AUDIT SUMM - DOH PER AUD
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S TATE OF R HODE I SLAND-GENERAL A SSEMBLY OFFICE of the AUDITOR GENERAL AUDIT SUMMARYERNEST A. ALMONTE, CPA, CFE AUDITOR GENERAL INTEGRITY ♦ RELIABILITY ♦ INDEPENDENCE ♦ ACCOUNTABILITY ernest.almonte@oag.ri.gov FEBRUARY 2005 Federal regulations require a Office of Facilities Regulation comprehensive certification survey of nursing facilities not later than 15 Division of Health Services Regulation months after the previous survey; Department of Health however, a statewide average of 12 months between surveys must be Performance Audit maintained. In practice, the federal July 1, 2002 – December 31, 2004 certification survey also meets the required annual State licensing survey. We completed a performance audit of comply with federal regulatory requirements State law further requires two the Office of Facilities Regulation (OFR) to maintain participation in the Medicaid and unannounced surveys (interim surveys) within the Department of Health. The Medicare programs. The federal each year. We found that OFR did not performance audit focused on the government supports these activities with meet this requirement–interim surveys practices and procedures utilized by the federal grants and the federal requirements were not conducted for most nursing OFR in regulating nursing facilities are largely complied with by OFR. State facilities in both fiscal years 2003 and laws, in most ...
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ST A T EO FRH O D EIS L A N D GE N E R A LAS S E M B L YO F F I C Eo ft h eA U D I T O RG E N E R A L AUDITORGENERALUSMMIDTURA ERNESTA. ALMONTE, CPA, CFE NT E G R I T Y♦ RE L I A B I L I T Y♦ IN D E P E N D E N C E♦ AC C O U N T A B I L I T Yernest.almonte@oag.ri.govI FEBRUARY 2005 Federalregulations require a Office of Facilities Regulation comprehensive certification survey of nursing facilities not later than 15 Division of Health Services Regulationmonths after the previous survey; Department of Health however, a statewide average of 12 months between surveys must be Performance Audit maintained. Inpractice, the federal Jul 12002December 312004certification survey also meets the required annual State licensing survey. Wecompleted a performance audit ofcomply with federal regulatory requirementsState law further requires two the Office of Facilities Regulation (OFR)to maintain participation in the Medicaid andunannounced surveys (interim surveys) within the Department of Health.The Medicareprograms. Thefederal eachyear. Wefound that OFR did not performance audit focused on thegovernment supports these activities withmeet this requirement–interim surveys practices and procedures utilized by thefederal grants and the federal requirementswere not conducted for most nursing OFR in regulating nursing facilitiesare largely complied with by OFR.State facilitiesin both fiscal years 2003 and operating within the State.Our objectivelaws, in most instances, layer additional2004. Statelaw also requires that any was to determine whether these practicesrequirements over the federalfacility cited for substandard care shall and procedures complied with federal andrequirements—these additional statebe inspected on a bimonthly basis for state laws and regulations, and wererequirements are usually not met principallythe twelvemonth period immediately effective and efficient.Our audit wasdue to lack of resources within OFR.following the citation.We found that conducted in accordance withGovernment Auditing Standardsand covered primarily the fiscal years ended June 30, 2003 and AUDITHIGHLIGHTS2004, and the current fiscal year through December 31, 2004. OFR is largely complying with federal requirements for surveying nursing facilities but is not complying with more stringent state survey TheDepartment of Health’s Office of requirements principally due to lack of resources. Facilities Regulation (OFR) did notperform all surveys of nursing facilitiesNine nursing facilities were issued a 2005 license without the required required by state law and did not meetannual survey in calendar year 2004. state timeframes for investigating OFR did not meet the state requirement for interim surveys for most complaints for nursing facilities.Nine nursing facilities in both fiscal years 2003 and 2004. nursing facilities were issued a 2005 Complaints are not being investigated within the 7day timeframe license without the required annual survey required by State law.The prioritization of complaints using federal in calendar year 2004. guidelines needs to be improved. Bothfederal and state laws and OFR needs additional resources to perform its mandated federal and regulations govern the regulation of state functions.nursing homes.Because the federal Financial condition information could be used as an indicator of government, through the Medicaid and increased risk of deteriorating quality of care in nursing facilities.Cost Medicare programs, is the largest payor of data currently collected by the Department of Human Services for rate nursing home costs, nursing facilities must setting purposes may, with minimal supplement, be able to be used to develop a fiscal rating for each nursing facility.
AUDITSUMMARY–PAGE2 OFFICE OFFACILITIESREGULATION six out of seven facilities cited forresponsibilities assigned by state law shoulddeliberation which are not solely within substandard care between July 2002 andbe reexamined to affirm that these are thethe control of the Department of December 2004 were not inspected on afunctions that best ensure overall quality ofHealth. Webelieve these issues bimonthly basis as required.care in nursing facilities.State requirementswarrant consideration as corrective thatexceed federal requirements should beaction, statutory changes, and budget Werecommended improvements inevaluated concurrently with estimating theappropriations are considered. procedures to allow the tracking ofadditional resources needed to meet those Copies of the Single Audit deficiencies found on nursing facilitiesstatutory provisions.For example, meeting Report can be obtained by calling surveys throughout the survey process toa sevenday complaint investigation 2222435 or by visiting our website final reporting.We also recommendedtimeframe may require as many as 11 staff at www.oag.ri.gov. that the Department of Health adopt thededicated just to this task. federal conflict of interest policy for all OFR employees to enhance the integrityOFR has prepared a staffing analysis to of its regulatory process.support its request for additional personnel; however,we found the analysis to be Wefound that OFR, in most instances,incomplete and unsupported in various met the federal timeframes for complaintrespects. Whilethe flaws in OFR’s work investigations but did not meet the moreplan analysis precluded us from concurring stringent sevenday investigationwith the exact number of additional requirement mandated by state law.We personnelthat are needed, it is clear that also found that the prioritization ofadditional resources are needed to comply complaints using federal guidelines needswith existing state requirements.We to be improved.The timeframe forrecommended that OFR revise and update investigating a complaint is dictated by theits personnel budget request and severity category assigned during triage.accumulate data to support its estimates. Because the individuals performing the triage of complaints are responsible forOFR does not currently review any activities which compete for the samefinancial data or assess the financial position resources, there is an inherent risk ofof a nursing facility in conjunction with prioritizing the complaints in a less severeperforming its federal and state regulatory category to allow more time forfunctions. However,there is general investigation. Werecommended theseagreement that a direct relationship exists functions be segregated and that anbetween the fiscal soundness of a nursing immediate supervisory review befacility and its ability to provide consistent performed of complaint triage.quality care.Our report includes discussion ofhow financial condition information could TheState LongTerm Carebe used as an indicator of increased risk of Ombudsperson (LTCO) also receives anddeteriorating quality of care and prompt investigates nursing homes complaints.more frequent inspections.Cost data All LTCO complaints are not forwarded tocurrently collected by the Department of the Department of Health for considerationHuman Services for rate setting purposes and investigation.We believe this maymay, with minimal supplement, be able to be distort OFR’s perspective on conditions inused to develop a fiscal rating for each a specific nursing home and limit its abilitynursing facility.This financial rating factor to perform fully its federal and statecould be provided by DHS to OFR for use in regulatory functions.We recommendeda riskbased model, along with other relevant that the LTCO forward all complaintsrisk factors to determine frequency of received to the Department of Health toinspection. Theseissues are discussed in a allow concurrent investigations assection of our report entitledMatters necessary.Requiring Further Study or Legislative Deliberation. TheOFR needs additional resources toperform its mandated federal and stateWe have also highlighted other matters functions. First,we believe that OFR’sthat require further study or legislative
