Nursing Homes: Success of Quality Initiatives Requires Sustained Federal
and State Commitment (Testimony, 09/28/2000, GAO/T-HEHS-00-209).

Pursuant to a congressional request, GAO discussed the quality of care
in nursing homes, focusing on: (1) progress in improving the detection
of quality problems during annual surveys; (2) how the prevalence of
identified problems has changed; (3) the status of efforts to strengthen
states' complaint investigation processes and federal enforcement
policies; and (4) additional activities occurring at the federal level
to improve oversight of states' quality assurance activities.

GAO noted that: (1) overall, the series of federal quality initiatives
begun 2 years ago has produced a range of nursing home oversight
activities that need continued federal and state commitment to reach
their full potential; (2) certain of the federal initiatives seek to
strengthen the rigor with which states conduct their required annual
surveys of nursing homes; (3) others focus on the timeliness and
reporting of complaint investigations and the use of management
information to guide federal and state oversight efforts; (4) the states
are in a period of transition with regard to the implementation of these
initiatives, partly because the Health Care Financing Administration
(HCFA) is phasing them in and partly because states did not begin their
efforts from a common starting point; (5) HCFA's efforts toward
improving the oversight of states' quality assurance activities have
begun but are unfinished or need refinement; (6) the results from
states' recent standard surveys provide a picture of federal and state
efforts in progress; (7) on average, a slightly higher proportion of
homes were cited nationwide for actual harm and immediate jeopardy
deficiencies on their most recent survey than were cited during the
previous survey cycle; (8) while it was expected that more deficiencies
would be identified owing to the increased rigor in nursing home
inspections, the survey results could also suggest that nursing homes
may not have made sufficient strides to measurably improve residents'
quality of care; (9) the results also show a wide variation across
states in the proportion of homes with identified serious care
deficiencies; (10) while these proportions are expected to vary somewhat
from one state to another, the wide range may reflect the extent to
which the inspection of homes is inconsistent across states; and (11) in
GAO's view, the full potential of the nursing home initiatives to
improve quality will more likely be realized if greater uniformity in
the oversight process can be achieved.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-00-209
     TITLE:  Nursing Homes: Success of Quality Initiatives Requires
	     Sustained Federal and State Commitment
      DATE:  09/28/2000
   SUBJECT:  Nursing homes
	     Federal/state relations
	     Elder care
	     Patient care services
	     Surveys
	     Safety standards
IDENTIFIER:  Medicare Program
	     Medicaid Program
	     HCFA Online Survey, Certification, and Reporting System
	     California
	     Maryland
	     Michigan
	     Missouri
	     Tennessee
	     Washington

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GAO/T-HEHS-00-209

   * For Release on Delivery
     Expected at 8:30 a.m.

Thursday, September 28, 2000

GAO/T-HEHS-00-209

Nursing Homes

Success of Quality Initiatives Requires Sustained Federal and State
Commitment

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Statement of William J. Scanlon, Director

Health Financing and Public Health Issues

Health, Education, and Human Services Division

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[0x08 graphic]

Testimony

Before the Special Committee on Aging, United States Senate

United States General Accounting Office

GAO

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Nursing Homes: Success of Quality Initiatives Requires Sustained Federal and
State Commitment

Mr. Chairman and Members of the Committee:

I am pleased to be here today as you discuss quality of care in the nation's
17,000 nursing homes for their 1.6 million residents. The federal government
has a major stake in ensuring nursing home care quality and will have paid
homes an estimated $39 billion in fiscal year 2000. Over 2 years ago, this
Committee held a hearing to discuss nursing home care in California.
Troubled by our findings of poor care in the state's homes and weak
oversight by the Health Care Financing Administration (HCFA) and the state
oversight agency, the Committee held additional hearings on nursing home
care and oversight nationwide. These hearings prompted the Administration to
announce a series of nursing home quality initiatives and the states to
initiate greater oversight activity. In our reports and testimony since July
1998, we identified the following key weaknesses:

   * State surveyorsthe professional staff in state agencies who inspect
     nursing homesunderstated the extent of serious care problems, which are
     those technically classified as causing actual harm to residents and
     those placing residents' health, safety, or lives in immediate
     jeopardy. The understatement problem reflected procedural weaknesses in
     the states' performance of surveys, or inspections, of the homes and
     the predictable timing of these surveys.
   * Complaints by residents, family members, or facility staff alleging
     harm to residents remained uninvestigated for weeks or months.
   * When serious deficiencies were identified, federal and state
     enforcement policies did not ensure that the deficiencies were
     addressed and remained corrected.
   * Federal mechanisms for overseeing state monitoring of nursing home
     quality were limited in their scope and effectiveness.

In providing you information today on the status of federal and state
efforts to ensure improvements in nursing home quality since the
identification of these weaknesses and introduction of the quality
initiatives, my remarks will focus on (1) progress in improving the
detection of quality problems during annual surveys, (2) how the prevalence
of identified problems has changed, (3) the status of efforts to strengthen
states' complaint investigation processes and federal enforcement policies,
and (4) additional activities occurring at the federal level to improve
oversight of states' quality assurance activities. These remarks are based
on a report we are issuing today that addresses these issues in more detail.

Overall, the series of federal quality initiatives begun 2 years ago has
produced a range of nursing home oversight activities that need continued
federal and state commitment to reach their full potential. Certain of the
federal initiatives seek to strengthen the rigor with which states conduct
their required annual surveys of nursing homes. Others focus on the
timeliness and reporting of complaint investigations and the use of
management information to guide federal and state oversight efforts. The
states are in a period of transition with regard to the implementation of
these initiatives, partly because HCFA is phasing them in and partly because
states did not begin their efforts from a common starting point. HCFA's
efforts toward improving the oversight of states' quality assurance
activities have begun but are unfinished or need refinement.

The results from states' recent standard surveys provide a picture of
federal and state efforts in progress. On average, a slightly higher
proportion of homes were cited nationwide for actual harm and immediate
jeopardy deficiencies on their most recent survey than were cited during the
previous survey cycle. While it was expected that more deficiencies would be
identified owing to the increased rigor in nursing home inspections, the
survey results could also suggest that nursing homes may not have made
sufficient strides to measurably improve residents' quality of care. The
results also show a wide variation across states in the proportion of homes
with identified serious care deficiencies. While these proportions are
expected to vary somewhat from one state to another, the wide range may
reflect the extent to which the inspection of homes is inconsistent across
states. In our view, the full potential of the nursing home initiatives to
improve quality will more likely be realized if greater uniformity in the
oversight process can be achieved.

Background

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Oversight of nursing homes is a shared federal and state responsibility. On
the basis of statutory requirements, HCFA defines standards that nursing
homes must meet to participate in the Medicare and Medicaid programs and
contracts with states to certify that homes meet these standards through
annual inspections and complaint investigations. The annual inspection,
called a survey, which must be conducted on average every 12 months and no
less than every 15 months at each home, entails a team of state surveyors
spending several days in the home to determine whether care and services
meet the assessed needs of the residents. HCFA establishes specific
protocols, or investigative procedures, for state surveyors to use in
conducting these comprehensive surveys. In contrast, complaint
investigations, also conducted by state surveyors within certain federal
guidelines and time frames, typically target a single area in response to a
complaint filed against a home by a resident, the resident's family or
friends, or nursing home employees. Quality-of-care problems identified
during either standard surveys or complaint investigations are classified in
1 of 12 categories according to their scope (the number of residents
potentially or actually affected) and their severity (potential for or
occurrence of harm to residents).

Ensuring that documented deficiencies are corrected is likewise a shared
responsibility. HCFA is responsible for enforcement actions involving homes
with Medicare certificationabout 86 percent of all homes. States are
responsible for enforcing standards in homes with Medicaid-only
certificationabout 14 percent of the total. Enforcement actions can involve,
among other things, requiring corrective action plans, monetary fines,
denying the home Medicare and Medicaid payments until corrections are in
place, and, ultimately, terminating the home from participation in these
programs. Sanctions are imposed by HCFA on the basis of state referrals.
States may also use their state licensure authority to impose state
sanctions.

HCFA is also responsible for overseeing each state survey agency's
performance in ensuring quality of care in its nursing homes. One of its
primary oversight tools is the federal monitoring survey, which is required
annually for at least 5 percent of the nation's Medicare- and
Medicaid-certified nursing homes. HCFA also maintains a central databasethe
On-Line Survey, Certification, and Reporting (OSCAR) Systemthat compiles,
among other information, the results of every state survey conducted on
Medicare- and Medicaid-certified facilities nationwide.

Improvements Made in Annual Survey Methods

Federal initiatives were introduced to strengthen the rigor with which
states conduct required annual surveys of nursing homes. The states we
visited have begun to use the new methods introduced by the initiatives to
spot serious (actual harm and immediate jeopardy) deficiencies when
conducting surveys, but HCFA is still developing important additional steps,
some of which will not be introduced until 2002 or 2003. HCFA and the states
have also attempted to address problems with the predictable timing of the
surveys, but improvements made have been modest at best.

Improvements Made in Standard Survey Methodology

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In our prior work, we found that surveyors often missed significant care
problemssuch as pressure sores, malnutrition, and dehydrationbecause the
methods they used to select a sample of a home's residents for review lacked
sufficient rigor. To select the sample, surveyors rely on information from
prior surveys, a facility-prepared census of residents grouped by medical
condition, and observations of residents made during an initial tour of the
home. Certain HCFA initiatives effective July 1999 were intended to
introduce greater objectivity in the sample selection process. Under these
initiatives, state survey agencies are instructed to use quality indicators
to guide their decisions on where to focus their investigative efforts.
Quality indicators are essentially numeric warning signs that flag the
prevalence of care problems, such as greater-than-expected instances of
weight loss, dehydration, or pressure sores. These outcome measures enable
surveyors to rank the facility against other nursing homes in the state and
the nation on 24 care dimensions. In selecting a sample of residents for
review, surveyors use information developed from the quality indicators,
which they later supplement with personal observations.

In conjunction with the use of quality indicators, HCFA also instructed
surveyors to begin using a new set of investigative protocols, or procedural
instructions, intended to make the facility inspections more thorough and
more uniform, thus reducing the variation in the conduct of surveys within
and across states. However, HCFA's new guidance on the use of quality
indicators and protocols does not address all of the identified weaknesses
in the survey methodology. HCFA needs to ensure the reliability of the data
on which the quality indicators are based, because the data are
self-reported by the nursing homes and are not independently verified. Also,
in our view, the size of the sample of resident cases reviewed may not be
sufficient to establish the prevalence of certain identified problems. HCFA
plans to introduce additional survey methodology guidance in 2002 or 2003.

Efforts to Reduce Predictability in the Timing of Standard Surveys Have Been
Modest

[0x08 graphic]
Surveyors can also miss care problems during the standard surveys when the
timing of these visits is predictable, allowing facilities time to present
themselves at inspection in ways that do not represent the home's normal
routines or care practices. To address the predictability problem, HCFA
required states to start at least 10 percent of standard surveys outside
normal workday hourseither early morning, evening, or on weekendsbeginning
January 1, 1999. HCFA also instructed the states to avoid, if possible,
scheduling a home's survey for the same month as the one in which the home's
previous standard survey was conducted.

HCFA's tracking of states' progress in implementing the off-hour survey
requirement has not been timely. Although the agency instructed states to
begin the off-hour initiative in January 1999, it did not modify its
national OSCAR database to enable identifying such surveys until 8 months
later, in August 1999, and did not instruct the states to enter the data on
such surveys until February 2000. It was another 6 months, in August 2000,
before HCFA began contacting those states that fell short of meeting the
10-percent requirement to elicit improved performance.

Our analysis of successive standard surveys shows that many homes in the six
states we reviewed continued to have their annual inspection within a short
time from the anniversary of their previous inspection or at the end of the
maximum allowed 15-month period between consecutive surveys. Both
circumstances allow a home to anticipate when their survey will occur. (See
table 1.)

Table 1: Predictability of Surveys
                       Percentage      Percentage    Percentage    Total
                       surveyed        surveyed      surveyed      percentage
            Number     within 15       14-15         15-16         of
 State      of         days of         months        months
            homes      anniversary     after         after         surveys
                       of previous     previous      previous      considered
                       survey          survey        survey        predictable
 California 1,301      8.0             31.4          15.0          54.4
 Maryland   243        4.9             14.8          9.0           28.7
 Michigan   434        14.0            14.3          9.9           38.2
 Missouri   476        11.1            13.9          8.8           33.8
 Tennessee  351        56.1            0             0             56.1
 Washington 278        15.1            17.6          1.0          33.7

Note: Data were extracted from OSCAR in August 2000. Homes not showing a
prior survey date were not included in this analysis.

Over half the surveys in Tennessee were conducted within 15 days of the
anniversary of the previous standard survey. In California and Maryland,
where a large share of the surveys occurred late in the 15-month cycle,
officials explained that an increased emphasis on conducting complaint
investigations more promptly drew on the same surveyor staff who perform the
annual surveys, which resulted in postponing many of the surveys until as
late as possible.

In our view, the off-hour scheduling of surveys is too limited a step to
effectively restrict homes' opportunities to prepare for their annual
inspection. As we recommended in our July 1998 report, the predictability
problem could be mitigated by segmenting the surveys into more than one
visit. Currently, surveys are comprehensive reviews that can last several
days and entail examining not only a home's compliance with resident care
standards but also with administrative and housekeeping standards. Dividing
the survey into segments performed over several visits, particularly for
those homes with a history of serious deficiencies, would increase the
presence of surveyors in these homes and provide an opportunity for
surveyors to initiate broader reviews when warranted. With a segmented set
of inspections, homes would not be able to relax their efforts to provide
quality care because they could no longer rely on the likelihood of the next
surveyor's visit being 12 to 15 months away.

Increase in Identified Deficiencies Difficult to Interpret

In reviewing the identification of actual harm and immediate jeopardy
deficiencies, we conducted an analysis of homes cited for these deficiencies
in the periods before and after the introduction of the quality initiatives.
We found the following:

   * Overall, the proportion of homes with documented actual harm and
     immediate jeopardy deficiencies increased marginally, although some
     states experienced a decrease in the number of homes with these
     deficiencies.
   * The variation across states in the share of homes cited for actual harm
     and immediate jeopardy deficiencies after the introduction of the
     initiatives remained wideranging from under 11 percent of homes in
     Maine to 58 percent of homes in Washingtonbut narrowed slightly from
     the period before the initiatives.

These results suggest that states may have become more rigorous in their
identification and classification of serious deficiencies. The results could
also indicate that, nationwide, the volume of such deficiencies may have
increased slightly, which may be attributable in part to reported facility
staff shortages during this time period. With regard to the variation in the
shares of homes cited for serious deficiencies, the expectation is that, as
the performance of standard surveys becomes more consistent across states,
differences in results will shrink. (See table 2.)

Table 2: Percentage of Homes With Actual Harm and Immediate Jeopardy
Deficiencies Before and After Implementation of the Quality Initiatives
                              Percentage of homes with actual
                              harm and immediate jeopardy
                              deficiencies
               Number of
               homes surveyed Before          After           Percentage
 Statea        b              initiatives     initiatives     point
                                                              difference
               (1/99 to 7/00) (1/97 to 7/98)  (1/99 to 7/00)
 Increase of 5 percentage points or greater
 Arizona       125b           17.2            36.8            19.6
 Arkansas      253 b          14.7            30.8            16.1
 New York      606            13.3            27.6            14.3
 Tennessee     353            11.1            24.1            13.0
 North
 Carolina      409            31.0            42.1            11.1
 New Jersey    336 b          13.0            23.8            10.8
 Oregon        157            43.9            53.5            9.6
 Massachusetts 541            24.0            32.9            8.9
 West Virginia 144            12.3            20.1            7.8
 Indiana       581            40.5            48.2            7.7
 Louisiana     365 b          12.7            20.3            7.6
 Georgia       364            17.8            25.0            7.2
 Mississippi   196 b          24.8            31.6            6.8
 Oklahoma      394 b          8.4             15.0            6.6
 Colorado      229            11.1            16.6            5.5
 Maryland      188 b          19.0            24.5            5.5
 Missouric     565            21.0            25.7            4.7
 Change of less than 5 percentage points
 Maine         124            7.4             10.5            3.1
 Minnesota     437            29.6            32.5            2.9
 Texas         1313           22.2            24.9            2.7
 Michigan      442            43.7            45.9            2.2
 Nation        16,854         27.7            29.5            1.8
 Pennsylvania  774            29.3            30.7            1.4
 Illinois      891            29.8            31.1            1.3
 South
 Carolina      176            28.6            29.5            0.9
 Connecticut   260            52.9            53.5            0.6
 Montana       105            38.7            39.0            0.3
 California    1,301 b        28.2            28.2            0.0
 Wisconsin     424            17.1            14.6            -2.5
 Ohio          995            31.2            28.6            -2.6
 Kentucky      306            28.6            25.2            -3.4
 Decrease of 5 percentage points or greater
 Virginia      282            24.7            19.5            -5.2
 Washington    281            63.2            57.7            -5.5
 Nebraska      241            32.3            26.6            -5.7
 Alabama       225            51.1            41.3            -9.8
 Kansas        404 b          47.0            36.9            -10.1
 South Dakota  112 b          40.3            29.5            -10.8
 Florida       746            36.3            21.7            -14.6
 Iowa          428 b          39.2            22.7            -16.5

aTwelve states and the District of Columbia were excluded from this analysis
because they had fewer than 100 homes surveyed since January 1999.

b The number of homes cited in this state for the 1999-2000 period differed
by 10 percent or more from the number documented for the prior period. In
part, these differences are explained by the fact that some states have
still not recorded the results of a home's most recent survey in OSCAR.

cAlthough our work in Missouri focused on the agency that is responsible for
surveying nonhospital-based nursing homes, the state's number of homes shown
in this table also includes hospital-based facilities.

In July 2000, HCFA released a report indicating a direct relationship
between low nursing home staffing levels and poor quality of care. While
recruiting and retaining staff have been long-standing concerns, state
officials and nursing home surveyors we interviewed recently believe the
problem has become acute and has directly affected the quality of care
provided to nursing home residents. Reasons cited for the growing staffing
problems include a highly competitive job market resulting from a robust
economy combined with lower wages and benefits for nurse's aides compared
with other health and non-health sector opportunities, and increased demand
for staff from alternatives to nursing homes, such as assisted living
facilities. We identified 16 states that have increased their Medicaid
payments to supplement nursing home staff wages and benefits by a specific
amount.

Complaint And Enforcement Processes Are Improving, but More Time and
Refinement Needed to Reach Goals

The states we contacted have also made strides in addressing complaint
investigations, but not enough time has elapsed to fully implement or
evaluate the success of these efforts. For example, the states in our review
were not yet investigating within 10 days all complaints that allege actual
harm to a resident, as HCFA's complaint investigation initiative now
requires, but they have efforts under way to reach that goal. Similarly,
HCFA has begun applying stronger enforcement policies to ensure that homes
comply with federal standards, but it is too early in their implementation
to determine whether these policies have been effective.

The states we contacted generally attributed their inability to meet the
10-day investigative time frame for serious allegations to an increase in
the number of complaints received, limited staffing levels, and competing
priorities, particularly the need to complete standard surveys within the
required cycle. Nevertheless, the increased attention HCFA and the states
have placed on conducting complaint investigations in the past 18 months has
resulted in some improvements. For example, among the states in our review,
we noted the following:

   * Increased survey resources. Several states have increased, or plan to
     increase, the number of surveyors, some of whom will be assigned
     specifically to conduct complaints investigations. Michigan created a
     complaints investigation team of 11 surveyors, representing about 10
     percent of the state's total surveyor staff. Washington plans to
     increase its number of complaints investigators from 8 to 13.
   * Improvements in classifying complaints. All the states in our study
     require the seriousness of complaints to be determined by an
     experienced surveyor; Tennessee and Washington further require that the
     surveyor be a licensed nurse. In Missouri, individuals without survey
     experience had been responsible for classifying complaints, but now an
     experienced district office surveyor, normally a nurse, does so.
     Nevertheless, the proper classification of complaints remains an
     important issue. For example, Michigan's small number of complaints
     alleging actual harm17 of 902 complaints (2 percent) in the last half
     of 1999raises questions about whether the complaints were appropriately
     classified. For the same time period, Maryland put 62 percent of its
     complaints in the actual harm category.
   * Organizational changes. To improve control and oversight of complaints,
     both Maryland and Michigan have consolidated their nursing home
     complaint and survey activities into one office under a single manager.
     Michigan also added a manager responsible for direct oversight of the
     complaint investigation team. Missouri created a state complaint
     coordinator to ensure that complaints are handled in a timely manner.
   * Upgrade of information systems. Several states are automating their
     information systems to track complaints more effectively. The use of
     these data systems enables oversight officials to ensure that states
     are complying with HCFA guidance on setting complaint investigation
     priorities and meeting prescribed investigation time frames. For
     example, Missouri plans to implement a new automated system in 2001
     that should significantly improve management's ability to track the
     status and results of complaint investigations. Tennessee also is
     implementing a new system that will replace the manual tracking of
     complaints. Washington has modified its complaint tracking system to
     facilitate its use by the state agency's district offices.

HCFA intends to issue more detailed guidance to the states in 2001 as part
of its complaint process improvement project. Among other things, the
project will identify best practices for complaint investigations.

The Congress and the Administration recognized that additional resources
were needed to address expanded workloads associated with implementing the
nursing home quality initiatives. As a result, the Medicare survey and
certification budget was increased in fiscal years 1999 and 2000, of which
$8 million and $23.5 million, respectively, reflected funding for the
nursing home initiatives. According to states' expenditure reports on the
fiscal year 1999 allocation, much of the $8 million appears to have gone
unspent. However, a precise accounting of these funds is not available. On
the one hand, discrepancies between the initiatives expenditure reports and
the separate reports that capture all survey and certification expenditures
(including the initiatives) raise the possibility that some states may have
spent their initiatives funding but failed to account separately for
initiatives expenditures as required by HCFA. On the other hand, the two
sets of reports indicate that 28 states did not use their full fiscal year
1999 initiatives or survey and certification funding allocations, suggesting
that a substantial portion of the $8 million was not used for the nursing
home initiatives in fiscal year 1999. States have not yet submitted final
expenditure reports regarding the fiscal year 2000 initiative allocations.

HCFA has also strengthened the enforcement options available to impose
sanctions on nursing homes that are cited for actual harm and immediate
jeopardy violations. In September 1998, HCFA modified its policy to require
that states refer for immediate sanctions any nursing home with a pattern of
harming a significant number of residents on successive surveys. Effective
December 15, 1999, HCFA expanded this policy to include deficiencies that
harmed only one or a small number of residents on successive surveys. In an
earlier report, we estimated that this change could increase the percentage
of homes referred immediately for sanctions from approximately 1 percent to
as many as 15 percent of homes nationally. Early indications from some
states are that their referrals of homes to HCFA for sanctions are on the
rise.

Additional funds were also provided in fiscal years 1999 and 2000 to hire
more federal staff to reduce the large number of pending appeals by nursing
homes and collect assessed fines faster. The expectation is that the more
expeditious resolution of appeals will heighten the deterrent effect of
civil fines. It is too early to assess the effect of the additional funding
on the number of pending appeals because the new staff were only hired
within the past year and other changes in enforcement policy are expected to
increase the volume of nursing home appeals.

To improve nursing home oversight at the federal level, HCFA has begun
making changes, largely in how its regional offices and central office
interact, in information management capabilities, and in nursing home
oversight funding.

HCFA has made organizational changes to address past consistency and
coordination problems among its central office and 10 regional offices. In
our earlier work, we raised concerns about the diffusion of accountability
among HCFA's central and regional office components responsible for
monitoring states' survey agencies. The absence of clear and connected
organizational lines of authority weakened regional office oversight of the
state agencies and blurred accountability when problems arose. Regional
offices and state surveyors could not be assured of providing or receiving
consistent information on nursing home oversight policies and practices.

Improvements in Federal Oversight of Nursing Home Quality Are Under Way or
Planned

To address the problems of coordination and accountability, HCFA has made or
is in the process of making organizational changes. For example, in May 2000
it established a policy oversight board covering nursing home survey and
certification issues. The board's composition, which includes both regional
office and central office representatives, is intended to improve
communication and coordination among senior HCFA managers responsible for
nursing home oversight. HCFA has also designated two officials, one from the
central and one from a regional office, to direct the daily management of
nursing home oversight activities. The intention is to provide a national
perspective on oversight activities and help ensure consistency across
regions. In June 2000, the agency established a clearinghouse, with
representatives from HCFA's central office, regional offices, and state
survey agencies, to ensure that regional office directives to states are
consistent with national policy.

HCFA also intends to intensify its use of management information to verify
and assess states' oversight activities and view more closely the
performance of the homes themselves. For one thing, it plans to make the
federal OSCAR database more user-friendly. Although OSCAR provides extensive
information about state surveyssuch as the timing of surveys, the
deficiencies cited, and the time spent conducting various survey
activitiescomputer programming knowledge is typically needed to conduct data
analysis. Unless the data are analyzed, regulators will not have a complete
picture of an individual facility's performance record, of the facility's
performance relative to others in the state, and of state and regional
oversight performance relative to their counterparts nationwide. Refinements
will allow users to access such information with much greater ease and are
expected to be completed by the summer of 2001.

In another effort to enhance the use of management information, HCFA
recently directed the regional offices to prepare and submit periodically 18
tracking reports on areas that measure both state and regional office
performance. Examples include weekly reports on nursing home terminations,
monthly reports on surveys for special focus facilities, quarterly reports
on meeting OSCAR data entry deadlines, semiannual tallies of state surveys
that find homes deficiency-free, and annual analyses of the most frequently
cited deficiencies by states. HCFA will begin using these reports effective
October 2000. In standard format, the reports will enable regions to make
comparisons within and across states. This information should help surface
problems and identify the need for intervention, either on the part of the
HCFA regional or central office.

The value of these data, which were previously available but not
systematically reviewed, is illustrated by the case of Missouri's
deficiency-free homes in the 1999-2000 survey cycle that we reviewed. Had
HCFA oversight officials cross-checked Missouri's survey results with the
homes' history of complaint allegations, it would have found that the
state's 84 supposedly deficiency-free homes had received 605 complaints. One
of these homes had 39 complaints and 19 homes had 10 or more complaints.
Significant numbers of these complaints were substantiated when
investigated.

HCFA's efforts remain weak in one area that is rich in the potential to
provide useful informationfederal monitoring surveys. HCFA conducts two
types of federal monitoring surveys to assess how well states are performing
their standard annual inspections. One type is called a comparative survey,
in which a team of federal surveyors conducts a complete survey of a nursing
homesubsequent to and independent of the state's standard survey of that
homeand compares the results of the two surveys. The other type is called an
observational survey, in which generally one or two federal surveyors
accompany state surveyors to a nursing home either as part of the home's
annual standard survey, as part of a follow-up visit to a home found to be
out of compliance with federal standards, or as part of a complaint
investigation. In an observational survey, federal surveyors watch state
surveyors perform a variety of tasks, discuss their observations with the
state surveyors under review, and later provide a written performance rating
to the surveyors' supervisors.

Last November, we reported that the observational surveys, which HCFA relied
on most of the time, were of limited value in evaluating the adequacy of the
state survey process because they may have caused state surveyors to perform
their tasks more attentively than they would have if the federal observers
had not been present. At the same time, HCFA's use of comparative surveys
was negligible, despite their merit in providing a more objective measure of
state surveyors' performance. Between October 1998 and May 2000, 70 percent
of the 157 federally conducted comparative surveys found more serious care
problems than did the state surveys of the same facilities. In our November
1999 report, we recommended that HCFA increase the proportion of federal
monitoring surveys conducted as comparative surveys. In response, HCFA is
considering either increase the number of federal surveyors available to
conduct comparative surveys or narrowing their scope to allow more such
surveys to be done.

HCFA is also planning to change its process of allocating funding for survey
and certification activities to the states. Under the current budget
process, funding requests and state funding allocations are based on states'
historical activity levels and costs. Such a process rewards states that
spent substantial amounts in the past and holds down funding for those that
historically spent little on these activities. HCFA's fiscal year 2001
annual performance plan, as required under the Government Performance and
Results Act of 1993, establishes a performance goal of moving from the
current budget process to a need-based process. HCFA proposes developing
national standard survey measures and costs that would be used to price the
workload for each state survey agency.

Conclusions

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Over the past 2 years, the considerable attention focused on nursing home
quality of care has resulted in heightened awareness and responses at many
levelsthe federal government, the states, and the nursing home industry.
Many of the resulting new policies and practices have only recently been
instituted and will need time to take hold. For example, better detection
and classification of serious deficiencies through the standard survey
process will require further methodological developments aimed at improving
the selection of resident cases for review. New efforts will be required to
reduce the opportunities for homes to predict the timing of and prepare for
these inspections. States' efforts to expedite complaint investigations and
systematize the reporting of investigation results are at various stages of
completion. More time must elapse to know whether strengthened federal
enforcement policies in fact create the incentives and environment that
discourage poor care and ensure permanent corrections. Similarly, with
respect to improved federal oversight, the effectiveness of recent internal
HCFA reorganizations and management information reporting enhancements can
only be judged in the months to come.

Vigilance by both state and federal officials must be unrelenting to ensure
the safety and well-being of the nation's nursing home residents. The
performance of oversight can neither be taken for granted nor relaxed, which
means that neither HCFA nor the states can afford to lose their current
momentum. The Congress, too, can play an important role in keeping the
spotlight on oversight agencies and the nursing home industry to achieve
quality improvements. We will continue to assist this Committee and the
Congress as needed to assess progress on these issues.

Mr. Chairman and Members of the Committee, this concludes my prepared
statement. I will be happy to answer any questions you may have.

GAO Contacts and Acknowledgments

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For future contacts regarding this testimony, please call Kathryn G. Allen
at (202) 512-7118 or Walter Ochinko at (202) 512-7157. Connie Peebles
Barrow, Jack Brennan, Hannah Fein, Robert Lappi, Peter Oswald, Peter
Schmidt, Don Walthall, and Opal Winebrenner also made contributions to this
statement.

Related GAO Products

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the
Quality Initiatives (GAO/HEHS-00-197, Sept. 28, 2000).

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better
Ensure Quality (GAO/HEHS-00-6, Nov. 4, 1999).

Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies to
Better Ensure Quality Care (GAO/T-HEHS-00-27, Nov. 4, 1999).

Nursing Home Oversight: Industry Examples Do Not Demonstrate That Regulatory
Actions Were Unreasonable (GAO/HEHS-99-154R, Aug. 13, 1999).

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but Will
Require Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999).

Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes Has
Merit (GAO/HEHS-99-157, June 30, 1999).

Nursing Homes: Complaint Investigation Processes in Maryland
(GAO/T-HEHS-99-146, June 15, 1999).

Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect
Residents (GAO/HEHS-99-80, Mar. 22, 1999).

Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better
Ensure Adequate Care (GAO/T-HEHS-99-89, Mar. 22, 1999).

Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal
Quality Standards (GAO/HEHS-99-46, Mar. 18, 1999).

California Nursing Homes: Care Problems Persist Despite Federal and State
Oversight (GAO/HEHS-98-202, July 27, 1998).

California Nursing Homes: Federal and State Oversight Inadequate to Protect
Residents in Homes With Serious Care Violations (GAO/T-HEHS-98-219, July 28,
1998).

(201108)

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Orders by Internet

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Contact one:

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1-800-424-5454 (automated answering system)

California Nursing Homes: Care Problems Persist Despite Federal and State
Oversight (GAO/HEHS-98-202, July 27, 1998).

Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the
Quality Initiatives (GAO/HEHS-00-197).

In addition to visiting California, Missouri, Washington, and Tennessee, we
contacted officials in Maryland and Michigan, two states in which we had
conducted reviews previously

Until recently, Tennessee law limited the annual inspection time frame to 12
months. In May 2000, Tennessee modified this law to permit nursing homes to
be surveyed at a maximum interval of 15 months.

See Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes ,Vols.
I-III (Baltimore, Md.: HCFA, Summer 2000).

A 1996 Institute of Medicine study documented similar reasons for turnover
and retention problems among nurses aides. Institute of Medicine, Nursing
Staff in Hospitals and Nursing Homes: Is it Adequate? (Washington, D.C.:
National Academy Press, 1996).

Wage pass-throughs provide a specific amount or percentage increase in
reimbursement, earmarked typically for the salaries, benefits, or both of
direct care staffsuch as nurses and nurse's aides. States that have enacted
wage pass-throughs include Arkansas, California, Connecticut, Florida,
Kansas, Maine, Michigan, Minnesota, Montana, Oklahoma, South Carolina,
Texas, Utah, Vermont, Virginia, and Wisconsin. Four other statesLouisiana,
Maryland, Massachusetts, and Missourionly recently passed legislation and
have not yet implemented their wage pass-through programs.

HCFA determined that additional state resources would be consumed by
initiatives requiring states to better target and monitor poorly performing
homes and to investigate any complaint alleging actual harm within 10 days
of complaint receipt. HCFA also anticipated that the use of quality
indicators would increase surveyor preparation time before visiting a
nursing home and that this could lead to a net increase in total survey
time.

Nursing Homes: HCFA Initiatives to Improve Care Are Under Way But Will
Require Continued Commitment (GAO/T-HEHS-99-155, June 30, 1999), p. 12.

Nursing Home Care: Enhanced HCFA Oversight of State Programs Would Better
Ensure Quality (GAO/HEHS-00-6, Nov. 4, 1999).
*** End of document. ***