State of Missouri
Single Audit
Corrective Action Plan
Year Ended June 30, 2023
State Agency: Department of Health and Senior Services (DHSS)
Audit Finding Number: 2023-015 Medicaid Facility Survey Timeliness
Name of the contact person responsible for corrective action: Tracy Niekamp, ...
State of Missouri
Single Audit
Corrective Action Plan
Year Ended June 30, 2023
State Agency: Department of Health and Senior Services (DHSS)
Audit Finding Number: 2023-015 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, 2024
Corrective action planned is as follows:
Missouri Department of Health and Senior Services (DHSS) through the Section for Long-term Care Regulation (SLCR) will continue its efforts to conduct survey procedures within required timeframes.
Since 2019, there has been a substantial increase in the number and severity of complaints, as well as the severity of violations in long term care facilities. Complaints have increased overall by thirty-six percent (36%) from 9,011 complaints in FY2019 to 12,236 complaints in FY2023. The largest increase has been in severe complaints, including a 125% increase in immediate jeopardy complaints (which require an onsite investigation within 24 hours) and a twenty-five percent (25%) increase in non-immediate jeopardy high priority complaints (which require onsite investigation within 10 working days). Surveyors often must be reassigned to investigate these serious complaints, which results in delays in conducting revisits and sending statements of deficiencies.
In addition to frequency and severity of complaints, DHSS has seen an increase in the number of citations issued per recertification survey and per complaint investigation. 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. The number of citations issued at an immediate jeopardy level scope and severity have increased from 2021 to 2023 by almost 38%.
These increases require additional time devoted to investigating often complex violations and additional time spent performing write up activities, including the creation of the Statement of Deficiency, plan of correction reviews, onsite and offsite revisit activities and communication with complainants and facilities. Workload increases often require team members to begin investigating new complaints prior to the write up activities or revisits from earlier surveys. 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 a 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 shortage in the labor market for these professionals. The shortage has driven salaries well beyond the DHSS surveyor salary structure. DHSS has experienced turnover among surveyors leaving for other opportunities offering a much higher salary. DHSS invests at least one calendar year into training new surveyors to meet Centers for Medicare and Medicaid Services (CMS) requirements for surveyor qualifications. In 2015, the number of Registered Nurse vacancies in the Section for Long-Term Care averaged 14 positions. In 2023, the average was 27 positions. Candidates routinely will not apply for positions or show up for interviews because of the salary gap.
In order to attempt to meet these time frames, DHSS has and will continue to request additional funding from both federal and state sources to increase across the board salaries for Registered Nurse and other survey staff.
DHSS has also hired retired federally-qualified surveyors part-time to help with survey and complaint backlogs. DHSS continually works to identify inefficiencies and implement 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 CMS and the Centers for Disease Control and Prevention (CDC) Epidemiology and Laboratory Capacity Enhancing Detection Expansion grant (ELC EDEX), DHSS has contracted with three third-party contractors to complete recertification surveys.