By Chuck Bell, Charlene Harrington, and Trudy Lieberman (March 16, 2007)
E-mails: bellch@consumer.org; charlene.harrington@ucsf.edu; trudy.lieberman@joumalism.cuny.edu
In some ways, nursing homes are the easiest of health service providers to cover. There is much useful information available in federal and state data bases, and pleadings in the numerous lawsuits filed against nursing homes alleging abuse and mistreatment provide rich detail about life inside a nursing facility. Furthermore, it is easy to observe care yourself by visiting nursing homes at different times of the day-following the advice you would give any family. Although the nursing home industry is not as sophisticated as other health providers in branding their facilities or in pushing their services, they are very powerful players in state government. State legislators have been known to take the side of particular facilities to help blunt negative publicity. So any investigation should also examine the industry influence in your state.
| Regulatory agencies | Other sources |
What It Does: In every state, the health department and its division of licensing and certification inspect all nursing homes in the state, whether or not they accept Medicare and Medicaid funding. Although most nursing homes accept federal money, the states do the inspections on behalf of the federal government which results in a bifurcated regulatory structure. States inspect each facility every 12 to 15 months, but they also investigate complaints. So if there are complaints, the state may visit the facility more often. The inspection report is called Form 2567, and it often graphically details the kind of care or lack of care inspectors have found. Nursing facilities then file a plan of correction which explains how and when they plan to correct the deficiencies inspectors have found. In addition to the federal regulations, states may issue deficiencies for violations of state regulations. Almost every state can levy civil money penalties (fines) and other penalties against facilities for federal violations and 39 states may issue fines for state violations. If the civil money penalties are for federal violations, CMS makes the final decisions about the penalties. Sometimes states do one of the other or both.
Where To Find CMS Form 2567: The state health department keeps these records, and you will want to examine them in detail. But it may be hard to get them from the agency. Only five states currently make the Form 2567 available online: Five states currently make the Form 2567 available online: Alabama, Colorado, Iowa, Minnesota, and New Mexico. (For more information, see “Where to Find state information on Nursing Home Performance,” below, and the web addresses on the attached handout.)
Federal law also requires that each nursing home prominently display the Form 2567, and often it’s best to go to the nursing home and ask to see the document. By law, it must be “readily accessible” to residents and visitors. You will typically find the document near the front desk in the lobby, often in a binder labeled “state survey.” If you can’t find it, or the facility is reluctant to give it to you, that’s a bad sign, and your reportorial antennae should go up immediately. Many state licensing and certification programs have websites that show deficiencies issued to facilities for failure to make the form available.
A lengthy inspection report usually reveals numerous problems at a facility. When reviewing the Form 2567, look carefully at such factors as the following:
- RESIDENT ASSESSMENTS: Nursing homes are required to assess each newly arrived resident’s physical, social, emotional, and mental condition. Under federal law, they must devise a comprehensive care plan within seven days after completing the assessment. Unfortunately, that is often not done. In the three most recent state surveys that Consumer Reports analyzed for all nursing homes in the country, 6,012 homes received at least one citation for not developing appropriate care plans. On the Form 2567 you may find evidence that care plans are not being developed. If you place a relative in a facility that fails to write care plans or doesn’t revise them as a resident’s condition changes, that’s a bad sign. It’s an indication that you will have to ask about care plans and monitor the situation to be sure the facility’s staff members follow the plan. Often they don’t.
- QUALITY OF CARE: If nursing home residents are not properly cared for, serious injury or death can be the result. The Form 2567 often describes serious lapses in providing good care. Look for indications of problems such as doctors’ orders that were not followed, laboratory tests that were not done, soiled linens that were not changed, and so forth. In this section of the report, you might find evidence of medication errors, which are common at nursing homes. In the Consumer Reports’ survey analysis, 1,836 facilities received at least one citation for medication errors. Sometimes they are described in a separate section.
- DIETARY SERVICES: While food service might seem to be a minor issue, it is not. Food is important to nursing home residents, and most residents look forward to mealtimes. It’s not uncommon for facilities to skimp on snacks, which residents also enjoy. If you find that a facility you are considering is not providing snacks, that could mean a general lack of concern for the residents’ little pleasures in life. Also look for evidence of unsanitary food practices that can breed infections.
- PHARMACY SERVICES: If the survey notes problems, such as improperly labeling or storing pharmaceuticals or using expired medications, that could mean the facility is lax in monitoring the medications it gives to residents.
- INFECTION CONTROL: Infections, particularly those of the urinary tract, are common among nursing home residents. If the report describes residents who have developed urinary tract infections, you should ask more questions of the facility’s administrator. Why did they get them? Were residents allowed to lie in their own wastes too long? How many residents needed to go to the hospital for treatment resulting from such an infection? Also see if the survey indicates whether residents have been denied flu shots or the pneumococcal vaccine, sometimes called Pneumovax. All residents should be receiving these inoculations. Note whether residents have been screened for tuberculosis, which is highly contagious among people living in close quarters. If residents have not been screened for TB or have not been offered a pneumonia vaccination within the last five years, as required by law, that again may indicate lazy care.
- QUALITY OF LIFE: The Form 2567 may provide clues as to whether the home is providing activities or otherwise helping residents enjoy a better quality of life. Here little things matter, such as not giving residents a cup of coffee when they ask for one or making them go to bed early when they prefer to stay up late.
- SOCIAL SERVICES: The federal nursing home reform law passed in 1987 requires that homes provide medically related social services to help each resident “attain or maintain the highest practicable physical, mental, and psychosocial well-being.” Many times nursing homes don’t do that. On the state survey, you might find that a facility has not provided dental care, a growing problem in nursing homes. Or you might learn that residents were not given assistance with eating or other activities of daily living.
- ENVIRONMENT: Look for examples of mops and brooms left around or of other obstacles that could cause falls. That indicates carelessness on the part of the facility. Also look for lapses in routine maintenance, such as dirt, broken plumbing, peeling paint, laundry strewn about, or a strong odor of urine. The state of a nursing home’s housekeeping says a lot about the facility.
- COMPLAINT SURVEYS: As you examine the Form 2567 for the nursing home, look specifically for complaint surveys, which are reports generated by the state based on a complaint, typically made by a resident or a resident’s relative. If a complaint surveyor several surveys were completed after the date of the regular inspection, check to see what triggered the complaint. If the complaint involves a problem similar to one detailed in the previous regular inspection, that may mean the facility has not cleaned up its act or has failed to follow the plan of correction described in the regular inspection survey. That is a bad sign and should make you think twice before placing a family member there.
- PLANS OF CORRECTION: The Form 2567 notes how the facility says it plans to correct each deficiency that inspectors have listed. If you find that the same problem persists, consider it a warning that the nursing home may not have not been serious about addressing the problem.
Bottom Line: The Form 2567 is one of the best consumer information and reporting tools around. If your state is serious about enforcement, you are likely to find lots of problems detailed. You will also want to note whether complaint surveys, which are part of the record, indicate issues that inspectors have previously cited. You may also want to match up plans of correction to see if problems are indeed solved. Also be aware that a state survey with no deficiencies does not necessarily mean that the nursing home is wonderful. It could mean that the inspectors aren’t looking very hard. In that case, you may have a very different story.
Where to Find State Information on Nursing Home Performance: Many states have their own way of rating nursing home quality, and you’ll find the URL’s to the state’s quality care information in this guide to State Website Information About Nursing Homes. The guide was compiled by Professors Charlene Harrington, Ph.D., and Prof. Theo Tsoukalas, Ph.D., in October 2005.
In addition, AARP published a useful guide to state sources of nursing home performance data in October 2005. This information may not be current, but it’s also a good place to check for links to state web sites.
If your state has online information on nursing home performance, you might look there, but keep in mind, any state rating scheme is likely to be a compromise with the industry. State regulators often solicit guidance from the industry in putting together their evaluation metrics. It’s a good bet the evaluation is designed to put the nursing facilities in the best light possible.
Where To Find State Penalty Information: The states are the best sources for this data although be forewarned: most states do not have it readily accessible. Check this guide for Web sites and background information. If you can’t find it online, your next step is to contact the State Survey Agency – the Department or Division of Licensure and Certification. Contact information for all state survey agencies.
Often the names and contact information change, but this is a good place to start. Keep in mind that requesting this data can cost money – for copies and research time.
Where to Find Your State Licensing and Certification agency: Another online source to find your state licensing agency is the Association of State Health Facility Agencies, a professional association made up of the state licensing and certification agencies in all 50 states, the District of Columbia and Puerto Rico. You can generally find up-to-date contact information and links to web sites for the agency in your state at: http://www.ahfsa.org
2. The Centers for Medicare and Medicaid Services (CMS)
A. OSCAR DATABASE
The Online Survey, Certification, and Reporting (OSCAR) data base includes data for all certified nursing homes in the U.S. The data are collected in three separate sets of files: (1) provider information, which include facility characteristics and staffing data; (2) health survey file (with facility-level summary information regarding resident characteristics); and the (3) survey deficiencies. OSCAR is an on-line data system from the Health Care Financing Administration (HCF A). The OSCAR data for this report included the most recent surveys for all facilities for the period of 1997-2003. These data were available on several sets of tapes.
The results of the state inspections are entered into the OSCAR data base at CMS. There are over 185 deficiencies that homes can be cited, called F-tags. For example, F-tag 253 says the facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. And F-tag 514 says the facility must maintain clinical records on each residence. Each deficiency carries a scope and severity code designated by the letters A through L. Citations labeled G through L indicate actual harm or the potential for death. Codes I through L denote that the harm was widespread affecting many people. (There are also other violations for fire and life safety codes, called K tags). For information on the deficiencies, you can look up individual facilities at www.Medicare.gov/NHCompare/ You can also download the entire OSCAR database at: http://www.medicare.gov/download/downloadDB.asp
Be aware, however, that as a consumer information tool, the online version of Nursing Home Compare has many shortcomings and is not particularly easy to use. For details see, Consumer Reports, “Why the Fed’s Web Site Falls Short,” September 2006, available online at www.ConsumerReports.org/nursinghomes
SHORTCOMINGS: Inspectors are writing fewer deficiencies with codes noting actual harm. In fact, most are being written with lower codes. Some advocates believe this is cause for concern. The federal government has used OSCAR data to construct its Nursing Home Compare web site. Also the reports on deficiencies are frequently delayed or held until they have been reviewed by states.
B. FACILITY CHARACTERISTICS
The information on the nursing homes’ characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.
For information on the facility characteristics, you can look up individual facilities at www.Medicare.gov/NHCompare/
SHORTCOMINGS: These data are not audited so they are not always completely accurate.
C. MINIMUM DATA SET REPOSITORY (MDS)
These data are supposed to provide a window into the care that is actually delivered. Nursing homes are supposed to do an assessment of each resident upon entering the facility and report the results to CMS. The MDS indicates such quality metrics as the number of residents who were not at risk for becoming incontinent but later became incontinent and those whose needs for help with activities of daily living has increased. These data are expressed as a percentage for each facility. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident. Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.
The data are used to construct the Quality Measures which are such information as: pressure sores, incontinence, pain, depression, restraints, and others. These data are available for each facility on the federal website at www.Medicare.gov/NHCompare/
SHORTCOMINGS: All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. This information changes frequently as residents are discharged and admitted, or resident conditions change. Studies have found many inaccuracies in the data. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman’s office. the State Survey Agency, or other sources.
D. COST REPORTS
Medicare requires nursing facilities to submit cost report data to CMS each year. These reports provide detail information on Medicare revenues, expenditures, and operating margins. They would be available from CMS upon request. States require facilities to file Medicaid cost reports which are used for rate setting and monitoring facilities. Some of these reports are available through state Medicaid agencies.
A few states like California have combined cost reports for all payers. These reports have detailed information on revenues, expenditures, operating margins, staffing levels, wages and benefits, and staff turnover levels.
E. STAFFING LEVELS
Nursing homes are required to report on the number of staff that they had during a two week period prior to the annual survey. These data are entered into the Online Survey, Certification, and Reporting (OSCAR) data base.
Nursing personnel included: registered nurses (RNs); licensed practical/ vocational
nurses (LPN/LVNs), and nursing aides/orderlies/assistants (NAs). Staffing hours (including full-time, part-time, and contract staff) are reported by facilities as total hours worked in a fourteen-day period. Nursing personnel hours are examined for each of the above three categories separately, for all licensed nursing personnel (RNs and LPN/LVNs combined), and for total nursing personnel (RNs, LPN/LVNs, and NAs). The staff time includes all administrative and direct care time.
To compute the staffing ratios for this report, the total number of staffing payroll hours reported in a two-week period was divided by the total number of residents and by the 14 days in the reporting period.
Nursing facilities are required by regulation to meet minimum nursing standards. Facilities must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents. Facilities must also provide sufficient numbers of licensed nursing personnel to provide care on a 24 hour basis to all residents in accordance with resident care plans. Facilities must also use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, except when they have been given a waiver. A Medicare-only skilled nursing facility may have a waiver if it is located in a rural area and has one registered nurse who is on duty 40 hours a week. Waivers may also be granted under certain conditions where there is a shortage of appropriate personnel and where the health and safety of individuals is not jeopardized.
SHORTCOMINGS: Staffing varies by the types of nursing facilities – dually certified facilities (Title 18/19), for Medicare-only facilities (Title 18), and for Medicaid- only facilities (Title 19). It should be noted that the reported staffing ratios reflect reported hours per resident day and not the actual hours of care delivered directly to residents. Staffing data are not audited.
Studies have shown that staffing data are better indicators of quality than the quality measures from the Minimum Data Set.
F. FEDERAL CIVIL MONETARY PENALTIES
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87), which contained provisions for improving enforcement and care in the nation’s nursing homes, also provided for a system of federal civil monetary penalties also known as CMPs. Unfortunately, according to GAO, CMS doesn’t collect these fines consistently, and representatives of CMS have indicated that their data collection about fines levied is imperfect and imprecise.
INFORMATION FROM OTHER SOURCES
SOURCE: Consumer Reports Nursing Home Quality Monitor
In September, 2006, ConsumerReports.org published on online package of stories entitled Profits vs. Patients: CR Investigates Nursing Homes.
To prepare the report, CR analyzed the three most recent state inspection reports for some 16,000 nursing homes across the U.S. The investigation also examined staffing levels and so-called quality indicators, such as how many residents develop pressure sores when they have no risk factors for them.
Using this data, CR created a “Nursing Home Quality Monitor,” which is available online as a clickable state map. The Nursing Home Quality Monitor is a database of homes to consider-and homes to avoid-in each state. The monitor also indicates if a home is for-profit, non-profit, or government-owned, and whether it’s part of a chain or independently owned. These are key facts to know, as the Consumer Reports analysis found that nonprofit homes are more likely to provide good care than for-profits. Researchers also learned that independently run homes are more likely to provide good care than chains.
In the lead piece, “Business as Usual,” CR found that the state agencies responsible for overseeing nursing home care have often failed to correct problems. Many states are lax in penalizing bad homes. Only 50 percent of the facilities in our sample that could have received a state fine actually did.
The article also found that eight of the 12 five-time repeaters on CR’s list of poorly performing homes had not received state fines between 1999 and 2004. The others received minimal penalties.
The online package also included sidebars on “Why the Feds’ Web Site Falls Short,” “Why Suing a Nursing Home is Getting More Difficult,” “CMS Form 2567: How to Read This Important Government Form, and “How You Can Find Good Nursing Home Care.”
SOURCE: State by State Data on Nursing Homes
A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for the 1999 through 2005. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S. Centers for Medicare and Medicaid.
Harrington, c., Carrillo, H., & LaCava, C. (2006). Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1998 through 2005. University of California, San Francisco.
SOURCE: Joint Commission on Accreditation of Healthcare Organizations
The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations, is a private accrediting body that evaluates health care organizations. It is best known for its accreditation of hospitals. It has encountered criticism for being too soft on the industry. Only about five percent of the nation’s 16,000 nursing homes have been accredited by JACHO. Sometimes when you visit a nursing home, you’ll see a certificate on the wall indicating the facility is JCAHO accredited. You might even see that certificate instead of the Form 2567 which the facility is supposed to post. If you do, that’s a warning sign.
This is a private organization that makes money rating health care organizations. Sometimes these health care providers pay HealthGrades to use their ratings in promotional materials. This raises questions about the objectivity of the information. Families must also pay for reports. The information provided is taken from the OSCAR data and is presented with the same shortcomings of Nursing Home Compare. HealthGrade’s summaries of the state inspection reports hides the graphic details that tell you what is really going on in the facility.
SOURCE: CONSUMER ORGANIZATIONS
The National Citizen’s Coalition for Nursing Home Reform is a national coalition made up of over 200 member organizations and individuals from 42 states. Member groups include local citizen action groups, state and local long-term care ombudsmen, legal services programs, religious organizations, professional groups, nursing home employees’ unions, concerned providers, national organizations, and family and resident councils. Phone: 202-332-2275
NCCNHR maintains a good list of citizen action groups in the states, available from their Web site.
State-based advocacy organizations that focus on nursing home quality and affordability issues include:
California Advocates for Nursing Home Reform
650 Harrison Street, 2nd Floor
San Francisco, CA 94107-1311
Contact: Patricia McGinnis
ph: (415) 974-5171
fax: (415) 777-2904
e-mail: PatM@canhr.org website: http://www.canhr.org
Long Term Care Community Coalition
242 West 30th Street, Suite 306
New York, NY 10001
Contact: Richard Mollot
ph: (212) 385-0355
fax: (212) 239-2801
e-mail: richard@ltccc.org website: www.ltccc.org/
Friends and Relatives of the Institutionalized Aged (FRIA)
18 John Street, Suite 905
New York, NY 10038
Contact: Amy Paul
ph: (212) 732-5667
fax: (212) 732-6945
e-mail: apaul@fiia.org
website: www.fria.org/fria/
SOURCE: California Nursing Home Search
The California HealthCare Foundation and the University of California San Francisco have created a tree website on long term care services in California that is designed for consumers, caregivers, providers, discharge planners, and advocates. This site provides comprehensive information about the quality of long term care in the state including nursing and intermediate care facilities, home health, hospice, adult day health and other long term care services such as residential care. The site has information on Nursing Home Alternatives, How to Select a Service, Questions to ask when visiting potential choices, Resident and Family Rights, and Links.
This site does not address intermediate care facilities for the developmentally disabled, senior living communities, or retirement homes but it has extensive resources to guide in finding services.
Web: www.calqualitycare.org/learn/nursing-homes
SOURCE: Campaign Contributions Databases
Federal: The Center for Responsive Politics Open Secrets database tracks political contributions and lobbying at the national level.
Web: www.opensecrets.org
States: The nonpartisan National Institute on Money in State Politics tracks contributions in all 50 states and makes this data easily searchable online.
American Association of Homes and Services for the Aging – National association that represents nonprofit organizations providing long-term care services, including nursing homes.
Web: www.aahsa.org Phone (202) 783-2242
