Long-Term Care Hospitals: CMS Oversight Is Limited and Should Be Strengthened
Released: 2011-10-17T00:00:00

Letter

Background

An LTCH is a type of ACH that specializes in treating critically ill individuals who require an intense level of health care with frequent physician and nurse visits for relatively extended periods—more than 25 days, on average. For example, a significant subset of LTCH patients is dependent on a ventilator for breathing and receives therapy to help them breathe on their own. Most LTCH patients have been transferred from intensive or critical care units of ACHs, which provide general, short-term care for a broad range of medical conditions. LTCHs are not evenly distributed across the nation and patients who could be treated by LTCHs might instead receive care at ACHs, other types of hospitals, or nursing homes. Medicare generally pays more for hospital stays in LTCHs than in ACHs. In fiscal year 2010, Medicare paid an estimated $4.7 billion for care provided in more than 400 LTCHs for about 138,000 discharges, which averages more than $34,000 per discharge.

Surveys, Survey Organizations, and Standards

To assess whether LTCHs meet federal quality standards, state survey agencies and AOs conduct two types of surveys—routine and complaint. Routine surveys are unannounced and are conducted at specific intervals. State survey frequencies are resource driven and depend on CMS’s annual funding level for such activities. CMS’s policy has been for state survey agencies to conduct surveys every 3 to 5 years since fiscal year 2001. In contrast, AO policy is to conduct surveys every 3 years. Complaint surveys are conducted in response to allegations of quality problems made by families, patients, health care workers, or others and provide survey organizations the opportunity to intervene promptly if problems arise between routine surveys. Complaint surveys may be conducted either by a state survey agency or an AO. However, most complaints are filed with state survey agencies, which conduct complaint surveys both at the LTCHs they survey as well as at AO- surveyed LTCHs. Complaint surveys focus on the specific allegations made and surveyors generally only assess the hospital’s compliance with standards related to those allegations.

In general, hospitals have a choice of who conducts their surveys—state survey agencies using federal Medicare standards or CMS-approved AOs that use requirements CMS has determined to be at least equivalent to those standards. Federal Medicare standards consist of 74 standards that are organized under 23 conditions of participation (COP), including categories such as Medical Staff, Infection Control, and Emergency Services. TJC, one of three AOs approved by CMS to survey hospitals, surveys the majority of LTCHs. TJC’s standards for hospitals are organized into 17 categories, such as Medication Management, Leadership, and Medical Staff; each category consists of numerous standards. Prior to the Medicare Improvements for Patients and Providers Act of 2008, TJC had unique statutory deeming authority for hospitals and did not need to apply to CMS to be recognized as a national accreditation body for hospitals. This legislation revoked TJC’s statutory deeming authority effective July 15, 2010, and gave CMS the authority to review and approve TJC’s hospital accreditation program. As a result, in 2009, CMS evaluated the standards and processes used by TJC to conduct hospital surveys, including a comparison of TJC’s standards to Medicare’s and a review of the qualifications of its surveyors. CMS approved TJC’s hospital accreditation program effective July 15, 2010, through July 15, 2014.

When surveyors find quality problems during routine and complaint surveys, they cite either deficiencies or requirements for improvement (RFI), depending on the survey organization.  State survey agencies cite deficiencies that are characterized as either standard- or COP-level based on the seriousness of the deficiency. Standard-level deficiencies denote less serious quality problems, while COP-level deficiencies are cited when the problems are serious or systemic in nature. A serious problem is defined as a shortcoming in a hospital’s quality of services that adversely affects, or has the potential to adversely affect, the quality of patient care. When deficiencies are found, a hospital may be required to submit a plan of correction, detailing how and when it will address the deficiencies. If a hospital does not correct the deficiencies cited within the required time frame, CMS may terminate the hospital’s participation in the Medicare program.  TJC cites direct and indirect RFIs when hospitals are found to be out of compliance with TJC’s standards on routine or complaint surveys. According to TJC, direct RFIs are cited when compliance issues are directly tied to quality, such as untreated pain; while indirect RFIs are cited when compliance issues are indirectly related to quality, such as hospital leadership. A hospital that does not correct all of its RFIs may receive conditional or preliminary denial of accreditation. A hospital may be denied accreditation if it has exhausted all review and appeal opportunities, failed to pay the accreditation fee, or refused to allow a survey. CMS may subsequently terminate hospitals from Medicare participation if they lose their accreditation.

CMS collects information on state survey results in its On-line Survey, Certification, and Reporting system (OSCAR). To collect data on the results of AO surveys, CMS established its Accrediting Organization System for Storing User Recorded Experiences (ASSURE) database in 2008. On a quarterly basis, all AOs update ASSURE with survey results that are crosswalked from their own standards and RFIs to federal Medicare quality standards and deficiencies.

Hospital Quality Measures

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provided for the establishment of hospital quality measures and created a penalty for hospitals that do not report related data beginning in 2005. Those hospitals that fail to report quality data are subject to a 2.0 percent reduction in the hospital’s annual Medicare payment rate for the subsequent year. This payment reduction applies to hospitals paid under Medicare’s inpatient prospective payment system, which covers most types of hospitals but not LTCHs. ACHs began voluntarily reporting data for quality measures in 2004. For fiscal year 2011, there are 60 quality measures organized into six areas, including heart attack, heart failure, and pneumonia. For example, the pneumonia quality measures assess several aspects of care, including whether the patients received an antibiotic within 6 hours of arriving at the hospital and if the appropriate antibiotic was provided. In April 2005, CMS launched a Web site called “Hospital Compare” to make information on hospital data available to consumers. CMS posts information for each hospital’s quality measures on a quarterly basis.

CMS Survey Activity Oversight

CMS and its 10 regional offices oversee state and AO survey activities in order to monitor the performance of survey organizations and hold them accountable for meeting CMS’s survey requirements. To do so, CMS: (1) established performance measures, (2) has states conduct validation surveys of AO-surveyed hospitals, and (3) collects data from survey results for all types of hospitals.

State survey agencies and AOs have separate performance measures. State survey agency performance measures focus on states’ ability to meet the requirements for the survey and certification program. These measures are organized into three sections: frequency, quality, and enforcement. For example, state performance measures assess states’ abilities to prioritize and conduct complaint surveys within specific time frames. AO performance measures focus on their ability to provide CMS with consistent, accurate, complete, and timely information on the facilities they survey. In October 2008, CMS established three categories of performance measures for AOs: (1) use of an electronic database to track accreditation and enforcement activity; (2) submission of facility notification letters—which contain information on individual facilities’ accreditation status—for all accreditation actions; and (3) submission of survey schedule information. CMS monitors each AO’s performance on the measures and provides written feedback on a quarterly basis. CMS reports to the Congress annually on the extent to which TJC and other AOs meet its performance measures.

Validation surveys are conducted to measure the effectiveness of the AO survey process in identifying areas of serious non-compliance with federal Medicare quality standards in accredited facilities, such as LTCHs. Validation surveys have consequences for both AOs and facilities. State survey agencies conduct two types of validation surveys. The first type is a full survey of a sample of AO-surveyed facilities, known as traditional validation surveys. Traditional validation surveys are generally conducted within 60 days following a routine survey conducted by an AO. CMS selects a sample of hospitals for these surveys based on the hospital’s most recent routine survey date and available resources. While CMS policy calls for approximately 1 percent of AO-surveyed hospitals to receive traditional validation surveys each fiscal year, since fiscal year 2007 CMS has supplemented the funding provided to states in order to increase the sample size to 2 percent or higher. Because of budgetary constraints, the number has fluctuated from a 10-year high of 235 in fiscal year 1999 to about 90 in fiscal year 2009. The second type of validation survey is a complaint validation survey, which occurs when a state survey agency investigates a complaint for a hospital surveyed by an AO. Unlike traditional validation surveys that are conducted within 60 days of a routine survey, complaint validation surveys are generally conducted when the complaint is received. Such surveys initially focus on the condition(s) alleged to be out of compliance. If the complaint validation survey cites one or more COP-level deficiencies, the facility is placed under the jurisdiction of the state survey agency. Subsequently, the state survey agency conducts a full survey of all COPs. When all COP-level deficiencies have been corrected, the facility again becomes the responsibility of the AO.

CMS submits an annual report to Congress after the end of the fiscal year—known as the CMS Financial Report—that includes information on traditional validation surveys conducted at hospitals surveyed by AOs. Based on such surveys, CMS calculates a hospital disparity rate for each AO. The disparity rate measures the extent to which an AO has failed to cite one or more deficiencies during its routine survey that were later identified by a state survey agency during a traditional validation survey. If the validation survey results for an AO indicate a disparity rate that reaches the threshold of 20 percent or greater, CMS is to notify the AO that its approval to survey and accredit hospitals may be in jeopardy and that the agency may initiate a review.

CMS collects data on the results of state survey agency surveys in its OSCAR database and AO surveys in its ASSURE database. The databases include information such as the number and type of surveys conducted and any deficiencies cited, including the specific standard or COP out of compliance. In addition, OSCAR contains data on the number of surveyors and amount of time devoted to the health portion of the survey.

CMS Has Data on the Quality of Care at LTCHs, but Currently the Data Are Limited

Although CMS collects some data on the quality of care at LTCHs, the data are currently limited. First, CMS does not have data on prior survey results for the majority of LTCHs because TJC only recently began submitting detailed deficiency data on the results of its surveys to CMS. In addition, current survey results in OSCAR and ASSURE may be incomplete because these databases do not always accurately identify (1) which survey organization is responsible for surveying each LTCH or (2) whether a facility is, in fact, an LTCH. Second, CMS does not currently collect data for quality measures because LTCHs are not yet required to report them.

CMS Has No Detailed Prior Survey Data and Incomplete Current Survey Results on the Majority of LTCHs

Because TJC only recently began submitting detailed survey data to CMS, ASSURE has no prior data and limited current data—surveys conducted since July 2009—for TJC-surveyed LTCHs, which constitute a majority (about 80 percent) of such hospitals. As of December 2010, TJC had surveyed and submitted data on about half of the LTCHs it surveys. CMS has prior and current survey data in OSCAR for state-surveyed LTCHs, which represent about 16 percent of LTCHs. Appendix I reports prior and fiscal year 2010 data on the proportion of LTCHs with COP-level deficiencies, lists the most commonly cited deficiencies, and compares these results to those of ACHs. Because fiscal year 2010 data does not include at least one survey for each LTCH, these results may not reflect the quality of care across all LTCHs.

We found that there were 447 LTCHs listed in OSCAR or ASSURE as of fiscal year 2010. However, both the OSCAR and ASSURE databases inaccurately identified the responsible survey organization and the ASSURE database was incomplete. For example,  OSCAR categorizes 89 LTCHs as state-surveyed, but we found that only 71 of these LTCHs are actually state-surveyed. The remaining 18 LTCHs are surveyed by AOs. CMS officials told us that OSCAR data are not always updated when LTCHs switch from being surveyed by an AO to being surveyed by a state survey agency and vice versa.  We found that 56 LTCHs were either misidentified in ASSURE as ACHs or were missing from the database. LTCHs may initially be classified as ACHs until they demonstrate their average length of stay is at least 25 days and then need to be reclassified. According to a TJC official, about 30 LTCHs submitted ACH identification numbers on their TJC accreditation applications and were thus misidentified in ASSURE. CMS subsequently issued new LTCH identification numbers to these facilities, but TJC officials told us that neither CMS nor the LTCHs had notified them. In a few cases, the LTCHs’ initial survey occurred after TJC’s last quarterly ASSURE update, the LTCH had submitted the identification number of a nearby facility with the same owner, or the LTCH had closed. Finally, in a couple cases, TJC could not explain why the LTCH was not listed in ASSURE.

CMS officials told us that they recognize these limitations, but have not yet established an approach for addressing these issues.

CMS Does Not Require LTCHs to Report Data on Quality Measures, but Will Do So Beginning in 2014

CMS currently does not have quality measures for LTCHs because LTCHs were not required to report on the quality measures developed for most ACHs in 2003 or later. While LTCHs are not currently reporting on quality measures, under the Patient Protection and Affordable Care Act (PPACA) enacted in 2010, they must begin doing so by 2014. PPACA directed HHS to publish measures for LTCHs and required the department to consider measures endorsed by a consensus-based entity, such as NQF. To identify these measures, CMS reviewed LTCH measures currently used by the National Association of Long Term Hospitals and TJC. CMS also has received feedback from MedPAC, convened a technical expert panel, and held stakeholder information sessions. In May 2011, CMS published a proposed rule on three potential quality measures that LTCHs would be required to report on from October 1, 2012, through December 31, 2012, for their fiscal year 2014 payment determination: (1) catheter-associated urinary tract infection rate, (2) central-line associated blood stream infection rate, and (3) new or worsened pressure ulcers. None of the three measures have been endorsed by NQF for use by LTCHs, but NQF has endorsed their use in other settings. CMS is working with NQF to have these measures endorsed for the LTCH setting. The proposed rule includes some additional quality measures that CMS may require LTCHs to report in the future, some of which, such as patient fall rate, also have been endorsed by NQF for other types of health care facilities.

CMS Oversight of Survey Activities at LTCHs Is Limited

CMS and its regional offices’ oversight of state survey agency and AO survey activities in LTCHs is limited because two of its oversight strategies—performance measures and selection of hospitals for traditional validation surveys—focus on hospitals in general rather than LTCHs specifically. CMS’s third oversight strategy—collection and analysis of survey data—is also limited because the agency does not utilize all of the available data to identify weaknesses in the survey process that may require further investigation. As a result of these oversight limitations, CMS cannot ensure that state survey agencies and AOs are held accountable and that they meet CMS’s survey requirements.

CMS’s Performance Measures for Survey Activities Do Not Focus on LTCHs

None of the performance measures that CMS uses to assess the survey activities of state survey agencies and AOs focus specifically on LTCHs. Thus, CMS analyzes data on survey activities at LTCHs together with data for other types of hospitals and facilities and does not analyze or report the results separately for LTCHs. One of CMS’s performance measures for state survey agencies examines the timeliness of state surveys. CMS’s policy is for all hospitals to be surveyed every 3 to 5 years. We used OSCAR data to analyze the timeliness of routine surveys conducted by state survey agencies in LTCHs. For LTCHs that had both a current and prior state survey (52 of 71), we found that more than 5 years had elapsed between surveys for about 38 percent of LTCHs. About 19 percent of LTCHs were surveyed by states within 3 years and about 42 percent were surveyed from more than 3 up to 5 years after their prior surveys.

Similarly, CMS does not analyze the results of its AO performance measures separately for LTCHs. CMS’s performance measures for AOs generally focus on the AOs’ ability to provide the agency with timely, complete, and accurate survey findings, facility notification letters, and survey schedules for all of the types of facilities they survey (such as hospitals, home health agencies, ambulatory surgery centers, and hospices). In addition, CMS recently added a measure that assesses whether AOs are conducting surveys of the accredited facilities within a 3-year period. CMS provides feedback on its analysis of performance measures to each AO, including TJC, on an ongoing basis. These results are also reported to Congress in CMS’s annual financial report. However, CMS does not provide feedback to AOs or publicly report on the performance measures for any particular type of AO-surveyed facility, including LTCHs.

LTCHs Are Not Systematically Included in the Hospital Validation Survey Sample, and Results from Complaint Validation Surveys Are Not Always Shared with TJC

CMS does not systematically include 1 percent of AO-surveyed LTCHs— fewer than five—in its sample of traditional hospital validation surveys conducted by state survey agencies. In contrast, state survey agencies conduct a large number of complaint investigations at TJC-surveyed LTCHs—known as complaint validation surveys. However, the results are not always shared with TJC, limiting the effectiveness of oversight.

CMS’s policy requires that approximately 1 percent of AO-surveyed hospitals receive a traditional validation survey each year. While CMS has used this strategy to oversee AO survey activities at hospitals generally, it has not done so for LTCHs specifically. Agency officials told us that the sample was unlikely to have included LTCHs prior to 2011 because they had not made LTCH status a basis for assignment of validation surveys. However, using OSCAR data, we found that about 1 percent or more of TJC-surveyed LTCHs received a traditional validation survey each year from fiscal years 2006 through 2010. The results of LTCH validation surveys were included in CMS’s annual calculations of TJC’s hospital disparity rates for fiscal years 2006 through 2009.

Following the publicized allegations of poor care at LTCHs, CMS decided to have state survey agencies conduct validation surveys in fiscal year 2011 at 34 AO-surveyed LTCHs. CMS selected the LTCHs using a stratified random sample methodology that considered the workload of the state survey agencies and the locations of the LTCHs. CMS officials were not definitive in how they would use the results of these LTCH validation surveys. They suggested that they may compare the results of these surveys, including the extent to which COP-level deficiencies are cited, to their prior analysis of state LTCH survey data and to survey data for other types of hospitals. However, these surveys do not constitute a solution to CMS’s lack of a systematic way of including LTCHs in its annual sample of traditional validation surveys at hospitals because these surveys are a one-time activity and will not be conducted within 60-days of a routine survey. As a result, CMS will not be able to calculate a disparity rate, which measures the effectiveness of the AOs’ survey process.

Through state survey agencies, CMS conducts a significant number of complaint validation surveys in TJC-surveyed LTCHs while TJC conducts few complaint surveys in the LTCHs it surveys. From fiscal years 2006 through 2010, state survey agencies conducted 1,224 complaint validation surveys at TJC-surveyed LTCHs compared with TJC’s 67 complaint surveys at LTCHs it surveys. CMS officials told us that state survey agencies receive more complaints than the TJC because patients and their advocates may not always be aware that complaints can be filed with an AO. They also told us that complaint allegations, including the patients name and the name of the complainant could not be referred to the appropriate AOs for investigation because of privacy concerns unless the AO specifically asked for each complaint. However, when we discussed this issue with both CMS privacy and program officials, they concluded that CMS regional offices could refer hospital complaints to AOs for investigation or share complaint information with AOs prior to a state complaint validation survey. TJC officials told us that they are willing to conduct complaint surveys in response to referrals from CMS.

CMS told us that while it had not shared actual complaints with AOs it had increased its communication with TJC, including the results of complaint validation surveys. For example, CMS provided its regional offices with the e-mail address of each AO in order to provide AOs with copies of hospital correspondence and the results of surveys conducted by state agencies in accredited facilities. However, TJC officials told us that CMS regional offices do not consistently provide the results of the complaint validation surveys and sometimes the information provided is not timely. We spoke with officials from two CMS regional offices that authorized two state agency complaint validation surveys at TJC-surveyed LTCHs in fiscal year 2007 and fiscal year 2009, respectively. Officials from one regional office told us that not all of the information on the results of complaint validation surveys was forwarded to TJC; thus, a letter might be sent to TJC that outlined the COP-level deficiencies cited, but not the standard-level deficiencies. TJC told us that they did not even know that an additional complaint validation survey at this facility had been conducted in 2009 until we informed them. Officials from the other regional office said that they did not forward any information from the complaint survey, including the official record of all the deficiencies cited. TJC officials also said that information on the findings from state complaint validation surveys could lead them to conduct their own survey or could be used by TJC as it prepares for the facility’s next survey. Additionally, officials from the CMS regional offices we contacted told us that state survey agencies do not review the results of an AO’s most recent routine survey prior to conducting complaint validation surveys and therefore, may not be familiar with any deficiencies cited by TJC. Given that complaint validation surveys may provide insights into concerns that occur between routine surveys, information sharing between CMS regional offices and AOs is an important aspect of effective oversight.

CMS Is Not Using All Available ASSURE and OSCAR Survey Data to Oversee Survey Activities at LTCHs

CMS has not yet analyzed ASSURE survey data to oversee TJC’s LTCH survey activities or used these data in combination with OSCAR data to identify issues that may warrant further examination and strengthen oversight and accountability. By recognizing and adjusting for limitations in these databases, we identified several areas where the data may assist CMS in more effectively overseeing survey activities at LTCHs. For example:  CMS has data on the results of all surveys conducted by both state survey agencies and TJC that could provide information on the proportion of LTCHs and ACHs cited with COP-level deficiencies by state survey agencies and TJC. Although CMS conducted an internal analysis of the proportion of surveys at LTCHs and ACHs that cited COP-level deficiencies, it used only OSCAR data, which primarily consists of complaint surveys conducted by state survey agencies. We did our own analysis using both ASSURE and OSCAR data and found that the inclusion of ASSURE data influenced whether LTCHs or ACHs had more COP-level deficiencies. See app. I for the results of our data analysis.  CMS has data on complaint validation surveys conducted in LTCHs that could provide information on how effectively states triage and conduct complaint surveys at TJC-surveyed LTCHs. For example, our analysis found that a small proportion of state complaint validation surveys cited deficiencies. Specifically, we found that about 6 percent of the 1,224 complaint validation surveys conducted at TJC-surveyed LTCHs between 2006 and 2010 had one or more COP-level deficiencies and about 66 percent did not cite any deficiencies. We also found that two state agencies conducted nearly half (40 percent) of the complaint validation surveys, but cited almost no COP-level deficiencies. CMS and TJC officials told us that the small proportion of state complaint validation surveys that cite COP-level deficiencies indicated that state survey agencies may not be adequately triaging complaints, that is, some of these complaints may not have warranted on-site surveys. In addition, CMS officials suggested that states may have cited deficiencies at the standard level to avoid conducting a full survey and may not have reviewed all standards related to the COP alleged by the complainant to have been out of compliance.  CMS has data to compare the results from routine and complaint surveys that could provide information on the thoroughness of routine surveys at LTCHs that also had complaint validation surveys. CMS has not compared routine survey data for TJC-surveyed LTCHs it has in ASSURE with complaint validation survey data it has in OSCAR. We compared these two databases to determine if routine surveys by TJC had missed COP-level deficiencies identified by state complaint validation surveys. We identified 32 complaint validation surveys that were conducted within 2 to 60 days of a TJC routine survey reported in ASSURE. Four of the 32 surveys identified COP-level deficiencies that were not identified on the LTCHs most recent survey by TJC. While there may be reasonable explanations, further information could improve CMS oversight of survey activities.  CMS has data on the survey resources used during routine surveys by state survey agencies and TJC that could provide information on the efficiency and effectiveness of survey activities. We compared the survey resources—number of surveyors and amount of time devoted to conducting a survey—used by state surveyors and TJC for the health portion of routine surveys at similar sized LTCHs between 2006 and 2010. We found that state surveyors spent about two times as many hours per survey and utilized about two times more surveyors per survey than TJC. The appropriate level of resources for an LTCH survey is unclear and CMS, state survey agencies, and TJC may not be in agreement.

CMS officials told us that they are not using all available ASSURE and OSCAR survey data because they are currently focusing on obtaining complete and accurate information from TJC and other AOs. They told us that they intend to more fully use the available data in the future to oversee LTCH survey activities; however, they have not developed a plan to do so. One CMS official also told us that in the future the agency might consider merging the information collected in ASSURE with OSCAR, thereby establishing one database for hospital survey data.

Conclusions

LTCHs are a specialized type of ACH that care for very sick and clinically complex patients. Most patients in LTCHs have been transferred from an intensive care unit of another hospital because they need a continued intense level of care for an extended period of time. Because these patients are so vulnerable, it is important that oversight of the quality of care delivered by LTCHs is monitored and, if shortcomings are identified, action is promptly taken. However, our review found several limitations in the oversight of LTCHs that are cause for concern, including weaknesses that affect the availability of data to oversee the quality of care and the ability of CMS to hold both state survey agencies and accrediting organizations accountable for their survey activities.

We found several weaknesses in the availability of data on the quality of care in LTCHs. The results of surveys are stored in more than one database, which affects CMS’s ability to use the data to understand the quality of care in LTCHs. For example, CMS is unable to accurately identify all LTCHs from these databases and which entity—state survey agencies or AOs—is responsible for conducting routine surveys of the facility. The inability to accurately identify all LTCHs has implications, particularly when CMS implements a new COP for LTCHs and when LTCHs have to begin reporting quality measures. The fragmentation of data across different databases also affects CMS’s ability to review the data for LTCHs specifically and ensure that the data are updated as needed and may inhibit the sharing of data between the state survey agencies and AOs, both of which may have surveyors in the same LTCHs at different times, conducting different types of surveys.

We also found weaknesses in CMS’s ability to hold state survey agencies and accrediting organizations accountable. CMS’s traditional strategies for holding these entities accountable—performance measures and validation surveys—do not focus on LTCHs. Although CMS conducts traditional validation surveys in hospitals in general as a means for assessing the effectiveness of an AO’s survey activities, CMS cannot assure that LTCHs are systematically included in their review; when such surveys have been conducted in LTCHs, CMS has not separated out the LTCH surveys from surveys of all other hospitals and so is unable to identify whether there may be areas of concern specific to AO survey activities in LTCHs. Furthermore, CMS is not effectively using the data it collects from surveys to review and understand the activities conducted by state survey agencies and AOs. For example, there are differences in the workload and resources devoted to survey activities between state survey agencies and AOs; however, the reasons for these differences were not clear. CMS officials said they plan to more fully use the data in the future to oversee survey activities in LTCHs, but have not yet developed a plan for doing so.

CMS oversight of LTCHs is hampered by inaccurate data and ineffective use of the data it currently collects. By increasing the use of its existing databases and more effectively using the data it currently collects, CMS has the opportunity to improve the accuracy of the data it has and the effectiveness of its oversight. Unless CMS more effectively uses the data it collects, the agency cannot provide assurances that the quality of care in LTCHs meets federal quality standards and ensure that vulnerable patients are not at risk.

Recommendations for Executive Action

In order to improve the data available on the quality of care at LTCHs, the Administrator of CMS should take the following two actions: 1. Improve the accuracy of the databases that track LTCH survey results  working with AOs and state survey agencies to develop a complete and accurate list of the LTCHs that they each survey and an approach to ensuring that the list is updated in a timely manner, and  expanding the OSCAR database to include the results of all LTCH surveys, such as those conducted by TJC, which are currently stored in the separate ASSURE database. 2. Improve information sharing with TJC regarding complaint validation survey results for TJC-surveyed LTCHs, such as ensuring that all survey findings are shared in a timely fashion.

In order to improve CMS’s oversight of survey activities at LTCHs, the Administrator of CMS should take the following three actions: 1. Conduct traditional validation surveys at a sample of LTCHs each fiscal year and include an LTCH disparity rate in its annual financial report to Congress. 2. Explore differences in survey workload and in the resources survey organizations devote to LTCH surveys in order to identify areas for efficiencies, and  determine whether the workload associated with complaint validation surveys could be more equitably shared with TJC. 3. Develop a plan to use available data on survey activities to hold survey organizations accountable for conducting surveys consistent with CMS requirements for evaluating the quality of care provided by LTCHs.

Agency and Other External Comments and Our Evaluation

We provided a draft of this report to HHS and TJC for comment. In its written comments, HHS concurred with our recommendations and acknowledged that their implementation would further strengthen the continued improvement in the oversight of AOs that CMS has undertaken since fiscal year 2006. TJC agreed with most of our recommendations, but disagreed with the recommendation related to traditional validation surveys, that is, state oversight surveys at AO-surveyed LTCHs. HHS’s and TJC ‘s comments are reproduced in appendix II and III, respectively.

HHS Comments

HHS concurred with all five of our recommendations. With respect to our recommendation to improve the accuracy of the databases that track LTCH survey results, HHS noted that it had been working since 2007 to identify and correct serious problems in both the AO and CMS databases and had made significant progress. HHS acknowledged that one issue is that LTCHs must enroll initially as acute care hospitals and are later converted to LTCHs, which affects the identification of LTCHs in the database. HHS outlined steps it had taken to address the fact that we found many LTCHs identified as acute care hospitals in the ASSURE database. HHS also said that it has begun the process of converting ASSURE to a Web-enabled application, which would provide more flexibility and allow it to explore methods to increase the accuracy of the database.

HHS also concurred with our four other recommendations. HHS said that it intends to: reinforce existing CMS policy on sharing information with AOs and work with regional offices to enhance compliance,  explore an option to increase its traditional validation survey sample for hospitals, which would permit the inclusion of a stratified sample of LTCHs annually,  explore the differences in survey workload and resource allocation, which it characterized as definitely meriting attention, while working with regional offices to clarify the policy for triaging complaint surveys at AO-surveyed LTCHs and for referring certain complaints to the appropriate AO, and review the available data to determine to what extent it can be used to develop additional AO performance measures for evaluating quality of care at hospitals, including LTCHs.

TJC Comments

TJC agreed that there was room for improvement in CMS’s oversight of the quality of care provided by LTCHs and of survey activities at such hospitals and noted that CMS had already taken positive steps toward achieving these goals. However, it questioned our conclusion that CMS oversight of LTCHs was limited. It suggested, instead, that a more accurate conclusion was that CMS oversight was not separated in a focused manner from that of other hospitals. We believe that our report appropriately acknowledged CMS’s progress in collecting data from TJC since TJC’s statutory deeming authority was revoked. We found that CMS oversight of LTCHs was limited because it was (1) focused on hospitals in general and not LTCHs specifically and (2) not effectively using the survey data it collected to review and understand the activities of state survey agencies and AOs at LTCHs.

TJC agreed with our recommendations to improve the accuracy of the survey databases, improve information sharing, and use available data to improve oversight. However, it disagreed with our recommendation to conduct traditional validation surveys at a sample of LTCHs each fiscal year and to include a LTCH-specific disparity rate in its annual financial report to Congress. Specifically, TJC questioned the value of LTCH- specific validation surveys for several reasons:  TJC questioned whether validation surveys were the most appropriate measure of AO performance because we had previously reported that state surveyors understate (i.e., miss) serious deficiencies on nursing home surveys. We do not believe that these findings are directly applicable to traditional LTCH validation surveys because the findings cited by TJC relate to routine nursing home surveys. Moreover, understatement, if it did exist on validation surveys, would not diminish the fact that state surveyors have identified serious deficiencies that AOs should have, but did not cite. We agree with TJC that CMS should monitor complaint validation survey findings as another indicator of AOs performance. For example, we pointed out that state survey agencies identified condition-level deficiencies not cited by TJC on several complaint validation surveys that were conducted within 60 days of TJC’s routine survey.  TJC stated that the inclusion of a representative number of LTCHs as part of the annual validation survey schedule would require a significant increase in the federal budget allocated to validation surveys. TJC said this would be necessary in order to arrive at a statistically valid sample size that would in turn support a LTCH- specific disparity rate calculation. As we pointed out and HHS comments noted, CMS has been conducting a small number of traditional validation surveys at LTCHs each year—approximately 1 percent of LTCHs. In addition, HHS noted that it would explore an option to increase its traditional validation survey sample for hospitals, thereby permitting the inclusion of a stratified sample of LTCHs each year.

TJC noted that it had provided CMS with information such as the accreditation status resulting from surveys, demographic information, and up-to-date survey schedules prior to the establishment of ASSURE in 2009 and, therefore, it was inaccurate to say that CMS has no prior survey data on TJC-surveyed LTCHs. TJC’s comments acknowledged that the information provided to CMS prior to 2009 did not include detailed information on the specific deficiencies identified. We added a footnote to our report acknowledging the information that TJC did provide to CMS before 2009 and clarified the report to make it clear that the prior survey data we are referring to involved detailed data on the deficiencies cited.

HHS and TJC also provided technical comments, which we incorporated as appropriate.

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If your staff have any questions about this report, please contact me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV.

Appendix I: Condition-Level Deficiencies Cited at Long-Term and Acute Care Hospitals During Routine and Complaint Surveys

This appendix presents the Centers for Medicare & Medicaid Services (CMS) data on the results of surveys at long-term care hospitals (LTCH). In the course of our analyses, we identified some data limitations, which we discussed with both CMS and The Joint Commission (TJC). We report only data that we determined to be reliable.

CMS has several years worth of data on condition of participation-level (COP) deficiencies cited by state survey agencies at LTCHs, but TJC only began submitting similar data in July 2009. Table 1 shows data on COP- level deficiencies cited by state survey agencies from fiscal years 2005 through 2009. Table 2 shows fiscal year 2010 survey results for both state survey agencies and TJC for LTCHs and acute care hospitals (ACH). Fiscal year 2010 is the first full year for which data are available for both survey organizations. However, most hospitals did not have a routine survey in fiscal year 2010 because surveys are conducted every 3 to 5 years. Because fiscal year 2010 data does not include at least one survey for each LTCH, these results may not reflect the quality of care across all LTCHs. Finally, tables 3 and 4 show the most commonly cited COP-level deficiencies at LTCHs and ACHs surveyed by state survey agencies, during fiscal year 2010.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: Comments from The Joint Commission

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact name above, Walter Ochinko, Assistant Director; Sarah Harvey; Kristin Helfer Koester; Dan Lee; Elizabeth T. Morrison; Phillip J. Stadler; and Jennifer Whitworth made key contributions to this report.