House Commerce Subcommittee Issues Testimony From GAO Director
"Chairman Harper, Ranking Member DeGette, and Members of the Subcommittee:
"I'm pleased to be here today to discuss our work on nursing home quality and the
"For many years, we and the
"However, as you know, news stories and reports continue to identify potential problems in nursing homes. For example, a
"To help inform today's discussion, my testimony will focus on the findings from our
1. trends in nursing home quality through 2014, and
2. changes CMS had made to its oversight activities as of
"In addition, I will highlight key actions that we recommended HHS take, including HHS's response and the current status of those recommendations.
"While my comments today focus on the findings of our
"In our
Background
"Oversight of nursing homes is a shared federal-state responsibility, with CMS central and regional offices overseeing activities completed by state survey agencies. Specifically, CMS central office (1) oversees the federal quality standards nursing homes must meet to participate in the Medicare and Medicaid programs and (2) establishes the responsibilities of CMS's regional offices and state survey agencies to ensure federal quality standards for nursing homes are met. CMS regional offices oversee state activities and report results back to CMS central office. Specifically, regional offices are required to conduct annual federal monitoring surveys to assess the adequacy of surveys conducted by state survey agencies. CMS regional offices also evaluate state surveyors' performance on factors such as the frequency and quality of state surveys. Finally, in each state, under agreement with CMS, a state survey agency assesses whether nursing homes meet CMS's standards by conducting regular surveys and investigations of complaints regarding resident care or safety, as needed.
"CMS collects data on nursing home quality through annual standard surveys and complaint investigations, as well as other sources, such as staffing data and clinical quality measures.
* Standard surveys. By law, every nursing home receiving Medicare or Medicaid payment must undergo a standard survey during which teams of state surveyors conduct a comprehensive on-site evaluation of compliance with federal quality standards.10 Nursing homes with consistently poor performance can be selected for the Special Focus Facility (SFF) program, which requires more intensive oversight, including more frequent surveys.11
* Complaint investigations. Nursing homes also are surveyed on an as-needed basis with investigations of consumer complaints. These complaints can be filed with state survey agencies by residents, families, ombudsmen, or others acting on a resident's behalf. During an investigation, state surveyors evaluate the nursing home's compliance with a specific federal quality standard.
* Staffing data. Nurse staffing levels are considered a key component of nursing home quality and are often measured in total nurse hours per resident day. Higher nurse staffing levels are typically linked with higher quality nursing home care.
* Clinical quality measures. Nursing homes are required to provide data on certain clinical quality measures--such as the incidence of pressure ulcers--for all residents to CMS. CMS currently tracks data for 18 clinical quality measures.
"CMS publicly reports a summary of each nursing home's quality data on its
Nursing Home Quality Data Show Mixed Results, Although Data Issues Complicate Ability to Assess Quality Trends
"In our
Data on Nursing Home Quality Showed Mixed Results
"Nationally, one of the four data sets--consumer complaints--suggested consumers' concerns over nursing home quality increased from 2005 to 2014. However, the other three data sets--deficiencies, staffing levels, and clinical quality measures--indicated potential improvement in nursing home quality (see Table 1). Specifically, we found consumer complaints--which can originate from residents, families, ombudsmen, or others acting on a resident's behalf--had a 21 percent increase from 2005 to 2014. In contrast, nurse staffing levels increased 9 percent from 2009 to 2014 and selected quality measure scores showed decreases in the number of reported quality problems, such as falls resulting in major injury from 2011 to 2014.
(Table 1 omitted)
"In addition, we identified 416 homes in 36 states that had consistently poor performance across the four data sets we examined. Of the 416 homes, 71 (17 percent) were included in the Special Focus Facility (SFF) program at some point between 2005 and 2014.
Data Issues Complicated CMS's Ability to Assess Quality Trends
"In our
"Consumer complaints: The average number of consumer complaints reported per nursing home increased in the 10 years of data we examined, although it is unclear to what extent this can be attributed to a change in quality or to state variation in the recording of complaints. Some state survey agency officials explained that changes in how they recorded complaints into CMS's complaint tracking system could in part account for the jump in reported complaints. In addition, officials at one state survey agency explained the increase in complaints could also reflect state-level efforts to provide consumers with more user-friendly options for filing complaints. Similarly, in
"Deficiencies cited on standard surveys: The decline in the number of serious deficiencies--deficiencies that at a minimum caused a harm to the resident--in the data we examined may have indicated an improvement in quality, although it may also be attributed to inconsistencies in measurement. For example, the use of multiple survey types, such as both traditional paper-based surveys and electronic surveys, to conduct the standard survey that every nursing home receiving Medicare or Medicaid payment must undergo complicates the ability to compare the results of these surveys nationally.14 In our
"Nurse staffing: CMS data showed the average total nurse hours per resident day increased from 2009 through 2014, although CMS did not have assurance these data were accurate. Many of the regional office and state survey agency officials we spoke with expressed concern over the self-reported nature of these data, noting that it may be easy to misrepresent nurse staff hours. At the time of our 2015 report, CMS was in the process of implementing a system to collect staffing information based on payroll and other verifiable data and has now completed that implementation, as required by law. We recommended in 2015 that CMS establish and implement a clear plan for ongoing auditing of its staffing data and other quality data. HHS agreed with this recommendation and in
"Selected quality measures: Nursing homes generally improved their performance on the eight selected quality measures we reviewed, although it is unclear to what extent this can be attributed to a change in quality or possible inaccuracies in self-reported data. Like the nurse staffing data used by CMS, data on nursing homes' performance on these measures were self-reported, and until 2014 CMS conducted little to no auditing of these data to ensure their accuracy. In our 2015 report, we found CMS had begun taking steps to help mitigate the problem with self-reported data by starting to audit the data in 2015; however, the agency did not have clear plans to continue the audits beyond 2016. As such, in our recommendation we indicated the need for ongoing auditing of data used to calculate clinical quality measures. As of
"Collectively, these data issues have broader implications related to nursing home quality trends, including potential effects on the quality benchmarks CMS sets and consumers' decisions about which nursing home to select.17 Furthermore, data used by CMS to assess quality measures are also used when determining Medicare payments to nursing homes, so data issues--and CMS's internal controls related to the data--could affect the accuracy of payments. Moreover, the use of quality data for payment purposes will expand in fiscal year 2019 when a nursing home value-based purchasing program will be implemented, which will increase or reduce Medicare payments to nursing homes based on certain quality measures.
CMS Had Modified Oversight Activities by 2015, But Had Not Monitored Potential Effect on Nursing Home Quality Oversight
"Our 2015 report found that CMS had made numerous modifications to its nursing home oversight activities in recent years, but had not monitored the potential effect of these modifications on nursing home quality oversight. Some of these modifications expanded or added new oversight activities--for example, CMS expanded the number of tools available to state surveyors when investigating medication-related adverse events, increased the amount of nursing home quality data available to the public, and created new trainings for surveyors on unnecessary medication usage.18 However, other modifications reduced existing oversight activities.
"In 2015, we highlighted modifications that reduced two existing oversight activities--the federal monitoring survey program and the SFF program.
* Federal monitoring surveys: CMS reduced the scope of the federal monitoring surveys regional offices use to evaluate state surveyors' skills in assessing nursing home quality. CMS requires regional offices to complete federal monitoring surveys in at least 5 percent of nursing homes surveyed by the state each year. Starting in 2013, CMS required fewer federal monitoring surveys to be standard surveys and allowed more monitoring surveys to be the narrower scoped and less-resource intensive revisits and complaint investigations.19
* Special Focus Facilities: CMS reduced the number of nursing homes participating in the SFF program.20 In 2013, CMS began to reduce the number of homes in the program by instructing states to terminate homes that had been in the program for 18 months without improvement from participating in Medicare and Medicaid. As we have previously reported, between 2013 and 2014, the number of nursing homes in the SFF program dropped by more than half--from 152 to 62. In 2014, CMS began the process of re-building the number of facilities in the SFF program; however, according to CMS officials, the process would be slow, and as of
"In 2015, CMS said some of the reductions to oversight activities were in response to an increase in oversight responsibilities and limited number of staff and financial resources. Specifically, CMS officials said increasing oversight responsibilities and a limited number of staff and financial resources at the central, regional, and state levels required the agency to evaluate its activities and reduce the scope of some activities. In the
"Chairman Harper, Ranking Member DeGette, and Members of the Subcommittee, this concludes my prepared statement. I would be pleased to respond to any questions that you may have at this time."
* * *
Footnotes:
1Medicaid, a federal-state health financing program for low-income and medically needy individuals, is the nation's primary payer of long-term services and supports for children and adults with disabilities and aged individuals. Medicare, the federal health insurance program for people age 65 and older, individuals under age 65 with certain disabilities, and individuals diagnosed with end-stage renal disease, covers some short-term skilled nursing and rehabilitative care for beneficiaries following an acute care hospital stay.
2See, for example, OIG, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370 (
3See GAO,
4See GAO,
5CMS, Nursing Home Data Compendium 2015 Edition.
6J. Rau, "Like a
7See
8Attorneys General of
9See GAO, Nursing Home Quality: CMS Should Continue to Improve Data And Oversight, GAO-16-33 (
10For most deficiencies identified during surveys, a home is required to prepare a plan of correction, and, depending on the severity of the deficiency, surveyors may conduct a revisit to ensure that the nursing home has implemented its plan and corrected the deficiency. The scope and severity of a deficiency determine the enforcement actions--such as requiring training for staff, imposing monetary penalties, or termination from the Medicare and Medicaid programs.
11According to CMS guidance, SFF nursing homes that fail to significantly improve after three standard surveys, or about 18 months, may be involuntarily terminated from Medicare and Medicaid. The SFF program is statutorily required, and CMS is mandated to conduct its SFF program for homes that have "substantially failed" to meet applicable requirements of the Social Security Act. For more information on the SFF program, see GAO,
12See GAO,
13See GAO,
14Some regional offices and state survey agencies we spoke to for the
15CMS, letter to
16See CMS, letter to
17In our 2016 report on CMS's
18See GAO-16-33 for additional information on oversight modifications made.
19Before 2013, CMS required 80 percent of these federal monitoring surveys be standard surveys--the most comprehensive type--which cover a broad range of quality issues within a nursing home. The remaining 20 percent of surveys were permitted to be either revisit or complaint surveys, which are more narrow in scope and are also less-resource intensive.
20Nursing homes placed in the SFF program receive additional oversight because of the homes' history of poor performance. If homes do not improve the quality of their care, CMS can terminate their participation in Medicare and Medicaid.
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