The report Trends in Nursing Home Deficiencies and Complaints recently released by the Office of the Inspector General (OIG) of the Department of Health & Human Services (DHHS) provides the following information:
- In each year from 2005 to 2007, more than 91 percent of nursing homes were cited for deficiencies.
- Seventeen percent of nursing homes surveyed in 2007 were cited for actual harm or immediate jeopardy deficiencies, and 3.6 percent were cited for substandard quality-of- care deficiencies – a slight increase since 2005.
- The number of substantiated complaints decreased nearly 3 percent since 2005.
In order to determine if this information is helpful/useful to the general public, it is important to consider:
- Factors that impact the overall conclusions; and
- The accuracy of the data used to reach each conclusion;
Factors that impact the overall conclusions
First and foremost, what conclusions can be drawn from the data provided in this report? The 91 percent of nursing homes that were cited for deficiencies includes homes that had just one deficiency, as well as homes that had multiple deficiencies. There is no distinction between facilities that had deficiencies that were at a severity level of no actual harm with potential for more than minimal harm as opposed to facilities that had actual harm or immediate jeopardy deficiencies. According to the report, the most common scope and severity ratings in 2007 were at the D and E levels, these are deficiencies that did not result in actual harm nor had the potential for more than minimal harm.
While the OIG reports that 91 percent of nursing homes surveyed were cited for deficiencies, it provides no commentary or analysis to help the public understand which deficiencies are very important or of less importance. The OIG reports on 16 categories of deficiencies and gives equal weight to all requirements. In other words, a dented can in the kitchen, which can result in a deficiency, has equal footing with improperly storing or serving food at unsafe temperatures.
Accuracy of the data
- Inconsistency of survey application and interpretation across the country
- A caveat put forth in the 2003 report by the OIG (and not refuted in the 2008 report) clearly reflects the Office’s concern about using survey results to assess the quality of care provided in nursing homes. The report published in March 2003 by the OIG of DHHS entitled Nursing Home Deficiency Trends and Survey and Certification Process Consistency states:
“Our review of the survey process reveals states differ in how they determine both the number and type of deficiencies. We identified four factors that contribute to this variability in citing deficiencies: (1) an inconsistent survey focus; (2) unclear guidelines; (3) the lack of a common review process for draft survey reports; and (4) high surveyor staff turnover (emphasis added). As a result, we conclude that nursing home survey results are not always consistent among states, therefore limiting the comparability of the data. Further, we cannot conclude whether trends in deficiencies are due to deteriorating care, variations in the survey process, and/or increased enforcement.”
- Earlier this year, in response to concerns raised by providers in states represented in Centers for Medicare & Medicaid Services (CMS) Regions IV (Alabama, Georgia, Florida, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and V (Michigan, Wisconsin, Ohio, Minnesota, Illinois, and Indiana), AHCA contracted with PointRight (formerly LTCQ) to complete an analysis of Immediate Jeopardy (IJ) deficiencies for both Standard Health Surveys and Complaint Surveys in these regions as compared to the rest of the country. PointRight also analyzed differences from state to state within each region. Following are key points resulting from this research:
All states in Region IV are above the national average for the median (the median number shows the “midpoint” – where ½ of the facilities had more IJ deficiencies and ½ had less) number of IJ deficiencies. The analysis becomes most interesting when individual states were analyzed, and clearly Tennessee and Kentucky are outliers.
- The proportion of facilities with IJ deficiencies in standard survey is higher than the national average.
- Those facilities with IJ deficiencies from standard survey have more IJs than the national average.
- The proportion of facilities with IJ deficiencies in compliant surveys is increasing.
- The median and minimum numbers of IJ deficiencies in complaint surveys are above the national average
- Since Quarter One of 2007, the median number of IJ standard deficiencies has increased from slightly over 5 to 13.
- Since Quarter One 2007, the proportion of facilities with IJ deficiencies from complaint surveys has almost doubled (from under 4% to over 6%).
The use of deficiencies resulting from complaint data is extremely problematic because states have different requirements for nursing homes to self-report incidents. Thus, a self-reported incident that the nursing home has addressed, corrected, and implemented processes to prevent or minimize the chance of such an incident recurring, frequently results in a deficiency. On Nursing Home Compare, CMS does not differentiate self-reported incidents resulting in a complaint investigation versus actual complaints by residents or families.
- Two different survey systems: results combined for one conclusion
CMS is now using two different survey systems – the standard survey and the Quality Indicator Survey (QIS). According to Dr. Andrew Kramer, with the University of Colorado and instrumental in the development of the QIS, in January of 2008, the following represents the number of citations that nursing homes had when surveyed with QIS:
- 4% facilities - deficiency free
- 25% facilities - 25 or more deficiencies
- average increase of 2 deficiencies
- 55% facilities – more deficiencies under QIS
- 35% facilities – fewer deficiencies
- 10% facilities – about the same
It is important to note that fifty-five percent of nursing homes had more deficiencies under the QIS than the standard survey and twenty-five percent of the nursing homes had 25 or more deficiencies. It is irresponsible to use QIS outcomes in the same way as the standard survey outcomes, when the methodology of the QIS leads to significantly more deficiencies for 25% of the nursing homes, at least during the first time it is used to survey a home.
- Apparently conflicting information
Despite the findings in the OIG report, there is a failure to acknowledge that nationwide, there is a positive trend in the quality measures posted on Nursing Home Compare with improvements in key areas for short-term and long stay patients in pain, restraints, and pressure ulcers.
- Pain for long term stay patients was improved from a rate of 10.7 percent in 2002 to 4.6 percent in 2007.
- Pain in short-term patients was reduced from 25.4 percent in 2002 to 20.7 percent in 2007.
- Use of physical restraints for long stay patients dropped from 9.7 percent in 2002 to 5.6 percent in 2007.
- For short-term patients, the pressure ulcer measure also improved – from 20.4 percent in 2002 to 17.5 percent in 2007.
Usefulness of information for the general public
The information contained in this report is not useful to the public. The data is based on a flawed survey system (see above) and as such does not provide adequate and useful information for the general public.