Late Additions

HCFA Oversight of State Nursing Facility Inspections Is Insufficent, GAO Finds

The Health Care Financing Administration’s (HCFA) methods for assessing state agency inspections of nursing facilities are “limited in their scope and effectiveness” and are not being applied consistently across each of HCFA’s 10 regional offices, according to a recently released report from the U.S. General Accounting Office (GAO). As a result of these limitations, the report states, HCFA does not have sufficient, consistent, or reliable data to evaluate state agencies or to measure the success of its other nursing facility initiatives.

The report was prepared by GAO at the request of Senate Special Committee on Aging Chairman Sen. Charles Grassley (R-Iowa) and released at a hearing of the committee on November 4.

To ensure that nursing facility residents receive proper care, state agencies under contract with the federal government are required to conduct surveys of nursing homes. HCFA’s 10 regional offices are, in turn, responsible for ensuring the quality of these state inspections. The GAO report finds that HCFA makes “negligible” use of comparative surveys (independent repeat surveys of facilities), which the report calls “its most effective technique for determining whether state agencies are failing to catch deficiencies in care. HCFA surveyors identified deficiencies missed by state inspectors in about two-thirds of the 64 comparative surveys conducted between October 1998 and July 1999. However, HCFA still requires that only one or two comparative surveys be performed each year.

Approximately 90% of HCFA oversight of state inspections consists of “observational” surveys, in which HCFA regional surveyors accompany and observe state surveyors as they inspect facilities. The report questions whether this technique provides an accurate picture of a typical state inspection, as the presence of federal surveyors would tend to “cause state surveyors to perform their survey tasks more attentively.” Furthermore, federal surveyors are not required to observe state surveyors performing most of their survey tasks, and the amount of time HCFA surveyors spend observing varies widely from inspection to inspection, from an average of 27 hours to a high of 71 hours.

The report also notes that the lag time between state surveys and comparative resurveys averages 33 days and can be as long as two months. Because some nursing facility characteristics, such as residents, staffing, and ownership, can change in a short period of time, accurate assessment of state surveyors’ performance can be difficult after such a lapse in time.

The report’s recommendations to HCFA include increasing the use of comparative surveys and ensuring that they are conducted promptly following state surveys, as well as standardization of procedures for selecting and conducting federal monitoring surveys.

The report, “Nursing Home Care: Enhanced HCFA Oversight of States Agencies Would Better Ensure Quality” (GAO/HEHS-00-6), is available through the General Accounting Office, P.O. Box 37050, Washington, DC 20013. The report can be downloaded in ASCII and Adobe Acrobat formats free of charge from the GAO Web site (www.gao.gov).

Will Judy
Editorial Assistant