Poorly Performing Nursing Homes
Special Focus Facilities Are Often Improving, but CMS's Program Could Be Strengthened Gao ID: GAO-10-197 March 19, 2010CMS established the Special Focus Facility (SFF) Program in 1998 to help address poor nursing home performance. States select a subset of homes as SFFs from a list of the 15 poorest performing homes in each state, but the program is limited to 136 homes nationwide because of resource constraints. CMS guidance directs states to survey SFFs twice as frequently as other homes and to propose more robust enforcement, including termination, for SFFs that fail to improve within about 18 months. GAO was asked to (1) determine the factors states consider in selecting SFFs and how SFFs differed from other nursing homes, (2) evaluate CMS regional office and state adherence to program guidance and the program's impact on homes' performance, and (3) identify other strategies that have been used to improve poorly performing homes. In general, GAO's analysis used CMS data from 2005 through 2009 on SFFs and other homes as well as interviews with officials in 14 states selected based on the number of SFFs in each state and other factors.
When selecting SFFs from the candidate list, state officials considered factors other than rank on that list, such as their own knowledge of each candidate's circumstances. For example, state officials might not select a nursing home as an SFF if the home had a new owner they perceived as committed to addressing the home's quality problems. GAO found that states selected SFFs from among the five worst-ranked candidates about 57 percent of the time from January 2006 through February 2009. State discretion in selecting SFFs is key not only because of states' familiarity with each candidate's circumstances but because the list has limitations. Some officials from the 14 states that GAO interviewed noted that candidate lists included current SFFs, resulting in an insufficient number of homes from which to select new SFFs. The characteristics of SFFs differed from those of other nursing homes in terms of organization type and the number of beds and residents. For example, SFFs were more likely than other homes to be chain affiliated and for-profit and to have more beds and more total residents. GAO found that some states did not consistently follow CMS's basic SFF Program requirements. When CMS began monitoring SFF survey frequency in fiscal year 2008, 8 states did not conduct twice as many surveys for SFFs as required--a significant improvement compared to 26 states in the previous fiscal year. GAO also found that CMS's enforcement guidance is vague and results in inconsistent interpretations. For example, one SFF was assessed no civil money penalties (CMP) even though it was cited for consecutive deficiencies that could have resulted in fines of up to $825 per day of noncompliance while a home with a similar compliance history was assessed CMPs that increased from $300 to $600 per day of noncompliance. Most SFFs did eventually graduate, but not all met CMS's graduation criteria, and some SFFs remained in the program well beyond CMS's expected 18-month time frame for improvement. For example, 17 percent of active SFFs as of February 2009 had been in the program for 25 months or longer--some since 2005. However, most graduates showed significant improvement while in the program but some failed to sustain that improved performance after graduation. CMS and states have used a variety of additional strategies to help address care problems identified at SFFs and other nursing homes. For example, a few CMS regional offices have negotiated agreements requiring SFFs to take specific actions, such as hiring quality improvement consultants. In addition, each year one SFF per state can volunteer to work with an organization under contract with CMS to deal more directly with the root causes of poor quality. Some states have adopted their own quality improvement strategies that offer assistance to both poorly performing and other homes, including on-site technical assistance from nurse consultants or monthly training opportunities for nursing home staff on the most frequently cited care problems. Further, one state charges homes for the cost of additional surveys that it conducts under a program that resembles the SFF Program.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: John E. Dicken Team: Government Accountability Office: Health Care Phone: (202) 512-7043GAO-10-197, Poorly Performing Nursing Homes: Special Focus Facilities Are Often Improving, but CMS's Program Could Be Strengthened
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
March 2010:
Poorly Performing Nursing Homes:
Special Focus Facilities Are Often Improving, but CMS's Program Could
Be Strengthened:
GAO-10-197:
GAO Highlights:
Highlights of GAO-10-197, a report to congressional requesters.
Why GAO Did This Study:
CMS established the Special Focus Facility (SFF) Program in 1998 to
help address poor nursing home performance. States select a subset of
homes as SFFs from a list of the 15 poorest performing homes in each
state, but the program is limited to 136 homes nationwide because of
resource constraints. CMS guidance directs states to survey SFFs twice
as frequently as other homes and to propose more robust enforcement,
including termination, for SFFs that fail to improve within about 18
months. GAO was asked to (1) determine the factors states consider in
selecting SFFs and how SFFs differed from other nursing homes, (2)
evaluate CMS regional office and state adherence to program guidance
and the program‘s impact on homes‘ performance, and (3) identify other
strategies that have been used to improve poorly performing homes. In
general, GAO‘s analysis used CMS data from 2005 through 2009 on SFFs
and other homes as well as interviews with officials in 14 states
selected based on the number of SFFs in each state and other factors.
What GAO Found:
When selecting SFFs from the candidate list, state officials
considered factors other than rank on that list, such as their own
knowledge of each candidate‘s circumstances. For example, state
officials might not select a nursing home as an SFF if the home had a
new owner they perceived as committed to addressing the home‘s quality
problems. GAO found that states selected SFFs from among the five
worst-ranked candidates about 57 percent of the time from January 2006
through February 2009. State discretion in selecting SFFs is key not
only because of states‘ familiarity with each candidate‘s
circumstances but because the list has limitations. Some officials
from the 14 states that GAO interviewed noted that candidate lists
included current SFFs, resulting in an insufficient number of homes
from which to select new SFFs. The characteristics of SFFs differed
from those of other nursing homes in terms of organization type and
the number of beds and residents. For example, SFFs were more likely
than other homes to be chain affiliated and for-profit and to have
more beds and more total residents.
GAO found that some states did not consistently follow CMS‘s basic SFF
Program requirements. When CMS began monitoring SFF survey frequency
in fiscal year 2008, 8 states did not conduct twice as many surveys
for SFFs as required”a significant improvement compared to 26 states
in the previous fiscal year. GAO also found that CMS‘s enforcement
guidance is vague and results in inconsistent interpretations. For
example, one SFF was assessed no civil money penalties (CMP) even
though it was cited for consecutive deficiencies that could have
resulted in fines of up to $825 per day of noncompliance while a home
with a similar compliance history was assessed CMPs that increased
from $300 to $600 per day of noncompliance. Most SFFs did eventually
graduate, but not all met CMS‘s graduation criteria, and some SFFs
remained in the program well beyond CMS‘s expected 18-month time frame
for improvement. For example, 17 percent of active SFFs as of February
2009 had been in the program for 25 months or longer”some since 2005.
However, most graduates showed significant improvement while in the
program but some failed to sustain that improved performance after
graduation.
CMS and states have used a variety of additional strategies to help
address care problems identified at SFFs and other nursing homes. For
example, a few CMS regional offices have negotiated agreements
requiring SFFs to take specific actions, such as hiring quality
improvement consultants. In addition, each year one SFF per state can
volunteer to work with an organization under contract with CMS to deal
more directly with the root causes of poor quality. Some states have
adopted their own quality improvement strategies that offer assistance
to both poorly performing and other homes, including on-site technical
assistance from nurse consultants or monthly training opportunities
for nursing home staff on the most frequently cited care problems.
Further, one state charges homes for the cost of additional surveys
that it conducts under a program that resembles the SFF Program.
What GAO Recommends:
GAO is recommending that the CMS Administrator take six actions to
strengthen the SFF Program, including (1) notifying homes that are on
the SFF candidate list and (2) seeking legislative authority to charge
SFFs for the costs of conducting additional surveys. HHS generally
agreed with five of GAO‘s recommendations and said it would consider
the other.
View [hyperlink, http://www.gao.gov/products/GAO-10-197] or key
components. For more information, contact John Dicken at (202) 512-
7114 or dickenj@gao.gov.
[End of section]
Contents:
Letter:
Background:
States Considered Factors Other Than Rank When Selecting SFFs, Which
Were More Likely to Be Chain Affiliated and For-Profit Than Other
Nursing Homes:
State and Regional Office Adherence to SFF Program Guidance Was
Uneven, but Most SFFs Improved Their Performance While in the Program:
Other Quality Improvement Strategies to Assist SFFs Have Merit, and
Some Could Inform CMS Efforts:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Special Focus Facility Financial Performance:
Appendix II: Scope and Methodology:
Appendix III: Characteristics of Special Focus Facilities and Other
Nursing Homes:
Appendix IV: Chronological Summary of All 10 Systems Improvement
Agreements (SIA):
Appendix V: Comments from the Department of Health and Human Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Table 2: Points Assigned to Deficiencies in the SFF Methodology:
Table 3: Average Compliance Histories of Selected SFFs Compared to
Those of Other Nursing Homes:
Figures:
Figure 1: CMS's Allocation of SFFs, by State:
Figure 2: Operation of the SFF Program:
Figure 3: SFF Score Ranges for the 15 Program Candidates in Each State:
Figure 4: Percentage of SFFs, SFF Candidates, and Other Nursing Homes
That Had at Least One CMP and DPNA Implemented from 2006 through 2008:
Figure 5: Average Number and Range of Months Nursing Homes Spent in
the SFF Program, by Status and Year Added to the Program:
Abbreviations:
AEM: Automated Survey Processing Environment Enforcement Manager:
CIA: Corporate Integrity Agreement:
CMP: civil money penalty:
CMS: Centers for Medicare & Medicaid Services:
DPNA: denial of payment for new Medicare or Medicaid admissions:
HHS: Department of Health and Human Services:
NHIN: Nursing Homes in Need:
OIG: Office of Inspector General:
OSCAR: On-Line Survey, Certification, and Reporting system:
QIO: Quality Improvement Organization:
SFF: Special Focus Facility:
SIA: Systems Improvement Agreement:
SQC: substandard quality of care:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
March 19, 2010:
The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
The nation's 1.4 million nursing home residents are a highly
vulnerable population of elderly and disabled individuals who rely on
nursing homes to provide high-quality care. The Centers for Medicare &
Medicaid Services (CMS) contracts with state survey agencies to
conduct inspections, known as standard surveys, and complaint
investigations to determine whether nursing homes are complying with
federal quality standards.[Footnote 1] Nursing homes must meet those
standards to participate in Medicare and Medicaid.[Footnote 2] Our
prior reports have found that some nursing homes are chronically
noncompliant; that is, they have been cited repeatedly by state survey
agencies for serious deficiencies such as residents having preventable
pressure sores that harmed them or put them at risk of death or
serious injury.[Footnote 3] In 1998, CMS developed the Special Focus
Facility (SFF) Program to monitor two poorly performing nursing homes
per state, as one way to address issues of chronic noncompliance and
improve the performance of these nursing homes. CMS's program guidance
directs states to conduct more extensive oversight of SFFs and the
agency's regional offices to monitor state implementation of the SFF
Program. CMS expanded the program's size in 2005 to 136 SFFs and up to
6 per state--less than 1 percent of the nation's roughly 16,000
nursing homes--and since then has issued additional guidance to states
regarding the operation of the SFF Program.[Footnote 4] The agency has
not further expanded the SFF Program, with officials citing resource
constraints.[Footnote 5]
You expressed interest in CMS's efforts to influence the performance
of poorly performing nursing homes. Our August 2009 report estimated
the number and characteristics of homes in the United States that
could be considered the most poorly performing.[Footnote 6] We found
that (1) about 580 (4 percent) of the nation's nursing homes could be
considered the most poorly performing and (2) the homes selected as
SFFs are not necessarily the most poorly performing homes in the
nation but rather are among the poorest performers in each state. To
improve the targeting of scarce resources, we recommended that the
Administrator of CMS consider an alternative approach for allocating
the 136 SFFs across states by placing more emphasis on the relative
performance of homes nationally rather than on a state-by-state basis,
which could result in some states having only one or not any SFFs and
other states having more than they are currently allocated. In
response, CMS noted that it would evaluate a hybrid approach that
would assign some SFFs using homes' performance in each state and
other SFFs on their relative national ranking.
In this report, we examined the operation of the SFF Program.
Specifically, we (1) determined the factors states consider in
selecting homes for the SFF Program and how such homes differ from
other nursing homes; (2) evaluated the extent to which the CMS
regional offices and states followed CMS guidance in implementing the
SFF Program and the program's impact on homes' performance; and (3)
identified other strategies that have been employed to improve the
performance of poorly performing homes, including SFFs. You also asked
us to provide information on the financial performance of SFFs, which
can be found in appendix I.
To determine the factors that states consider in selecting SFFs and
how such homes differ from other nursing homes, we analyzed (1) the
scores for all nursing homes as determined by CMS in January 2009
using a methodology it employs for the SFF Program as well as the rank
for all homes added to the program from January 2006 through February
2009 using that same methodology, (2) deficiencies and revisit dates
associated with standard surveys conducted in 2008 and deficiencies
from complaint investigations conducted in the year prior to the 2008
standard survey from CMS's On-Line Survey, Certification, and
Reporting system (OSCAR), and (3) other CMS data, which describe
nursing home characteristics as of December 2008 and January 2009.
[Footnote 7] For the data analyses throughout this report on SFFs, we
used a CMS list of homes that were placed in the SFF Program from
January 2005 through February 2009. We limited our analysis to the
period 2005 through 2009 because in late 2004 CMS announced
significant changes to strengthen the SFF Program, which became
effective in 2005.
To determine the extent to which its regional offices and states
followed CMS's SFF Program guidance and the program's impact on homes'
performance, we analyzed CMS data on (1) survey dates and deficiencies
as reported in OSCAR; (2) sanctions for SFFs, SFF candidates, and all
other nursing homes using CMS's Automated Survey Processing
Environment Enforcement Manager (AEM) for calendar years 2006 through
2008; (3) dates SFFs were placed in and left the program through
termination or graduation; (4) homes that terminated from Medicare and
Medicaid as reported in the Provider of Service file dated December
2008; and (5) scores of nursing homes from December 2005 through
January 2009, which CMS determined using its SFF methodology. In
addition, we used OSCAR deficiency data to identify SFFs that had
serious deficiencies on consecutive standard surveys and reviewed
enforcement reports that summarize data from AEM which we obtained for
these homes from regional offices.
To determine what other strategies have been employed to improve the
quality of care provided by poorly performing nursing homes, including
SFFs, we reviewed (1) Systems Improvement Agreements (SIA) between CMS
and some SFFs, which require the homes to take specific steps to
address quality of care problems; (2) quality of care Corporate
Integrity Agreements (CIA) between the Department of Health and Human
Services (HHS) Office of Inspector General (OIG) and nursing home
corporations, which are intended to bring about quality improvements
across the corporations' homes; and (3) the Nursing Homes in Need
(NHIN) initiative, an element of CMS's August 1, 2008, through July
31, 2011, contract with Quality Improvement Organizations (QIO) that
requires QIOs to work with a limited number of homes, generally SFFs,
to improve the care delivered to residents.[Footnote 8]
Our three objectives were informed by interviewing officials from
CMS's Survey and Certification Group, which we refer to as CMS's
central office, all 10 of its regional offices, and 14 state survey
agencies.[Footnote 9] CMS's central office is responsible for the SFF
Program and for oversight of the 10 CMS regional offices, which in
turn monitor states' nursing home oversight activities and their
implementation of the SFF Program. In our interviews, we asked
regional offices and states about their implementation of the SFF
Program and other topics, such as whether states offer additional
activities that may improve the performance of SFFs and other nursing
homes. We also interviewed officials from (1) CMS's Office of Clinical
Standards and Quality, the office responsible for oversight of the QIO
contract; (2) the HHS OIG; and (3) an official with an independent
monitoring association that assists HHS OIG in the monitoring of
nursing home quality of care CIAs. In addition, we reviewed our prior
reports and CMS's guidance to states on nursing home oversight
activities and the SFF Program and analyzed information available at
CMS's Providing Data Quickly Web site, which produces a variety of
reports using data collected by CMS to oversee providers of Medicare
and Medicaid services. For a more detailed discussion of our scope and
methodology, see appendix II. To ensure the reliability of the various
data we analyzed, we interviewed CMS officials, reviewed CMS
documentation, conducted electronic testing to identify obvious
errors, and traced a selection of records to another CMS reporting
system. Based on these activities, we determined that CMS data were
sufficiently reliable for our analysis.
We conducted this performance audit from December 2008 through March
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 objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
Titles XVIII and XIX of the Social Security Act establish minimum
standards that all nursing homes must meet to participate in the
Medicare and Medicaid programs, respectively. Provisions added by the
Omnibus Budget Reconciliation Act of 1987 focused the standards on the
quality of care actually provided by a home.[Footnote 10] To encourage
improvement at nursing homes that demonstrate chronic noncompliance
with these quality of care standards, CMS initiated the SFF Program in
1998 and subsequently expanded and strengthened the program in
December 2004.
Ensuring Compliance with Federal Quality of Care Standards:
To assess whether nursing homes meet federal quality of care
standards, state survey agencies conduct standard surveys, which occur
on average once a year, and complaint investigations as
needed.[Footnote 11] A standard survey involves a comprehensive
assessment of federal quality standards.[Footnote 12] In contrast,
complaint investigations generally focus on a specific allegation
regarding resident care or safety made by a resident, family member,
or nursing home staff member. Deficiencies identified during either
standard surveys or complaint investigations are classified in 1 of 12
categories labeled A through L according to their scope (i.e., the
number of residents potentially or actually affected) and severity
(i.e., the potential for or occurrence of harm to residents). (See
table 1.) An A-level deficiency is the least serious and is isolated
in scope, while an L-level deficiency is the most serious and is
widespread throughout the nursing home. Nursing homes with
deficiencies at the A, B, or C levels are considered to be in
substantial compliance with quality standards; homes with D-level or
higher deficiencies are considered noncompliant. For most
deficiencies, 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.[Footnote 13]
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Severity: Immediate jeopardy[A];
Scope: Isolated: J;
Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm;
Scope: Isolated: G;
Scope: Pattern: H;
Scope: Widespread: I.
Severity: Potential for more than minimal harm;
Scope: Isolated: D;
Scope: Pattern: E;
Scope: Widespread: F.
Severity: Potential for minimal harm[B];
Scope: Isolated: A;
Scope: Pattern: B;
Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in substantial compliance.
[End of table]
Federal Enforcement:
Nursing homes that fail to meet federal quality standards may be
subject to federal enforcement actions known as sanctions. Sanctions
can affect a home's revenues and therefore provide financial
incentives to return to and maintain compliance. Enforcement of
nursing home quality of care standards is a shared federal-state
responsibility. In general, sanctions are (1) initially proposed by
the state based on a cited deficiency, (2) reviewed and imposed by CMS
regional offices, and (3) implemented--that is, put into effect--by
the same CMS regional office.[Footnote 14] Homes may have an
opportunity to correct deficiencies after the imposition of a
sanction, which can result in the sanction being rescinded, that is,
not implemented. At state and regional office discretion, sanctions
may be imposed immediately without giving homes an opportunity to
correct deficiencies after a required notice period.[Footnote 15]
Sanctions are generally reserved for serious deficiencies--those at
the G through L levels--that constitute actual harm and immediate
jeopardy to residents.[Footnote 16]
Sanctions include fines known as civil money penalties (CMP), denial
of payment for new Medicare or Medicaid admissions (DPNA), and
termination from the Medicare and Medicaid programs.[Footnote 17]
Overall, two sanctions--CMPs and DPNAs--accounted for about 75 percent
of federal sanctions from 2005 through 2008, while terminations were
less than 1 percent. By statute, DPNA and termination are mandatory
sanctions in certain circumstances, but discretionary DPNA and
termination may also be imposed.
* CMP. Unlike most other sanctions, CMPs require no notice period; in
addition, they can be applied retroactively to the first date of
noncompliance. CMPs may be either per day or per instance. CMS
regulations specify a per day CMP range from $50 to $10,000 for each
day a home is noncompliant--from $50 to $3,000 for nonimmediate
jeopardy and $3,050 to $10,000 for immediate jeopardy. Per instance
CMPs range from $1,000 to $10,000 per episode of noncompliance. In
2007, CMS issued guidance to states and regional offices to encourage
consistency in CMP amounts.
* DPNA. A DPNA denies a home payments for new admissions until
deficiencies are corrected. A DPNA is required by statute within 3
months of the end of a survey if, for example, a home fails to correct
deficiencies and return to compliance. In contrast, discretionary
DNPAs can go into effect much sooner--after a 15-day notice period,
which is shortened to 2 days in the case of immediate jeopardy.
[Footnote 18] Unlike CMPs, DPNAs cannot be imposed retroactively.
* Termination. CMS can terminate a nursing home by implementing either
a mandatory or a discretionary termination. Mandatory termination is
required by regulation if within 23 days of the end of a survey a home
fails to correct immediate jeopardy deficiencies or within 6 months if
it fails to correct nonimmediate jeopardy deficiencies. CMS may also
impose discretionary terminations in situations other than those
specified above, which require the same notice period applicable to
discretionary DPNAs. In addition, nursing homes can and do terminate
voluntarily, which may be related to the fact that the home is at risk
of involuntary termination.
The SFF Program:
The objective of the SFF Program is to decrease the number of
persistently poorly performing nursing homes by focusing more
attention on a small number of nursing homes in each state with a
record of poor quality performance. Since the program's inception, CMS
has changed the SFF Program's scope and methodology to enhance the
agency's goal of improving nursing home performance.
CMS's SFF Methodology and Selection of SFFs:
CMS uses its SFF methodology to identify a list of the 15 worst
performing nursing homes in each state. The SFF methodology assigns
points to deficiencies on standard surveys and complaint
investigations, and to revisits associated with deficiencies cited on
standard surveys.[Footnote 19],[Footnote 20] More points are assigned
to deficiencies that are higher in scope and severity, and additional
points are assigned to deficiencies classified as substandard quality
of care (SQC).[Footnote 21] (See table 2.) For every nursing home, CMS
sums the points associated with the deficiencies (including SQC) and
the revisits to create a cycle score for each of the last three
cycles.[Footnote 22] CMS then creates the total score by weighting the
more recent cycle scores more heavily.[Footnote 23] Nursing homes with
the highest number of points are the worst performing homes.
Table 2: Points Assigned to Deficiencies in the SFF Methodology:
SFF points:
Scope and Severity: Potential for minimal harm: A: 0;
Scope and Severity: Potential for minimal harm: B: 0;
Scope and Severity: Potential for minimal harm: C: 0;
Scope and Severity: Potential for more than minimal harm: D: 2;
Scope and Severity: Potential for more than minimal harm: E: 4;
Scope and Severity: Potential for more than minimal harm: F: 6;
Scope and Severity: Actual harm: G: 10;
Scope and Severity: Actual harm: H: 20;
Scope and Severity: Actual harm: I: 30;
Scope and Severity: Immediate jeopardy: J: 50;
Scope and Severity: Immediate jeopardy: K: 100;
Scope and Severity: Immediate jeopardy: L: 150.
Additional SQC points:
Scope and Severity: Potential for minimal harm: A: 0;
Scope and Severity: Potential for minimal harm: B: 0;
Scope and Severity: Potential for minimal harm: C: 0;
Scope and Severity: Potential for more than minimal harm: D: 0;
Scope and Severity: Potential for more than minimal harm: E: 0;
Scope and Severity: Potential for more than minimal harm: F: 4;
Scope and Severity: Actual harm: G: 0;
Scope and Severity: Actual harm: H: 5;
Scope and Severity: Actual harm: I: 5;
Scope and Severity: Immediate jeopardy: J: 25;
Scope and Severity: Immediate jeopardy: K: 25;
Scope and Severity: Immediate jeopardy: L: 25.
Source: CMS.
Note: CMS agreed in principle with our recommendations to (1) assign
points to G-level deficiencies in SQC areas equivalent to those
additional points assigned to H-and I-level deficiencies in SQC areas,
and (2) consider adopting the points used by CMS's Five-Star Quality
Rating System for the SFF methodology. See GAO-09-689.
[End of table]
CMS refers to the resulting list of the 15-worst performing homes in
each state as the SFF candidate list. The list is generally
distributed quarterly to CMS's regional offices, which then distribute
it to states as necessary. Except for Alaska, each state and the
District of Columbia have between one and six SFFs at any time,
depending on the total number of nursing homes in the state.[Footnote
24] (See figure 1.) If there is an opening in the state's program
because an SFF has graduated from the program or been terminated from
Medicare and Medicaid, the state selects a new SFF from its candidate
list. CMS allows states discretion in determining which of the
candidates to choose for the program, and the CMS regional office
concurs with the states' selections.
Figure 1: CMS's Allocation of SFFs, by State:
[Refer to PDF for image: map of the U.S.]
Alabama: 2;
Alaska: 0;
Arizona: 2;
Arkansas: 2;
California: 6;
Colorado: 2;
Connecticut: 2;
Delaware: 1;
District of Columbia: 1;
Florida: 5;
Georgia: 3;
Hawaii: 1;
Idaho: 1;
Illinois: 5;
Indiana: 4;
Iowa: 4;
Kansas: 3;
Kentucky: 3;
Louisiana: 3;
Maine: 2;
Maryland: 2;
Massachusetts: 4;
Michigan: 4;
Minnesota: 4;
Mississippi: 2;
Missouri: 4;
Montana: 2;
Nebraska: 2;
Nevada: 1;
New Hampshire: 1;
New Jersey: 3;
New Mexico: 1;
New York: 5;
North Carolina: 4;
North Dakota: 1;
Ohio: 5;
Oklahoma: 3;
Oregon: 2;
Pennsylvania: 5;
Rhode Island: 1;
South Carolina: 2;
South Dakota: 2;
Tennessee: 3;
Texas: 6;
Utah: 1;
Vermont: 1;
Virginia: 3;
Washington: 3;
West Virginia: 2;
Wisconsin: 4;
Wyoming: 1.
Source: GAO analysis of CMS data; copyright Corel Corp. All rights
reserved (map).
Note: Alaska does not participate in the SFF Program because it has so
few nursing homes.
[End of figure]
SFF Program Guidance:
In addition to specifying that states select SFFs from a list of
candidate nursing homes, figure 2 shows that CMS's guidance to states
on the operation of the SFF Program includes two other key
requirements:
* States are instructed to increase scrutiny of SFFs in the following
ways:
- Survey frequency. States provide additional scrutiny of SFFs by
conducting two surveys per fiscal year for each SFF, which is twice as
frequent as at other nursing homes. CMS measures each state's
compliance with this requirement annually through state performance
reviews.[Footnote 25] The state performance reviews emphasize three
aspects of the survey program: survey timeliness, survey quality, and
the enforcement and remedy of problems found during surveys. If a
regional office determines that a state has not conducted two surveys
for every SFF allotted to the state per fiscal year, the state must
develop a corrective action plan.[Footnote 26]
- Enforcement. States are required to impose sanctions that increase
in severity and are more immediate when SFFs do not improve. For
example, a state should propose a CMP or a DPNA with the minimum
notice period.
* After three standard surveys (approximately 18 months) in the SFF
Program, one of the following three outcomes are expected:
- Graduation. States determine if the SFF is eligible to "graduate"
from the program by meeting CMS's criteria for improved performance:
two consecutive standard surveys and any intervening complaint
investigations must have no deficiencies at the F level or higher. In
addition, an SFF cannot have a deficiency higher than the F level on
the fire safety portion of its most recent standard survey.
- Retention. States keep the SFF in the program if it does not meet
the graduation criteria but is showing improvement.
- Termination. States recommend that the SFF be terminated from
participation in Medicare and Medicaid if it fails to make significant
progress.
Figure 2: Operation of the SFF Program:
[Refer to PDF for image: illustration]
SFF Selection:
State, with CMS concurrence, selects a nursing home for the SFF
Program from the candidate list.
Increased scrutiny:
SFF receives increased state scrutiny: 1) State conducts two surveys
per fiscal year, which is twice as frequent as at other nursing homes.
2) State imposes more robust enforcement actions when SFF does not
improve.
After three standard surveys (approximately 18 months):
Graduation:
State determines if the SFF meets CMS's criteria for graduation from
the program.
Retention:
If an SFF cannot gradual state retains SFF in the program and
increased scrutiny continues.
Termination:
If an SFF fails to make significant progress the state can recommend
that the home be terminated from Medicare and Medicaid.
When a home graduates or is terminated, the state makes a new SFF
selection.
Source: GAO (data); Art Explosion (graphics).
[End of figure]
Additional Changes to the SFF Program in 2007 and 2008:
CMS made several key changes to the SFF Program in 2007 and 2008 to
increase both provider and public awareness of the program. In 2007,
CMS began requiring states to notify the governing bodies, owners,
operators, and administrators that a facility had been designated an
SFF. CMS also issued a press release in 2007 listing those SFFs that
had failed to significantly improve their care; previously, the
identity of SFFs was not provided to the public. In an effort to
increase transparency, CMS added the identity of all SFFs to its
Nursing Home Compare Web site during 2008. That same year, information
on the SFF methodology and on SFFs, such as those that failed to
significantly improve their care after about one survey, was added to
CMS's Web site.[Footnote 27]
In 2008, CMS also added ratings from its Five-Star Quality Rating
System to its Nursing Home Compare Web site to further assist
consumers in judging nursing home quality. Every home in the United
States is rated from one star (much below average) to five stars (much
above average). The Five-Star System provides an overall quality
rating based on individual ratings for three separate components: (1)
health inspections--deficiencies cited on standard surveys and any
associated revisits and complaint investigations;[Footnote 28] (2)
nursing home staffing levels; and (3) quality of care measures, which
are computed using data submitted to CMS by nursing homes on their
residents' health, physical functioning, mental status, and general
well-being. SFFs can have high ratings on any one of the three
components, but their overall rating is capped at three stars.
However, as of February 2009, no SFFs had a five star rating in the
health inspection component of the Five-Star System.
States Considered Factors Other Than Rank When Selecting SFFs, Which
Were More Likely to Be Chain Affiliated and For-Profit Than Other
Nursing Homes:
When selecting SFFs from the candidate list, state officials
considered factors other than rank, such as their own knowledge of
each candidate's circumstances. Such discretion is key not only
because of states' familiarity with each candidate's circumstances but
also because the list has limitations. The characteristics of SFFs
differed from those of other nursing homes in terms of the homes'
organization type and the number of beds and residents. For example,
SFFs were more likely than other homes to be chain affiliated and for-
profit and to have more beds and more total residents.
States Exercise Discretion When Selecting SFFs by Considering Factors
Such as Surveyor Workload or Nursing Home Ownership:
Although rank and score play an important role in the selection of
SFFs, the states we interviewed consider additional factors when
making their selections, including the candidate's compliance and
enforcement history, state surveyor workload, nursing home ownership,
and financial concerns. We found that a majority of states selected
SFFs from among their five worst performers. While the first-ranked
candidate (the worst performing home) was selected about 17 percent of
the time from January 2006 through February 2009, about 57 percent of
SFFs selected during that period were among the five worst-ranked
candidates.[Footnote 29]
* Compliance and enforcement history. Most states we interviewed
specified that they review the details of a nursing home's overall
compliance with federal quality standards. For example, a state might
review the scope and severity level, type, and repetitiveness of
deficiencies for candidates it considers. When reviewing a nursing
home's history, a few states indicated that they are likely to select
candidates with more recent poor performance, which is also reflected
in the SFF score beginning in 2008. In addition, some states we
interviewed review and take into consideration a nursing home's
enforcement history, such as any CMPs or DPNAs imposed for
noncompliance with federal standards.
* State surveyor workload. Some states we interviewed avoid
concentrating SFFs in the same district in their state due to the
additional workload associated with the SFF Program. For example,
California tries to distribute SFFs geographically so that no state
district office has more than one SFF at a time. To help accomplish
this, the California state survey agency meets with the district
offices to review the candidate list.
* Nursing home ownership. Some states we interviewed consider the
nursing home's ownership, including any recent changes or knowledge of
other homes owned by the same chain. State officials explained that a
recent change of ownership could influence their SFF selection. For
example, if state officials are aware of a history of problems with
the new owner, they may select the home for the SFF Program in order
to scrutinize it more closely; on the other hand, they may not select
a home if they perceive that the new owner has a good reputation,
which would give the new owner adequate time to correct quality
problems.
* Financial concerns. Officials from three of the states we
interviewed said they might consider any known financial concerns when
making an SFF selection. In addition, regional offices told us that
they may learn about nursing homes' financial difficulties on an ad-
hoc basis, such as through resident and staff complaints about
inadequate services or the home's inability to meet its payroll or
through a home's request to delay or reduce payments from CMPs due to
financial hardship.
Limitations in the Candidate List Highlight the Necessity for States'
Discretion:
The majority of state officials we interviewed told us that CMS's
candidate list accurately identifies poorly performing nursing homes
in each state, such as those homes that habitually cycle in and out of
compliance with federal nursing home standards; however, we found that
certain limitations in the list highlight the importance of states'
discretion in selecting SFFs. First, because of lag times between when
surveys are conducted and when the results are reflected on the SFF
candidate list, some states and regions found that the candidate list
may not reflect a home's most recent survey.[Footnote 30]
Consequently, some candidates could appear to have a better or worse
score than reflected in the most recent survey, or homes may be
included or excluded inappropriately from the list. Second, some
states told us that the candidate list does not provide them with a
sufficient number of nursing homes from which to select new SFFs.
Specifically, the list includes current SFFs if they are still ranked
among the worst 15 homes in the state, which narrows the state's
selection possibilities. Officials from Indiana, Illinois, and
California, which are allocated 4, 5, and 6 SFFs, respectively,
explained that having existing SFFs on their list left them with fewer
than 15 nursing homes to consider for the program.
Moreover, we found additional limitations to the list, including
considerable variation in SFF candidate scores, that further highlight
the importance of states' discretion. As noted in our August 2009
report, the candidate list identifies poorly performing nursing homes
in each state but does not necessarily identify the most poorly
performing nursing homes in the nation.[Footnote 31] This limitation
becomes apparent when comparing SFF scores for nursing homes on the
candidate list both across and within states. As a result of the
variation across states, some candidates may have the worst score in
their state and yet not score among the worst homes in the nation. In
addition, wide variation in candidates' scores is also found within
individual states. For example, on the January 2009 candidate list,
the score of the worst home in Tennessee was about 1,512. However, all
SFF candidates in each of 22 states had lower scores than the 15th
worst candidate in Tennessee, which had a score of about 253. (See
figure 3.)
Figure 3: SFF Score Ranges for the 15 Program Candidates in Each State:
[Refer to PDF for image: horizontal bar graph]
State: Tennessee:
Maximum: 1512;
Minimum: 253.
State: Kentucky:
Maximum: 925;
Minimum: 185.
State: Arkansas:
Maximum: 863;
Minimum: 241.
State: Louisiana:
Maximum: 743;
Minimum: 249.
State: South Carolina:
Maximum: 698;
Minimum: 117.
State: New York:
Maximum: 639;
Minimum: 229.
State: Oklahoma:
Maximum: 605;
Minimum: 167.
State: Mississippi:
Maximum: 574;
Minimum: 139.
State: Florida:
Maximum: 571;
Minimum: 165.
State: Illinois:
Maximum: 558;
Minimum: 259.
State: Texas:
Maximum: 557;
Minimum: 301.
State: Wisconsin:
Maximum: 547;
Minimum: 125.
State: Alabama:
Maximum: 500;
Minimum: 117.
State: Maine:
Maximum: 454;
Minimum: 78.
State: Kansas:
Maximum: 435;
Minimum: 161.
State: California:
Maximum: 431;
Minimum: 215.
State: Oregon:
Maximum: 391;
Minimum: 66.
State: New Hampshire:
Maximum: 390;
Minimum: 37.
State: Missouri:
Maximum: 377;
Minimum: 176.
State: Georgia:
Maximum: 363;
Minimum: 127.
State: New Jersey:
Maximum: 356;
Minimum: 112.
State: New Mexico:
Maximum: 321;
Minimum: 87.
State: North Carolina:
Maximum: 320;
Minimum: 91.
State: Indiana:
Maximum: 308;
Minimum: 189.
State: Michigan:
Maximum: 307;
Minimum: 159.
State: District of Columbia:
Maximum: 286;
Minimum: 32.
State: Vermont:
Maximum: 278;
Minimum: 42.
State: Connecticut:
Maximum: 254;
Minimum: 86.
All SFF candidates in the following 22 states scored better than the
15th-ranked candidate in Tennessee.
State: Nebraska:
Maximum: 245;
Minimum: 66.
State: Wyoming:
Maximum: 243;
Minimum: 50.
State: Rhode Island:
Maximum: 238;
Minimum: 29.
State: Utah:
Maximum: 230;
Minimum: 27.
State: Colorado:
Maximum: 229;
Minimum: 101.
State: Massachusetts:
Maximum: 229;
Minimum: 67.
State: Virginia:
Maximum: 229;
Minimum: 79.
State: Arizona:
Maximum: 209;
Minimum: 84.
State: Washington:
Maximum: 204;
Minimum: 113.
State: Ohio:
Maximum: 183;
Minimum: 96.
State: Minnesota:
Maximum: 182;
Minimum: 99.
State: Iowa:
Maximum: 174;
Minimum: 100.
State: Hawaii:
Maximum: 173;
Minimum: 22.
State: Pennsylvania:
Maximum: 171;
Minimum: 94.
State: West Virginia:
Maximum: 170;
Minimum: 75.
State: Maryland:
Maximum: 151;
Minimum: 81.
State: Montana:
Maximum: 140;
Minimum: 51.
State: Delaware:
Maximum: 126;
Minimum: 52.
State: Idaho:
Maximum: 117;
Minimum: 68.
State: Nevada:
Maximum: 111;
Minimum: 31.
State: North Dakota:
Maximum: 79;
Minimum: 16.
State: South Dakota:
Maximum: 68;
Minimum: 30.
Source: GAO analysis of CMS data, as of January 2009.
Notes: (1) The left side of each bar (minimum) represents the candidate
with the lowest score, and the right side (maximum) represents the
candidate with the highest score. (2) This figure excludes Alaska,
which does not have SFFs.
[End of figure]
SFFs Were More Likely to Be Chain Affiliated and For-Profit Than Other
Nursing Homes:
SFFs differed from other nursing homes not only in terms of their
compliance history but also in terms of other key characteristics. We
compared deficiencies from the 59 SFFs that (1) were added to the SFF
Program in 2008 and (2) had a standard survey that occurred prior to
their entry into the program to deficiencies from other homes that had
a standard survey conducted in 2008. We included in this analysis
deficiencies from complaint investigations that occurred in the year
prior to the 2008 standard survey and revisits associated with the
standard survey.[Footnote 32] Consistent with the SFF methodology, we
found that, on average, these 59 SFFs had both a greater number of D-
through L-level deficiencies, including more at each scope and
severity level, and a greater number of deficiencies cited on standard
surveys and complaint investigations than other nursing homes.
[Footnote 33] For example, SFFs had, on average, 5.5 times more actual
harm deficiencies and 19 times more immediate jeopardy deficiencies.
In addition, these SFFs had, on average, a greater number of revisits.
(See table 3.)
Table 3: Average Compliance Histories of Selected SFFs Compared to
Those of Other Nursing Homes:
Compliance history: Total deficiencies at the D level or higher;
Selected SFFs (59 homes)[A]: 19.9;
Other nursing homes (14,686 homes)[B]: 7.5.
Compliance history: Deficiencies at the D through F levels;
Selected SFFs (59 homes)[A]: 15.8;
Other nursing homes (14,686 homes)[B]: 7.0.
Compliance history: Deficiencies at the actual harm level (G-I);
Selected SFFs (59 homes)[A]: 2.2;
Other nursing homes (14,686 homes)[B]: 0.4.
Compliance history: Deficiencies at the immediate jeopardy level (J-L);
Selected SFFs (59 homes)[A]: 1.9;
Other nursing homes (14,686 homes)[B]: 0.1.
Compliance history: Deficiencies by survey type (D-L);
Selected SFFs (59 homes)[A]: [Empty];
Other nursing homes (14,686 homes)[B]: [Empty].
Compliance history: Deficiencies cited on standard surveys;
Selected SFFs (59 homes)[A]: 14.0;
Other nursing homes (14,686 homes)[B]: 6.3.
Compliance history: Deficiencies cited on complaint investigations;
Selected SFFs (59 homes)[A]: 5.9;
Other nursing homes (14,686 homes)[B]: 1.3.
Compliance history: Number of revisits[C];
Selected SFFs (59 homes)[A]: 0.7;
Other nursing homes (14,686 homes)[B]: 0.2.
Source: GAO analysis of CMS data.
Notes: (1) We analyzed the standard survey in 2008, complaint
investigations in the year prior to that standard survey, and revisits
associated with that standard survey. (2) All differences between
groups are significant at the 0.05 level.
[A] "Selected SFFs" included 59 nursing homes that were added to the
SFF Program beginning in January 2008 and had a standard survey in
2008 prior to entering the program.
[B] "Other nursing homes" excludes facilities that did not have a
standard survey in 2008 and that were SFFs from 2005 through February
2009.
[C] The number of revisits excludes homes with only one revisit
because those homes would not be assigned any points under the SFF
methodology. Only homes with two, three, or four revisits are assigned
points under the SFF methodology.
[End of table]
Additional key characteristics of SFFs also differentiated them from
other nursing homes. Comparing the characteristics of 133 homes in the
SFF Program as of February 2009 to those of other homes, we found that
they differed in terms of type of organization and participation in
Medicare and Medicaid, the number of beds and residents, nurse
staffing levels, and ratings on CMS's Five-Star System.[Footnote 34]
(See appendix III.)
* Type of organization and participation in Medicare and Medicaid. A
higher percentage of SFFs were part of a chain organization, for-
profit organization, or both. For example, about 55 percent of SFFs
were for-profit and chain affiliated, compared to about 42 percent of
other nursing homes. Furthermore, fewer SFFs participated in Medicaid
only compared to other nursing homes--about 2 percent and about 5
percent, respectively.
* Beds and residents. On average, SFFs had more beds and total
residents, but a lower occupancy rate, than other nursing homes.
Specifically, SFFs averaged approximately 131 beds and 104 residents--
about a 79 percent occupancy rate; other nursing homes had
approximately 106 beds and 90 residents--about an 85 percent occupancy
rate. SFFs also had a greater share of Medicaid patients on average
than other nursing homes--71 percent compared to 60 percent.
* Nurse staffing. SFFs had fewer registered nurse hours per resident-
day as a share of total hours per resident-day--about 9.0 percent
compared to about 9.9 percent for other nursing homes.[Footnote 35]
* CMS's Five-Star System. SFFs were much more likely than other
nursing homes to be ranked lower on the overall quality rating and
health inspection component rating of the Five-Star System.[Footnote
36] Specifically, about 74 percent of SFFs received one star on the
overall quality rating, and about 93 percent received one star on the
health inspection component of the rating.[Footnote 37] In comparison,
about 22 percent of other nursing homes received one star on the
overall quality rating, and about 19 percent received one star on the
health inspection component.[Footnote 38]
State and Regional Office Adherence to SFF Program Guidance Was
Uneven, but Most SFFs Improved Their Performance While in the Program:
We found that some states did not consistently follow CMS's basic SFF
Program requirements, such as surveying SFFs twice a year. We also
found that CMS's enforcement guidance is vague and results in
inconsistent interpretations. Most SFFs did eventually graduate, not
all met CMS's graduation criteria, and some remained in the program
well beyond CMS's 18-month time frame for improvement. However, most
SFFs improved their performance while in the program, although many
graduates failed to sustain their performance.
Some States Did Not Meet CMS's Requirement to Survey SFFs Twice a Year:
Some states did not meet CMS's requirement to conduct standard surveys
of SFFs twice a year. While states improved their compliance with this
requirement in fiscal year 2008--8 states did not conduct two surveys
for SFFs, compared to 26 states in the previous fiscal year--some SFFs
were still not receiving increased scrutiny through additional
standard surveys, a fundamental component of the program. In addition,
18 states had at least one SFF that had more than 10 months between
surveys from calendar year 2005 through 2008. Further, between January
2005 and February 2009, 15 states did not survey at least one of their
SFFs within the first 7 months that the home was in the program.
A CMS official told us the agency was aware that states were not
always conducting two surveys per fiscal year for SFFs. In fiscal year
2007, CMS began measuring states' adherence to this requirement as
part of its annual state performance reviews. CMS required seven
states that did not meet this standard in fiscal year 2008 to complete
corrective action plans.
CMS's Enforcement Guidance Is Vague and Results in Inconsistent
Interpretations:
CMS's SFF Program guidance on enforcement, under which states and
regions must impose more robust enforcement on SFFs that do not
demonstrate significant improvement, is vague and open to
interpretations. According to CMS, "more robust" is intended to mean
that homes with continued noncompliance should receive sanctions that
both increase in severity and are immediate; that is, homes should not
be provided with an opportunity to correct deficiencies before the
sanction goes into effect.[Footnote 39] CMS guidance also allows
states discretion in determining significant improvement, and
therefore which homes receive more robust enforcement and which do
not. In our interviews with CMS's central office, an official stated
that CMS's SFF enforcement guidance could be more specific and noted
that CMS plans to release descriptive guidance explaining exactly how
states and regions should apply more robust enforcement. In addition,
we found that officials in the regional offices and states we
interviewed had inconsistent interpretations of the guidance. For
example, some officials told us that when determining sanctions, they
treat SFFs no differently than they would any poorly performing
nursing home. For other officials, there was little consensus on the
most appropriate sanctions for SFFs--CMPs, or other sanctions, such as
discretionary DPNAs or discretionary termination.[Footnote 40]
Despite the existence of SFF Program enforcement guidance, we found
that SFFs were not necessarily more likely to be subject to CMPs and
DPNAs--the most frequently cited sanctions--than SFF candidates, which
are also poorly performing nursing homes. For example, about 28
percent of SFFs had at least one CMP implemented in 2008, compared to
about 34 percent of candidates in the same year. In addition, the
rates of implemented CMPs and DPNAs decreased for SFFs relative to
candidates from 2006 to 2008, while the rates of other nursing homes
remained low.[Footnote 41] (See figure 4.) We found similar trends in
the average CMP values; for example, SFF candidates received the
highest average per day CMPs in 2008--approximately $4,262 per day--
compared to approximately $3,969 for SFFs and $1,990 for other nursing
homes. However, it is unclear if improvement in SFFs' performance
could explain the higher rates and average values we observed for SFF
candidates compared to SFFs.
Figure 4: Percentage of SFFs, SFF Candidates, and Other Nursing Homes
That Had at Least One CMP and DPNA Implemented from 2006 through 2008:
[Refer to PDF for image: 2 multiple line graphs]
CMPs:
Year: 2006;
SFFs: 34.7%;
SFF candidates: 29.7%;
Other nursing homes: 11.8%.
Year: 2007;
SFFs: 25.1%;
SFF candidates: 28.6%;
Other nursing homes: 12.3%.
Year: 2008;
SFFs: 27.7%;
SFF candidates: 33.5%;
Other nursing homes: 11.7%.
DPNAs:
Year: 2006;
SFFs: 28.7%;
SFF candidates: 16.9%;
Other nursing homes: 5.2%.
Year: 2007;
SFFs: 20.5%;
SFF candidates: 19.3%;
Other nursing homes: 4.9%.
Year: 2008;
SFFs: 17.1%;
SFF candidates: 19.7%;
Other nursing homes: 4.6%.
Source: GAO analysis of CMS data.
Note: For both CMPs and DPNAs, other nursing homes are significantly
different from SFFs and from SFF candidates for all 3 years. However,
for CMPs, SFFs and SFF candidates are significantly different from
each other for only 2006 and 2008 and, for DPNAs, SFFs and candidates
are significantly different from each other only in 2006.
[End of figure]
Our review of the detailed enforcement histories of six SFFs with
consecutive noncompliance cycles at the G level or higher found that
the sanctions imposed by regions and states on the homes ranged in
terms of their immediacy and severity.[Footnote 42] For example, in
three out of seven noncompliance cycles with G-level or higher
deficiencies, one SFF was allowed an opportunity to correct its
deficiencies before sanctions could go into effect. Still, this same
SFF had sanctions of increasing severity imposed with each successive
recurrence of noncompliance at the G level--the state and regional
office increased CMPs from $300 per day of noncompliance to $600 per
day of noncompliance. Conversely, another SFF was assessed no CMPs,
even though it had a similar history of consecutive noncompliance
cycles that could have resulted in CMPs ranging from $300 to $825 per
day of noncompliance, suggesting that CMS's monitoring of enforcement
is insufficient.[Footnote 43] However, both of these SFFs had
immediate sanctions imposed; that is, the state and regional offices
imposed discretionary rather than mandatory DPNAs and terminations.
Discretionary DPNAs and terminations provide nursing homes with a
shorter opportunity to correct deficiencies before the sanction goes
into effect compared to mandatory DPNAs and terminations. Despite this
shorter correction period, both of these SFFs were typically able to
correct their deficiencies and avoid these sanctions.
Most SFFs Did Eventually Graduate, but States and CMS Regions Kept
Some SFFs in the Program beyond the Program's Expected 18-Month Time
Frame:
Although most SFFs eventually graduated, CMS regions and states often
chose to keep SFFs in the program beyond the 18-month time frame. More
homes have graduated from the SFF Program than were terminated, but
some graduates did not meet CMS's criteria. States we interviewed
indicated that some SFFs were able to improve their performance while
others lingered in the program for various reasons, including not
improving enough to meet the graduation criteria nor performing poorly
enough to terminate from Medicare and Medicaid. As a result, other
nursing homes whose performance may have been worse could not be
selected for the program.
Of the 355 nursing homes placed in the SFF Program from January 2005
through February 2009, 181 graduated (51 percent) and 41 were
terminated (12 percent).[Footnote 44] CMS terminated 21 SFFs
involuntarily, and 20 left the program voluntarily.[Footnote 45] We
found that nursing homes sharing the same physical location as 13 of
the 41 SFFs that terminated have since been certified to participate
in Medicare or Medicaid again. However, at least 24 of the 181 SFF
graduates did not actually meet elements of CMS's graduation criteria--
two consecutive standard surveys and any intervening complaint
investigations with no deficiencies at the F level or higher; 15 of
these 24 SFFs should not have graduated because they had deficiencies
at the F level or higher.[Footnote 46] For example, a Florida SFF had
four deficiencies at the F level on the two standard surveys that
occurred prior to its graduation.
We found that CMS's regions and states often chose to keep SFFs in the
program instead of terminating them, even though CMS's SFF Program
guidance establishes the expectation that SFFs will be terminated from
Medicare and Medicaid if they fail to make significant progress after
being in the program for 18 months.[Footnote 47] The fact that some
homes did not graduate or terminate after being in the program for 18
months prevented other nursing homes whose performance may have been
worse from being selected for the program.
* SFFs added to the program from 2005 through 2007. Of the 254 homes
that became SFFs during this time frame, 102 (40 percent) were in the
program for 25 months or more as of February 2009.
* Active SFFs. Of the 133 active SFFs as of February 2009, 23 (17
percent) were in the program for 25 months or more, and 11 had been in
the program since 2005.
However, the length of time that SFFs spent in the program before
graduating or terminating has decreased since 2005. (See figure 5.)
For example, as of the end of February 2009, SFFs added to the program
in 2005 graduated on average after 28 months, compared to an average
of 20 and 13 months for SFFs that were added to the program in 2006
and 2007, respectively.[Footnote 48]
Figure 5: Average Number and Range of Months Nursing Homes Spent in
the SFF Program, by Status and Year Added to the Program:
[Refer to PDF for image: vertical bar graph]
Graduated SFFs: Year: 2005;
Minimum: 5.5;
Maximum: 49;
Mean: 27.5.
Graduated SFFs: Year: 2006;
Minimum: 4.6;
Maximum: 34.7;
Mean: 19.5.
Graduated SFFs: Year: 2007;
Minimum: 6.3;
Maximum: 22.7;
Mean: 13.4.
Terminated SFFs: Year: 2005;
Minimum: 0.6;
Maximum: 47;
Mean: 18.2.
Terminated SFFs: Year: 2006;
Minimum: 1.8;
Maximum: 23.6;
Mean: 15.4.
Terminated SFFs: Year: 2007;
Minimum: 4.2;
Maximum: 14.5;
Mean: 9.5.
Active SFFs: Year: 2005;
Minimum: 39.2;
Maximum: 50.7;
Mean: 49.7.
Active SFFs: Year: 2006;
Minimum: 28.9;
Maximum: 37.3;
Mean: 33.4.
Active SFFs: Year: 2007;
Minimum: 14.6;
Maximum: 26.3;
Mean: 19.9.
Source: GAO analysis of CMS data, as of February 2009.
Notes: (1) SFFs added to the program in 2008 and 2009 are not included
in this figure because they had not yet been in the program for a full
18 months--CMS's expected time frame for graduation--as of February
2009. (2) Although the declining trend for active SFFs is consistent
with the trend for graduated and terminated SFFs, it is unclear to
what extent that trend is influenced by the amount of time since these
SFFs entered the program. (3) Differences between years were
significant for graduated and active SFFs at the 0.05 level but were
not significant for terminated SFFs at the 0.05 level.
[End of figure]
Some CMS regions and states we interviewed offered several reasons
that might help to explain why they chose to keep some SFFs in the
program beyond 18 months. First, nursing homes may not improve enough
to meet CMS's criteria for graduation, nor be performing poorly enough
to terminate from Medicare and Medicaid. Second, closing a nursing
home requires the state to transfer residents to another nursing home,
and some residents with special care needs--such as children or those
that have behavioral health issues--may be difficult to relocate.
Third, if the SFF recently had a change in ownership, it may have the
potential to improve and therefore should not be terminated: new
management or capital investment in a poorly performing nursing home
may bring about needed changes in quality. For example, officials in
CMS's New York regional office described a case in which all three
reasons influenced their decision to allow a nursing home to remain in
the program for over 45 months.[Footnote 49] The home:
* had initially demonstrated improvement until two consecutive surveys
resulted in deficiencies at the F level or higher,
* had a behavioral health population that was large, making it
difficult to place them in other homes, and:
* experienced two changes of ownership while in the SFF Program. The
most recent owners invested millions of dollars to improve the
physical environment at the facility and hired a nurse consultant.
Regional office officials indicated that a more recent survey had
shown improvement with no deficiencies higher than the D level, which
they attributed to the investments made by the most recent owner.
Conversely, some SFFs were able to improve enough to graduate in less
than 19 months. Our analysis shows that between 2005 and February
2009, 32 states graduated at least one facility in less than 19
months. According to some state and regional office officials we
interviewed, such SFFs showed improvement after being selected for the
program because of factors such as the home's ability to establish
stable leadership, a willingness to adopt new improvements, or the
hiring of outside consultants. Some state and regional office
officials indicated that homes might be able to graduate earlier if
the graduation criteria were less stringent. For example, one regional
office and one state did not think that F-level deficiencies in
kitchen sanitation should prevent homes from graduating.[Footnote 50]
Two regions suggested that a more appropriate graduation criterion
would be to allow homes with F-level deficiencies to graduate as long
as the deficiencies were not in SQC areas, rather than the current
criterion of no F-level or higher deficiencies.[Footnote 51] We found
that 27 percent of the 328 SFFs (90 homes) had at least one instance
where one or more F-level deficiency prevented them from graduating
and over half of those SFFs (54 homes) had F-level deficiencies in
kitchen sanitation.
Beginning in 2007, CMS introduced two program changes that may
contribute to a decline in the amount of time that SFFs remain in the
program. For example, CMS began identifying SFFs on its Nursing Home
Compare Web site each month. The majority of CMS regional offices and
states we interviewed believed CMS's identification of SFFs had a
positive impact on the SFF Program because of the media and public
attention. Florida indicated that there had been little concern by
providers about being in the SFF Program until SFFs were publicly
identified. An additional factor may also have influenced the amount
of time SFFs remain in the program. As noted earlier, CMS began
requiring states to formally notify homes in 2007 that they had been
placed in the program, including each home's governing body, owner,
operator, and administrator. Michigan has applied a more aggressive
notification policy since 2005, sending a notification letter to each
SFF candidate explaining that they are at risk of being selected as an
SFF if they fail to address performance problems. A copy of the letter
is also sent to the owner and operator of the nursing home the first
time the home appears on CMS's candidate list. The Michigan official
we interviewed believed that this notification policy has motivated
the state's SFF candidates to improve. In December 2008, the state of
Missouri also began notifying SFF candidates that they were at risk of
being selected as SFFs.
Most SFFs Improved, but Some Graduates Failed to Sustain Their
Performance:
While in the program, most SFFs improved their performance, but some
failed to sustain their improved performance after graduation. The
scores of SFF graduates showed a statistically significant improvement
when compared to their scores before entering the program, as did the
scores of active SFFs, but to a lesser degree than graduates.[Footnote
52] Officials from some CMS regions and states told us that the SFF
Program was helping nursing homes to improve their performance, but
others were unsure of the program's effectiveness. For example,
officials from New York, which graduated 8 of 13 SFFs from January
2005 to February 2009, told us that more frequent surveys and the
state's presence at the facilities had a positive effect on the
behavior of SFFs. Conversely, officials in Alabama, which graduated 2
of 5 SFFs in the same period, believed that it was difficult to say
whether the program had improved nursing home performance. Alabama
officials noted that while the program had motivated a few of the
states' SFFs to take a closer look at their operations, SFFs did not
always understand the consequences that might result for failing to
improve their performance.
Despite the improvement in scores, we also found that 75 (50 percent)
of the 149 graduates from calendar years 2005 through 2008 that had a
standard or complaint survey after graduation received at least one F-
level or greater deficiency after graduation, which would have
prevented their graduation had they still been SFFs.[Footnote 53] For
example, one graduate had one F-level deficiency, two G-level
deficiencies, and two J-level deficiencies on its first standard
survey after graduating.[Footnote 54] A smaller subset of these 149
SFF graduates--22 homes (15 percent)--received at least one J-through
L-level deficiency (immediate jeopardy) on either a standard or a
complaint survey after they graduated.
Other Quality Improvement Strategies to Assist SFFs Have Merit, and
Some Could Inform CMS Efforts:
While the core of the SFF Program is more frequent surveys and
stringent enforcement, CMS and others have adopted a variety of other
quality improvement strategies to help address care problems
identified at SFFs and other nursing homes; both the HHS OIG and state
strategies hold potential lessons that could help inform CMS's
efforts. Through Systems Improvement Agreements (SIA) and the Nursing
Homes in Need (NHIN) initiative, CMS has attempted to deal more
directly with the root causes of poor quality in a limited number of
SFFs. In contrast to CMS's focus on individual facilities, the HHS OIG
has identified corporations that own poorly performing homes and
negotiated Corporate Integrity Agreements (CIA) to bring about quality
improvements across the homes in the corporation. States have adopted
quality improvement strategies that sometimes resemble CMS's efforts
but that may also be offered to homes that have not exhibited
performance problems.
SIAs and the NHIN Initiative Hold Promise, but the Use of Such
Interventions Has Been Limited:
While both SIAs and the NHIN initiative have the potential to help
SFFs improve the quality of care provided to residents, their use has
been limited. More than 2 years after the first SIA was implemented,
CMS's central office has not yet collected and shared information
about this intervention with its 10 regional offices. Moreover, the
measures used by CMS to monitor the impact of the NHIN initiative are
inconsistent with those used to measure whether an SFF is improving.
Systems Improvement Agreements with SFFs. SIAs are agreements between
CMS and SFFs that identify concrete actions that the homes are
required to take, generally within a specific time, in order to avoid
termination and to improve and maintain quality. CMS did not develop
the first SIA with an SFF until 2007--9 years after the creation of
the SFF Program. Overall, four CMS regional offices have negotiated a
total of 10 SIAs. SFFs that agreed to SIAs retained their SFF
designation and were still subject to more frequent surveys than other
homes.
SIAs share some common requirements and sometimes describe similar
elements using different terminology. SIAs may differ because regional
offices attempt to craft agreements that reflect each SFF's particular
circumstances or the specific regional office goals for the home.
Common SIA elements include:
* hiring an independent consultant to provide technical assistance
with quality improvement activities at the home;
* requiring the consultant to identify solutions to issues that were
preventing the SFF from attaining or maintaining compliance, often
referred to as a root-cause analysis, and to develop an action plan to
address quality problems;[Footnote 55] and:
* providing periodic reports prepared by either the consultant or the
home to the regional office on the status of actions or
recommendations to improve quality.
Two of the SIAs required the SFFs to commit funds ranging from
$850,000 to $956,000 for the improvement of clinical care systems or
facility capital improvements. For example, one SIA required the SFF
to dedicate $956,000, primarily for capital improvements such as a new
roof and a heating and cooling system but also to go into an escrow
fund to pay for quality improvements consistent with the consultant's
root-cause analysis and action plan.
In general, regional offices have used SIAs as an alternative to
terminating homes that had been in the program for 18 months. Five of
the 10 homes with SIAs had been in the SFF Program from 27 to 42
months when they signed SIAs. (See appendix IV for a chronological
summary of all SIAs as of August 2009.) One regional office negotiated
an SIA to avoid bed shortages that would have resulted had the SFF
been terminated from Medicare and Medicaid. Another SFF at risk of
termination had recently undergone a change in ownership, and the new
owner had made substantial clinical and capital improvements. With 6
of the 10 SIAs, Dallas is the only regional office with an SIA that
has established specific criteria for the use of the agreements. Any
SFF that has failed to graduate from the SFF Program in 18 months and
that has no deficiencies above the F level is given one last chance by
signing an SIA.[Footnote 56] Dallas regional office officials stressed
that in applying these criteria they have also begun to assess the
SFF's commitment to improve through the SIA process.
Whether or not the agreements result in improved nursing home
performance, they have the potential to address the problem of homes
that linger in the SFF Program for years. Although three of the
regional offices with SIAs indicated that SIAs were effective, the
Dallas regional office thought it was too early to say because the
future performance of the homes was unknown.
* Four homes met the terms of their SIAs and graduated from the SFF
Program. As of August 2009, one of these homes was above average
according to CMS's Five-Star System, and three were below or much
below average.
* Two homes were terminated, one for failing to meet terms of the SIA.
The other home voluntarily left the Medicare and Medicaid programs
before CMS could terminate it.
* Two homes are still SFFs even though the SIAs have ended.[Footnote
57] These homes were rated as below and much below average in August
2009.
* Two homes are still subject to the terms of their SIAs, and both
were rated as much below average in August 2009.
Although the first SIA was implemented more than 2 years ago, CMS
central office officials told us they had not yet disseminated
information to the regions describing the elements that should be part
of SIAs or catalogued any lessons learned from their use. We found
that most SIAs were initiated by regional offices with limited CMS
central office involvement and varying levels of state involvement.
[Footnote 58] As of May 2009, CMS's central office was not aware of
some SIAs that we identified in an interview with officials in the
Dallas regional office. According to officials at three of the six
regional offices that have not used SIAs, they prefer other agreements
to improve and maintain quality, including agreements between state
licensing authorities and SFFs. Of the three remaining regional
offices, two indicated they would be likely to develop an SIA when
they have facilities deemed appropriate and the other had not heard of
SIAs.
Nursing Homes in Need Initiative. The technical assistance provided by
QIOs to a limited number of nursing homes (one per year per state)
from August 1, 2008, through July 31, 2011, under the NHIN initiative
resembles the actions outlined in SIAs.[Footnote 59] For example, QIOs
are required to conduct an on-site assessment of each home to identify
the underlying causes of poor quality of care, prepare a root-cause
analysis based on those findings, and develop an action plan to
address the home's problems. Given the voluntary nature of the QIO
program, SFFs must agree to work with QIOs; however, CMS did direct
QIOs to contact SFFs recommended by state survey agencies instead of
relying on homes to request QIO assistance.[Footnote 60] According to
CMS, 44 QIOs assisted one SFF per state from August 2008 through July
2009, the first year of the NHIN initiative, and the remaining 6 QIOs
assisted other homes, including SFF candidates. CMS told us that these
states' QIOs were not working with SFFs for various reasons, such as
the SFFs were already showing improvement.[Footnote 61] Officials from
a majority of the states we interviewed thought it would be beneficial
for QIOs to work with every SFF instead of just one per state per
year.[Footnote 62]
In addition to the small number of SFFs that participate each year of
the contract, the initiative's effectiveness is also limited by the
misalignment between the measures CMS uses to monitor the effect of
QIO assistance and those used to measure whether an SFF is improving.
Specifically, CMS monitors the improvement in two quality of care
measures to determine the effect of QIO assistance during the
initiative--the percentage of long-term residents of a facility who
were either physically restrained or were high risk and had pressure
ulcers.[Footnote 63] An alternative approach would be to use the
measures that CMS uses to evaluate whether homes in the SFF Program
are improving, that is, the number or scope and severity of deficiency
citations. CMS officials responsible for the QIO program indicated
that they were aware of this discrepancy and would consider
alternative methods for measuring QIO performance.
HHS OIG's Experience with Quality of Care CIAs Is Relevant to CMS
Activities to Address Poor Quality at SFFs and Other Nursing Homes:
CMS officials told us that SIAs are not modeled on the HHS OIG quality
of care CIAs--corporate-level interventions to address quality
problems--and CMS and HHS OIG officials have indicated that they have
had preliminary discussions regarding SIAs. SIAs and CIAs are similar
in that they are intended to improve and maintain the quality of
participating facilities in lieu of termination or exclusion,
respectively, but quality of care CIAs are more commonplace, have been
in use since 2000, and are generally in effect for longer periods.
[Footnote 64] According to a 2009 HHS OIG report, by June 2008, 35
nursing home corporations had entered into such agreements, which are
generally in effect for 3 to 5 years.[Footnote 65] In its report, HHS
OIG examined 15 of these nursing home corporations under quality of
care CIAs, which collectively operated 1,104 nursing homes as of
December 31, 2006. Both SIAs and quality of care CIAs require homes or
corporations to seek outside technical assistance to identify changes
that will help address quality problems. In addition, quality of care
CIAs may require corporations to take other actions to help improve
quality, such as the establishment of corporate-level compliance
officers, quality assurance committees, and quality assurance
monitoring committees. The HHS OIG requires the corporations to hire
an independent entity, or monitor, to assess the quality assurance and
quality improvement systems in place in the corporations' homes.
According to an official with one such entity, staff members are
embedded in the nursing home corporation to help ensure that planned
quality improvements are actually implemented. In addition, the
corporations must provide the HHS OIG with a list of all homes that
belong to the same corporation at the beginning of the CIA and update
the HHS OIG with information on the homes bought and sold; the
independent quality monitor commonly contracts with a data analysis
organization, subject to HHS OIG approval, to analyze state survey
results and quality of care measures across the homes in the
corporation[Footnote 66]. The 2009 HHS OIG report evaluated the extent
to which required quality of care structures and processes were
implemented through CIAs. Based on its review of 15 such CIAs, the OIG
found that all 15 corporations had enhanced their quality of care
structures and processes while subject to these agreements. As of
September 2008, an HHS OIG official was aware of three corporations
with quality of care CIAs that had homes that were also in the SFF
Program, and two of these SFFs had SIAs. However, there is little
coordination between CMS and the HHS OIG to determine whether there is
overlap among homes with these agreements.
The HHS OIG's experience with quality of care CIAs is relevant and may
contain lessons that could improve the effectiveness of CMS's efforts
to deal with poorly performing nursing homes even though CMS central
office officials told us that the agency's relationship is with the
individual home and not the parent company. Thus, we found that some
regional offices do interact with corporations. One SIA we reviewed
was signed by the Vice President of Clinical Services of a large
nursing home chain. Moreover, officials from two regional offices told
us that they are aware of and monitor problems at chains operating in
their regions, such as by conducting federal monitoring surveys at
homes belonging to a problem chain.[Footnote 67] In fact, one of these
regions indicated that CMS's central office had directed closer
scrutiny of certain nursing home corporations in the past. Officials
from two regions provided a concrete example of their interactions
with officials from one corporation. These two regions noticed that
several homes with compliance problems had a common name, and one
regional office determined through a Google search that the homes were
part of the same chain; this chain operated almost 50 homes in five
states, and some of this chain's homes were SFFs. In one instance,
regional office officials met with the chief executive officer and
regional operations manager to discuss an improvement plan for one of
the chain's homes after this home became an SFF. In another instance,
officers from the same chain approached a regional office. Ultimately,
the chain developed a quality improvement plan intended to cover all
of its facilities across three CMS regions; however, regional office
officials did not consider this plan to be an SIA because it did not
provide for enforcement.
Some States Have Also Adopted Nursing Home Quality Improvement
Strategies That Are Relevant to CMS's Efforts to Address SFF Quality
Problems:
Officials from the majority of the 14 states we interviewed detailed
strategies they use to promote quality improvement in nursing homes,
including poorly performing homes. Their strategies have incorporated
a range of activities, such as having nurse monitors visit all nursing
homes, training nursing home staff on clinical best practices,
conducting expedited or more frequent surveys of nursing homes with
performance problems, and hiring consultants to provide technical
assistance to homes. These activities can be voluntary, and some
states target certain poorly performing nursing homes for
participation. According to some states, the SFF Program is more
effective when combined with state-based quality improvement
activities, which may make it difficult to determine whether
performance improvements are attributable to the SFF Program or to
state activities. Officials from three states described the following
noteworthy quality activities:
* Florida. Florida law requires the state agency to survey nursing
homes with serious performance problems more frequently (every 6
months for 2 years).[Footnote 68] Such homes must pay a fine of $6,000
in installments over the 2-year period to cover the expenses
associated with the additional surveys.[Footnote 69] As of August
2008, state officials told us that 26 nursing homes, including 3 SFFs,
met these criteria.
* Missouri. The state's Quality Improvement Program for Missouri's
Long Term Care Facilities offers a voluntary nurse consultant program
that provides in-person, on-site technical assistance for nursing
homes deemed to be at risk. While any nursing home in the state can
ask to participate in the program, the state also determines which
homes it deems eligible to participate and has included SFFs in this
determination since July 2008.[Footnote 70] As of October 2008, 85
nursing homes were targeted for program participation because the
state deemed them to be at risk.
* Arkansas. Arkansas's Innovative Performance Program, which began in
August 2005, provides most nursing homes with (1) monthly training
opportunities, covering a variety of topics for nursing home staff,
such as the top 10 most frequently cited deficiencies or clinical best
practices; and (2) intensive reviews of a home's operations to help
identify and correct systemic problems and put controls in place to
ensure the changes are implemented. Under its contract with the
Arkansas Office of Long Term Care, the state's QIO administers this
voluntary program and helps identify the homes most in need of
assistance.[Footnote 71] As of September 2009, 141 nursing homes were
participating in the program, including 5 of 6 SFFs.
Conclusions:
Improving the performance of poorly performing nursing homes through
efforts such as the SFF Program is essential to protecting highly
vulnerable elderly and disabled residents. Paradoxically, we found
that many SFFs improved their performance and graduated from the
program even though some may not always have been surveyed as
frequently as required or subjected to more robust enforcement--
actions called for in CMS SFF Program guidance to states and regional
offices. Important program changes made by CMS since 2004, such as the
2007 decisions to publicly report the names of SFFs and ensure that
owners and boards of directors are explicitly informed of their
facility's SFF status, have given homes additional incentives to
improve their performance. The effectiveness of the SFF Program could
be further improved if CMS implemented our August 2009 recommendation
to target scarce resources by placing more emphasis on the worst homes
nationally rather than on the worst homes in each state.[Footnote 72]
We found that state discretion in selecting SFFs is a key element of
the program, but that limitations in the candidate list restrict that
discretion. For example, homes that are selected as SFFs remain on
each state's list of 15 candidates, giving states with six SFFs, such
as California and Texas, fewer options when homes graduate from the
program or are terminated, compared to states with only one or two
SFFs. Moreover, at least two states--Michigan and Missouri--have
expanded on CMS's public disclosure strategy in an attempt to
influence the performance of SFF candidates by informing them that
they are at risk of being selected as an SFF if they fail to address
performance problems.
CMS's guidance to states regarding enforcement for SFFs is vague and
interpreted inconsistently by regional offices and states. We found
that for six SFFs with consecutive noncompliance, severe deficiencies
did not consistently result in more severe or immediate sanctions. For
example, one SFF received no civil money penalties even though it was
cited for consecutive deficiencies that could have resulted in fines
ranging from $300 to $825 per day of noncompliance, while a home with
a similar compliance history received CMPs that increased from $300 to
$600 per day of noncompliance, suggesting that CMS's monitoring of
enforcement is insufficient.
The significant percentage of SFFs that remained in the program for
considerably longer than CMS's 18-month time frame for improved
performance or termination is troubling because it prevents other
poorly performing nursing homes from receiving enhanced attention by
becoming SFFs since the program is limited by resources to 136 at a
time. For a limited number of homes that failed to show improvement or
where termination was seen as an option of last resort, 4 of CMS's 10
regional offices have negotiated agreements requiring homes to address
quality problems. Although the first SIA was implemented over 2 years
ago, CMS has not disseminated information to the regional offices
describing the elements that should be part of SIAs, or catalogued any
lessons learned from their use. It is probably too early to evaluate
the longer-term effectiveness of SIAs, but they do have the potential
to address the problem of homes that linger in the program for
extended periods.
Other efforts also have the potential to help address performance
problems at poorly performing nursing homes, and some may hold lessons
for improving the operation of the SFF Program.
* Nursing Homes in Need Initiative. QIOs are employing interventions
similar to those used in SIAs at poorly performing nursing homes,
primarily SFFs, at the rate of one home per state each year for 3
years. However, the QIO measures used to monitor the effect of QIO
assistance are inconsistent with the measures CMS uses to evaluate
whether SFFs are improving.
* Corporate Integrity Agreements. The HHS OIG has considerable
experience negotiating legal agreements with corporations that own
poorly performing nursing homes, agreements that also employ more
direct interventions to address quality problems across the homes in a
chain. Currently, there is little coordination between CMS and the HHS
OIG, even though we found that some regional offices also work with
chain corporate offices and a few homes were subject to both SIAs and
CIAs.
* State Quality Improvement Initiatives. Some states have adopted
quality improvement strategies to address problems at poorly
performing homes. For example, Florida requires homes with serious
performance problems to pay $6,000 to cover the costs associated with
more frequent surveys over a 2-year period. Although SFFs and other
poorly performing nursing homes that frequently harm residents or
place them in immediate jeopardy increase survey costs, CMS does not
currently have the authority to charge them for additional survey
activities.[Footnote 73] Charging such a fee could improve the linkage
between the costs associated with more frequent surveys and the
nursing homes that give rise to these costs.
Recommendations for Executive Action:
To increase the SFF Program's effectiveness in helping to address
quality of care problems at poorly performing nursing homes, we
recommend that the Administrator of CMS take the following five
actions:
* Expand the SFF Program's public disclosure strategy by directing
states to notify nursing homes that have been identified as SFF
Program candidates that they are at risk of being selected as an SFF.
* Revise the SFF candidate list by removing homes that states have
selected as SFFs and including additional homes so that states with a
large number of SFFs have a full complement of candidates to choose
from each time they select a new SFF.
* Ensure that states impose more stringent enforcement, such as higher
CMPs or termination; clarify SFF Program guidance regarding
appropriate sanctions; and monitor SFF sanctions more closely.
* Provide CMS regional offices with a description of the elements that
should be part of SIAs and catalog any lessons learned from their use.
* Coordinate more systematically with the HHS OIG regarding its
experiences with CIAs.
To offset the additional costs imposed by SFFs and create incentives
for poorly performing nursing homes to improve resident care more
quickly, we recommend that the Administrator of CMS seek legislative
authority to charge SFFs for the costs associated with conducting
additional surveys.
Agency Comments and Our Evaluation:
We obtained written comments on our draft report from HHS, which are
reprinted in appendix V. HHS noted its commitment to further
strengthening the SFF Program and indicated that our report would help
to further improve what could work better and reaffirm what is already
working well. HHS agreed fully with four of our six recommendations,
agreed in principle with a fifth recommendation, and indicated that it
would take a sixth recommendation under advisement.
In its comments, HHS reported on additional analyses it had conducted,
which found that in comparing SFF graduates to candidates, (1) a
higher percentage of graduates had no deficiencies at the F-level or
higher both 6 months and 12 months after graduation from the program,
and (2) an average of 21.5 months and 15.6 months, respectively,
elapsed before 50 percent of the homes in either group had an F-level
or higher deficiency. HHS concluded that while these analyses did not
suggest that SFF graduates had transformed into high-quality nursing
homes, they did indicate that the greater efforts made by SFF
graduates had some lasting and positive effects on quality of care.
Despite the improvements demonstrated by SFFs, HHS expressed concern
about those SFF graduates that relapse into a pattern of serious
deficiencies. HHS noted that it will re-examine the 18-month time
frame for SFFs to demonstrate improved performance given our finding
that a significant percentage of SFFs remain in the program beyond 18
months.
HHS fully concurred with the following four recommendations: (1)
directing states to notify SFF candidates that they are at risk of
being selected for the SFF Program; (2) clarifying SFF Program
guidance on appropriate sanctions and monitoring SFF sanctions more
closely; (3) providing CMS regional offices with a description of the
elements of an SIA and cataloging lessons learned from their use; and
(4) coordinating more systematically with the HHS OIG regarding its
experiences with CIAs. In addition, HHS agreed in principle with our
recommendation that CMS revise the SFF candidate list by removing
homes that have already been selected as SFFs and including additional
homes so that states have a full complement of candidates from which
to choose; however, HHS said that CMS will operationalize the
recommendation in a different manner by sizably increasing the SFF
candidate list for most states. If implemented, CMS's proposed
approach would address our recommendation. Finally, HHS indicated it
would take under advisement our recommendation that the Administrator
of CMS seek legislative authority to charge SFFs for the costs
associated with conducting additional surveys.
HHS also provided technical comments, which we incorporated as
appropriate. We also provided excerpts of the report to the HHS OIG
and the three state survey agencies whose specific quality improvement
strategies we described in the report--Arkansas, Florida, and
Missouri--and incorporated technical comments from those agencies as
appropriate.
As we agreed with your offices, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it
until 30 days from the date of this letter. At that time, we will send
copies to the Administrator of the Centers for Medicare & Medicaid
Services and appropriate congressional committees. The report also is
available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or at dickenj@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made key contributions
to this report are listed in appendix VI.
Signed by:
John E. Dicken:
Director, Health Care:
[End of section]
Appendix I: Special Focus Facility Financial Performance:
This appendix addresses your interest in the financial performance of
Special Focus Facilities (SFF).[Footnote 74] Officials from the
Centers for Medicare & Medicaid Services's (CMS) central office told
us that they do not attempt to determine whether poor financial
performance contributed to the poor quality of care provided by SFFs.
However, three of the four regional offices we interviewed did not
believe that poor financial performance was more common for SFFs than
for other nursing homes. An official from the remaining regional
office did not comment because he told us the office assesses only
quality of care. Regional offices told us that they may learn about
homes' financial problems on an ad hoc basis. For example, they might
learn that a home failed to meet payroll, that lenders were unwilling
to extend credit to a home, or that a resident's complaint, such as a
low building temperature or limited food supply, might indicate
financial problems. In addition, regional offices are made aware of
potential financial problems when a home requests a delay or reduction
in payment on civil money penalties (CMP) based on poor financial
condition. CMS guidance provides a suggested list of sources for
information to determine if a CMP should be delayed or reduced due to
a home's financial condition, but does not indicate how the regional
office should make this determination. Furthermore, two regional
offices told us that requests for delayed or reduced CMPs are rare.
CMS's central office also has access to another source of financial
information--annual Medicare cost reports, which nursing homes
receiving Medicare payments are required to submit to Medicare
Administrative Contractors.[Footnote 75] However, according to the
Medicare Payment Advisory Commission (MedPAC), the financial
information provided in these reports has several limitations for
assessing total financial performance of nursing homes. For example,
the cost reports do not follow the format of standard audited
financial statements or receive serious audit attention. Despite these
limitations, the Medicare Administrative Contractor we interviewed,
which processes Medicare claims in addition to receiving Medicare cost
reports, told us that it could conduct a financial analysis of nursing
homes if CMS were to request and fund this activity, but noted that it
would first want to verify their information.
We did identify two entities that have initiatives that collect
information about nursing home financial performance. First, Virginia
passed legislation on health care data reporting in 1996, which
resulted in the state's contracting with Virginia Health Information
to report both nursing home financial information and an assessment of
homes' efficiency and productivity, among other information, on its
Web site.[Footnote 76] The financial information that providers,
including nursing homes, are required to file annually includes
details about revenue, expenses, and assets. This information is
summarized from either certified audited financial statements or, if
the nursing home is part of a publicly held company, unconsolidated
unaudited financial statements submitted by the home. Second, the
Department of Housing and Urban Development (HUD) classifies the
financial performance of all facilities that participate in the
Section 232 Mortgage Insurance for Residential Care Facilities
program.[Footnote 77] According to HUD officials, 12 SFFs as of June
2009 had insured mortgages and the officials classified 8 of them as
financially troubled based on various criteria, such as the home
making a late mortgage payment or concerns about the home's ability to
make future mortgage payments.
[End of section]
Appendix II: Scope and Methodology:
This appendix provides additional details regarding our scope and
methodology.
State interviews. We selected a nongeneralizable sample of 14 states
to interview based on a combination of factors, including: (1) the
number of SFFs allocated to the state, (2) the inclusion of at least
one state from each CMS region, (3) states that had many homes with
high SFF scores, (4) the number of SFFs that either graduated from the
program or were terminated from Medicare and Medicaid for failing to
improve their performance, (5) the use of Systems Improvement
Agreements, and (6) the existence of state ranking methodologies. We
interviewed officials from the following 14 states: Alabama, Arkansas,
California, Colorado, Connecticut, Florida, Illinois, Indiana,
Massachusetts, Missouri, New York, Pennsylvania, Texas, and Washington.
SFF candidate lists. CMS provided us with 16 SFF candidate lists
generated from December 2005 to January 2009, which contain the score
and rank of all nursing homes using CMS's SFF methodology. Since 2006,
CMS has issued candidate lists quarterly, but it generates additional
lists when necessary.
* To determine the factors that states considered in selecting SFFs
from January 2006 through February 2009, we determined the rank of
each home on the candidate list that was generated before, but closest
to, the date of that home's selection for the program.
* To determine the factors that states considered in selecting SFFs,
we analyzed the scores of SFF candidates from CMS's January 2009
candidate list.
* To determine the SFF Program's impact on homes' performance, we
analyzed the scores for each of the three cycles provided on CMS's
candidate lists from December 2005 to January 2009 by calculating
state average indexed scores. We then created a mean indexed score for
all SFF graduates for three points in time--before the home entered
the program, while the home was in the program, and after graduation--
and compared them to each other. For SFFs that were active in the
program as of February 2009, we also compared the mean indexed score
before the home entered the program to the mean indexed score while
the home was in the program.
OSCAR survey and deficiency data. We conducted several analyses using
data from CMS's On-Line Survey, Certification, and Reporting system
(OSCAR) for standard surveys and complaint investigations generally
conducted between January 2005 and July 31, 2009. We analyzed survey
dates, deficiencies cited on standard surveys and complaint
investigations, and any revisits associated with the standard surveys.
To be consistent with the SFF methodology and avoid potential double-
counting, we did not include deficiencies that also appeared on
complaint surveys conducted within 15 days of a standard survey
(either prior to or after the standard survey).[Footnote 78]
* To determine how SFFs differ from other nursing homes, we calculated
the average number of deficiencies and revisits for certain SFFs
compared to other nursing homes. We identified SFFs that were added to
the SFF Program in 2008 and that also had a 2008 standard survey prior
to their entry into the program. We compared these SFFs to other homes
that had a standard survey conducted in 2008. Our analysis included
deficiencies identified during the 2008 standard survey, deficiencies
from complaint investigations that occurred in the year prior to the
2008 standard survey, and revisits associated with the standard survey.
* To determine whether states followed CMS's guidance to survey SFFs
twice a year, we analyzed the dates of the standard surveys conducted
while nursing homes were in the SFF Program. We determined the number
of surveys that should have been conducted each year by multiplying
the state's SFF allotment by two. We then summed the number of SFF
surveys conducted by each state for fiscal years 2007 and 2008 and
determined if the number of surveys conducted was fewer than the total
number of surveys that should have been conducted. In addition, we
calculated the number of states that did not survey at least one of
their SFFs within the first 7 months after the home entered the
program and that had at least one SFF with more than 10 months between
surveys from calendar year 2005 through 2008.
* To determine whether CMS regional offices and the states followed
the agency's SFF Program graduation criteria, we analyzed survey dates
and data on deficiencies from standard surveys and complaint
investigations. We determined which SFFs did not graduate
appropriately because (1) states conducted standard surveys zero or
only one time while the home was in the SFF Program; (2) the home had
deficiencies at the F level or higher on the two standard surveys
preceding their graduation; or (3) the home had deficiencies at the F
level or higher on any complaint surveys that occurred from the two
standard surveys preceding their graduation through the date of their
graduation.
* To determine if SFFs had F-level deficiencies that may have
contributed to the length of time they were in the SFF Program, we
determined the number of SFFs that had various combinations of
standard and complaint surveys that resulted in deficiencies at the F
level and lower.
* To determine the program's impact on SFF graduates, we analyzed
deficiencies from standard and complaint surveys for SFFs after they
graduated from the program. Specifically, we determined the number of
SFFs that after graduation had F-level or higher deficiencies on any
survey, F-level or higher deficiencies on consecutive standard
surveys, and immediate jeopardy deficiencies.
Nursing home enforcement. To determine whether CMS regional offices
and states followed the agency's SFF Program enforcement guidance, we
first identified homes that were SFFs as of January 1, 2007, and that
had two consecutive standard surveys, both of which cited at least one
G-level or higher deficiency; we then analyzed Nursing Home
Enforcement History reports and Nursing Home Enforcement Case Profiles
for these homes that we obtained from the regional offices and which
summarize data from CMS's Automated Survey Processing Environment
Enforcement Manager (AEM).[Footnote 79] In addition, we analyzed AEM
data on CMPs and denials of payment for new Medicare or Medicaid
admissions (DPNA) that were in effect for calendar years 2006 through
2008 for each of three categories of nursing homes--SFFs, SFF
candidates, and other nursing homes. We determined the percentage of
homes in each category that had at least one CMP or DPNA by year. In
addition, we calculated mean CMP amounts (per day and per instance) by
home type and year by summing each home's CMPs for the year. For SFFs,
we included only sanctions that occurred while the home was in the SFF
Program. SFF candidates were those homes ranked as among the worst 15
homes per state based on the CMS candidate lists for that same year.
Termination. To determine the number of SFFs that were terminated--
voluntarily or involuntarily--and later became certified to
participate in Medicare or Medicaid again, we analyzed information
available from CMS's Provider of Service file dated December 2008. To
do so, we identified the addresses of SFFs that terminated, and then
we identified nursing homes that shared the same physical location as
the terminated SFFs and that later began participating in Medicare or
Medicaid.
Nursing home characteristics data. To determine how SFFs differ from
other nursing homes, we analyzed CMS data that describe the
characteristics of nursing homes: a December 17, 2008, extract of
OSCAR variables, such as type of organization and number of beds;
nurse staffing hours, which were case-mix adjusted by CMS for use in
its Five-Star Quality Rating System and which were dated January 2009;
and nursing home ratings from the Five-Star System available from
Nursing Home Compare, which were dated December 2008. Following are
highlights of how we analyzed certain characteristics:
* Nursing homes self-report their ownership type. We created the
ownership type of for-profit by combining for-profit individual, for-
profit partnership, for-profit corporation, and limited liability
corporation; the ownership type of nonprofit by combining nonprofit
corporation, nonprofit church-related, and nonprofit other; and the
ownership type of government by combining the six government
designations (state, county, city, city/county, hospital district, and
federal).
* CMS maintains a variable in its data called "multi-nursing home
(chain) ownership," which is self-reported by nursing homes and which
we refer to as chain affiliation. According to CMS, multi-nursing home
chains have two or more homes under one ownership or operation. We
determined the percentage of nursing homes that were for-profit and
chain affiliated, nonprofit and chain affiliated, or government-owned
and chain affiliated by combining the ownership types described above
with CMS's designation of multi-nursing home (chain) ownership.
* We used the number of beds certified for payment for Medicare and/or
Medicaid to calculate the average number of beds per nursing home.
* We calculated the percentage of residents by type (Medicare,
Medicaid, or other) by dividing the number of Medicare, Medicaid, and
other patients by the number of total residents.
* We calculated the occupancy rate of nursing homes by dividing the
total number of residents by the number of certified beds.
* We analyzed the following case-mix adjusted nurse staffing hours:
registered nurse hours per resident per day; licensed practical nurse
and vocational nurse hours per resident per day; nurse aide hours per
resident per day; and total staffing hours per resident per day.
[Footnote 80] We calculated registered nurse hours as a share of the
total. Unadjusted nurse staffing hours data are collected by CMS, are
self-reported by nursing homes, and represent staffing levels for a 2-
week period prior to the state inspection. CMS case-mix adjusted the
staffing data using the average minutes of nursing care used to care
for residents in a given resource utilization group category as
reflected in the Medicare skilled nursing facility prospective payment
system.[Footnote 81] CMS acknowledges that the staff hours collected
from nursing homes have certain limitations. In order to increase the
accuracy and comprehensiveness of the staffing data, CMS has been
investigating whether it can use nursing home payroll data to report
staffing levels on Nursing Home Compare.
[End of section]
Appendix III: Characteristics of Special Focus Facilities and Other
Nursing Homes:
Participation type (percentage):
Medicare and Medicaid:
Special Focus Facilities: 97.7%;
Other Nursing Homes: 90.3%.
Medicare only:
Special Focus Facilities: 0%;
Other Nursing Homes: 5.2%.
Medicaid only:
Special Focus Facilities: 2.3%;
Other Nursing Homes: 4.5%.
Beds and residents:
Average number of beds per home (number):
Special Focus Facilities: 131.4;
Other Nursing Homes: 105.8.
Average number of residents per home (number):
Special Focus Facilities: 103.7;
Other Nursing Homes: 89.6.
Occupancy rate (percentage):
Special Focus Facilities: 78.6%;
Other Nursing Homes: 84.5%.
Share of resident type (percentage):
Medicare:
Special Focus Facilities: 12.0%;
Other Nursing Homes: 15.8%.
Medicaid:
Special Focus Facilities: 70.8%;
Other Nursing Homes: 59.6%.
Other:
Special Focus Facilities: 17.2%;
Other Nursing Homes: 24.7%.
Type of ownership (percentage):
Ownership type: For-profit (individual, partnership, or corporation);
Special Focus Facilities: 81.2%;
Other Nursing Homes: 67.4%.
Ownership type: Nonprofit (corporation, church, or other);
Special Focus Facilities: 15.0%;
Other Nursing Homes: 26.7%.
Ownership type: Government-owned;
Special Focus Facilities: 3.8%[A];
Other Nursing Homes: 5.9%[A].
Chain affiliation:
Special Focus Facilities: 65.4%;
Other Nursing Homes: 53.4%.
For-profit and chain affiliated:
Special Focus Facilities: 54.9%;
Other Nursing Homes: 41.7%.
Nonprofit and chain affiliated:
Special Focus Facilities: 9.0%[A];
Other Nursing Homes: 11.0%[A].
Government-owned and chain affiliated:
Special Focus Facilities: 1.5%[A];
Other Nursing Homes: 0.7%[A].
Type of staff (average hours per resident-day):
Registered nurse:
Special Focus Facilities: 0.31;
Other Nursing Homes: 0.36.
Licensed practical and vocational nurses:
Special Focus Facilities: 1.04[A];
Other Nursing Homes: 0.99[A].
Nurse aide:
Special Focus Facilities: 2.39[A];
Other Nursing Homes: 2.40[A].
Total:
Special Focus Facilities: 3.48[A];
Other Nursing Homes: 3.55[A].
Registered nurse hours as a share of total hours (percentage):
Special Focus Facilities: 8.95%;
Other Nursing Homes: 9.94%.
Five-Star System[B] (percentage):
Overall quality rating: 1 star;
Special Focus Facilities: 74.4%;
Other Nursing Homes: 22.1%.
Overall quality rating: 2 stars;
Special Focus Facilities: 22.6%;
Other Nursing Homes: 20.5%.
Overall quality rating: 3 stars;
Special Focus Facilities: 3.0%;
Other Nursing Homes: 21.4%.
Overall quality rating: 4 stars;
Special Focus Facilities: 0%;
Other Nursing Homes: 23.7%.
Overall quality rating: 5 stars;
Special Focus Facilities: 0%;
Other Nursing Homes: 12.3%.
Health inspection component: 1 star;
Special Focus Facilities: 92.5%;
Other Nursing Homes: 18.9%.
Health inspection component: 2 stars;
Special Focus Facilities: 5.3%;
Other Nursing Homes: 23.4%.
Health inspection component: 3 stars;
Special Focus Facilities: 1.5%;
Other Nursing Homes: 23.4%.
Health inspection component: 4 stars;
Special Focus Facilities: 0.8%;
Other Nursing Homes: 23.7%.
Health inspection component: 5 stars;
Special Focus Facilities: 0%;
Other Nursing Homes: 10.7%.
Source: GAO analysis of CMS data.
Notes: (1) All characteristics are percentages unless otherwise
indicated. (2) SFFs enter and exit the program on an ongoing basis;
therefore, there may be fewer than 136 SFFs at any given time. We
compared the characteristics of the 133 SFFs that were active in the
program as of February 2009 to those of other nursing homes, which
excluded facilities that were SFFs from 2005 through February 2009.
However, three of these SFFs were missing nurse staffing data. (3)
Unless otherwise noted, all differences between groups are significant
at the 0.05 level. (4) The data we analyzed were as of December 2008,
except for the data on nurse staffing, which were as of January 2009.
[A] The difference between SFFs and all other nursing homes for this
variable is not significant.
[B] Individual entries may not sum to 100 percent because of rounding.
[End of table]
[End of section]
Appendix IV: Chronological Summary of All 10 Systems Improvement
Agreements (SIA):
State/SFF: SC 1;
CMS region: Atlanta;
Duration in SFF Program (prior to SIA)[A]: 25 months;
Start and end date of SIA: 3/07-10/07;
Duration of SIA[A]: 8 months;
SFF status (date graduated/terminated)[B]: Graduated (10/08);
CMS's Five-Star System Rating: Below average.
State/SFF: TX 2;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 27 months;
Start and end date of SIA: 3/07-8/07;
Duration of SIA[A]: 5 months;
SFF status (date graduated/terminated)[B]: Graduated (3/08);
CMS's Five-Star System Rating: Much below average.
State/SFF: DE 3;
CMS region: Philadelphia;
Duration in SFF Program (prior to SIA)[A]: 29 months;
Start and end date of SIA: 5/07-5/09;
Duration of SIA[A]: 24 months;
SFF status (date graduated/terminated)[B]: Graduated (4/08);
CMS's Five-Star System Rating: Below average.
State/SFF: DC 4;
CMS region: Philadelphia;
Duration in SFF Program (prior to SIA)[A]: 34 months;
Start and end date of SIA: 9/07-6/09;
Duration of SIA[A]: 22 months;
SFF status (date graduated/terminated)[B]: Active;
CMS's Five-Star System Rating: Below average.
State/SFF: CA 5;
CMS region: San Francisco;
Duration in SFF Program (prior to SIA)[A]: 18 months;
Start and end date of SIA: 12/07-12/08;
Duration of SIA[A]: 12 months;
SFF status (date graduated/terminated)[B]: Active;
CMS's Five-Star System Rating: Much below average.
State/SFF: TX 6;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 42 months;
Start and end date of SIA: 6/08-8/08;
Duration of SIA[A]: 2 months;
SFF status (date graduated/terminated)[B]: Graduated (3/09);
CMS's Five-Star System Rating: Above average.
State/SFF: OK 7;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 19 months;
Start and end date of SIA: 6/08-11/08;
Duration of SIA[A]: 4 months;
SFF status (date graduated/terminated)[B]: Terminated (10/08);
CMS's Five-Star System Rating: Not rated[D].
State/SFF: TX 8;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 16 months;
Start and end date of SIA: 9/08-3/09;
Duration of SIA[A]: 6 months;
SFF status (date graduated/terminated)[B]: Terminated (3/09);
CMS's Five-Star System Rating: Not rated[D].
State/SFF: OK 9;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 20 months;
Start and end date of SIA: 6/09[C];
Duration of SIA[A]: Ongoing;
SFF status (date graduated/terminated)[B]: Active;
CMS's Five-Star System Rating: Much below average.
State/SFF: AR 10;
CMS region: Dallas;
Duration in SFF Program (prior to SIA)[A]: 16 months;
Start and end date of SIA: 8/09[C];
Duration of SIA[A]: Ongoing;
SFF status (date graduated/terminated)[B]: Active;
CMS's Five-Star System Rating: Much below average.
Source: GAO analysis of SIAs, information obtained from CMS, and
Nursing Home Compare data from August 2009.
[A] Duration is rounded to the nearest month. Two homes were in the
SFF Program for less than 18 months before entering into SIAs;
however, both homes had three standard surveys between the time that
they were added to the SFF Program and the beginning of their SIAs.
[B] Active means that the nursing home was still in the SFF Program.
Terminated means that the nursing home was terminated from Medicare
and Medicaid.
[C] SIA was in effect as of August 2009.
[D] Nursing home was not rated by CMS because it terminated prior to
August 2009.
[End of table]
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
March 9, 2010:
John E. Dicken:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Mr. Dicken:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: "Poorly Performing Nursing Homes: Special Focus
Facilities Are Often Improving but CMS's Program Could Be
Strengthened" (GA0-10-197).
The Department appreciates the opportunity to review this report
before its publication.
Sincerely,
Signed by:
Andrea Palm:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
General Comments Of The Department Of Health And Human Services On The
Government Accountability Office's (GAO) Draft Report Entitled,
"Poorly Performing Nursing Homes: Special Focus Facilities Are Often
Improving But Cms's Program Could Be Strengthened" (GAO-10-197):
The Department appreciates the opportunity to review and comment on
this draft report. In this report GAO examined operation of CMS'
Special Focus Facility (SFF) Program for nursing homes. GAO described
the factors that States consider in selecting homes for the SFF
Program and how such nursing homes differ from other nursing homes.
GAO also evaluated the extent to which the CMS regional offices and
States followed CMS guidance in implementing the SFF Program and the
program's impact on the homes' performance. Finally, GAO identified
other strategies that have been employed to improve the performance of
poorly performing homes, including SFFs.
The CMS initiated the SFF Program to address important public policy
challenges posed by certain nursing homes that persist over time in
providing poor quality of care. In recent years CMS strengthened the
program by improving enforcement provisions and expanding the number
of nursing homes in the program (2005), expanding both provider and
public awareness of the program (2007), and posting on the CMS Web
site the identity of all SFF nursing homes (2008).
Prior CMS analysis resulted in many improvements to the program. We
expect that GAO's analysis will help us further improve what could
work better and reaffirm what is already working well. We agree fully
with five of the six GAO recommendations and will consider the sixth
recommendation.
The GAO found that most SFF nursing homes improved and that the
"scores of SFF graduates showed a statistically significant
improvement when compared to their scores before entering the program,
as did the scores of active SFFs..."
Figure 1: Percent of NHs with No F-Level or Higher Deficiency:
[Refer to PDF for image: vertical bar graph]
6 Months:
SFF Graduates: 85%;
Candidates: 72%.
12 Months:
SFF Graduates: 65%;
Candidates: 54%.
[End of figure]
A further question is whether improvements made by SFF nursing homes
are sustained over time after the nursing homes graduate. GAO, for
example, found that about 50 percent of the SFF graduates from
calendar years 2005 through 2008 later had a deficiency finding at the
F-level or greater (systemic potential for harm, or greater). Since
the SFF nursing homes begin with a very poor track record, it is
difficult to determine whether this 50 percent figure is better or
worse than would have occurred without the SFF Program. To address the
question of sustained improvement, we compared the performance of 180
SFF graduates that were enrolled in the program beginning January 2005
and that graduated before March 2009 with performance of a comparison
group composed of the highest-ranked (most poorly performing) nursing
homes that were candidates but were not selected for the SFF
Program[Footnote 1].
Since GAO's analysis found that SFF nursing homes had slightly worse
initial track records than the other candidates, we would not be
surprised if the SFF nursing homes continued to show
worse performance even after the SFF nursing homes graduate. Figure 1,
however, shows the opposite - a higher percentage of the SFF graduates
had no deficiency at the F-level or higher at 6 months after
graduation (85 percent free of such deficiencies) compared to the
comparison group of candidates (72 percent). Similarly, after 12
months, 65 percent of the SFF graduates still had no deficiency at the
F-level or higher, compared to only 54 percent of the candidates.
Using the statistic employed by GAO, Figure 2 shows the same
phenomenon of sustained, improved performance for the SFF graduates.
Figure 2 asks: "on average, how many months elapse before 50 percent
of each group has had at least one deficiency at the F-level or
higher?"
Figure 2: Average Number of Months Until 50% of NHs Have an F-Level or
Higher Deficiency:
[Refer to PDF for image: vertical bar graph]
SFF Graduates: 21.5 months;
Candidates: 15.6 months.
In this case, 21.5 months elapsed on average before 50 percent of the
SFF graduates had an F-level or higher deficiency, but only 15.6
months elapsed for the candidate group until such a serious deficiency
was identified. While the data do not suggest that the SFF graduates
have transformed themselves into high quality nursing homes, they do
indicate that the greater efforts made by nursing homes in order to
graduate from the SFF initiative have had some lasting and positive
effects on quality of care.
Among other findings, GAO also observed that a significant percentage
of SFFs remained in the program for considerably longer than CMS'
expectation of an 18-month time frame for improved performance (or
termination from Medicare/Medicaid). From interviews, GAO identified a
number of reasons for this phenomenon, and we will therefore reexamine
the time frame.
While we are encouraged by data indicating that CMS's Special Focus
Facility initiative is producing positive and enduring results, we
remain concerned by those nursing homes in the program that do relapse
into a pattern of serious deficiencies, and by the length of time it is
taking for some nursing homes to evidence improvement. During any
period of relapse, nursing home residents suffer. During the time we
await improvement, the affected nursing home residents endure poor
quality of care and the potential or the reality of serious harm. We
are therefore committed to further strengthening of the SFF nursing
home initiative.
The GAO issued six recommendations for executive action. We concur
with five of them and will consider the sixth. Below are CMS'
responses to each of the recommendations.
GAO Recommendation 1:
Expand the SFF Program's public disclosure strategy by directing
States to notify nursing homes that have been identified as SFF
Program candidates that they are at risk of being selected as an SFF.
CMS Response:
We agree with this recommendation. CMS will ensure that all SFF
candidate facilities are notified that they are at risk of being
selected as an SFF.
GAO Recommendation 2:
Revise the SFF candidate list by removing homes that States have
selected as SFFs and including additional homes so that States with a
large number of SFFs have a full complement of candidates to choose
from each time they select a new SFF.
CMS Response:
We agree with this recommendation in principle, though we will
operationalize it in a slightly different manner. Specifically, CMS
will sizably increase the SFF candidate list for most States so that
they will have an adequate number from which to choose. We will not
continually adjust the candidate list by removing those nursing homes
already selected, but the expanded list will address the problem that
States have cited and obtain the same result as the GAO recommendation.
GAO Recommendation 3:
Ensure that States impose more stringent enforcement, such as higher
civil money penalties (CMP) or termination; clarify SFF Program
guidance regarding appropriate sanction; and monitor SFF sanctions
more closely.
CMS Response:
We agree with this recommendation. CMS will clarify SFF Program
guidance to emphasize more consistent application of CMS' policy of
progressive enforcement. In addition, CMS will systematically review
the enforcement remedies levied against SFF facilities to ensure that
CMS guidelines are followed.
GAO Recommendation 4:
Provide CMS regional offices with a description of the elements that
should be part of systems improvement agreements (SIA) and catalog any
lessons learned from their use.
CMS Response:
We agree with this recommendation. CMS will issue guidance to States
and regional offices on the use of SIA's. This guidance will include a
model SIA to use as a template.
GAO Recommendation 5:
Coordinate more systematically with the Department of Health and Human
Services (HHS) Office of the Inspector General (OIG) regarding its
experiences with corporate integrity agreements (CIA).
CMS Response:
We agree with this recommendation. CMS will work with the HHS OIG to
determine appropriate methods by which the two agencies can more
systematically coordinate their efforts.
GAO Recommendation 6:
Seek legislative authority to charge SFFs for the costs associated
with conducting additional surveys.
CMS Response:
The CMS will take this recommendation under advisement. Congress
temporarily approved use of a "Revisit User Fee" in Fiscal Year 2007.
The Revisit User Fee applied only to those nursing homes that had a
deficiency such that a revisit was required to verify that corrections
had been made and the facility was in substantial compliance with CMS
requirements. Since SFF facilities have more serious deficiencies than
other nursing homes (on average), and therefore have many more
revisits, the cost of the Revisit User Fee was borne proportionately
more by SFF facilities than others. SFFs paid about $1500 in revisit
user fees on average, compared with about $1100 for non-SFF nursing
homes.
Appendix 5 Footnote:
[1] The comparison group consisted of 301 nursing homes that were
active for at least 18 months after their appearance on a SFF
candidate list and that were ranked among the 5 worst performing
candidates in a State. If a nursing home appeared on more than one
candidate list, the selection date corresponding with the worst survey
score was retained.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
John E. Dicken, (202) 512-7114 or dickenj@gao.gov:
Acknowledgments:
In addition to the contact name above, Walter Ochinko, Assistant
Director; Ramsey Asaly; Daniel Lee; Shannon Legeer; Jessica Morris;
Roseanne Price; Jennifer Rellick; Kathryn Richter; and Jessica Smith
made key contributions to this report.
[End of section]
Related GAO Products:
Nursing Homes: Addressing the Factors Underlying Understatement of
Serious Care Problems Requires Sustained CMS and State Commitment.
[hyperlink, http://www.gao.gov/products/GAO-10-70]. Washington, D.C.:
November 24, 2009.
Nursing Homes: Opportunities Exist to Facilitate the Use of the
Temporary Management Sanction. [hyperlink,
http://www.gao.gov/products/GAO-10-37R]. Washington, D.C.: November
20, 2009.
Nursing Homes: CMS's Special Focus Facility Methodology Should Better
Target the Most Poorly Performing Homes, Which Tended to Be Chain
Affiliated and For-Profit. [hyperlink,
http://www.gao.gov/products/GAO-09-689]. Washington, D.C.: August 28,
2009.
Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine
Its Approach for Funding State Oversight of Health Care Facilities.
[hyperlink, http://www.gao.gov/products/GAO-09-64]. Washington, D.C.:
February 13, 2009.
Nursing Homes: Federal Monitoring Surveys Demonstrate Continued
Understatement of Serious Care Problems and CMS Oversight Weaknesses.
[hyperlink, http://www.gao.gov/products/GAO-08-517]. Washington, D.C.:
May 9, 2008.
Nursing Home Reform: Continued Attention Is Needed to Improve Quality
of Care in Small but Significant Share of Homes. [hyperlink,
http://www.gao.gov/products/GAO-07-794T]. Washington, D.C.: May 2,
2007.
Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
Deterred Some Homes from Repeatedly Harming Residents. [hyperlink,
http://www.gao.gov/products/GAO-07-241]. Washington, D.C.: March 26,
2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety. [hyperlink,
http://www.gao.gov/products/GAO-06-117]. Washington, D.C.: December
28, 2005.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. [hyperlink,
http://www.gao.gov/products/GAO-03-561]. Washington, D.C.: July 15,
2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. [hyperlink,
http://www.gao.gov/products/GAO-03-187]. Washington, D.C.: October 31,
2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. [hyperlink,
http://www.gao.gov/products/GAO-02-279]. Washington, D.C.: February
15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-197]. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-6]. Washington, D.C.: November
4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-154R]. Washington, D.C.:
August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing
Homes Has Merit. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157]. Washington, D.C.: June
30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-80]. Washington, D.C.: March
22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46]. Washington, D.C.: March
18, 1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-98-202]. Washington, D.C.: July
27, 1998.
[End of section]
Footnotes:
[1] Every nursing home receiving Medicare or Medicaid payment must
undergo a standard survey not less than once every 15 months, and the
statewide average interval for these surveys must not exceed 12
months. See 42 U.S.C. § 1395i-3(g)(2)(A)(iii); 42 U.S.C. §
1396r(g)(2)(A)(iii). CMS generally interprets these requirements to
permit a statewide average interval of 12.9 months and a maximum
interval of 15.9 months for each home.
[2] Medicare is the federal health care program for elderly and
disabled individuals. Medicaid is the joint federal-state health care
financing program for certain categories of low income individuals.
Combined Medicare and Medicaid payments for nursing home services were
about $78 billion in 2007, including a federal share of about $54
billion.
[3] See GAO, Nursing Homes: Additional Steps Needed to Strengthen
Enforcement of Federal Quality Standards, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46] (Washington, D.C.: March
18, 1999), and Nursing Homes: Proposal to Enhance Oversight of Poorly
Performing Homes Has Merit, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157] (Washington, D.C.: June
30, 1999).
[4] Prior to 2005, each state had two SFFs, including Alaska. Alaska
no longer participates in the SFF Program because it has few nursing
homes--only 15 in fiscal year 2008.
[5] CMS's fiscal year 2010 survey and certification program budget
request sought an increase of $53.8 million over the prior fiscal
year. This request was approved by both the House and Senate
Committees on Appropriations. H.R. Rep. No. 111-220, at 158 (2009); S.
Rep. No. 111-66, at 137 (2009). In August 2009, the agency indicated
that it expected to increase the number of SFFs (about one per state)
if fiscal year 2010 funding reflected this increase. An increase in
the number of SFFs would be consistent with our 2007 recommendation
for CMS to expand the SFF Program. See GAO, Nursing Homes: Efforts to
Strengthen Federal Enforcement Have Not Deterred Some Homes from
Repeatedly Harming Residents, GAO-07-241 (Washington, D.C.: Mar. 26,
2007).
[6] See GAO, Nursing Homes: CMS's Special Focus Facility Methodology
Should Better Target the Most Poorly Performing Homes, Which Tended to
Be Chain Affiliated and For-Profit, [hyperlink,
http://www.gao.gov/products/GAO-09-689] (Washington, D.C.: August 28,
2009).
[7] OSCAR data change continually as new surveys are conducted and
entered into the database, but there can be a lag between the date a
survey is conducted and the date when the results are entered into the
database.
[8] The statutory mission of the QIO Program is to improve the
effectiveness, efficiency, economy, and quality of the services
delivered to Medicare beneficiaries. QIOs are private, mostly not-for-
profit organizations that contract with CMS. They are staffed
primarily by physicians and other health care professionals, who are
trained to review medical care, help beneficiaries with complaints
about the quality of care, and implement improvements in the quality
of care delivered.
[9] In this report, we use the term states to refer to state survey
agencies, including the District of Columbia. We interviewed a
nongeneralizable sample of 14 states, which were selected based on a
combination of factors, including the number of SFFs allocated to the
state and SFF scores. These states were Alabama, Arkansas, California,
Colorado, Connecticut, Florida, Illinois, Indiana, Massachusetts,
Missouri, New York, Pennsylvania, Texas, and Washington.
[10] Pub. L. No. 100-203, §§ 4201, 4211, 101 Stat. 1330, 1330-160,
1330-182 (codified in pertinent part at 42 U.S.C. § 1395i-3 and 42
U.S.C. § 1396r).
[11] In general, state survey activities are funded through a
combination of Medicare, Medicaid, and non-Medicaid state funds. In
the annual appropriation act for HHS, Congress authorizes the transfer
of a specific amount from the Medicare Trust Funds to the CMS Program
Management Account and includes an amount for the approximately 75
percent federal share of Medicaid expenditures (states generally pay
the remaining 25 percent). States also contribute non-Medicaid state
funds for the benefit they derive from facilities meeting federal
quality standards and the survey costs associated with meeting state
licensing requirements. See GAO, Medicare and Medicaid Participating
Facilities: CMS Needs to Reexamine Its Approach for Funding State
Oversight of Health Care Facilities, [hyperlink,
http://www.gao.gov/products/GAO-09-64] (Washington, D.C.: Feb. 13,
2009).
[12] The standard survey also includes an assessment of federal fire
safety standards. The fire safety portion of a standard survey is not
always conducted concurrently with the assessment of other standards.
[13] Revisits are not required for most deficiencies below the actual
harm level--A through F. However, revisits are required for G-level or
higher deficiencies as well as certain F-level deficiencies.
[14] Regional offices typically accept state-proposed sanctions but
can modify them.
[15] CMS requires states to refer for immediate sanction homes that
receive at least one G-through L-level deficiency on successive
standard surveys or intervening complaint investigations. Under CMS's
immediate sanctions policy, sanctions may be imposed without giving
homes an opportunity to correct serious deficiencies that resulted in
actual resident harm or put residents at risk of death or serious
injury.
[16] The scope and severity of a deficiency is one of the factors that
CMS may take into account when imposing sanctions. CMS may also
consider a home's prior compliance history, desired corrective action
and long-term compliance, and the number and severity of all the
home's deficiencies.
[17] Other sanctions include directed in-service training, state
monitoring, and temporary management. For information on the use of
temporary management, see GAO, Opportunities Exist to Facilitate the
Use of the Temporary Management Sanction, GAO-10-37R (Washington,
D.C.: Nov. 20, 2009).
[18] Because of the notice period, discretionary DPNAs provide homes
with a grace period during which they are able to avoid the sanction
if they correct the deficiencies.
[19] To avoid potential double-counting, deficiencies that appear on
complaint surveys conducted within 15 days of a standard survey
(either prior to or after the standard survey) are counted only once.
If the scope or severity differs on the two surveys, the highest scope
and severity combination is used.
[20] From 1999 to 2004, the SFF methodology assigned a different
number of points to deficiencies using only about 1 year of deficiency
data. In 2005, CMS altered the number of points assigned to
deficiencies and based a nursing home's numeric score on about 3 years
of deficiency data, weighted equally. In 2007, CMS removed fire safety
deficiencies from the SFF methodology, to provide an increased focus
on quality of care deficiencies.
[21] A nursing home with one or more deficiencies at the F through L
level--but not G level--in Quality of Care, Quality of Life, or
Resident Behavior and Facility Practices must be cited for substandard
quality of care.
[22] Each cycle consists of a standard survey, which occurs roughly
annually, revisits associated with the standard survey, and 12 months
of complaint investigations.
[23] The most recent score is assigned a weighting factor of one-half,
the second most recent score is assigned a weighting factor of one-
third, and the third most recent score (from the earliest period) is
assigned a weighting factor of one-sixth.
[24] CMS allocated SFFs to states in December 2004 based on the number
of nursing homes in each state at that time and does not reallocate
SFFs as the number of nursing homes in each state changes. In
addition, CMS increased the candidate list size from 4 to 15 per state.
[25] CMS implemented state performance reviews in fiscal year 2001 and
reorganized the reviews in fiscal year 2006. In fiscal year 2008, CMS
began measuring states' adherence to this requirement.
[26] The state performance reviews also specify that the state should
conduct a standard survey within 6 months of the SFF's selection, but
CMS does not measure adherence to this element.
[27] CMS launched its Nursing Home Compare Web site in 1998 to provide
information to consumers on nursing home performance. The Web site
provides consumers with information intended to help them evaluate the
quality of care provided by a nursing home, such as the number and
type of deficiencies identified during state surveys.
[28] As described in our August 2009 report, there had been only one
significant variation between CMS's SFF methodology and the health
inspections component of the Five-Star System as of March 2009: the
Five-Star System assigns more points to D-through I-level deficiencies
than does the SFF methodology. CMS has since made several other
modifications to the health inspections component of the Five-Star
System. See GAO-09-689 and Centers for Medicare & Medicaid Services,
Design for Nursing Home Compare Five-Star Quality Rating System:
Technical Users' Guide, October 2009, [hyperlink,
http://www.cms.hhs.gov/CertificationandComplianc/Downloads/usersguide.pd
f] (accessed December 28, 2009).
[29] Contrary to CMS guidance, states selected nursing homes not on
their candidate list 10 times. The rank of these homes ranged from 22
to 519. According to CMS officials, states are not allowed to select a
nursing home ranked other than 1 to 15. Nine of the 10 homes were
added to the SFF Program in 2006 or 2007.
[30] Candidate lists are generated from deficiency and revisit data.
According to data from CMS's Providing Data Quickly Web site, 11
percent of surveys in fiscal year 2008 were updated in CMS's database
70 days after the survey was conducted and the average amount of time
between a state survey and database update was a month and a half.
[31] See [hyperlink, http://www.gao.gov/products/GAO-09-689].
[32] We did not analyze the compliance histories of all SFFs because
some had received standard surveys after being added to the program.
"Other nursing homes" excludes facilities that were SFFs from 2005
through February 2009.
[33] The SFF methodology uses deficiencies from the three most recent
standard surveys and from the three most recent 12 months of
complaints, as well as the number of revisits associated with the
three most recent standard surveys. Our analysis took a similar
approach but looked only at the most recent period.
[34] SFFs enter and exit the program on an ongoing basis; therefore,
there may be fewer than 136 SFFs at any given time. We compared the
characteristics of the 133 SFFs that were active in the program as of
February 2009 to those of other nursing homes, which excluded
facilities that were SFFs from 2005 through February 2009. However, 3
of the 133 SFFs were missing nurse staffing data.
[35] The nurse staffing hours data we analyzed were case-mix adjusted
by CMS. SFFs averaged fewer total nurse staffing hours per resident
per day compared to other nursing homes, but this difference was not
statistically significant.
[36] These differences in ratings are not surprising because the
health inspection component is generally based on the SFF methodology
and is the first step in determining the overall quality rating.
[37] Of the remaining SFFs, about 23 percent received a 2-star rating
and 3 percent received 3 stars on the overall rating. In technical
comments provided on a draft of this report, HHS highlighted the
report's findings regarding agreement in the SFF and Five-Star System,
but expressed concern about those nursing homes that appear to be
better performing under the Five-Star System when compared to the SFF
Program. HHS suggested that understanding where the two systems
diverge may help to clarify nursing home characteristics that require
further attention.
[38] There was no statistically significant difference between the
number of stars SFFs and other nursing homes received for the nursing
home staffing and quality measures components of the Five-Star System.
[39] CMS requires states to refer for immediate sanction homes that
receive at least one G-through L-level deficiency on successive
standard surveys or intervening complaint investigations. In March
2007, we reported that the "immediate sanctions" label is misleading
because CMS's policy requires only that homes be notified immediately
of CMS's intent to implement sanctions, not that sanctions be
implemented immediately. See [hyperlink,
http://www.gao.gov/products/GAO-07-241].
[40] CMPs can be imposed retroactively to the first date of
noncompliance and do not require a notice period. CMS requires that
nursing homes be provided a notice period for most other sanctions,
which can result in homes avoiding the sanction if they are able to
correct deficiencies during the notice period. However, discretionary,
rather than mandatory, sanctions provide homes with a shorter
opportunity to correct deficiencies before the sanction goes into
effect.
[41] Less frequently cited sanctions, such as temporary management and
directed in-service training, are also infrequently implemented for
SFFs and candidates.
[42] A noncompliance cycle begins on the date of the survey finding
noncompliance and ends when the home has achieved substantial
compliance by correcting deficiencies.
[43] To determine potential CMP values, we used CMS's CMP Analytic
Tool, issued in June 2007. Regional offices use this tool to evaluate
the reasonableness of state-recommended CMP amounts for all nursing
homes.
[44] There are generally 136 active SFFs in the program at any time,
nationwide. As of the end of February 2009, only one state, the
District of Columbia, had never graduated or terminated an SFF.
[45] SFFs that choose to voluntarily terminate may do so because they
are at risk of involuntary termination from Medicare and Medicaid.
[46] For another four SFFs, about 1 year elapsed between the last two
standard surveys which led to their graduation; therefore, while these
homes met the graduation criteria, they were not surveyed twice in the
last year they were in the SFF Program.
[47] For fiscal years 2007 through 2010, CMS's state performance
reviews also measured, but did not require states to implement
corrective action plans for a failure to recommend termination from
Medicare and Medicaid for SFFs that did not improve their performance
within CMS's 18-month time frame.
[48] Additionally, as of the end of February 2009, we found that 40
SFFs (28 percent) that entered the program in 2005 were in the program
for 36 months or more--twice the amount of time CMS intended.
[49] As of August 2009, this home was still in the program, for a
total of 55 months.
[50] This kitchen sanitation requirement, which is not in an SQC area,
involves the proper storage, preparation, distribution, and service of
food. In fiscal year 2009 it was the third most frequently cited
deficiency.
[51] A nursing home with one or more deficiencies at the F through L
level--but not G level--in Quality of Care, Quality of Life, or
Resident Behavior and Facility Practices must be cited for SQC.
[52] The differences between groups were significant at the 0.05 level.
[53] However, during the same period a much smaller share of SFFs--7
percent--received an F-level or greater deficiency on two consecutive
standard surveys after they graduated. We analyzed data as of July 31,
2009.
[54] This home was terminated involuntarily in October 2008.
[55] Five of the six Dallas regional office SIAs use the term
"directed plan," calling for the facility to use a consultant to help
it develop a resident-centered, outcome-measurement-based resident
care system that can promptly identify and effectively and efficiently
respond to any and all resident needs. This approach sounds analogous
to "a directed plan of correction"--a CMS sanction requiring a home to
take specified action within a certain time frame; however, Dallas
officials said the "directed plan" called for in their SIAs was more
far reaching than "a directed plan of correction," because it better
ensured that the home developed tools to not only come into, but also
stay in, compliance. Directed plans of correction were used about
1,000 times from fiscal years 2006 through 2008.
[56] If an SFF has a G-level or higher deficiency after 18 months in
the SFF Program, the Dallas region generally notifies the home that it
will be terminated from Medicare and Medicaid.
[57] Completing the terms of the SIA does not ensure that the nursing
home will graduate from the SFF Program; the home must also meet the
SFF Program's graduation requirements--two consecutive standard
surveys and any intervening complaint investigations with no F-level
or greater deficiencies.
[58] CMS's central office played an integral role in the development
of the first SIA.
[59] In our May 2007 report, we recommended that CMS increase the
number of poorly performing nursing homes that QIOs assist
intensively. See GAO, Nursing Homes: Federal Actions Needed to Improve
Targeting and Evaluation of Assistance by Quality Improvement
Organizations, [hyperlink, http://www.gao.gov/products/GAO-07-373]
(Washington, D.C.: May 29, 2007).
[60] CMS asked states to recommend SFFs that were most in need of help
and most appropriate for the initiative by considering the following
criteria listed in priority order: SFFs that had not improved; new
SFFs; and SFFs that had improved.
[61] Additionally, while Alaska does not have an SFF Program, the QIO
in that state did work with a nursing home under this initiative.
[62] States have from one to six SFFs.
[63] CMS also monitors QIO performance by evaluating nursing home
satisfaction.
[64] Our analysis focused on quality of care CIAs for nursing homes
and excluded the over 1,000 CIAs and similar agreements that the HHS
OIG has developed in cases of financial fraud. HHS may exclude a
nursing home from participating in Medicare or Medicaid for failure to
furnish medically necessary services or for violating a variety of
civil false claims statutes. See 42 U.S.C. § 1320a-7b.
[65] Of the 35 agreements, 16 were original CIAs and 19 were initiated
as successor agreements because the corporations under original CIAs
sold nursing homes, split into two or more corporations, or
reorganized as a new corporation. See "Nursing Home Corporations under
Quality of Care Corporate Integrity Agreements," Department of Health
and Human Services, Office of Inspector General, April 2009, OEI-06-06-
00570, [hyperlink,
http://www.oig.hhs.gov/oei/reports/oei-06-06-00570.pdf] (accessed May
4, 2009).
[66] According to an individual with the data analysis organization
contracted by most of the nursing home quality of care independent
monitors, reports on the results of these analyses across the homes in
the corporation are not shared with CMS.
[67] Beginning in July 1998, CMS undertook a broad array of
initiatives intended to improve nursing home oversight and
enforcement, one of which involved seeking statutory authority to
allow but not require states to immediately refer chain-owned homes
with actual harm deficiencies for sanctions if any of the chain's
homes had poor performance records. According to a CMS official, this
initiative was not pursued because CMS was unable to obtain the
necessary statutory authority. Another significant barrier to this
initiative had been that CMS was unable to reliably identify homes
that belong to nursing home chains.
[68] See, Fla. Stat. §§ 400.118, 400.19(3). At the time of our
interview with state officials, Florida law also required nurse
monitors to visit all nursing homes at least quarterly to assess the
overall quality of life in the nursing home as it relates to resident
care. Monitors reported their findings to the state, and, if they
determined the home needed additional assistance, the monitors worked
directly with the nursing home, or referred the home to the state's
QIO. More recently, this requirement was repealed. Fla. Stat. §
400.118(2) (as repealed, effective 7-1-2009 by 2009-223, § 38).
[69] Unlike Florida, CMS does not generally have the authority to
charge nursing homes for survey activities. See 42 U.S.C. § 1395aa(e).
CMS has not specifically sought authority to charge SFFs for the costs
associated with conducting additional surveys. Following a request
from CMS, in fiscal year 2007, Congress required the agency to charge
user fees for revisit surveys and to use those fees to cover the costs
of revisits. Revised Continuing Appropriations Resolution, 2007, Pub.
L. No. 110-5, § 2, 121 Stat. 8, 33. A series of continuing resolutions
extended CMS's authority to charge and retain fees into fiscal year
2008 until the Consolidated Appropriations Act, 2008, which did not
renew the authority, became law on December 26, 2007. See, e.g., Pub.
L. No. 110-92, § 101, 121 Stat. 989 (2007). In its fiscal year 2010
budget request, CMS requested the authority to charge user fees to
cover the full cost of revisit surveys and about one-third of the cost
of standard surveys. Congress, however, did not provide this authority.
[70] Other criteria the state uses to determine which nursing homes to
recommend for participation include the following characteristics: the
home (1) is in the 85th percentile in terms of CMS's pressure ulcer
quality of care measures, (2) is identified on CMS's SFF candidate
list, (3) has had more than five complaints since the most recent
survey, (4) is operating under a legally binding agreement with the
state, or (5) has certain severe deficiencies based on the state's
deficiency classification.
[71] The state, the QIO, and certain provider organizations contribute
data, such as data regarding compliance with the top 10 most
frequently cited deficiencies, to identify homes that need the
services provided by the state's program.
[72] See [hyperlink, http://www.gao.gov/products/GAO-09-689].
[73] For further information on fee design, see GAO, Federal User
Fees: A Design Guide, [hyperlink,
http://www.gao.gov/products/GAO-08-386SP] (Washington, D.C.: May 29,
2008).
[74] To address this topic, we interviewed officials from (1) CMS's
survey and certification group, which we refer to as the central
office, and four of its regional offices--Atlanta, Chicago, Dallas,
and Denver; (2) CMS's Office of Financial Management; (3) a Medicare
Administrative Contractor; (4) the Office of Insured Health Care
Facilities in the Department of Housing and Urban Development; and (5)
Virginia Health Information, a contractor that manages a Virginia Web
site that includes nursing home financial information. Medicare
Administrative Contractors serve providers through paying claims for
services and handling appeals of denied claims.
[75] In addition to information from a home's financial statements,
Medicare cost reports include information on facility characteristics,
utilization data, cost and charges (in total and for Medicare), and
Medicare settlement data.
[76] The Virginia Health Information Web site is available at
[hyperlink, http://www.vhi.org]. See Va. Code Amn. §§ 32.1-276.2-32.1-
276.11 (2009).
[77] The Section 232 Mortgage Insurance for Residential Care
Facilities program was established in 1959 by Section 232 of the
National Housing Act, as amended, and expanded in 1987 by the Housing
and Community Development Act. The program insures mortgages for
certain nursing homes, assisted living facilities, board and care
homes, and intermediate care facilities. According to HUD in June
2009, approximately 1,500 nursing homes held these loans. See GAO,
Residential Care Facilities Mortgage Insurance Program: Opportunities
to Improve Program and Risk Management, [hyperlink,
http://www.gao.gov/products/GAO-06-515] (Washington, D.C.: May 24,
2006).
[78] If the scope or severity differed on the two surveys, the highest
scope and severity combination was used.
[79] At the time of our analysis, six homes met our criteria and we
analyzed sanctions data for all six of these homes. We subsequently
learned that another home for which we did not analyze sanctions data
had met our criteria.
[80] Nurse staffing hours were not available for 6.5 percent of homes.
Reasons these data were not available include that CMS deemed the data
to be unreliable (e.g., very high nursing hours per resident per day)
or that CMS had newly certified the nursing home.
[81] See Centers for Medicare & Medicaid Services, Design for Nursing
Home Compare Five-Star Quality Rating System: Technical Users' Guide,
revised October 2009, [hyperlink,
http://www.cms.hhs.gov/CertificationandComplianc/Downloads/usersguide.pd
f] (accessed December 28, 2009). This document also describes how CMS
derived its overall quality rating and the health inspections
component rating in its Five-Star System.
[End of section]
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