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.

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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.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In our November 2009 report on the understatement of deficiencies on nursing home surveys, we reported that five state agency directors indicated the Quality Indicator Survey (QIS) survey methodology required more time than the traditional survey while the overall effect of the QIS approach on understatement was inconclusive. Yet, an independent evaluation of the QIS generated a number of recommendations for improving the QIS that were consistent with reducing understatement, such as evaluating how well the new methodology accurately identifies the areas in which there are potential quality problems. To address concerns about weaknesses in Centers for Medicare & Medicaid Services (CMS) survey methodology and guidance, we recommended that the Administrator of CMS 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. In its response to our report, CMS concurred with this recommendation. To address concerns about the QIS methodology which were raised in our report, CMS has been working since 2010 to improve the accuracy of the QIS in identifying potential quality problems. CMS has updated the trigger thresholds for several of the Quality of Care/Quality of Life (QCLI) Indicators from 2010 through 2013. It has revised QCLI indicators used in the survey process to make them more sensitive with respect to triggering and citation rates. In addition, CMS has updated the QIS survey instrument and released new versions of associated software in 2013 and 2014. CMS?s efforts to improve the QIS survey methodology will result in a more efficient and accurate process for identifying potential quality problems which should help reduce the understatement of deficiencies on nursing home surveys.

    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

  2. Status: Closed - Implemented

    Comments: In our November 2009 report on the understatement of deficiencies on nursing home surveys, we reported that because the Centers for Medicare & Medicaid Services? (CMS) written guidance was too long or complex, it contributed to the understatement of deficiencies. Both state agency directors and surveyors that responded to our questionnaires mentioned concerns about the length, complexity, and subjectivity of the written guidance. Further, state agency directors and surveyors indicated in their responses to our questionnaire that CMS?s written guidance for certain federal nursing home quality standards could be improved and that the revised investigative protocols were helpful. In particular, on our questionnaire fewer surveyors reported concerns with the guidance on quality standards which were revised through CMS?s guidance update initiative. To address concerns about weaknesses in CMS survey methodology and guidance, we recommended that the Administrator of CMS 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. In its response, CMS agreed in principle with our recommendation to clarify and revise existing written guidance to simplify its application in the field, and reduce confusion. However, CMS disagreed with shortening the guidance as the preferred method for achieving such clarification. Instead, the agency suggested an alternative?the creation of some short reference documents for use in the field that contain cross-links back to the full guidance?that we believe would fulfill the intent of our recommendation. An official in CMS?s Survey and Certification Group reported that to address the concerns with the written guidance which were raised in our report, CMS convened a federal/state workgroup in 2010. The official indicated that the conclusion of discussions included that the new Quality Indicator Survey (QIS) would have critical element pathways which would streamline analysis and decision-making. For example, in 2013 CMS created at least two critical element pathways (CEP) to guide surveyors with respect to assessing Pressure Ulcers and Unnecessary Medications. In addition to the creation of CEPs for the QIS, in 2014 CMS has revised the State Operations Manual to incorporate past Survey and Certification memos from 2003 to May 2014 in an effort to clarify and centralize existing guidance. CMS?s efforts to create critical pathway tools for application during a survey and clarify its guidance can only reduce the potential for understatement due to confusion regarding the guidance.

    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

  3. 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 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

  4. Status: Closed - Implemented

    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. June 2013 Update: Development of performance standards for training have had to be delayed due to the implementation of ACA. Nevertheless, the Training Staff has begun to implement other workgroup recommendations for improvements related to measuring the effectiveness of training applied by both Federal and State Agency (SA) resources. For example, we continued to measure individual student performance via increased use of testing in all Basic courses, in all provider-types. Student testing has been gradually expanded to cover advanced topics training. We also ask for student evaluation of the quality of the training, its applicability to their work environment, and suggestions for improvement. Continued growth in the numbers and kinds of federally-supplied trainings (such as webinars and more and different distance learning tools) help to provide for advance topics. These are also measured at the individual level. In early 2014, we will be undertaking a repeat of a survey of SA Directors and RO executives to determine whether they are able to see performance improvement as a result of more trainings, more topics, more easily accessible materials, and at times convenient for the individual learner.

    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

  5. Status: Closed - Implemented

    Comments: In our November 2009 report on the understatement of deficiencies on nursing home surveys, we reported that state supervisory reviews, which generally occurred more frequently on higher-level deficiencies, often were not designed to identify understated deficiencies. According to state agency directors? responses to our questionnaire, states generally focused supervisory review on surveys with higher-level deficiencies, rather than on the surveys with deficiencies at the potential for more than minimal-harm level?the deficiencies most likely to be understated. To address inconsistencies in state supervisory reviews, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (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 and that provides feedback to surveyors regarding changes made to citations. In its response to our report, CMS concurred with this recommendation. To address state inconsistencies in state supervisory review and our recommendation, CMS has taken two approaches to address issues with state supervisory reviews. First, as outlined in the fiscal year 2014 State Performance Standards System (SPSS), CMS regional offices assess states on the documentation of deficiencies for nursing homes, including that the scope and severity rating reflects the number of residents affected or potentially affected by the deficient practice and the evidence and the actual or potential outcome to residents. Regional offices make such assessments through reviews of survey reports. According to an official in CMS?s Survey and Certification Group, in 2012 the regional offices began engaging the states more closely to confront variations in state agency practices. She stated that regional offices have undertaken practices to identify and clarify issues including reviewing survey reports. Second, for the 26 states QIS CMS has provided a regular report on surveyor patterns and activities since 2012. State agencies use these reports to provide individualized feedback to the surveyors. The improvements to the SPSS and regular reporting of surveyor patterns and activities to state agencies and regional offices, will aid in the detection of problems in the identification of deficiencies during surveys.

    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

  6. Status: Open

    Comments: May 2014: Though the best method to address external pressures on State Agencies was not identified, CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings. CMS is looking to review specific regulatory deficiencies for trends and areas where additional guidance is needed. Anticipated completion date of October 31, 2014. 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. June 2013 Update: Though the best method to address external pressures on State Agencies was not identified. CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings.

    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

  7. Status: Open

    Comments: May 2014: CMS has undertaken a broader review of both the QIS and traditional survey processes, and the extent to which the methodology and guidance result in an effective and efficient survey process. In August 2012, CMS convened a broad group of surveyors to address these issues and make recommendations which have resulted in continuing work to develop and test alternative guidance and processes. CMS is looking to review specific regulatory deficiencies for trends and areas where additional guidance is needed. Anticipated Completion date of December 31, 2014. 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. CMS will continue to work on developing next steps. June 2013 Update: Though the best method to address external pressures on State Agencies was not identified. CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings.

    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

 

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