HHAs do not need health care experience to be certified by Medicare. Initial Surveys Provide Little Assurance That HHAs Are Capable of Furnishing Quality Care

Medicare’s initial certification process does not provide a sound basis for judging whether an HHA does or will provide quality care in accordance with Medicare’s conditions of participation. HHAs Are Not Assessed Against All Conditions of Participation

HCFA recertifies most HHAs without requiring them to demonstrate compliance with all the conditions of participation. This legislation increased the allowed intervals between recertification surveys to up to 36 months, from the previous requirement of approximately every 12 months. By not surveying branch operations, significant problems can go undetected. For example, one Texas HHA has branch offices located over 300 miles from the parent office. Once Certified, Few HHAs Lose Their Certification

Once an HHA has been certified as a Medicare provider, it is virtually assured of remaining in the program, with no penalty, even if found to be repeatedly deficient in complying with Medicare’s conditions of participation. Given multiple opportunities to correct their deficiencies, it is not unusual for HHAs to have conditions and standards out of compliance from one survey to another and remain in the program, as the following examples illustrate:
A California HHA’s second recertification survey revealed that the HHA had deficiencies in meeting five standards and that three of the deficiencies had been identified in the previous year’s survey and supposedly corrected. As a result, few HHAs are denied entry to the program. Revise the survey frequency criteria to include consideration of other factors that may indicate problem HHAs, such as rapid growth and high utilization patterns. Additionally, these states are among the 10 states with the highest numbers of certified HHAs. To determine how HCFA ensures that certified HHAs continue to comply with Medicare’s conditions of participation and provide quality care, we reviewed HCFA’s On-line Survey, Certification and Reporting (OSCAR) database to determine the extent to which HHAs (1) do not meet Medicare’s conditions of participation during surveys, (2) have repeated violations of Medicare’s conditions and associated standards over time, and (3) create branch offices. Aides must be supervised. Home Health Care: HCFA Properly Evaluated JCAHO’s Ability to Survey Home Health Agencies (GAO/HRD-93-33, Oct. 26, 1992). 4, 1983).
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed how the Health Care Financing Administration (HCFA): (1) controls the entry of home health agencies (HHA) into the Medicare program; (2) ensures that certified HHAs continue to comply with Medicare's conditions of participation and associated standards; and (3) decertifies HHAs that are not complying with Medicare's requirements.

What GAO Found

GAO noted that: (1) becoming a Medicare-certified HHA is relatively easy-- probably too easy, given the large number of problem agencies identified in various studies over the past few years; (2) if HHA owners have not been previously barred from Medicare, they can obtain certification without having any health care experience; (3) although such entrepreneurs can hire qualified health care professionals, Medicare's initial certification survey is so limited that it does not provide a sound basis for judging an HHA's ability to provide quality care; (4) although certified HHAs must be periodically recertified, serious deficiencies in the process allow problems to go undetected; (5) HCFA recertifies HHAs by screening them against a subset of the conditions of participation, but when surveyors assessed 44 targeted HHAs against all applicable conditions of participation, almost half had problems serious enough to warrant decertification; (6) many HHAs operate branch offices, but these offices are not subject to the same oversight afforded the parent offices; (7) HHAs are resurveyed every 12 to 36 months, depending on a variety of factors, but rapid growth and high utilization rates, which may indicate potential problem HHAs, are not included among those factors; (8) once certified, HHAs have little reason to fear that they will suffer serious consequences from failing to comply with Medicare's conditions of participation and associated standards; (9) few problem HHAs are terminated from the program; instead they are provided repeated opportunities to correct their deficiencies, even if the same deficiencies recur from one survey to the next; and (10) moreover, HCFA has not implemented a range of penalties to sanction problem HHAs, even though the Congress provided it the authority to do so over 10 years ago.