Nursing Homes: Complaint Investigation Processes in Maryland (Testimony,
06/15/1999, GAO/T-HEHS-99-146).
In a March report, GAO cited nursing home problems in 14 states,
including Maryland. These deficiencies ranged from procedures that may
limit the filing of complaints to failures to investigate serious
complaints promptly. Compared with other states, Maryland devoted fewer
resources to investigating complaints, recorded substantially fewer
complaints than Michigan or Washington, generally classified similar
complaints as needing less prompt investigation, did not meet the
assigned time periods for investigating many complaints, and had a large
backlog of uninvestigated cases and poor tracking of the status of
investigations. Consequently, serious complaints alleging that nursing
home residents are being harmed can remain uninvestigated for weeks or
months in Maryland. Such delays can prolong situations in which
residents may be subject to abuse or neglect resulting in serious care
problems like malnutrition and dehydration, preventable accidents, and
medication errors. In response to GAO's findings, the Health Care
Financing Administration has told states to investigate any complaint
alleging actual harm to a resident within 10 workdays. The Maryland
General Assembly recently approved funding to significantly increase the
number of nursing home surveyors. However, the seriousness and systemic
nature of the weaknesses GAO identified require sustained commitment and
strengthened oversight to help ensure adequate care to nursing home
residents.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: T-HEHS-99-146
TITLE: Nursing Homes: Complaint Investigation Processes in
Maryland
DATE: 06/15/1999
SUBJECT: Nursing homes
Comparative analysis
Elder care
Long-term care
Elderly persons
Negligence
Federal/state relations
Safety standards
State programs
Noncompliance
IDENTIFIER: Maryland
Medicare Program
Michigan
Washington
Medicaid Program
HCFA Online Survey, Certification, and Reporting System
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United States General Accounting Office GAO
Testimony Before the Committee on Environmental Matters, House of
Delegates, Maryland General Assembly For Release on Delivery
Expected at 1:00 p.m. NURSING HOMES Tuesday, June 15, 1999
Complaint Investigation Processes in Maryland Statement of Kathryn
G. Allen, Associate Director Health Financing and Public Health
Issues Health, Education, and Human Services Division GAO/T-HEHS-
99-146 Nursing Homes: Complaint Investigation Processes in
Maryland Mr. Chairman and Members of the Committee: We appreciate
your invitation to discuss our recent findings on the
effectiveness of federal and state nursing home complaint
investigation practices, with a specific focus on our work in
Maryland. The 1.6 million elderly and disabled residents living in
nursing homes nationwide- including 26,000 in Maryland-are among
the sickest and most vulnerable populations in the nation. They
are frequently dependent on extensive assistance in basic
activities of daily living like dressing, grooming, feeding, and
using the bathroom, and many require skilled nursing or
rehabilitative care. The quality of care in nursing homes is a
shared federal and state responsibility. The federal government,
which will pay nearly $39 billion for nursing home care in 1999,
has a major stake in ensuring that residents receive adequate
quality of care. On the basis of federal statutory requirements,
the Health Care Financing Administration (HCFA) defines standards
that nursing homes must meet to participate in the Medicare and
Medicaid programs, and it contracts with states to certify that
homes meet these standards through annual inspections and
complaint investigations. Complaint investigations are an integral
part of the federal-state process to protect nursing home
residents and to ensure that homes participating in Medicare and
Medicaid comply with federal standards. Our recent work on this
issue is one of several related projects on quality of care in
nursing homes that we have conducted or are currently conducting
at the request of the Senate Special Committee on Aging. In
related efforts,1 we have reported that * one-fourth of the more
than 17,000 nursing homes nationwide had serious deficiencies that
caused actual harm to residents or placed them at risk of death or
serious injury; * 40 percent of these had repeated serious
deficiencies; * the extent of serious care problems portrayed in
federal and state data is likely to be understated; and * even
when serious deficiencies are identified, federal and state
enforcement policies have not been effective in ensuring that the
deficiencies are corrected and remain corrected. 1California
Nursing Homes: Care Problems Persist Despite Federal and State
Oversight (GAO/HEHS-98-202, July 27, 1998); and Nursing Homes:
Additional Steps Needed to Strengthen Enforcement of Federal
Quality Standards (GAO/HEHS-99-46, Mar. 18, 1999). Page 1
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland Complaint investigations coupled with annual surveys,
and any follow-up visitsvisits targeted at problems found on
recent surveys-are tools regulators use to assess the quality of
care in a nursing home. Our work in Maryland focused on complaint
investigations and did not evaluate either standard surveys or
follow-up visits resulting from standard surveys. However, our
work in other states has shown that systemic weaknesses also exist
in many states' survey and enforcement practices. Even though they
represent only one component of a state's nursing home oversight,
complaint investigations provide a unique opportunity to visit a
home as it appears to the resident on a day-to-day basis.
Complaints provide important indicators of problems and are also
one of the only mechanisms other than legal or police action for
residents and family members to express concerns related to
quality of care. In this context, I would like to focus the
remainder of this statement on our findings on complaint
investigations, particularly in Maryland. In March, we reported on
the effectiveness of states' complaint processes in protecting
residents, based on our review of three states, including
Maryland, and state auditor reviews in 11 other states.2 We also
assessed HCFA's role in establishing standards and conducting
oversight of states' complaint practices and in using information
about the results of complaint investigations to ensure compliance
with nursing home standards. In brief, federal and states'
practices for investigating complaints about care provided in
nursing homes are often not effective. Among many of the 14 states
we examined, we found numerous problems, including procedures or
practices that * may limit the filing of complaints, * understate
the seriousness of complaints, and * fail to investigate serious
complaints promptly. In Maryland, we identified many of these and
other concerns regarding the responsiveness and effectiveness of
complaint investigations. Compared with other states we reviewed,
Maryland * dedicated fewer resources to investigating complaints,
2See Nursing Homes: Complaint Investigation Processes Often
Inadequate to Protect Residents (GAO/HEHS-99-80, Mar. 22, 1999).
We examined Maryland, Michigan, and Washington as well as 11 other
states reviewed by state auditors-Iowa, Kansas, Kentucky,
Louisiana, New York, North Carolina, Ohio, Pennsylvania,
Tennessee, Texas, and Wisconsin. Page 2
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland * recorded substantially fewer complaints than
Michigan or Washington, * generally classified similar complaints
as needing less prompt investigation, * did not meet the assigned
time frames for investigating many complaints, and * had a large
backlog of uninvestigated cases and poor tracking of the status of
investigations. As a consequence, serious complaints alleging that
nursing home residents are being harmed can remain uninvestigated
for weeks or months in Maryland. Such delays can prolong
situations in which residents may be subject to abuse or neglect
resulting in serious care problems like malnutrition and
dehydration, preventable accidents, and medication errors. Despite
problems such as those in Maryland, HCFA has minimal standards and
has exercised limited oversight related to states' complaint
practices. To address these issues, we recommended that HCFA
strengthen its standards for and oversight of states' complaint
practices as well as its management information systems to more
completely include complaint investigation results. In response to
our March report, both HCFA and the state of Maryland have
initiated several important improvements intended to increase the
responsiveness and effectiveness of complaint investigations. For
example, HCFA has instructed states to investigate any complaint
alleging actual harm to a resident within 10 workdays. In
Maryland, the recent budget approved by the General Assembly
includes funding for a significant increase in the number of
nursing home surveyors. Complaint Practices Although
investigations of complaints filed against nursing homes can
Provide Limited provide a valuable opportunity for
determining whether the health and safety of residents are
threatened, complaint investigation practices do not Protection to
consistently achieve this goal in many of the states we reviewed.
In Residents Maryland, several factors hindered the
effectiveness of complaint investigations: limited resources,
policies or practices that limited the filing of complaints and
understated their severity, slow response times, and poor tracking
of complaints. Consequently, we found substantiated complaints in
which residents had been in harmful situations for extended
periods, numerous complaints alleging serious care problems that
remained uninvestigated, and other cases in which the state was
unable to Page 3
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland determine whether the allegations were true, partly
because so much time had elapsed since the complaint was received.
Maryland Dedicated Fewer While we did not assess the
resource requirements for an effective state Resources to
Complaint complaint process, our work indicates that
Washington, which commits Investigations Than Other more
resources to its complaint process than Maryland or Michigan, has
a States more responsive complaint
system. Compared with the other two states we reviewed, Washington
received a much higher volume of complaints, conducted more
complaint investigations per home, prioritized most complaints
within its two highest categories, and was more timely in
conducting investigations. But to do this, Washington spent nearly
2 times the national average on complaint investigations per
certified home in fiscal year 1998. In contrast, Maryland spent
about one-fourth the national average and Michigan spent about 80
percent of the national average in fiscal year 1998. (See table
1.) In commenting on our report, Maryland and Michigan officials
highlighted resource constraints as contributing to their problems
with complaint investigations. Table 1: Complaint Investigation
Expenditures, FY 1998
Maryland Michigan Washington U.S. total
Percentage of total survey and certification expenditures
8 16 30 20 Average
expenditures per home $885
$2,694 $7,592 $3,397 Some Practices May Limit
Some states have practices that may limit the number of complaints
that the Filing of Complaints or are filed and
investigated. For example, Maryland's policy is to accept and
Quick Responses to act on a complaint submitted
by telephone even though callers are Complaints
encouraged to submit a written complaint. However, state officials
gave us conflicting information as to whether calls would be
consistently documented and investigated when callers agreed to
submit a written complaint but did not do so. Over 70 percent of
Maryland's publicly reported complaints that the state
investigated were identified as written complaints between July
1997 and June 1998.3 In contrast, Washington readily accepted and
acted on telephone complaints without encouraging a written
follow-up, and nearly all its complaints were received by
telephone. This practice appears to contribute to the much higher
volume of complaints in Washington compared with Maryland. (See
table 2.) 3The percentage is based on the total number of
complaints in which information was available about whether the
complaint was in writing or by telephone. Page 4
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland Table 2: Complaints Received, July 1997-June 1998
Maryland Michigan Washington No. of complaints
642 2,243 8,748 No. of complaints per 1,000
nursing home beds 21 45
336 Maryland, Michigan, and Washington each have a toll-free "800"
telephone number that they make available for residents and
families, the concerned public, and nursing homes to report
complaints. For example, nursing homes in Maryland display a sign
with the 800 number. However, our calls to 800 numbers indicated
that some states are less consumer-friendly than others. As
recently as June 11, 1999, the message on the Maryland 800 number
indicated that it is for complaints regarding home health, with no
mention of nursing homes. Also, Maryland's 800 number is not
accessible by out-of-state family or friends who may have concerns
about a resident's care. In addition, the direct (non-800)
telephone number that Maryland publicizes rang unanswered and did
not provide a message when we called it during nonbusiness hours.
In contrast, Washington's 800 number is accessible both in and out
of state, clearly states that it is for complaints regarding
nursing homes and other settings, provides clear automated menu
options allowing consumers to record their initial complaints, and
promises to call the complainant back during business hours to
confirm receipt of the complaint. The differences in the ease for
consumers to file complaints among the states we examined may
contribute to the large differences in the volume of complaints
received. Low Priority Levels Often We found that some
states classify few complaints at high-priority levels Assigned to
Serious that would require an immediate or
prompt investigation. In the 1-year Complaints
period from July 1997 through June 1998, Maryland did not classify
any complaints as having the potential to immediately jeopardize
residents and thereby, according to federal policy, require a
visit by an investigator within 2 workdays. In contrast, Michigan
categorized about 2 percent and Washington about 8 percent of
investigated complaints as requiring an investigation within 2
workdays. (See table 3.) Page 5
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland Table 3: State-Investigated Complaints Considered
Potential Immediate
Maryland Michigan Washington Jeopardy,
July 1997-June 1998 No. of complaints classified as
immediate jeopardy 0
24 223 No. of immediate jeopardy complaints per
1,000 nursing home beds
0 0.5 8.6 Immediate jeopardy
complaints as a percentage of total complaints investigated
0 2 8 Some states also
categorized relatively few complaints in other high-priority
categories, such as those to be investigated within 10 days. For
example, Maryland most frequently placed complaints in its lowest-
priority categoryto be investigated at the next on-site survey.
This contrasts with Washington, which categorized nearly 90
percent of its complaints to be investigated within 10 workdays.
Table 4 compares the three states' relative prioritization of
complaints. Table 4: Percentage of State-Investigated Complaints
by Priority time frame Maryland
Michigana Washington Priority Category, July 1997-
June 1998 Within 2 workdays
0 2 8 Within 10 workdays
22 N/A 81 Within 45
workdays 34
92 9 At next surveyb
44 N/A 3 Other
N/A 5 N/A Notes:
Percentages may not add to 100 because of rounding. N/A = not
available. aMichigan defines its priority time frames in terms of
calendar days rather than workdays. bMaryland defines this
category as "the next on-site survey," whereas Washington defines
it as being within 90 days or at the next on-site survey,
whichever is sooner. Several states have explicit procedures or
operating practices that do not place serious complaints in high-
priority categories for investigation. A Maryland official, for
example, acknowledged reducing the priority of some complaints
because the agency recognized that it could not meet shorter time
frames because of insufficient staff. Both Maryland and Michigan
gave some complaints low priority if the resident was no longer at
the nursing home when the complaint was received-even if the
resident had died or been transferred to a hospital or another
nursing home as a result of care problems. For example, in
testimony before the Page 6
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland Senate Special Committee on Aging, one complainant
indicated that she was told that her complaint regarding the care
her mother received in a Maryland nursing home was given low
priority because her mother had died. In reviewing complaints from
Maryland, we identified several that raised questions about why
they were not considered as involving potential immediate
jeopardy, thereby requiring a visit within 2 workdays. Examples of
these allegations include the following: * An alert resident who
was placed in a nursing home for a 20-day rehabilitation stay to
recover from hip surgery was transferred in less than 3 weeks to a
hospital because of an "unprecedented rapid decline [in his
condition]." A member of the ambulance crew transporting the
resident to the hospital reported that the resident "had dried . .
. blood in his fingernails and on his hands . . . sores all over
his body . . . smelled like feces . . . and [was] unable to walk
or take care of himself . . .. I personally feel he was not being
properly cared for." The Maryland state agency eventually
determined that the nursing home had harmed the resident, but only
after categorizing this complaint as not needing an investigation
until the next on-site inspection, which was more than 4 months
after receipt of the complaint. * In another instance, the police
reported suspected abuse and neglect to the state survey agency
after a resident was brought twice to the hospital emergency room
because of falls. The resident's first hospitalization identified
a broken elbow, and the second found a contusion on the resident's
cheek. The police did not believe the nursing home staff's account
of how the resident had sustained these injuries. This complaint,
filed 13 workdays before our visit, was being held by the Maryland
state agency until the next on-site investigation. Complaint
Investigations Furthermore, we found that states often did
not conduct investigations Often Not Conducted in within
the set time frames for the categories to which they assigned
Timely Manner complaints, even though some states
frequently placed complaints in priority categories that would
increase the time available to investigate them. Some of these
complaints, despite alleging serious risk to resident health and
safety, remained uninvestigated for several months after the
deadline for investigation. As shown in table 5, Maryland met its
time frames for only 21 percent of complaints assigned to the 10-
workday category and for 69 percent of complaints assigned to the
45-workday category. Page 7
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland Table 5: Percentage of State-Investigated Complaints
Meeting Marylanda
Michigan Washington Time Frame for Investigation, by
Within 2 workdays N/A
42b 78 Priority Category, July 1997-June
1998 Within 10 workdays 21
N/A 47 Within 45 workdays
69 26c 89 Within 90
workdays N/A
N/A 100 Note: N/A = not applicable. aMaryland's
data provide information on the last date of the investigation,
but not when the investigation was initiated. On the basis of our
review of complaints received in early 1998, only 1 of 18
complaints was initiated within the assigned time frame of 10
workdays, and only 4 of 11 complaints were initiated within the
assigned time frame of 45 workdays. bWhen using the state
requirement of 24 hours to investigate immediate jeopardy
complaints, Michigan investigated 21 percent of these complaints
on time. cMichigan defines this as 45 calendar days rather than
workdays. Overall, Michigan met its time frames in about one-
fourth of cases. Washington, which assigned most complaints to the
category requiring a visit within 10 workdays, met its time frames
for more than half (55 percent) of all complaints. Failure by
states to investigate complaints promptly can delay the
identification of serious problems in nursing homes and postpone
needed corrective actions. For nearly three-fourths of
investigated complaints in 1998, the Maryland state agency was
unable to make a determination as to whether or not the complaint
was valid. The state agency's poor timeliness record in
investigating complaints may in part contribute to the difficulty
in establishing the validity of the allegations. These delayed
investigations can prolong, for extended periods, situations in
which residents are harmed. We reviewed all available complaints
received in Maryland during the first 2 months of 1998 and found
that in the following four cases, the state agency substantiated
that residents had been harmed by poor care after an extended
delay in investigating the complaint: * A nurse charted that the
resident's intravenous fluid was flowing well; however, the fluid
was going under the resident's skin and not into a vein. The
resident had to be hospitalized. The state investigated this
complaint 139 days after receipt and confirmed that the home had
harmed the resident. * In the example cited earlier in which an
ambulance crew member reported the resident smelled like feces and
had dried blood under his nails and Page 8
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland pressure sores, the state substantiated harm to the
resident 130 days after receiving the complaint. * The state found
that one home's inadequate supervision led to resident falls,
including a resident who suffered a dislocated jaw and could not
chew, which required a feeding tube, and who later developed
pneumonia and was placed on life support in the hospital. The
state cited the home with a deficiency for harming the resident
after investigating 59 days after receiving the complaint. * Three
residents were hospitalized with several pressure sores. One
resident had a sore that was exposed to the bone. Another resident
had four sores; a third resident had three sores. The state,
investigating 39 days after the complaint, noted only that the
home did not ensure proper nutrition for one of these residents to
prevent the development of the sores. Since our report was issued,
the state agency informed us it has conducted 170 complaint
investigations to address pending complaints that exceeded the
assigned time frame for investigating them. The state reported
that about 20 percent of these investigations resulted in finding
deficiencies that the home caused serious harm to residents.
Backlogs of Uninvestigated Each of the three states we
visited had a backlog of complaints to be Complaints and
Inadequate investigated and that exceeded the designated
investigation time frames. Tracking System As of
December 1998, 12 nursing homes in the Baltimore metropolitan
Contribute to Delayed area had at least three complaints
that had not yet been assigned to an 4 Responses
investigator and that exceeded the designated time frames. These
unassigned complaints included a nursing home with three
complaints alleging neglect or abuse that had not yet been
investigated and had been pending for at least 3 or 4 months.
These allegations included a resident who was not fed for nearly 2
days and was hospitalized with dehydration, pressure sores, and an
infection; a resident whose condition had deteriorated, who had
lost 10 percent of her body weight in 2 months and suffered from
poor hygiene; and a resident who, as a result of being improperly
repositioned, suffered two fractured legs. The unassigned
complaints in the Baltimore area represented only a subset of the
complaints that had not been investigated. We were not able to
fully identify the scope of Maryland's backlog, in part because of
the inadequate information available in its tracking system. The
Maryland 4For complaints designated to be investigated during a
home's next on-site survey, we included only those received 45 or
more workdays before our review. Page 9
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland backlog listed in our March 1999 report included only
unassigned complaints, whereas the largest metropolitan areas in
the other two states were held to stricter criteria-all unassigned
and uninvestigated complaints for homes with at least three such
complaints. We did not request all 209 Baltimore-area complaints
that met these criteria because of the large volume-they
represented 30 percent of all complaints filed in Maryland in
1998. Federal and state tracking systems are vital to the timely
investigation of complaints. The ability to track complaint
investigations is important for quality assurance as well as
ensuring that complaints are conducted within appropriate time
frames. The incompleteness of Maryland's tracking data indicates
that Maryland's automated system cannot be effectively used as a
management tool for handling complaints. At the time of our visit,
two-thirds of complaints received in 1998 did not have an
investigation date recorded in the tracking system. Missing
investigation dates went back to complaints received in 1995. In
contrast, Washington State has developed a complaint management
information system that is used both for recording when complaints
are called in to the agency and for tracking purposes. In
addition, Washington has developed an electronic referral system
for complaints that need to be sent to other state or external
agencies. Its computer system also allows central office staff,
who receive complaints statewide, to fax complaints directly to
the district offices responsible for investigating them.
Washington's tracking system allows active management of
complaints throughout the investigation process, whereas this
appeared to be lacking in Maryland. As discussed in our report, we
found that inadequacies in HCFA's data system and the linkage
between federal and state systems hinder HCFA's and states'
ability to adequately track the status of complaint investigations
and for HCFA to maintain a full nursing home compliance history.
In short, one HCFA official stated that the complaint system,
contained in the On-Line Survey, Certification, and Reporting
System is "not used as a management tool."5 5For an assessment of
the weaknesses of HCFA's management information systems and the
effect those weaknesses have on HCFA's enforcement activities, see
GAO/HEHS-99-46, Mar. 18, 1999. Page 10
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland HCFA Oversight of Although states have the
primary investigatory role in complaint States' Complaint
investigations, HCFA also plays a role in both oversight of states
and partnerships with states through guidance, technical
assistance, and Processes Is Limited training efforts.
Although federal funds finance over 70 percent of complaint
investigations nationwide and 60 percent of complaint
investigations in Maryland, HCFA plays a minimal role in providing
states with oversight or guidance regarding these investigations.
HCFA has left it largely to the states to determine which
complaints are so serious that they must be investigated within
the federally mandated 2 workdays. Until March 1999, HCFA had no
formal requirements for the prompt investigation of serious
complaints that could harm residents but were not classified as
potentially placing residents in immediate jeopardy. Moreover,
HCFA's oversight of state agencies that certify federally
qualified nursing homes has not focused on complaint
investigations. We found the following: * A HCFA initiative to
strengthen federal requirements for complaint investigations was
discontinued in 1995, and resulting guidance developed for states'
optional use had not been widely adopted. * Federal monitoring
reviews of state nursing home inspections primarily focus on the
annual standard survey of nursing homes, with very few conducted
of complaint investigations. HCFA's Philadelphia regional office
did not conduct any federal monitoring reviews of complaint
investigations in Maryland in 1998. * Since 1998, HCFA has
required state agencies to develop their own performance measures
and quality improvement plans for their complaint investigations,
but for several states we reviewed, complaint processes were
addressed superficially or not at all. Maryland's 1998 report to
HCFA indicates that it had not developed a quality improvement
program or baseline performance measures for nursing home
complaints.6 Responses by HCFA In our March report, we
recommended that HCFA develop additional and Maryland to GAO
standards for the prompt investigation of serious complaints,
strengthen its oversight of state complaint investigations, and
develop better Findings Since March management information
systems to integrate the results of complaint 1999
investigations. HCFA concurred with our recommendations and
immediately initiated several actions to address issues raised in
our report: 6While not reflected as a part of HCFA's quality
improvement program, the director of Maryland's survey and
certification unit indicated that the unit had implemented some
improvements during this time. Page 11
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland * HCFA instructed states to investigate complaints
alleging actual harm to residents within 10 workdays. HCFA is
developing additional guidance to further clarify which types of
complaints meet this criterion. * HCFA also reemphasized that
states should cite federal deficiencies based on complaint
investigations where appropriate, thereby reporting these
deficiencies in the federal On-Line Survey, Certification, and
Reporting System as well as in relevant state licensing systems.
This allows HCFA and states to better capture and use the complete
history of nursing homes' adherence to quality standards. * HCFA
is developing a Complaint Improvement Project that will develop
additional standards and guidance for effective complaint
investigations as well as establish performance measures and
enhance HCFA oversight related to complaints. As you know, the
Maryland legislature has enacted and the state agency reported
several important changes intended to improve the state's
oversight of nursing homes in general and investigation of
complaints in particular. While we have not evaluated the extent
to which these have been implemented or their effectiveness, these
actions appear to be important steps toward addressing the issues
we raised. Maryland's recent actions include the following: * An
additional 20 long-term-care survey staff have been approved,
including 10 additional staff in the current and next fiscal year.
This represents a significant increase in resources from the
existing 35 long-term-care survey staff. * The state agency
reported that all backlogged complaints were resolved. However,
these complaints were resolved in part by temporarily suspending
annual surveys. According to a state official, by integrating the
surveyors responsible for conducting complaint and annual surveys
and gaining additional staff resources, the state agency intends
to maintain a better balance between complaint investigations and
annual surveys. * The state agency is developing a new complaint
tracking database. * After the state licensing and certification
office moves to a new space in the late summer, a new telephone
system will allow the long-term-care unit to have a separate 800
number. A message system is being considered but has not yet been
agreed upon. * A new Web page was put on the Internet 2 months
ago, and several updates have been made since then. A system is
being designed to allow complaints to be submitted via this
Internet site. Page 12
GAO/T-HEHS-99-146 Nursing Homes: Complaint Investigation Processes
in Maryland In addition, as you know, this Committee established a
task force to study the quality of care in Maryland nursing homes
and required the Health Care Access and Cost Commission to produce
a nursing home report card. Also, the General Assembly has
required the Maryland Department of Health and Mental Hygiene to
report by October 1 of this year on steps it has taken to improve
the efficiency and effectiveness of the system to address
complaints. Conclusions As the Congress, HCFA, and the
states seek to better ensure adequate quality of care for nursing
home residents, our work has demonstrated that complaint
investigations need to be strengthened to provide better
protections for the growing number of elderly and disabled
Americans who rely on nursing homes for their care. Without such
improvements, many federal and state policies and practices will
continue to allow weeks or months to elapse before investigation
of complaints that allege serious harm to residents. Both HCFA and
Maryland have taken positive initial steps aimed at improving the
responsiveness and effectiveness of complaint investigations.
However, the seriousness and systemic nature of the weaknesses we
identified in our review require sustained commitment and
strengthened oversight to ensure that complaint investigations are
used effectively to better ensure adequate care to nursing home
residents. Mr. Chairman, this concludes my prepared statement. I
will be happy to answer any questions that you or other members of
the Committee may have. GAO Contacts and For future contacts
regarding this testimony, please call Kathryn G. Allen
Acknowledgment at (202) 512-7118 or John Dicken at (202) 512-
7043. Gloria Eldridge also made key contributions to this
statement. (101852) Page 13
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