Long-Term Care Hospitals
Differences in Their Oversight Compared to Other Types of Hospitals and Nursing Homes Gao ID: GAO-11-130R November 30, 2010This report formally transmits the briefing highlighting differences in the oversight of long-term care hospitals (LTCH), other types of hospitals, and nursing homes. This report is a partial response to a congressional request letter and was used to brief congressional staff on November 29, 2010. We provided a draft of this report to the Department of Health and Human Services (HHS) and to The Joint Commission (TJC)--an accrediting organization that oversees the majority of LTCHs.
GAO-11-130R, Long-Term Care Hospitals: Differences in Their Oversight Compared to Other Types of Hospitals and Nursing Homes
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GAO-11-130R:
United States Government Accountability Office:
Washington, DC 20548:
November 30, 2010:
The Honorable Max Baucus:
Chairman:
The Honorable Charles E. Grassley: Ranking Member:
Committee on Finance:
United States Senate:
Subject: Long-Term Care Hospitals: Differences in Their Oversight
Compared to Other Types of Hospitals and Nursing Homes:
This report formally transmits our briefing slides highlighting
differences in the oversight of long term care hospitals (LTCH), other
types of hospitals, and nursing homes (see enclosure I). The slides
are a partial response to your request letter and were used to brief
your staff on November 29, 2010. We provided a draft of this report to
the Department of Health and Human Services (BHS) and to The Joint
Commission (TJC)-”an accrediting organization that oversees the
majority of LTCHs. BHS's comments, which indicated that the briefing
slides were a welcome resource, are reproduced in appendix III of the
slides. We also received technical comments from BHS and TJC, which we
incorporated as appropriate.
We will address your questions about the types of quality and patient
safety information collected on LTCHs by the Centers for Medicare &
Medicaid Services (CMS) and the coordination among oversight
organizations in a subsequent report.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Secretary of BHS, the Administrator of CMS, and relevant
congressional committees. In addition, the report will be available at
no charge on the GAO Website at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions regarding this report, please
contact me at (202) 512-7114 or kohnl@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Key contributors to this report were
Walter Ochinko, Assistant Director; Sarah Harvey; Kristin Helfer
Koester; Elizabeth T. Morrison; Phillip J. Stadler; and Jennifer
Whitworth.
Signed by:
Linda T. Kohn:
Director, Health Care:
Enclosure:
[End of section]
Enclosure I: Long-Term Care Hospitals: Differences in Their Oversight
Compared to Other Types of Hospitals and Nursing Homes:
Briefing for Staff of Committee on Finance United States Senate:
November 29, 2010:
Overview:
* Introduction;
* Objective;
* Scope and Methodology;
* Background;
* Results;
* Summary of Differences in Oversight among LTCHs, Other Hospitals,
and Nursing Homes;
* Agency Comments.
Overview:
* Appendix I: CMS's 23 Hospital Conditions of Participation.
* Appendix II: TJC's17 Categories of Hospital Standards.
* Appendix III: Comments from HHS.
Introduction:
Long-term care hospitals (LTCH) provide acute and post acute care to
clinically complex individuals who have multiple acute or chronic
conditions and need care for relatively extended periods”more than 25
days, on average.[A]
* Unlike LTCHs, other types of hospitals, such as acute-care hospitals
(ACH), do not have length of stay requirements for Medicare payment.[B]
* Most LTCH patients are transferred from an intensive or critical
care unit of an ACH.
[A] The Social Security Act permits certain LTCHs to maintain an
average length of stay of more than 20 days. See 42 U.S.C.
§1395ww(d)(1)(B)(iv)(II).
[B] Medicare is the federal health insurance program for people aged
65 and older, certain individuals with disabilities, and individuals
with end-stage renal disease. Among other things, Medicare covers
inpatient hospital stays and physician services.
In fiscal year (FY) 2009, about 7 percent of hospitals were LTCHs, up
from 4.5 percent in FY 2001.
* Changes in the Medicare payment system, among other factors,
contributed to the increase in the number of LTCHs.
* After growth in the number of LTCHs, Congress placed a moratorium on
the establishment of new LTCHs and on increases in bed size for
existing LTCHs, with limited exceptions, beginning in 2007.[A]
Medicare payments to LTCHs:
* Medicare paid about $5 billion in FY 2009 for care provided in 434
LTCHs for about 140,000 discharges”an average of more than $32,000 per
discharge.[B]
* Following a 2010 article in The New York Times, you expressed
concern about the oversight of and quality of care provided in
LTCHs.[C]
[A] The Medicare, Medicaid, and SCRIP Extension Act of 2007, Pub. L.
No. 110-173, § 114(d), 121 Stat. 2492, 2503-04.
[B] According to CMS, there were 439 LTCHs as of November 2010.
[C] Alex Berenson, "Long-Term Care Hospitals Face Little Scrutiny,"
The New York Times, February 10, 2010.
Objective:
Our briefing focuses on the oversight of LTCHs and how it differs from
the oversight at other types of hospitals and nursing homes.
Scope and Methodology:
To describe oversight of LTCHs, other types of hospitals”ACHs,
psychiatric hospitals, and rehabilitation hospitals”and nursing
homes.[A]
* We reviewed documents and interviewed officials from:
- The Centers for Medicare & Medicaid Services (CMS), which contracts
with state survey agencies to survey hospitals, nursing homes, and
other facility types that participate in the Medicare and Medicaid
programs;[B] and;
- The Joint Commission (TJC), an accreditation organization (AO) that
surveys most hospitals, including most LTCHs.
* We analyzed data from CMS on FY 2009 survey activities, facility
characteristics, and sanctions applied to these facilities from FY
2005 through FY 2009.
- We obtained data on these FYs from CMS's Providing Data Quickly
(PDQ) Website, which we downloaded on September 14, 2010.[C]
* We analyzed data from TJC on FY 2009 survey activities and
accreditation actions applied to these types of hospitals from FY 2007
through FY 2009.
[A] We compared LTCHs to psychiatric hospitals and rehabilitation
hospitals because these hospitals often provide post acute care. We
included ACHs because LTCH patients are transferred from an ACH. Some
ACHs have psychiatric and rehabilitation units, which are excluded
from the inpatient prospective payment system (IPPS), that provide
services similar to psychiatric or rehabilitation hospitals; they have
the same CMS identification number as the ACH in which they are
located and are considered part of the ACH. Throughout these slides,
we use all types of hospitals" to refer to LTCHs, ACHs, and
psychiatric and rehabilitation hospitals. We included information on
hospitals and nursing homes from all 50 states, the District of
Columbia, and 5 territories”American Samoa, Guam, Puerto Rico, the
Commonwealth of the Northern Mariana Islands, and the United States
Virgin Islands.
[B] Medicaid is the joint federal-state health care financing program
for certain categories of low-income individuals.
[C] PDQ was created for use by CMS and state survey agencies and
provides data on survey activities. PDQ is updated weekly.
Data Limitations:
We excluded critical access hospitals, children's hospitals, and
cancer hospitals because they generally do not provide post acute care
services.
We generally excluded two of the three AOs that accredit hospitals
from our analysis”the American Osteopathic Association and Det Norske
Veritas Healthcare, Inc.”because combined they surveyed 2 percent of
LTCHs in 2009; however, we interviewed officials at these AOs to
understand their accreditation policies.
We generally used FY 2009 data for our analyses because FY 2009 was
the most recent year for which complete data were available; these
data included information on any facility that operated during FY 2009.
To ensure the reliability of the data we analyzed, we interviewed CMS
and TJC officials, reviewed CMS and TJC documentation, and traced a
selection of CMS records to verify internal consistency. Based on the
information obtained from CMS and TJC, we determined that the data
were sufficiently reliable for the purposes of this report.
We conducted this performance audit from July 2010 through November
2010 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objective.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objective.
Background: Types of Hospitals:
ACHs: Provide general, short-term care for a broad range of medical
conditions and provide diagnostic or therapeutic services, surgery,
and limited rehabilitation services.
* Medicare pays for ACH services using the inpatient prospective
payment system (IPPS). IPPS rates are based on the average costs per
case for each diagnosis.
While all hospitals are expected to treat individuals who require an
acute level of care, some may also specialize in post acute care.
Other types of hospitals (excluded from the IPPS)[A] that may
specialize in post acute care include:
* LTCHs: Provide acute and post acute care for relatively extended
periods of time, such as for individuals requiring ventilator care.
* Psychiatric hospitals: Provide clinical psychiatric services to
patients with mental illness.
* Rehabilitation hospitals: Provide intensive rehabilitation to
patients recovering from medical conditions.
[A] These facilities are paid under prospective payment systems that
are specific to each facility type.
Background: Hospital Categories:
Freestanding Hospitals:
* Are self-contained hospitals, not located in or on the campus of
another hospital.
* Are identified with a unique CMS identification number.[A]
Hospitals within Hospitals (HwH):
* Are located in a building used by another hospital”known as the host
hospital”or in one or more separate buildings located on the same
campus as another hospital.
* Must be licensed and operate separately from the host hospital,
maintain a separate board and administrative structure, and have
separate medical staff to be excluded from IPPS.
* Are identified with a unique CMS identification number.
* According to CMS officials, approximately half of LTCHs are HwHs.
- Other types of hospitals”-including psychiatric and rehabilitation
hospitals-”can also be HwHs, but CMS officials told us that this is
less common.
[A] Hospitals that separately participate in the Medicare program are
assigned a unique identification number by CMS, called the CMS
Certification Number.
Background: Nursing Homes:
* Provide skilled nursing, rehabilitation, and/or custodial care to
elderly and disabled individuals.
- Medicare covers up to 100 days of skilled nursing home care
following a hospital stay.
- Medicaid covers nursing home stays for certain low-income
individuals.
- Combined Medicare and Medicaid payments for nursing home services in
2008 were about $82 billion”with a federal share of $58 billion”which
represented about 45 percent of total U.S. nursing home
expenditures.[A]
* Can be freestanding or located within hospitals.[B]
* Ninety percent provide services for both Medicare and Medicaid
patients; of the remaining 10 percent, half accept Medicare patients
only and half accept Medicaid patients only.
[A] FY 2008 data were the most recent data available at the tine we
did our work.
[B] Freestanding and hospital-based nursing homes are considered to be
independent facilities and are identified with unique CMS
identification numbers.
Background: Differences in Hospital and Nursing Home Ownership:
Fifty-eight percent of LTCHs are for-profit.
* Thirty-one percent of LTCHs are owned by two for-profit chains.
- Select Medical Corporation owns 18 percent of LTCHs.
- Kindred Healthcare owns 13 percent of LTCHs.
In contrast, 27 percent of all types of hospitals are for-profit.
Table: Differences in Hospital Ownership, FY 2009:
Number (percentage) of hospitals:
For-profit:
LTCHs: 252 (58%);
ACHs[A]: 764 (21%);
Psychiatric hospitals: 154 (30%);
Rehabilitation hospitals: 139 (61%);
Total: 1,309 (27%).
Nonprofit:
LTCHs: 150 (34%);
ACHs[A]: 2,185 (60%);
Psychiatric hospitals: 136 (26%);
Rehabilitation hospitals: 80 (35%);
Total: 2,551 (53%).
Government:
LTCHs: 32 (7%);
ACHs[A]: 706 (19%);
Psychiatric hospitals: 224 (44%);
Rehabilitation hospitals: 10 (4%);
Total: 972 (20%).
Total:
LTCHs: 434 (100%)[B];
ACHs[A]: 3,655 (100%);
Psychiatric hospitals: 514 (100%);
Rehabilitation hospitals: 229 (100%);
Total: 4,832 (100%).
Source: GAO analysis of CMS data.
Note: Numbers do not always sum to 100 percent because of rounding.
[A] Some ACHs have IPPS-excluded psychiatric and rehabilitation units
that provide services similar to those of psychiatric and
rehabilitation hospitals, but these units have the same CMS
identification number as the ACH in which they are located.
[B] According to CMS, there were 439 LTCHs as of November 2010.
[End of table]
Table: Differences in Nursing Home Ownership, FY 2009:
The majority (68 percent) of nursing homes are for-profit.
Number (percentage) of nursing homes:
For-profit:
Freestanding: 10,655 (72%);
Hospital-based: 152 (13%);
Total nursing homes, by type of ownership: 10,807 (68%).
Nonprofit:
Freestanding: 3,453 (23%);
Hospital-based: 730 (62%);
Total nursing homes, by type of ownership: 4,183 (26%).
Government:
Freestanding: 640 (4%);
Hospital-based: 293 (25%);
Total nursing homes, by type of ownership: 933 (6%).
Total nursing homes:
Freestanding: 14,748 (100%);
Hospital-based: 1,175 (100%);
Total nursing homes, by type of ownership: 15,923 (100%).
Source: GAO analysis of CMS data.
Note: Numbers do not always sum to 100 percent because of rounding.
[End of table]
Geographic Distribution of LTCHs, ACHs, and Nursing Homes:
LTCHs are not evenly distributed across the nation (see next slide).
* Four states-”ME, NH, VT, WY”-do not have LTCHs.
* One state”-TX-”has 76 LTCHs (18 percent of LTCHs).
* Patients who can be treated by LTCHs may instead receive care in
ACHs, other types of hospitals, or nursing homes.
In contrast, every state has ACHs and nursing homes, although
distribution patterns vary (i.e., rural vs. urban).[A]
[A] Additionally, two U.S. territories do not have nursing homes”
American Samoa and the Commonwealth of the Northern Mariana Islands.
Figure: Geographic Distribution of LTCHs:
[Refer to PDF for image: illustrated U.S. map]
Sources: GAO analysis of CMS data; Map Resources (map).
[End of figure]
Results:
There are differences in the oversight of LTCHs, other types of
hospitals, and nursing homes. These differences exist in four areas:
* Medicare and Medicaid participation requirements.
* Quality standards.
* Surveys.
* Enforcement of quality standards.
Medicare and Medicaid Participation Requirements:
Hospitals (All Types) and Nursing Homes:
Hospitals All Types:
* Must demonstrate compliance, through unannounced on-site surveys,
with Medicare quality standards established by CMS called Conditions
of Participation (COP).
- AOs conduct on-site surveys using standards that CMS has deemed to
be at least equivalent to the COPs.
Nursing Homes:
* Must demonstrate compliance, through unannounced on-site surveys,
with Medicare and Medicaid nursing home quality standards that focus
on the delivery of care, resident outcomes, and facility conditions.
Surveys for hospitals and nursing homes may be either:
* Routine-”conducted at specific intervals or;
* Complaint-”conducted in response to allegations of quality problems
made by families, patients, health care workers, or others.
Hospitals have a choice of being surveyed either by state survey
agencies or AOs; nursing homes can only be surveyed by state survey
agencies because no AOs are currently approved to survey them.[A]
* For hospitals and nursing homes, surveys by state survey agencies
result in their certification to participate in Medicare and/or
Medicaid.
* For hospitals, surveys by AOs result in facility accreditation,
which CMS accepts as a basis for facility certification for Medicare
participation.
Facilities that fail to meet CMS or AO standards may be sanctioned,
may lose accreditation, or both.
[A] AOs charge a fee for accreditation; state survey agency surveys
are generally funded by Medicare.
Table: State- and Accreditation-Organization-Surveyed Hospitals and
Nursing Homes, FY 2009:
Number (percentage) of facilities:
State-surveyed:
Hospital: LTCHs: 90 (21%);
Hospital: ACHs[A]: 508 (14%);
Hospital: Psychiatric hospitals: 108 (21%);
Hospital: Rehabilitation hospitals: 37 (16%);
Total Hospitals: 743 (15%);
Nursing homes: 15,923 (100%).
AO-surveyed[B]:
Hospital: LTCHs: 334 (79%);
Hospital: ACHs[A]: 3,147 (86%);
Hospital: Psychiatric hospitals: 406 (79%);
Hospital: Rehabilitation hospitals: 192 (84%)
Total Hospitals: 4,089 (85%)
Nursing homes: N/A.
Total:
Hospital: LTCHs: 434[C] (100%);
Hospital: ACHs[A]: 3,655 (100%);
Hospital: Psychiatric hospitals: 514 (100%);
Hospital: Rehabilitation hospitals: 229 (100%);
Total Hospitals: 4,832 (100%);
Nursing homes: 15,923(100%).
Source: GAO analysis of CMS data.
[A] Some ACHs have IPPS-excluded psychiatric and rehabilitation units
that provide services similar to those of psychiatric and
rehabilitation hospitals, but these units have the same CMS
identification number as the ACH in which they are located.
[B] These numbers include hospitals that were accredited by TJC, Det
Norske Veritas Healthcare, Inc., and the American Osteopathic
Association. In FY 2009, hospitals accredited by TJC accounted for
over 95 percent of accredited hospitals.
[C] According to CMS, there were 439 LTCHs as of November 2010.
[End of table]
Quality Standards: Hospital COPs and Standards:
CMS has 74 standards organized under 23 COPs, including categories
such as Medical Staff, Infection Control, and Emergency Services (see
appendix l).[A]
* COPs were created in 1966 and significantly revised in 1986.
* CMS has since updated the COPs several times on a variety of topics,
including Patients' Rights.
* In August 2010, CMS adopted an update to the Rehabilitation and
Respiratory Services COPs.
* Additionally, since 2000 CMS has been updating the guidance used to
interpret and apply these standards.
TJC's standards are organized into 17 categories, such as Medication
Management and Leadership (see appendix II).
* TJC last updated its standards in 2010.
[A] Hospitals that provide certain specialized services may be
required to meet additional COPs. For example, hospitals that provide
transplant services must also meet the 13 COPs governing transplant
services.
In addition, TJC:
* Measures hospitals against its National Patient Safety Goals, which
are intended to promote specific improvements in patient safety.
* Requires hospitals to complete and submit annual self-assessments of
compliance with standards.
* Requires hospitals to submit data for selected measures of clinical
performance.
LTCHs are surveyed by state survey agencies and AOs using the same
standards that are applied to ACHs; there are no additional survey
standards or patient care requirements that are specific to LTCHs.
Psychiatric hospitals and rehabilitation hospitals are surveyed using
the same standards that are applied to ACHs, but must meet additional
standards.[A]
* Psychiatric hospitals must meet two additional COPs:
- Adequate staffing of qualified mental health professionals, and;
- Medical record requirements that stress the psychiatric components
of the evaluation(s) and treatment(s) provided.
* Rehabilitation hospitals must:
- Comply with IPPS exclusion requirements for inpatient rehabilitation
facilities.
[A] Surveys for these additional standards are not conducted by AOs.
Most surveys of the additional psychiatric hospital COPs are conducted
by CMS contractors with psychiatric expertise. IPPS-excluded
psychiatric and rehabilitation units within ACHs must meet additional
standards similar to those for psychiatric and rehabilitation
hospitals. These units meet the additional standards primarily through
self-attestation. In addition, state survey agencies survey a small
sample of the units annually to validate compliance.
According to CMS, the agency is developing LTCH-specific regulations
in the hospital COPs in response to requirements in the Medicare,
Medicaid, and SCHIP Extension Act of 2007.
* CMS officials told us that the changes to the COPs may reflect the
patient admission and discharge process, staffing requirements, and
the level of patient care.
* Estimated release for public comment is in May 2011, with the final
rule expected to be issued in May 2012.
* TJC officials also reported that they are developing standards
specific to LTCHs.
CMS will ensure that the LTCH-specific standards developed by TJC and
other AOs are at least equivalent to those developed by CMS.
Quality Standards: Nursing Home Standards:
CMS has about 200 nursing home standards, such as preventing avoidable
pressure sores, weight loss, and accidents. The standards are grouped
into 15 categories, including quality of life, resident assessment,
quality of care, and administration.
* Uniform standards for Medicare and Medicaid were created in 1987.
* Since 2000, CMS has been updating the guidance used to interpret and
apply these standards.
Surveys: Frequency of Routine Surveys-”Hospitals (All Types):
According to CMS policy, all state-surveyed hospitals are to be
surveyed every 3 years, on average, with an interval not to exceed 5
years.[A]
* From 25 to 33 percent of psychiatric hospitals are to be surveyed
annually for their two additional COPs.
* Rehabilitation hospitals must attest annually to meeting IPPS
exclusion criteria.
TJC-surveyed hospitals are to be surveyed every 3 years, but to ensure
that surveys are unannounced, the interval between surveys ranges from
18 months to 39 months.[B]
* According to CMS policy, AOs are required to conduct surveys every 3
years, on average.
Survey schedules are established when a hospital enters the Medicare
program.
* Because HwHs are independently licensed and operated, their schedule
is not necessarily tied to the host hospital's survey schedule.
[A] We have previously found that not all hospitals are surveyed
within the maximum survey interval of 5 years. See GAO, Medicare and
Medicaid Participating Facilities: CMS Needs to Reexamine Its Approach
for Funding State Oversight of Health Care Faculties, GAO-09-64
(Washington, D.C.: Feb. 13, 2009).
[B] Effective January 1, 2011, TJC's survey interval will range from
18 months to 36 months.
Surveys: Frequency of Routine Surveys-”Nursing Homes:
Nursing homes are to be surveyed every 12 months, on average, with an
interval not to exceed 15 months.
The nursing home survey interval is a statutory requirement.[A]
[A] See 42 U.S.C. § 1395i-3(g)(2)(A)(iii)(I), § 1396r(g)(2)(A)(iii)(I).
Table: Percentage of Hospitals and Nursing Homes That Had Routine
Surveys, Based on Their Respective Survey Intervals:
State-surveyed[A]:
Hospitals (FY 2007 through 2009): LTCHs: 63%;
Hospitals (FY 2007 through 2009): ACHs: 87%;
Hospitals (FY 2007 through 2009): Psychiatric hospitals: 79%;
Hospitals (FY 2007 through 2009): Rehabilitation hospitals: 54%;
Nursing homes (FY 2009): 99%.
TJC-surveyed:
Hospitals (FY 2007 through 2009): LTCHs: 100%[B];
Hospitals (FY 2007 through 2009): ACHs: 100%;
Hospitals (FY 2007 through 2009): Psychiatric hospitals: 100%[B];
Hospitals (FY 2007 through 2009): Rehabilitation hospitals: 100%[B];
Nursing homes (FY 2009): N/A.
Source: GAO analysis of CMS data and TJC data.
[A] State-surveyed hospitals are generally surveyed every 3 to 5
years; nursing homes are surveyed every year, on average.
[B] In these years, 100 percent of hospitals were surveyed, but a few
hospitals received more than one survey during the 3-year period. To
ensure that TJC surveys are unannounced, the survey interval ranges
from 18 months to 39 months.
[End of table]
Surveys: Complaint Surveys-”Hospitals (All Types):
State survey agencies may conduct complaint surveys for allegations
made against state-surveyed hospitals.
* State survey agencies conduct an on-site survey to evaluate
compliance with the COP(s) and standard(s) related to the complaint.
* If surveyors find a hospital is out of compliance with one or more
COPs during a complaint survey, the survey may be expanded to include
all Medicare COPs.
State survey agencies' complaint surveys for allegations involving AO-
surveyed hospitals require CMS regional office authorization.
* CMS may place the hospital under the state's jurisdiction until it
returns to compliance with the COP(s).
TJC may conduct complaint surveys when it receives complaints against
hospitals it accredits.
* TJC conducts an on-site survey to evaluate compliance with the
standard(s) related to the complaint, but the survey may be expanded
if warranted.
* If a TJC complaint survey finds a hospital is out of compliance with
one or more TJC standard(s) that are equivalent to CMS's COP(s), TJC
conducts an on-site follow-up survey within 45 days.
Surveys: Complaint Surveys-”Nursing Homes:
State survey agencies are to conduct all nursing home complaint
surveys, which focus on specific allegations, and may be expanded to
examine all Medicare and Medicaid standards.
Table: Number of Hospital and Nursing Home Complaint Surveys
Conducted, FY 2009:
State-survey-agency-conducted complaint surveys:
State-surveyed:
Hospitals: LTCHs: 70;
Hospitals: ACHs: 483;
Hospitals: Psychiatric hospitals: 67;
Hospitals: Rehabilitation hospitals: 10;
Nursing homes: 47,160.
TJC-surveyed[A]:
Hospitals: LTCHs: 234;
Hospitals: ACHs: 4,195;
Hospitals: Psychiatric hospitals: 304;
Hospitals: Rehabilitation hospitals: 70;
Nursing homes: N/A.
TJC-conducted complaint surveys:
TJC-surveyed:
Hospitals: LTCHs: 14;
Hospitals: ACHs: 177;
Hospitals: Psychiatric hospitals: 38;
Hospitals: Rehabilitation hospitals: 5;
Nursing homes: N/A.
Source: GAO analysis of CMS data and TJC data.
[A] State survey agencies may investigate complaints against hospitals
that are surveyed by TJC.
[End of table]
Enforcement of Quality Standards: State-Surveyed Hospitals-”All Types:
State survey agencies may cite COP- and standard-level deficiencies on
routine or complaint surveys.
* COP-level deficiencies are more serious and can jeopardize or
adversely affect the health of a patient if they recur or are not
resolved.
* Standard-level deficiencies are less serious and may not adversely
affect the health of patients.
Hospitals, including LTCHs, must prepare corrective action plans for
both types of deficiencies.
* For COP-level deficiencies, the state survey agency may return to
the facility to ensure that the deficiencies have been corrected prior
to the facility's next survey.
State-surveyed hospitals that are unable to correct COP-level
deficiencies may be terminated from the Medicare program.
Survey findings are not available on CMS's Website for any type of
hospital.
Enforcement of Quality Standards: Accreditation-Organization-Surveyed
Hospitals”-All Types:
TJC cites two types of requirements for improvement (RFI) for
hospitals found out of compliance with its standards on routine or
complaint surveys:
* Direct RFIs: Cited when compliance issues are directly tied to
quality, such as pain.
* Indirect RFIs: Cited when compliance issues are indirectly related
to quality, such as hospital leadership.
Hospitals must document corrective actions to demonstrate that they
have returned to compliance within 45 days for direct RFIs and within
60 days for indirect RFIs.
* Hospitals may be resurveyed by TJC to verify the implementation of
the corrective actions.
TJC officials said they use the term RFI instead of deficiency because
they consider the survey process to be an opportunity to consult with
and educate hospitals about quality-of-care issues.
A hospital that does not correct all of its RFIs within the required
time frames may receive[A].
* Conditional accreditation: The hospital is not in substantial
compliance with applicable TJC standards; the hospital must remedy
identified problem areas by submitting a plan of correction and be
resurveyed, or;
* Preliminary denial of accreditation: The hospital has an immediate
threat to health or safety for patients or has failed to resolve the
requirements of a conditional accreditation, but the appeal process
may result in a decision other than denial of accreditation.
A hospital may be denied accreditation if it has exhausted all review
and appeal opportunities, failed to pay the accreditation fee, or
refused to allow a survey.
CMS may subsequently terminate hospitals that lose their accreditation
from the Medicare program.
A hospital's final accreditation decision is posted on TJC's Website.
According to TJC officials, findings of noncompliance with the
standards evaluated during the survey are available on the Website
only if the hospital received conditional or preliminary denial of
accreditation.
[A] Effective January 1, 2011, TJC plans to change the titles of these
categories.
Enforcement of Quality Standards: Nursing Homes:
Deficiencies identified by state survey agencies during routine or
complaint surveys are classified according to:
* Scope: the number of affected residents, and;
* Severity: four levels, ranging from minimal harm to immediate
jeopardy.
Plans of correction are required for all deficiencies at the more than
minimal harm level.
* State survey agencies revisit facilities to ensure correction of
serious deficiencies.
Generally, CMS imposes sanctions (enforcement actions) for serious
deficiencies.
* Nursing homes may be terminated from the Medicare and Medicaid
programs but may also receive intermediate sanctions such as denial of
payment or civil money penalties.
* Past compliance with CMS standards is considered when determining
severity of sanctions.
* In FY 2009, CMS data showed that state survey agencies used
intermediate sanctions in about 17 percent of all nursing homes.
The deficiencies cited during nursing home surveys are available on
CMS's Website.[A]
[A] See Nursing Home Compare, [hyperlink,
http://www.medicare.gov/NHcompare] (accessed Sept. 29, 2010).
Table: Hospitals and Nursing Homes Terminated from Medicare, FY 2005
through FY 2009[A]:
Number (percentage) terminated:
State-surveyed:
Hospitals: LTCHs: 2 (2.5%).
Hospitals: ACHs: 7 (1.3%).
Hospitals: Psychiatric hospitals: 2 (2.1%).
Hospitals: Rehabilitation hospitals: 0 (0%).
Nursing homes: 88 (0.6%).
TJC-surveyed:
Hospitals: LTCHs: 0 (0%);
Hospitals: ACHs: 3 (0.1%);
Hospitals: Psychiatric hospitals: 4 (1.0%);
Hospitals: Rehabilitation hospitals: 1 (0.5%);
Nursing homes: N/A.
Source: GAO analysis of CMS data.
[A] Hospitals and nursing homes may voluntarily choose to terminate
their participation in the Medicare program for a number of reasons
including merger or change of ownership. We have excluded these
facilities from our analysis.
[End of table]
Summary of Differences in Oversight among LTCHs, Other Hospitals, and
Nursing Homes:
Although some aspects of the oversight of LTCHs are similar to those
of other types of hospitals and nursing homes, there are more aspects
in which the oversight differs.
Similarities:
* All facility types must meet certain minimum quality requirements in
order to participate in the Medicare and Medicaid programs.
* Compliance for all facility types is determined during unannounced,
on-site surveys.
Differences:
* While LTCHs are assessed using the same standards that are applied
to ACHs, other types of hospitals have additional standards or patient
care requirements that are specific to their facility type; nursing
homes also have a specific set of standards that reflect the
characteristics of the population served.
* LTCHs and other types of hospitals may choose to be surveyed by AOs
or state survey agencies, and most choose the former; in contrast,
nursing homes are only surveyed by state survey agencies because no
AOs are currently approved to survey them.
* The interval between surveys for LTCHs surveyed by state survey
agencies may be longer than the interval for AO-surveyed LTCHs;
nursing homes are surveyed more frequently than all types of
hospitals, including LTCHs.
* Survey findings for LTCHs and other types of hospitals are not
always publicly available, but nursing home deficiencies are always
published on CMS's Nursing Home Compare Website.
* The only sanction that may be imposed upon any type of hospital is
termination from the Medicare and Medicaid programs; nursing homes may
receive a variety of sanctions when they fail to meet federal quality
standards.
Agency Comments:
We provided a draft of these briefing slides to the Department of
Health and Human Services (HHS) and TJC for comment, and HHS provided
CMS's response (see app. III). CMS noted that it is in the process of
developing a LTCH-specific regulation within the hospital COPs in
response to requirements in the Medicare, Medicaid, and SCHIP
Extension Act of 2007. CMS also noted that the briefing slides were a
welcome resource for highlighting the statutory and other differences
in how the agency exercises oversight of these types of health care
facilities. Both CMS and TJC provided technical comments, which we
incorporated as appropriate.
Appendix I: CMS's 23 Hospital COPs:
Table: COPs reviewed by state survey agencies:
1. Anesthesia Services:
If anesthesia services are provided, they must be well organized and
directed by a qualified doctor of medicine or osteopathy. The service
is responsible for all anesthesia administered.
2. Compliance with Federal, State, and Local Laws:
The hospital must comply with applicable federal laws on patient
health and safety and state and local laws on hospital and personnel
licensing.
3. Discharge Planning:
A hospital must have a discharge planning process applicable to all
patients. Policies and procedures must be in writing.
4. Emergency Services:
If emergency services are provided, they must be organized under the
direction of a qualified member of the medical staff and have adequate
medical and nursing personnel qualified in emergency care to meet the
needs anticipated by the facility.
5. Food and Dietetic Services:
Dietary services must be organized, directed, and staffed by qualified
personnel. Contracted services must meet certain requirements.
6. Governing Body:
The hospital must have a legally responsible governing body or persons
charged with the responsibilities of a governing body.
7. Infection Control:
A hospital's sanitary environment must avoid sources and transmission
of infections and communicable diseases. It must have an active
program to prevent, control, and investigate infections and
communicable diseases.
8. Laboratory Services:
The hospital must maintain, or have available, adequate laboratory
services.
9. Medical Record Services:
A hospital must have a medical record service that has administrative
responsibility for medical records.
10. Medical Staff:
A hospital must have an organized medical staff that abides by bylaws
approved by the governing body and is responsible for the quality of
patient medical care.
11. Nuclear Medicine Services:
If nuclear medicine services are provided, they must meet the needs of
the patients in accordance with acceptable standards of practice.
12. Nursing Services:
An organized nursing service must provide 24-hour nursing services
that are supervised or furnished by registered nurses.
13. Organ, Tissue, and Eye Procurement:
The hospital must have and implement written protocols on procurement,
have adequate organ transplant policies, and meet the 13 COPs
governing transplant services if transplants are performed in the
hospital.
14. Outpatient Services:
If outpatient services are provided, they must meet patient needs
consistent with acceptable standards of practice.
15. Patients' Rights:
A hospital must protect and promote each patient's rights.
16. Pharmaceutical Services:
The hospital must have pharmaceutical services that meet patient needs.
17. Physical Environment:
Hospital construction, arrangements, and maintenance must ensure
patient safety and provide diagnostic and treatment facilities and
special hospital services appropriate to community needs.
18. Quality Assessment and Performance Improvement Program:
A hospital must have an effective, hospitalwide quality assurance
program.
19. Radiologic Services:
The hospital must maintain, or have available, diagnostic radiologic
services. Therapeutic services provided must meet professionally
approved standards for safety and personnel qualifications.
20. Rehabilitation Services:
If rehabilitation, physical therapy, occupational therapy, audiology
or speech pathology services are provided, they must be organized and
staffed to ensure the health and safety of patients.
21. Respiratory Care Services:
If respiratory services are provided, they must meet patient needs in
accordance with acceptable standards of practice.
22. Surgical Services:
If surgical services are provided, they must be well organized and
provided in accordance with acceptable standards of practice.
Outpatient services must be consistent with inpatient care quality in
accordance with the complexity of services offered.
23. Utilization Review:
Utilization review plans must provide for review of the services that
a hospital and its medical staff provide to Medicare and Medicaid
patients.
Source: GAO summary of CMS's hospital COPs.
[End of table]
Appendix II: TJC's 17 Categories of Hospital Standards:
Table: Standards reviewed by TJC:
1. Environment of Care:
The hospital must manage risks to its environment, including safety
and security, hazardous materials and waste, medical equipment,
utility systems, and fire. This standard also requires hospitals
establish a safe, functional environment. The hospital is required to
monitor and make improvements to the environment based on its analysis
of environment of care issues.
2. Emergency Management:
The hospital is required to develop a written emergency operations
plan that includes how it will communicate, manage security and
safety, and manage patients during emergencies. The hospital also
evaluates the effectiveness of its emergency management plan.
3. Human Resources:
The hospital is required to establish and verify staff qualifications,
orient staff, and provide staff with training to support hospital
care, treatment, and services. The hospital is required to assess
staff competence and performance on a regular basis.
4. Infection Prevention and Control:
The hospital must establish a systematic infection prevention and
control program. The systematic approach to infection prevention and
control includes requirements to plan, implement, and evaluate the
program.
5. Information Management:
The hospital must establish a plan for managing information and
maintaining the security of the health information. The requirements
include planning for continuity of information management processes in
the event of any interruptions.
6. Leadership:
The hospital is required to have a leadership structure to support
operations and develop a culture of safety and quality. The
requirements include leadership's responsibilities regarding
relationships, communications, and systems performance and operations.
7. Life Safety:
The hospital is required to design and manage its physical environment
to prevent fires and protect individuals in the event of fires.
8. Medication Management:
The hospital is required to safely, clearly, and appropriately manage
the medication it procures, dispenses, administers, and monitors and
reduce the potential for medication errors. The hospital is required
to evaluate its medication management processes and take action on
improvement opportunities.
9. Medical Staff:
The medical staff and governing body of the hospital must provide
oversight of the quality of care, treatment, and services delivered by
the hospital's practitioners. The hospital uses a process to determine
the competency of practitioners by collecting, verifying, and
evaluating data relevant to the practitioners' professional
performance. The hospital evaluates practitioner performance on an
ongoing basis.
10. National Patient Safety Goals:
The hospital's patient safety goals include improving the accuracy of
patient identification, effectiveness of caregiver communication, and
safety of using medications.
11. Nursing:
The hospital is required to employ a qualified nurse executive to
establish guidelines and direct the hospital's nursing services,
policies, and procedures and delivery of care, treatment, and
services. The nurse executive functions at the senior leadership level.
12. Provision of Care, Treatment, and Services:
The hospital is required to accept, provide, and coordinate safe,
interdisciplinary care, treatment, and services for all patients if it
is able to meet their needs.
13. Performance Improvement:
The hospital is required to collect and analyze data to monitor and
continually improve performance. The hospital uses data to implement
performance improvement activities and monitors the effectiveness of
these activities.
14. Record of Care, Treatment, and Services:
The hospital is required to maintain and audit complete, timely,
authentic, and accurate medical records for each patient.
15. Rights and Responsibilities of the Individual:
The hospital must respect protect, and promote patients' rights.
16. Transplant Safety:
The hospital is required to develop and implement policies and
procedures for organ and tissue donation and procurement.
17. Waived Testing:
The hospital is required to have current, approved, and readily
available policies and procedures for waived testing.
Source: GAO summary of TJC's hospital standards.
[End of table]
Appendix III: Comments from the Department of Health and Human
Services:
Department Of Health and Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
November 6, 2010:
Linda T. Kohn:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Kohn:
Attached are comments on the U.S. Government Accountability Office's
(GAO) draft briefing slides entitled: "Differences in the Oversight of
Long-Term Care Hospitals, Other Types of Hospitals, and Nursing Homes"
(Job Code 290871). The Department appreciates the opportunity to
review this correspondence before its publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
General Comments Of The U.S. Department Of Health And Human Services
(HHS) On The Government Accountability Office's (GAO) Draft Briefing
Slides Entitled: "Differences In The Oversight Of Long-Term. Care
Hospitals, Other Types Of Hospitals, And Nursing Homes (Job Code
290871):
The Centers for Medicare & Medicaid Services (CMS) appreciates the
opportunity to review and comment on the subject draft report. We have
included a number of technical6omments which we hope will facilitate
an accurate overview of certain data on hospitals and nursing homes as
well as of CMS' oversight mechanisms for the different types of
facilities. We are committed to providing vigorous oversight of all
types of hospitals and nursing homes in order to ensure that, patients
and residents receive safe, high quality care.
Long-term care hospitals (LTCHs) are a type of hospital that
participates in the Medicare program and which provides acute care to
clinically complex patients whose length of stay exceeds 25 days on
average. Currently there are 439 LTCHs participating in the Medicare
program, in order to be paid under the Medicare LTCH prospective
payment system, hospitals must Satisfy a number of specific
requirements based on the Medicare payment regulations. In addition,
like all other hospitals, LTCHs must comply with the hospital health
and safety standards as a condition of participation;in the Medicare
program. The CMS is also in the process of developing LTCH-specific
regulations within the hospital conditions of participation,
consistent with the requirements for LTCHs found in the Medicare,
Medicaid, and State Children's Health Insurance Program (SCHIP)
Extension Act of 2007. Location of these provisions in the conditions
of participation will allow enforcement through Federal surveys or
surveys by Medicare-approved hospital accreditation programs. We
believe that this will strengthen CMS' oversight of the quality of
care in LTCH facilities.
The GAO's draft briefing slides, Differences in the Oversight of Long
Term Care Hospitals, Other Types of Hospitals, and Nursing Homes, job
code 290871, provides a welcome resource for highlighting the
statutory and other differences in the manner in which CMS, exercises
oversight of these various types of health care facilities. This
report makes no recommendations.
[End of briefing slides]
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