GAO examines whether nursing home quality is improving

In a new Government Accountability Report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight,” the GAO analyzed CMS quality data for nursing homes to see whether it has improved in the last decade in these facilities. As the report shows, it’s not really a simple yes or no answer, thanks to a myriad of changes made in the way CMS completes its oversight, the way different SAs and ROs conduct their work, and one of the biggest factors –  differences by state on how surveys are conducted.

Is Quality Improving?

While more states saw increases in consumer complaints in recent years, the number of actual harm deficiencies on surveys has shown a 41% decline over the 10-year period analyzed in this report, 2005-2014. The average number of hours of total nurse hours per day increased in almost every state, and the average RN hours per resident per day has increased across the nation over this time period. The eight quality measures that were reviewed showed that there were decreases in the number of reported quality issues in these categories, suggesting improvement in quality in these areas. So that’s all good, right? Nursing homes, using the data in this report, appear to be performing better over the past 10 years.

Well, the data isn’t as cut and dry as it appears. For its review of survey data, for instance, CMS looked at all 50 states plus Washington, D.C. for national trends, but limited their review of states to 5 – California, Florida, Massachusetts, Michigan and West Virginia. These states were selected based on a variety of factors, including standardized state performance scores. There are significant differences between the states related to survey and compliance.

When the GAO got to digging, it found many changes had been made to the way data is recorded and reported which may account for some of these statistical changes.

  • Complaints – SA officials that were interviewed potentially attributed the jump in consumer complaints to making it easier to submit complaints, such as via email. Others noted that they have updated the way complaints are put into CMS’ complaint tracking system for better monitoring.
  • Survey – There are still 2 survey types in use – the paper-based traditional survey and the electronic Quality Indicator Survey (QIS). According to the report, as of late 2014, 23 states were fully using QIS, 25 states were using traditional surveys still (the rollout was paused in 2012), and 3 states use both survey types. It’s no wonder that there will be variations from state to state in performance on survey, particularly when the QIS is known to account for less serious deficiencies in quality of care areas. Changing the survey type for some states versus others makes it hard to generalize whether the survey process itself has led the way for less serious deficiencies or if the facilities are performing that differently. What is CMS doing to try to sort all this out? Well for one thing, they are working on a “hybrid” version of the traditional and standard survey types that would be standardized across the country. At this point, HHS has not set a timeframe for development and implementation of this standardized survey, which will rely heavily on any current regulations as well as the newly proposed and accepted ones.
  • Staffing – As we all know, there has been uproar about “staffing up” ahead of survey, thanks to media outlets. The end result of the public outcry is the implementation of Payroll-Based Journal, which nursing homes will use to upload verifiable payroll/time and attendance data to show their staffing. This, in theory, is supposed to prevent nursing homes from fudging their hours, but as of August 2015, the GAO notes that CMS still did not have a plan for auditing the new system. This means that for the near-term, data may still not be as accurate as it can be.
  • Quality Measures – The lack of auditing of self-reported measures for QMs has also led to the need for increased oversight. Currently, CMS is conducting those focused survey types that it rolled out in 2014 to examine whether self-reported data matches what is in the residents’ medical records. The Agency plans to continue conducting focused surveys nationally in 2016 to assist with this auditing, and hopefully the results of these focused surveys will show that the data is pretty much where it needs to be.
  • Special Focus Facilities (SFF) – The number of SFFs was recalibrated in 2014, creating a smaller set number of facilities on the list per state. This is mainly related to a budgetary issue for CMS, but the end result is that it makes it more difficult to provide the necessary oversight to help these poorly performing facilities improve.
  • Federal Monitoring Surveys – In 2013, CMS reduced the number of these surveys required in to 5+% of nursing homes per state. Before that, 80% of those surveys needed to be standard surveys, but more complaint surveys are being added into the mix, which are less time-consuming. This means CMS has less oversight of SAs and how they are conducting surveys, which could impact how nursing home quality is calculated.

CMS has recognized the issues with data collection, and the signs of its initiative to capture data more accurately are evident over the past few years. More standardized data requirements are being put into place, the Five-Star Quality Rating was recalculated earlier this year, and more and more Quality Measures are being proposed. At the same time that these measurements are being rolled out, it’s also clear that there are signs of improved quality of care across the country. For instance, the National Partnership to Improve Dementia Care in Nursing Homes announced on a recent MLN Connects call that nursing homes have achieved a 24.8% reduction in antipsychotic use in these facilities since the program started. Focused initiatives like these help facilities to be on target to achieve the overarching goal of improving the quality of care in our nation’s nursing homes. Just remember, the more data CMS collects, the more things it has to compare. In the next few years, there will be an increase in the data being captured in order to show a clear picture on the continued quality improvement in our nursing homes.

Read the October 2015 GAO Report here.

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