The Department of Public Health Did Not Always Perform Required On-Site Investigation Surveys.

DPH does not have procedures in place to properly ensure that all intakes designated for on-site investigations are adequately documented by staff.

Overview

Out of a population of 1,781 intakes during our audit period that the Department of Public Health (DPH) determined required an on-site investigation survey, 9 did not have surveys completed, even though 7 of the 9 included allegations of abuse or of misappropriation of a resident’s funds. When an on-site investigation survey does not take place, there is an increased risk that significant problems may exist at the nursing home and continue to pose a threat of physical or financial harm to a resident.

Authoritative Guidance

According to Chapter 5 of the Centers for Medicare & Medicaid Services’ (CMS’s) State Operations Manual,

At a minimum, if the intake information requires an onsite survey and the allegation may involve both Federal and State licensure requirements, a Federal onsite survey is completed.

All intakes that DPH investigates with an on-site investigation survey allege facility noncompliance⁷ that, pursuant to Section 153.012 of Title 105 of the Code of Massachusetts Regulations, may involve licensure requirements, including substandard quality of care, resident safety or comfort issues, and resident abuse.

Additionally, according to Section 72H of Chapter 111 of the Massachusetts General Laws, “[DPH] shall . . . investigate and evaluate the information reported in any such report.”⁸

Reasons for Issue

DPH does not have adequate policies and procedures in place that define and implement monitoring controls to ensure that all intakes designated for on-site investigation surveys in DPH’s Health Care Facility Reporting System (HCFRS) are subsequently transcribed by staff members into CMS’s Automated Survey Process Environment (ASPEN). When intakes requiring an investigation survey are not transcribed into ASPEN, those intakes do not receive on-site investigation surveys, because the survey process does not begin until the intake is entered in ASPEN.

Recommendation

DPH should enhance its policies and procedures that define and implement monitoring controls over its intake process to ensure that all intakes requiring on-site investigation surveys are properly transcribed from HCFRS to ASPEN.

Auditee’s Response

The Complaint Unit received the following number of nursing home and rest home intake cases annually, which as the draft report states, were either prioritized as an on-site investigation, off­site investigation, referred to another agency or reviewed:

• July 1, 2015 through June 30, 2016: 10,895 complaints
• July 1, 2016 through June 30, 2017: 11,859 complaints
• July 1, 2017 through June 30, 2018: 14,760 complaints

Of the cases listed above, there were 12 [Immediate Jeopardy intakes] which represent .03% of the total complaints received. [Immediate Jeopardy intakes] are the most concerning intake cases that are investigated on-site and then found to have substantial non-compliance that affects several residents at a severe level of harm. [Immediate Jeopardy intakes] often require extensive surveyor resources and coordination to ensure that the nursing home undertakes corrections to restore resident safety and well-being. . . .

Prior to the start of the audit, DPH had identified and hired staff to address an identified triage backlog. Further, a process of continuous quality improvement monitoring was put into place to proactively address the number of intake cases awaiting onsite investigation weekly. As of December 2018, no backlog of intake cases existed.

DPH disagrees with [the] finding that “DPH does not have adequate policies and procedures in place.” DPH notes that the Complaint Unit’s manual provides detailed policies and procedures for properly triaging intake cases. The purpose of the manual is to provide standardization of the intake process.

Auditor’s Reply

As noted above, during our audit period we found nine instances where DPH did not conduct required on-site investigations, even though seven of the nine included allegations of abuse or of misappropriation of a resident’s funds. Although we acknowledge that this represents a small percentage of the total complaints received by DPH during our audit period, all required on-site investigation surveys need to be conducted promptly so that any potential problems at the nursing home do not continue to pose a threat of physical or financial harm to a resident. Additionally, the Office of the State Auditor (OSA) acknowledges that DPH’s Complaint Unit Intake Process Manual does provide policies and procedures for triaging intake cases; however, as stated in our report, DPH needs to establish monitoring controls to ensure that these established policies and procedures are adhered to.

Based on its response, DPH is taking measures to address our concerns in this area.

7.    Noncompliance can include assessments of performance below the expected levels for facility administration, nursing care, resident rights, food, or living environment.

8.    For the purposes of this law, “such report” is a report alleging abuse, neglect, or mistreatment of a resident, or misappropriation of a resident’s funds or property, at a facility.

Date published:	September 11, 2019