Nursing Home Quality
Implementation of the Quality Indicator Survey Gao ID: GAO-11-403R April 6, 2011This report discusses the approach that the Centers for Medicare & Medicaid Services (CMS) is taking to implement the Quality Indicator Survey (QIS) nationally. CMS developed the QIS--a new electronic process used to conduct nursing home inspections--to provide a more reliable assessment of the quality of care in nursing homes. Congress asked us to review the implementation of the QIS. As Congress requested, this report provides background information on the nursing home inspection process and describes the approach CMS is taking to implement the QIS.
GAO-11-403R, Nursing Home Quality: Implementation of the Quality Indicator Survey
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GAO-11-403R:
United States Government Accountability Office:
Washington, DC 20548:
April 6, 2011:
The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on the Judiciary:
United States Senate:
Subject: Nursing Home Quality: Implementation of the Quality Indicator
Survey:
This report formally transmits our briefing slides that describe the
approach that the Centers for Medicare & Medicaid Services (CMS) is
taking to implement the Quality Indicator Survey (QIS) nationally (see
enclosure I). CMS developed the QIS--a new electronic process used to
conduct nursing home inspections--to provide a more reliable
assessment of the quality of care in nursing homes. You asked us to
review the implementation of the QIS. As you requested, these slides
provide background information on the nursing home inspection process
and describe the approach CMS is taking to implement the QIS. These
slides were used to brief your staff on March 28, 2011. We will
address other issues related to implementation of the QIS in a
subsequent report. We provided a draft of this report to the
Department of Health and Human Services (HHS) and the agency provided
technical comments, which we incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Secretary of HHS, the Administrator of CMS, and relevant
congressional committees. In addition, the report will be available at
no charge on the GAO Website at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions regarding this report, please
contact me at (202) 512-7114 or kohnl@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Key contributors to this report were
Anne Laffoon, Assistant Director; George Bogart; Krister Friday; Seta
Hovagimian; Samantha Poppe; and Priyanka Sethi.
Signed by:
Linda T. Kohn:
Director, Health Care:
Enclosure:
[End of section]
Enclosure I: Nursing Home Quality: Implementation of the Quality
Indicator Survey:
Briefing for staff of:
Special Committee on Aging:
United States Senate, and:
Committee on the Judiciary:
United States Senate:
March 28, 2011:
Overview:
* Introduction;
* Objective;
* Scope and Methodology;
* Background;
* Results;
* Agency Comments.
Introduction:
Nursing homes provide skilled nursing, rehabilitation, and/or
custodial care to elderly and disabled individuals.
Federal and state governments share responsibility for ensuring that
nursing homes provide quality care in a safe environment for the
nation‘s 1.5 million residents dependent on such care.
The Centers for Medicare & Medicaid Services (CMS) is responsible for
ensuring that nursing homes participating in the Medicare and Medicaid
programs meet federal quality standards. To do so, among other
activities, CMS contracts with state survey agencies to conduct
periodic inspections of nursing homes.
Over the last decade, we have reported significant weaknesses in these
inspections, which include poor measurement of serious care problems
in nursing homes.[Footnote 1]
To improve the inspection process, CMS developed the Quality Indicator
Survey (QIS),a new electronic method for conducting nursing home
inspections that is designed to provide a more reliable assessment of
the quality of nursing homes.
In 2005, CMS launched a demonstration of the QIS in five states:
California, Connecticut, Kansas, Louisiana, and Ohio.
CMS is in the process of implementing the QIS in all 50 states, the
District of Columbia, and two territories.[Footnote 2]
[End of Introduction section]
Objective:
Our briefing describes the approach that CMS is taking to implement
the QIS nationally.
[End of Objective section]
Scope and Methodology:
This briefing will describe CMS‘s efforts to implement the QIS
nationally from August 2009, when CMS announced its implementation
plan, to February 2011.
To describe the agency‘s implementation approach, we:
* Reviewed CMS policies, procedures and other relevant documents,
including CMS‘s QIS implementation plan.
* Interviewed CMS officials regarding the implementation plan.
* Conducted interviews with subject matter experts outside of CMS,such
as the CMS contractor who led the development of the new QIS process,
to further our understanding of the QIS and how CMS plans to implement
it.
* Reviewed CMS data on the number of states that have implemented the
QIS and the number of nursing home inspections conducted using the QIS.
Limitations to our research are as follows:
* We focus on steps taken by CMS at the federal level to facilitate
implementation of the QIS; state-level perspectives are not included
in this product.
* CMS data on the number of nursing home inspections conducted in
fiscal year (FY) 2010 are not yet complete; the numbers we present are
the most current as of February 2011 but may not reflect all QIS
surveys conducted in FY 2010.
To ensure reliability of the nursing home inspection data collected,
we reviewed key documents and checked data for obvious errors. Based
on these activities, we determined that the data are sufficiently
reliable for our purposes.
We conducted this audit from October 2010 through March 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objective. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objective.
[End of Scope and Methodology section]
Background:
Medicare and Medicaid Coverage for Nursing Home Care:
Medicare covers up to 100 days of skilled nursing home care following
a hospital stay.
Medicaid covers nursing home stays for certain low-income individuals.
Approximately 15,700 nursing homes receive payment from Medicare
and/or Medicaid programs. According to a CMS official, combined
Medicare and Medicaid payments for nursing home care in 2009 were
about $89 billion.[Footnote 3]
Oversight of Nursing Homes:
Oversight of nursing homes is a shared federal-state responsibility.
To help ensure quality of care in nursing homes, CMS, among other
tasks, sets federal quality standards that focus on the delivery of
care, resident outcomes, and facility conditions.
* For example, some of these standards focus on areas such as the
prevention of pressure sore development and keeping the resident
environment as free from accident hazards as possible.
Nursing Home Inspection Process:
To determine whether nursing homes meet federal standards, CMS
contracts with state survey agencies to conduct on-site nursing home
inspections, which consist of routine surveys and complaint
investigations. State surveyors are to conduct routine surveys, on
average, every 12 months, and complaint investigations are conducted
in response to allegations of quality problems.
During a routine survey, teams of state surveyors evaluate nursing
homes‘ compliance with federal quality standards, in part by measuring
resident outcomes such as the incidence of preventable pressure sores,
weight loss, and accidents.
During both routine surveys and complaint investigations, state
surveyors may cite deficiencies”-that is, areas in which facilities
fail to meet federal quality standards.[Footnote 4]
* Nursing homes must prepare a correction plan to address most
deficiencies.
* State surveyors may conduct revisit surveys to ensure that the homes
implemented their plans and corrected the deficiencies.
CMS generally imposes sanctions for serious deficiencies which may
result in the termination of a nursing home‘s participation in
Medicare and Medicaid programs.
CMS is required to ensure the reliability of state survey agencies‘
routine surveys by conducting federal monitoring surveys. According to
CMS, these consist of two types of reviews”-comparative and
observational surveys.
* In a comparative survey, a federal survey team conducts an
independent inspection of a home recently surveyed by a state survey
agency in order to compare and contrast its findings with those of the
state survey team.
* In an observational survey, federal surveyors accompany a state
survey team to a nursing home to evaluate how well the state surveyors
identify and investigate concerns and document deficiencies.
Traditional Routine Survey Process:
The traditional process for routine surveys involves offsite
preparation as well as an on-site inspection.
* During offsite survey preparation, surveyors identify at-risk
residents and facility-related areas of concern to focus on during the
on-site inspection by reviewing various sources of information and
relying on their professional judgment.[Footnote 5]
* During on-site inspections, surveyors review the quality of care
provided to select residents by interviewing and observing residents;
interviewing residents‘ family members; reviewing medical records; and
observing staff and nursing home conditions and practices. Throughout
this process, surveyors manually complete a paper-based questionnaire
to document findings.
Development of the QIS:
In 1998, CMS began to revise the traditional process used to conduct
routine surveys. According to the agency, the new process”-the QIS--
was developed to:
* Improve consistency and accuracy of surveys.
* Improve documentation of survey findings.
* Systematically review critical aspects of nursing home care.
* During an inspection, focus survey resources on areas where the
greatest quality concerns exist.
Comparison of the QIS & Traditional Process:
The approach used to conduct routine surveys largely remains the same
with the introduction of the QIS.[Footnote 6] Both the QIS and the
traditional survey process involve:
* analyzing information available about the facilities and their
residents offsite to identify areas of care that have been
historically problematic and residents who may be at higher risk for
poor care;
* interviewing residents, family members, and staff;
* observing staff and nursing home practices;
* reviewing medical records; and;
* citing deficiencies when necessary.
According to CMS officials, the QIS differs from the traditional
survey process in two key areas:
* The method of collecting, recording, and analyzing information and
documenting findings during the onsite inspection.
* The method of selecting residents to interview and observe and
medical records to review during the onsite inspection.
Conducting the survey with QIS‘s specialized software on personal
tablet computers is expected to enhance the survey process by:
* Guiding surveyors through the survey process to ensure that they ask
all applicable questions and consider all applicable quality standards.
* Allowing surveyors to electronically record observations and view
guidance on their computers as they conduct the inspection.
* Automatically synthesizing and organizing findings; for example, the
software compares surveyors‘ preliminary findings with national
quality thresholds and flags areas that exceed these thresholds for
further inspection.
Using the traditional approach, surveyors select residents for the
review using various sources of information combined with professional
judgment. Using the QIS software, surveyors select a random sample of
residents that is representative of the home‘s population.
* The traditional process allows surveyors to review a group of
residents”-20 percent of the current facility census-”and relies on
the surveyors‘ use of various reports, data sets, guidance and
professional judgment to select residents who may be at-risk for poor
quality of care.
* The QIS software allows surveyors to draw a larger, random sample of
up to 70 residents.[Footnote 7]
According to CMS, the change in how residents are selected as part of
the inspection allows surveyors to:
* Ensure that the number of residents interviewed and observed during
the on-site inspection is sufficient to draw conclusions about the
overall facility population.
* Help ensure that a sufficient number of at-risk residents are
included in the inspection. For example, the process helps ensure that
newly admitted residents, who may be at higher risk for
rehospitalization or functional decline, are included in the sample.
[End of Background section]
Results:
CMS‘s approach to implementing the QIS nationally relies on three main
activities implemented concurrently over the span of several years:
* Adopting a train-the-trainer approach to train state surveyors to
use the QIS for routine surveys.
* Gradual roll-out of the QIS with the goal of all routine surveys
being conducted using the QIS.
* Developing QIS-based tools to conduct federal monitoring surveys,
revisit surveys, and complaint investigations.
Train-the-Trainer Approach:
In August 2009, CMS issued a national plan for training surveyors in
states that had not yet begun QIS training:[Footnote 8]
* Under this plan, CMS grouped states into training cohorts and then
assigned each cohort to one of six training periods. Each cohort is
comprised of surveyors from five to eight states. The first training
period began in 2009; the last begins between June 2014 to June 2015.
* In each training period, CMS will train a small number of surveyors
to (1) conduct routine surveys using the QIS and (2) train other
surveyors in their states to use the QIS.
According to CMS officials, time needed to train all surveyors within
a state could vary from one to three years depending on factors such
as the number and availability of surveyors in any given state.
The last CMS training period is scheduled to begin between June 2014
and June 2015. Therefore, training of all surveyors nationwide may not
be completed until 2018.
Budgetary concerns and other state-specific issues may cause states to
postpone their training. For example, officials in one state requested
to postpone training because they lacked funding to purchase the
necessary tablet computers. CMS officials indicated that QIS
implementation is mandatory and that this state has been added to the
last scheduled training period.
Gradual Roll-out of the QIS:
QIS implementation involves the gradual roll-out of the QIS with the
goal of conducting all routine surveys of nursing homes across the
country using the QIS.
* Until all surveyors in a state have been trained in the QIS, states
may use both the QIS and the traditional survey processes for routine
surveys. According to CMS, once all surveyors in a state have been
trained in the QIS, all routine surveys should be conducted using the
QIS.
* States that have not yet begun to train surveyors in the QIS will
continue to conduct routine surveys using the traditional survey
process.
As of February 2011:
* 7 state survey agencies have completed training of all surveyors
within their states.
* 14 state survey agencies have started training surveyors within
their states.
* 32 state survey agencies are scheduled to start training surveyors
between now and 2015.
Figure: States‘ QIS Training Status as of February 2011:
[Refer to PDF for image: illustrated U.S. Map]
Training of surveyors completed:
Connecticut:
Florida:
Kansas:
Maine:
Minnesota:
New Mexico:
West Virginia:
Training of surveyors begun:
Arizona:
Colorado:
Georgia:
Indiana:
Louisiana:
Maryland:
Nebraska:
New York:
North Carolina:
Ohio:
Utah:
Vermont:
Washington:
Training of surveyors scheduled to begin between February 2011 and
June 2015:
Alabama:
Alaska:
Arkansas:
California:
Delaware:
District of Columbia:
Hawaii:
Idaho:
Illinois:
Iowa:
Kentucky:
Massachusetts:
Michigan:
Mississippi:
Missouri:
Montana:
Nevada:
New Hampshire:
New Jersey:
North Dakota:
Oklahoma:
Oregon:
Pennsylvania:
Puerto Rico:
Rhode Island:
South Carolina:
South Dakota:
Tennessee:
Texas:
Virginia:
Wisconsin:
Wyoming:
Note: Figure does not portray the U.S. Virgin Islands, which plans for
training of surveyors to begin between February 2011 and June 2015.
Source: GAO analysis of CMS data.
[End of figure]
Table: Routine Surveys Using the QIS, FY 2009-2010[A]:
State: Connecticut;
Date that Training of Surveyors Started: 9/2005;
Number of Routine Surveys, FY09[B]: 232;
Number of Routine Surveys, FY10[B]: 223;
Percent QIS-Based Routine Surveys, FY09[B]: 98.3%;
Percent QIS-Based Routine Surveys, FY10[B]: 98.7%.
State: Kansas;
Date that Training of Surveyors Started: 9/2005;
Number of Routine Surveys, FY09[B]: 298;
Number of Routine Surveys, FY10[B]: 301;
Percent QIS-Based Routine Surveys, FY09[B]: 52.7%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 97.0%.
State: Florida;
Date that Training of Surveyors Started: 10/2006;
Number of Routine Surveys, FY09[B]: 665;
Number of Routine Surveys, FY10[B]: 690;
Percent QIS-Based Routine Surveys, FY09[B]: 79.5%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 99.1%.
State: Minnesota;
Date that Training of Surveyors Started: 1/2008;
Number of Routine Surveys, FY09[B]: 391;
Number of Routine Surveys, FY10[B]: 390;
Percent QIS-Based Routine Surveys, FY09[B]: 60.4%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 93.3%.
State: New Mexico;
Date that Training of Surveyors Started: 8/2008;
Number of Routine Surveys, FY09[B]: 72;
Number of Routine Surveys, FY10[B]: 65;
Percent QIS-Based Routine Surveys, FY09[B]: 47.2%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 72.3%[D].
State: West Virginia;
Date that Training of Surveyors Started: 2/2009;
Number of Routine Surveys, FY09[B]: 120;
Number of Routine Surveys, FY10[B]: 71;
Percent QIS-Based Routine Surveys, FY09[B]: 14.2%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 35.2%[D].
State: Maine;
Date that Training of Surveyors Started: 7/2009;
Number of Routine Surveys, FY09[B]: 106;
Number of Routine Surveys, FY10[B]: 107;
Percent QIS-Based Routine Surveys, FY09[B]: 10.4%[C];
Percent QIS-Based Routine Surveys, FY10[B]: 96.3%.
State: Total;
Number of Routine Surveys, FY09[B]: 1,884;
Number of Routine Surveys, FY10[B]: 1,848;
Percent QIS-Based Routine Surveys, FY09[B]: 64.3%;
Percent QIS-Based Routine Surveys, FY10[B]: 93.9%.
Source: GAO analysis of CMS data.
[A] This table reflects data for those states that have completed
training of all surveyors.
[B] As of February 2011, CMS data for FY10 are not complete, and these
numbers are subject to change.
[C] For these states, the percentage of QIS-based routine surveys has
increased between FY 2009 and FY 2010.
[D] Two of the states that have completed training of surveyors are
not using the QIS-based routine survey at or near 100%.
[End of table]
Development of other QIS-based Tools:
According to CMS officials, the agency is also developing QIS-based
tools to conduct:
* revisit surveys,
* complaint investigations, and:
* federal monitoring surveys.
As of February 2011, the QIS-based tools are still under development.
[End of Results section]
Agency Comments:
We provided a draft of these briefing slides to the Department of
Health and Human Services (HHS) for comment. HHS provided technical
comments, which we incorporated as appropriate.
[End of Enclosure I]
Footnotes:
[1] See, for example, GAO, 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) and GAO, 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).
[2] In this briefing, we use the term ’states“ to refer to the 50
states, the District of Columbia, and territories.
[3] Calendar year 2009 data were the most recent data available at the
time we conducted our study.
[4] Deficiencies are classified according to scope (i.e., the number
of residents potentially or actually affected) and severity (i.e., the
degree of relative harm involved).
[5] Information reviewed includes reports containing demographic
information about residents, previous survey findings regarding
facilities and their residents, and the facility‘s status on various
quality measures as compared to state and national averages.
[6] Additionally, according to CMS officials, the underlying federal
quality standards for nursing homes, as well as surveyor guidance on
identifying deficiencies, were not changed due to the implementation
of the QIS.
[7] Additional residents may be added to the sample at the surveyors‘
discretion.
[8] Eleven states began QIS training prior to the issuance of this
plan: Connecticut, Kansas, Ohio, Louisiana, Florida, Minnesota, North
Carolina, New Mexico, West Virginia, Maryland, and Washington.
[End of section]
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