July 14,2004
July 13, 2004
The Honorable Mark McClellan
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Dr. McClellan:
Following upon my letter, dated July 9, 2004, which expressed my belief that the surveyand certification process is broken, I want to focus your attention on the latest troubling findingsabout the information that Americans rely upon for accurate, objective and independent dataabout the operation and activities of nursing homes.
Today, the Department of Health & Human Services, Office of Inspector General (OIG)publicly released a report that questions the completeness and accuracy of information theCenters for Medicare & Medicaid Services (CMS) provides Americans about nursing homes.The OIG concluded that:
Overall, Nursing Home Compare’s [NHC] inspection results provide consumers with avaluable resource on the past-performance of Medicare- and Medicaid-certified nursing homes.… However, one or more surveys were missing from 19 percent of nursing homes, leavingconsumers with incomplete information about those homes’ survey and complaint histories.Inspection results on [NHC] are largely accurate, but one or more deficiencies were missing from11 percent of nursing homes’ inspection results, and [NHC] presents deficiencies not found onsurvey documentation for 15 percent of nursing homes. Inaccuracies may be due to lack of dataentry by State survey agencies, no tracking of accuracy reports by CMS, and failure of Statesurvey agencies to transmit data on amended deficiencies. (emphasis added).
While the OIG suggests that information available to the public about nursing homes is“largely accurate,” that finding is only true if the information is taken at face value and only if theodds are on your side. In fact, as the OIG’s findings point out, anyone who entrusts their lovedone to a nursing home based on CMS’s Nursing Home Compare stands a one in five chance thatthe information relied upon was inaccurate. Couple those odds with the disturbing reality that thevery integrity of the quality data contained in the nursing home inspection results and complainthistories has been called into question and the bedrock value of Nursing Home Comparecrumbles.
As I mentioned in my letter to you last week, my Committee staff have reported storyafter story to me about surveyors who question the integrity and effectiveness of the nursinghome survey process, as well as the enforcement and complaint process. Likewise, theGovernment Accounting Office has documented, and continues to document, serious deficienciesin the survey and certification process. American’s struggling with the difficult decision tochoose a nursing home deserve better information than CMS is providing them. I look forward tohearing whether CMS will step to the plate and address the concerns shared by many about theintegrity of publicly available nursing home performance information. Thank you again for yourattention to this critical matter.
Sincerely,
Charles E. Grassley
Chairman
July 7, 2004
The Honorable Mark McClellan
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Dr. McClellan:
Since 1997, I have focused considerable attention on improving the quality of care in ourNation’s nursing homes, which provide care for about 1.7 million elderly and disabled residentsin about 17,000 nursing homes. As former chairman of the Committee on Aging, and presentlyas chairman of the Committee on Finance (Committee), I have conducted numerous hearingsover the years to address the problems that plague nursing home care. In July 2003, I held ahearing updating my previous work on nursing home quality of care. Although it wasencouraging that modest improvements in the reported quality care have been made as a result ofefforts in recent years, the Committee also heard evidence that called into question the integrityof the quality data. Specifically, we continue to hear that state inspectors understate the existenceof serious quality-of-care problems.
As a result of that hearing, I instructed my staff to independently review the nursing homesurvey and certification process from the surveyors’ perspective. My staff has since interviewedapproximately 20 surveyors from around the country to obtain their views, guidance and opinionsregarding the survey and certification process.
The purpose of this letter is three fold; to: 1) share with you the serious concerns thatwere raised to us by the surveyors interviewed; 2) identify the themes and concerns that wererepeatedly raised during the interviews conducted; and 3) set forth one or more initiatives foryour consideration to address a process that appears to have been corrupted by someunscrupulous individuals.
Surveyors are "on the front lines" in the fight to improve the quality of care provided toour nation’s sick and disabled. Indeed, we depend on their eyes and ears to document serious careproblems, procedural weaknesses, as well as, improvements. Unfortunately, it is becoming moreand more apparent that the survey and certification process, in all likelihood, has been seriouslycorrupted.
As recently as a few weeks ago it was reported that the Oklahoma Board of Healthmember Ron Osterhout said, "he received tips during the past six months from sources inside andoutside the state Health Department alleging that surveyors are being pressured to go easy onlong-term facilities . . . Among those allegedly pressuring surveyors are state lawmakers actingon behalf of facility administrators." The dismal picture painted by such articles and by surveyorsinterviewed by the Finance Committee must be addressed and corrected if we wish todramatically improve the quality of care provided to nursing home residents. Former surveyorsstated that they resigned or retired from their positions out of sheer disgust at how their handswere tied while doing their jobs. Listening to their trials and tribulations has been extremelydisconcerting. My staff reported story after story to me about surveyors who question theintegrity and effectiveness of the nursing home survey process, as well as, the enforcement andcomplaint process.
Survey and Reporting Integrity and Effectiveness
Surveyors interviewed stated that the survey and enforcement process is in desperate needof improvement. Many stated that high level state bureaucrats, "tie their hands" routinely.Perhaps, most troubling is the fact that several surveyors stated that there is an unspoken"political presence" intertwined in the survey process that puts pressure on surveyors to"overlook" or "downgrade" deficiencies. Still other surveyors told the Committee that they wereroutinely instructed "not" to cite certain high level deficiencies because it was consideredineffective to "rock the boat" because high level deficiencies would be omitted from the finalreport anyway.
For example, one surveyor described a very alarming situation. While responding to anursing home complaint with a police escort, the surveyor witnessed nursing home staffmembers allegedly using illegal drugs and ignoring patients. Subsequently, the surveyor, whofully expected to return to the home for appropriate follow-up was told not to return. Reportedly,the nursing home owner’s friend, who served in a state legislature, called requesting that thefacility continue with "business as usual" and not be bothered by further review.
Surveyors frequently described the systematic downgrading of citations. This matter hasbeen repeatedly discussed as a concern by the General Accounting Office (GAO) over the years,most recently in a July 2003 report conducted at my request. Apparently, and according to thesurveyors interviewed, the scope and severity of surveys is being low-balled. Surveyors routinelystated that they were "instructed" by their superiors to downgrade citations or not write upfacilities for certain high level deficiencies. Some surveyors went on to say that if a high leveldeficiency is cited, most of the time it would be reduced to a lower level deficiency or completelyomitted from the final report by management without consultation with the citing surveyor. Othersurveyors advised that they are told to "rewrite" or "change" survey findings to make the facility"look better" than it really was. And still others advised us that, from time to time, multipleviolations were bundled and cited as one violation instead of many.
Enforcement and Complaint Process
In addition to a lack of effectiveness and integrity in the survey and reporting process, thesurveyors interviewed stated that facilities are given too many "free passes" to correctdeficiencies that survive downgrading and re-writing. Surveyors noted that in most instances afacility would, as an initial matter, correct the deficiency only to revert back to its "old ways"once a follow up review is completed. It seems that "roller coaster compliance"—the cycling inand out of compliance without taking care of the underlying care problems—has not beenremedied despite being identified and raised as a matter of great concern at Committee hearings.
The majority of surveyors interviewed also complained about what I have reported ontime and time again—surveys remain too predictable. As you know, the predictability of surveyshas been an issue for many years and the reality is that most facilities know when a survey teamis coming for a visit. The GAO reported to me in July 2003 that fully one-third of the most recentstate surveys of nursing homes nationwide occurred on a predictable schedule, allowing homes toconceal problems if they choose to do so. Unfortunately, this does not allow for an accurate andfair representation of the operation and activities of the facility. Let me ask: How can we have aneffective and efficient survey and enforcement process if there is no element of surprise? While Iacknowledge that some efforts have been made to make surveys less predictable, it is just notenough.
The Committee was also advised that the complaint investigation process needsimprovement. Surveyors interviewed stated that complaints are rarely reviewed thoroughly. Forexample, some surveyors stated that: patients and/or family members are rarely interviewed;administrative and medical records are rarely reviewed; valuable information is routinelyrecorded incorrectly; and the word of the facility is often taken at face value over that of aresident and/or family member. As a result of these inherent procedural failures, complaints arerarely substantiated and serious quality problems are therefore not corrected.
Quality of Care Concerns
In addition to the problems noted above, most of the surveyors interviewed discussed theeveryday problems they faced when they visited nursing homes. One nursing home surveyorreported to my staff that medical charts would be filled out weeks in advance, a concern that hasbeen brought to my attention repeatedly. If true, this constitutes outright fraud. Another examplereported to the Committee involved nursing home staff members routinely filling in drugadministration information well after the fact and all at once, as opposed to completing theinformation on a timely basis during the course of the day as the drugs were administered orchanged depending on the needs of the patient.
Unfortunately, these quality of care concerns are not new. The GAO has documented, andcontinues to document, these and other serious quality of care problems throughout the nursinghome industry. Indeed, the GAO reviewed a sample of nursing homes with a history of qualityof-care problems, but the nursing homes most recent survey inspection showed no actual harmdeficiencies. The GAO determined that 40 percent of these homes in fact had documentedincidents of actual harm—such as serious, avoidable pressure sores, severe weight loss, andmultiple falls resulting in broken bones and other injuries—despite the fact that none were cited.Dr. McClellan, it is apparent from our review that the survey and certification processupon which we rely for accurate, objective and independent data on the operation and activitiesof facilities, is just plain broke. It has been corrupted by unscrupulous individuals and we need torestore the integrity of the system in every state and locale.
Despite years of reports, evaluations, and investigations the surveyors that we interviewedportray a bleak and dismal situation in America’s nursing homes. The surveyors themselves aredemoralized when blatant quality of care deficiencies and findings are watered down,substantively altered, and/or blatantly ignored or dismissed. These surveyors have raisedenormously disturbing issues for anyone who cares a wit about the very health and safety of frailnursing home residents.
The federal government expends tremendous amounts of money to ensure that surveyorsvisit facilities routinely and are able to do their jobs efficiently, effectively and most of all,objectively and independently. The survey process, I am sure you will agree, is meant to improvethe quality of care for residents, not to ignore it, gloss over it, and most of all, not make it worse.If the survey and certification process is not working—and it looks like it is not—it must befixed.
The concerns elicited from surveyors during these interviews raise other issues, includingquestions about the integrity and reliability of the information provided to the public through theNursing Home Compare website. A plan of attack is needed to restore the integrity of the system.In that regard let me set forth a number of proposals for your consideration.
To begin, perhaps CMS can give consideration to contacting all surveyors periodicallyand provide them with an opportunity to anonymously report instances of corruption,manipulation of data and other concerns affecting them. In addition, CMS perhaps can begintargeting its look behind survey activities to homes that have a history of poor care that then"improved" to determine if the improvement is "real." Lastly, CMS should conduct exitinterviews of surveyors who depart the state survey agencies. One difficulty that my staff had inconducting this investigation was the deep-seated fear of retaliation even among retiredsurveyors.
Please be advised that the ideas set forth above are by no means all inclusive. I believethat the road to achieving accurate, timely, independent on-site reviews, which in turn willprovide accurate information to the public, is a challenge that must be met aggressively and inthe near future. Accordingly, I look forward to hearing from you no later than August 17, 2004,regarding the concerns set forth in this letter. In that response, please be prepared to include somespecific initiatives to address the many serious concerns relayed to us by surveyors.
In closing, thank you for your attention to this important matter and I look forward toyour response. Should you have any questions regarding this letter, please do not hesitate tocontact Emilia DiSanto or Michelle Anderson at (202) 224-4515.
Sincerely,
Charles E. Grassley
Chairman
Grassley seeks more reliable and complete information about nursing homes
WASHINGTON — Sen. Chuck Grassley said the federal government should improve thequality of information it makes available to the public about the care provided in the nation'snursing homes.
Grassley based his comments on a report issued today by the Inspector General for the Department of Health and Human Services. The report found that Americans who rely onNursing Home Compare stand a one in five chance that the information will be accurate.Nursing Home Compare is a Web site that provides information about the past performance ofevery Medicare- and Medicaid-certified nursing home in the country.
Grassley said that the odds may be even worse for individuals and families searching for information about nursing homes because the data presented by Nursing Home Compare is based on inspection results, and there are serious deficiencies in the federal-state survey and certification process for nursing homes.
Last week, Grassley spelled out his concerns about this process to Mark McClellan, the Administrator of the Centers for Medicare and Medicaid Services. This federal agency oversees enforcement by the states of federal nursing home standards. Grassley said his concerns were based on the findings of his investigative staff. The text of Grassley's July 7 letter to McClellan about the survey and certification process follows the text of Grassley's July 13 letter toMcClellan about Nursing Home Compare.
July 13, 2004
The Honorable Mark McClellan
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Dr. McClellan:
Following upon my letter, dated July 9, 2004, which expressed my belief that the surveyand certification process is broken, I want to focus your attention on the latest troubling findingsabout the information that Americans rely upon for accurate, objective and independent dataabout the operation and activities of nursing homes.
Today, the Department of Health & Human Services, Office of Inspector General (OIG)publicly released a report that questions the completeness and accuracy of information theCenters for Medicare & Medicaid Services (CMS) provides Americans about nursing homes.The OIG concluded that:
Overall, Nursing Home Compare’s [NHC] inspection results provide consumers with avaluable resource on the past-performance of Medicare- and Medicaid-certified nursing homes.… However, one or more surveys were missing from 19 percent of nursing homes, leavingconsumers with incomplete information about those homes’ survey and complaint histories.Inspection results on [NHC] are largely accurate, but one or more deficiencies were missing from11 percent of nursing homes’ inspection results, and [NHC] presents deficiencies not found onsurvey documentation for 15 percent of nursing homes. Inaccuracies may be due to lack of dataentry by State survey agencies, no tracking of accuracy reports by CMS, and failure of Statesurvey agencies to transmit data on amended deficiencies. (emphasis added).
While the OIG suggests that information available to the public about nursing homes is“largely accurate,” that finding is only true if the information is taken at face value and only if theodds are on your side. In fact, as the OIG’s findings point out, anyone who entrusts their lovedone to a nursing home based on CMS’s Nursing Home Compare stands a one in five chance thatthe information relied upon was inaccurate. Couple those odds with the disturbing reality that thevery integrity of the quality data contained in the nursing home inspection results and complainthistories has been called into question and the bedrock value of Nursing Home Comparecrumbles.
As I mentioned in my letter to you last week, my Committee staff have reported storyafter story to me about surveyors who question the integrity and effectiveness of the nursinghome survey process, as well as the enforcement and complaint process. Likewise, theGovernment Accounting Office has documented, and continues to document, serious deficienciesin the survey and certification process. American’s struggling with the difficult decision tochoose a nursing home deserve better information than CMS is providing them. I look forward tohearing whether CMS will step to the plate and address the concerns shared by many about theintegrity of publicly available nursing home performance information. Thank you again for yourattention to this critical matter.
Sincerely,
Charles E. Grassley
Chairman
July 7, 2004
The Honorable Mark McClellan
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Dr. McClellan:
Since 1997, I have focused considerable attention on improving the quality of care in ourNation’s nursing homes, which provide care for about 1.7 million elderly and disabled residentsin about 17,000 nursing homes. As former chairman of the Committee on Aging, and presentlyas chairman of the Committee on Finance (Committee), I have conducted numerous hearingsover the years to address the problems that plague nursing home care. In July 2003, I held ahearing updating my previous work on nursing home quality of care. Although it wasencouraging that modest improvements in the reported quality care have been made as a result ofefforts in recent years, the Committee also heard evidence that called into question the integrityof the quality data. Specifically, we continue to hear that state inspectors understate the existenceof serious quality-of-care problems.
As a result of that hearing, I instructed my staff to independently review the nursing homesurvey and certification process from the surveyors’ perspective. My staff has since interviewedapproximately 20 surveyors from around the country to obtain their views, guidance and opinionsregarding the survey and certification process.
The purpose of this letter is three fold; to: 1) share with you the serious concerns thatwere raised to us by the surveyors interviewed; 2) identify the themes and concerns that wererepeatedly raised during the interviews conducted; and 3) set forth one or more initiatives foryour consideration to address a process that appears to have been corrupted by someunscrupulous individuals.
Surveyors are "on the front lines" in the fight to improve the quality of care provided toour nation’s sick and disabled. Indeed, we depend on their eyes and ears to document serious careproblems, procedural weaknesses, as well as, improvements. Unfortunately, it is becoming moreand more apparent that the survey and certification process, in all likelihood, has been seriouslycorrupted.
As recently as a few weeks ago it was reported that the Oklahoma Board of Healthmember Ron Osterhout said, "he received tips during the past six months from sources inside andoutside the state Health Department alleging that surveyors are being pressured to go easy onlong-term facilities . . . Among those allegedly pressuring surveyors are state lawmakers actingon behalf of facility administrators." The dismal picture painted by such articles and by surveyorsinterviewed by the Finance Committee must be addressed and corrected if we wish todramatically improve the quality of care provided to nursing home residents. Former surveyorsstated that they resigned or retired from their positions out of sheer disgust at how their handswere tied while doing their jobs. Listening to their trials and tribulations has been extremelydisconcerting. My staff reported story after story to me about surveyors who question theintegrity and effectiveness of the nursing home survey process, as well as, the enforcement andcomplaint process.
Survey and Reporting Integrity and Effectiveness
Surveyors interviewed stated that the survey and enforcement process is in desperate needof improvement. Many stated that high level state bureaucrats, "tie their hands" routinely.Perhaps, most troubling is the fact that several surveyors stated that there is an unspoken"political presence" intertwined in the survey process that puts pressure on surveyors to"overlook" or "downgrade" deficiencies. Still other surveyors told the Committee that they wereroutinely instructed "not" to cite certain high level deficiencies because it was consideredineffective to "rock the boat" because high level deficiencies would be omitted from the finalreport anyway.
For example, one surveyor described a very alarming situation. While responding to anursing home complaint with a police escort, the surveyor witnessed nursing home staffmembers allegedly using illegal drugs and ignoring patients. Subsequently, the surveyor, whofully expected to return to the home for appropriate follow-up was told not to return. Reportedly,the nursing home owner’s friend, who served in a state legislature, called requesting that thefacility continue with "business as usual" and not be bothered by further review.
Surveyors frequently described the systematic downgrading of citations. This matter hasbeen repeatedly discussed as a concern by the General Accounting Office (GAO) over the years,most recently in a July 2003 report conducted at my request. Apparently, and according to thesurveyors interviewed, the scope and severity of surveys is being low-balled. Surveyors routinelystated that they were "instructed" by their superiors to downgrade citations or not write upfacilities for certain high level deficiencies. Some surveyors went on to say that if a high leveldeficiency is cited, most of the time it would be reduced to a lower level deficiency or completelyomitted from the final report by management without consultation with the citing surveyor. Othersurveyors advised that they are told to "rewrite" or "change" survey findings to make the facility"look better" than it really was. And still others advised us that, from time to time, multipleviolations were bundled and cited as one violation instead of many.
Enforcement and Complaint Process
In addition to a lack of effectiveness and integrity in the survey and reporting process, thesurveyors interviewed stated that facilities are given too many "free passes" to correctdeficiencies that survive downgrading and re-writing. Surveyors noted that in most instances afacility would, as an initial matter, correct the deficiency only to revert back to its "old ways"once a follow up review is completed. It seems that "roller coaster compliance"—the cycling inand out of compliance without taking care of the underlying care problems—has not beenremedied despite being identified and raised as a matter of great concern at Committee hearings.
The majority of surveyors interviewed also complained about what I have reported ontime and time again—surveys remain too predictable. As you know, the predictability of surveyshas been an issue for many years and the reality is that most facilities know when a survey teamis coming for a visit. The GAO reported to me in July 2003 that fully one-third of the most recentstate surveys of nursing homes nationwide occurred on a predictable schedule, allowing homes toconceal problems if they choose to do so. Unfortunately, this does not allow for an accurate andfair representation of the operation and activities of the facility. Let me ask: How can we have aneffective and efficient survey and enforcement process if there is no element of surprise? While Iacknowledge that some efforts have been made to make surveys less predictable, it is just notenough.
The Committee was also advised that the complaint investigation process needsimprovement. Surveyors interviewed stated that complaints are rarely reviewed thoroughly. Forexample, some surveyors stated that: patients and/or family members are rarely interviewed;administrative and medical records are rarely reviewed; valuable information is routinelyrecorded incorrectly; and the word of the facility is often taken at face value over that of aresident and/or family member. As a result of these inherent procedural failures, complaints arerarely substantiated and serious quality problems are therefore not corrected.
Quality of Care Concerns
In addition to the problems noted above, most of the surveyors interviewed discussed theeveryday problems they faced when they visited nursing homes. One nursing home surveyorreported to my staff that medical charts would be filled out weeks in advance, a concern that hasbeen brought to my attention repeatedly. If true, this constitutes outright fraud. Another examplereported to the Committee involved nursing home staff members routinely filling in drugadministration information well after the fact and all at once, as opposed to completing theinformation on a timely basis during the course of the day as the drugs were administered orchanged depending on the needs of the patient.
Unfortunately, these quality of care concerns are not new. The GAO has documented, andcontinues to document, these and other serious quality of care problems throughout the nursinghome industry. Indeed, the GAO reviewed a sample of nursing homes with a history of qualityof-care problems, but the nursing homes most recent survey inspection showed no actual harmdeficiencies. The GAO determined that 40 percent of these homes in fact had documentedincidents of actual harm—such as serious, avoidable pressure sores, severe weight loss, andmultiple falls resulting in broken bones and other injuries—despite the fact that none were cited.Dr. McClellan, it is apparent from our review that the survey and certification processupon which we rely for accurate, objective and independent data on the operation and activitiesof facilities, is just plain broke. It has been corrupted by unscrupulous individuals and we need torestore the integrity of the system in every state and locale.
Despite years of reports, evaluations, and investigations the surveyors that we interviewedportray a bleak and dismal situation in America’s nursing homes. The surveyors themselves aredemoralized when blatant quality of care deficiencies and findings are watered down,substantively altered, and/or blatantly ignored or dismissed. These surveyors have raisedenormously disturbing issues for anyone who cares a wit about the very health and safety of frailnursing home residents.
The federal government expends tremendous amounts of money to ensure that surveyorsvisit facilities routinely and are able to do their jobs efficiently, effectively and most of all,objectively and independently. The survey process, I am sure you will agree, is meant to improvethe quality of care for residents, not to ignore it, gloss over it, and most of all, not make it worse.If the survey and certification process is not working—and it looks like it is not—it must befixed.
The concerns elicited from surveyors during these interviews raise other issues, includingquestions about the integrity and reliability of the information provided to the public through theNursing Home Compare website. A plan of attack is needed to restore the integrity of the system.In that regard let me set forth a number of proposals for your consideration.
To begin, perhaps CMS can give consideration to contacting all surveyors periodicallyand provide them with an opportunity to anonymously report instances of corruption,manipulation of data and other concerns affecting them. In addition, CMS perhaps can begintargeting its look behind survey activities to homes that have a history of poor care that then"improved" to determine if the improvement is "real." Lastly, CMS should conduct exitinterviews of surveyors who depart the state survey agencies. One difficulty that my staff had inconducting this investigation was the deep-seated fear of retaliation even among retiredsurveyors.
Please be advised that the ideas set forth above are by no means all inclusive. I believethat the road to achieving accurate, timely, independent on-site reviews, which in turn willprovide accurate information to the public, is a challenge that must be met aggressively and inthe near future. Accordingly, I look forward to hearing from you no later than August 17, 2004,regarding the concerns set forth in this letter. In that response, please be prepared to include somespecific initiatives to address the many serious concerns relayed to us by surveyors.
In closing, thank you for your attention to this important matter and I look forward toyour response. Should you have any questions regarding this letter, please do not hesitate tocontact Emilia DiSanto or Michelle Anderson at (202) 224-4515.
Sincerely,
Charles E. Grassley
Chairman
Next Article Previous Article