CMS Has Data on the Quality of Care at LTCHs, but Currently the Data Are Limited

Although CMS collects some data on the quality of care at LTCHs, the  data are currently limited. In addition, current survey results in OSCAR and ASSURE may be  incomplete because these databases do not always accurately identify   (1) which survey organization is responsible for surveying each LTCH or  (2) whether a facility is, in fact, an LTCH. Second, CMS does not currently  collect data for quality measures because LTCHs are not yet required to  report them. CMS Has No Detailed Prior Survey Data and Incomplete Current Survey Results on the Majority of LTCHs

Because TJC only recently began submitting detailed survey data to  CMS, ASSURE has no prior data and limited current data—surveys  conducted since July 2009—for TJC-surveyed LTCHs, which constitute a  majority (about 80 percent) of such hospitals. We found that there were 447 LTCHs listed in OSCAR or ASSURE as of  fiscal year 2010. CMS Does Not Require LTCHs to Report Data on Quality Measures, but Will Do So Beginning in 2014

CMS currently does not have quality measures for LTCHs because  LTCHs were not required to report on the quality measures developed for  most ACHs in 2003 or later. While LTCHs are not currently reporting on  quality measures, under the Patient Protection and Affordable Care Act  (PPACA) enacted in 2010, they must begin doing so by 2014. CMS Oversight of Survey Activities at LTCHs Is Limited

CMS and its regional offices’ oversight of state survey agency and AO  survey activities in LTCHs is limited because two of its oversight  strategies—performance measures and selection of hospitals for  traditional validation surveys—focus on hospitals in general rather than  LTCHs specifically. CMS’s third oversight strategy—collection and  analysis of survey data—is also limited because the agency does not  utilize all of the available data to identify weaknesses in the survey  process that may require further investigation. CMS’s Performance Measures for Survey Activities Do Not Focus on LTCHs

None of the performance measures that CMS uses to assess the survey  activities of state survey agencies and AOs focus specifically on LTCHs. One of CMS’s performance  measures for state survey agencies examines the timeliness of state  surveys. LTCHs Are Not Systematically Included in the Hospital Validation Survey Sample, and Results from Complaint Validation Surveys Are Not Always Shared with TJC

CMS does not systematically include 1 percent of AO-surveyed LTCHs— fewer than five—in its sample of traditional hospital validation surveys  conducted by state survey agencies. By recognizing and adjusting for limitations  in these databases, we identified several areas where the data may assist  CMS in more effectively overseeing survey activities at LTCHs.   CMS has data on complaint validation surveys conducted in LTCHs  that could provide information on how effectively states triage and  conduct complaint surveys at TJC-surveyed LTCHs. We found several weaknesses in the availability of data on the quality of  care in LTCHs. Although CMS conducts  traditional validation surveys in hospitals in general as a means for  assessing the effectiveness of an AO’s survey activities, CMS cannot  assure that LTCHs are systematically included in their review; when such  surveys have been conducted in LTCHs, CMS has not separated out the  LTCH surveys from surveys of all other hospitals and so is unable to  identify whether there may be areas of concern specific to AO survey  activities in LTCHs. Improve the accuracy of the databases that track LTCH survey results    working with AOs and state survey agencies to develop a  complete and accurate list of the LTCHs that they each survey  and an approach to ensuring that the list is updated in a timely  manner, and    expanding the OSCAR database to include the results of all LTCH  surveys, such as those conducted by TJC, which are currently  stored in the separate ASSURE database. TJC agreed with most of our recommendations,  but disagreed with the recommendation related to traditional validation  surveys, that is, state oversight surveys at AO-surveyed LTCHs. HHS said that  it intends to:  reinforce existing CMS policy on sharing information with AOs and  work with regional offices to enhance compliance,    explore an option to increase its traditional validation survey sample  for hospitals, which would permit the inclusion of a stratified sample of  LTCHs annually,    explore the differences in survey workload and resource allocation,  which it characterized as definitely meriting attention, while working  with regional offices to clarify the policy for triaging complaint surveys  at AO-surveyed LTCHs and for referring certain complaints to the  appropriate AO, and  review the available data to determine to what extent it can be used to  develop additional AO performance measures for evaluating quality of  care at hospitals, including LTCHs. Appendix I: Condition-Level Deficiencies Cited at Long-Term and Acute Care Hospitals During Routine and Complaint Surveys

This appendix presents the Centers for Medicare & Medicaid Services  (CMS) data on the results of surveys at long-term care hospitals (LTCH). In the course of our analyses, we identified some data limitations, which  we discussed with both CMS and The Joint Commission (TJC).
Why GAO Did This Study

Allegations about quality-of-care problems have raised questions about the oversight of long-term care hospitals (LTCH), which provide care to individuals with multiple acute or chronic conditions. Medicare pays for about 80 percent of LTCH patient care. To ensure compliance with federal quality standards, accrediting organizations (AO) and state survey agencies under contract with the Centers for Medicare & Medicaid Services (CMS) conduct routine and complaint surveys. One AO, The Joint Commission (TJC), surveys most LTCHs. In a November 2010 report, GAO compared oversight of LTCHs to that of other facilities. In this report, GAO examined the extent to which CMS collects data about LTCHs' quality of care and oversees LTCH survey activities. To do this work, GAO analyzed CMS data on the results of LTCH surveys and discussed oversight activities with both CMS and AO officials. GAO assessed the reliability of the survey data and took steps to ensure that the data presented were reliable.

What GAO Found

CMS collects some data on the quality of care at LTCHs, but the data are limited for several reasons. First, CMS does not have detailed data on the results of surveys conducted by TJC prior to 2009 and has limited data on current surveys because TJC did not begin submitting detailed data to CMS until July 2009. CMS does have prior year and current survey data for state-surveyed LTCHs--about 16 percent of LTCHs. In addition, current survey results in CMS's databases may be incomplete because these databases do not always accurately identify (1) the organization responsible for surveying each LTCH and (2) whether a facility is, in fact, an LTCH. As of fiscal year 2010, CMS data showed a total of 447 LTCHs, but GAO identified 18 LTCHs incorrectly categorized in one CMS database as having been surveyed by state survey agencies. GAO also found 56 LTCHs either misidentified as acute care hospitals or missing from another CMS database that contains information on LTCHs surveyed by accrediting organizations. Second, CMS does not currently collect data on quality measures--information used to evaluate how health care is delivered--from LTCHs because, unlike other types of hospitals, LTCHs are not yet required to report them. The Patient Protection and Affordable Care Act enacted in 2010 requires LTCHs to report quality measures by 2014. CMS's oversight of state survey agency and AO survey activities of LTCHs is limited. Two of CMS's three oversight approaches do not focus on LTCHs specifically, but on hospitals in general. First, CMS established performance measures--expectations regarding survey activities or the reporting of survey results--for survey organizations, but reports the results of its assessments for hospitals in general rather than for LTCHs specifically. Second, state survey agencies conduct surveys annually in AO-accredited hospitals--known as validation surveys--to assess the effectiveness of the AO surveys, but have not systematically included some LTCHs in the sample of hospitals subject to validation surveys. Additional validation surveys are done based on complaints. State survey agencies conducted more than 1,000 validation surveys over a 5-year period based on complaints in LTCHs that had been surveyed by TJC. CMS does not refer such complaints to TJC for investigation. As a result, TJC conducted few complaint surveys. Although CMS has instructed its regional offices to provide TJC with the results of these surveys, GAO found that these data were not always shared. CMS's third oversight approach--collection and analysis of data on the results of survey organizations' activities--has not utilized all the available data to identify problems that may require further investigation. GAO identified several potential areas where the data may assist CMS in more effectively overseeing survey activities at LTCHs, such as how effectively states triage and conduct complaint validation surveys.

What GAO Recommends

GAO recommends that CMS strengthen its oversight of LTCHs by improving available data on quality of care and by improving oversight of LTCH survey activities. HHS concurred with all of the recommendations. TJC agreed with most of them, but disagreed with the value of state oversight surveys of AO-surveyed LTCHs. We continue to believe that such surveys are an important part of CMS oversight of LTCH survey activities.