Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of State Complaint Investigations

GAO-11-280 Published: Apr 07, 2011. Publicly Released: May 09, 2011.
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Highlights

CMS, the agency within HHS that manages Medicare and Medicaid, contracts with state survey agencies to investigate complaints about nursing homes from residents, family members, and others. CMS helps assure the adequacy of state complaint processes by issuing guidance, monitoring data that state survey agencies enter into CMS's database, and annually assessing performance against specific standards. Concerns have been raised about the timeliness and adequacy of complaint investigations and CMS's oversight. GAO examined (1) complaints received, investigated, and substantiated by state survey agencies; (2) whether those agencies were meeting CMS performance standards and other requirements; and (3) the effectiveness of CMS's oversight. In addition to analyzing CMS data on complaints and performance reviews, GAO examined CMS guidance and conducted interviews with officials from three high- and three low-performing state survey agencies and their CMS regional offices. GAO addressed data reliability concerns by reporting only data we determined to be reliable.

CMS's complaints data showed that state survey agencies received 53,313 complaints about nursing homes in 2009. The number and types of complaints varied among states. For example, 11 states received 15 or fewer complaints per 1,000 nursing home residents while 14 states received more than 45. State survey agencies assess the severity of a complaint and assign a priority level, which dictates if and when an investigation must be initiated. About 10 percent of complaints were prioritized as immediate jeopardy, requiring investigation within 2 working days of receipt, while 45 percent were prioritized as actual harm-high, requiring investigation within 10 working days of prioritization. State survey agencies investigated all but 102 complaints that required an investigation. Among investigated complaints, 19 percent were substantiated and resulted in the citation of at least one federal deficiency. The percentage of immediate jeopardy and actual harm-high complaints that were substantiated with at least one federal deficiency cited was higher if the investigation was initiated on time. In CMS's performance assessment for fiscal year 2009, many state survey agencies had difficulty meeting some of CMS's nursing home complaint standards, most of which also assess performance with regard to incidents--specific care issues that nursing homes are required to report. In particular, 19 state survey agencies had difficulty investigating actual harm-high complaints and incidents within the required time frame. However, most states were able to meet other CMS standards--timely investigation of immediate jeopardy complaints and incidents and appropriate prioritization of complaints and incidents. Although CMS's performance assessment does not review state survey agencies' communication with complainants, CMS does expect the agencies to convey investigation findings according to CMS guidelines. GAO found state survey agencies had varied interpretations of those guidelines, and some provided limited information to complainants. CMS's oversight of state survey agencies' complaint investigation processes, through its performance standards system and complaints database, is hampered by data reliability issues. While CMS's performance standards are consistent with certain key criteria for performance measures identified by GAO and other audit agencies, performance scores are not always reliable, due in part to inadequate sample sizes and inconsistent interpretation of some standards by CMS reviewers. In addition, CMS has not made full use of the information it collects. For example, in part because of data reliability concerns, CMS does not routinely use data from the complaints database to calculate certain measures that could enhance its understanding of agencies' performance. Although CMS requires state survey agencies that fail performance standards to develop corrective action plans, states' plans do not necessarily address the underlying causes of performance issues, such as staffing shortages. GAO recommends that the CMS Administrator take several steps to strengthen oversight of complaint investigations, such as improving the reliability of its complaints database and clarifying guidance for its state performance standards to assure more consistent interpretation. HHS generally agreed with our recommendations.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To ensure that information entered into CMS's complaints database is reliable and consistent, the Administrator of CMS should identify issues with data quality and clarify guidance to states about how particular fields in the database should be interpreted, such as what it means to substantiate a complaint.
Closed – Implemented
HHS concurred with this recommendation and in 2014 CMS officials reported beginning a multi-year review of it's business processes that would seek to provide clarification on all aspects of the complaint process, including what it means to substantiate a complaint. In June 2022 CMS issued revised long-term care surveyor guidance, removing the term "substantiate" and instructing surveyors to specify whether non-compliance was identified during a complaint investigation. In addition, CMS officials said that through the State Performance Standards System, CMS reviewed data trends to improve State performance, including looking at substantiation rates (i.e., citation rates) during complaint investigations and developed an updated training.
Centers for Medicare & Medicaid Services To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should conduct additional monitoring of state performance using information from CMS's complaints database, such as additional timeliness measures.
Closed – Implemented
HHS agreed with this recommendation and CMS officials reported beginning to take some actions in 2014. In October 2022 CMS reported on their initiative to evaluate the State Performance Standards System (SPSS), an effort aimed at improving the efficiency and effectiveness of measuring and improving state performance. CMS said that as a result of the evaluation they made revisions to their guidance, such as introducing performance indicators to help identify and monitor potential lapses in performance, including issues related to the management of complaints. CMS officials said they also have made changes that (1) automatically upload complaints within 70 days to ensure that CMS has information in the national database regarding the status of complaints and (2) monitor the complaint process backlog across states attributable to the challenges conducting surveys during the public health emergency. Finally, in June 2022 CMS revised guidance to strengthen the oversight of nursing home complaints and facility reported incidents and include revisions to timeframes for investigation.
Centers for Medicare & Medicaid Services To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should assess state survey agencies' performance in certain areas--specifically, documentation of deficiencies, prioritization of complaints, and quality of investigations--less frequently than once a year.
Closed – Not Implemented
In November 2014, CMS officials reported that the agency continues to follow a protocol of annual reviews of state agency performance, including performance in specific areas for which GAO recommended less-frequent reviews. CMS officials stated that they believe annual reviews are an effective method of analyzing state agency performance. Officials also noted that, due to serious declines in state agency performance as a consequence of budget and personnel restrictions enacted in response to the 2008-2009 recession, CMS has been focusing on enforcement of states' basic statutory obligations.
Centers for Medicare & Medicaid Services To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should assure greater consistency in assessments by identifying differences in interpretation of the performance standards and clarifying guidance to state survey agencies and CMS regional offices.
Closed – Implemented
HHS agreed that CMS needed to strengthen its assessment of state survey agencies' performance in the management of nursing home complaints. In November 2014, CMS officials reported that the agency's fiscal year 2014 protocol for assessment of state agencies' performance requires CMS regional offices to review the extent to which the states' policies are consistent with CMS policies. CMS officials acknowledged that there was some variation among states and noted that the agency's Survey and Certification Group is in the early stages of a multi-year review of all of its business processes. Officials expected this review would identify additional opportunities to improve consistency among states in the application of the performance standards. In October 2019 CMS officials provided information to show that guidance had been clarified to help address inconsistency in assessments.
Centers for Medicare & Medicaid Services To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should clarify guidance to the state survey agencies about the minimum information that should be conveyed to complainants at the close of an investigation.
Closed – Implemented
HHS agreed with this recommendation and CMS officials reported in 2014 they would review guidance to identify any needed changes. In June 2022 CMS issued revised long-term care surveyor guidance to clarify the minimum information that should be conveyed to complainants, including how a complainant may request a copy of the investigation report.
Centers for Medicare & Medicaid Services To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should provide guidance encouraging state survey agencies to prioritize complaints at the level that is warranted, not above that level.
Open
HHS agreed with this recommendation and CMS officials began providing information in 2014. In October 2022 CMS described how guidance changes made in June 2022 can address this recommendation; in response GAO requested additional information and will consider closure when provided.
Centers for Medicare & Medicaid Services To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should implement CMS's proposed plans to publish state survey agencies' scores but limit publication to those performance standards that CMS considers the most reliable and clear.
Closed – Implemented
HHS agreed that CMS needed to take steps to strengthen and increase accountability of state survey agencies' management of the nursing home complaints process and said that CMS would work with state officials and others to identify key performance information that would be of public value. In November 2014, CMS officials reported that the agency had not yet outlined a method or timetable for publishing states' performance scores. In October 2019 CMS officials provided information to show that state survey agencies' scores are publicly available through its website and the key elements that CMS considers the most reliable and clear are highlighted in a summary memo.

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