Nursing Home Care:

Enhanced HCFA Oversight of State Programs Would Better Ensure Quality

HEHS-00-6: Published: Nov 4, 1999. Publicly Released: Nov 4, 1999.

Contact:

Kathryn G. Allen
(202) 512-3000
contact@gao.gov

 

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

Pursuant to a congressional request, GAO provided information on the Health Care Financing Administration's (HCFA) oversight programs of state agencies' nursing home survey process, focusing on the: (1) effectiveness of HCFA's approaches to assessing state agency performance; (2) extent to which HCFA's regional offices vary in their application of these approaches; and (3) the corrective actions available to HCFA when it identifies poor state agency performance.

GAO noted that: (1) since last year, HCFA has undertaken a series of initiatives intended to address quality problems facing the nation's nursing home residents, including redesigning its program for overseeing state agencies that survey nursing homes to ensure quality care; (2) the objective of HCFA's oversight program is to evaluate the adequacy of each state agency's performance in ensuring quality care in nursing homes, but the mechanisms it has created to do so are limited in their scope and effectiveness; (3) HCFA's oversight mechanisms are not applied consistently across each of its 10 regional offices; (4) HCFA does not have sufficient, consistent, and reliable data to evaluate the effectiveness of state agency performance or the success of its recent initiatives to improve nursing home care; (5) given the wide range in the frequencies with which states identify serious deficiencies, HCFA cannot be certain whether some states are failing to identify serious deficiencies that harm nursing home residents; (6) HCFA does not have an adequate array of effective sanctions to encourage a state agency to correct serious or widespread problems with its survey process; (7) HCFA's primary mechanism to monitor state survey performance stems from its statutory requirement to survey annually at least 5 percent of the nation's 17,000 nursing homes that states have certified as eligible for Medicare or Medicaid funds; (8) but HCFA's approach to these federal monitoring surveys does not produce sufficient information to assess the adequacy of state agency performance; (9) to fulfill its 5 percent monitoring mandate, HCFA makes negligible use of its most effective technique--an independent survey done by HCFA surveyors following completion of a state's survey--for assessing state agencies' abilities to identify serious deficiencies in nursing homes; (10) a second HCFA oversight mechanism also has significant shortcomings; (11) about 3 years ago, HCFA implemented the State Agency Quality Improvement Program (SAQIP), a program under which the state agency does a self-assessment to inform HCFA, at least once a year, whether the state is in compliance with seven standard requirements; and (12) SAQIP is limited as an oversight program, however, because HCFA: (a) does not independently validate the information that the states provide, so it is uncertain whether all serious problems are identified or whether identified problems are being corrected; and (b) has no policy regarding consequences for states that do not comply.

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 ensure that states effectively meet federal standards for certifying nursing homes and to consistently implement the more stringent requirements of HCFA's recent initiatives, HCFA needs to strengthen its oversight of state survey agencies' activities. To accomplish this, the Administrator, HCFA, should improve the scope and rigor of HCFA's oversight process by: (1) increasing the proportion of federal monitoring surveys conducted as comparative surveys to ensure that a sufficient number are completed in each state to assess whether the state appropriately identifies serious deficiencies; (2) ensuring that comparative surveys are initiated closer to the time the state agency completes the home's annual standard survey; (3) requiring regions to provide more timely written feedback to the states after the completion of federal monitoring surveys; and (4) improving the data system for observational surveys so that it is an effective management tool for HCFA to properly assess the findings of observational surveys.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

    Status: Closed - Implemented

    Comments: CMS awarded a contract in the fall of 2003 for the conduct of approximately 170 additional comparative surveys each year, bringing the annual total performed by both federal surveyors and the contractor to about 330. As of July 2004, 15 surveyors have been hired and trained and were participating in trial comparative surveys with federal surveyors. Although these trial surveys identified the need for additional training, CMS expects to begin the additional comparative surveys by the fall of 2004. With regard to other elements of this recommendation, CMS has (1) successfully reduced the time between the state and the comparative surveys, (2) instructed the regions to timely report the results of observational surveys to the state agencies, and (3) improved the FOSS data system to make it more responsive to surveyors' needs.

    Recommendation: To ensure that states effectively meet federal standards for certifying nursing homes and to consistently implement the more stringent requirements of HCFA's recent initiatives, HCFA needs to strengthen its oversight of state survey agencies' activities. To accomplish this, the Administrator, HCFA, should improve the consistency in how HCFA holds state survey agencies accountable by standardizing procedures for selecting state surveys and conducting federal monitoring surveys, including: (1) ensuring that the regions target surveys for review that will provide a comprehensive assessment of state surveyor performance; and (2) requiring federal surveyors to include as many of the same residents as possible in their comparative survey sample as the state included in its sample (here HCFA surveyors have determined that the state sample selection process was appropriate).

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

    Status: Closed - Implemented

    Comments: In 2000, CMS (formerly HCFA) introduced clear guidance setting out seven specific standards, review protocols, and a reporting mechanism for assessing state performance. In 2001, CMS assessed each state's performance against the standards in the first of what will be an annual review. CMS previously instructed federal surveyors conducting comparative surveys to include in their sample all of the residents that the State Agency included in its sample. CMS, however, did not, and has no plans to address, GAO's observation that individual state surveys should be selected for federal review in a manner that ensures that regions observe as many state surveyors as possible.

    Recommendation: To ensure that states effectively meet federal standards for certifying nursing homes and to consistently implement the more stringent requirements of HCFA's recent initiatives, HCFA needs to strengthen its oversight of state survey agencies' activities. To accomplish this, the Administrator, HCFA, should further explore the feasibility of appropriate alternative remedies or sanctions for those states that prove unable or unwilling to meet HCFA's performance standards.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

    Status: Closed - Implemented

    Comments: HCFA revised its guidelines on assessing state performance standards in December 1999, including new sanctions of placing the state agency on notice that it is not in compliance, and meeting with high-level state officials to attempt to improve state performance. However, the report concluded that the potential effectiveness of these sanctions is doubtful because HCFA still does not conduct sufficient number of comparative surveys to effectively assess state performance and the new sanctions are likely to be ineffective in improving state performance. HCFA continues to consider whether to conduct an increased share of comparative surveys.

    Aug 13, 2014

    Aug 11, 2014

    Jul 30, 2014

    Jul 29, 2014

    Jul 23, 2014

    Jul 16, 2014

    Jul 15, 2014

    Jul 10, 2014

    Looking for more? Browse all our products here