Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight
GAO-03-561 Published: Jul 15, 2003. Publicly Released: Jul 17, 2003.
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Since July 1998, GAO has reported numerous times on nursing home quality-of-care issues and identified significant weaknesses in federal and state oversight. GAO was asked to assess the extent of the progress made in improving the quality of care provided by nursing homes to vulnerable elderly and disabled individuals, including (1) trends in measured nursing home quality, (2) state responses to previously identified weaknesses in their survey, complaint, and enforcement activities, and (3) the status of oversight and quality improvement efforts by the Centers for Medicare & Medicaid Services (CMS).
Recommendations for Executive Action
|Centers for Medicare & Medicaid Services||To strengthen the ability of the nursing home survey process to identify and address problems that affect the quality of care, the Administrator of CMS should finalize the development, testing, and implementation of a more rigorous survey methodology, including guidance for surveyors in documenting deficiencies at the appropriate level of scope and severity.||
In addition, CMS developed the new Quality Indicator Survey (QIS) to improve the consistency and efficiency of state surveys and provide a more reliable assessment of quality. As of August 2009, it has started implementing the QIS in eleven states: Connecticut, Florida, Kansas, Louisiana, Maryland, Minnesota, New Mexico, North Carolina, Ohio, Washington and West Virginia, and prioritized the remaining 39 states, District of Columbia, Puerto Rico and Virgin Islands for QIS implementation. The QIS uses an expanded sample and structured interviews with residents in a two-stage process. State surveyors are guided through the QIS process using customized software on tablet personal computers. In stage 1, a large resident sample is drawn and relevant data from on- and off-site sources is analyzed to develop a set of quality-of-care indicators, which will be compared to national benchmarks. Stage 2 systematically investigates potential quality-of-care concerns identified in stage 1 CMS concluded a five-state demonstration project of the QIS in 2007 and has since released the QIS evaluation. Based on the QIS evaluation, CMS has identified several areas for improvement such as increasing the specificity and usability of investigative guidelines and evaluating how well the new methodology accurately identifies the areas in which there are potential quality problems. In addition, CMS articulated that future QIS development efforts should concentrate on improving survey consistency and giving supervisors more tools to assess performance of surveyor teams.
|Centers for Medicare & Medicaid Services||To better ensure that state survey and complaint activities adequately address quality-of-care problems, the Administrator of CMS should require states to have a quality assurance process that includes, at a minimum, a review of a sample of survey reports below the level of actual harm (less than G level) to assess the appropriateness of the scope and severity cited and to help reduce instances of understated quality-of-care problems.||
In September 2004, a cognizant CMS official advised GAO that CMS had taken no action with respect to the issue of requiring states to have a quality assurance process focusing on reviewing survey reports below the level of actual harm to assess the appropriateness of the scope and severity cited, and has no plans to do so.
|Centers for Medicare & Medicaid Services||To better ensure that state survey and complaint activities adequately address quality-of-care problems, the Administrator of CMS should finalize the development of guidance to states for their complaint investigation processes and ensure that it addresses key weaknesses, including the prioritization of complaints for investigation, particularly those alleging harm to residents; the handling of facility self-reported incidents; and the use of appropriate complaint investigation practices.||
In fiscal year 2004, CMS completed two actions that improve guidance to states for conducting investigations of complaints. In 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. This guidance targets, among other things, the issue of prioritizing complaints, particularly those alleging harm to residents. 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.
|Centers for Medicare & Medicaid Services||To better ensure that states comply with statutory, regulatory, and other CMS nursing home requirements designed to protect resident health and safety, the Administrator of CMS should further refine annual state performance reviews so that they (1) consistently distinguish between systemic problems and less serious issues regarding state performance, (2) analyze trends in the proportion of homes that harm residents, (3) assess state compliance with the immediate sanctions policy for homes with a pattern of harming residents, and (4) analyze the predictability of state surveys.||
A cognizant CMS official advised GAO in September 2004, that CMS had taken no specific action on this recommendation and has no current plans to do so.