Long-Term Care Hospitals: CMS Oversight Is Limited and Should Be Strengthened
Published: 2011-09-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Allegations about quality-of-care problems have raised questions about the oversight of long-term care hospitals (LTCH), which provide care to individuals with multiple acute or chronic conditions. Medicare pays for about 80 percent of LTCH patient care. To ensure compliance with federal quality standards, accrediting organizations (AO) and state survey agencies under contract with the Centers for Medicare & Medicaid Services (CMS) conduct routine and complaint surveys. One AO, The Joint Commission (TJC), surveys most LTCHs. In a November 2010 report, GAO compared oversight of LTCHs to that of other facilities. In this report, GAO examined the extent to which CMS collects data about LTCHs' quality of care and oversees LTCH survey activities. To do this work, GAO analyzed CMS data on the results of LTCH surveys and discussed oversight activities with both CMS and AO officials. GAO assessed the reliability of the survey data and took steps to ensure that the data presented were reliable.
section_title: What GAO Found
paragraphs: CMS collects some data on the quality of care at LTCHs, but the data are limited for several reasons. First, CMS does not have detailed data on the results of surveys conducted by TJC prior to 2009 and has limited data on current surveys because TJC did not begin submitting detailed data to CMS until July 2009. CMS does have prior year and current survey data for state-surveyed LTCHs--about 16 percent of LTCHs. In addition, current survey results in CMS's databases may be incomplete because these databases do not always accurately identify (1) the organization responsible for surveying each LTCH and (2) whether a facility is, in fact, an LTCH. As of fiscal year 2010, CMS data showed a total of 447 LTCHs, but GAO identified 18 LTCHs incorrectly categorized in one CMS database as having been surveyed by state survey agencies. GAO also found 56 LTCHs either misidentified as acute care hospitals or missing from another CMS database that contains information on LTCHs surveyed by accrediting organizations. Second, CMS does not currently collect data on quality measures--information used to evaluate how health care is delivered--from LTCHs because, unlike other types of hospitals, LTCHs are not yet required to report them. The Patient Protection and Affordable Care Act enacted in 2010 requires LTCHs to report quality measures by 2014. CMS's oversight of state survey agency and AO survey activities of LTCHs is limited. Two of CMS's three oversight approaches do not focus on LTCHs specifically, but on hospitals in general. First, CMS established performance measures--expectations regarding survey activities or the reporting of survey results--for survey organizations, but reports the results of its assessments for hospitals in general rather than for LTCHs specifically. Second, state survey agencies conduct surveys annually in AO-accredited hospitals--known as validation surveys--to assess the effectiveness of the AO surveys, but have not systematically included some LTCHs in the sample of hospitals subject to validation surveys. Additional validation surveys are done based on complaints. State survey agencies conducted more than 1,000 validation surveys over a 5-year period based on complaints in LTCHs that had been surveyed by TJC. CMS does not refer such complaints to TJC for investigation. As a result, TJC conducted few complaint surveys. Although CMS has instructed its regional offices to provide TJC with the results of these surveys, GAO found that these data were not always shared. CMS's third oversight approach--collection and analysis of data on the results of survey organizations' activities--has not utilized all the available data to identify problems that may require further investigation. GAO identified several potential areas where the data may assist CMS in more effectively overseeing survey activities at LTCHs, such as how effectively states triage and conduct complaint validation surveys.
section_title: What GAO Recommends
paragraphs: GAO recommends that CMS strengthen its oversight of LTCHs by improving available data on quality of care and by improving oversight of LTCH survey activities. HHS concurred with all of the recommendations. TJC agreed with most of them, but disagreed with the value of state oversight surveys of AO-surveyed LTCHs. We continue to believe that such surveys are an important part of CMS oversight of LTCH survey activities.

section_title: Letter
paragraphs: Allegations about quality-of-care problems have raised questions about  the oversight of long-term care hospitals (LTCH). The more than 400  LTCHs are a small subset of the approximately 4,800 acute care,  psychiatric, and rehabilitation hospitals that also provide post-acute care  services to clinically complex individuals who have multiple acute or  chronic conditions. Medicare is the predominant payer for LTCHs.  According to a recent report prepared for the Centers for Medicare   & Medicaid Services (CMS), about 80 percent of patients admitted to  LTCHs are covered by Medicare. CMS is an agency within the  Department of Health and Human Services (HHS).
As part of evaluating the quality of care provided to patients, CMS  requires all hospitals, including LTCHs, to demonstrate compliance with  federal Medicare quality standards. Compliance is assessed through   (1) routine surveys, which are unannounced, on-site inspections  conducted every 3 to 5 years, and (2) complaint surveys, which may be  conducted when a complaint is received. LTCHs are surveyed using the  same quality standards that are applied to acute care hospitals (ACH)— there are currently no additional quality standards that are specific to  LTCHs. Although LTCHs are a type of ACH, they do not necessarily  provide the full range of surgical, diagnostic, and emergency services and  may not have the same level of staffing provided in a typical ACH.  During a routine or complaint survey, surveyors may identify areas where  a quality standard is not being met and may cite a deficiency, which  demonstrates that the LTCH has failed to meet federal Medicare quality  standards. In general, LTCHs may choose who conducts their routine  surveys—a state survey agency under contract with CMS or a CMS- approved accreditation organization (AO). Most LTCHs—about   80 percent—are surveyed by one AO, The Joint Commission (TJC). In  turn, CMS is responsible for overseeing the survey activities of both state  survey agencies and AOs, which depends on the availability of accurate  and timely information. In our November 2010 report for you, we noted  that CMS’s oversight focuses on hospitals in general and not LTCHs  specifically. In this report, we examine other issues you raised.  Specifically, we examine the extent to which CMS (1) collects data about  the quality of care at LTCHs and (2) oversees survey activities at LTCHs.
To examine the extent to which CMS collects data about the quality of  care provided at LTCHs, we analyzed data on the results of routine and  complaint surveys from CMS databases, including the number of and  most commonly cited deficiencies. For state survey agencies, we  analyzed deficiency data for surveys conducted from fiscal year 2005  through fiscal year 2010 to ensure that we had as many routine surveys  for state-surveyed LTCHs as possible. For TJC-surveyed LTCHs, we  analyzed deficiency data for surveys conducted in fiscal year 2010  because TJC did not begin submitting detailed data to CMS on the  deficiencies identified during its surveys until July 2009. We compared the  survey results for LTCHs to those for ACHs because LTCHs are a type of  ACH. We also examined CMS efforts to develop quality measures.  Quality measures are used to evaluate how health care is delivered, and  information obtained from such measures can promote accountability  among health care providers and help consumers make informed choices  about their care.
To examine the extent to which CMS oversees survey activities at  LTCHs, we examined (1) federal statutes, as well as CMS regulations  and guidance, on state survey agency and AO survey activities;   (2) performance measures that are used to assess the activities of state  survey agencies and AOs; and (3) CMS’s use of survey data to assess  the adequacy of survey processes, including the results of surveys  conducted by state survey agencies in TJC-surveyed LTCHs from fiscal  year 2005 through fiscal year 2010. To better understand the type and  quality of information that CMS and TJC share with each other, we  examined two judgmentally selected state survey agency complaint  surveys conducted at TJC-surveyed LTCHs. Criteria we used to select  these surveys included media coverage, the involvement of different CMS  regional offices, and complaint surveys that occurred both before and  after CMS issued guidance in 2008 intended to improve information  sharing between CMS and AOs. We interviewed officials at CMS  headquarters and two regional offices to obtain information on the  feedback provided to TJC on the results of these complaint surveys.  Additionally, we analyzed CMS data on the results of all types of surveys,  including the number of surveys, the number that cited serious  deficiencies, and the resources used to conduct the surveys.
For both objectives, we reviewed documents and interviewed officials  from CMS, including officials from CMS’s Office of Survey and  Certification, Division of National Systems, Office of Clinical Standards  and Quality, and seven regional offices; TJC; National Quality Forum  (NQF); Medicare Payment Advisory Commission (MedPAC); and the two  LTCH associations—Acute Long Term Hospital Association and National  Association of Long Term Hospitals. We excluded two of the three AOs  that survey LTCHs from our analyses—the American Osteopathic  Association and Det Norske Veritas Healthcare, Inc.—because,  combined, they surveyed approximately 3 percent of LTCHs in fiscal year  2010. To ensure the reliability of the data we collected, we interviewed  officials from CMS and TJC to verify completeness and accuracy of our  data and reviewed documentation related to the data collected to identify  obvious errors. We identified data limitations involving accurate  identification of the survey organization responsible for surveying each  LTCH, which we discussed with CMS and the AOs. Based on these  discussions and further analyses, we made appropriate adjustments to  ensure the reliability of the data we report on LTCH quality of care. Based  on these activities, we determined that the data were sufficiently reliable  for our purposes.
We conducted this performance audit from November 2010 through  September 2011 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: An LTCH is a type of ACH that specializes in treating critically ill  individuals who require an intense level of health care with frequent  physician and nurse visits for relatively extended periods—more than   25 days, on average. For example, a significant subset of LTCH patients  is dependent on a ventilator for breathing and receives therapy to help  them breathe on their own. Most LTCH patients have been transferred  from intensive or critical care units of ACHs, which provide general,   short-term care for a broad range of medical conditions. LTCHs are not  evenly distributed across the nation and patients who could be treated by  LTCHs might instead receive care at ACHs, other types of hospitals, or  nursing homes. Medicare generally pays more for hospital stays in  LTCHs than in ACHs. In fiscal year 2010, Medicare paid an estimated  $4.7 billion for care provided in more than 400 LTCHs for about 138,000  discharges, which averages more than $34,000 per discharge.
subsections: section_title: Surveys, Survey Organizations, and Standards
paragraphs: To assess whether LTCHs meet federal quality standards, state survey  agencies and AOs conduct two types of surveys—routine and complaint.  Routine surveys are unannounced and are conducted at specific  intervals. State survey frequencies are resource driven and depend on  CMS’s annual funding level for such activities. CMS’s policy has been  for state survey agencies to conduct surveys every 3 to 5 years since  fiscal year 2001. In contrast, AO policy is to conduct surveys every   3 years. Complaint surveys are conducted in response to allegations of  quality problems made by families, patients, health care workers, or  others and provide survey organizations the opportunity to intervene  promptly if problems arise between routine surveys. Complaint surveys  may be conducted either by a state survey agency or an AO. However,  most complaints are filed with state survey agencies, which conduct  complaint surveys both at the LTCHs they survey as well as at AO- surveyed LTCHs. Complaint surveys focus on the specific allegations  made and surveyors generally only assess the hospital’s compliance with  standards related to those allegations.
In general, hospitals have a choice of who conducts their surveys—state  survey agencies using federal Medicare standards or CMS-approved AOs  that use requirements CMS has determined to be at least equivalent to  those standards. Federal Medicare standards consist of 74 standards  that are organized under 23 conditions of participation (COP), including  categories such as Medical Staff, Infection Control, and Emergency  Services. TJC, one of three AOs approved by CMS to survey hospitals,  surveys the majority of LTCHs. TJC’s standards for hospitals are  organized into 17 categories, such as Medication Management,  Leadership, and Medical Staff; each category consists of numerous  standards. Prior to the Medicare Improvements for Patients and Providers  Act of 2008, TJC had unique statutory deeming authority for hospitals and  did not need to apply to CMS to be recognized as a national accreditation  body for hospitals. This legislation revoked TJC’s statutory deeming  authority effective July 15, 2010, and gave CMS the authority to review  and approve TJC’s hospital accreditation program. As a result, in 2009,  CMS evaluated the standards and processes used by TJC to conduct  hospital surveys, including a comparison of TJC’s standards to  Medicare’s and a review of the qualifications of its surveyors. CMS  approved TJC’s hospital accreditation program effective July 15, 2010,  through July 15, 2014.
When surveyors find quality problems during routine and complaint  surveys, they cite either deficiencies or requirements for improvement  (RFI), depending on the survey organization.    State survey agencies cite deficiencies that are characterized as  either standard- or COP-level based on the seriousness of the  deficiency. Standard-level deficiencies denote less serious quality  problems, while COP-level deficiencies are cited when the problems  are serious or systemic in nature. A serious problem is defined as a  shortcoming in a hospital’s quality of services that adversely affects,  or has the potential to adversely affect, the quality of patient care.  When deficiencies are found, a hospital may be required to submit a  plan of correction, detailing how and when it will address the  deficiencies. If a hospital does not correct the deficiencies cited within  the required time frame, CMS may terminate the hospital’s  participation in the Medicare program.    TJC cites direct and indirect RFIs when hospitals are found to be out  of compliance with TJC’s standards on routine or complaint surveys.  According to TJC, direct RFIs are cited when compliance issues are  directly tied to quality, such as untreated pain; while indirect RFIs are  cited when compliance issues are indirectly related to quality, such as  hospital leadership. A hospital that does not correct all of its RFIs may  receive conditional or preliminary denial of accreditation. A hospital  may be denied accreditation if it has exhausted all review and appeal  opportunities, failed to pay the accreditation fee, or refused to allow a  survey. CMS may subsequently terminate hospitals from Medicare  participation if they lose their accreditation.
CMS collects information on state survey results in its On-line Survey,  Certification, and Reporting system (OSCAR). To collect data on the  results of AO surveys, CMS established its Accrediting Organization  System for Storing User Recorded Experiences (ASSURE) database in  2008. On a quarterly basis, all AOs update ASSURE with survey results  that are crosswalked from their own standards and RFIs to federal  Medicare quality standards and deficiencies.
section_title: Hospital Quality Measures
paragraphs: The Medicare Prescription Drug, Improvement, and Modernization Act of  2003 provided for the establishment of hospital quality measures and  created a penalty for hospitals that do not report related data beginning in  2005. Those hospitals that fail to report quality data are subject to a   2.0 percent reduction in the hospital’s annual Medicare payment rate for  the subsequent year. This payment reduction applies to hospitals paid  under Medicare’s inpatient prospective payment system, which covers  most types of hospitals but not LTCHs. ACHs began voluntarily reporting  data for quality measures in 2004. For fiscal year 2011, there are   60 quality measures organized into six areas, including heart attack, heart  failure, and pneumonia. For example, the pneumonia quality measures  assess several aspects of care, including whether the patients received  an antibiotic within 6 hours of arriving at the hospital and if the appropriate  antibiotic was provided. In April 2005, CMS launched a Web site called  “Hospital Compare” to make information on hospital data available to  consumers. CMS posts information for each hospital’s quality measures  on a quarterly basis.
section_title: CMS Survey Activity Oversight
paragraphs: CMS and its 10 regional offices oversee state and AO survey activities in  order to monitor the performance of survey organizations and hold them  accountable for meeting CMS’s survey requirements. To do so, CMS:   (1) established performance measures, (2) has states conduct validation  surveys of AO-surveyed hospitals, and (3) collects data from survey  results for all types of hospitals.
State survey agencies and AOs have separate performance measures.  State survey agency performance measures focus on states’ ability to  meet the requirements for the survey and certification program. These  measures are organized into three sections: frequency, quality, and  enforcement. For example, state performance measures assess states’  abilities to prioritize and conduct complaint surveys within specific time  frames. AO performance measures focus on their ability to provide CMS  with consistent, accurate, complete, and timely information on the  facilities they survey. In October 2008, CMS established three categories  of performance measures for AOs: (1) use of an electronic database to  track accreditation and enforcement activity; (2) submission of facility  notification letters—which contain information on individual facilities’  accreditation status—for all accreditation actions; and (3) submission of  survey schedule information. CMS monitors each AO’s performance on  the measures and provides written feedback on a quarterly basis. CMS  reports to the Congress annually on the extent to which TJC and other  AOs meet its performance measures.
Validation surveys are conducted to measure the effectiveness of the AO  survey process in identifying areas of serious non-compliance with federal  Medicare quality standards in accredited facilities, such as LTCHs.  Validation surveys have consequences for both AOs and facilities. State  survey agencies conduct two types of validation surveys. The first type is  a full survey of a sample of AO-surveyed facilities, known as traditional  validation surveys. Traditional validation surveys are generally conducted  within 60 days following a routine survey conducted by an AO. CMS  selects a sample of hospitals for these surveys based on the hospital’s  most recent routine survey date and available resources. While CMS  policy calls for approximately 1 percent of AO-surveyed hospitals to  receive traditional validation surveys each fiscal year, since fiscal year  2007 CMS has supplemented the funding provided to states in order to  increase the sample size to 2 percent or higher. Because of budgetary  constraints, the number has fluctuated from a 10-year high of 235 in fiscal  year 1999 to about 90 in fiscal year 2009. The second type of validation  survey is a complaint validation survey, which occurs when a state survey  agency investigates a complaint for a hospital surveyed by an AO. Unlike  traditional validation surveys that are conducted within 60 days of a  routine survey, complaint validation surveys are generally conducted  when the complaint is received. Such surveys initially focus on the  condition(s) alleged to be out of compliance. If the complaint validation  survey cites one or more COP-level deficiencies, the facility is placed  under the jurisdiction of the state survey agency. Subsequently, the state  survey agency conducts a full survey of all COPs. When all COP-level  deficiencies have been corrected, the facility again becomes the  responsibility of the AO.
CMS submits an annual report to Congress after the end of the fiscal  year—known as the CMS Financial Report—that includes information on  traditional validation surveys conducted at hospitals surveyed by AOs.  Based on such surveys, CMS calculates a hospital disparity rate for each  AO. The disparity rate measures the extent to which an AO has failed to  cite one or more deficiencies during its routine survey that were later  identified by a state survey agency during a traditional validation survey. If  the validation survey results for an AO indicate a disparity rate that  reaches the threshold of 20 percent or greater, CMS is to notify the AO  that its approval to survey and accredit hospitals may be in jeopardy and  that the agency may initiate a review.
CMS collects data on the results of state survey agency surveys in its  OSCAR database and AO surveys in its ASSURE database. The  databases include information such as the number and type of surveys  conducted and any deficiencies cited, including the specific standard or  COP out of compliance. In addition, OSCAR contains data on the number  of surveyors and amount of time devoted to the health portion of the  survey.
section_title: CMS Has Data on the Quality of Care at LTCHs, but Currently the Data Are Limited
paragraphs: Although CMS collects some data on the quality of care at LTCHs, the  data are currently limited. First, CMS does not have data on prior survey  results for the majority of LTCHs because TJC only recently began  submitting detailed deficiency data on the results of its surveys to CMS.  In addition, current survey results in OSCAR and ASSURE may be  incomplete because these databases do not always accurately identify   (1) which survey organization is responsible for surveying each LTCH or  (2) whether a facility is, in fact, an LTCH. Second, CMS does not currently  collect data for quality measures because LTCHs are not yet required to  report them.
subsections: section_title: CMS Has No Detailed Prior Survey Data and Incomplete Current Survey Results on the Majority of LTCHs
paragraphs: Because TJC only recently began submitting detailed survey data to  CMS, ASSURE has no prior data and limited current data—surveys  conducted since July 2009—for TJC-surveyed LTCHs, which constitute a  majority (about 80 percent) of such hospitals. As of December 2010, TJC  had surveyed and submitted data on about half of the LTCHs it surveys.  CMS has prior and current survey data in OSCAR for state-surveyed  LTCHs, which represent about 16 percent of LTCHs. Appendix I reports  prior and fiscal year 2010 data on the proportion of LTCHs with COP-level  deficiencies, lists the most commonly cited deficiencies, and compares  these results to those of ACHs. Because fiscal year 2010 data does not  include at least one survey for each LTCH, these results may not reflect  the quality of care across all LTCHs.
We found that there were 447 LTCHs listed in OSCAR or ASSURE as of  fiscal year 2010. However, both the OSCAR and ASSURE databases  inaccurately identified the responsible survey organization and the  ASSURE database was incomplete. For example,    OSCAR categorizes 89 LTCHs as state-surveyed, but we found that  only 71 of these LTCHs are actually state-surveyed. The remaining 18  LTCHs are surveyed by AOs. CMS officials told us that OSCAR data  are not always updated when LTCHs switch from being surveyed by  an AO to being surveyed by a state survey agency and vice versa.    We found that 56 LTCHs were either misidentified in ASSURE as  ACHs or were missing from the database. LTCHs may initially be  classified as ACHs until they demonstrate their average length of stay  is at least 25 days and then need to be reclassified. According to a  TJC official, about 30 LTCHs submitted ACH identification numbers  on their TJC accreditation applications and were thus misidentified in  ASSURE. CMS subsequently issued new LTCH identification  numbers to these facilities, but TJC officials told us that neither CMS  nor the LTCHs had notified them. In a few cases, the LTCHs’ initial  survey occurred after TJC’s last quarterly ASSURE update, the LTCH  had submitted the identification number of a nearby facility with the  same owner, or the LTCH had closed. Finally, in a couple cases, TJC  could not explain why the LTCH was not listed in ASSURE.
CMS officials told us that they recognize these limitations, but have not  yet established an approach for addressing these issues.
section_title: CMS Does Not Require LTCHs to Report Data on Quality Measures, but Will Do So Beginning in 2014
paragraphs: CMS currently does not have quality measures for LTCHs because  LTCHs were not required to report on the quality measures developed for  most ACHs in 2003 or later. While LTCHs are not currently reporting on  quality measures, under the Patient Protection and Affordable Care Act  (PPACA) enacted in 2010, they must begin doing so by 2014. PPACA  directed HHS to publish measures for LTCHs and required the  department to consider measures endorsed by a consensus-based entity,  such as NQF. To identify these measures, CMS reviewed LTCH  measures currently used by the National Association of Long Term  Hospitals and TJC. CMS also has received feedback from MedPAC,  convened a technical expert panel, and held stakeholder information  sessions. In May 2011, CMS published a proposed rule on three potential  quality measures that LTCHs would be required to report on from   October 1, 2012, through December 31, 2012, for their fiscal year 2014  payment determination: (1) catheter-associated urinary tract infection  rate, (2) central-line associated blood stream infection rate, and (3) new  or worsened pressure ulcers. None of the three measures have been  endorsed by NQF for use by LTCHs, but NQF has endorsed their use in  other settings. CMS is working with NQF to have these measures  endorsed for the LTCH setting. The proposed rule includes some  additional quality measures that CMS may require LTCHs to report in the  future, some of which, such as patient fall rate, also have been endorsed  by NQF for other types of health care facilities.
section_title: CMS Oversight of Survey Activities at LTCHs Is Limited
paragraphs: CMS and its regional offices’ oversight of state survey agency and AO  survey activities in LTCHs is limited because two of its oversight  strategies—performance measures and selection of hospitals for  traditional validation surveys—focus on hospitals in general rather than  LTCHs specifically. CMS’s third oversight strategy—collection and  analysis of survey data—is also limited because the agency does not  utilize all of the available data to identify weaknesses in the survey  process that may require further investigation. As a result of these  oversight limitations, CMS cannot ensure that state survey agencies and  AOs are held accountable and that they meet CMS’s survey  requirements.
subsections: section_title: CMS’s Performance Measures for Survey Activities Do Not Focus on LTCHs
paragraphs: None of the performance measures that CMS uses to assess the survey  activities of state survey agencies and AOs focus specifically on LTCHs.  Thus, CMS analyzes data on survey activities at LTCHs together with  data for other types of hospitals and facilities and does not analyze or  report the results separately for LTCHs. One of CMS’s performance  measures for state survey agencies examines the timeliness of state  surveys. CMS’s policy is for all hospitals to be surveyed every 3 to   5 years. We used OSCAR data to analyze the timeliness of routine  surveys conducted by state survey agencies in LTCHs. For LTCHs that  had both a current and prior state survey (52 of 71), we found that more  than 5 years had elapsed between surveys for about 38 percent of  LTCHs. About 19 percent of LTCHs were surveyed by states within 3  years and about 42 percent were surveyed from more than 3 up to 5  years after their prior surveys.
Similarly, CMS does not analyze the results of its AO performance  measures separately for LTCHs. CMS’s performance measures for AOs  generally focus on the AOs’ ability to provide the agency with timely,  complete, and accurate survey findings, facility notification letters, and  survey schedules for all of the types of facilities they survey (such as  hospitals, home health agencies, ambulatory surgery centers, and  hospices). In addition, CMS recently added a measure that assesses  whether AOs are conducting surveys of the accredited facilities within a   3-year period. CMS provides feedback on its analysis of performance  measures to each AO, including TJC, on an ongoing basis. These results  are also reported to Congress in CMS’s annual financial report.  However, CMS does not provide feedback to AOs or publicly report on  the performance measures for any particular type of AO-surveyed facility,  including LTCHs.
section_title: LTCHs Are Not Systematically Included in the Hospital Validation Survey Sample, and Results from Complaint Validation Surveys Are Not Always Shared with TJC
paragraphs: CMS does not systematically include 1 percent of AO-surveyed LTCHs— fewer than five—in its sample of traditional hospital validation surveys  conducted by state survey agencies. In contrast, state survey agencies  conduct a large number of complaint investigations at TJC-surveyed  LTCHs—known as complaint validation surveys. However, the results are  not always shared with TJC, limiting the effectiveness of oversight.
CMS’s policy requires that approximately 1 percent of AO-surveyed  hospitals receive a traditional validation survey each year. While CMS  has used this strategy to oversee AO survey activities at hospitals  generally, it has not done so for LTCHs specifically. Agency officials told  us that the sample was unlikely to have included LTCHs prior to 2011  because they had not made LTCH status a basis for assignment of  validation surveys. However, using OSCAR data, we found that about   1 percent or more of TJC-surveyed LTCHs received a traditional  validation survey each year from fiscal years 2006 through 2010. The  results of LTCH validation surveys were included in CMS’s annual  calculations of TJC’s hospital disparity rates for fiscal years 2006 through  2009.
Following the publicized allegations of poor care at LTCHs, CMS decided  to have state survey agencies conduct validation surveys in fiscal year  2011 at 34 AO-surveyed LTCHs. CMS selected the LTCHs using a  stratified random sample methodology that considered the workload of  the state survey agencies and the locations of the LTCHs. CMS officials  were not definitive in how they would use the results of these LTCH  validation surveys. They suggested that they may compare the results of  these surveys, including the extent to which COP-level deficiencies are  cited, to their prior analysis of state LTCH survey data and to survey data  for other types of hospitals. However, these surveys do not constitute a  solution to CMS’s lack of a systematic way of including LTCHs in its  annual sample of traditional validation surveys at hospitals because these  surveys are a one-time activity and will not be conducted within 60-days  of a routine survey. As a result, CMS will not be able to calculate a  disparity rate, which measures the effectiveness of the AOs’ survey  process.
Through state survey agencies, CMS conducts a significant number of  complaint validation surveys in TJC-surveyed LTCHs while TJC conducts  few complaint surveys in the LTCHs it surveys. From fiscal years 2006  through 2010, state survey agencies conducted 1,224 complaint  validation surveys at TJC-surveyed LTCHs compared with TJC’s   67 complaint surveys at LTCHs it surveys. CMS officials told us that state  survey agencies receive more complaints than the TJC because patients  and their advocates may not always be aware that complaints can be filed  with an AO. They also told us that complaint allegations, including the  patients name and the name of the complainant could not be referred to  the appropriate AOs for investigation because of privacy concerns unless  the AO specifically asked for each complaint. However, when we  discussed this issue with both CMS privacy and program officials, they  concluded that CMS regional offices could refer hospital complaints to  AOs for investigation or share complaint information with AOs prior to a  state complaint validation survey. TJC officials told us that they are willing  to conduct complaint surveys in response to referrals from CMS.
CMS told us that while it had not shared actual complaints with AOs it had  increased its communication with TJC, including the results of complaint  validation surveys. For example, CMS provided its regional offices with  the e-mail address of each AO in order to provide AOs with copies of  hospital correspondence and the results of surveys conducted by state  agencies in accredited facilities. However, TJC officials told us that CMS  regional offices do not consistently provide the results of the complaint  validation surveys and sometimes the information provided is not timely.  We spoke with officials from two CMS regional offices that authorized two  state agency complaint validation surveys at TJC-surveyed LTCHs in  fiscal year 2007 and fiscal year 2009, respectively. Officials from one  regional office told us that not all of the information on the results of  complaint validation surveys was forwarded to TJC; thus, a letter might be  sent to TJC that outlined the COP-level deficiencies cited, but not the  standard-level deficiencies. TJC told us that they did not even know that  an additional complaint validation survey at this facility had been  conducted in 2009 until we informed them. Officials from the other  regional office said that they did not forward any information from the  complaint survey, including the official record of all the deficiencies  cited. TJC officials also said that information on the findings from state  complaint validation surveys could lead them to conduct their own survey  or could be used by TJC as it prepares for the facility’s next survey.  Additionally, officials from the CMS regional offices we contacted told us  that state survey agencies do not review the results of an AO’s most  recent routine survey prior to conducting complaint validation surveys and  therefore, may not be familiar with any deficiencies cited by TJC. Given  that complaint validation surveys may provide insights into concerns that  occur between routine surveys, information sharing between CMS  regional offices and AOs is an important aspect of effective oversight.
section_title: CMS Is Not Using All Available ASSURE and OSCAR Survey Data to Oversee Survey Activities at LTCHs
paragraphs: CMS has not yet analyzed ASSURE survey data to oversee TJC’s LTCH  survey activities or used these data in combination with OSCAR data to  identify issues that may warrant further examination and strengthen  oversight and accountability. By recognizing and adjusting for limitations  in these databases, we identified several areas where the data may assist  CMS in more effectively overseeing survey activities at LTCHs. For  example:    CMS has data on the results of all surveys conducted by both state  survey agencies and TJC that could provide information on the  proportion of LTCHs and ACHs cited with COP-level deficiencies by  state survey agencies and TJC. Although CMS conducted an internal  analysis of the proportion of surveys at LTCHs and ACHs that cited  COP-level deficiencies, it used only OSCAR data, which primarily  consists of complaint surveys conducted by state survey agencies.  We did our own analysis using both ASSURE and OSCAR data and  found that the inclusion of ASSURE data influenced whether LTCHs  or ACHs had more COP-level deficiencies. See app. I for the results  of our data analysis.    CMS has data on complaint validation surveys conducted in LTCHs  that could provide information on how effectively states triage and  conduct complaint surveys at TJC-surveyed LTCHs. For example, our  analysis found that a small proportion of state complaint validation  surveys cited deficiencies. Specifically, we found that about 6 percent  of the 1,224 complaint validation surveys conducted at TJC-surveyed  LTCHs between 2006 and 2010 had one or more COP-level  deficiencies and about 66 percent did not cite any deficiencies. We  also found that two state agencies conducted nearly half (40 percent)  of the complaint validation surveys, but cited almost no COP-level  deficiencies. CMS and TJC officials told us that the small proportion  of state complaint validation surveys that cite COP-level deficiencies  indicated that state survey agencies may not be adequately triaging  complaints, that is, some of these complaints may not have warranted  on-site surveys. In addition, CMS officials suggested that states may  have cited deficiencies at the standard level to avoid conducting a full  survey and may not have reviewed all standards related to the COP  alleged by the complainant to have been out of compliance.    CMS has data to compare the results from routine and complaint  surveys that could provide information on the thoroughness of routine  surveys at LTCHs that also had complaint validation surveys. CMS  has not compared routine survey data for TJC-surveyed LTCHs it has  in ASSURE with complaint validation survey data it has in OSCAR.  We compared these two databases to determine if routine surveys by  TJC had missed COP-level deficiencies identified by state complaint  validation surveys. We identified 32 complaint validation surveys that  were conducted within 2 to 60 days of a TJC routine survey reported  in ASSURE. Four of the 32 surveys identified COP-level deficiencies  that were not identified on the LTCHs most recent survey by TJC.  While there may be reasonable explanations, further information could  improve CMS oversight of survey activities.    CMS has data on the survey resources used during routine surveys  by state survey agencies and TJC that could provide information on  the efficiency and effectiveness of survey activities. We compared the  survey resources—number of surveyors and amount of time devoted  to conducting a survey—used by state surveyors and TJC for the  health portion of routine surveys at similar sized LTCHs between 2006  and 2010. We found that state surveyors spent about two times as  many hours per survey and utilized about two times more surveyors  per survey than TJC. The appropriate level of resources for an LTCH  survey is unclear and CMS, state survey agencies, and TJC may not  be in agreement.
CMS officials told us that they are not using all available ASSURE and  OSCAR survey data because they are currently focusing on obtaining  complete and accurate information from TJC and other AOs. They told us  that they intend to more fully use the available data in the future to  oversee LTCH survey activities; however, they have not developed a plan  to do so. One CMS official also told us that in the future the agency might  consider merging the information collected in ASSURE with OSCAR,  thereby establishing one database for hospital survey data.
section_title: Conclusions
paragraphs: LTCHs are a specialized type of ACH that care for very sick and clinically  complex patients. Most patients in LTCHs have been transferred from an  intensive care unit of another hospital because they need a continued  intense level of care for an extended period of time. Because these  patients are so vulnerable, it is important that oversight of the quality of  care delivered by LTCHs is monitored and, if shortcomings are identified,  action is promptly taken. However, our review found several limitations in  the oversight of LTCHs that are cause for concern, including weaknesses  that affect the availability of data to oversee the quality of care and the  ability of CMS to hold both state survey agencies and accrediting  organizations accountable for their survey activities.
We found several weaknesses in the availability of data on the quality of  care in LTCHs. The results of surveys are stored in more than one  database, which affects CMS’s ability to use the data to understand the  quality of care in LTCHs. For example, CMS is unable to accurately  identify all LTCHs from these databases and which entity—state survey  agencies or AOs—is responsible for conducting routine surveys of the  facility. The inability to accurately identify all LTCHs has implications,  particularly when CMS implements a new COP for LTCHs and when  LTCHs have to begin reporting quality measures. The fragmentation of  data across different databases also affects CMS’s ability to review the  data for LTCHs specifically and ensure that the data are updated as  needed and may inhibit the sharing of data between the state survey  agencies and AOs, both of which may have surveyors in the same LTCHs  at different times, conducting different types of surveys.
We also found weaknesses in CMS’s ability to hold state survey agencies  and accrediting organizations accountable. CMS’s traditional strategies  for holding these entities accountable—performance measures and  validation surveys—do not focus on LTCHs. Although CMS conducts  traditional validation surveys in hospitals in general as a means for  assessing the effectiveness of an AO’s survey activities, CMS cannot  assure that LTCHs are systematically included in their review; when such  surveys have been conducted in LTCHs, CMS has not separated out the  LTCH surveys from surveys of all other hospitals and so is unable to  identify whether there may be areas of concern specific to AO survey  activities in LTCHs. Furthermore, CMS is not effectively using the data it  collects from surveys to review and understand the activities conducted  by state survey agencies and AOs. For example, there are differences in  the workload and resources devoted to survey activities between state  survey agencies and AOs; however, the reasons for these differences  were not clear. CMS officials said they plan to more fully use the data in  the future to oversee survey activities in LTCHs, but have not yet  developed a plan for doing so.
CMS oversight of LTCHs is hampered by inaccurate data and ineffective  use of the data it currently collects. By increasing the use of its existing  databases and more effectively using the data it currently collects, CMS  has the opportunity to improve the accuracy of the data it has and the  effectiveness of its oversight. Unless CMS more effectively uses the data  it collects, the agency cannot provide assurances that the quality of care  in LTCHs meets federal quality standards and ensure that vulnerable  patients are not at risk.
section_title: Recommendations for Executive Action
paragraphs: In order to improve the data available on the quality of care at LTCHs, the  Administrator of CMS should take the following two actions:  1.  Improve the accuracy of the databases that track LTCH survey results    working with AOs and state survey agencies to develop a  complete and accurate list of the LTCHs that they each survey  and an approach to ensuring that the list is updated in a timely  manner, and    expanding the OSCAR database to include the results of all LTCH  surveys, such as those conducted by TJC, which are currently  stored in the separate ASSURE database.  2.  Improve information sharing with TJC regarding complaint validation  survey results for TJC-surveyed LTCHs, such as ensuring that all  survey findings are shared in a timely fashion.
In order to improve CMS’s oversight of survey activities at LTCHs, the  Administrator of CMS should take the following three actions:  1.  Conduct traditional validation surveys at a sample of LTCHs each  fiscal year and include an LTCH disparity rate in its annual financial  report to Congress.  2.  Explore differences in survey workload and in the resources survey  organizations devote to LTCH surveys in order to  identify areas for efficiencies, and    determine whether the workload associated with complaint  validation surveys could be more equitably shared with TJC.  3.  Develop a plan to use available data on survey activities to hold  survey organizations accountable for conducting surveys consistent  with CMS requirements for evaluating the quality of care provided by  LTCHs.
section_title: Agency and Other External Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and TJC for comment. In its  written comments, HHS concurred with our recommendations and  acknowledged that their implementation would further strengthen the  continued improvement in the oversight of AOs that CMS has undertaken  since fiscal year 2006. TJC agreed with most of our recommendations,  but disagreed with the recommendation related to traditional validation  surveys, that is, state oversight surveys at AO-surveyed LTCHs. HHS’s  and TJC ‘s comments are reproduced in appendix II and III, respectively.
subsections: section_title: HHS Comments
paragraphs: HHS concurred with all five of our recommendations. With respect to our  recommendation to improve the accuracy of the databases that track  LTCH survey results, HHS noted that it had been working since 2007 to  identify and correct serious problems in both the AO and CMS databases  and had made significant progress. HHS acknowledged that one issue is  that LTCHs must enroll initially as acute care hospitals and are later  converted to LTCHs, which affects the identification of LTCHs in the  database. HHS outlined steps it had taken to address the fact that we  found many LTCHs identified as acute care hospitals in the ASSURE  database. HHS also said that it has begun the process of converting  ASSURE to a Web-enabled application, which would provide more  flexibility and allow it to explore methods to increase the accuracy of the  database.
HHS also concurred with our four other recommendations. HHS said that  it intends to:  reinforce existing CMS policy on sharing information with AOs and  work with regional offices to enhance compliance,    explore an option to increase its traditional validation survey sample  for hospitals, which would permit the inclusion of a stratified sample of  LTCHs annually,    explore the differences in survey workload and resource allocation,  which it characterized as definitely meriting attention, while working  with regional offices to clarify the policy for triaging complaint surveys  at AO-surveyed LTCHs and for referring certain complaints to the  appropriate AO, and  review the available data to determine to what extent it can be used to  develop additional AO performance measures for evaluating quality of  care at hospitals, including LTCHs.
section_title: TJC Comments
paragraphs: TJC agreed that there was room for improvement in CMS’s oversight of  the quality of care provided by LTCHs and of survey activities at such  hospitals and noted that CMS had already taken positive steps toward  achieving these goals. However, it questioned our conclusion that CMS  oversight of LTCHs was limited. It suggested, instead, that a more  accurate conclusion was that CMS oversight was not separated in a  focused manner from that of other hospitals. We believe that our report  appropriately acknowledged CMS’s progress in collecting data from TJC  since TJC’s statutory deeming authority was revoked. We found that CMS  oversight of LTCHs was limited because it was (1) focused on hospitals in  general and not LTCHs specifically and (2) not effectively using the  survey data it collected to review and understand the activities of state  survey agencies and AOs at LTCHs.
TJC agreed with our recommendations to improve the accuracy of the  survey databases, improve information sharing, and use available data to  improve oversight. However, it disagreed with our recommendation to  conduct traditional validation surveys at a sample of LTCHs each fiscal  year and to include a LTCH-specific disparity rate in its annual financial  report to Congress. Specifically, TJC questioned the value of LTCH- specific validation surveys for several reasons:    TJC questioned whether validation surveys were the most appropriate  measure of AO performance because we had previously reported that  state surveyors understate (i.e., miss) serious deficiencies on nursing  home surveys. We do not believe that these findings are directly  applicable to traditional LTCH validation surveys because the findings  cited by TJC relate to routine nursing home surveys. Moreover,  understatement, if it did exist on validation surveys, would not  diminish the fact that state surveyors have identified serious  deficiencies that AOs should have, but did not cite. We agree with  TJC that CMS should monitor complaint validation survey findings as  another indicator of AOs performance. For example, we pointed out  that state survey agencies identified condition-level deficiencies not  cited by TJC on several complaint validation surveys that were  conducted within 60 days of TJC’s routine survey.    TJC stated that the inclusion of a representative number of LTCHs as  part of the annual validation survey schedule would require a  significant increase in the federal budget allocated to validation  surveys. TJC said this would be necessary in order to arrive at a  statistically valid sample size that would in turn support a LTCH- specific disparity rate calculation. As we pointed out and HHS  comments noted, CMS has been conducting a small number of  traditional validation surveys at LTCHs each year—approximately   1 percent of LTCHs. In addition, HHS noted that it would explore an  option to increase its traditional validation survey sample for hospitals,  thereby permitting the inclusion of a stratified sample of LTCHs each  year.
TJC noted that it had provided CMS with information such as the  accreditation status resulting from surveys, demographic information, and  up-to-date survey schedules prior to the establishment of ASSURE in  2009 and, therefore, it was inaccurate to say that CMS has no prior  survey data on TJC-surveyed LTCHs. TJC’s comments acknowledged  that the information provided to CMS prior to 2009 did not include detailed  information on the specific deficiencies identified. We added a footnote to  our report acknowledging the information that TJC did provide to CMS  before 2009 and clarified the report to make it clear that the prior survey  data we are referring to involved detailed data on the deficiencies cited.
HHS and TJC also provided technical comments, which we incorporated  as appropriate.
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If your staff have any questions about this report, please contact me at  (202) 512-7114 or at kohnl@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix IV.
section_title: Appendix I: Condition-Level Deficiencies Cited at Long-Term and Acute Care Hospitals During Routine and Complaint Surveys
paragraphs: This appendix presents the Centers for Medicare & Medicaid Services  (CMS) data on the results of surveys at long-term care hospitals (LTCH).  In the course of our analyses, we identified some data limitations, which  we discussed with both CMS and The Joint Commission (TJC). We report  only data that we determined to be reliable.
CMS has several years worth of data on condition of participation-level  (COP) deficiencies cited by state survey agencies at LTCHs, but TJC only  began submitting similar data in July 2009. Table 1 shows data on COP- level deficiencies cited by state survey agencies from fiscal years 2005  through 2009. Table 2 shows fiscal year 2010 survey results for both  state survey agencies and TJC for LTCHs and acute care hospitals  (ACH). Fiscal year 2010 is the first full year for which data are available  for both survey organizations. However, most hospitals did not have a  routine survey in fiscal year 2010 because surveys are conducted every 3  to 5 years. Because fiscal year 2010 data does not include at least one  survey for each LTCH, these results may not reflect the quality of care  across all LTCHs. Finally, tables 3 and 4 show the most commonly cited  COP-level deficiencies at LTCHs and ACHs surveyed by state survey  agencies, during fiscal year 2010.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: Comments from The Joint Commission
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Walter Ochinko, Assistant  Director; Sarah Harvey; Kristin Helfer Koester; Dan Lee; Elizabeth T.  Morrison; Phillip J. Stadler; and Jennifer Whitworth made key  contributions to this report.