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.

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)