Medicare:

Assuring the Quality of Home Health Services

HRD-90-7: Published: Oct 10, 1989. Publicly Released: Jan 10, 1990.

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Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) process for surveying home health care agencies and certifying them for Medicare participation.

GAO found that: (1) HCFA contracted with states to periodically survey home health agencies, and certified those agencies that state surveyors determined to be in compliance with HCFA standards; (2) HCFA planned to issue guidance to help state surveyors implement recent legislative requirements that surveyors include measures of how agency services affected patient health status; (3) recent legislation also provided HCFA with a range of sanctions to impose on agencies that did not comply with standards; (4) HCFA guidance did not ensure that surveyors used sound methods to sample patient records for review or consistently interpret Medicare standards; (5) HCFA did not provide surveyors with the data that its claims processing contractors and peer review organizations developed during their reviews of home health agency performance; (6) HCFA regional offices did not fully analyze existing survey data to assess how well the states conducted surveys; and (7) HCFA home health agency standards did not address the qualifications and training of persons who provide high-technology treatments to Medicare beneficiaries.

Matter for Congressional Consideration

  1. Status: Closed - Not Implemented

    Comments: There has been no action taken on this recommendation, and there does not appear to be any potential for action in the foreseeable future.

    Matter: Congress should amend the Social Security Act to require the Secretary of Health and Human Services to develop and enforce training standards for all persons who perform high-technology medical procedures in the home that present a risk to Medicare beneficiaries.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA has issued revised guidance concerning state survey agency budgets to its regional offices.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to revise the assumptions used in developing budgets for agency survey operations to recognize the changes in the survey process that recent legislation mandates and that GAO recommends. In particular, the budget process should recognize that surveys of agencies with large case loads, at which larger samples of patient records should be reviewed, will require more time and resources.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HCFA has instructed its regional offices to review documentation for a random sample of surveys and for all surveys meeting certain criteria.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to direct HCFA regional offices to: (1) review all documentation submitted with a sample of surveys conducted by each state survey agency to determine whether the states are complying with standards for record selection and sampling; and (2) discuss the results of this review in the regional offices' periodic evaluations of the state agencies.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: Standard survey forms have been prepared and issued to the state survey agencies.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to adopt standard survey forms to be used by state surveyors that will provide enough information on records reviewed during the survey to allow HCFA to assess the adequacy of records review and the validity of conclusions reached.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: HCFA has performed studies using Medicare/Medicaid Automated Certification System data that compare the performance of state survey agencies.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to direct HCFA central and regional offices to increase the use of Medicare/Medicaid Automated Certification System data as a means of monitoring and comparing the performance of state survey agencies.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Implemented

    Comments: HCFA developed instructions that direct fiscal intermediaries and peer review organizations to provide relevant information to state survey agencies.

    Recommendation: The Secretary of Health and Human Services should establish a procedure to give state surveyors relevant information concerning agency performance that fiscal intermediaries and peer review organizations develop.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Implemented

    Comments: The Omnibus Budget Reconciliation Act of 1987 directed HCFA to report to Congress on implementation of required changes to the survey process. HCFA is contracting an 18-month study which will analyze the new survey process. The report to Congress should be made by March 1994.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to conduct field tests to determine whether survey guidance is sufficient to ensure that surveyors reach consistent conclusions when conducting surveys.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Implemented

    Comments: Revised instructions covering survey methodology and procedures have been issued to the state survey agencies.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop specific guidelines to clarify the circumstances under which state surveyors should examine branch offices and the qualifications of contract personnel in order to determine agency compliance with the conditions of participation.

    Agency Affected: Department of Health and Human Services

  8. Status: Closed - Implemented

    Comments: Revised instructions covering survey methodology and procedures have been issued to the state survey agencies.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to establish standards for selecting samples of patient records for review during surveys that require: (1) the surveyor, rather than agency staff, to control the record selection process; (2) a random sampling selection process; (3) a sampling plan that provides for selecting enough records to have sufficient confidence in the conclusions drawn about agency performance; and (4) coverage of all services the agency offers.

    Agency Affected: Department of Health and Human Services

 

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