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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