Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight
Released: 2003-07-17T00:00:00

Letter

Background

Combined Medicare and Medicaid payments to nursing homes for care provided to vulnerable elderly and disabled beneficiaries were expected to total about $63 billion in 2002, with a federal share of approximately $42 billion. Oversight of nursing homes is a shared federal-state responsibility. Based on statutory requirements, CMS defines standards that nursing homes must meet to participate in the Medicare and Medicaid programs and contracts with states to assess whether homes meet these standards through annual surveys and complaint investigations. A range of statutorily defined sanctions is available to help ensure that homes maintain compliance with federal quality requirements. CMS is also responsible for monitoring the adequacy of state survey activities.

Standard Surveys

Every nursing home receiving Medicare or Medicaid payment must undergo a standard survey not less than once every 15 months, and the statewide average interval for these surveys must not exceed 12 months. A standard survey entails a team of state surveyors, including registered nurses (RN), spending several days in the nursing home to assess compliance with federal long-term care facility requirements, particularly whether care and services provided meet the assessed needs of the residents and whether the home is providing adequate quality care, such as preventing avoidable pressure sores, weight loss, or accidents. Based on our earlier work indicating that facilities could mask certain deficiencies, such as routinely having too few staff to care for residents, if they could predict the survey timing, HCFA directed states in 1999 to (1) avoid scheduling a home’s survey for the same month of the year as the home’s previous standard survey and (2) begin at least 10 percent of standard surveys outside the normal workday (either on weekends, early in the morning, or late in the evening).

State surveyors’ assessment of the quality of care provided to a sample of residents during the standard survey serves as the basis for evaluating nursing homes’ compliance with federal requirements. CMS establishes specific investigative protocols for state surveyors to use in conducting these comprehensive surveys. These procedural instructions are intended to make the on-site surveys thorough and consistent across states. In response to our earlier recommendations concerning the need to better ensure that surveyors do not miss significant care problems, HCFA planned a two-phase revision of the survey process. In phase one, HCFA instructed states in 1999 to (1) begin using a series of new investigative protocols covering pressure sores, weight loss, dehydration, and other key quality areas, (2) increase the sample of residents reviewed with conditions related to these areas, and (3) review “quality indicator” information on the care provided to a home’s residents, before actually visiting the home, to help guide survey activities. Quality indicators are essentially numeric warning signs of the prevalence of care problems such as greater-than-expected instances of weight loss, dehydration, or pressures sores. They are derived from nursing homes’ assessments of residents and rank a facility in 24 areas compared with other nursing homes in the state. By using the quality indicators to select a preliminary sample of residents before the on-site review, surveyors are better prepared to identify potential care problems. Surveyors augment this preliminary sample with additional resident cases once they arrive in the home. To address remaining problems with sampling and the investigative protocols, CMS is planning a second set of revisions to its survey methodology. The focus of phase two is (1) improving the on-site augmentation of the preliminary sample selected off-site using the quality indicators and (2) strengthening the protocols used by surveyors to ensure more rigor in their on-site investigations.

Complaint Investigations

Complaint investigations provide an opportunity for state surveyors to intervene promptly if quality-of-care problems arise between standard surveys. Within certain federal guidelines and time frames, surveyors generally follow state procedures when investigating complaints filed against a home by a resident, the resident’s family, or nursing home employees, and typically target a single area in response to the complaint.

Historically, HCFA had played a minimal role in providing states with guidance and oversight of complaint investigations. Until 1999, federal guidelines were limited to requiring the investigation of complaints alleging immediate jeopardy conditions within 2 workdays. In March 1999, HCFA acted to strengthen state complaint procedures by instructing states to investigate any complaint alleging harm to a nursing home resident within 10 workdays. Additional guidance provided to states in late 1999 specified that, as with immediate jeopardy complaints, investigations should generally be conducted on-site at the nursing home. This guidance also identified techniques to help states identify complaints having a higher level of actual harm. As part of a complaint improvement project, also initiated in late 1999, HCFA plans to issue more detailed guidance to states, such as identifying model programs or practices to increase the effectiveness of complaint investigations.

Deficiency Reporting

Quality-of-care deficiencies identified during either standard surveys or complaint investigations are classified in 1of 12 categories according to their scope (i.e., the number of residents potentially or actually affected) and their severity. An A-level deficiency is the least serious and is isolated in scope, while an L-level deficiency is the most serious and is considered to be widespread in the nursing home (see table 1). States are required to enter information about surveys and complaint investigations, including the scope and severity of deficiencies identified, in CMS’s OSCAR database.

The importance of accurate and timely reporting of nursing home deficiency data has increased with the public reporting of survey deficiencies, which HCFA initiated in 1998 on its Nursing Home Compare Web site. The public reporting of deficiency data is intended to assist individuals in differentiating among nursing homes. In November 2002, CMS augmented the deficiency data available on its Web site with 10 clinical indicators of quality, such as the percentage of residents with pressure sores, in nursing homes nationwide. While the intent of this new initiative is worthwhile, CMS had not resolved several important issues that we raised prior to moving from a six-state pilot to nationwide implementation. These issues included: (1) the ability of the new information to accurately identify differences in nursing home quality, (2) the accuracy of the underlying data used to calculate the quality indicators, and (3) the potential for public confusion over the available data.

Enforcement Policy

Ensuring that documented deficiencies are corrected is a shared federal- state responsibility. CMS imposes sanctions on homes with Medicare or dual Medicare and Medicaid certification on the basis of state referrals. CMS normally accepts a state’s recommendation for sanctions but can modify it. The scope and severity of a deficiency determine the applicable sanctions that can involve, among other things, requiring training for staff providing care to residents, imposing monetary fines, denying the home Medicare and Medicaid payments for new admissions, and terminating the home from participation in these programs. Before a sanction is imposed, federal policy generally gives nursing homes a grace period of 30 to 60 days to correct the deficiency. We earlier reported, however, that the threat of federal sanctions did not prevent nursing homes from cycling in and out of compliance because they were able to avoid sanctions by returning to compliance within the grace period, even when they had been cited for actual harm on successive surveys. In 1998, HCFA began a two- stage phase-in of a new enforcement policy. In the first stage, effective September 1998, HCFA required states to refer for immediate sanction homes found to have a pattern of harming residents or exposing them to actual or potential death or serious injury (H-level deficiencies and above on CMS’s scope and severity grid). Effective January 14, 2000, HCFA expanded this policy to also require referral of homes found to have harmed one or a small number of residents (G-level deficiencies) on successive standard surveys.

CMS Oversight

CMS is responsible for overseeing each state survey agency’s performance in ensuring quality of care in state nursing homes. Its primary oversight tools are statutorily required federal monitoring surveys conducted annually in 5 percent of the nation’s certified Medicare and Medicaid nursing homes, on-site annual state performance reviews instituted during fiscal year 2001, and analysis of periodic oversight reports that have been produced since 2000. Federal monitoring surveys can be either comparative or observational. A comparative survey involves a federal survey team conducting a complete, independent survey of a home within 2 months of the completion of a state’s survey in order to compare and contrast the findings. In an observational survey, one or more federal surveyors accompany a state survey team to a nursing home to observe the team’s performance. Roughly 85 percent of federal surveys are observational. State performance reviews, implemented in October 2000, measure state performance against seven standards, including statutory requirements regarding survey frequency, requirements for documenting deficiencies, timeliness of complaint investigations, and timely and accurate entry of deficiencies into OSCAR. These reviews replaced state self-reporting of their compliance with federal requirements. In October 2000, HCFA also began to produce 19 periodic reports to monitor both state and regional office performance. The reports are based on OSCAR and other CMS databases. Examples of reports that track state activities include pending nursing home terminations (weekly), data entry timeliness (quarterly), tallies of state surveys that find homes deficiency free (semiannually), and analyses of the most frequently cited deficiencies by states (annually). These reports, in a standard format, enable comparisons within and across states and regions and are intended to help identify problems and the need for intervention. Certain reports—such as the timeliness of state survey activities—are used to monitor compliance with state performance standards.

Magnitude of Problems Remains Cause for Concern Even Though Fewer Serious Nursing Home Quality Problems Reported

The magnitude of the problems uncovered during standard nursing home surveys remains a cause for concern even though OSCAR deficiency data indicate that state surveyors are finding fewer serious quality problems. Compared to an earlier period, the percentage of homes nationwide cited since mid-2000 for actual harm or immediate jeopardy has decreased in over three-quarters of states—with seven states reporting a drop of 20 percentage points or more. State surveys conducted since about mid-2000 showed less variance from federal comparative surveys, suggesting that (1) state surveyors’ performance in documenting serious deficiencies has improved and (2) the decline in serious nursing home quality problems is potentially real. However, federal comparative surveys, as well as our review of a sample of survey reports from homes with a history of quality- of-care problems, continued to find understatement of actual harm deficiencies.

Proportion of Nursing Homes with Documented Actual Harm or Immediate Jeopardy Care Problems Has Declined since 2000

Compared to the preceding 18-month period, the proportion of nursing homes cited for actual harm or immediate jeopardy has declined nationally from 29 percent to 20 percent since mid-2000. In contrast, from early 1997 through mid-2000, the percentage of homes cited for such serious deficiencies was either relatively stable or increased in 31 states. From July 2000 through January 2002, 40 states cited a smaller percentage of homes with such serious deficiencies, while only 9 states and the District of Columbia cited a larger proportion of homes with such deficiencies. Despite these changes, there is still considerable variation in the proportion of homes cited for serious deficiencies, ranging from about 7 percent in Wisconsin to about 50 percent in Connecticut. Appendix II provides trend data on the percentage of nursing homes cited for serious deficiencies for all 50 states and the District of Columbia.

Table 2 shows the recent change in actual harm and immediate jeopardy deficiencies for states that surveyed at least 100 nursing homes. Specifically: Twenty-five states had a 5 percentage point or greater decrease in the proportion of homes identified with actual harm or immediate jeopardy. For over two-thirds of these states, the decrease in serious deficiencies was greater than 10 percentage points. Seven states—Arizona, Alabama, California, Michigan, Indiana, Pennsylvania, and Washington— experienced declines of 15 percentage points or more.

Two states, South Dakota and Colorado, experienced an increase of 5 percentage points or greater in the proportion of homes with actual harm or immediate jeopardy deficiencies (6.6 and 10.8, respectively).

The remaining 11 states were relatively stable—experiencing approximately a 4 percentage point change or less.

States offered several explanations for the declines in actual harm and immediate jeopardy deficiencies, including (1) changing guidance from CMS regional offices as to what constitutes actual harm, (2) hiring additional staff, and (3) surveyors failing to properly identify actual harm deficiencies.

Federal Comparative Surveys Show Decreased Variance with State Survey Findings, but Understatement of Actual Harm Deficiencies Continued

Our analysis of federal comparative surveys conducted nationwide prior to and since June 2000 showed a decreased variance between federal and state survey findings (see app. I for a description of our scope and methodology). For comparative surveys completed from October 1998 through May 2000, federal surveyors found actual harm or higher-level deficiencies in 34 percent of homes where state surveyors had found no such deficiencies, compared to 22 percent for comparative surveys completed from June 2000 through February 2002. In addition, while federal surveyors found more serious care problems than state surveyors on 70 percent of the earlier comparative surveys, this percentage declined to 60 percent for the more recent surveys.

Despite the decline in understatement of actual harm deficiencies from 34 percent to 22 percent, the magnitude of the state surveyors’ understatement of quality problems remains an issue. For example, from June 2000 through February 2002, federal surveyors found at least one actual harm or immediate jeopardy quality-of-care deficiency in 16 of the 85 homes (19 percent) that the states had found to be free of deficiencies. For example, federal surveyors found that 1 of the 16 homes failed to prevent pressure sores, failed to consistently monitor pressure sores when they did develop, and failed to notify the physician promptly so that proper treatment could be started. The federal surveyors who conducted the comparative survey of this nursing home noted in the file that a lack of consistent monitoring of pressure sores existed at the home during the time of the state’s survey and that the state surveyors should have found the deficiency.

Several states that reviewed a draft of this report questioned the value of federal comparative surveys because of their timing. Arizona noted that comparative surveys do not have to begin until up to 2 months after the state’s survey, and Iowa and Virginia officials said they might occur so long after the state’s survey that conditions in the home may have significantly changed. Although legislation requires comparative surveys to begin within 2 months of the state’s survey, CMS is continuing to make progress in reducing the timeframe between the state and the comparative survey. Based on our earlier recommendation that comparative surveys begin as soon after the state’s survey as possible, CMS instructed the regions to begin these surveys no later than one month following the state’s survey, and the average time between surveys nationally has decreased from 33 calendar days in 1999 to about 26 calendar days for surveys conducted from June 2000 through February 2002.

Quality-of-Care Problems Were Understated in Homes with a History of Problems

Even with the reported decline in serious deficiencies, an unacceptably high number of nursing homes—one in five nationwide—still had actual harm or immediate jeopardy deficiencies. Moreover, we found widespread understatement of actual harm deficiencies in a sample of surveys we reviewed that were conducted since July 2000 at homes with a history of harming residents (see app. I for a description of our methodology in selecting this sample). In 39 percent of the 76 survey reports we reviewed, we found sufficient evidence to conclude that deficiencies cited at a lower level (generally, potential for more than minimal harm, D or E) should have been cited at the level of actual harm or higher (G level or higher on CMS’s scope and severity grid). We were unable to assess whether the scope and severity of other deficiencies in our sample of surveys were also understated because of weaknesses in the investigations conducted by surveyors and in the adequacy with which they documented those deficiencies.

Of the surveys we reviewed, 30 (39 percent) contained sufficient evidence for us to conclude that deficiencies cited at the D and E level should have been cited as at least actual harm because a deficient practice was identified and linked to documented actual harm involving at least one resident (see table 3). These 30 survey reports depicted examples of actual harm, including serious, avoidable pressure sores; severe weight loss; and multiple falls resulting in broken bones and other injuries (see app. III for abstracts of these 30 survey reports). The following example illustrates understated actual harm involving the failure to provide necessary care and services. A nurse at one facility noted a large area of bruising and swelling on an 89-year-old resident’s chest. Nothing further was done to explore this injury until 11 days later when the resident began to experience shortness of breath and diminished breath sounds. Then a chest x ray was taken, revealing that the resident had sustained two fractured ribs and fluid had accumulated in the resident’s left lung. A facility investigation determined that the resident had been injured by a lift used to transfer the resident to and from the bed. It was clear from the surveyor’s information that the facility failed to take appropriate action to assess and provide the necessary care until the resident developed serious symptoms of chest trauma. Nevertheless, the surveyor concluded that there was no actual harm and cited a D-level deficiency—potential for more than minimal harm.

State survey agency officials in Alabama, California, Iowa, and Nebraska told us that surveyors had originally cited G-level deficiencies in 10 of the surveys we reviewed, but that the deficiencies had been reduced to the D level during the states’ reviews because of inadequate surveyor documentation. We concluded that 5 of the 10 surveys did contain adequate documentation to support actual harm because there was a clear link between the deficient facility practice and the documented harm to a resident. For example, the survey managers in one state changed a G- to a D-level deficiency because the surveyor only cited one source of evidence to support the deficiency—nurses’ notes in the residents’ medical records. According to the surveyor, a resident with dementia, experiencing long- and short-term memory problems, fell 11 times and sustained a fractured wrist, three fractured ribs, and numerous bruises, abrasions, and skin tears. According to the notes of facility nurses, a personal alarm unit was in place as a safety device to prevent falls. The surveyor found that the facility had (1) failed to provide adequate interventions to prevent accidents and (2) continued to use the alarm unit even though it did not prevent any of the falls. The medical record documentation of these events was extensive and, in our judgment, was sufficient evidence of a deficiency that resulted in actual harm to the resident.

In many of the 76 surveys we reviewed, including surveys in which we found no D- or E-level deficiencies that would appear to meet the criteria for actual harm deficiencies, we identified serious investigation or documentation weaknesses that could further contribute to the understatement of serious deficiencies in nursing homes. In some cases, the survey did not clearly describe the elements of the deficient practice, such as whether the resident developed a pressure sore in the facility or what the facility did to prevent the development of a facility-acquired pressure sore. In other cases, the survey omitted critical facts, such as whether a pressure sore had worsened or the size of the pressure sore.

Weaknesses Persist in State Survey, Complaint, and Enforcement Activities

Widespread weaknesses persist in state survey, complaint investigation, and enforcement activities despite increased attention to these issues in recent years. Several factors at the state level contribute to the understatement of serious quality-of-care problems, including poor investigation and documentation of deficiencies, the absence of adequate quality assurance processes, and a large number of inexperienced surveyors in some states due to high attrition or hiring limitations. In addition, our analysis of OSCAR data indicated that the timing of a significant proportion of state surveys remained predictable, allowing homes to conceal problems if they choose to do so. Many states’ complaint investigation policies and procedures were still inadequate to provide intended protections. For example, many states do not investigate all complaints identified as alleging actual harm in a timely manner, a problem some states attributed to insufficient staff and an increase in the number of complaints. Although HCFA strengthened its enforcement policy by requiring state survey agencies, beginning in January 2000, to refer for immediate sanction homes that had a pattern of harming residents, we found that many states did not fully comply with this new requirement. States failed to refer a substantial number of homes for sanction, significantly undermining the policy’s intended deterrent effect.

Investigation Weaknesses and Other Factors Contribute to Underreporting of Care Problems

CMS and state officials identified several factors that they believe contribute to state surveys continuing to miss significant care problems. These weaknesses persist, in part, because many states lack adequate quality assurance processes to ensure that deficiencies identified by surveyors are appropriately classified. According to officials we interviewed, the large number of inexperienced surveyors in some states due to high attrition has also had a negative impact on the quality of state surveys and investigations. Our analysis of OSCAR data also indicated that nursing homes could conceal problems if they choose to do so because a significant proportion of current state surveys remain predictable.

Investigation and Documentation Weaknesses

Consistent with the investigation and documentation weaknesses we found in our review of a sample of survey reports from homes with a history of actual harm deficiencies, CMS officials told us that their own activities had identified similar problems that could contribute to an understatement of serious deficiencies at nursing homes.

CMS reviews of state survey reports during fiscal year 2001 demonstrated weaknesses in a majority of states, including: (1) inadequate investigation and documentation of a poor outcome, such as reviewing available records to help identify when a pressure sore was first observed and how it changed over time, (2) failure to specifically identify the deficient practice that contributed to a poor outcome, or (3) understatement of the seriousness of a deficiency, such as citing a deficiency at the D level (potential for actual harm) when there was sufficient evidence in the survey report to cite the deficiency at the G level (actual harm).

State survey agency officials expressed confusion about the definition of “actual harm” and “immediate jeopardy,” suggesting that such confusion contributes to the variability in state deficiency trends. For example, officials in one state told us that, in their view, residents must experience functional impairment for state surveyors to cite an actual harm deficiency, an interpretation that CMS officials told us was incorrect. Under such a definition, repeated falls that resulted in bruises, cuts, and painful skin tears would not be cited as actual harm, even if the facility failed to assess the resident for measures to prevent falls.

CMS officials also told us that, contrary to federal guidance, state surveyors in at least one state did not cite all identified deficiencies but rather brought them to the homes’ attention with the expectation that the deficiencies would be corrected. CMS officials told us that they identified the problem by asking state officials about the unusually high number of homes with no deficiencies on their standard surveys.

Inadequate Quality Assurance Processes

Some state officials told us that considerable staff resources are devoted to scrutinizing the support for actual harm and higher-level deficiencies that could lead to the imposition of a sanction. While most of the 16 states we contacted had quality assurance processes to review deficiencies cited at the actual harm level and higher, half did not have such processes to help ensure that the scope and severity of less serious deficiencies were not understated. State officials generally told us that they lacked the staff and time to review deficiencies that did not involve actual harm or immediate jeopardy, but some states have established such programs. For example, Maryland established a technical assistance unit in early 2001 to review a sample of survey reports; the review looks at all deficiencies— not just those involving actual harm or immediate jeopardy. A Maryland official told us that she had the resources to do so because the state legislature authorized a substantial increase in the number of surveyors in 1999. However, staff cutbacks in late 2002 due to the state’s budget crisis have resulted in the reviews being less systematic than originally planned. In Colorado, two long-term-care supervisors reviewed all 1,351 deficiencies cited in fiscal year 2001. Maryland and Colorado officials told us that the reviews have identified shortcomings in the investigation and documentation of deficiencies, such as the failure to interview residents or the classification of deficiencies as process issues when they actually involved quality of care. The reviews, we were told, provide an opportunity for surveyor feedback or training that improves the quality and consistency of future surveys.

Inexperienced State Surveyors

State officials cited the limited experience level of state surveyors as a factor contributing to the variability in citing actual harm or higher-level deficiencies and the understatement of such deficiencies. Data we obtained from 42 state survey agencies in July 2002 revealed the magnitude of the problem: in 11 states, 50 percent or more of surveyors had 2-years’ experience or less; in another 13 states, from 30 percent to 48 percent of surveyors had similarly limited experience (see app. IV). For example, Alabama’s and Louisiana’s recent annual attrition rates were 29 percent and 18 percent, respectively, and, as a result, almost half of the surveyors in both states had been on the job for 2 years or less. In California and Maryland—states that hired a significant number of new surveyors since 2000—52 percent and 70 percent of surveyors, respectively, had less than 2 years of on-the-job experience. According to CMS regional office and state officials, the first year for a new surveyor is essentially a period of training and low productivity, and it takes as long as 3 years for a surveyor to gain sufficient knowledge, experience, and confidence to perform the job well. High staff turnover was attributed, in part, to low salaries for RN surveyors—salaries that may not be competitive with other employment opportunities for nurses. Overall, 29 of the 42 states that responded to our inquiry indicated that they believed nurse surveyor salaries were not competitive (see app. IV). Officials in several states also told us that the combination of low starting salaries and a highly competitive market forced them to hire less qualified candidates with less breadth of experience.

Predictable Surveys

Even though HCFA directed states, beginning January 1, 1999, to avoid scheduling a nursing home’s survey for the same month of the year as its previous survey, over one-third of state surveys remain predictable. Our analysis demonstrated little change in the proportion of predictable nursing home surveys. Predictable surveys can allow quality-of-care problems to go undetected because homes, if they choose to do so, may conceal problems. We recommended in 1998 that HCFA segment the standard survey into more than one review throughout the year, simultaneously increasing state surveyor presence in nursing homes and decreasing survey predictability. Although HCFA disagreed with segmenting the survey, it did recognize the need to reduce predictability.

Our analysis of OSCAR data demonstrated that, on average, the timing of 34 percent of current surveys nationwide could have been predicted by nursing homes, a slight reduction from the prior surveys when about 38 percent of all surveys were predictable. The predictability of current surveys ranged from 83 percent in Alabama to 10 percent in Michigan (see app. V for data on all 50 states and the District of Columbia). In 34 states, 25 percent to 50 percent of current surveys were predictable, as shown in table 4. In 9 states, more than 50 percent of current surveys were predictable.

Many State Complaint Investigation Systems Still Have Timeliness Problems and Other Weaknesses

Most state agencies did not investigate serious complaints filed against nursing homes within required time frames, and practices for investigating complaints in many states may not be as effective as they could be. A CMS review of states’ timeliness in investigating complaints alleging harm to residents revealed that most states did not investigate all such complaints within 10 days, as CMS requires. Additionally, a CMS-sponsored study of complaint practices in 47 states raised concerns about state approaches to accepting and investigating complaints.

Until March 1999, states could set their own complaint investigation time frames, except that they were required to investigate within 2 workdays all complaints alleging immediate jeopardy conditions. In March 1999, we reported that inadequate complaint intake and investigation practices in states we reviewed had too often resulted in extensive delays in investigating serious complaints. As a result of our findings, HCFA began requiring states to investigate complaints that allege actual harm, but do not rise to the level of immediate jeopardy, within 10 workdays. CMS’s 2001 review of a sample of complaints in all states demonstrated that many states were not complying with these requirements. Specifically, 12 states were not investigating all immediate jeopardy complaints within the required 2 workdays, and 42 states were not complying with the requirement to investigate actual harm complaints within 10 days. The agency also found that the triaging of complaints to determine how quickly each complaint should be investigated was inadequate in many states.

The extent to which states did not meet the 2-day and 10-day investigation requirements varied considerably. Officials from 12 of the 16 states we contacted indicated that they were unable to investigate complaints on time because of staff shortages. Oklahoma investigated only 3 of the 21 immediate jeopardy complaints that CMS sampled within the required 2- day period and none of 14 sampled actual harm complaints in 10 days. Oklahoma officials attributed this timeliness problem to staff shortages and a surge in the number of complaints received in 2000, from about 5 per day to about 35. The rising volume of complaints is a particular problem for California, which receives about 10,000 complaints annually, and had a 20 percent increase in complaints from January 2001 through July 2002. State officials told us that California law requires all complaints alleging immediate jeopardy to a resident to be investigated within 24 hours and all others to be investigated within 10 days, and that the increase in the number of complaints requires an additional 32 surveyor positions. CMS regional officials told us that the vast majority of California complaints were investigated within 10 days. However, the 2001 review also showed that about 9 percent of the state’s standard surveys were conducted late. Both CMS and California officials indicated that the priority the state attaches to investigating complaints affected survey timeliness. Officials from Washington told us that their practice of investigating facility self- reported incidents led to their not meeting the 10-day requirement on all complaints that CMS reviewed. Washington investigated 18 of 20 sampled actual harm complaints on time—missing the 10-day requirement for the other two by 2 days and 4 days, respectively. Washington officials pointed out that the two complaints not investigated within 10 days were facility self-reported incidents and commented that many other states do not even require investigation of such incidents. Thus, in these other states, such incidents would not even have been included in CMS’s review.

In its review of state complaint files, CMS also evaluated whether states had appropriately triaged complaints—that is, determined how quickly each complaint should be investigated. Most of the regions told us that one or more of their states had difficulty determining the investigation priority for complaints. In an extreme case, a regional office discovered that one of its states was prioritizing its complaints on the basis of staff availability rather than on the seriousness of the complaints. Several regions indicated that some states improperly assigned complaints to categories that permitted longer investigation time frames, and one region indicated that triaging difficulties involved state personnel not collecting enough information from the complainant to make a proper decision. Officials from some of the 16 state survey agencies we contacted indicated that HCFA’s 1999 guidance to states on what constitutes an actual harm complaint was unclear and confusing.

In an effort to improve state responsiveness to complaints, HCFA hired a contractor in 1999 to assess and recommend improvements to state complaint practices. The study identified significant problems with states’ complaint processes, including complaint intake activities, investigation procedures, and complaint substantiation practices. For example, the report noted that 15 states did not have toll-free hotlines for the public to file complaints. In our earlier reports, we noted that the process of filing a complaint should not place an unnecessary burden on a complainant and that an easy-to-use complaint process should include a toll-free number that permits the complainant to leave a recorded message when state staff are unavailable. Table 5 summarizes major findings from the contractor’s report to CMS.

States Did Not Refer a Substantial Number of Nursing Homes to CMS for Immediate Sanctions

State survey agencies did not refer 711 cases in which nursing homes were found to have a pattern of harming residents to CMS for immediate sanction as required by CMS policy. Our earlier work found that nursing homes tended to “yo-yo” in and out of compliance, in part because HCFA rarely imposed sanctions on homes with a pattern of deficiencies that harmed residents. In response, the agency required that homes found to have harmed residents on successive standard surveys be referred to it for immediate sanction. Most states did not refer at least some cases that should have been referred under this policy. Figure 1 shows the results of our analysis for the four states—Massachusetts, New York, Pennsylvania, and Texas—with the greatest numbers of cases that should have been referred and for the nation (see app. VII for information on all states). These four states accounted for 55 percent of the 711 cases.

State and CMS officials identified several reasons why state agencies failed to forward cases to CMS for immediate sanction, including (1) an initial misunderstanding of the policy on the part of some states and regions, (2) poor state systems for monitoring the survey history of homes to identify those meeting the criteria for referral for immediate sanction, and (3) actions, by two states, that were at variance with CMS policy. First, officials from some states—and some CMS regional officials as well—told us that they did not initially fully understand the criteria for referring homes for immediate sanction. For example, several states and CMS regional offices reported that they did not understand that CMS required states to look back before the January 2000 policy implementation date to determine if there was an earlier survey with an actual-harm-level deficiency. The look-back requirement was specifically addressed in a February 10, 2000, CMS policy clarification specifying that state agencies were to consider the home’s survey history before the January 14, 2000, implementation date in determining if a home met the criteria for immediate referral for sanction. However, officials in one region told us that they had instructed three of four states not to look back before the January 2000 implementation date of the policy. Two other regional offices told us that CMS policy did not require the state to look back before January 2000 for earlier surveys. Officials at another regional office did not recall the look-back policy at the time we talked to them in mid-2002, and were not sure what advice they had given their states when the policy was first implemented.

Second, some state survey agencies told us that their managers responsible for enforcement did not have an adequate methodology for checking the survey history of homes to identify those meeting the criteria. Some states said that their managers relied on manual systems, which are less accurate and sometimes failed to identify cases that should have been referred. Officials in one state told us that its district offices had no consistent procedure for checking the survey history of homes. An official in another state told us that some cases were not referred because time lags in reporting some surveys meant that an earlier survey—such as a complaint survey—with an actual harm deficiency might not have been entered in the state’s tracking system until after a later survey that also found harm-level deficiencies.

Third, two states did not implement CMS’s expanded policy on immediate sanctions. New York was in direct conflict with CMS policy. Although CMS policy calls for state referrals to CMS regardless of the type of deficiency, a state agency official told us that the state only referred a home to CMS for immediate sanction if both actual harm citations were for the exact same deficiency. A CMS official indicated that New York began complying with the policy in September 2002. Texas, the second state, did not implement the CMS policy statewide until July 2002, when it received our inquiry about the cases not referred for immediate sanction. In the interim from January 2000 through July 2002, three of Texas’s 11 district offices specifically requested from state survey agency officials, and were granted, permission to implement the policy.

CMS Oversight of State Survey Activities Requires Further Strengthening

While CMS has increased its oversight of state survey and complaint activities and instituted a more systematic oversight process by initiating annual state performance reviews, CMS officials acknowledged that the effectiveness of the reviews could be improved. In particular, CMS officials told us that for the initial state performance review in fiscal year 2001, they lacked the capability to systematically distinguish between minor lapses identified during the reviews and more serious problems that require intervention. CMS oversight is also hampered by continuing limitations in OSCAR data, the inability or reluctance of some CMS regions to use such data to monitor state activities, and inadequate oversight of certain areas, such as survey predictability and state referral of homes for immediate enforcement actions. CMS has restructured regional office responsibilities to improve the consistency of federal oversight and plans to further strengthen oversight by increasing the number of federal comparative surveys. However, three federal initiatives critical to reducing the subjectivity evident in the current survey process and the investigation of complaints have been delayed.

CMS Reviews of State Performance Have Identified Areas for Improvement

In the first of what is planned as an annual process, CMS’s 10 regional offices reviewed states’ fiscal year 2001 performance for seven standards to determine how well states met their nursing home survey responsibilities (see app. VIII for a description of the seven standards). This enhanced oversight of state survey agency performance responds to our prior recommendations. In 1999, we reported that HCFA’s oversight of state efforts had limitations preventing it from developing accurate and reliable assessments of state performance. HCFA regional office policies, practices, and oversight had been inconsistent, a reflection of coordination problems between HCFA’s central office and its regional staffs. In important areas, such as the adequacy of surveyors’ findings and complaint investigations, HCFA relied on states to evaluate their own performance and report their findings to HCFA. Although OSCAR data were available to HCFA for monitoring state performance, they were infrequently used, and neither the states nor HCFA’s regional offices were held accountable for failing to meet or enforce established performance standards.

To promote consistent application of the standards across the 10 regions, the agency developed detailed guidance for measuring each standard, including the method of evaluation, the data sources to be used, and the criteria for determining whether a state met a standard. Only two states met each of the five standards we reviewed and many did not meet several standards. Appendix IX identifies the standards we analyzed and the results of CMS’s review of these standards. During the 2001 review, CMS elected not to impose the most serious sanctions available for inadequate state performance, including reducing federal payments to the state or initiating action to terminate the state’s agreement, but advised the states that annual reviews in subsequent years will serve as the basis for such actions. While imposing no sanctions during the 2001 review, CMS did require several states to prepare corrective action plans. Each year, CMS plans to update and improve the standards based on experience gained in prior years.

CMS’s State Performance Standards and Review Had Shortcomings

Characterizing its fiscal year 2001 state performance review as a “shakeout cruise,” CMS is working to address several weaknesses identified during the reviews, including difficulty in determining if identified problems were isolated incidents or systemic problems, flawed criteria for evaluating a critical standard, and inconsistencies in how regional offices conducted the reviews. In our discussions of the results of the performance reviews with officials of CMS’s regional offices, it was evident that some regions had a much better appreciation of the strengths and weaknesses of survey activities in their respective states than was reflected in the state performance reports. However, this information was not readily available to CMS’s central office. In addition, CMS has not released a summary of the review to permit easy comparison of the results. For subsequent reviews, CMS plans to more centrally manage the process to improve consistency and help ensure that future reviews distinguish serious from minor problems.

Distinctions in State Performance Were Hard to Identify

CMS officials acknowledged that the first performance review did not provide adequate information regarding the seriousness of identified problems. The agency indicated that it had since revised the performance standards to enable it to determine the seriousness of the problems identified. Some regional office summary reports provided insufficient information to determine whether a state did not meet a particular standard by a wide or a narrow margin. For example, although California did not meet the standard to investigate all complaints alleging actual harm within 10 days, the regional office summary provided no details about the results. Regional officials told us that they found very few California complaints that were not investigated within the 10-day deadline and those that were not were generally investigated by the 13th day. Conversely, although the report for Oregon shows that the state met the 10-day requirement, our discussions with regional officials revealed that serious shortcomings nevertheless existed in the state’s complaint investigation practices. Officials in the Seattle region told us that for many years Oregon had contracted out investigations of complaints to local government entities not under the control of the state agency and, as a result, exercised little control over the roughly 2,000 complaints the state receives against nursing homes each year. For instance, under this arrangement, information about complaint investigations, including deficiencies identified, was not entered into CMS’s database. Regional officials told us that the Oregon state agency recently assumed responsibility for investigating complaints filed by the public, but that the local government entities continue to investigate facility self-reported incidents.

CMS’s Standard for Measuring States’ Documentation of Deficiencies Was Flawed

CMS’s standard for measuring how well states document deficiencies identified during standard surveys was flawed because it mixed major and minor issues, blurring the significance of findings. CMS’s protocol required assessment of 33 items, ranging from the important issue of whether state surveyors cited deficiencies at the correct scope and severity level to the less significant issue of whether they used active voice when writing deficiencies. Because of the complexity of the criteria and concerns about the consistency of regional office reviews of states’ documentation practices, CMS decided not to report the results for this standard for 2001. For the 2002 review, CMS reduced the number of criteria to be assessed from 33 to 7. Based on the available evidence of the understatement of actual harm deficiencies, we believe that successful implementation of the documentation standard in 2002 and future years is critical to help ensure that deficiencies are cited at the appropriate scope and severity level.

CMS Regions’ Reviews Were Inconsistent

CMS’s regional offices were sometimes inconsistent in how they conducted their reviews, raising questions about the validity and fairness of the results. For example: Although the guidelines for the review indicated that the regional offices were to assess the timeliness of complaint investigations based on the state’s prioritization of the complaint, officials from one region told us that they judged timeliness based on their opinion of how the complaint should have been prioritized.

Two regional offices acknowledged that they did not use clinicians to review complaint triaging. Officials from two states questioned the credibility of reviews not conducted by clinicians.

Although one objective of the reviews was to review some immediate jeopardy complaints in every state, the random samples selected in some states did not yield such complaints. In such cases, one region indicated that it specifically selected a few immediate jeopardy complaints outside the sample while another region did not. To eliminate this inconsistency in future years, CMS has instructed the regions to expand their sample to ensure that at least two immediate jeopardy complaints are reviewed in each state.

While some regions examined more than the required number of complaints to assess overall timeliness, one region felt that additional reviews were unnecessary. For instance, surveyors reviewing California, which receives thousands of complaints per year, expanded the number of complaints reviewed beyond the minimum number required because they felt that the required random sample of 40 complaints did not provide sufficient information about overall timeliness in the state. To assess overall timeliness, they visited all but 1 of the state’s 17 district offices to review complaints. However, surveyors from another CMS region reviewed only 3 or 4 of the roughly 18 complaints a state received and told us that additional reviews were unnecessary because the state had already failed the timeliness criterion based on the few complaints reviewed. Although the review of 3 or 4 complaints technically met CMS’s sampling requirement, we believe examination of most or all of the relatively few remaining complaints would have provided a more complete picture of the state’s overall timeliness.

Performance Standards Excluded Some Important Areas

While CMS has addressed some of the weaknesses in its 2001 state performance review by revising the standards and guidance for the 2002 review, including simplifying the criteria for assessing documentation and requiring regions to assess states’ complaint prioritization efforts separately from the timeliness issue, the performance standards do not yet address certain issues that are important for assessing state performance and that would further strengthen CMS oversight of state survey activities. These issues include: Assessing the predictability of state surveys. Although CMS monitored compliance with its requirement for state survey agencies to initiate at least 10 percent of their standard surveys outside normal working hours to reduce predictability, it did not examine compliance with its 1999 instructions for states to avoid scheduling a home’s survey during the same month each year. As shown in app. V, our analysis of CMS data found that from 10 percent to 31 percent of surveys in 31 states were predictable because they were initiated within 15 days of the 1-year anniversary of the prior survey.

Evaluating states’ compliance with the requirement to refer nursing homes that have a pattern of harming residents for immediate sanctions. CMS officials confirmed that there was no consistent oversight of state agencies’ implementation of this policy. Several CMS regional offices generally did not know, for example, how their states were monitoring homes’ survey history to detect cases that should be referred for immediate sanction. CMS could have used the enforcement database to determine that New York was not adhering to the agency’s immediate sanctions policy. During calendar years 2000 and 2001, New York cited actual harm at a relatively high proportion of its nursing homes but only referred 19 cases for immediate sanction. Over a comparable period, New Jersey, a state with far fewer homes and citations, referred almost three times as many cases.

Developing better measures of the quality of state performance, in addition to process measures. Several CMS regional officials believed that the scope of the state performance standards should address additional areas of performance, including assessing the adequacy of nursing homes’ plans of correction submitted in response to deficiencies and the appropriateness of states’ recommended enforcement remedies. In particular, several regions noted that rather than focusing only on the timeliness of complaint investigations, regions should also assess the adequacy of the investigation itself, including whether the complaint should have been substantiated. The introduction of a new CMS complaint tracking database, discussed below, should enable regions to automate the review of complaint timeliness, thereby allowing them to focus more attention on such issues.

Data Limitations and Inconsistent Use of Periodic Reports Hamper Oversight

CMS’s oversight of state survey activities is further hampered by limitations in the data used to develop the 19 periodic reports intended to assist the regions in monitoring state performance and by the regions’ inconsistent use of the reports. For instance, CMS’s current complaint database does not provide key information about the number of complaints each state receives (including facility self-reported incidents) or the time frame in which each complaint is investigated. In addition, officials from one region emphasized to us that information about complaints provided in the reports did not correspond with CMS’s required complaint investigation time frames. The reports identify the number of state on-site complaint investigations that took place in three different time periods—3 days, from 4 to 14 days, and 15 days or more; however, required time frames for complaint investigations are 2 days for complaints alleging immediate jeopardy and 10 days for those alleging harm. Additionally, a regional official pointed out that investigations shown in one of the reports as taking place within 3 days do not necessarily represent complaints that the state prioritized as immediate jeopardy. Despite the problems with these data, however, several regional offices indicated that the reports could at least serve as a starting point for discussions with states about their complaint programs and often lead to a better understanding of state complaint activities. CMS indicated that the deficiencies in complaint data should be addressed by the new automated complaint tracking system that it is developing for use by all states as part of the redesign of OSCAR.

Officials from several regions also told us that the value of some of the 19 periodic reports was unclear, and officials in three regions said they either lacked the staff expertise or the time to use the reports routinely to oversee state activities. For example, officials in one region told us that they used one of the reports about complaints to ask states questions about their prioritization practices. But a different region appeared unaware that the reports showed that two of its states might be outliers in terms of the percentage of complaints they prioritized as actual harm or immediate jeopardy. Additionally, because the periodic reports do not include trend data, many regional offices were unaware of the trends in the percentage of homes cited in their states for actual harm or immediate jeopardy. We believe that such data could be useful to CMS’s regions in identifying significant trends in their states.

CMS indicated that it is continuing to make progress in redesigning the OSCAR reporting system. In 1999, we recommended that the agency develop an improved management information system that would help it track the status and history of deficiencies, integrate the results of complaint investigations, and monitor enforcement actions. Another objective of the OSCAR redesign is to make it easier to analyze the data it contains, addressing the problem that generating analytical reports from OSCAR was difficult and most regions lacked the expertise to do so. The redesigned system, called the Quality Improvement and Evaluation System, would also eliminate the need for duplicate data entry, which should reduce the potential for data entry errors to which OSCAR is susceptible. CMS has faced some problems in the implementation of the new system, such as inadvertent modifications of survey data results when data are transferred from the old OSCAR database into the new system, but the agency indicated that its target date for completing the redesign is 2005.

CMS Is Making Progress but Also Encountering Delays in Several Key Efforts

CMS has taken, or is undertaking, several other efforts to improve federal oversight and survey procedures, including making structural changes to the regional offices to improve coordination, expanding the number of comparative surveys conducted each year, improving the survey methodology, developing clearer guidance for surveyors, and developing additional guidance to states for investigating complaints. As of April 2003, only the effort to restructure the regional offices had been completed. The other efforts critical to reducing the subjectivity evident in the current survey process and the investigation of complaints have been delayed.

CMS Is Taking Additional Steps to Address Inconsistencies in Regional Office Performance and Improve Federal Oversight

In December 2002, CMS reduced the number of regional managers in charge of survey activities from 10 (1 per region) to 5, a change intended to provide more management attention to survey matters and to improve accountability, direction, and leadership. Our prior and current work found that regional offices’ policies, practices, and oversight were often inconsistent. For example, in 1999 we reported that regional offices used different criteria for selecting and conducting comparative surveys. The 5 regional managers will be responsible only for survey and certification activities, while in the past many of the 10 were also responsible for managing their regions’ Medicaid programs.

In response to our prior recommendations, CMS plans to more than double the number of federal comparative surveys in which federal surveyors resurvey a nursing home within 2 months of the state survey to assess state performance. We noted in 1999 that, although insufficient in number, comparative surveys were the most effective technique for assessing state agencies’ abilities to identify serious deficiencies in nursing homes because they constitute an independent evaluation of the state survey. CMS plans to hire a contractor to perform approximately 170 additional comparative surveys per year, bringing the annual total of comparative surveys performed by both CMS surveyors and the contractor to about 330. Although CMS had intended to award a contract and begin surveys by spring 2003, as of July 2003, it was still in the process of identifying qualified contractors. CMS officials stated that using a contractor would provide CMS flexibility because if it suspects that a state or region is having problems with surveys, it can quickly have the contractor conduct several comparative surveys there. Being able to direct the contractor to quickly focus on states or regions where state surveys may be problematic could represent a significant improvement in CMS’s oversight of state survey agencies.

Key Initiatives to Improve Survey Consistency and Complaint Investigations Have Been Delayed

CMS’s implementation schedules have slipped for three critical initiatives intended to enhance the consistency and accuracy of state surveys and complaint investigations, delaying the introduction of improved methodologies or guidance until 2003 or 2004. Because surveyors often missed significant care problems due to weaknesses in the survey process, HCFA took some initial steps to strengthen the survey methodology, with the goal of introducing an improved survey process in 2000. In July 1999, the agency introduced quality indicators to help surveyors do a better job of selecting a resident sample, instructed states to increase the sample size in areas of particular concern, and required the use of investigative protocols in certain areas, such as pressures sores and nutrition, to help make the survey process more systematic. However, HCFA recognized that additional steps were required to ensure that surveyors thoroughly and systematically identify and assess care problems.

To address remaining problems with sampling and the investigative protocols, CMS contracted for the development of a revised survey methodology. The contractor has proposed a two-phase survey process. In the first phase, surveyors would initially identify potential care problems using quality indicators generated off-site prior to the start of the survey and additional, standardized information collected on-site, from a sample of as many as 70 residents. During the second phase, surveyors would conduct an investigation to confirm and document the care deficiencies initially identified. According to CMS officials, this process differs from the current methodology because it would more systematically target potential problems at a home and give surveyors new tools to more adequately document care outcomes and conduct on-site investigations. Use of the new methodology could result in survey findings that more accurately identify the quality of care provided by a nursing home to all of its residents. Initial testing to evaluate the proposed methodology focused primarily on the first phase and was completed in three states during 2002. As of April 2003, a CMS official told us that the agency lacked adequate funding to conduct further testing that more fully incorporates phase two. As a result, it is not clear when changes to survey methodology will be implemented. We continue to believe that redesign of the survey methodology, under way since 1998, is necessary for CMS to fully respond to our past recommendation to improve the ability of surveys to effectively identify the existence and extent of deficiencies. While CMS’s goal of not adding additional time to surveys is an important consideration, it should not take priority over the goal of ensuring that surveys are as effective as possible in identifying the quality of care provided to residents.

Recognizing inconsistencies in how the scope and severity of deficiencies are cited across states, in October 2000, HCFA began developing more structured guidance for surveyors, including survey investigative protocols for assessing specific deficiencies. The intent of this initiative is to enable surveyors to better (1) identify specific deficiencies, (2) investigate whether a deficiency is the result of poor care, and (3) document the level of harm resulting from a home’s identified deficient care practices. The areas originally targeted for this initiative included deficiencies related to pressure sores, urinary catheters and incontinence, activities programming, safe food handling, and nutrition. Delays have occurred because CMS is committed to incorporating the work of multiple expert panels and two rounds of public comments for each deficiency. The project has been further delayed because the approach used to identify resident harm shifted during the course of work. The process should proceed more quickly, however, now that CMS has developed its approach. CMS expected to release the first new guidance, addressing pressure sores, in early 2003, but officials were unable to tell us how many of the 190 federal nursing home requirements will ultimately receive new guidance or a specific time line for when this initiative will be completed. As discussed earlier, CMS’s state performance reviews include an assessment of state surveyors’ documentation of the scope and severity of a sample of deficiencies cited, which should provide CMS with an opportunity to assess the effectiveness of the new guidance.

Finally, despite initiation of a complaint improvement project in 1999, CMS has not yet developed detailed guidance for states to help improve their complaint systems. Effective complaint procedures are critical because complaints offer an opportunity to assess nursing home care between standard surveys, which can be as long as 15 months apart. In 1999, HCFA commissioned a contractor to assess and recommend improvements to state complaint practices. CMS received the contractor’s final report in June 2002, and indicated agreement with the contractor that reforming the complaint system is urgently needed to achieve a more standardized, consistent, and effective process. The study identified serious weaknesses in state complaint processes (see table 5) and made numerous recommendations to CMS for strengthening them. Key recommendations were that CMS increase direction and oversight of states’ complaint processes and establish mechanisms to monitor states’ performance. CMS indicated that it has already taken steps to address these recommendations by initiating annual performance reviews that include evaluating the timeliness of state complaint investigations and the accuracy of states’ complaint triaging decisions, and by developing the new ASPEN complaint tracking system, which should provide more complete data about complaint activities than the current system. The contractor also recommended that CMS (1) expand outreach for the initiation of complaints, such as use of billboards or media advertising, (2) enhance complaint intake processes by using professional intake staff, (3) improve investigation and resolution processes by using available data about the home being investigated and establishing uniform definitions and criteria for substantiating complaints, (4) make the process more responsive by conducting timely investigations and allowing the complainant to track the progress of the investigation, and (5) establish a higher priority for complaint investigations in the state survey agency. CMS noted that some of these recommendations are beyond the agency’s purview and will require the support of all stakeholders to accomplish. CMS told us that it plans to issue new guidance to the states in late fiscal year 2003—about 4 years after the complaint improvement project initiative was launched.

Conclusions

As we reported in September 2000, continued federal and state attention is required to ensure necessary improvements in the quality of care provided to the nation’s vulnerable nursing home residents. The reported decline in the percentage of homes cited for serious deficiencies that harm residents is consistent with the concerted congressional, federal, and state attention focused on addressing quality-of-care problems. More active and data- driven oversight is increasing CMS’s understanding of the nature and extent of weaknesses in state survey activities. Despite these efforts, however, the proportion of homes reported to have harmed residents is still unacceptably high. It is therefore essential that CMS fully implement key initiatives to improve the rigor and consistency of state survey, complaint investigation, and enforcement processes.

The seriousness of the challenge confronting CMS in ensuring consistency in state survey activities is also becoming more apparent. Our work, as well as that of CMS, demonstrates the persistence of several long-standing problems and also provides insights on factors that may be contributing to these shortcomings: state surveyors continue to understate serious deficiencies that caused actual harm or placed residents in immediate jeopardy; deficiencies are often poorly investigated and documented, making it difficult to determine the appropriate severity category; states focus considerable effort on reviewing proposed actual harm deficiencies, but many have no quality assurance processes in place to determine if less serious deficiencies are understated or have investigation and documentation problems; the timing of too many surveys remains predictable, allowing problems to go undetected if a home chooses to conceal deficiencies; numerous weaknesses persist in many states’ complaint processes, including the lack of consumer toll-free hotlines in many states, confusion over prioritization of complaints, inconsistent complaint investigation procedures, and the failure of most states to investigate all complaints alleging actual harm within 10 days, as required; and states did not refer a substantial number of homes that had a pattern of harming residents to CMS for immediate sanctions.

Over the past several years, CMS has taken numerous steps to improve its oversight of state survey agencies, but needs to continue its efforts to help better ensure consistent compliance with federal requirements. Several areas that require CMS’s ongoing attention include (1) the newly established standard performance reviews to ensure that critical elements of the review, such as assessing states’ ability to properly document deficiencies, are successfully implemented, (2) the successful modernization of CMS’s data system by 2005 to support the survey process and provide key information for monitoring state survey activities, (3) the planned expansion of comparative surveys to improve federal oversight of the state survey process, (4) the survey methodology redesign intended to make the survey process more systematic, (5) the development of more structured guidance for surveyors to address inconsistencies in how the scope and severity of deficiencies are cited across states, and (6) the provision of detailed guidance to states to ensure thorough and consistent complaint investigations. Some of these efforts have been under way for several years, and CMS has consistently extended their estimated completion and implementation dates. We believe that effective implementation of planned improvements in each of these six areas is critical to ensuring better quality care for the nation’s 1.7 million nursing home residents.

Recommendations for Executive Action

To strengthen the ability of the nursing home survey process to identify and address problems that affect the quality of care, we recommend that the Administrator of CMS finalize the development, testing, and implementation of a more rigorous survey methodology, including guidance for surveyors in documenting deficiencies at the appropriate level of scope and severity.

To better ensure that state survey and complaint activities adequately address quality-of-care problems, we recommend that the Administrator require states to have a quality assurance process that includes, at a minimum, a review of a sample of survey reports below the level of actual harm (less than G level) to assess the appropriateness of the scope and severity cited and to help reduce instances of understated quality-of-care problems. finalize the development of guidance to states for their complaint investigation processes and ensure that it addresses key weaknesses, including the prioritization of complaints for investigation, particularly those alleging harm to residents; the handling of facility self-reported incidents; and the use of appropriate complaint investigation practices.

To better ensure that states comply with statutory, regulatory, and other CMS nursing home requirements designed to protect resident health and safety, we recommend that the Administrator further refine annual state performance reviews so that they (1) consistently distinguish between systemic problems and less serious issues regarding state performance, (2) analyze trends in the proportion of homes that harm residents, (3) assess state compliance with the immediate sanctions policy for homes with a pattern of harming residents, and (4) analyze the predictability of state surveys.

Agency and State Comments and Our Evaluation

We provided a draft of this report to CMS and the 22 states we contacted during the course of our review. (CMS’s comments are reproduced in app. X.) CMS concurred with our findings and recommendations, stating that it already had initiatives under way to improve the effectiveness of the survey process, address the understatement of serious deficiencies, provide better data on state complaint activities, and improve the annual federal performance reviews of state survey activities. Although CMS concurred with our recommendations, its comments on intended actions did not fully address our concerns about the status of the initiative to improve the effectiveness of the survey process or the recommendation regarding state quality assurance systems. Eleven of the 22 states also commented on our draft report. CMS and state comments generally covered five areas: survey methodology, state quality assurance systems, definition of actual harm, survey predictability, and resource constraints.

Survey Methodology Redesign

In response to our recommendation that the agency finalize the development, testing, and implementation of a more rigorous nursing home survey methodology, under way since 1998, CMS commented that it had already taken steps to improve the effectiveness of the survey process, such as the development of surveyor guidance on a series of clinical issues. However, the agency did not specifically comment on any actions it would take to finalize and implement its new survey methodology, which is broader than the actions CMS described. Our draft report noted that, earlier this year, CMS said it lacked adequate funding for the additional field testing needed to implement the new survey methodology. Through September 2003, CMS will have committed $4.7 million to this effort. While CMS did not address the lack of adequate funding in its comments on our draft report, a CMS official subsequently told us that about $508,000 has now been slated for additional field testing. This amount, however, has not yet been approved. Not funding additional field testing could jeopardize the entire initiative, in which a substantial investment has already been made. We continue to believe that CMS should implement a revised survey methodology to address our 1998 finding that state surveyors often missed significant care problems due to weaknesses in the survey process.

State Quality Assurance Systems

We recommended that CMS require states to have a quality assurance process that includes, at a minimum, a review of a sample of survey reports below the level of actual harm to help reduce instances of understated quality-of-care problems. CMS commented on the importance of this concept and noted it had already incorporated such reviews into CMS regional offices’ reviews of the state performance standards. However, the agency did not indicate whether it would require states to initiate an ongoing process that would evaluate the appropriateness of the scope and severity of documented deficiencies, as we recommended. While federal oversight is critical, the annual performance reviews conducted by federal surveyors examine only a small, random sample of state survey reports and should not be considered a substitute for appropriate and ongoing state quality assurance mechanisms. In its comments, New York stated that, in April 2003, it had implemented a process consistent with our recommendation and it had already realized positive results. New York is using the results of these reviews to provide surveyor feedback and expects that instances where deficiencies may be understated will decrease. California also commented that it fully supports this recommendation but indicated that a new requirement could not be implemented without additional resources.

State Resource Constraints

Officials from five states indicated that resource shortages are a challenge in meeting federal standards for oversight of nursing homes. Alabama commented that there is a relationship among (1) the scheduling of nursing home standard surveys, (2) the number and timing of complaint surveys, (3) the tasks that must be accomplished during each survey, and (4) the resources that are available to state agencies. According to Alabama, the funding provided by CMS is insufficient to meet all of the CMS workload demands, and many of the serious problems identified in our draft report were attributable to insufficient funding for state agencies to hire and retain the staff necessary to do the required surveys. For example, Alabama indicated that the inability of some states to meet survey time frames—maintaining a 12-month average between standard surveys and investigating complaints alleging actual harm within 10 days— is almost always the result of states not having enough surveyors to accomplish the required workload.

Comments from other states echoed Alabama’s concerns about the adequacy of funding provided by CMS. Arizona said that, in order to hire and retain qualified surveyors, it increased surveyor salaries in 2001. Because CMS did not increase the state’s survey and certification budget to accommodate these increases, the state left surveyor positions unfilled and curtailed training to make up for the funding shortfall. Arizona also observed that CMS’s priorities sometimes conflict, further complicating effective resource use. CMS’s performance standards require states to investigate all complaints alleging immediate jeopardy or actual harm in 2 and 10 days, respectively. For budgeting purposes, however, CMS ranks complaint investigations as a lower priority than annual surveys and instructs states to ensure that annual surveys will be completed before beginning work on complaints. California and Connecticut officials said that the growing volume of complaints in their states, combined with limited resources, is a concern. California officials observed that the growth in the number of complaints, coupled with the lack of significant funding increase from CMS, has made it impossible to meet all federal and state standards. They added that they received a 3-percent increase in survey funding from fiscal years 2000 through 2003, but documented the need for a 24-percent increase over this period. As noted in our draft report, the higher priority California attaches to investigating complaints affected survey timeliness—about 12 percent of the state’s homes were not surveyed within the required 15 months. Connecticut indicated that 90 percent of the complaints it receives allege actual harm and require investigation within 10 days, but that with fairly stagnant budget allocations from CMS, its ability to initiate investigations of so many complaints within 10 days was limited. CMS’s fiscal year 2001 state performance review found that Connecticut did not investigate about 30 percent of the sampled actual harm complaints in a timely manner. Although not specifically mentioning resources, New York noted that the increasing volume of complaints was a concern and indicated that any assistance CMS could provide would be welcome.

Definition of Actual Harm

Comments from four states on our analysis of a sample of survey deficiencies from homes with a history of harming residents revealed state confusion about CMS’s definition of actual harm and immediate jeopardy, a situation that contributes to the variability in state deficiency trends shown in table 2. CMS’s written comments did not address our review of these deficiencies; however, during an interview to follow up on state comments, CMS officials told us that they agreed with our determinations of actual harm as detailed in appendix III.

Arizona and California agreed that some of the deficiencies we reviewed for nursing homes in their states should have been cited at the level of actual harm. However, their disagreement regarding others stemmed from differing interpretations of CMS guidance, particularly the language on the extent of the consequences to a resident resulting from a deficiency. For example, Arizona stated that one of the two deficiencies we reviewed could not be supported at the actual harm level because the injuries from multiple falls—including skin tears and lacerations of the extremities and head requiring suturing—did not compromise the residents’ ability to function at their highest optimal level (table 8, Arizona 3). In these cases, it was documented that nursing home staff had failed to implement plans of care intended to prevent such falls. In contrast, California agreed with us that state surveyors should have cited actual harm for similar injuries resulting from falls—head lacerations and a minimal impaction fracture of the hip—due to the inappropriate use of bed side rails (table 8, California 9). CMS officials noted that the definition of actual harm uses the term “well-being” rather than function because harm can be psychological as well as physical. Moreover, they indicated that whether the consequence was small or large was irrelevant to determining harm. CMS central office officials acknowledged that the language linking actual harm to practices that have “limited consequences” for a resident has created confusion for state surveyors and that this reference will be eliminated in an upcoming revision of the guidance.

Regarding preventable stage II pressure sores, California stated that guidance received from CMS’s San Francisco regional office in November 2000 precluded citing actual harm unless the pressure sores had an impact on residents’ ability to function. According to a California official, this and similar guidance on weight loss was the CMS regional office’s reaction to the growing volume of appeals by nursing homes of actual harm citations as well as a reaction to administrative law hearing decisions. Prior to this written guidance, which California received in late 2000, it routinely cited preventable stage II pressure sores as actual harm. The guidance noted that small stage II pressure sores seldom cause actual harm because they have the potential to heal relatively quickly and are usually of limited consequence to the resident’s ability to function. We discussed the San Francisco regional office guidance with another regional office as well as with CMS central office officials, who agreed that the San Francisco region’s pressure sore guidance was inconsistent with CMS’s definition of harm, which judges the impact of a deficiency on a resident’s “well-being” rather than functioning. Moreover, central office officials indicated that the regional office’s guidance should have been submitted to CMS’s Policy Clearinghouse for approval. This entity was created in June 2000 to ensure that regional directives to states are consistent with national policy. San Francisco regional office officials indicated that the individual responsible for the guidance provided to California had since left the agency.

California also disagreed with our assessment that state surveyors should have cited immediate jeopardy for a resident who repeatedly wandered (eloped) outside the facility near a busy intersection. According to state officials, California’s policy on immediate jeopardy requires the surveyor to witness the incident. A San Francisco regional office official told us that surveyors did not have to witness an elopement to cite immediate jeopardy. An official from a different regional office agreed and noted that repeated elopements suggested the existence of a systemic problem that warranted citation of immediate jeopardy.

Although Iowa and Nebraska did not comment specifically on the deficiencies in their surveys that we determined to be actual harm, they did address the definition of harm and the role of surveyor judgment in classifying deficiencies. Iowa officials indicated that a more precise definition of harm is needed because of varying emphasis over the last several years on the degree of harm—harm that has a small consequence for the resident or serious harm. Nebraska commented that we may have based our conclusion that two deficiencies in its surveys should have been cited at the actual harm level on insufficient information because citing actual harm is a judgment call that varies among state and federal surveyors based on experience and expertise. As noted in our draft report, we found sufficient evidence in the surveys we reviewed to conclude that some deficiencies should have been cited as actual harm because a deficient practice was identified and linked to documented actual harm.

Survey Predictability

CMS, Arizona, and Iowa commented that nursing home surveys, as currently structured, are inherently predictable because of the statutory requirement to survey nursing homes on average every 12 months with a maximum interval of 15 months between each home’s survey. We agree but believe that survey predictability could be further mitigated by segmenting the surveys into more than one visit, a recommendation we made in 1998 but that CMS has not implemented. Currently, surveys are comprehensive reviews that can last several days and entail examining not only a home’s compliance with resident care standards but also with administrative and housekeeping standards. Dividing the survey into segments performed over several visits, particularly for those homes with a history of serious deficiencies, would increase the presence of surveyors in these homes and provide an opportunity for surveyors to initiate broader reviews when warranted. With a segmented set of inspections, homes would be less able to predict their next scheduled visit and adjust the care they provide in anticipation of such visits.

CMS also commented that our report captures only the number of days since the prior survey and does not take into account other predictors, for example the time of day or day of the week. Rather than segmenting standard surveys as we earlier recommended, the agency instructed states to reduce survey predictability by starting at least 10 percent of surveys outside the normal workday—either on weekends, in the early morning, or in the evening. It also instructed states to avoid, if possible, scheduling a home’s survey for the same month as its previous standard survey. Though varying the starting time of surveys may be beneficial, this initiative is too limited in reducing survey predictability, as evidenced by our finding that 34 percent of current surveys were predictable. Arizona commented that it was unaware of any CMS guidance to avoid scheduling a home’s survey for the same month of the year as the home’s previous standard survey and indicated the state will now incorporate the requirement into its scheduling process.

Comments from CMS and Arizona stated that the window of time for a survey to be unpredictable was limited and, as a result, little could be done to reduce predictability. CMS’s technical comments noted that many states have annual state licensing inspection requirements that would limit the window available to conduct surveys to 9 to 12 months after the prior survey, particularly since most inspections are done in conjunction with the federal survey to maximize available resources. CMS, however, was unable to provide a list of such states. None of the 10 states we subsequently contacted had state licensure inspection requirements that would explain their high levels of survey predictability. Arizona commented that the state’s licensing inspections are triggered by facilities applying to renew their licenses 60-120 days before their annual license expires. Due to budgetary constraints, Arizona conducts both this state and the federal survey at the same time. While not a requirement, the state strives to complete surveys during this 60-120 day period of time. Thus, nursing homes in Arizona may have some level of control over when federal surveys are conducted, particularly when the state begins complying with CMS guidance to avoid scheduling a home’s survey for the same month as its previous survey. As we reported in September 2000, Tennessee also had an annual licensing inspection requirement that contributed to survey predictability, but the state modified its law to permit homes to be surveyed at a maximum interval of 15 months. Since then, the proportion of predictable surveys in Tennessee decreased from about 56 percent to 29 percent. Arizona also stated that surveys had to be conducted within a 45-day window after the 1-year anniversary of the prior survey to be considered unpredictable. Arizona’s comments erroneously assume that a survey cannot take place before the 1-year anniversary of the prior survey. There is no prohibition on resurveying a home prior to the 1-year anniversary of its last survey, and many states do so. In fact, from October 1, 2000 through September 30, 2001, Arizona conducted 23 percent of its surveys before the 1-year anniversary.

CMS provided several technical comments that we incorporated as appropriate.

As arranged with your offices, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time, we will send copies of this report to the Administrator of the Centers for Medicare & Medicaid Services and appropriate congressional committees. We also will make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov.

Please contact me at (202) 512-7118 or Walter Ochinko, Assistant Director at (202) 512-7157 if you or your staffs have any questions. GAO staff acknowledgments are listed in appendix XI.

Appendix I: Scope and Methodology

This appendix describes our scope and methodology following the order that findings appear in the report.

Nursing home deficiency trends. To identify trends in the proportion of nursing homes cited for actual harm or immediate jeopardy, we analyzed data from CMS’s OSCAR system. We compared standard survey results for three approximately 18-month periods: (1) January 1, 1997, through June 30, 1998, (2) January 1, 1999, through July 10, 2000, and (3) July 11, 2000, through January 31, 2002. Because surveys are to be conducted at least once every 15 months (with a required 12-month state average), it is possible that a facility was surveyed more than once in a time period. To avoid double counting of facilities, we included only the most recent survey of a facility from each of the time periods. The data from the two earliest time periods were included in our September 2000 report. We updated our earlier analysis of surveys conducted from January 1, 1999, through July 10, 2000, because it excluded approximately 300 surveys that had been conducted but not entered into OSCAR at the time we conducted our analysis in July 2000.

Sample of state survey reports. To assess the trends in actual harm and immediate jeopardy deficiencies discussed above, we (1) identified 14 states in which the percentage of homes cited for actual harm had declined to below the national average since mid-2000 or was consistently below that average and (2) reviewed 76 survey reports from homes that had G-level or higher quality-of-care deficiencies on prior surveys but whose current survey had quality-of-care deficiencies at the D or E level, suggesting that the homes had improved. All the surveys we reviewed were conducted from July 2000 through April 2002. Our review focused on four quality-of-care requirements that are the most frequently cited nursing home deficiencies nationwide (see table 6). According to OSCAR data, 99 surveys in the 14 states conducted on or after July 2000 documented a D- or E-level deficiency in at least one of these four quality-of-care requirements. We reviewed all such deficiencies in surveys from 13 states but randomly selected 22 surveys from California, which cited the majority (45) of these deficiencies. In reviewing the surveys, we looked for a description of the resident’s diagnoses, any assessment of special problems, and a description of the care plan and physician orders connected with the deficiency identified. We also looked for a clear statement of the home’s deficient practice and the relationship between the deficiency and the care outcome.

Federal comparative surveys. In September 2000, we reported on the results of 157 comparative surveys completed from October 1998 through May 2000. To update our analysis, we asked each CMS region to provide the results of more recent comparative surveys, including data on the corresponding state survey. The regions identified and provided information on the deficiencies identified in 277 comparative surveys that were completed from June 2000 through February 2002.

Survey predictability. In order to determine the predictability of nursing home surveys, we analyzed data from CMS’s OSCAR database. We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 1-year anniversary of their prior survey or (2) homes were surveyed within 1 month of the maximum 15-month interval between standard surveys. Consistent with CMS’s interpretation, we used 15.9 months as the maximum allowable interval between surveys. Because homes know the maximum allowable interval between surveys, those whose prior surveys were conducted 14 or 15 months earlier are aware that they are likely to be surveyed soon.

Complaints. We analyzed the results of CMS’s state performance review for fiscal year 2001 to determine states’ success in investigating both immediate jeopardy complaints and actual harm complaints within time frames required either by statute or by CMS instructions. To better understand the results of state performance as determined by CMS’s review, we interviewed officials from CMS’s 10 regional offices and 16 state survey agencies (see state performance standards below for a description of how these states were chosen). We also reviewed the report submitted to CMS by its contractor, which was intended to assess and recommend ways to strengthen state complaint practices. Finally, to assess the implementation of CMS’s new automated system for tracking information about complaints, we reviewed CMS guidance materials and interviewed CMS officials and state survey agency officials from our 16 sample states.

Enforcement. To determine if states had consistently applied the expanded immediate sanction policy, we analyzed state surveys in OSCAR that were conducted before April 9, 2002, and identified homes that met the criteria for referral for immediate sanction. We included surveys conducted prior to the implementation of the expanded immediate sanction policy because actual harm deficiencies identified in such surveys were to be considered by states in recommending a home for immediate sanction beginning in January 2000. To be affected by CMS’s expanded policy, a home with actual harm on two surveys must have an intervening period of compliance between the two surveys. Because OSCAR is not structured to consistently record the date a home with deficiencies returned to compliance, we had to estimate compliance dates using revisit dates as a proxy. We compared the results of our analysis to CMS’s enforcement database to determine if CMS had opened enforcement cases for the homes we identified. Our analysis compared the survey date in OSCAR to the survey date in CMS’s enforcement database. We considered any survey date in the enforcement database within 30 days of the OSCAR survey date to be a match. CMS officials reviewed and concurred with our methodology. We then asked CMS to analyze the resulting 1,334 unmatched cases to determine if a referral should have been made.

State performance standards. To assess state survey activities as well as federal oversight of state performance, we analyzed the conduct and results of fiscal year 2001 state survey agency performance reviews during which the CMS regional offices determined compliance with seven federal standards; we focused on the five standards related to statutory survey intervals, deficiency documentation, complaint activities, enforcement requirements, and OSCAR data entry. Because some regional office summary reports on the results of their reviews for each state did not provide detailed information about the results, we also obtained and reviewed regions’ worksheets on which the summary reports were based. In addition, we conducted structured interviews with officials from CMS, CMS’s 10 regional offices, and 16 state survey agencies to discuss nursing home deficiency trends, the underlying causes of problems identified during the performance reviews, and state and federal efforts to address these problems. We also discussed these issues with officials from 10 additional states during a governing board meeting of the Association of Health Facility Survey Agencies. We selected the 16 states with the goal of including states that (1) were from diverse geographic areas, (2) had shown either an increase or a decrease in the percentage of homes cited for actual harm, (3) had been contacted in our prior work, and (4) represented a mixture of results from federal performance reviews of state survey activities. We also obtained data from 42 state survey agencies on surveyor experience, vacancies, and related staffing issues.

Appendix II: Trends in The Proportion of Nursing Homes Cited for Actual Harm or Immediate Jeopardy Deficiencies, 1997-2002

Nationwide, the proportion of nursing homes cited for actual harm or immediate jeopardy during state standard surveys declined from 29 percent in mid-2000 to 20 percent in January 2002. From July 2000 through January 2002, 40 states cited a smaller percentage of homes with such serious deficiencies while only 9 states and the District of Columbia cited a larger proportion of homes with such deficiencies. In contrast, from early 1997 through mid-2000, the percentage of homes cited for such serious deficiencies was either relatively stable or increased in 31 states.

To identify these trends, we analyzed data from CMS’s OSCAR system. We compared results for three approximately 18-month periods: (1) January 1, 1997, through June 30, 1998, (2) January 1, 1999, through July 10, 2000, and (3) July 11, 2000, through January 31, 2002 (see table 7). Because surveys are to be conducted at least once every 15 months (with a required 12- month state average), it is possible that a facility was surveyed more than once in a time period. To avoid double counting of facilities, we included only the most recent survey from each of the time periods. Some of the data in table 7 were included in our September 2000 report. However, we updated our analysis of surveys conducted from January 1, 1999, through July 10, 2000, because it excluded approximately 300 surveys that had been conducted but not entered into OSCAR at the time we conducted our analysis in July 2000.

Appendix III: Abstracts of Nursing Home Survey Reports That Understated Quality-of- Care Problems

Our analysis of a sample of 76 nursing home survey reports demonstrated a substantial understatement of quality-of-care problems. Our sample was selected from 14 states in which the percentage of homes cited for actual harm had declined to below the national average since mid-2000 or was consistently below that average. We identified survey reports in these states from homes that had G-level or higher quality-of-care deficiencies (see table 1) on prior surveys but whose current survey had quality-of-care deficiencies at the D or E level, suggesting that the homes had improved. All the surveys we reviewed were conducted from July 2000 through April 2002. Our review focused on four quality-of-care requirements that are the most frequently cited nursing home deficiencies nationwide (see table 6).

In our judgment, 30 of the 76 surveys (39 percent) from 9 of the 14 states had one or more deficiencies that documented actual harm to residents— G-level deficiencies—and 1 survey contained a deficiency that could have been cited at the immediate jeopardy level. While state surveyors classified these deficiencies as less severe, we believe that the survey reports document that poor care provided to and injuries sustained by these residents constituted at least actual harm. Table 8 provides abstracts of the 39 deficiencies that understated quality problems.

Appendix IV: Information on State Nursing Home Surveyor Staffing

Table 9 summarizes state survey agencies’ responses to our July 2002 questions about nursing home surveyor experience, vacancies, hiring freezes, competitiveness of salaries, and minimum required experience.

Appendix V: Predictability of Standard Nursing Home Surveys

Our analysis found that 34 percent of current nursing home surveys were predictable, allowing nursing homes to conceal deficiencies if they choose to do so. In order to determine the predictability of nursing home surveys, we analyzed data from CMS’s OSCAR database (see table 10). We considered surveys to be predictable if (1) homes were surveyed within 15 days of the 1-year anniversary of their prior survey or (2) homes were surveyed within 1 month of the maximum 15-month interval between standard surveys. Consistent with CMS’s interpretation, we used 15.9 months as the maximum allowable interval between surveys. Because homes know the maximum allowable interval between surveys, those whose prior surveys were conducted 14 or 15 months earlier are aware that they are likely to be surveyed soon.

Appendix VI: Immediate Sanctions Implemented Under CMS’s Expanded Immediate Sanctions Policy

From January 2000 through March 2002, states referred 4,310 cases to CMS under its expanded immediate sanctions policy when nursing homes were found to have a pattern of harming residents. Because some homes had more than one sanction or may have had multiple referrals for sanctions, 4,860 sanctions were implemented (see table 11). Table 12 summarizes the amounts of federal civil money penalties (CMP) implemented against nursing homes referred for immediate sanction. Although these monetary sanctions were implemented, CMS’s enforcement database does not track collections. In addition, states may have imposed other sanctions under their own licensure authority, such as state monetary sanctions, in addition to or in lieu of federal sanctions. Such state sanctions are not recorded in CMS’s enforcement database.

Appendix VII: Cases States Did Not Refer to CMS for Immediate Sanction

State survey agencies did not refer to CMS for immediate sanction a substantial number of nursing homes found to have a pattern of harming residents. Most states failed to refer at least some cases and a few states did not refer a significant number of cases. While seven states appropriately referred all cases, the number of cases that should have been but were not referred ranged from 1 to 169. Four states accounted for about 55 percent of cases that should have been referred. Table 13 shows the number of cases that states should have but did not refer for immediate sanction (711) as well as the number of cases that states appropriately referred (4,310) from January 2000 through March 2002.

Appendix VIII: HCFA State Performance Standards for Fiscal Year 2001

Table 14 summarizes HCFA’s state performance standards for fiscal year 2001, describes the source of the information CMS used to assess compliance with each standard, and identifies the criteria the agency used to determine whether states met or did not meet each standard.

Appendix IX: Highlights of State Compliance with CMS Performance Standards

Table 15 summarizes the results of CMS’s fiscal year 2001 state performance review for each of the five standards we analyzed. We focused on five of CMS’s seven performance standards: statutory survey intervals, the supportability of survey findings, enforcement requirements, the adequacy of complaint activities, and OSCAR data entry. Because several standards included multiple requirements, the table shows the results of each of these specific requirements separately.

Appendix X: Comments from the Centers for Medicare & Medcaid Services

Appendix XI: GAO Contact and Staff Acknowledgements

GAO Contact

Acknowledgements

The following staff made important contributions to this work: Jack Brennan, Patricia A. Jones, Dan Lee, Dean Mohs, and Peter Schmidt.

Related GAO Products

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Nursing Homes: Quality of Care More Related to Staffing than Spending. GAO-02-431R. Washington, D.C.: June 13, 2002.

Nursing Homes: More Can Be Done to Protect Residents from Abuse. GAO-02-312. Washington, D.C.: March 1, 2002.

Nursing Homes: Federal Efforts to Monitor Resident Assessment Data Should Complement State Activities. GAO-02-279. Washington, D.C.: February 15, 2002.

Nursing Homes: Success of Quality Initiatives Requires Sustained Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.: September 28, 2000.

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.: September 28, 2000.

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.: November 4, 1999.

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to Better Ensure Quality of Care. GAO/T-HEHS-00-27. Washington, D.C.: November 4, 1999.

Nursing Home Oversight: Industry Examples Do Not Demonstrate That Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington, D.C.: August 13, 1999.

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington, D.C.: June 30, 1999.

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.

Nursing Homes: Complaint Investigation Processes in Maryland. GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999.

Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.: March 22, 1999.

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March 18, 1999.

California Nursing Homes: Federal and State Oversight Inadequate to Protect Residents in Homes with Serious Care Problems. GAO/T-HEHS- 98-219. Washington, D.C.: July 28, 1998.

California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.