Nursing Homes:

Complaint Investigation Processes Often Inadequate to Protect Residents

HEHS-99-80: Published: Mar 22, 1999. Publicly Released: Mar 22, 1999.

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Pursuant to a congressional request, GAO provided information on how states implement the federal requirement that establishes a process for nursing home complaint investigations, focusing on the: (1) effectiveness of state complaint investigation practices as a component of the system to ensure sustained compliance with federal nursing home quality-of-care standards; and (2) Health Care Financing Administration's (HCFA) role in establishing standards and conducting oversight of states' complaint investigation practices and in using information about the results of complaint investigations to ensure compliance with nursing home standards.

GAO noted that: (1) federal and states' practices for investigating complaints about care provided in nursing homes are often not as effective as they should be; (2) among many of the 14 states GAO examined, GAO found numerous problems, including: (a) procedures or practices that may limit the filing of complaints; (b) understatement of the seriousness of complaints; and (c) failure to investigate serious complaints promptly; (3) serious complaints alleging that nursing home residents are being harmed can remain uninvestigated for weeks or months; (4) such delays can prolong situations in which residents may be subject to abuse, neglect resulting in serious care problems like malnutrition and dehydration, preventable accidents, and medication errors; (5) although federal funds finance over 70 percent of complaint investigations nationwide, HCFA plays a minimal role in providing states with direction and oversight regarding these investigations; (6) HCFA has left it largely to the states to decide which complaints potentially place residents in immediate jeopardy and must be investigated within the federally mandated 2 workdays; (7) if a serious complaint that could harm residents is not classified as potentially placing residents in immediate jeopardy, there is no formal requirement for prompt investigation; (8) more generally, HCFA's oversight of state agencies that certify federally qualified nursing homes has not focused on complaint investigations; and (9) GAO found that: (a) a HCFA initiative to strengthen federal requirements for complaint investigations was discontinued in 1995, and resulting guidance developed for states' optional use has not been widely adopted; (b) federal reviews of state nursing home inspections are primarily intended to focus on the annual surveys of nursing homes, and very few reviews are conducted of complaint investigations; (c) since 1998, HCFA has required state agencies to develop their own performance measures and quality improvement plans for their complaint investigations, but for several of the 14 states GAO reviewed, such assessments addressed complaint processes superficially or not at all; and (d) HCFA reporting systems for nursing homes' compliance history and complaint investigations do not collect timely, consistent, and complete information.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In fiscal year 2004, CMS (formerly HCFA) completed two actions that improve guidance to states for conducting investigations of complaints. The first action, effective January 2004, in conjunction with the nationwide implementation of its new complaint tracking system, CMS provided detailed direction and guidance to the states for managing complaint investigations for numerous types of providers, including nursing homes. The second action, effective in June 2004, was the publication on the Internet of an updated chapter of CMS's State Operations Manual that consolidates complaint investigation procedures for numerous types of providers.

    Recommendation: To make complaint investigations a more effective tool for protecting nursing home residents' health and safety, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by developing additional standards for the prompt investigation of serious complaints alleging situations that may harm residents but are categorized as less than immediate jeopardy. These standards should include maximum allowable timeframes for investigating serious complaints and for complaints that may be deferred until the next scheduled annual survey. States may continue to set priority levels and timeframes that are more stringent than these federal standards.

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

  2. Status: Closed - Implemented

    Comments: In response to this recommendation, HCFA (now CMS) developed and issued detailed guidance for the state survey agencies to follow to make complaint investigations more effective, and has also developed a new performance standard to guide CMS Regional Office staff in evaluating state survey agencies' handling of complaint investigations.

    Recommendation: To make complaint investigations a more effective tool for protecting nursing home residents' health and safety, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by strengthening federal oversight of state complaint investigations, including monitoring states' practices regarding priority-setting, on-site investigation, and timely reporting of serious health and safety complaints.

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

  3. Status: Closed - Implemented

    Comments: CMS implemented its new ASPEN Complaint Tracking System nationwide in January 2004. With its implementation, CMS is better able to track information about complaint investigations performed by all state agencies.

    Recommendation: To make complaint investigations a more effective tool for protecting nursing home residents' health and safety, the Administrator, HCFA, should revise federal guidance and ensure state agency compliance by requiring that the substantiated results of complaint investigations be included in federal data systems or be accessible by federal officials.

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

 

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