South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

The Government Accountability Office issued a new report titled Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment.  Not surprisingly South Carolina is one of the worst offenders.  Reducing understatement is critical to protecting the health and safety of vulnerable nursing home residents and ensuring the credibility of the survey process. Federal and state efforts will require a sustained, long-term commitment because understatement arises from weaknesses in several interrelated areas—including CMS’s survey process, surveyor workforce and training, supervisory review processes, and state agency practices and external pressure.

The conclusions reached include as follows:
Concerns about CMS’s Survey Process. Survey methodology and guidance are integral to reliable and consistent state nursing home surveys, and we found that weaknesses in these areas were linked to understatement by both surveyors and state agency directors. Both groups reported struggling to interpret existing guidance, and differences in interpretation were linked to understatement, especially in determining what constitutes actual harm. Surveyors noted that the current survey guidance was too lengthy, complex, and subjective. Additionally, they had fewer concerns about care areas for which CMS has issued revised interpretive protocols.

Ongoing Workforce and Surveyor Training Challenges. Workforce shortages in state survey agencies increase the need for high-quality initial and ongoing training for surveyors. Currently, high vacancy rates can place pressure on state surveyors to complete surveys under difficult circumstances, including compressed time frames, inadequately staffed survey teams, and too many inexperienced surveyors. States are responsible for hiring and retaining surveyors and have grappled with pervasive and intractable workforce shortages. State agency directors struggling with these workforce issues reported the need for more readily accessible training for both their new and experienced surveyors that did not involve travel to a central location. Nearly 30 percent of surveyors in high-understatement states stated that initial surveyor training, which is primarily a state activity that incorporates two CMS on-line computer courses and a 1-week federal basic training course culminating in the SMQT, was not adequate to identify deficiencies and cite them at the appropriate scope and severity level. State agency directors reported that workforce shortages also impede states’ ability to provide ongoing training opportunities for experienced staff and that additional CMS online training and electronic training media would help states maintain an experienced, well-informed workforce.

Supervisory Review Limitations. Currently, CMS provides little guidance on how states should structure supervisory review processes, leaving the scope of this important quality-assurance tool exclusively to the states and resulting in considerable variation throughout the nation in how these processes are structured. We believe that state quality assurance processes are a more effective preventive measure against understatement because they have the potential to be more immediate and cover more surveys than the limited number of federal comparative surveys conducted in each state. However, compared to reviews of serious deficiencies, states conducted relatively fewer reviews of deficiencies at the D through F level, those that were most frequently understated throughout the nation, to assess whether or not such deficiencies were cited at too low a scope and severity level.  In addition, we found that frequent changes to survey results made during supervisory review were symptomatic of workforce shortages and survey methodology weaknesses.

State Agency Practices and External Pressure.  In a few states, noncitation practices, challenging relationships with the industry or legislators, or unbalanced IDR processes—those that surveyors regard as favoring nursing home operators over resident welfare—may have had a negative effect on survey quality and resulted in the citation of fewer nursing home deficiencies than was warranted.  In one state, both the state agency director and over 40 percent of surveyors acknowledged the existence of a noncitation practice such as allowing a home to correct a deficiency without receiving a citation.  Forty percent of surveyors in four other states also responded on our questionnaire that noncitation practices existed.   Twelve state agency directors reported on our questionnaire experiencing some kind of external pressure. For example, in one state a legislator attended a survey and questioned surveyors as to whether state agency executives were coercing them to find deficiencies. Under such circumstances, it is difficult to know if the affected surveyors are consistently enforcing federal standards and reporting all deficiencies at the appropriate scope and severity levels. States’ differing experiences regarding the enforcement of federal standards and collaboration with their CMS regional offices in the face of significant external pressure also may confuse or undermine a thorough and independent survey process. If surveyors believe that CMS does not fully or consistently support the enforcement of federal standards, these surveyors may choose to avoid citing deficiencies that they perceive may trigger a reaction from external stakeholders. In addition, deficiency determinations may be influenced when IDR processes are perceived to favor nursing home operators over resident welfare.

Recommended Action includes:

Make sure that action is taken to address concerns identified with the new QIS methodology, such as ensuring that it accurately identifies potential quality problems; and clarify and revise existing CMS written guidance to make it more concise, simplify its application in the field, and reduce confusion, particularly on the definition of actual harm.

To address surveyor workforce shortages and insufficient training, we recommend that the Administrator of CMS take the following two actions: (1)  consider establishing a pool of additional national surveyors that could augment state survey teams or identify other approaches to help states experiencing workforce shortages; and (2) evaluate the current training programs and division of responsibility between federal and state components to determine the most cost-effective approach to: (1) providing initial surveyor training to new surveyors, and (2) supporting the continuing education of experienced surveyors.

To address inconsistencies in state supervisory reviews, we recommend that the Administrator of CMS take the following action:
Set an expectation through guidance that states have a supervisory review program as a part of their quality-assurance processes that includes routine reviews of deficiencies at the level of potential for more than minimal harm (D-F) and that provides feedback to surveyors regarding changes made to citations.

To address state agency practices and external pressure that may compromise survey accuracy, we recommend that the Administrator of CMS take the following two actions: (1)  reestablish expectations through guidance to state survey agencies that noncitation practices—official or unofficial—are inappropriate, and systematically monitor trends in states’ citations; and (2) establish expectations through guidance to state survey agencies to communicate and collaborate with their CMS regional offices when they experience significant pressure from legislators or the nursing home industry that may affect the survey process or surveyors’ perceptions

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The AP had an article about the federal program that identifies problem nursing homes.  The program brings extra scrutiny to poorly performing nursing homes but leaves out hundreds of troubled facilities, investigators report.  The Centers for Medicare and Medicaid Services identifies up to 136 nursing homes as "special focus facilities" subject to more frequent inspections because of their living conditions. In every state except for Alaska, there are between one and six such facilities. But investigators said four times as many homes, or 580, should be considered among the nation's worst.

Sen. Herb Kohl, the chairman of the Senate Aging Committee, said it indicated to him that the special focus is too limited. At the least, he wants more explicit warnings about nursing homes as people study quality ratings on a Medicare Web site, Nursing Home Compare — http://www.medicare.gov/nhcompare

The report being released Monday also suggests adjusting the methods used to identify the worst performing nursing homes. The home now under special attention are the worst performing in their state. But not all states are created equal when it comes to nursing home quality. Comparing the homes nationally would ensure that scarce resources go to inspecting the nursing homes that truly need the most attention.

Some states have far more poorly performing nursing homes than are designated as special focus facilities.   Investigators also found that the worst-performing ones tend to be for-profit facilities affiliated with a chain of nursing homes. They are more likely to be a larger facility, averaging 102 residents, while other nursing homes not identified as among the worst had 89 residents on average.

Nationally, there are about 16,000 nursing homes. So the 580 homes that GAO describes as the worst-performing represents almost 4 percent of the nation's nursing homes.

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GAO released a Study of CMS's Special Focus Facility Program.

What GAO Found:

According to the Government Accountability Office, almost 4 percent (580) of the 16,000 nursing homes in the United States could be considered "the most poorly performing" under CMS's Special Focus Facility program. States currently identify some 755 nursing homes (the 15 worst in each state) as "candidates" for the program, and 136 are actually designated as SFFs. Under GAO's methodology, the report says, the most poorly performing homes are distributed unevenly across states, with 8 states having no homes that actually qualify and 10 others having from 21 to 52.

The most poorly performing homes tended to be chain-affiliated and for-profit and have more beds and residents.

CMS has structured the SFF Program so that every state (except Alaska) has at least one SFF, even though the worst performing homes in each state are not necessarily the worst performing homes in the nation, according to the GAO. To identify the worst homes in the nation, GAO applied CMS's SFF methodology on a nationwide basis and made refinements to the methodology that "strengthened" GAO's estimate.

GAO found that the most poorly performing nursing homes had notably more deficiencies with the potential for more than minimal harm or higher and more revisits than all other nursing homes. For example, the most poorly performing nursing homes averaged about 56 such deficiencies and 2 revisits, compared to about 20 such deficiencies and less than 1 revisit for all other homes.

CMS established the Special Focus Facility Program in 1998. The SFF methodology assigns points to deficiencies cited during standard surveys and complaint investigations, and to revisits conducted to ensure that deficiencies have been corrected. CMS uses its methodology to identify candidates for the program--nursing homes with the 15 worst scores in each state--but the program is limited to 136 homes at a time because of resource constraints.

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A recent Cornell University study reports aggression is commonplace in nursing homes--between residents themselves and between residents and employees of the nursing home.  Verbal and physical abuse is more common than the industry acknowledges. In an online report with McKnight’s Long Term Care News, the study documents many observations made at a city-based nursing home which found at least 35 different types of abuse, with screaming being the most popular. Physical violence included pushing, punching, and fighting.

The report also referenced another two-week study wherein researchers found that 2.4 percent of nursing home residents have been victims of physical aggression; 7.3 percent claimed they were verbally abused. A third report discussed an investigation in which 12 nurse observers found 30 incidents of aggression between residents in one eight-hour shift. Victims were most commonly male and often had “wandering cognitive processing problems.”

A report released earlier this year by the Congressional Government Accountability Office (GAO) revealed a widespread “understatement of deficiencies,” that included malnutrition, severe bedsores, overuse of prescription medications, and nursing home resident abuse in the nation’s nursing home inspection reports. The report stated that nursing home inspectors routinely ignore or minimize problems that pose serious, immediate patient threats.

Facilities are generally only inspected once a year by overworked and underpaid state employees. Federal officials sometimes attempt to validate state inspector work by joining them on visits or conducting follow-ups. It was in a follow-up that the GAO discovered the state missed at least one serious deficiency in 15 percent of all inspections. Worse, in nine states, inspectors missed serious problems in over 25 percent from 2002 to 2007.

There are 16,400 nursing homes with over 1.5 million residents nationwide; approximately one-fifth of the homes were cited for serious deficiencies last year. “Poor quality of care—worsening pressure sores or untreated weight loss—in a small, but unacceptably high number of nursing homes, continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury,” the report said. Taxpayers spend about $72.5 billion annually to subsidize nursing home care and facilities must meet federal standards to participate in Medicaid and Medicare, which covers over two-thirds of its residents, at a cost of over $75 billion annually.

Unfortunately, nursing home abuse tends to be underreported because individual homes do not take elder abuse seriously and residents fear embarrassment, injury, even incapacitation for speaking up.

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