happening let me ask you one question if i can haul off into the hospital person call and say we're discharging such and such you just said major surgery can you handle them or what would you recommend do you have that much interaction with the hospital on a discharge or is it just the family heard about it and showed up with their loved one we have a tremendous of interaction with acute care setting the discharge planners in the hospital routinely contact nursing facilities to understand their capabilities of caring for patients they will then find several options for the family they will form the family of their choices we know from our satisfaction surveys that we conduct that our family members visit several facilities before alternately deciding on ours so from our corporation standpoint and i believe i can say for the industry as a whole there's tremendous interaction with  let me think this panel it's been most interesting then and i thank you very much for your input into this problem that it's been thirty one years since this committee has a visit we will keep on it i can guarantee you i think we all have some personal experiences we can relate to  and we appreciate what you do and in helping us understand it thank you thank you  called up our third witness and third panel we have mr kerry weems is the acting administrator at the centers for medicare and medicaid services c m s as we call it within the department of health and human services and we appreciate the fact that you stayed with us all day today and have been interacting as i had a chance it's the policy of the subcommittee to take all testimony under oath please be advised that witness has the right under the rules of the house to before this committee thank you sir let the record reflect the witness replied in the affirmative he is now under oath we will begin with your opening statement and again the five and opening statement larger or long length statement can be submitted for the record mr williams thank you very much mr chairman good afternoon mr shimkus good afternoon gratulations on your decision to retire which i guess we have from the army reserve reserve not quite my wife called integrated no you're not leaving graduations on your service there thank you for inviting me to testify today roughly one and a half million americans reside in the nation's sixteen thousand nursing homes on any given day more than three million rely on the services provided by a nursing home at some point during the year those individuals their families and friends must be able to count on nursing homes to provide reliable care consistently high quality charged with overseeing the medicare and medicaid programs whose enroll populations comprise a vast majority of home residents c m s takes nursing home quality very seriously our efforts are broad including initiatives to enhance consumer awareness transparency as well as vigorous survey enforcement processes focused on safety and quality consistent with statutory requirements we conduct onsite reviews of every nursing home in the country at least once every fifteen months once a year on average surveys focus on the quality of care experienced by facility residents regardless of who owns of syllabus our focus on actual outcomes ensures that medicare's quality assurance system does not depend on particular ownership of a facility we do continuously to seek to improve the effectiveness of both the survey process and the enforcement of quality care requirements an example of such continuous improvement is our special focus facility in the shift of which addresses the issue of nursing nursing homes that persist in providing poor quality this relatively new initiative is just one of many efforts underway at c m s to further improve nursing home quality i brought a chart with me today that includes a set of commitments i made last november before a senate panel and it's been updated to show progress to date beginning with the green checks those represent actions completed c m s participation leadership in advancing excellence in nursing home campaign continues on nov twenty ninth two thousand and seven we posted on our website the nursing home compare the names of the special focus facilities a major step toward greater transparency toward nursing home quality we expanded the quality indicators survey pilot in february to include a six and we're looking for six states and we're looking to forward to more promising results last month co sponsored a well attended national symposium on nursing home culture change it's now moving to the work in front of us which represent actions in progress i believe we are nearly ready to be able to roll out a demonstration project focusing on value based purchasing for nursing homes which would test payment incentives to improve quality we're also working on a final evaluation of a three year pilot to test a system of criminal and other background checks for prospective new hires a nursing homes target release of this final report is this summer in june we expect to publish results from an ongoing campaign to reduce the incidence of pressure alters and nursing homes and to reduce the use of restraints in july we hope to publish new guidance to surveyors on nutrition nutrition and nursing homes the latest of an ongoing c m s efforts to improve the consistency and effectiveness of the survey process in august our new contract with the quality of proven organizations will take effect we plan to build into that contract an ambitious unprecedented three year agenda for q o s to work on nursing homes that have poor quality through the special including those in the special focus facilities also august we plan to release a final regular regulation on fire protection safety requiring all nursing homes to be fully sprinkled by a faith period in september we have to issue a report describing the methods for improving the accuracy of staffing information available for posting on the nursing home compare site finally as i've stated previously we would invision supporting legislation to permit the collection escrow deposit of civil monetary penalties as soon as the penalties are imposed in closing i'd like to again to stress the regardless of setting or ownership quality health and long term care for medicare and medicaid beneficiaries is of upmost importance to c m s be happy to answer your questions thank you for the opportunity to appear today him problem nursing home chains and facilities what's wrong with that idea has c m s doesn't have an obligation to protect those vulnerable patients in these homes and why can't see  last three summary of the last three surveys are available on the web site so what are these seven thousand nursing homes or so sixteen thousand sixteen thousand i'm sorry sixteen thousand so you get forty five almost fifty two thousand some result there yes ok then why in the pecos system that's your provider and roman and chain ownership system currently only has seventy percent of the nursing home ownership information that a base even if the medicare provider disclose everything requested on your roman forms can take us we're still missing thirty percent as to ownership and other identify identifiable features that would help people to  we enroll them at all providers except one particular type we enroll them at a particular pace pace is about two hundred fifty to three hundred thousand a year and so the seventy percent figure represents the progress that we've made in rolling a very very large number of providers into the system well they tell me that the ownership issue is one that folks that will be on that because that's what we've been talking about done the first battle is really not link to that c m s website to the nursing home compare web site right so so you almost ethical two different places to even try to find it yes and one of the things that we focused on for for nursing home compare are indicators that we believe that would be useful in selecting a nursing home so you know some of the quality indicators things like that we're collecting the ownership information as a matter of and as a data field in pecos and in fact will collect it down to fractional ownership of five percent i think  the question that we all confront is how meaningful is that information in selecting a nursing home to put it on nursing home compare it may have it may have other meaning but it wasn't just for a private family just like the power so when you go to and even the attorney general indicating trouble i guess i and i think mr weldon said in this modern era data is available it seems like sort of piecemeal here we need a central location we sort of need to link the ownership database to a quality database in the one database so for looking for quality if we're looking for the family if you're looking for who's in charge to a low pressure to clean up a matter at a facility or  unfortunate the state attorney general has to do something like that had to do there's one place we can go let me begin by agreeing with that but then but but let's step back and think about how we how we make that information useful is our goal to populate pecos one hundred percent having done that is also our goal then to link that to the quality data that we have so let me tell you that yes we do that have that as a goal that will have some use let's separate that use however from what's on nursing home compare nursing home compare we want to make sure that we have information that is usable in selecting a  nursing home so i'm not sure that integrating those databases achieve the kind of objective that that you have in mind i think we have different purposes for different databases i guess that's the only place we can go to to to really look promising way to deal with nursing homes that have a record of actually harming or jeopardizing patients geale has repeatedly reported that about twenty percent of nursing homes have serious problems and cycle in and out of compliance and with the figure you  over sixteen thousand before they would be about thirty two hundred facilities nationwide move in and out of compliance yet only a couple hundred of facilities are in the s f f program why was that program to be expanded to try to get  this total twenty percent we would look to expand the program the program right now has about one hundred and thirty four hundred thirty five facilities in it it is a program that is resource  intensive it requires surveying at twice the normal rate within the resources that we have it's something that we would look to expand let me ask this since i asked dr kramer and i like to have your response on it dr kramer's group at the university of colorado the report commonly referred to as a cradle report which was completed in march of last year two thousand and seven and it was approved by the project officer so why hasn't c m s released that report you  have we are reviewing one of the things we like to do when we have a report and when we release it is to have an action plan associated with it i'd like to have both of those reports out and vailable this summer rather than just releasing a report let's have an don't think it would take fifteen sixteen months seventeen months to put forth an action plan it takes a while to go through a report review it and produce those things let me ask you this nursing home industry is presented as a strong case here and i would get from their testimony a takeaway that voluntary quality initiatives can take the place of regulation at least that's what i heard them say but information about whether chain or facility has achieved voluntary benchmark is not public unless the company chooses to make the information public you believe that this type of system can or should replace the current regulatory system or the system i think it's something that is worth looking at in a very serious way i think going through the through the research being able to see if if in fact it makes a difference and i think it's important to separate the regulatory system from the for system be love to to suggest that we need to loosen up the enforcement system perhaps we can take another look at the regulatory system we are doing that we've seen that you know the cultural change more person centric care that we're looking at that can make a difference we need to proceed carefully down that path maybe lift off some of the regulations keep the enforcement regimen in place forsman you know so we keep bringing up their state responsibility here too there's licensing and there's you know what what they have to do to be involved with it in my opening statement i quoted the fact that you know we have been successful to some extent in recovery around fortunately recovering millions of dollars in penalties you know for noncompliance the  the r hook in this debate is because we're big payers and they're right correct and we're big pairs because of the medicare and medicaid yes so how in this  let me ask me a lot of this debate is trying to follow the money to the ultimate ownership for quality care and really is that is is finding out the owners i can see how it's beneficial but is it the end all to improving quality care let me tell you how we think about and are thinking about ownership now currently c m s is relationship is with the owner of the provider agreements whoever has upright or provider agreements is the is the entity with which we have the relationship so what would  change ownership or some other ownership tell us looking for instance at the case with this committee had in front of it this morning so if you see a couple of homes in a chain beginning to fail what does that tell you and that's the thing that we need to work on so is it two of twenty then that would require an intervention or is that just statistical chance as opposed to a corporate strategy is it four is it six those are the kinds of things that we need to investigate with understanding ownership distinguish the difference between does matter or how it matters and when to intervene in your kind of following up on the same question in your testimony on page eight you said medicare's quality assurance system does not depend on any area of ownership that's correct our relationship is with the the facility itself and the holder of the provider agreement in that facility so we don't we're saying because of the holder of the provider agreement but i guess part of the debate is the holder of the provider agreement may not be the final owner and so that's the disconnect that we're trying to try and declare the homeowners can have a negative effect on the quality of their facilities if we take a look what happened at the quality of care at the haven health care chain didn't it make a difference who owned the the chain for quality of care why should owners be percent but see that's why i want the data at one place whether so it's a police attorney general's whatever forces regulators at one place to go along with the family so you can see what's happening at all aspects of it so  isn't it more the seriousness of the deficiency which would say when you'd step in it would be both i would say that we don't have the research now to be able to separate you know as as we would say the signal from the noise and it's a very it's a very  serious question and one that we should look at because there are varieties of chains varieties of types of ownership of varieties of numbers of facilities in a chain and varieties of size in a chain each each one of those could be a variable in what could be a very complex equation this is work that we want to proceed but we're just not in a position now to be able to say to a hundred of this particular type o i'll give you that as far as ownership issue but but where we should be go on the value of these surveys the information gleaned there from i think it's sort of fallen on deaf ears at the c m s and  hundred ninety eight was the last time jail did a study and they just released another one today and i know you probably you know had time to take a look at it we commented on it but yeah but if you take what happened in ninety eight and you go back to look what happened today today's you've had for about seventeen months that have been released and to the o i g mr morris who testified and again the ninety eight so i look at the ninety eight i look at the one today i had a chance to read it between votes take a look at a couple things it's almost the same you put that with the cramer report as i call it a kramer study from dr kramer on university colorado oh i g's and seems like we're seeing the same thing very serious problem with the current system of nursing home survey system so you know today they that surveys failed to identify serious deficiency twenty five percent or more of the time even more troubling in all but five states surveyors missed deficiencies at the lowest level of compliance in the lowest level of compliance undetected care problems at this level are concerned because they could become more serious if nursing homes are not required to take corrective action so how will c m s remedy the situation stepping back from that for a while the one of the first things that we'd like to were we're down to about four tenths of one percent are being done so as a first step at least the surveys themselves are being done sure but surveys got to have quality they got the quality surveys and go and give you every survey you want and i can follow up on the phone and if it doesn't affect even a minor deficiencies which have done to go in the majors go ahead secondly the working working through that we need to make sure that we educate the surveyors and we have new guidance to surveyors to improve their accuracy on items like pressure all servers incontinence quality assurance making sure that they're getting the medications they need we're educating the surveyors to make sure that that happens thirdly is the quality indicator service that will produce greater consistency across  surveys you can see that we're undertaking that effort we are in will be in eight states this year and continue to expand that effort that will give us more substantial consistency across state surveys sure and dr kramer said jail found the reasons for surveyors not identifying problem is that they lack a investigative skills and be ability to integrate and analyze the information they collect it to make an appropriate deficiency determination  so as to get out there and in the cramer report has to get out there so in the meantime since you're into an action plan what the c m s do to train the surveyors who are taking new surveyors if we're missing all this what are the numbers we deal with twenty million doesn't seem too far of a stretch when you're talking about one point eight one point five million people or billion people and their million people in nursing homes if  if i could adjust your question slightly it would be is the budget a rate limiting factor i would say if if if you said today mr williams we're going to give you twenty million dollars and we expect to have this implemented in a year i'd resist that for the reason we roll something out nationally let's proceed carefully we've learned a lot from these eight states as we go along we can pick up the pace but this this isn't a matter of going nationwide right away but at the same time if we say mr william wins here's your twenty million dollars you contract with states to do surveyors and do the surveys don't you and therefore the states would begin to would have the resources then the do adequate survey and do the training necessary i s i would be thinking that twenty million would just go right to c m s and stay there but would go to the states because you contract out to do the surveys and then you follow up either by telephone or a couple weeks later the federal surveyors go and sure so it won't be that much of a burden to the already have a system in place but i guess the part to worry bothers us twenty million dollars but we want to make sure the twenty million dollars is going to surve ors who are doing a q o s and it's been done accurately and they have the training to do it so we can get accurate data and then it's gone into one central location so we can all find it and the and to make sure that we're doing q o s properly as i said we're learning as we go i really would want to think carefully about doing thirty two states well if you've had since last december in your budget then did you ask for money having having raised that for the the last four years in a row c m s has not even achieved the the president's budget level for surveillance sort of rotation and you know that's the budget that that comes that  say let's bring in all these people to fix this issue if it becomes special focus first of all is that a wrong observation and if it's not why don't we just go after the root cause right when we've identified them in this special focus arena when special focus facilities are selected they're selected off of candidate list that the states give us these are chronically underperforming facilities once they enter the special focus facility designation they are then surveyed at twice the rate that a normal facility is and given how they perform on those ok but the issue is why not send in not just why don't just try to identify the root cause then i mean there are identified as problematic why not just say let's go be quite expensive ok and i think we would so you think by upping the investigations you you move them in to compliance you you've got to experience i don't you move them into compliance by saying ok we're going to be come around and if you don't then we're going to bring in all these people try to find the root cause that they are going to they're going to be on either a path of improvement where they will graduate where they have shown some improvement but they will still stay in the special focus facility program and continue to be surveyed every six months or they will be on a path from a nation that's that's what it means to be in that designation we've also taken the step of putting the special focus facility designation on the nursing home compare website if you go to the nurse some compare web site you can see that that home is on the special focus of cillit you can also see what the most recent update is whether or not they are on a path to improvement or whether they are on the road determination and my final question is in two thousand and eight action plan for nursing home quality c m s psych expansion of the collaborative focus facility project what is this project and what holmes does it cover in the the most recent scope of work for the quality improvement organizations we've designated specific facilities with specific problems for the quality for the quality improvement organizations to work with those facilities to produce specific quality outcomes in those in those facilities and this kind of wraps up around the initial question why not use these a quality improvement organizations more extensively is it cost with other problems or sing i mean you know quality improvement organizations have wide missions including the hospitals for which we gave them specific quality improvement assignments this year as well so they have a very broad mission that extends just  of a blueprint for enforcement to improve the survey system in fifteen seventeen months nothing is happening while we're not doing anything or rolling that out because you don't have an action plan i think the kramer report sort of gives you the action plan because we have people suffering and we want to get this  taken care of and the industry as all as a whole looks pretty good from what i'm hearing today but there's that twenty percent that's a repeat out of deficiencies and i think we've got to have quicker job of taking care of it and if it's twenty million dollars i'm sure when you present people that years since this committee looked at it i plan on staying on top of that we will have another hearing i know we're always talking about the follows up so we would hope you'll take this quality indicators survey the cramer report get your action plan done let's get it implemented let's get a database we can draw from i think it's a fair assessment where we've been today any comments on that mr weems i thank you for your comments but the way that i would characterize first of all but what i've learned today is that improvement is multifactorial the chief counsel to the inspector general i think made an interesting suggestion about maybe doing a demonstration project that really reaches to the the far reaches of ownership let's let's see if that makes a difference i think we need to look one of the things we haven't spent time talking about today are financial incentives  nursing homes i think we need to move to the ability to pay for quality right now under medicare we pay under a perspective payment system our payment system is quality neutral it doesn't make a difference we need to change that we need to change that in the medicaid world we need more consistency among the surveys we need all of those things mr chairman so i agree with you we shouldn't concentrate on a few things we make progress only by moving on many fronts well moving on many fronts but it is not just you but some the frustrations i see is like the ninety eight report the oh i just report we got another one out today it seems like this is repeated itself for the last ten years and and i'm sure it's before that to money tied just to quality what i'm concerned about is the people who do the work those dedicated workers who work day and day out to take care of our loved ones who we entrust to them these workers there's a lot of times in the sea that money many of these jobs are minimum wage paying jobs in certain states i would look at or i would suggest that if you're not a target of state for demonstration project we should be able to put more than one state as demonstration project number one but if we do why don't we when we do a demonstration project on a bad chain we know they're out there maybe we have an opportunity with our carlyle group by the manner which always had a good reputation maybe that's a demonstration project we could do and make sure the quality stays up or improve the carlyle group because there is concern as we heard today it's a five point five billion dollar investment going to recoup their investment so if you take money to quality as that then hype the reports on quality so we reap more money to pay down that five point five billion dollars but when reality because we don't have strong surveys or accurate surveys who are getting deficiencies patient care is committee on both sides of it would like to see the resources because you've heard every one of us have been affected by a family member or someone who are at these centers or nursing home facilities and we want to make sure that they have the quality care that we all think they know and these are you that concludes our question i want to thank all of our witnesses for coming today and for their testimony i ask unanimous consent that the hearing record will remain open for thirty days for additional questions for the record i thought objection the record will remain open