The Centers for Medicare and Medicaid Services (CMS)—the agency within Health and Human Services (HHS) that manages Medicare and Medicaid—contracts with state survey agencies to investigate complaints about nursing homes from residents, family members, and others. In Minnesota, CMS contracts with the Minnesota Department of Health (MDH) Division of Compliance Monitoring, who in turn assigns this important task to the Office of Health Facility Complaints (OHFC).

CMS helps assure the adequacy of state complaint processes by issuing guidance, monitoring data that state survey agencies enter into CMS’s database, and annually assessing performance against specific standards.

Concerns have been raised about the timeliness and adequacy of complaint investigations and CMS’s oversight. As a result, in April 2011 the Government Accountability Office (GAO) released a report that examined:

(1) complaints received, investigated, and substantiated by state survey agencies;
(2) whether those agencies were meeting CMS performance standards and other requirements; and
(3) the effectiveness of CMS’s oversight.

In addition to analyzing CMS data on complaints and performance reviews, GAO examined CMS guidance and conducted interviews with officials from three high- and three low-performing state survey agencies and their CMS regional offices. GAO addressed data reliability concerns by reporting only data they determined to be reliable.

CMS’s complaints data showed that state survey agencies received 53,313 complaints about nursing homes in 2009. The number and types of complaints varied among states. For example, 11 states received 15 or fewer complaints per 1,000 nursing home residents while 14 states received more than 45. State survey agencies assess the severity of a complaint and assign a priority level, which dictates if and when an investigation must be initiated. About 10 percent of complaints were prioritized as immediate jeopardy, requiring investigation within 2 working days of receipt, while 45 percent were prioritized as actual harm-high, requiring investigation within 10 working days of prioritization. State survey agencies investigated all but 102 complaints that required an investigation. Among investigated complaints, 19 percent were substantiated and resulted in the citation of at least one federal deficiency. The percentage of immediate jeopardy and actual harm-high complaints that were substantiated with at least one federal deficiency cited was higher if the investigation was initiated on time.

In CMS’s performance assessment for fiscal year 2009, many state survey agencies had difficulty meeting some of CMS’s nursing home complaint standards, most of which also assess performance with regard to incidents—specific care issues that nursing homes are required to report. In particular, 19 state survey agencies had difficulty investigating actual harm-high complaints and incidents within the required time frame. However, most states were able to meet other CMS standards—timely investigation of immediate jeopardy complaints and incidents and appropriate prioritization of complaints and incidents. Although CMS’s performance assessment does not review state survey agencies’ communication with complainants, CMS does expect the agencies to convey investigation findings according to CMS guidelines. GAO found state survey agencies had varied interpretations of those guidelines, and some provided limited information to complainants.

The GAO gave Minnesota’s OHFC a passing score (over 95%) regarding the timeliness of actual harm-high investigations, and failing scores on the prioritizing of complaints (60% with a score of 90% needed to pass) and the timeliness of immediate jeopardy investigations (87.5% with a score of needed 95% to pass). Although CMS requires state survey agencies that fail performance standards to develop corrective action plans, the GAO report suggests that states’ plans do not necessarily address the underlying causes of performance issues.

GAO recommends that the CMS Administrator take several steps to strengthen oversight of complaint investigations, such as improving the reliability of its complaints database and clarifying guidance for its state performance standards to assure more consistent interpretation. HHS generally agreed with these recommendations. The seven specific GAO recommendations include:

1. Recommendation: To ensure that information entered into CMS's complaints database is reliable and consistent, the Administrator of CMS should identify issues with data quality and clarify guidance to states about how particular fields in the database should be interpreted, such as what it means to substantiate a complaint.
2. Recommendation: To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should conduct additional monitoring of state performance using information from CMS's complaints database, such as additional timeliness measures.
3. Recommendation: To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should assess state survey agencies' performance in certain areas—specifically, documentation of deficiencies, prioritization of complaints, and quality of investigations—less frequently than once a year.
4. Recommendation: To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should assure greater consistency in assessments by identifying differences in interpretation of the performance standards and clarifying guidance to state survey agencies and CMS regional offices.
5. Recommendation: To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should clarify guidance to the state survey agencies about the minimum information that should be conveyed to complainants at the close of an investigation.
6. Recommendation: To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should provide guidance encouraging state survey agencies to prioritize complaints at the level that is warranted, not above that level.
7. Recommendation: To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should implement CMS's proposed plans to publish state survey agencies' scores, but limit publication to those performance standards that CMS considers the most reliable and clear.

View the full 58-page GAO report.

Doug Beardsley
952.851.2489
dbeardsl@careproviders.org

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