State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services Audit Finding Number: 2024-011 – Medicaid Facility Survey Timeliness Name of the contact person responsible for corrective action: Tracy Niekamp, Administrator, Secti...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services Audit Finding Number: 2024-011 – Medicaid Facility Survey Timeliness Name of the contact person responsible for corrective action: Tracy Niekamp, Administrator, Section for Long Term Care Regulation, Division of Regulation and Licensure Anticipated completion date for corrective action: December 31, 2026 Corrective action planned is as follows: Missouri Department of Health and Senior Services (DHSS) partially agrees with the audit finding. Regarding the timeliness of revisits DHSS does not agree with the finding or that corrective action is needed. The reasons for disagreement are stated below. Related to timely mailing of Statements of Deficiencies, DHSS agrees with the finding and the corrective action plan is stated below. As previously stated, since 2019, DHSS has seen increases in the number and severity of complaints, and the severity of violations found in long term care facilities. Complaints increased overall by thirty-six percent (36%) from 9,011 complaints in FY2019 to 12,236 in FY2023. In FY2024, DHSS investigated 12,237 complaints. The largest increase has been in severe complaints, including immediate jeopardy complaints (which require an onsite investigation within 24 hours to seven days) and non-immediate jeopardy, high priority complaints (which require onsite investigation within 15 working days). Because of the seriousness of these complaints, often surveyors have to be reassigned to investigate these complaints, which results in a delay in conducting revisits or sending a statement of deficiencies timely. In addition to frequency and severity of complaints, changes to the survey process, and increased regulatory requirements, DHSS continues to see increases in the number of citations issued per recertification survey and in complaint investigations. Since 2019, the average number of health citations issued to a facility during a recertification survey has increased by 25% and the number of citations issued from stand-alone complaint findings has increased 100% during the same timeframe. These increases require additional time devoted to investigating often complex violations, increase time spent with write up activities, including the creation of the Statement of Deficiency, plan of correction review, onsite and offsite revisit activity and communication with complainants and facilities. Increases in this workload often require team members to begin investigating new complaints prior to the write up activities or revisits related to other processes being completed. Additionally, subsequent complaint investigations often cause revisits to be delayed due to open enforcement cases and substantial compliance date conflicts. DHSS continues to experience staffing shortages, particularly in the Registered Nurse job classification, which impacts the ability to complete work consistently within the prescribed time frames. Each recertification survey requires at least one team member to be Registered Nurse and due to the nature of many complaints, a Registered Nurse must also complete these investigations. There has been no meaningful increase in the federal budget since 2015, which further impacts the ability to hire and retain Registered Nurses. In addition, there is an ongoing labor shortage in the labor market for these professionals. The shortage has driven salaries well beyond the surveyor salary structure. DHSS has experienced turnover among surveyors leaving for other opportunities at a much higher salary. DHSS invests at least one calendar year into training new surveyors. This is training required by CMS in order to meet the stringent surveyor qualifications. In 2015, the number of RN vacancies the Section for Long-Term Care had averaged around 14 positions. In 2023, the average vacancy was 27 positions. In 2024 SLCR was able to hire several Registered Nurse positions statewide. Given the required training to independently conduct complaint investigations takes 12 months, SLCR hopes to see continued improvement in meeting deadlines in FY2025 due to a greater number of trained and qualified team members. DHSS has seen significant progress in meeting expectations since FY2023. During the FFY23 audit, 19 of the sampled statements of deficiency did not meet the 10-day timeframe for release to the facility and 9 of the sampled revisits did not occur within 60 calendar days of the exit date. Results of the FFY24 audit shows improvement in DHSS performance: 10 of the sampled statements of deficiency did not meet the 10-day timeframe for release to the facility and only one of the sampled revisits did not occur within 60 calendar days of the exit date. DHSS has and will continue to request increased funding from both federal and state sources to support competitive salaries for Registered Nurses and other survey staff. DHSS will continue to hire retired, federally qualified surveyors part-time to help with survey and complaint backlog, as able. DHSS continually works toward identifying inefficiencies and implementing measures to address them, such as bundling complaint investigations with other regulatory processes. As a short-term, time-limited solution possible through one-time additional funding from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention Epidemiology and Laboratory Capacity (CDC-ELC), DHSS contracted with three third-party contractors to assist with workload completion. However, this funding was terminated on March 24, 2025. DHSS will continue to track timeframes for completion of Statements of Deficiencies and revisits and make every effort to meet those timeframes. DHSS will continue to assign workload based on CMS’ stated priorities in the Mission and Priority Document, taking into account the potential for direct impact on residents. The agency does not agree with the audit findings and believes that corrective action is not required for timely revisits within 60 days. Explanation and specific reasons are as follows: The Centers for Medicare and Medicaid Services (CMS) completes performance standard reviews of states each federal fiscal year. The CMS expectation provided in the Fiscal Year (FY) 2024 State Performance Standards System (SPSS) Guidance is that the state meets the requirement for revisits within 60 days 70% of the time. States are not required to submit a corrective action plan to the CMS unless they fall below the 70% threshold. During the FFY24 audit, only one of the sampled revisits did not occur within 60 calendar days of the exit date, which means DHSS did meet the timeframe requirement 96.3% of the time. This percentage is well above the CMS’s acceptable rate of 70% and, therefore, should not require a finding or corrective action plan.