Nursing Homes:

Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment

GAO-10-70: Published: Nov 24, 2009. Publicly Released: Dec 28, 2009.

Additional Materials:

Contact:

John E. Dicken
(202) 512-7043
contact@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

Under contract with the Centers for Medicare and Medicaid Services (CMS), states conduct surveys at nursing homes to help ensure compliance with federal quality standards. Over the past decade, the Government Accountability Office (GAO) has reported on inconsistencies in states' assessment of nursing homes' quality of care, including understatement--that is, when state surveys fail to cite serious deficiencies or cite them at too low a level. In 2008, GAO reported that 9 states had high and 10 had low understatement based on CMS data for fiscal years 2002 through 2007. This report examines the effect on nursing home deficiency understatement of CMS's survey process, workforce shortages and training, supervisory reviews of surveys, and state agency practices. GAO primarily collected data through two Web-based questionnaires sent to all eligible nursing home surveyors and state agency directors, achieving 61 and 98 percent response rates, respectively.

A substantial percentage of both state surveyors and directors identified general weaknesses in the nursing home survey process, that is, the survey methodology and guidance on identifying deficiencies. On the questionnaires, 46 percent of surveyors and 36 percent of directors reported that weaknesses in the traditional survey methodology, such as too many survey tasks, contributed to understatement. Limited experience with a new data-driven survey methodology indicated possible improvements in consistency; however, an independent evaluation led CMS to conclude that other tools, such as survey guidance clarification and surveyor training and supervision, would help improve survey accuracy. According to questionnaire responses, workforce shortages and greater use of surveyors with less than 2 years' experience sometimes contributed to understatement. Nearly three-quarters of directors reported that they always or frequently experienced a workforce shortage, while nearly two-thirds reported that surveyor inexperience always, frequently, or sometimes led to understatement. Substantial percentages of directors and surveyors indicated that inadequate training may compromise survey accuracy and lead to understatement. According to about 29 percent of surveyors in 9 high understatement states compared to 16 percent of surveyors in 10 low understatement states, initial surveyor training was not sufficient to cite appropriate scope and severity--a skill critical in preventing understatement. Furthermore, over half of directors identified the need for ongoing training for experienced surveyors on both this skill and on documenting deficiencies, a critical skill to substantiate citations. CMS provides little guidance to states on supervisory review processes. In general, directors reported on our questionnaire that supervisory reviews occurred more often on surveys with higher-level rather than on those with lower-level deficiencies, which were the most frequently understated. Surveyors who reported that survey teams had too many new surveyors also reported frequent changes to or removal of deficiencies, indicating heavier reliance on supervisory reviews by states with inexperienced surveyors. Surveyors and directors in a few states informed us that, in isolated cases, state agency practices or external pressure from stakeholders, such as the nursing home industry, may have led to understatement. Forty percent of surveyors in five states and four directors reported that their state had at least one practice not to cite certain deficiencies. Additionally, over 40 percent of surveyors in four states reported that their states' informal dispute resolution processes favored concerns of nursing home operators over resident welfare. Furthermore, directors from seven states reported that pressure from the industry or legislators may have compromised the nursing home survey process, and two directors reported that CMS's support is needed to deal with such pressure. If surveyors perceive that certain deficiencies may not be consistently upheld or enforced, they may choose not to cite them.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To address state agency practices and external pressure that may compromise survey accuracy, the Administrator of CMS should reestablish expectations through guidance to state survey agencies that noncitation practices--official or unofficial--are inappropriate, and systematically monitor trends in states' citations.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: September 2010 Update: CMS held a State/Federal meeting in April 2010. The discussion with the State/Federal meeting did not shed light on best method to address possible external pressures on State Agencies. Some expressed that poor documentation/inadequate investigation may cause deficiencies to be dropped and not necessarily external pressure. They will continue to work on developing next steps.

    Recommendation: To address inconsistencies in state supervisory reviews, the Administrator of CMS should set an expectation through guidance that states have a supervisory review program as a part of their quality-assurance processes that includes routine reviews of deficiencies at the level of potential for more than minimal harm (D-F) and that provides feedback to surveyors regarding changes made to citations.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: September 2010 Update: CMS agreed with this recommendation and reported that it would form a State/Federal workgroup to identify promising practices and initiative the process of setting more defined expectations for quality review. CMS held a State/Federal meeting in April 2010. As a result, CMS will undertake a more formal needs assessment project identify promising practices and develop a more comprehensive strategy.

    Recommendation: To address surveyor workforce shortages and insufficient training, the Administrator of CMS should evaluate the current training programs and division of responsibility between federal and state components to determine the most cost-effective approach to: (1) providing initial surveyor training to new surveyors, and (2) supporting the continuing education of experienced surveyors.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: May 2010 Update: A National training policy workgroup of State/Federal survey management was convened on 4/10/2010 to work on consistency in training and oversight by CMS of State agency training activities. CMS is working with this workgroup to develop several State performance standards regarding their training activities.

    Recommendation: To address surveyor workforce shortages and insufficient training, the Administrator of CMS should consider establishing a pool of additional national surveyors that could augment state survey teams or identify other approaches to help states experiencing workforce shortages.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Closed - Not Implemented

    Comments: May 2010 Update: CMS non-concurred with this recommendation. We held a State/CMS meeting in April 2010 to discuss a number of nursing home issues. We did not identify any circumstances where a national pool would be advisable. Workforce shortages are State specific and barriers exist that go beyond CMS' span of control.

    Recommendation: To address concerns about weaknesses in CMS survey methodology and guidance, Administrator of CMS should clarify and revise existing CMS written guidance to make it more concise, simplify its application in the field, and reduce confusion, particularly on the definition of actual harm.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: September 2010 Update: CMS specified in its reply that it would seek alternative methods to address these issues and will work with a State/Federal workgroup to do so. CMS solicited workgroup members in Jan 2010 and held a face-to-face meeting in April 2010. Conclusion of discussions are that the new Quality Indicator Survey (QIS) will have competency pathways which will streamline analysis and decision-making and there needs to be some focus on consistency between CMS Regional Offices. Although CMS does not anticipate reissuing guidance on recent interpretive guidance, it will aim simpler guidance in the future. The workgroup is in the process of deciding what the next steps will be.

    Recommendation: To address concerns about weaknesses in CMS survey methodology and guidance, Administrator of CMS should make sure that action is taken to address concerns identified with the new QIS methodology, such as ensuring that it accurately identifies potential quality problems.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: September 2010: CMS updated the trigger thresholds for 14 of the Quality of Care/Quality of Life Indicators on April 1, 2010. CMS plans to enhance the Quality Indicator Survey (QIS) interview and observation tools as well. These enhancements are developed and implemented in a staged process prior to their inclusion in the survey process and ultimately the QIS software.

    Recommendation: To address state agency practices and external pressure that may compromise survey accuracy, the Administrator of CMS should establish expectations through guidance to state survey agencies to communicate and collaborate with their CMS regional offices when they experience significant pressure from legislators or the nursing home industry that may affect the survey process or surveyors' perceptions.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

    Status: Open

    Comments: September 2010 Update: CMS held a State/Federal meeting in April 2010. The discussion with the State/Federal meeting did not shed light on best method to address possible external pressures on State Agencies. We will continue to work on developing next steps.

    Apr 18, 2014

    Apr 8, 2014

    Apr 2, 2014

    Mar 26, 2014

    Mar 24, 2014

    Mar 10, 2014

    Mar 7, 2014

    Mar 6, 2014

    Looking for more? Browse all our products here