[Congressional Record Volume 144, Number 145 (Tuesday, October 13, 1998)]
[Extensions of Remarks]
[Pages E2139-E2140]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




   WHY THE JOINT COMMISSION ON ACCREDITING HEALTHCARE ORGANIZATIONS 
                         (JCAHO) MUST DO BETTER

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                       Tuesday, October 13, 1998

  Mr. STARK. Mr. Speaker, we need to take immediate action to make 
JCAHO accountable to the public. The Administration's July 1, 1998 
report on nursing home quality [``Private Accreditation (Deeming) of 
Nursing Homes, Regulatory Incentives, and Non-Regulatory Initiatives, 
and Effectiveness of the Survey and Certification System''] shows that 
the nation's premier, private health accrediting organization--the 
Joint Commission on Accrediting Healthcare Organizations needs to do a 
much better job of protecting Medicare patients and dollars. Before 
JCAHO extends its accrediting activities to other areas--such as 
hospice agencies where it is applying to be an accrediting 
organization--it needs to prove it can do its current job of inspecting 
nursing homes and hospitals.
  As I said in my opening remarks to the Ways and Means Health 
Subcommittee on July 1, 1990, ``Validating the JCAHO status is critical 
given that HCFA, through a process termed `deemed Status' relies on 
JCAHO to assure that most hospitals are providing quality health 
services to Medicare beneficiaries. If a hospital (or now other health 
care facility) is accredited by JCAHO, it is deemed to meet the 
Medicare conditions of participation.'' We found many problems eight 
years ago and many still continue, which would indicate a fundamental 
problem with JCAHO culture caused, I believe, by the system of 
financing JCAHO inspections. This is why I have introduced H.R. 800 to 
increase public access to and influence on JCAHO.
  H.R. 800 will require that one-third of the members of the governing 
boards of Medicare-accrediting agencies are members of the public. 
JCAHO currently claims to have 6 public members on its board. In fact, 
a recent appointee to one of the scarce public seats, is also a 
director of the second-largest investor-owned hospital company. This 
recent appointment is just one example of the conflict of interest 
rampant in JCAHO's operating procedures. My bill also outlines a 
definition of ``members of the public'' to prevent similar appointments 
in the future.
  On July 1, 1998, HCFA issued a Report to Congress entitled, ``Study 
of Private Accreditation (Deeming) of Nursing Homes, Regulatory 
Incentives, and Effectiveness of the Survey and Certification System''. 
This damning report detailed numerous deficiencies in JCAHO's current 
inspection system. To extend JCAHO's deeming to hospice care would 
permit an inadequate program greater authority.
  JCAHO recently announced its intention to expand its scope of 
inspection to include hospice facilities. JCAHO currently surveys 
nursing homes, hospitals, and other health providers. But according to 
a recent HCFA/Abt study, JCAHO is unable to effectively administer 
surveys, identify problems, and implement problem correction policies. 
Allowing an organization riddled with problems further authority would 
be a terrible mistake.
  JCAHO accredits health care facilities at the facilities' request. 
The federal government recognizes JCAHO hospital and home health agency 
accreditation as equivalent to meeting its Medicare Conditions of 
Participation.
  According to the recent HCFA/Abt report to Congress, JCAHO has to 
make drastic changes to meet the basic Medicare requirements. JCAHO 
continues to deem facilities Medicare eligible, when in fact these 
facilities do not meet Medicare standards. Facilities that want to be 
accredited pay JCAHO to survey their site. Allowing JCAHO to accredit 
facilities that pay for surveys represent a conflict of interest. 
JCAHO's lack of objectivity plagues the current accreditation process.
  Furthermore, JCAHO accreditation does not meet current Medicare 
guidelines for allowing facilities to participate in the program. The 
most serious allegation against JCAHO is that it overlooks regulatory 
infractions at the expense of patients for example: One nursing home 
administrator responded to questions about JCAHO's procedures with the 
following. ``They (JCAHO) are big into policies and procedures * * * 
they are more interested in quality improvement and assessment than 
problem correction.'' \1\
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     \1\ Pp. 617-618 ``Study of Private Accreditation of (Deeming) 
     of Nursing Homes, Regulatory Incentives and Non-Regulatory 
     Initiatives, and Effectiveness of the Survey and 
     Certification'', Health Care Financing Administration. July 
     1, 1998.
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  Lack of problem correction is of special concern given the nature of 
nursing home residents. This population is one of the most vulnerable 
parts of the health care population, with 48 percent of nursing home 
patients suffering from some form of dementia.
  JCAHO is unable to effectively accredit private nursing homes, and 
thus should not be allowed to additionally accredit hospice facilities 
until its inspection system is improved. The results of empirical 
studies included in the Study demonstrate the need for overhaul of the 
current regulatory system.
  While the medicare system may benefit from reduced regulatory costs 
by using JCAHO, the savings do not outweigh the risk of severe 
deficiencies in care. Although deeming may save Medicare $2 to $37 
million a year by private accreditation, JCAHO surveyors often miss 
serious deficiencies, which in some cases may even result in 
unjustified deaths. We must not sacrifice the welfare of the most 
vulnerable for minimal financial gains.
  JCAHO does not effectively administrate regulatory surveys. The 
timing of JCAHO surveys was easy for nursing home administrators to 
predict. Surveys were never conducted at night or on the weekends. Thus 
once a provider paid JCAHO to accredit the facility they could 
hypothetically increase staff levels on only Monday and Tuesday day 
shifts in anticipation of a pending survey.
  Furthermore, the current system fails miserably to identify problems. 
The Incidence of serious deficiencies found decreased with the 
implementation of the new accreditation program. The new process may 
also tend to identify deficiencies as less serious than they actually 
are.
  Flaws in the problem identification system are evidenced by the fact 
that simultaneous public accreditation found more serious deficiencies 
than JCAHO did. More importantly, the current system under-addresses 
malnutrition and violence problems. Currently nursing home aides are 
not required to undergo criminal background checks. Furthermore some 
employers seek out recent parolees knowing that these employees will 
work for a lower salary. JCAHO fails to detect inadequate and even 
fraudulent staff training practices: Frequently reported actions to 
provide in-staff training to staff result in no evidence on quality and 
content. Very high staff turnover suggests that the staff is not 
benefitting from the required training. In one case, workers were asked 
to sign an attendance sheet for an in-staff training session they never 
attended. \2\
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     \2\ Pg. xii, Executive Summary; Study: HCFA
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  HCFA standards are generally more stringent than JCAHO standards. 
JCAHO surveyors seem to miss serious deficiencies that HCFA surveyors 
frequently identify. JCAHO standards are heavily weighted toward 
structure and process measures, while HCFA standards have a more 
resident-centered and outcome-oriented focus.
  The JCAHO accreditation and HCFA validation inspections differed 
widely in their approach as well. JCAHO surveyors spent little time 
assessing quality of life issues or observing clinical treatments. 
JCAHO surveyors also spent little time observing clinical care or with 
residents, and those residents who JCAHO surveyors did interview were 
often pre-selected by nursing home staff.\3\
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     \3\ Pg. 18, Vol. I Study: Health Care Financing 
     Administration
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  In the Report to Congress HCFA said that JCAHO lacked the ability to 
enforce findings

[[Page E2140]]

and to regulate nursing home care: Some Nursing homes need the punitive 
threat of review and enforcement to secure improvements. The current 
system has not worked as well as it should to eliminate poor quality 
nursing care. \4\
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     \4\ Pg. 13 Vol. I ``Study: Health Care Financing 
     Administration July 1, 1998
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  The Study concludes that JCAHO is not adequately ensuring quality 
nursing care. The potential cost savings of deeming does not appear to 
justify the risk to the health and safety of the vulnerable nursing 
home population.
  Although the study also found problems with the HCFA survey 
procedures, these concerns pale in comparison to the inadequacies of 
JCAHO survey procedures.
  The result of this study raise alarming concerns about the quality of 
nursing care in the nations nursing homes. JCAHO has proven itself 
unable to identify with facilities are providing substandard care and 
to implement programs which will correct these problems. JCAHO should 
not be allowed to accredit hospice facilities until we are sure 
fundamental changes in JCAHO's system of inspections are in place. The 
federal government has a responsibility to reevaluate the current 
deeming system to protect its most vulnerable citizens.

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