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a Health Services Management Centre, University of Birmingham, UK
b Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco
Correspondence: Charlene Harrington, PhD, Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94188. E-mail: chas{at}itsa.ucsf.edu.
Decision Editor: Laurence G. Branch, PhD
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Abstract |
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Key Words: Nursing homes • Licensing and certification • HCFA • CMS • Long-term care
More than 1.6 million Americans, mostly seniors, live in nursing facilities. The United States spent $90 billion in 1999 on nursing facility care, or about $55,900 per resident per year, most of which (60%) came from public funds through the Medicaid and Medicare programs (Heffler et al. 2001
). There were more than 17,000 nursing facilities, with a total of over 1,834,000 beds in 1998 (AHCA 1999). About 65% of nursing facilities are in the for-profit sector, and 56% are owned or operated by multifacility corporations, some of which have become very large and control many thousands of beds in hundreds of facilities (Harrington, Carrillo, Thollaug, Summers, and Wellin 2000).
The quality of nursing facility care has been a recurrent matter of public policy concern in the United States for at least 30 years. A succession of reports in the 1970s and 1980s highlighted long-standing, widespread, serious quality of care problems, including some horrific instances of the mistreatment and abuse of highly vulnerable nursing facility residents (Mendelson 1974; USGAO 1987; Vladeck 1980). In 1987, following the publication of a highly critical Institute of Medicine report (Institute of Medicine, 1986), Congress enacted a wholesale reform of the federal regulatory arrangements for nursing facilities participating in Medicare and Medicaid. Those reforms were gradually implemented between 1988 and 1995, but quality problems have persisted, and the effectiveness of the current system of regulation has been repeatedly questioned (USGAO 1998, USGAO 1999a, USGAO 1999b; USOIG 1999). Although some argue that nursing facilities are more heavily regulated than other health care organizations, the numerous public scandals associated with poor nursing home care and the vulnerability of residents continue to result in calls for improved oversight of the industry by the U.S. Senate Special Committee on Aging 1998, U.S. Senate Special Committee on Aging 1999. Although there is rather limited evidence of the effectiveness of current regulatory arrangements (Walshe 2001), a second report from the Institute of Medicine concluded that regulation has brought some improvements in the quality of nursing facility care, but that further reforms were needed in the survey and enforcement process to make the regulatory process more effective (Wunderlich and Kohler 2001). The Institute of Medicine Committee also recommended that a study should be undertaken on whether more funding for nursing facility regulation was required (Wunderlich and Kohler 2001).
This study examines the resources, staffing, and performance of the state survey agencies, which have primary responsibility for regulating nursing facilities—licensing them at a state level and certifying them for participation in Medicare and Medicaid on behalf of the Center for Medicare and Medicaid Services (CMS; formerly known as the Health Care Financing Administration). It provides an overview of the development of the current arrangements for regulating nursing facilities and summarizes concerns about state survey agency performance. This article then describes and analyzes the results of a study that collected quantitative and qualitative data on resources, staffing, and performance directly from state survey agencies through a telephone and fax survey of state licensing and certification agency directors. These data are supplemented by secondary data from CMS's On-Line Survey Certification and Reporting (OSCAR) system. The relationships between state survey agency resources and performance are examined, controlling for nursing facility characteristics at a state level, using a backward stepwise regression model. This article concludes by discussing the policy implications of its findings for future funding and management of state survey agencies.
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The Development of Nursing Facility Regulation |
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) to address the long-standing concerns about quality of care. The Omnibus Budget Reconciliation Act (OBRA) and the subsequent regulations (USDHHS 1988, USDHHS 1989, USDHHS 1994, USDHHS 1995a, USDHHS 1995b) mandated uniform comprehensive assessments of all nursing facility residents after admission and periodically thereafter; developed quality indicators that were more outcome-oriented than process-oriented; and changed federal survey procedures to make them more oriented toward the residents through interviews and assessments of residents rather than simply reviewing medical records. Deficiencies found during surveys of nursing facilities were required to be rated based on their scope and severity for the purposes of enforcement, and a range of new enforcement mechanisms were created, including the authority to impose intermediate sanctions (civil money penalties, the denial of payment for new admissions, and the imposition of temporary management), as well as the ultimate sanction of decertification (USDHHS 1995a, USDHHS 1995b).
State survey agencies are responsible both for licensing nursing facilities that meet state legal requirements, and for certifying those that meet the conditions for participation in the Medicare and Medicaid programs. Nursing facilities must be licensed to operate under state rules, but only have to meet the federal certification requirements if they wish to participate in the Medicare and Medicaid programs, although almost all do. State survey agencies have contracts with CMS to undertake the certification process and are funded by CMS to do so. Under federal regulations, the federal government pays for all of the certification activities for Medicare facilities at the state level and for 75% of the certification activities for Medicaid facilities, and states must fund the remainder (USGAO 2000). States must bear the entire costs for state-level licensing activities.
State agencies survey nursing facilities on average every 12 months and conduct additional surveys when complaints are made about poor quality of care. State surveyors are trained to follow federal regulations for surveying facilities and to record deficiencies using procedures laid down by CMS in its State Operations Manual (USHCFA 2000c). State agencies are also responsible for investigating complaints about the quality of nursing facility care within federal guidelines. When they find that a facility fails to meet a specific federal requirement, a deficiency notice is issued. State surveyors are responsible for rating the scope and severity of deficiencies. State survey agencies are responsible for taking enforcement actions for Medicaid-certified facilities, and they work with federal officials on enforcement actions for Medicare-certified facilities. Thus, the federal nursing facility regulatory system is largely decentralized or devolved to states and relies on state agencies for all the first-line regulatory activities.
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Survey and Enforcement of Regulations |
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, Edelman 1998). From an initial peak in 1991, the number of deficiencies found by surveyors steadily declined by 44% in 1997 (Harrington and Carrillo 1999), a trend that was believed to reflect diminishing oversight rather than improving quality. Few deficiencies were ranked in the highest categories of scope and severity (although the proportion was rising), and sanctions were rarely applied (USOIG 1999). There was wide variation in the numbers and types of deficiencies recorded across states, suggesting that they were not all using the regulatory process consistently. The U.S. General Accounting Office (USGAO 1998) conducted a study of the federal and state enforcement programs in California and reported to Congress that "nursing homes have not been and currently are not sufficiently monitored to guarantee the safety and welfare of their residents" (p. 3). Another USGAO study (1999a) found that one fourth of nursing facilities nationwide continue to be cited for deficiencies that either caused actual harm or the potential for death and serious injury. The Inspector General (USOIG 1999) and CMS (USHCFA 1998b) drew similar conclusions from separate studies. One of the most serious findings was that state surveyors were often unable to detect serious quality of care problems. Using concurrent reviews (where state surveyors visited the facilities at the same time as researchers), the USGAO (1998) concluded that CMS policies were not effective in ensuring that the deficiencies are identified, corrected, and remained corrected. They found that CMS and the states allowed most facilities to correct violations without penalties. Only a few facilities were terminated from the program, and most of these were later reinstated and continued to have violations.
The U.S. Senate Special Committee on Aging held a series of hearings between 1998 and 2000 regarding the USGAO's studies, and urged CMS to improve its survey and enforcement process. President Clinton and CMS began a new initiative to improve the enforcement process (USDHHS 1998), including strengthening regulatory enforcement and expanding the oversight of state inspections. CMS argued that additional funding was needed for the enforcement program (USHCFA 1998a), and the Congressional budget passed some increases in funding for state programs in the fall of 1998. The most recent CMS reports to the U.S. Senate Special Committee on Aging show some improvements in state regulatory activity (USHCFA 2000a, USHCFA 2001a). Even so, the recent Institute of Medicine report recommended further reforms of nursing facility regulation, including a greater focus on dealing with poor quality providers, efforts to make state survey and enforcement activities more uniform, more use of assistance and sanctions to improve performance, and an examination of whether increased funding for regulation is needed (Wunderlich and Kohler 2001).
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Methods |
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). At the same time, reports have also shown a wide variation in the total funds for nursing facility regulatory activities across states (Zimmerman and Stegemann 1999). This raises questions about whether some variation in performance is related to inadequate survey agency resources.
The new federal enforcement processes may have substantially increased the workload burdens on state survey agencies. These added requirements without sufficient agency funds may have detracted from the actual process of the detection of poor care. Perhaps, the federal funds for the enforcement effort were not sufficient at the federal and/or the state levels to maintain in-depth surveys of states. In 1998, CMS made these arguments that additional funding was needed for the enforcement program (USHCFA 1998a), and the Congressional budget passed some increases in funding for state programs in the fall of 1998. Under the federal regulations, the federal government pays for all of the certification activities for Medicare facilities at the state level and for 75% of the certification activities for Medicaid facilities, and the states are required to pay 25% of the costs in matching funds (USGAO 2000). States must bear the entire costs for licensing activities. States may use state general funds, state licensing fees, and other sources of state funds to meet the 25% matching requirement for the Medicaid certification activities.
Although new funds of $8 million were appropriated by Congress and from CMS's budget in 1999 and $23.5 million was appropriated by Congress in 2000 for nursing facility initiatives, it was not known whether these funds were sufficient to cover the new costs of the regulatory initiatives (USGAO 2000). CMS reported a total of $137.3 million for the Medicaid long-term care facility survey and certification activities, and about $86 million (estimated at 59% of total Medicare survey funds) for Medicare survey and certification funds in 1995 (USHCFA 2001b). Even with the new nursing facility initiative, the total Medicaid survey and certification funds was $147.8 million (but the proportion for nursing home surveys was unknown), and Medicare was $135.9 million for nursing facilities in 2000. This represents an average increase of only 5.4% annually over the 5-year period.
The hypothesis tested in this study was that the variation in the funding for nursing facility regulatory programs would explain some of the differences in regulatory performance. We compared the total state spending (federal and state) on nursing facility regulation standardized by the number of beds in a state. We also tested whether state agencies that had higher percentages of federal resources (with less state matching funds) would have poorer state agency performance. Those states that invest greater amounts in the regulatory program may place a greater importance on the program and therefore have better performance measures.
Measuring Facility Characteristics That May Impact on Quality and State Agency Performance
It was also expected that selected characteristics of nursing facilities would impact on quality. If these characteristics were associated with decreased quality, then they may increase the workload for survey agencies. For this study, we selected seven facility variables found to be important in previous studies of nursing facility quality and/or deficiencies as control variables: (1) if a facility was a multifacility organization, (2) if it was for-profit, (3) the percent of residents paid by Medicaid, (4) the percent of beds not certified for Medicare and Medicaid, (5) the average staff hours per resident day, (6) the size of the facility, and (7) facility occupancy. See Table 1 for the rationale for each and the related literature. All of these variables were considered to have a potential impact on the quality of care delivered by facilities; therefore, they could impact on the performance indicators for state licensing and certification agencies.
Measuring State Survey Agency Performance
Short of USGAO or CMS observations of state survey inspections, it is difficult to develop measures of state agency regulatory performance, and the choice of indicators is somewhat constrained by data availability. For purposes of this study, we examined seven statistical indicators of performance based on those identified by CMS, the USGAO, or others in the literature (Harrington and Carrillo 1999; USGAO 1998, USGAO 1999a, USGAO 1999b; USHCFA 1998b). Since the U.S. Senate Special Committee on Aging hearings in 1998 and 1999, CMS has been providing statistical reports on some of these indicators to the Committee on its efforts to improve regulatory activities.
Two measures of performance are the average number of deficiencies issued per facility and the percentage of facilities that receive no deficiencies. A third related measure of performance is the number of facilities that are given deficiencies rated by surveyors at the G level or above, meaning that the deficiencies are serious and have caused or have the potential to cause harm or immediate jeopardy to resident health and safety (USDHHS 1995b). The USGAO (1998, 1999a) found that surveyors sometimes fail to identify deficiencies that exist or do not issue deficiencies when problems are identified and thus may not be following CMS survey and enforcement procedures. The USGAO (1998, 1999a, 1999d) found that some agencies are reluctant to rank deficiencies at the higher levels of scope and severity because more deficiencies are contested through the informal dispute resolution process, and appealed and increased enforcement actions are then required to be taken by state agencies. Thus, state agencies with higher levels of resources should be more likely to issue deficiencies that are rated as more serious because they would not be as concerned about the cost consequences of such actions.
The quality of care may be expected to vary across states, so this can explain some of the differences in the number of deficiencies or no deficiencies issued by state agencies. It could also result in fewer facilities with the most serious deficiencies. Unfortunately, there is no way to separate these two factors in which deficiencies are used as an indicator, and no other source of data is available to make this distinction. Nonetheless, deficiencies and the severity of deficiencies represent a type of measure of stringency in regulatory activity that is used in this study to examine state differences.
Another performance measure identified by CMS is the mean time between surveys as a performance measure (USHCFA 1998a, USHCFA 2000b, USHCFA 2001a). Federal requirements call for state agencies to survey nursing facilities every 9–15 months and, on average, every 12 months (or 365 days) (OBRA 1987). Those states that survey less often than every 365 days, on average, are not in compliance with CMS requirements. CMS (USHCFA 1998a, USHCFA 2000b, USHCFA 2001b), has also identified some states that survey some facilities less often than the maximum federal requirement of at least every 15 months. Another performance measure was the percentage of surveys that take place more than 18 months after the last survey.
Finally, state agencies are also responsible for investigating complaints about the quality of nursing facility care within federal guidelines. The USGAO (1999c) estimated that 20% of total nursing home licensing and certification expenditures was spent on complaint investigations in 1998. CMS regulations require complaints that can cause immediate jeopardy to the health and safety of residents to be investigated within 2 days and other complaints of actual harm to be investigated within 10 days (timeframe adopted in 1999) (USGAO 2000). The USGAO (1999c) found that some states use procedures that discourage the public from filing complaints; states use widely varying categories for prioritizing complaints; complaints are given inappropriately low investigation status by states; states often fail to investigate within federal timeframes; and the investigation procedures are weak and ineffective. These problems are compounded by differences in state reporting of the number of complaints received and investigated. These problems, however, could not be identified in this study.
Recognizing the variation in state nursing facility complaint reporting systems, we developed two survey agency performance measures related to complaints about quality. First, the mean number of complaints investigated per 100 nursing facility beds was an indicator of complaint investigation activity. Second, the percentage of total complaints investigated within a state was selected as an indicator, assuming that states with a higher percentage of total complaints investigated were performing better than those with low investigation rates.
There are many other state agency performance indicators identified by Abt and CMS (USHCFA 1998b) and the USGAO (2000). One is the predictability of the annual surveys. CMS agreed to conducting 10% of standard surveys outside of the normal workday (weekends or early mornings or evenings). At this time, the numbers of staggered surveys are still small and do not seem to be the best indicator. Other indicators, such as determining the appropriateness of the surveyor findings and the scope and severity of determinations (USGAO 1999b), are beyond the scope of this study.
Data Collection and Analyses
Data for this study were collected from two sources. First, a telephone and fax survey of state licensing and certification agency directors or their designees was conducted during the year 2000. All 50 states and the District of Columbia participated in the survey. In the telephone survey, state licensing and certification officials were asked a series of structured questions about resources and whether resources were adequate to meet state and federal regulatory requirements, and state survey agency staff, recruitment, and retention. State officials were also asked to provide statistical data for 1999 and 2000 (by fax) on the sources and levels of resources and staff numbers and characteristics. Where responses to the telephone survey and statistical data were unclear, follow-up telephone calls were made for clarification.
Second, statistical data from the OSCAR system, on which state survey agencies record their survey activities, were used. OSCAR data were from three sources. First, OSCAR data from 15,086 nursing facilities with 1,578,309 beds surveyed in calendar year 1999 were used in the analysis (prepared by Harrington, Carrillo, et al. 2000). These data contained about 89% of total certified nursing facilities (because not all facilities are surveyed each calendar year) and was considered representative of the total certified nursing facilities in the United States. These data included numbers and types of deficiencies recorded; numbers of complaints recorded and investigated; facility characteristics, such as ownership and affiliation; Medicaid resident rates; occupancy rates; and staffing levels—all aggregated to the state level. Second, OSCAR data summarized in the American Health Care Association's (1999) annual nursing facilities sourcebook were also used, including the numbers of nursing facilities, numbers of nursing facility beds, and the numbers of Medicaid/Medicare certified beds. The third source of OSCAR data was reports complied by CMS for the U.S. Senate Special Committee on Aging (USHCFA 2000b). These data included the 1999 mean time between surveys and the percentage of surveys undertaken more than 18 months after a previous survey.
These data were then analyzed to examine overall rates and distributions and to explore differences between states; results are presented later. For the purposes of the analyses, the District of Columbia was included as if it were a state. To explore the relationships between indicators of performance for state survey agencies and levels of funding, we first identified a set of independent variables, which included two agency funding variables and seven control variables measuring various characteristics of nursing facility provision. Then, a set of eight dependent variables was identified, each of which could be seen as an indicator of the performance of state survey agencies. A correlation matrix was produced to check for collinearity, but the correlations were modest and in the subsequent regression analyses, tolerance tests showed that collinearity was not a problem. Then, a stepwise backwards regression analysis using SPSS was performed for each dependent variable in turn. For each regression analysis, the model with the greatest explanatory power (the largest significant adjusted value of R2) was selected.
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Results |
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). State agencies reported spending an average of $22,433 per nursing facility, or $208 per nursing facility bed for regulatory activities in 2000, including annual surveys, complaint visits, and other oversight activities. Nursing facility licensing and certification dominates the work of state survey agencies, taking up 64.8% of their overall funding, whereas the remaining 35.2% covers the licensing and certification of all other health care organizations (such as hospitals, clinics, home health care agencies, etc.). Spending on nursing facilities licensing and certification has been increasing, as shown by Table 2 . State survey agencies reported that total spending in 2000 was 9.6% higher than that in 1999, with most of the increase coming from a rise in federal funding and fee income. However, the nature and scope of licensing and certification activities required of state survey agencies by CMS and by state legislation have been increasing too, as a consequence of the new CMS regulations in 1995 and the more recent nursing homes initiative. Many state survey agencies indicated that they did not have sufficient resources to conduct their mandates. Overall, 37 (72.5%) state agencies reported that their current level of federal resources was not adequate to meet CMS's certification requirements, and 23 (45.1%) said that their state resources were insufficient to undertake state licensing requirements. State agency officials complained that the new federal funding increases for nursing facilities certification were insufficient to cover the new work they were being asked to do by CMS (e.g., staggered surveys, more complaint visits). In some states, the 1998–1999 funding increases had been delayed or came too late to be used during the state fiscal year.
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There were substantial differences in expenditure on nursing facilities licensing and certification across states, with some states apparently spending over eight times as much per bed as others. Although the mean level of state agency spending per bed reported for 2000 was $208, it ranged from $94 in West Virginia to $770 in Alaska. (Alaska is a special case, however, because of its small number of facilities and large geographical area.) Overall, 15 (29.4%) states reported spending less than $150 per nursing facility bed, whereas 11 (21.6%) states said that they spent more than $300 per bed. The level of state agency spending per facility survey also varied widely from $8,577 in West Virginia to $80,440 in Delaware, with a mean of $24,247. Although some of this variation might be explained by differences in geography, economies of scale in larger states, and differences in the nature and extent of state-level regulatory requirements, it is likely that it also represents significant differences in agency behavior, performance, and attitudes toward regulation. Indeed, one measure of this might be the extent to which states contribute to funding nursing facilities regulation. Federal funding covers 60.8% of the costs on average, but some states reported that they invest much more themselves than others. For example, California reported just 35.8% of funding for nursing facilities regulation from federal sources, with 28.2% coming from state revenues and 36.1% from other sources, such as licensing fees. In comparison, Montana reported 87.8% of funding from federal sources, the state provides 12.3%, and no income from other sources was reported.
State Survey Agency Staffing
Much of the resources invested in nursing facilities licensing and certification were used to employ agency staff who conduct the agency's federal and state mandates to survey nursing facilities, and investigate complaints and other problems. State survey agencies reported that they employed a total of 2,999 full-time equivalent (FTE) surveyors in 2000 to fulfill their nursing facility licensing and certification functions, of whom 71% were qualified nurses. Some states also employed specialist surveyors from other professional backgrounds, such as dietitians (44 states, 86.2%), social workers (38, 74.5%), pharmacists (29, 56.9%), therapists (14, 27.5%), and doctors (11, 21.6%), who not only provided assistance with nursing facility monitoring, but could also be assigned to the regulation of other types of providers (e.g., home health agencies). On average, across the United States, there was 1 FTE nursing facility surveyor for each 611.8 nursing facility beds, or 1 FTE surveyor for every 5.7 nursing facilities in 2000. Again, there were wide variations across states, with 1 FTE surveyor for every 102 beds in Alaska, 225 beds in Montana, 2,624 beds in Missouri, and 2,790 beds in Tennessee.
The total number of surveyor staff rose by 3.6% from 1999 to 2000, reflecting the increased resources discussed previously. This increase in staff numbers was less than the overall increase in budgetary resources, but many states (14, 27.5%) reported that they had problems in recruiting and retaining survey staff, with annual vacancy and turnover rates as high as 40%. The major reason reported was that surveyors are not well paid; the mean entry level salary reported by states for a qualified nurse surveyor was $36,017, and the mean for a non-nurse surveyor was even lower, at $33,416. These salaries compare poorly with the averages for nursing facility administrators ($59,849), directors of nursing ($49,606), and registered nurse supervisors ($37,627) in nursing facilities (AHCA 1999), which in turn are often lower than salaries for equivalent staff in other health care organizations. Although salary differentials between government and private sectors are not uncommon, 29 states (57%) cited low salaries as a barrier to recruitment, whereas other states reported that the current shortage of registered nurses is an important barrier. State officials reported other factors that made it difficult to recruit or retain survey staff, including the amount of travel and time away from home that the job demands; the requirement to work weekends, evenings, and nights to do "staggered" surveys; and the stressful and sometimes adversarial nature of the regulatory process, which was said to cause frustration and burnout.
Perhaps as a result, only 7 states (13.7%) said that they had ample or sufficient staff to fulfill their licensing and certification function for nursing facilities, whereas 15 states (29.4%) indicated that current staffing levels were barely adequate. The largest group—20 states (39.2%)—reported that staffing was not adequate, and a further 9 states (17.6%) described current staffing levels as seriously lacking. These staffing problems were related to the resource problems described previously.
Indicators of State Survey Agency Performance
Table 3 sets out seven performance indicators for state survey agencies, and it can be seen that on each one the results vary widely from state to state. First, some states find relatively few deficiencies at each nursing facility during their surveys, such as New Jersey (2.0), Maryland (2.8), and Colorado (2.8); other states find up to five times as many deficiencies, such as Nevada (11.4), California (11.3), and Michigan (9.9). Similar differentials exist for the percentage of nursing facilities that are found to have no deficiencies at all (which ranges from 1.5% to 48.5%), and the percentage found to have serious deficiencies (grade G or above) that ranges from 5.8% to 53.6%. Although some of these variations between states may be caused by real major differences in the quality of care in nursing facilities, it seems likely that these variations reflect differences in the behavior of the state survey agencies themselves, their resources, agency staffing, systems, and methods.
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The numbers and percentages of complaints about nursing facilities investigated also varied widely from state to state. There was a mean of 3.05 complaints investigated per 100 beds, but the rate varied from 0.09 to 18.2 across states. The proportion of complaints that were actually investigated when they were received (as opposed to be left to be addressed next time the facility was surveyed) ranged from 37.2% to 100%, with a mean of 79.1%.
Relationship Between Agency Resourcing and Performance
To explore the relationships between the indicators of performance discussed previously and survey agency funding, a series of linear regression models were created using each performance indicator listed in Table 3 as the dependent variable. A common set of state agency funding and nursing facility characteristics was used as the independent and control variables. All independent variables used in the linear regressions are shown in Table 4 , with their means and standard deviations. Table 5 shows the results of the stepwise backwards elimination regressions. For each dependent variable, backward elimination was used to find the model with the greatest explanatory power (highest value of adjusted R2). The table shows, for each model, which independent variables were included, their unstandardized coefficients, and whether they were significant or not.
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We found a number of other associations between the independent control variables and the dependent variables. For every performance indicator, there were associations with at least one (and sometimes several) control variable, suggesting that some caution should be exercised in interpreting differences between states. For example, the mean number of deficiencies per survey, as well as being positively associated with spending on licensing and certification, was also positively associated with the percentage of facilities with chain ownership or operation and the percentage of nursing facility beds not Medicaid/Medicare certified.
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The data we have presented on state survey agency performance, although incomplete and imperfect in many ways, demonstrate that there are alarmingly wide variations across states, which we believe primarily reflect differences in state agency behavior and commitment to regulation rather than underlying differences in the quality of care.
The regression analyses showed a direct relationship between state agency funding for licensing and certification, and the average number of deficiencies and the percentage of facilities that receive deficiencies rated as severe (at the G level or above, where intermediate sanctions are imposed). This association suggests that agencies with sufficient resources are better able to identify quality problems and are more willing to take actions against such facilities, as would be expected.
Surprisingly, other performance indicators were not directly associated with state agency resources in our regression analyses, but this may reflect the limited power of those analyses given the size of our data set or the nonlinearity of any relationships which exist. However, it is clear that there are many other influences on performance, apart from the level of licensing and certification resources. For example, state survey agencies may fall behind with their annual nursing facility surveys because of survey staff shortages or other workload priorities (such as complaint surveys or enforcement activities). Similarly, differences in complaint investigation performance may reflect differences in state procedures, definitions, and tracking systems (USGAO 1999c).
It is evident that, in many states, some resistance to expanding nursing facility regulation exists at a state level within the administration and/or legislature. This resistance is reflected in state-hiring moratoriums, funding caps, agency staff limits, and poor remuneration packages for agency staff—all of which may be significant obstacles to improving the performance of state licensing and certification agencies. The USGAO (2000) noted that states reported that a large proportion of the new appropriations for fiscal year 1999 survey initiatives were not fully used in part because of their late distribution, which slowed down the hiring of new staff.
Because the relationship between agency resources and performance is not robust, simply increasing the federal funding available to these state agencies may not solve their performance problems. It is clear that other measures to bring about improvements and efficiencies in agency performance may be needed. CMS has increased its surveyor training initiatives (USGAO 2000), but many state agencies report the need for additional training. CMS has agreed with the USGAO (1999b, 2000) and the U.S. Senate Special Committee on Aging that there is a need for more federal oversight of state agencies. To this end, CMS developed new nursing home survey protocols in July 1999; identified facilities in each state that need more frequent inspections and monitoring; implemented an abuse intervention campaign; and implemented enhanced regional office oversight, including more comparative surveys of state agency surveys and monitoring (USGAO 2000).
At present, CMS's arrangements for overseeing the performance of state survey agencies are rather limited, and it has little ability to deal with poor performance or encourage good performance (USGAO 1999c, USGAO 1999d, USGAO 2000). We would argue that CMS should do more to develop and promulgate models of good practice among state survey agencies, to improve the CMS central and regional office monitoring of state agency performance on a continuing basis, and to address problems of poor state agency performance. For example, CMS could set standards for survey team size and composition, and the number of days per survey for a range of facility sizes; CMS could build in travel factors as a means of standardizing the survey activities and the funding levels for state agencies. Moreover, CMS could standardize survey protocols that may ensure more efficiency and uniformity. The training of state surveyors is also an important area for CMS. Ultimately, CMS should be able and willing, if need be, to contract with another organization or agency to undertake Medicaid and Medicare certification or to perform the function itself where the state survey agency's performance is unacceptable.
The Forum
Book Reviews
Practice Concepts
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Data from the telephone survey were collected by Mary Millman, JD, from state Licensing and Certification officials. We also thank Allan Stegemann for his thoughtful and insightful review of the paper, and two anonymous reviewers for their helpful comments.
Kieran Walshe is now with the Manchester Centre for Healthcare Management, University of Manchester, UK.
Received for publication July 11, 2001. Accepted for publication December 21, 2001.
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L. Polivka, J. R. Salmon, K. Hyer, C. Johnson, and D. Hedgecock The Nursing Home Problem in Florida Gerontologist, April 1, 2003; 43(90002): 7 - 18. [Abstract] [Full Text] [PDF]
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