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Missouri State Auditor's Office - 2004-
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Office of the State Auditor of Missouri
Claire McCaskill

Report No. 2006-54

September 2006


The following findings were included in our audit report on the Department of Health and Senior Services' Monitoring of Nursing Homes and Handling of Complaint Investigations.

The Department of Health and Senior Services (DHSS) has only implemented 9 of 32 recommendations made in the two previous audits.  Some of the recommendations were included in both reports.  Significant cuts in surveyor positions contributed to some of the deficiencies noted.


The Section for Long-Term Care Regulation (SLCR) is responsible for conducting federal and state surveys/inspections on the nearly 1,160 licensed nursing homes and residential care facilities in the state.  During fiscal year 2005, the SLCR did not perform 72 (11 percent) and 400 (41 percent) of the full and interim state-mandated inspections, respectively, as required by state law.  58 of the facilities received neither a full nor an interim inspection in fiscal year 2005.  This situation represented a significant decline in the SLCR's compliance with its statutory inspection responsibilities compared to the 2003 audit.  In addition, some of these facilities have been cited repeatedly for the same deficiencies.  A review of 5 commonly cited deficiencies in 8 historically poor performing facilities disclosed 17 deficiencies were repeated at least once between fiscal year 2003 and 2005.  None of these facilities received an interim inspection in fiscal year 2005.


Certification and/or inspection packets were not always submitted to Central Office within the specified time frame.  In 20 of 88 files reviewed, the packets were submitted untimely. This condition was also noted in the prior two audit reports.


A review of 60 federal survey and state inspection files disclosed a 3 percent error rate in the proper classification of state deficiencies cited in inspections.  Also, during fiscal year 2005, the SLCR did not prepare performance evaluations of its survey employees as required by state law.  This condition was also noted in the 2003 audit report.


State surveyors tend to cite fewer deficiencies when federal inspectors are not present to monitor the federal survey process.  We determined that in those surveys in which federal inspectors accompanied the SLCR surveyors, 83 percent of the deficiencies cited by federal inspectors during the inspections were also cited by the state surveyors.  However, in those surveys where the federal inspectors conducted a separate inspection within two months of the state survey, only 15 to 20 percent of the deficiencies cited by the federal inspectors were also cited by state surveyors.


The SLCR is also  responsible for recording, investigating, and reporting the results of complaints made related to nursing facilities.  We identified the following concerns regarding SLCR's handling of such complaints:





The SLCR has no minimum staffing standard in place for nursing home facilities and does not track actual staff hours at those facilities.  We noted that of the eight states contiguous to Missouri, five of those states (Arkansas, Illinois, Kansas, Oklahoma, and Tennessee) have some sort of minimum nursing care staffing requirements in place.  Because Missouri has no minimum staffing standards, the SLCR cannot compare actual direct care staffing information to the level of staffing needed to prevent understaffing and negative resident outcomes.  This condition was also noted in the two previous audit reports.


As of October 2005, 224 of the state's licensed nursing facilities had an Alzheimer special care unit or program.  State law requires that any such facility disclose to the DHSS the form of care or treatment provided that distinguishes that unit or program as being especially applicable, or suitable, for persons with Alzheimer's disease or dementia.   This law also states that as part of the long-term care facility's regular license renewal procedure, the DHSS shall examine the disclosure form and verify the accuracy of the information disclosed.  It is not apparent that adequate actions are taken by the department, either during the licensing process or the inspection process, to verify the information on the disclosure form is accurate or that the nursing facility has followed the practices outlined in the form. 


The SLCR's Quality Assurance Unit (QAU) was established in 2001 to review a sample of completed inspections and complaint investigations to ensure those inspections/investigations were conducted efficiently, consistently, and in accordance with applicable standards and regulations.  As noted in the 2003 audit report, the QAU has not spent a significant amount of time performing this quality control function because QAU staff have been assigned other duties within the SLCR.  Since the last audit, the QAU has not performed any quality control reviews of any completed inspections and only a few reviews of complaint investigations. 


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Missouri State Auditor's Office