Improving the Quality of Care in Nursing Homes (1986) / Chapter Skim
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4. Monitoring Nursing Home Performance
4. Monitoring Nursing Home Performance
Pages 104-145
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From page 104... ...
The federal government also can decertify substandard facilities. The federal conditions and standards were designed for use by state surveyors in inspecting nursing homes.
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From page 105... ...
The first set of issues discussed in this chapter covers the inadequacies of the current survey process. Changes are recommended that follow from the new conditions and standards recommended in Chapter 3.
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From page 106... ...
These issues include funding of federal and state survey units and the numbers, qualifications, and training of surveyors. PROBLEMS WITH THE SURVEY PROCESS The survey process has several problems that should be addressed to make it more effective: predictability, inefficiency, emphasis on paper compliance, insensitivity to resident needs, inconsistency, isolation from related monitoring processes, and variable state regulatory capacity.
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From page 107... ...
A more efficient survey process would permit them to spend more time in poor facilities and less time in good facilities. Paper Compliance Not only are the current standards focused on theoretical facility capability rather than actual performance, but compliance is often determined on the basis of record reviews rather than direct observation.
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From page 108... ...
Isolation from Related Monitoring Processes In some states, there is little or no sharing of information or coordinated effort between the survey process and the processes for monitoring and investigating complaints, even though complaints can be an important source of information about quality problems in nursing homes. Relationships between the state survey agencies and ombudsman programs are often undeveloped or even adversarial.
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From page 109... ...
In conjunction with new survey protocols and scoring procedures based on empirical resident-outcome standards developed from standardized resident assessment data, the new conditions and standards should improve consistency of decision-making on deficiencies, although surveyor judgment will still play an important role. Development and use of a shorter inspection procedure and use of an outcome-orienteci survey protocol will permit surveyors to identify and concentrate their efforts on facilities with problems.
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From page 110... ...
The main features of the new survey process are discussed in detail in the remainder of this chapter. The following points are covered: · consolidation of Medicaid and Medicare survey procedures, ~ two-stage survey approach, · ~ ~ case-mix ret erenclng, key indicators of quality, scoring and decision-making, survey data sources, coordination with complaint programs, consumer involvement,
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From page 111... ...
The consensus among consumer, regulator, and provider groups is that annual surveys of nursing homes are both reasonable and necessary. The frequency and timing of standard surveys should be determined by each facility's performance history and should maximize the element of surprise.
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From page 112... ...
As a general principle, surveys should be unannounced and unanticipated by facilities, with the exception of followup visits to determine whether satisfactory corrections have been made. Whatever their record, all facilities should be at risk for a random, full-scale extended survey at any time.
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From page 113... ...
Two-Stage Survey Approach After an initial audit of a sample of resident assessment records, each annual survey would begin with a short standard survey protocol. The standard survey would be designed to use "key indicators" of performance to identify facilities with poor resident outcomes that might have resulted from substandard nursing home performance.
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From page 114... ...
To the extent possible, the standard survey would use a short protocol that would rely on "key indicators" of performance. Among the key indicators that may be used, depending on the availability of empirical evidence, are those elements in a standard that have been shown to be highly predictive of compliance with the other elements in that standard.
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From page 115... ...
A simple stratification approach using key variables important in dealing with nursing home residents is proposed in this section for initial use in the revised survey process. Eventually, however, case-mix categories should be defined on the basis of resident groupings that emerge from the resident assessment scores and on empirical evidence from the resident assessment data that
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From page 116... ...
The committee believes that the survey instruments and survey process can and should be organized to take into account these differences in resident need in different facility populations. It is time-consuming and therefore costly to have surveyors assess all residents in a nursing home.
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From page 117... ...
Accordingly, the case-mix referencing system should center around two parameters of resident condition that are central to the special care needs and vulnerabilities of nursing home residents: mental status and physical dependency. For survey purposes, there would be four major case-mix groups, each of which should be defined by scores on the resident assessment instrument.
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From page 118... ...
sample sizes required to attain a prespecified level of precision, should be established by the HCFA. Key Indicators The standard survey would consist of a number of key indicators, that is, outcome and process measures of quality of care and quality of life that are mostly resident-centered, although some relate to facility characteristics.
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From page 119... ...
Several states have attempted to refine the federal certification process to save money and concentrate scarce regulatory resources on facilities demonstrating poor care.6 These states include New York,7 Massachusetts,8 Wisconsin,9 Colorado, A and Illinois. ~i Ohio has a resident assessment system for reimbursement purposes that focuses on resident needs and service provision,~2~3 and Iowa has developed an outcome-oriented licensure survey that focuses on selected domains of quality.~4~~6 Evaluations of some of these survey systems that focus on key indicators of quality of care and quality of life, such as New York's sentinal health events, indicate they are at least as successful in detecting serious deficiencies in the quality of nursing home care as the current certification surveys.~7~8 Thus it seems possible to develop key indicators, many of them drawn from or modifications of existing protocols, that are resident-centered and oriented toward appropriate -- and away from inappropriate -- resident outcomes and care processes and that can differentiate between facilities on the quality of resident care and quality of life they provide.
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From page 120... ...
Recommendation 4-5: The standard survey should rely on "key ind icators" of quality of resid ent life and care that would be prescribed by the HCFA. These key indicators would measure poor resident outcomes and other resident and facility conditions that night be caused by noncompliance wits' the federal conditions and standards and should be investigated f~crt1~er by the survey agency.
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From page 121... ...
For the sample of mentally competent residents, for instance, the standard survey should include an interview protocol that is designed to determine their level of satisfaction with the quality of care they receive and with their quality of life. Also, their views of the facility's performance, including such things as its flexibility in matters of rising and retiring, its arrangements for privacy, and consideration of food preferences in meal planning.
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From page 122... ...
A facility that required no extended survey following the standard survey would thus pass inspection and be exempt from routine review for a certain period of time. Careful consideration will have to be given to deciding how many instances of poor care or negative but avoidable outcomes should constitute failure and trigger an extended survey or citation for noncompliance.
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From page 123... ...
Extended surveys, whether partial or complete, would sample more residents and include more structural and process indicators than the standard survey. Both the standard survey and extended surveys should be based primarily on observation of and interviews with residents and staff.
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From page 124... ...
They are convinced of its usefulness. Interviews with a sample of nursing home residents who are mentally competent, willing, and able to be interviewed without ~ undue physical or psychological strain, can yield important information about the day-to-day performance of the facilities and the residents' satisfaction with the quality of care and life they experience.~9320 Recommendation 4-7: Quality assessment in the survey process should rely heavily on interviews with, and observation of, residents and staff, and only seconclarily on "paper compliance," such as chart reviews, official policies anc!
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From page 125... ...
State licensure and certification agencies should be required to work out cooperative agreements for the reporting and handling of complaints with their state ombudsman program and the Medicaid fraud unit as well as with any state-mandated patient abuse or complaint programs. (The Medicaid fraud unit often obtains information relevant to a facility's compliance with licensure and certification standards.)
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From page 126... ...
Positive Incentives Facilities that pass the abbreviated survey will receive regulatory relief by not having to submit to further inspections until the next annual survey except for being subject to a random extended survey (and unless there is an ownership or other change requiring a new survey or a pattern of complaints triggers a new survey)
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From page 127... ...
Administration of the survey process also must be monitored and evaluated to improve consistency and en ~ 1clency. The development of new and better methods to assess quality of care and nursing home performance should be encouraged.
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From page 128... ...
To assure the validity of the standard survey, extended surveys should be taken in a random sample of facilities each year and the results compared with the findings of standard surveys of the same facilities. In addition to providing data for improving the conditions and standards, these surveys would provide a check on how well the two-stage survey process is working and should induce facilities to stay in compliance with all regulatory requirements, not just those that might be checked by the standard survey.
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From page 129... ...
It is therefore essential that state survey agencies make a serious effort to increase consistency of interpretation and decision-making by surveyors. It should be possible to improve surveyor consistency by means of better training, monitoring, and evaluation of surveyor performance as well as better design of survey instruments and procedures.
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From page 130... ...
More recently, the PaCS survey process has become the HCFA's response to the court's decision in Smith v. Heckler that the HCFA produce a more effective regulatory process for assuring adequate quality of care in nursing homes.
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From page 131... ...
Third, the PaCS survey process still relies on unguided surveyor judgment to make the important decisions of whether care problems demonstrated by a facility constitute deficiencies. PaCS does not have guidelines with criteria for making these decisions, but leaves them to unguided surveyor judgment.
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From page 132... ...
But as currently envisioned it is not conceptually or operationally part of a comprehensive revision of the nursing home regulatory system. It does not incorporate many of the other key changes in the nursing home performance criteria, in the survey process, and in the enforcement process that are necessary to make significant improvements in the regulatory system.
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From page 133... ...
The amount the states themselves contribute for the licensure part of the survey process varies greatly. As a result, the number of surveyors and the number of inspections (and their intensity as shown by average person-days of surveyor time in a facility)
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From page 134... ...
134 / NURSING HO3lE CARE TABLE 4-1 HCFA Expenditures for State Survey Agency Activities (in millions of dollars) · ~ Fiscal Year Medicare Medicaid Total 1977 $23.6 $33.2 $56.8 1978 24.9 36.2 61.1 1979 25.3 34.4 59.7 1980 27.4 38.4 65.8 1981 24.6 34.2 *
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From page 135... ...
This will require larger budgets for the state licensure and certification agencies. To facilitate cooperation by the states in introducing the new survey process and the resident assessment system and enhancing their survey staff supervisory capabilities, the Congress should once again authorize 100 percent federal support for state survey and certification activities (in nursing homes)
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From page 136... ...
For use on extended surveys, the survey agency should have specialists on staff (or, in small states, as consultantsJ in the clisciplinary areas coverer! by the conditions and stanalarcis (for exur,~ple, pharmacy, nutrition, social services, and activitiesJ.
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From page 137... ...
of transition to the new survey process, and cluring the implementation of the new resident assessment condition of participation. Dissemination of Research and Evaluation Results Information about survey operations and their results are inadequate at the state and federal levels.4 Evaluation of the new survey system will depend on the availability of performance data.
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From page 138... ...
Theoretically, the federal surveyors are supposed to conduct validation surveys of a 5 percent sample of nursing homes assess state survey performance. In practice, this goal rarely has been attained.
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From page 139... ...
An intermediate sanction, such as reducing the amount of Medicaid matching funds, is needed. Recommendation 4-19: The HCFA should increase its capabilities to oversee state survey and certification of nursing homes and to enforce federal requirements on states as well as facilities by · adding enough additional federal surveyors to each regional office to ensure that the random sample of nursing homes surveyed each year in each state is large enough to allow reasonable inferences about the adequacy of the state's survey and certification activities;
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From page 140... ...
ORGANIZATIONAL CHANGES Incorporation of Inspection of Care in the Survey Process Federal law and regulations currently require each state Medicaid agency to conduct at least one "inspection-ofcare" (IOC) review of all patients annually to determine the appropriateness and quality of care given to recipients.
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From page 141... ...
Combining IOC with the recommended new survey process would require a statutory change to permit reviews of a sample rather than of all residents. The transfer of IOC also will affect utilization review and control responsibilities.
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From page 142... ...
This function would be greatly facilitated by the availability of the standard resident assessment data. The placement of residents in the nursing home could be checked at the time of the standard survey and reported to the Medicaid agency.
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From page 143... ...
The primary role of the regional offices would still be to monitor the activities of the state survey agencies and to take steps, including the use of the sanctions referred to in the previous recommendation, to ensure adequate performance. This recommendation concerning certification authority should be implemented by overhauling the so-called "1864 agreement" -- the contract between the Secretary of Health and Human Services and each state health department to Le
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From page 144... ...
The HCFA implemented a revised 1864 agreement on July 1, 1985, in an attempt to hold the states more accountable. It should continue this effort to clarify the respective roles of the federal and state levels in conjunction with the other major recommendations cited above, that is, implementation of a resident-centered, outcome-oriented standards and survey process and increased resources at the federal and state levels.
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From page 145... ...
icaid f acilities (exce pt state institutions) according to federal requirements.
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