State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-013 - 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, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-013 - 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, 2028 Corrective action planned is as follows: Corrective Action Plan related to the finding regarding revisits not being performed within 60 days. DHSS disagrees with the finding and contends a finding, and corrective action plan is not required related to the three revisits not performed within 60 days. The SAO has determined these exceptions to be nonmaterial noncompliance and as such, a finding in the single audit is not required. In addition, Centers for Medicare and Medicaid Services (CMS) is well aware of DHSS’ compliance level with this requirement and has deemed it met. During Federal Fiscal Year 2025, DHSS met the performance standard set out by the CMS for onsite revisits as outlined in Fiscal Year (FY) 2025 State Performance Standards System (SPSS) Guidance. Admin Info: 25-03-ALL. The SAO’s exception listing is inaccurate. Despite documentation provided to the SAO, the SAO demonstrated a misunderstanding or disregard of CMS’ grading system. One exception did not fall into the SAO’s cited category and failed to meet the deficiency threshold requiring a 60-day revisit. For the other two exceptions, additional complaints were received between the original visit and revisit which, according to CMS guidelines, had to be resolved before the revisit could occur. Further, DHSS follows CMS’ stated work priorities to conduct surveys and revisits as mandated by CMS Mission and Priority Document. See the explanation below regarding the increase in severe complaints, including immediate jeopardy (IJ) complaints (which require an onsite investigation within 24 hours to seven days), and the impact on SLCR’s decision to address immediate threats to residents as required by CMS. Corrective action plan related to the delayed issuance of Statements of Deficiencies and Plans of Correction (SODs) within the required 10-day timeframe. DHSS partially agrees with this finding. While DHSS agrees that the 14 SODs were not issued within 10 days, DHSS disagrees that, as a nonmaterial noncompliance finding, this issue should be reported in the single audit and therefore disagrees that a corrective action plan is needed. DHSS has continued to make significant progress in meeting expectations since FY2023. During the FY23 audit, 19 of the sampled statements of deficiency did not meet the 10-day timeframe for release to the facility. Results of the FY24 and FY25 audits showed improvement in DHSS performance as the number of sampled statements of deficiency that did not meet the 10-day timeframe for release to the facility decreased to 13 and 14 respectively. 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 12,237 in FY2024. In FY2025, DHSS received 12,203 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 (require onsite investigation within 15 working days). Because of the seriousness of these complaints, and to adhere to the CMS Mission and Priority document, often surveyors must 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 a high volume of citations issued per recertification survey and 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, increased time spent on 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 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. Regulatory noncompliance identified during the survey is discussed with administration at the facility while surveyors are on site. Findings of immediate jeopardy require a prompt plan of correction to address the immediacy of the violation prior to surveyors exiting the process. For all violations, facilities typically begin to take immediate corrective action, not waiting for receipt of the written SOD from SLCR. 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 in more than a decade, 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 surveyor salary structure. DHSS has experienced turnover among surveyors leaving for other opportunities at a much higher salary. DHSS has and will continue to request increased funding from CMS to support competitive salaries for Registered Nurses and fully fund the federal portion of the survey and certification workload. DHSS will continue its endeavors to hire retired, federally qualified surveyors part-time to help with survey and complaint backlog. 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 CMS 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. (Note: That funding terminated on March 24, 2025.) DHSS will maintain current contracts with the entities so that if funding becomes available contract surveys can be set up shortly after. 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. DHSS will provide training to surveyors related to writing statements of deficiency to ensure a clear, concise, legally defensible document is produced and to reduce the review time required.