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On January 1, 2017, the KHI News Service became part of KCUR public radio’s new initiative, the Kansas News Service. The Kansas News Service will continue to cover health policy news and broaden its scope to include education and politics. All stories produced by the former KHI News Service are archived here. Stories and photos may be republished at no cost with proper attribution and a link back to KHI.org.

Lots of data, little agreement on nursing home quality

New survey process rolled out in Kansas and four other states gets mixed reviews

By Allison Kite | May 04, 2016

Margaret Farley’s father fell within five days of entering a Kansas nursing home. He died within seven days of surgery to treat his injuries.

Falls like his, Farley said, are one of the biggest dangers that nursing home residents face. They occur when there aren’t enough staff members to care for residents, and they can result in costly, dangerous injuries.

“If you don’t have somebody that’s answering that call light or checking on that person frequently or taking that person to (the) toilet frequently enough, that lack of staff directly results in injuries in a significant number of cases,” said Farley, the former executive director of Kansas Advocates for Better Care, an organization that advocates for quality care in nursing homes.

Over the next 50 years, the number of Kansans 65 and older is expected to more than double, from 415,823 in 2014 to 856,390 in 2064, surpassing the number of children for the first time. As that senior population grows, the cost and quality of long-term care are concerns for the state and the federal government — as well as nursing home residents and their families.

On average, nursing home care costs $60,225 to $65,700 annually in Kansas depending on whether the resident wants a private room. Nationally, average costs range between $80,300 and $91,250, according to Genworth, a long-term care insurance company.

Medicaid spent about $5 million on long-term care in Kansas in 2014, making it 49th out of the states and Washington, D.C., for nursing home reimbursements, according to the Kaiser Family Foundation. The Kansas Department for Aging and Disability Services also publishes specific nursing home rates on its website.

People who represent nursing homes say they need higher reimbursements. People who represent residents say they want money tied to quality care. There’s little agreement on how to measure that.

The U.S. Department of Justice recently announced that Kansas is one of 10 districts launching Elder Justice Task Forces to crack down on nursing homes that provide substandard care. The goal of the program is to bring together groups that handle cases of elder abuse to weed out abusive nursing homes. 

Farley and her successor, Mitzi McFatrich, said that understaffing, falls and overuse of antipsychotic drugs are some of the measures their group uses to determine facility quality.

Leaders of the Kansas nursing home industry say those measures have limitations and need more context.

Both sides agree that the system government surveyors use to score nursing homes is flawed. In what should be a step forward in that area, the Centers for Medicare and Medicaid Services recently introduced six new measures to provide a clearer picture on nursing home quality.

Federal system

Photo by Allison Kite/KHI News Service Nursing home surveyors use this matrix to rank deficiencies. The “severity” of the deficiency refers to the degree of harm, while the “scope” of the deficiency refers to the number of affected residents.

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From 2013 to 2015, CMS cited nursing facilities across the state 193 times for serious deficiencies under the “accident hazard” tag. A serious deficiency is defined as something that causes “actual harm” to residents or puts them in “immediate jeopardy.” The deficiencies are rated by level of severity and number of residents affected.

Advocates like Farley and McFatrich think those accidents are the direct result of understaffing in nursing homes. In 2014, Kansas nursing home residents received an average of 3.87 hours of direct care a day. The minimum recommended by studies presented to Congress is 4.1 hours.

“After adults wait five, 10 minutes, 30 minutes, 45 minutes, then they’re getting up on their own and they’re trying to go where they need to go, and they’re falling,” McFatrich said.

Farley said there also is a correlation between understaffing and inappropriate use of antipsychotic drugs, as overworked employees use the medications as a shortcut to deal with dementia-related behavioral problems.

Kansas ranks 47th — near the bottom — among states on use of antipsychotic drugs for long-stay nursing home residents, according to the National Partnership to Improve Dementia Care in Nursing Homes. That usage has gone down from 26.5 percent in late 2011 to 20.4 percent in late 2015, but some say it’s still too high.

Industry representatives have pointed out that the number includes nursing homes with mental health patients, a type of facility unique to Kansas that skews the results. State officials also have said the 10 specialized mental health facilities adversely affect Kansas’ ranking.

Cindy Luxem, president and CEO of the Kansas Health Care Association, and Debra Zehr, president and CEO of LeadingAge Kansas, point to recent declines in deficiencies as evidence of improving nursing home quality. From 2009 to 2012, the number of deficiencies cited per survey dropped from 10.4 to 8.

Assessing quality

Those deficiencies come from a routine survey process established by CMS. That process has mixed reviews, but stakeholders on all sides of the issue cite flaws.

Photo by Allison Kite/KHI News Service Surveyors from the Kansas Department for Aging and Disability Services use a new survey process designed to give a more accurate account of nursing home conditions. From left, Leila Simmons, Sandra Lee, Amanda Ehrlick and John Coffroth wrap up a survey of Tonganoxie Nursing Center in Tonganoxie. The survey process includes evaluating data, interviewing residents and touring the facility.

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Members of the nursing home industry have expressed concern about the survey’s stringency while care advocates, like Farley and McFatrich, have said the opposite. And the survey has long been plagued by inconsistencies that spurred the Government Accountability Office to call for improvement of the system in 2008, 2012 and 2015.

Surveys are done at least every 15 months, or when there is a complaint that needs to be investigated.

KDADS surveyors inspect homes and interview residents and employees to ensure the home is complying with federal regulations.

When surveyors find deficiencies, they record them with a description, scope and severity. Homes can face fines or loss of Medicare and Medicaid reimbursements until the deficiency is resolved.

Information about those deficiencies is then made available on the CMS Nursing Home Compare website to help consumers make decisions on care for themselves or their loved ones. The deficiencies also serve as a way to identify problems in the nursing home system and gauge improvement or decline.

Nursing homes also self-report quality measures, including staff levels, but those are inconsistently audited, according to the GAO, and can be inflated.

CMS announced last week that it will start displaying three new quality measures concerning rehospitalization, emergency room use and community discharge taken from Medicare claims data rather than information self-reported by the homes.

The website also will start displaying the percentages of short-stay residents whose functions improved and long-stay residents whose conditions worsened or were given antianxiety or hypnotic medication.

Beginning in July, those measures — with the exception of the medication data — will be incorporated into the Five-Star Quality Ratings nursing homes get on the site. CMS said it as too difficult to set benchmarks for medication use, so it won’t be included.

The change isn’t the first CMS has made to the process, but Zehr said the overall system should be reassessed. The original study and recommendations that created the survey process — done by the Institute of Medicine in the 1980s — hasn’t been revisited since, she said.

With the current survey process, there isn’t a consensus on whether changes come from improvement or changes in the way surveys are done.

In November, the GAO released a study saying the process was ineffective because of its fluctuating results. From 2005 to 2014, the number of deficiencies cited nationwide declined by 41 percent but the number of consumer complaints rose 21 percent.

Kansas followed that trend until 2012 when it started to see an uptick in serious deficiencies per home. Linda Kohn, author of the GAO study, said the recent increase could be a result of surveys catching up to the previous rise in complaints.

Audrey Sunderraj, director of survey and certification for KDADS, said the recent rise also could be the result of improvement on the part of the survey department staff.

Too much or too little scrutiny?

The previous decline in deficiencies worried McFatrich, who believed it didn’t indicate an improving system. Instead, she said, it was the result of a survey department stretched thin and unable to accurately count deficiencies.

“We don’t see in the things that we hear from staff or from families that practices have improved that much,” McFatrich said. “What we do see is a survey unit that is continuously understaffed and a huge amount of turnover, and so our concern is that the state’s not doing its job in enforcement and oversight of nursing facilities.”

Angela de Rocha, a KDADS spokeswoman, said in an email that there are 63 designated positions for surveying, but only 52 of them are filled.

Industry representatives say the recent uptick in deficiencies may be due to inexperienced surveyors taking a harder line.

Luxem said young KDADS employees who haven’t worked in long-term care are more likely to over-scrutinize homes.

Kansas nursing homes received an average of 10.7 health deficiencies per home during the last inspection cycle, which started in late 2014.

For-profit homes averaged 11.7 deficiencies, while government homes averaged 10. Nonprofit homes received fewer deficiencies than average at 9.1 per home during that time frame.

The average deficiencies per home listed for the nation on Nursing Home Compare was 6.9.

About 53 percent of the 345 nursing homes in Kansas are for-profit. Government homes make up 12.5 percent and nonprofit homes make up 34.5 percent.

Luxem and industry representatives also say the way Kansas homes are surveyed makes it unfair to compare their results across state lines.

In 2005, Kansas and four other states were selected to use a new survey process that was expected to give a more accurate account of what was happening in nursing homes. Following that change, reports to CMS showed a spike in deficiencies in Kansas nursing homes. They then declined for several years but still remain above other states.

The new survey process, called the quality indicator survey, uses a computer rather than paper and a clipboard.

Sunderraj said the new survey made the sample selection and calculation for the survey more accurate. The new survey also ensures steps are followed in a particular order, standardizing the process.

Luxem and Zehr said the new survey process could be a good one if it were implemented uniformly, but it gives the impression that nursing homes are worse in states where the process is used.

According to the GAO report, 23 states switched to the new survey process as of the end of 2014, which leaves nearly a 50-50 split in the style of data collection used by the states.

In addition to adjusting to the new survey method, Luxem said her members have been adapting to a flurry of state and federal regulatory changes — some the result of the Affordable Care Act — that also could explain the recent spike in deficiencies.

“There’s almost changes weekly for the providers, whether it’s making sure everybody’s CPR educated and trained to making sure — since 2011 we’ve been dealing with the reduction of the antipsychotic drug issue,” Luxem said. “There seems to be something all the time coming at the providers.”

Luxem said homes have been given serious deficiencies for failing to perform CPR on patients whom staff believed to be dead.

“How is it if you find a person dead and you didn’t give them CPR — how is that an immediate jeopardy to that person?” she said.

She said the situation is evidence of what she believes is a tendency to overstate deficiencies for the sake of calling attention to a particular issue — the opposite of McFatrich’s concerns.

A search of ProPublica’s nursing home deficiency database returned 11 immediate jeopardy deficiencies related to CPR, three of which indicated cases like Luxem described.

How to improve

The inconsistencies in surveys across the nation make it difficult to hold providers accountable, assess trends and — for consumers — select a facility.

Moving all states onto the same survey type could be a start, but for the industry, it’s still an “adversarial” system focused on penalizing rather than improving quality, Zehr said.

She said LeadingAge has been advocating at the national level for a study to assess the survey system, like the original one done in the 1980s. The industry needs regulation and oversight, she said, but the current system is antiquated.

“It really hasn’t had the effect of running out the truly bad performers,” she said.

“We don’t care if they get more money as long as they’re putting it toward staffing, because what has happened in the past is that they can put that money into central office costs or other things that will enrich the corporation without making a positive effect on the residents.” 

- Margaret Farley, former executive director of Kansas Advocates for Better Care

Farley said the system isn’t new, so providers know what needs to be done to have a good survey. If the fines aren’t significant enough, providers may choose to pay them rather than invest the money needed to adequately care for their residents. It’s a business decision, she said.

She said she’d like to see the Medicaid money that providers get from a state “bed tax” go toward adequate staffing levels.

“We don’t care if they get more money as long as they’re putting it toward staffing, because what has happened in the past is that they can put that money into central office costs or other things that will enrich the corporation without making a positive effect on the residents,” she said.

Industry groups have fought efforts by Kansas Advocates for Better Care to tie the bed tax proceeds to increases in mandatory staffing levels.

Luxem said mandatory staffing levels aren’t effective because facilities need to be able to staff to their patients’ needs. If a facility has a high population of patients with dementia, for example, they need more staff than other facilities.

Nursing Home Compare is just one resource for Kansans looking for a nursing home. Zehr also recommends seeking word-of-mouth reviews and visiting the facilities. She said to use all senses when assessing the facility and ask about the care they provide. Person-centered care approaches and freedoms are important, she said.

McFatrich agreed that the data is a good start, but she recommended reading the inspection reports for more information.

“You’ll only get that level of detail if you read the actual (report),” she said. “And so we always say to people, ‘Sure, start with what’s on the website in terms of the general categories, but read the detail.’ That’s really going to be what tells you whether the kind of care you need is being done well by this facility.”

— Allison Kite is an intern with KHI News Service.