Reporting of Results. CMS 2009 Data Show that States Received Over 50,000 Nursing Home Complaints and Substantiated the Complaint and Cited Federal Deficiencies in 19 Percent of Investigations

CMS’s national complaints data show that state survey agencies received  over 50,000 complaints about nursing homes in calendar year 2009. The  number and types of complaints varied among states. State survey  agencies investigated all but 102 of the complaints that required an  investigation. Additionally, 11 states received 15 or fewer complaints per  1,000 nursing home residents, while 14 states received more than 45. Roughly 10 percent  of complaints were prioritized as immediate jeopardy and about 4 percent  were prioritized as actual harm-low. According to CMS’s complaints  database, roughly 26 percent of the immediate jeopardy complaints that  were investigated were substantiated with at least one deficiency cited. In particular,  19 state survey agencies had difficulty investigating complaints and  incidents prioritized as actual harm-high within the required time frame. Although the standards do not assess state survey agencies’  communication with complainants, CMS does expect agencies to convey  investigation findings to complainants in accordance with CMS’s State  Operations Manual. CMS’s assessment of state  survey agencies’ performance found that some had difficulty meeting the  timeliness of investigations standard, which evaluates: (1) whether an  investigation was initiated within 10 working days of prioritization for  actual harm-high complaints and incidents for nursing homes, and   (2) whether an investigation was initiated within 2 working days of receipt  for immediate jeopardy complaints and incidents for nursing homes and  other facilities. Prioritization of Complaints Standard. Training and Guidance. 3). CMS’s Oversight of State Survey Agencies’ Complaint Investigation Processes Is Hampered by Data Reliability Issues, Due in Part to Inconsistent Interpretation of Performance Standards Among CMS Reviewers

CMS’s oversight of state survey agencies’ complaint investigation  processes, through its performance standards system and complaints  database, is hampered by data reliability issues. While the four  performance standards CMS uses to assess state survey agencies’  processes for investigating nursing home complaints are consistent with  certain key criteria for performance measures identified by GAO and other  audit agencies, the standards have weaknesses in areas related to other  key criteria, particularly data reliability, due in part to inadequate sample  sizes and inconsistent interpretation of some standards by CMS reviewers. In addition, CMS has not made full use of the information it collects about  state survey agencies’ complaint investigation processes. Although CMS requires state survey agencies that fail performance  standards to develop corrective action plans, these plans do not  necessarily address the underlying causes of performance issues, such as  staffing shortages. For example, CMS does not  routinely use data from its complaints database to calculate certain  measures that could enhance its understanding of state survey agencies’  performance investigating complaints and has not publicly reported state  survey agencies’ scores on the performance standards. CMS’s performance reviews highlight state workload issues. Additionally, CMS data for 2009  showed that, among investigated complaints prioritized as either  immediate jeopardy or actual harm-high, the percentage substantiated  with at least one federal deficiency cited was higher if the investigation  was initiated within required time frames than if it was not. To strengthen CMS’s assessment of state survey agencies’ performance in  the management of nursing home complaints, we recommend that the  Administrator of CMS take the following three actions:    Conduct additional monitoring of state performance using information  from CMS’s complaints database, such as additional timeliness measures. Assure greater consistency in assessments by identifying differences in  interpretation of the performance standards and clarifying guidance to  state survey agencies and CMS regional offices. HHS  generally concurred with all of our recommendations. Appendix I: CMS’s State-Level Data on Complaints Received, Investigated, and Substantiated by State Survey Agencies, 2009

This appendix provides additional information on the number of  complaints received, investigated, and substantiated by all 50 state survey  agencies and the survey agency for the District of Columbia for 2009 based  on complaints in Centers for Medicare & Medicaid Services’ (CMS)  national complaints database.
Why GAO Did This Study

CMS, the agency within HHS that manages Medicare and Medicaid, contracts with state survey agencies to investigate complaints about nursing homes from residents, family members, and others. CMS helps assure the adequacy of state complaint processes by issuing guidance, monitoring data that state survey agencies enter into CMS's database, and annually assessing performance against specific standards. Concerns have been raised about the timeliness and adequacy of complaint investigations and CMS's oversight. GAO examined (1) complaints received, investigated, and substantiated by state survey agencies; (2) whether those agencies were meeting CMS performance standards and other requirements; and (3) the effectiveness of CMS's oversight. In addition to analyzing CMS data on complaints and performance reviews, GAO examined CMS guidance and conducted interviews with officials from three high- and three low-performing state survey agencies and their CMS regional offices. GAO addressed data reliability concerns by reporting only data we determined to be reliable.

What GAO Found

CMS's complaints data showed that state survey agencies received 53,313 complaints about nursing homes in 2009. The number and types of complaints varied among states. For example, 11 states received 15 or fewer complaints per 1,000 nursing home residents while 14 states received more than 45. State survey agencies assess the severity of a complaint and assign a priority level, which dictates if and when an investigation must be initiated. About 10 percent of complaints were prioritized as immediate jeopardy, requiring investigation within 2 working days of receipt, while 45 percent were prioritized as actual harm-high, requiring investigation within 10 working days of prioritization. State survey agencies investigated all but 102 complaints that required an investigation. Among investigated complaints, 19 percent were substantiated and resulted in the citation of at least one federal deficiency. The percentage of immediate jeopardy and actual harm-high complaints that were substantiated with at least one federal deficiency cited was higher if the investigation was initiated on time. In CMS's performance assessment for fiscal year 2009, many state survey agencies had difficulty meeting some of CMS's nursing home complaint standards, most of which also assess performance with regard to incidents--specific care issues that nursing homes are required to report. In particular, 19 state survey agencies had difficulty investigating actual harm-high complaints and incidents within the required time frame. However, most states were able to meet other CMS standards--timely investigation of immediate jeopardy complaints and incidents and appropriate prioritization of complaints and incidents. Although CMS's performance assessment does not review state survey agencies' communication with complainants, CMS does expect the agencies to convey investigation findings according to CMS guidelines. GAO found state survey agencies had varied interpretations of those guidelines, and some provided limited information to complainants. CMS's oversight of state survey agencies' complaint investigation processes, through its performance standards system and complaints database, is hampered by data reliability issues. While CMS's performance standards are consistent with certain key criteria for performance measures identified by GAO and other audit agencies, performance scores are not always reliable, due in part to inadequate sample sizes and inconsistent interpretation of some standards by CMS reviewers. In addition, CMS has not made full use of the information it collects. For example, in part because of data reliability concerns, CMS does not routinely use data from the complaints database to calculate certain measures that could enhance its understanding of agencies' performance. Although CMS requires state survey agencies that fail performance standards to develop corrective action plans, states' plans do not necessarily address the underlying causes of performance issues, such as staffing shortages.

What GAO Recommends

GAO recommends that the CMS Administrator take several steps to strengthen oversight of complaint investigations, such as improving the reliability of its complaints database and clarifying guidance for its state performance standards to assure more consistent interpretation. HHS generally agreed with our recommendations.