Department of Health: Nursing Home Surveillance
[Pages:29]New York State Office of the State Comptroller Thomas P. DiNapoli Division of State Government Accountability
Nursing Home Surveillance
Department of Health
Report 2015-S-26
February 2016
2015-S-26
Executive Summary
Purpose
To determine whether the Department of Health (Department) consistently follows federal and State regulations and procedures for conducting nursing home surveys and whether survey processes, including the issuance of fines and other enforcement actions, are effective in improving the quality of care and safety in nursing homes. This audit covers the period January 1, 2012 through September 17, 2015.
Background
The Department, through its Division of Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities Surveillance (Division), is responsible for ensuring nursing homes comply with federal and State regulations, which establish standards that govern their operations. The Division also acts as an agent for the federal government's Centers for Medicare and Medicaid Services (CMS) in monitoring quality of care in nursing homes. Division staff assess compliance through on-site facility inspections, referred to as surveys. Standard Health and Life Safety Code surveys are unannounced and must be conducted at least every 15.9 months pursuant to CMS guidance. Complaint surveys investigate issues, and nursing home-reported incidents, that may involve non-compliance with regulations. Follow-up surveys are used to monitor nursing homes' progress in correcting previously noted deficiencies.
CMS requires states to investigate complaints and incidents for severity and urgency to assess whether a nursing home has violated a federal or State regulation. If any survey reveals violations, surveyors issue citations. Depending on the severity classification, the Department can implement a range of enforcement actions, such as fines, directed plans of correction, and, if warranted, facility closure. Between January 1, 2007 and May 12, 2015, the Division conducted over 39,000 surveys and issued more than 50,000 citations.
Key Findings
? The Department is generally meeting its obligations to conduct Standard Health and Complaint surveys in accordance with federal and State requirements, including the timeliness of inspections and the accuracy of scope and severity ratings of citations. However, the Department's enforcement policies and procedures need to be strengthened to better protect the health and well-being of nursing home residents.
? Inefficiencies in the Department's processes have significantly impaired its ability to assess fines timely, in some cases resulting in delays of up to six years between when the violation is cited and the resulting fine is imposed. This trend has worsened significantly in recent years.
? As a matter of policy, the Department does not utilize the full array of enforcement actions available to it under both State law and CMS guidelines, choosing to not levy fines for well over 80 percent of the violations it cites.
? These weaknesses appear to undermine the incentive that fines can have as a deterrent to deficient practices, as well as the sense of urgency for correcting the deficiencies, particularly in addressing cases of repeated non-compliance.
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Key Recommendations
? Eliminate the backlog in enforcement activity and maintain timely processing of future assessments of State fines.
? Consider assessing State fines for additional citations allowable by the Public Health Law and CMS guidelines, especially for facilities that demonstrate a pattern of repetitive citations.
Other Related Audit\Report of Interest
Department of Health: Facility Structure, Safety, and Health Code Waivers (2014-S-27)
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State of New York Office of the State Comptroller
Division of State Government Accountability
February 19, 2016
Howard A. Zucker, M.D., J.D. Commissioner Department of Health Corning Tower Empire State Plaza Albany, NY 12237
Dear Dr. Zucker:
The Office of the State Comptroller is committed to helping State agencies, public authorities, and local government agencies manage government resources efficiently and effectively and, by so doing, providing accountability for tax dollars spent to support government operations. The Comptroller oversees the fiscal affairs of State agencies, public authorities, and local government agencies, as well as their compliance with relevant statutes and their observance of good business practices. This fiscal oversight is accomplished, in part, through our audits, which identify opportunities for improving operations. Audits can also identify strategies for reducing costs and strengthening controls that are intended to safeguard assets.
Following is a report of our audit entitled Nursing Home Surveillance. This audit was performed according to the State Comptroller's authority under Article V, Section 1 of the State Constitution and Article II, Section 8 of the State Finance Law.
This audit's results and recommendations are resources for you to use in effectively managing your operations and in meeting the expectations of taxpayers. If you have any questions about this report, please feel free to contact us.
Respectfully submitted,
Office of the State Comptroller Division of State Government Accountability
Division of State Government Accountability
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Table of Contents
Background Audit Findings and Recommendations
Annual Certification and Complaint Survey Requirements Enforcement Practices Recommendations Audit Scope and Methodology Authority Reporting Requirements Contributors to This Report Exhibit A Exhibit B Exhibit C Exhibit D Exhibit E Exhibit F Agency Comments State Comptroller's Comments
State Government Accountability Contact Information: Audit Director: John Buyce Phone: (518) 474-3271 Email: StateGovernmentAccountability@osc.state.ny.us Address:
Office of the State Comptroller Division of State Government Accountability 110 State Street, 11th Floor Albany, NY 12236
This report is also available on our website at: osc.state.ny.us
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Background
The Department of Health (Department) oversees nursing home facilities in New York State through its Division of Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities Surveillance (Division). The Division also acts as an agent for the federal government's Centers for Medicare and Medicaid Services (CMS) in monitoring quality of care in nursing homes. The Division is responsible for ensuring nursing homes comply with federal and State regulations, which establish standards that govern their operations. These standards cover a range of requirements, such as residents' rights, clinical services, and administrative practices, and are intended to ensure the highest possible quality of care for all residents. In order to receive payment under Medicare and Medicaid programs, nursing homes must comply with these standards and be certified as compliant by the Department.
Division staff assess compliance through the following types of on-site facility inspections, commonly referred to as surveys:
? Standard Health and Life Safety Code surveys (usually conducted together and hereafter referred to as Standard Health surveys), which are unannounced and must be conducted at least every 15.9 months.
? Complaint surveys, which investigate complaints and incidents reported by the nursing homes or third parties that may involve non-compliance with federal or State regulations.
? Follow-up surveys to monitor nursing homes' progress in correcting previously noted deficiencies.
If a survey reveals violations of federal or State regulations, surveyors issue a Statement of Deficiencies detailing all deficiencies identified. For each deficiency, surveyors use record reviews, interviews, and observations to determine both the scope and the severity of the issue based on CMS's rating system (see Exhibit A). Depending on the severity classification, the Department can implement a range of enforcement actions, such as directed plans of correction, State fines, and, if warranted, facility closure.
The Division has seven regional offices throughout the State that carry out survey functions, including three in the New York City area, known as Metropolitan Area Region Offices (MARO). Of the 631 nursing home facilities currently active in New York State, over half are located in the MARO area. Between January 1, 2007 and May 12, 2015, the Division completed 39,373 surveys, including Standard Health and Complaint surveys, and issued over 50,000 citations (see Table 1). Additionally, the Division received over 79,000 complaints and incident reports, of which more than 37,000 were investigated.
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Table 1 ? Survey, Citation, and Complaint/Incident Data, 2007?May 12, 2015
2007 2008 2009 2010 2011 2012 2013 2014 2015 Totals
Surveys
5,884 4,391 4,508 4,144 4,733 4,533 4,759 4,809 1,612 39,3731
Citations
7,343 5,713 5,918 5,351 6,040 5,985 5,832 6,135 2,114 50,4312
Complaints /Incidents:
Intake
8,594 9,581 9,244 9,158 8,573 8,907 10,695 11,098 3,954 79,804
Investigated 5,077 5,304 4,765 4,471 3,726 4,276 4,104 4,400 1,180 37,303
1 Includes 478 Federal Monitoring surveys conducted directly by CMS.
2 Includes 968 citations from surveys before January 1, 2007 that had revisits after January 1, 2007 as well as 804 citations resulting from Federal Monitoring surveys.
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Audit Findings and Recommendations
We found that the Department is generally meeting its obligations to conduct periodic Standard Health and Complaint surveys in accordance with State and federal requirements, including the timeliness of those inspections, and the accuracy of the scope and severity of cited deficiencies. However, the Department's enforcement policies and procedures still need to be strengthened to better protect the health and well-being of nursing home residents. For instance, as a matter of policy, the Department does not utilize the full array of enforcement actions available to it under both State law and CMS guidelines, choosing to not levy fines for certain categories of violations that comprise almost 85 percent of the problems identified during its surveys. In fact, the Department only imposes fines if it finds that a problem has already resulted in actual harm to an individual or is currently placing people in immediate jeopardy, a condition that has historically comprised less than 4 percent of violations.
Even when fines are imposed, inefficiencies in the Department's processes for issuing and tracking these assessments have significantly impaired its timeliness, in some cases resulting in delays of up to six years between when a violation is cited and a resulting fine is imposed. This trend has worsened significantly in recent years. These weaknesses undermine the incentive that fines can have as a deterrent to deficient practices, as well as the sense of urgency for correcting the deficiencies, particularly in addressing cases of repeated non-compliance.
Annual Certification and Complaint Survey Requirements
The Department is required to comply with certain CMS performance standards when conducting Standard Health and Complaint surveys. As part of its Performance Standards System, CMS reviews the Department's surveys to ensure they are conducted in accordance with federal regulations. This includes examining the accuracy of the ratings assigned to the scope and severity of citations and the timeliness of the inspections themselves. We found the Department met CMS's quality measures for conducting surveys in accordance with federal regulations, including accurate assessment of the scope and severity of citations.
For each facility, the Department is required to conduct its Standard Health surveys within 15.9 months of the last day of the previous survey, and to maintain an overall statewide average of 12.9 months or less between consecutive Standard Health surveys. This schedule allows the Department flexibility in the frequency with which it conducts individual surveys based on nursing homes' performance. For example, better performing nursing homes can be surveyed only once every 12 to 15 months, while poorer performing nursing homes can be surveyed every 9 months. We found that between calendar years 2007 and 2014 the Department generally inspected all nursing homes within the 15.9-month cycle and had a statewide average of 11.8 months between surveys.
We also found the Department effectively utilized its discretion to conduct more frequent surveys of riskier nursing homes that had historically received more citations. Those facilities that were inspected more frequently ? at or less than 9.9 months between Standard Health surveys ? had
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