Debunking Nursing Home Myths about Quality of Care and Enforcement of Federal Care Standards

As policymakers in Washington, DC and beyond continue a national discussion about the state of long-term care in the United States, a critical component of the discussion is the quality of care provided in nursing homes across the country.

The nursing home industry argues that nursing home quality is improving, pointing to higher ratings on the Centers for Medicare & Medicaid Services' (CMS') Five-Star Quality Rating System.[1]  The industry also argues that the enforcement system is punitive and unfair.[2]  Both arguments are myths, dispelled by an analysis of data on CMS's nursing home website Nursing Home Compare.  In fact, as the Center's analysis of the lowest tier facilities in three states demonstrates, nursing home star ratings are going up only because nursing homes self-report that they are doing a good job in the quality measures and, often, the lowest tier facilities face trivial or no federal sanctions when they violate federal standards of care. 

Nursing Home Compare

Since the Clinton Administration, the federal government has maintained a website called Nursing Home Compare[3] to provide information to the public about nursing facilities that participate in the Medicare and Medicaid programs.  Over the years, the type and amount of information have increased significantly.  CMS uses the website to post information reflecting state survey results and, as reported by the facilities themselves, staffing levels and quality measures (QMs).  The website also reports federal sanctions that CMS imposes against facilities that are cited with deficiencies for violating federal standards of care.  Sanctions imposed under state licensing laws are not included in Nursing Home Compare.

Since 2008, CMS has rated facilities separately on each of three domains – health inspections, staffing, and quality measures – and on an overall or composite measure that combines the three individual measures.  In calculating the overall measure, CMS begins with the survey measure, which it may increase or decrease by one star in either direction, based on very high or very low star ratings in staffing or QMs, or both. 

Health Inspections

Nursing facilities that participate in the Medicare or Medicaid programs, or both, have an unannounced survey each year.  Surveys are conducted by state survey agencies, usually located in the state department of health, using a survey protocol that has been developed, tested, and validated by the federal government.[4]  Although the Government Accountability Office (GAO) has issued many reports over the past 15 years describing the enforcement system as underciting deficiencies and undercoding the significance (scope and severity) of deficiencies it identifies,[5] the publicly-conducted survey is the only objective, independent evaluation of the quality of care provided by nursing facilities.

The health inspection domain in the Five Star Quality Rating System is based on the results of annual and complaint surveys conducted over a three-year period, with more recent data weighted more heavily.[6]   The top 10% of facilities in a state receive five stars; the bottom 20%, one star; and the middle 70%, two, three, or four stars (23.33% each).  One star, the lowest score, is defined as "much below average," and five stars, the highest score, defined as "much above average."    

Quality Measures

On Nursing Home Compare, CMS publicly reports 18 different quality measures, which are derived from resident assessments that facilities conduct themselves, and electronically submit to CMS.  However, only nine of the measures are included in the rating system for the QM domain.[7] 

CMS assigns stars in quality measures, using resident assessment information that facilities report to CMS, although CMS does not "formally check" the assessment information "to ensure accuracy" for purposes of this measure.[8]  CMS's rating system for QMs is extremely complex: three of the nine measures (catheter, the long-stay pain measure, and short-stay pressure ulcers) are risk-adjusted; eight measures use national data (only one measure, activities of daily living for long-stay residents, uses state-level data); CMS has rules and imputation rules for missing data; and CMS assigns point thresholds for each star category.[9]  Half of the 18 measures are not used at all in calculating the publicly-reported QMs.

The accuracy of QM information is a matter of concern to CMS, which last month directed facilities to complete and submit by September 30, 2013 updated information on missing discharge assessments.  Federal regulations require these assessments to be completed within 14 days of a resident's discharge and to be reported to CMS within 14 days of their completion.  In its August 2013 guidance, CMS set out different rules for updating discharge data for residents discharged before and after October 2012.  CMS is concerned that facilities' late submission or non-submission of data on discharges is affecting "QM data integrity."[10]

The Center's Analysis

The Center selected three geographically diverse states – Georgia, Illinois, and Oregon – and identified the facilities in each state receiving an overall or composite score of one star (i.e. the bottom 20% of facilities by inspection).  Georgia identified 57 one-star facilities out of 357 facilities (16%); Illinois, 93 one-star facilities out of 773 facilities (12%); and Oregon, five one-star facilities out of 138 facilities (4.0%).    

As noted, these facilities all received one star based on inspections.

We then examined the self-reported QM ratings posted for each of the facilities, and the federal enforcement actions imposed against the facilities in the prior three years.  Note that researchers who are skeptical about the validity and value of rating all facilities report that the lowest-ratings are likely to be the most accurate ratings.[11]

The Center found that the one-star facilities in all three states had comparatively high star ratings on their QMs (often, three and four stars) and that, generally, only minimal or no sanctions were imposed against them in the prior three years.

Our Findings on Quality Measures

The three states report assessment information leading to higher QM data.  In Georgia, 29 of the 57 one-star facilities (51%) report assessments that lead to a four-star QM rating and 38 of the 57 one-star facilities (67%) report assessments leading to a three- or four-star rating.  In Illinois, 33 of the 93 one-star facilities (35%) report assessments that lead to a four-star QM rating and 61 of the 93 one-star facilities (66%) report assessments leading to a three- or four-star QM rating.

Our Findings on Enforcement

Federal law authorizes a range of intermediate sanctions that may, or in some instances, must be imposed against facilities that are cited with deficiencies.[12]  In practice, however, financial penalties (called civil money penalties, or CMPs) are often not imposed or are imposed at extremely low levels.  Denials of payment for new admissions (DPNAs) are also rarely imposed.  Nursing Home Compare reports the CMPs and DPNAs imposed against facilities in the prior three years.

Georgia did not impose either a CMP or a DPNA against 33 of the 57 one-star facilities (58%). Illinois did not impose either a CMP or a DPNA against 30 of the 93 one-star facilities (32%).

Oregon imposed CMPs, but no DPNAs, against any of the one-star facilities in the prior three years.

States usually imposed very low CMPs over the three-year period. 

Georgia imposed federal CMPs against 25 one-star facilities out of 57 facilities (44%), but the CMPs totaled less than $20,000 in 15 of the 25 facilities (60%).  Georgia imposed CMPs exceeding $200,000 against four one-star facilities, including CMPs totaling $357,490 against one facility.

Illinois imposed federal CMPs against 61 of the 93 one-star facilities (66%).  However, CMPs totaling less than $10,000 in the prior three years were imposed against 23 facilities (25%) and only four facilities (4%) had CMPs exceeding $40,000.   The highest penalty imposed against an Illinois facility was $74,628.

Oregon did not impose federal CMPs totaling $10,000 or more against any of the one-star facilities in the three-year period.

Conclusion

High QM ratings in one-star facilities do not indicate high quality of care when the ratings are based on resident assessments that CMS does not "formally check . . . to ensure accuracy" and advises the public to interpret "cautiously."[13]  The very limited financial sanctions imposed against the majority of the poorest quality facilities belie the notion that the federal enforcement system is punitive. The nursing home industry's arguments to the contrary are myths.