Nursing Homes
CMS's Special Focus Facility Methodology Should Better Target the Most Poorly Performing Homes, Which Tended to Be Chain Affiliated and For-Profit Gao ID: GAO-09-689 August 28, 2009In 1998, CMS established the Special Focus Facility (SFF) Program as one way to address poor performance by nursing homes. The SFF methodology assigns points to deficiencies cited on standard surveys and complaint investigations, and to revisits conducted to ensure that deficiencies have been corrected. CMS uses its methodology periodically 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 any point in time because of resource constraints. In 2008, CMS introduced a Five-Star Quality Rating System that draws on the SFF methodology to rank homes from one to five stars. GAO assessed CMS's SFF methodology, applied it on a nationwide basis using statistical scoring thresholds, and adopted several refinements to the methodology. Using this approach, GAO determined (1) the number of most poorly performing homes nationwide, (2) how their performance compared to that of homes identified using the SFF methodology, and (3) the characteristics of such homes.
According to GAO's estimate, almost 4 percent (580) of the roughly 16,000 nursing homes in the United States could be considered the most poorly performing. These 580 homes overlap somewhat with the 755 SFF Program candidates--the 15 worst homes in each state--and the 136 homes actually selected by states as SFFs. For example, GAO's estimate includes 40 percent of SFF Program candidates and about half of the active SFFs as of December 2008 and February 2009, respectively. Under GAO's estimate, however, the most poorly performing homes are distributed unevenly across states, with 8 states having no such homes and 10 others having from 21 to 52 such homes. 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. To identify the worst homes in the nation, GAO applied CMS's SFF methodology on a nationwide basis using statistical scoring thresholds and made three refinements to that methodology, which strengthened GAO's estimate. The scoring thresholds were (1) necessary because there were no natural break points that delineated the most poorly performing homes from all other nursing homes and (2) conservative, focusing on chronic poor performance generally over a 2- or 3-year period or very poor performance over about 1 year. The most poorly performing homes identified by GAO averaged over 46 percent more serious deficiencies that caused harm to residents and over 19 percent more deficiencies that placed residents at risk of death or serious injury (immediate jeopardy), compared to the 755 SFF Program candidates identified by CMS's approach. GAO's three refinements to CMS's SFF methodology had a moderate effect on the composition of the list of homes that GAO identified as the most poorly performing. First, deficiency points from CMS's Five-Star Quality Rating System were used because they decreased the disparity between immediate jeopardy and lower-level deficiencies, such as those with the potential for more than minimal harm, which compensates somewhat for the understatement of serious deficiencies in some states. Second, homes received extra points when certain actual harm deficiencies occurred in standards areas that CMS categorizes as substandard quality of care, an important change because we found that many homes had at least one such deficiency. Third, the full deficiency history of homes was included. CMS recognizes that its methodology overlooks deficiencies for some homes, which almost always results in scores that are lower than if all deficiencies were included in the scores. 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. In addition, the most poorly performing homes tended to be chain affiliated and for-profit and have more beds and residents.
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
August 2009:
Nursing Homes:
CMS's Special Focus Facility Methodology Should Better Target the Most
Poorly Performing Homes, Which Tended to Be Chain Affiliated and For-
Profit:
GAO-09-689:
GAO Highlights:
Highlights of GAO-09-689, a report to congressional requesters.
Why GAO Did This Study:
In 1998, CMS established the Special Focus Facility (SFF) Program as
one way to address poor performance by nursing homes. The SFF
methodology assigns points to deficiencies cited on standard surveys
and complaint investigations, and to revisits conducted to ensure that
deficiencies have been corrected. CMS uses its methodology periodically
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 any
point in time because of resource constraints. In 2008, CMS introduced
a Five-Star Quality Rating System that draws on the SFF methodology to
rank homes from one to five stars. GAO assessed CMS‘s SFF methodology,
applied it on a nationwide basis using statistical scoring thresholds,
and adopted several refinements to the methodology. Using this
approach, GAO determined (1) the number of most poorly performing homes
nationwide, (2) how their performance compared to that of homes
identified using the SFF methodology, and (3) the characteristics of
such homes.
What GAO Found:
According to GAO‘s estimate, almost 4 percent (580) of the roughly
16,000 nursing homes in the United States could be considered the most
poorly performing. These 580 homes overlap somewhat with the 755 SFF
Program candidates”the 15 worst homes in each state”and the 136 homes
actually selected by states as SFFs. For example, GAO‘s estimate
includes 40 percent of SFF Program candidates and about half of the
active SFFs as of December 2008 and February 2009, respectively. Under
GAO‘s estimate, however, the most poorly performing homes are
distributed unevenly across states, with 8 states having no such homes
and 10 others having from 21 to 52 such homes.
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. To
identify the worst homes in the nation, GAO applied CMS‘s SFF
methodology on a nationwide basis using statistical scoring thresholds
and made three refinements to that methodology, which strengthened GAO‘
s estimate. The scoring thresholds were (1) necessary because there
were no natural break points that delineated the most poorly performing
homes from all other nursing homes and (2) conservative, focusing on
chronic poor performance generally over a 2- or 3-year period or very
poor performance over about 1 year. The most poorly performing homes
identified by GAO averaged over 46 percent more serious deficiencies
that caused harm to residents and over 19 percent more deficiencies
that placed residents at risk of death or serious injury (immediate
jeopardy), compared to the 755 SFF Program candidates identified by CMS‘
s approach. GAO‘s three refinements to CMS‘s SFF methodology had a
moderate effect on the composition of the list of homes that GAO
identified as the most poorly performing. First, deficiency points from
CMS‘s Five-Star Quality Rating System were used because they decreased
the disparity between immediate jeopardy and lower-level deficiencies,
such as those with the potential for more than minimal harm, which
compensates somewhat for the understatement of serious deficiencies in
some states. Second, homes received extra points when certain actual
harm deficiencies occurred in standards areas that CMS categorizes as
substandard quality of care, an important change because we found that
many homes had at least one such deficiency. Third, the full deficiency
history of homes was included. CMS recognizes that its methodology
overlooks deficiencies for some homes, which almost always results in
scores that are lower than if all deficiencies were included in the
scores.
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. In addition, the most poorly
performing homes tended to be chain affiliated and for-profit and have
more beds and residents.
What GAO Recommends:
GAO is recommending that the CMS Administrator consider a home‘s
relative performance nationally when allocating SFFs across states and
take actions to refine the SFF methodology to improve the
identification of SFFs. CMS generally agreed in principle with our
recommendations and said that it would evaluate the effects of adopting
them.
View [hyperlink, http://www.gao.gov/products/GAO-09-689] or key
components. For more information, contact John Dicken at (202) 512-7114
or dickenj@gao.gov.
[End of section]
Contents:
Letter:
Background:
Five Hundred Eighty Nursing Homes Could Be Considered the Most Poorly
Performing--Fewer Than CMS's SFF Program Candidates but More Than the
Number of SFFs:
CMS's Application of the SFF Methodology Misses Many of the Nation's
Most Poorly Performing Nursing Homes:
Key Characteristics, such as Chain Affiliation and For-Profit Status
Differentiated the Most Poorly Performing Nursing Homes:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Detailed Compliance History for Two of the Most Poorly
Performing Nursing Homes, as of December 2008:
Appendix III: Performance by Standard Area for the Most Poorly
Performing and All Other Nursing Homes, as of December 2008:
Appendix IV: Comments from the Centers for Medicare & Medicaid
Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Table 2: Comparison of Points Assigned to Deficiencies in the SFF
Methodology and in the Five-Star System:
Table 3: Compliance History over the Last Three Cycles for Our Estimate
of the Most Poorly Performing Nursing Homes Compared to the SFF Program
Candidates, as of December 2008:
Table 4: Compliance Histories over the Last Three Cycles for Two of the
Most Poorly Performing Nursing Homes, as of December 2008:
Table 5: Compliance History over Last Three Cycles for the Most Poorly
Performing Nursing Homes and All Other Nursing Homes, as of December
2008:
Table 6: The 10 Standards Most Often Cited at the Immediate Jeopardy
Level in the Last Three Cycles among the Most Poorly Performing Homes
Compared to All Other Nursing Homes, as of December 2008:
Table 7: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Type of Organization, as of December 2008:
Table 8: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Medicare and Medicaid Participation, as of
December 2008:
Table 9: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Beds and Residents, as of December 2008:
Table 10: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Case-Mix-Adjusted Nurse Staffing Levels, as
of November 2008:
Table 11: Detailed Compliance History over Three Cycles for Two of the
Most Poorly Performing Nursing Homes in the Nation, as of December
2008:
Table 12: Percentage of the Most Poorly Performing and All Other
Nursing Homes Cited for Actual Harm or Immediate Jeopardy, by Standards
Area, in the Last Three Cycles as of December 2008:
Figures:
Figure 1: How CMS and States Operate the Special Focus Facility
Program:
Figure 2: Overlap between Our Estimate of the Most Poorly Performing
Nursing Homes in the Nation and the SFF Program Candidates, as of
December 2008:
Figure 3: Our Estimate of the Number of Most Poorly Performing Nursing
Homes as of December 2008 Compared to the Number of SFFs by State:
Figure 4: Total Score Ranges for the SFF Program Candidates, as of
December 2008:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
LPN/LVN: licensed practical nurse/licensed vocational nurse:
OSCAR: On-Line Survey, Certification, and Reporting system:
SFF: Special Focus Facility:
SQC: substandard quality of care:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
August 28, 2009:
The Honorable Herb Kohl:
Chairman:
Special Committee on Aging:
United States Senate:
The Honorable Charles E. Grassley: Ranking Member:
Committee on Finance:
United States Senate:
The nation's 1.4 million nursing home residents are a highly vulnerable
population of elderly and disabled individuals who rely on nursing
homes to provide high-quality care. The Centers for Medicare & Medicaid
Services (CMS) contracts with state survey agencies to conduct
inspections, known as standard surveys, and complaint investigations to
determine whether the nation's roughly 16,000 nursing homes are
complying with federal quality standards. Nursing homes must meet those
standards in order to participate in Medicare and Medicaid.[Footnote 1]
Our prior reports have found that some nursing homes are chronically
noncompliant; that is, they have been cited repeatedly by state survey
agencies for serious deficiencies, such as residents having preventable
pressure sores that harmed them or put them at risk of death or serious
injury.[Footnote 2] In 1998, CMS established the Special Focus Facility
(SFF) Program as one way to address poor performance by nursing homes.
CMS uses a formula--the SFF methodology--to score the relative
performance of nursing homes and identify the 15 poorest performing
homes in each state as candidates for the SFF Program. State survey
agencies then work with CMS to choose some of those candidates to
participate in the program; those selected receive more intensive
oversight, including more frequent surveys. CMS limits the SFF Program
to 136 nursing homes nationwide (fewer than 1 percent of nursing homes)
at any point in time because of resource constraints.[Footnote 3] Our
prior reports have demonstrated that not all chronically noncompliant
nursing homes are included in this program and that the number of
poorly performing nursing homes nationwide is therefore greater than
136.[Footnote 4]
You expressed interest in CMS's efforts to influence the performance of
poorly performing nursing homes. In this report, we (1) determined the
number of nursing homes in the United States that can be identified as
the most poorly performing, (2) analyzed how those homes' performance
compared to that of nursing homes identified using CMS's SFF
methodology, and (3) assessed the characteristics of the most poorly
performing nursing homes that distinguish them from all other nursing
homes. You also asked us to examine the operation of the SFF Program,
including its effect on the performance of homes selected as SFFs. We
will address this portion of your request in a subsequent report.
To determine the number of poorly performing nursing homes in the
nation and how the performance of such homes compared to that of homes
identified using CMS's SFF methodology, we began by interviewing CMS
officials, reviewing documentation related to the agency's SFF
methodology, obtaining a copy of the computer program CMS used to score
and rank nursing homes, and analyzing data on deficiencies and revisits
from CMS's On-Line Survey, Certification, and Reporting system (OSCAR)
database. The SFF methodology creates a total score for each nursing
home over three cycles by assigning points to (1) deficiencies cited
during the three most recent standard surveys, (2) deficiencies cited
on the last 3 years of complaint investigations, and (3) the number of
revisits surveyors made to ensure that the nursing home had corrected
the deficiencies cited on the three most recent standard surveys.
[Footnote 5] To determine the adequacy of the SFF methodology, we
compared it to other compliance-based measures of poor performance and
tested the sensitivity of the methodology to variations such as not
giving greater weight to recent poor performance compared to poor
performance that occurred in earlier years. Based on our examinations
of the SFF methodology, document review, and interviews, we concluded
that the SFF methodology is reasonable and comprehensive. Using our
assessment of the SFF methodology, we developed our estimate of the
most poorly performing nursing homes by (1) applying the SFF
methodology on a nationwide basis using statistical scoring thresholds
and (2) adopting three refinements that helped to identify some homes
that would otherwise have been missed but that had a moderate impact on
the composition of the list of homes we identified as the most poorly
performing. We estimated the number of most poorly performing nursing
homes in the nation and the number of homes identified using CMS's SFF
methodology--which we refer to as SFF Program candidates--by analyzing
OSCAR data from a particular point in time (December 2008).[Footnote 6]
We also analyzed a list obtained from CMS of SFFs that participated in
the program from January 2005 through February 2009 to determine the
number of poorly performing nursing homes that were also SFFs.
To determine the characteristics of the most poorly performing nursing
homes that distinguish them from all other nursing homes, we analyzed
CMS data as of December 2008 on deficiencies, revisits, and other
information that describe nursing home characteristics.[Footnote 7] We
also analyzed case-mix-adjusted nurse staffing hours available from
CMS's Five-Star Quality Rating System (Five-Star System), which were
dated November 2008, and data related to certain enforcement actions
obtained from CMS in October 2008.
Our work was also informed by analyzing information available at CMS's
Providing Data Quickly Web site; reviewing our prior reports;
interviewing experts in long-term care research; interviewing officials
from CMS's central office, all 10 CMS regions, and 14 state survey
agencies; and reviewing some states' approaches to rating nursing home
quality. For a more detailed discussion of our scope and methodology,
see appendix I. To ensure the reliability of the OSCAR deficiency and
revisit data for our purposes as well as the reliability of the data we
analyzed to determine the characteristics of the most poorly performing
nursing homes compared to those of all other nursing homes, we
interviewed CMS officials, reviewed CMS documentation, conducted
electronic testing to identify obvious errors, and traced a selection
of records to another CMS reporting system. Based on these activities,
we determined that the data we analyzed were sufficiently reliable for
our purposes.
We conducted this performance audit from February 2008 through August
2009 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
Titles XVIII and XIX of the Social Security Act establish minimum
requirements that all nursing homes must meet to participate in the
Medicare and Medicaid programs, respectively. The Omnibus Budget
Reconciliation Act of 1987 focused the requirements on the quality of
care actually provided by a home.[Footnote 8] To help beneficiaries
make informed decisions when selecting or evaluating nursing homes, CMS
increased the amount of information publicly available on its Nursing
Home Compare Web site in 2008 by rating the quality of each nursing
home on a five-level scale.[Footnote 9]
Standard Surveys and Complaint Investigations:
To assess whether nursing homes meet federal quality standards, state
survey agencies conduct standard surveys, which occur roughly once per
year, and complaint investigations.[Footnote 10] A standard survey
involves a comprehensive assessment of quality standards.[Footnote 11]
In contrast, complaint investigations generally focus on a specific
allegation regarding resident care or safety made by a resident, family
member, or nursing home staff.
Federal quality standards focus on the delivery of care, resident
outcomes, and facility conditions. These quality standards, totaling
approximately 200, are grouped into 15 categories, such as Resident
Rights, Quality of Care, Quality of Life, and Resident Behavior and
Facility Practices.[Footnote 12] Nursing homes that meet these quality
standards can be certified to participate in Medicare, Medicaid, or
both programs. Homes may occasionally change their participation type,
or, according to CMS, states may require nursing homes to change their
participation type. We refer to this type of change that results in a
new provider identification number as a "technical status change." Such
a change may affect the source of payment--Medicare or Medicaid--that
the nursing home is eligible to receive. When a technical status change
occurs, CMS's SFF methodology as applied does not incorporate the
nursing home's complete survey history.
Survey Deficiencies:
States classify deficiencies identified during either standard surveys
or complaint investigations in 1 of 12 categories according to their
scope (i.e., the number of residents potentially or actually affected)
and severity (i.e., the potential for or occurrence of harm to
residents).[Footnote 13] (See table 1.) An A-level deficiency is the
least serious and is isolated in scope, while an L-level deficiency is
the most serious and is widespread throughout the nursing home. Nursing
homes with deficiencies at the A, B, or C levels are considered to be
in substantial compliance with quality standards, whereas nursing homes
with D-level through L-level deficiencies are considered noncompliant.
For most deficiencies, a home is required to prepare a plan of
correction, and depending on the severity of the deficiency, surveyors
may conduct a revisit to ensure that the nursing home has implemented
its plan and corrected the deficiency. Revisits are not required for
most deficiencies below the actual harm level--A through F.[Footnote
14]
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Severity: Immediate jeopardy[A];
Scope: Isolated: J;
Scope: Pattern: K;
Scope: Widespread: L.
Severity: Actual harm;
Scope: Isolated: G;
Scope: Pattern: H;
Scope: Widespread: I.
Severity: Potential for more than minimal harm;
Scope: Isolated: D;
Scope: Pattern: E;
Scope: Widespread: F.
Severity: Potential for minimal harm[B];
Scope: Isolated: A;
Scope: Pattern: B;
Scope: Widespread: C.
Source: CMS.
[A] Actual or potential for death/serious injury.
[B] Nursing home is considered to be in "substantial compliance."
[End of table]
As we reported in May 2008, there can be considerable variation among
states in the proportion of nursing homes cited for deficiencies at the
G through L levels.[Footnote 15] We concluded that this interstate
variation suggests that surveyors in some states are missing some
serious deficiencies or understating their scope and severity. We
provided examples of such understatement in our May 2008 report.
Specifically, we reported that during fiscal years 2002 through 2007,
about 15 percent of federal comparative surveys nationwide found that
the state surveys had failed to cite at least one deficiency at the
most serious levels of noncompliance (G through L levels) and about 70
percent of them found that the state surveys had failed to cite at
least one deficiency at the potential for more than minimal harm level
(D through F levels).[Footnote 16]
Enforcement Actions:
When deficiencies are cited, federal enforcement actions known as
sanctions can be imposed to encourage homes to make corrections.
Sanctions are generally reserved for serious deficiencies--those at the
G through L levels--that constitute actual harm and immediate jeopardy
to residents.[Footnote 17] Sanctions include fines known as civil money
penalties, denial of payment for new Medicare or Medicaid admissions,
and termination from the Medicare and Medicaid programs. Such sanctions
can affect a home's revenues and therefore provide financial incentives
to return to and maintain compliance. CMS requires states to refer for
immediate sanction homes that receive at least one G-through L-level
deficiency on successive standard surveys or intervening complaint
investigations.[Footnote 18] In addition, a nursing home with one or
more deficiencies at the F through L level--but not G level--in Quality
of Care, Quality of Life, or Resident Behavior and Facility Practices
must be cited for substandard quality of care (SQC), which generally
results in the home's losing its approval to hold in-house or facility-
sponsored nurse aide training.
CMS Efforts That Identify Poorly Performing Nursing Homes:
Two of CMS's efforts that identify poorly performing nursing homes are
the SFF Program and the Five-Star System. CMS's Nursing Home Compare
Web site identifies nursing homes that are in the SFF Program, provides
a rating of from one to five stars, and also includes data on
deficiencies cited during standard surveys and complaint
investigations, selected quality of care measures, and nurse staffing
hours.[Footnote 19] Both the SFF Program and the Five-Star System score
nursing homes by assigning points to deficiencies and the number of
revisits, but the points assigned to certain deficiencies differ.
The Special Focus Facility Program:
CMS compiles a list of SFF candidates for each state generally on a
quarterly basis by using the numeric score generated by its SFF
methodology. The SFF candidates are those nursing homes with the 15
highest total scores in each state. From the candidate list, state
officials select, with CMS concurrence, nursing homes they think should
participate in the program based on their knowledge of the candidates'
circumstances. With the exception of Alaska, each state has between one
and six SFFs, depending on the number of nursing homes in the
state.[Footnote 20] CMS requires states to survey SFFs twice as
frequently as other nursing homes to help motivate SFFs to improve. If
an SFF meets CMS's criteria for improved performance, CMS removes the
SFF designation and the nursing home "graduates" from the
program.[Footnote 21] According to CMS guidance to states, SFFs that
fail to significantly improve after three standard surveys, or about 18
months, may be involuntarily terminated from Medicare and Medicaid.
Nursing homes may also choose to terminate from Medicare and Medicaid
voluntarily. (See figure 1.)
Figure 1: How CMS and States Operate the Special Focus Facility
Program:
[Refer to PDF for image: illustration]
Methodology:
Scores are calculated for all nursing homes using the SFF methodology.
Candidates:
CMS identifies about 750 SFF candidates nationwide, which are the
nursing homes that have the 15 highest total scores in each state.
SFFs:
As SFFs leave the program, states, with CMS concurrence, select SFFs –
for a total of 136 – based on their knowledge of the candidates‘
circumstances.
Increased scrutiny:
SFFs receive increased scrutiny, including surveys twice as frequently
as other nursing homes.
Graduation or termination:
SFFs that meet CMS‘s criteria ’graduate“ from the program. SFFs that
fail to significantly improve after three standard surveys, or
approximately 18 months, may be involuntarily terminated from Medicare
and Medicaid.
Sources: GAO analysis of CMS‘s SFF program (data); Art Explosion
(images).
Note: With 15 SFF candidates per state, including the District of
Columbia, but excluding Alaska (because Alaska does not have SFFs),
there are a total of 750 SFF candidates. There can be more than 750 SFF
candidates if nursing homes in the same state have the same total
score.
[End of figure]
The SFF methodology assigns points to deficiencies on standard surveys
and complaint investigations, and to revisits associated with
deficiencies cited on standard surveys, as follows:
* Deficiencies. More points are assigned to deficiencies that are
higher in scope and severity.[Footnote 22] Additional points are
assigned to deficiencies classified as SQC. For example, a nursing home
with one J-level deficiency in the Quality of Care category would be
assigned 75 points (50 points plus an additional 25 points because the
deficiency was SQC). See table 2 for a comparison of the deficiency
points assigned by the SFF methodology and the Five-Star System.
* Revisits. Multiple revisits are an indicator of more serious problems
in achieving or sustaining compliance. The points for revisits are as
follows: 0 for the first revisit, 50 for the second revisit, an
additional 75 (total 125) for the third revisit, and an additional 100
(total 225) for the fourth revisit.[Footnote 23]
Table 2: Comparison of Points Assigned to Deficiencies in the SFF
Methodology and in the Five-Star System:
Scope and severity:
Methodology: SFF points;
Potential for minimal harm: A: 0;
Potential for minimal harm: B: 0;
Potential for minimal harm: C: 0;
Potential for more than minimal harm: D: 2;
Potential for more than minimal harm: E: 4;
Potential for more than minimal harm: F: 6;
Actual harm: G: 10;
Actual harm: H: 20;
Actual harm: I: 30;
Immediate jeopardy: J: 50;
Immediate jeopardy: K: 100;
Immediate jeopardy: L: 150.
Methodology: Five-Star System points;
Potential for minimal harm: A: 0;
Potential for minimal harm: B: 0;
Potential for minimal harm: C: 0;
Potential for more than minimal harm: D: 4;
Potential for more than minimal harm: E: 8;
Potential for more than minimal harm: F: 16;
Actual harm: G: 20;
Actual harm: H: 35;
Actual harm: I: 45;
Immediate jeopardy: J: 50;
Immediate jeopardy: K: 100;
Immediate jeopardy: L: 150.
Methodology: Additional SQC points;
Potential for minimal harm: A: 0;
Potential for minimal harm: B: 0;
Potential for minimal harm: C: 0;
Potential for more than minimal harm: D: 0;
Potential for more than minimal harm: E: 0;
Potential for more than minimal harm: F: 4;
Actual harm: G: 0;
Actual harm: H: 5;
Actual harm: I: 5;
Immediate jeopardy: J: 25;
Immediate jeopardy: K: 25;
Immediate jeopardy: L: 25.
Source: CMS.
[End of table]
For each nursing home, CMS sums the points associated with the
deficiencies (including SQC) and the revisits to create a cycle score
for each of the last three cycles. CMS then creates the total score by
weighting the more recent cycle scores more heavily.[Footnote 24] The
effect of this weighting is that nursing homes that had more recent
poor performance have higher total scores and nursing homes that made
improvements have lower total scores.
Since the inception of the SFF Program, CMS has changed its scope and
methodology several times. For example:
* From 1999 to 2004, each state had two SFFs at any one time, which
they selected from a list of four candidates, and the SFF methodology
assigned a different number of points to deficiencies using only about
1 year of deficiency data.
* In 2005, CMS expanded the program's scope by changing the number of
SFFs from 1 to 6 per state (excluding Alaska), for a total of 136, and
altered the SFF methodology by changing the points assigned to
deficiencies and using about 3 years of deficiency data, weighted
equally.
* In 2007, CMS began requiring states to notify a nursing home and its
other accountable parties (i.e., the nursing home's administrator,
owners, operators, and governing body) when the nursing home was
designated as an SFF.
* In 2008, CMS began designating SFFs on the Nursing Home Compare Web
site and also changed the scoring methodology to assign weights to each
year, such that the most recent year's standard and complaint surveys
are given the greatest weight.
The Five-Star Quality Rating System:
During the course of our work, CMS implemented its Five-Star System for
nursing homes. Every nursing home in the United States is rated from
one (much below average) to five (much above average) stars.[Footnote
25]
The Five-Star System provides an overall quality rating based on
individual ratings for three separate components: (1) assessment of
federal quality standards from standard surveys and complaint
investigations, which CMS refers to in the Five-Star System as health
inspections; (2) ratings on nursing home staffing levels; and (3)
ratings on quality of care measures. In December 2008, CMS's Nursing
Home Compare Web site began reporting the star ratings that nursing
homes receive for each component of the Five-Star System as well as an
overall quality rating.[Footnote 26] According to CMS officials, as of
March 2009 the rating for the health inspections component was based on
CMS's SFF methodology, with one variation: the Five-Star System assigns
more points to D-through I-level deficiencies than does the SFF
methodology.[Footnote 27] (See table 2.) CMS explained that it changed
some of the points assigned to deficiencies in the Five-Star System
because the purpose is different from that of the SFF Program. The SFF
Program focuses on facilities in each state whose performance is
consistently extremely poor, and so it assigns many points to immediate
jeopardy deficiencies relative to other, lower-level deficiencies. In
contrast, the purpose of the Five-Star System is to distinguish
performance across all nursing homes, rather than focus on the poorest
performers, and so CMS modified the points to provide more emphasis on
deficiencies at the potential for more than minimal harm and actual
harm levels. The rating for the second component, staffing data, is
based on two elements--total nursing hours per resident day and
registered nurse hours per resident day.[Footnote 28] The rating for
the third component of the Five-Star System is based on nursing home
performance on 10 quality of care measures, such as percentage of high-
risk residents who have pressure sores.[Footnote 29]
Five Hundred Eighty Nursing Homes Could Be Considered the Most Poorly
Performing--Fewer Than CMS's SFF Program Candidates but More Than the
Number of SFFs:
We estimated that almost 4 percent--or 580--of the nation's roughly
16,000 nursing homes could be considered the most poorly performing.
These 580 homes overlap somewhat with the 755 SFF Program candidates
and the 136 nursing homes actually selected as SFFs.[Footnote 30] For
example, our estimate of 580 most poorly performing nursing homes
includes (1) 302, or 40 percent, of the 755 SFF Program candidates as
of December 2008 (see figure 2) and (2) 65 nursing homes that 31 states
selected as SFFs from among the SFF Program candidates, or about half
of the active SFFs as of February 2009.[Footnote 31] In addition, our
estimate resulted in some states having fewer or more poorly performing
homes than CMS currently allocates to states under the SFF Program. For
example, 10 states each had over 20 of the most poorly performing
nursing homes. Indiana had the greatest number, with 52 such nursing
homes, or almost 9 percent of the total of 580 homes. Eight states had
no such nursing homes. (See figure 3.)
Figure 2: Overlap between Our Estimate of the Most Poorly Performing
Nursing Homes in the Nation and the SFF Program Candidates, as of
December 2008:
[Refer to PDF for image: illustration]
Our estimate of the most poorly performing nursing homes in the nation:
580 total;
SFF Program candidates: the nursing homes in each state with the 15
worst scores: 755 total;
Overlap: 302.
Source: GAO analysis of CMS data.
Note: We determined the 755 SFF Program candidates using CMS's SFF
methodology. There are 755 such homes because some nursing homes in the
same state had the same total score and because we excluded nursing
homes in Alaska, which does not have SFFs, and included nursing homes
in the District of Columbia, which has one SFF.
[End of figure]
Figure 3: Our Estimate of the Number of Most Poorly Performing Nursing
Homes as of December 2008 Compared to the Number of SFFs by State:
[Refer to PDF for image: map of the United States]
Our estimate of the most poorly performing nursing homes: 508 total.
State: Alabama;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 7.
State: Alaska;
Special focus facilities: 0;
Our estimate of the most poorly performing nursing homes: 0.
State: Arizona;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 4.
State: Arkansas (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 34.
State: California (State with more than 20 of the most poorly
performing nursing homes);
Special focus facilities: 6;
Our estimate of the most poorly performing nursing homes: 40.
State: Colorado;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 12.
State: Connecticut;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 5.
State: Delaware;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 4.
State: District of Columbia;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 2.
State: Florida;
Special focus facilities: 5;
Our estimate of the most poorly performing nursing homes: 16.
State: Georgia;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 9.
State: Hawaii;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 0.
State: Idaho;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 2.
State: Illinois (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 5;
Our estimate of the most poorly performing nursing homes: 47.
State: Indiana (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 52.
State: Iowa;
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 10.
State: Kansas (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 38.
State: Kentucky;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 10.
State: Louisiana (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 21.
State: Maine;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 4.
State: Maryland;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 1.
State: Massachusetts;
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 2.
State: Michigan (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 30.
State: Minnesota;
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 4.
State: Mississippi;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 6.
State: Missouri (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 37.
State: Montana;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 0.
State: Nebraska;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 3.
State: Nevada;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 0.
State: New Hampshire;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 3.
State: New Jersey;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 8.
State: New Mexico;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 6.
State: New York;
Special focus facilities: 5;
Our estimate of the most poorly performing nursing homes: 18.
State: North Carolina;
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 2.
State: North Dakota;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 0.
State: Ohio;
Special focus facilities: 5;
Our estimate of the most poorly performing nursing homes: 3.
State: Oklahoma (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 36.
State: Oregon;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 1.
State: Pennsylvania;
Special focus facilities: 5;
Our estimate of the most poorly performing nursing homes: 6.
State: Rhode Island;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 0.
State: South Carolina;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 7.
State: South Dakota;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 0.
State: Tennessee;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 14.
State: Texas (State with more than 20 of the most poorly performing
nursing homes);
Special focus facilities: 6;
Our estimate of the most poorly performing nursing homes: 43.
State: Utah;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 0.
State: Vermont;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 1.
State: Virginia;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 4.
State: Washington;
Special focus facilities: 3;
Our estimate of the most poorly performing nursing homes: 14.
State: West Virginia;
Special focus facilities: 2;
Our estimate of the most poorly performing nursing homes: 5.
State: Wisconsin;
Special focus facilities: 4;
Our estimate of the most poorly performing nursing homes: 7.
State: Wyoming;
Special focus facilities: 1;
Our estimate of the most poorly performing nursing homes: 2.
Sources: Copyright © Corel Corp. All rights reserved (map); GAO
analysis of CMS data.
Note: Our estimate of 580 most poorly performing nursing homes included
65 nursing homes that were SFFs as of February 2009.
[End of figure]
CMS's Application of the SFF Methodology Misses Many of the Nation's
Most Poorly Performing Nursing Homes:
CMS has structured the SFF Program so that every state (except Alaska)
has at least one SFF, and therefore the agency applies the SFF
methodology to identify the 15 worst performing nursing homes in each
state, which are not necessarily the worst performing homes in the
nation. We developed an estimate that identified homes with worse
compliance histories--more deficiencies at the potential for more than
minimal harm level or higher and more revisits--than SFF Program
candidates by applying CMS's SFF methodology on a nationwide basis and
using statistical scoring thresholds. These two changes had the
greatest impact on the composition of the list of homes we identified
as the most poorly performing compared to CMS's approach. Our estimate
also incorporated several refinements to the SFF methodology that
moderately improve its ability to identify the most poorly performing
nursing homes.
Compliance history. Our estimate of 580 nursing homes identified homes
with more deficiencies at the potential for more than minimal harm
level or higher and more revisits, on average, compared to the 755 SFF
Program candidates. For example, the most poorly performing nursing
homes averaged 46.5 percent more actual harm-level deficiencies and
19.5 percent more immediate jeopardy-level deficiencies, compared to
the 755 SFF Program candidates. (See table 3.)
Table 3: Compliance History over the Last Three Cycles for Our Estimate
of the Most Poorly Performing Nursing Homes Compared to the SFF Program
Candidates, as of December 2008:
Average number of deficiencies and revisits in the last three cycles:
Compliance history: Total deficiencies at the D level or higher;
Most poorly performing nursing homes (580 homes): 55.7;
SFF Program candidates (755 homes): 43.9;
Percentage difference[A]: 26.9.
Compliance history: Deficiencies at the potential for more than minimal
harm level (D-F);
Most poorly performing nursing homes (580 homes): 47.3;
SFF Program candidates (755 homes): 37.7;
Percentage difference[A]: 25.5.
Compliance history: Deficiencies at the actual harm level (G-I);
Most poorly performing nursing homes (580 homes): 5.4;
SFF Program candidates (755 homes): 3.7;
Percentage difference[A]: 46.5.
Compliance history: Deficiencies at the immediate jeopardy level (J-L);
Most poorly performing nursing homes (580 homes): 3.0;
SFF Program candidates (755 homes): 2.5;
Percentage difference[A]: 19.5.
Compliance history: Deficiencies by survey type (D-L): Deficiencies
cited on standard surveys;
Most poorly performing nursing homes (580 homes): 40.8;
SFF Program candidates (755 homes): 33.7;
Percentage difference[A]: 21.3.
Compliance history: Deficiencies by survey type (D-L): Deficiencies
cited on complaint investigations;
Most poorly performing nursing homes (580 homes): 14.9;
SFF Program candidates (755 homes): 10.2;
Percentage difference[A]: 45.6.
Compliance history: Number of revisits;
Most poorly performing nursing homes (580 homes): 2.4;
SFF Program candidates (755 homes): 1.9;
Percentage difference[A]: 28.7.
Source: GAO analysis of CMS data.
Notes: (1) We determined the 755 SFF Program candidates using CMS's SFF
methodology. There are 755 of these nursing homes because some nursing
homes in the same state had the same total score and because we
excluded nursing homes in Alaska, which does not have SFFs, and
included nursing homes in the District of Columbia, which has one SFF.
(2) We did not determine whether the differences between groups were
significant because the nursing homes in each group overlapped.
[A] Percentage differences were calculated using unrounded data and
therefore differ slightly from percentage differences calculated
directly from this table.
[End of table]
Nationwide estimate. We developed a nationwide estimate because the
worst performing nursing homes in some states had high total scores
from a combination of numerous deficiencies, serious deficiencies, and
revisits, while the worst performing nursing homes in other states did
not (see figure 4).[Footnote 32] For example, in the preceding three
cycles, we found that the worst performing nursing home in South Dakota
had a score of about 68. The score was composed of 32 deficiencies at
the D level or higher, 2 of which were at the actual harm level (where
the highest scope and severity level was H) and none of which were at
the immediate jeopardy level. In contrast, during the same three
cycles, the worst performing nursing home in Tennessee had a score of
about 1,512, with 63 deficiencies at the D level or higher. Of these
deficiencies, 3 were at the actual harm level and 22 at the immediate
jeopardy level (where the highest scope and severity level was L). Even
the 15th highest-scoring home in Tennessee, with a score of about 253,
had notably more deficiencies at the D level or higher and more severe
deficiencies than the highest-scoring home in South Dakota:
specifically, the Tennessee home had 63 deficiencies at the D level or
higher, 2 of which were at the actual harm level and 8 of which were at
the immediate jeopardy level. If CMS applied its SFF methodology to
identify the worst 755 homes in the nation rather than the worst 15 in
each state, the home ranked 755 would have a score of about 127;
however, 48 percent of the SFF Program candidates had scores below this
threshold. As a result, the SFF Program is missing some of the worst
performing nursing homes in the nation.
Figure 4: Total Score Ranges for the SFF Program Candidates, as of
December 2008:
[Refer to PDF for image: horizontal bar graph]
State: Tennessee;
Minimum: 253;
Maximum: 1,512.
State: Kentucky;
Minimum: 185;
Maximum: 925.
State: Arkansas;
Minimum: 241;
Maximum: 863.
State: Louisiana;
Minimum: 246;
Maximum: 743.
State: South Carolina;
Minimum: 117;
Maximum: 698.
State: New York;
Minimum: 229;
Maximum: 638.
State: Oklahoma;
Minimum: 167;
Maximum: 605.
State: Mississippi;
Minimum: 141;
Maximum: 574.
State: Florida;
Minimum: 163;
Maximum: 571.
State: Texas;
Minimum: 350;
Maximum: 565.
State: Illinois;
Minimum: 241;
Maximum: 558.
State: Wisconsin;
Minimum: 133;
Maximum: 555.
State: Alabama;
Minimum: 116;
Maximum: 500.
State: Maine;
Minimum: 83;
Maximum: 454.
State: Kansas;
Minimum: 164;
Maximum: 436.
State: California;
Minimum: 215;
Maximum: 431.
State: Oregon;
Minimum: 66;
Maximum: 391.
State: New Hampshire;
Minimum: 35;
Maximum: 390.
State: Missouri;
Minimum: 177;
Maximum: 379.
State: Georgia;
Minimum: 127;
Maximum: 363.
State: New Jersey;
Minimum: 113;
Maximum: 356.
State: New Mexico;
Minimum: 90;
Maximum: 321.
State: North Carolina;
Minimum: 91;
Maximum: 320.
State: Indiana;
Minimum: 193;
Maximum: 308.
State: Michigan;
Minimum: 162;
Maximum: 307.
State: District of Columbia;
Minimum: 32;
Maximum: 286.
State: Vermont;
Minimum: 42;
Maximum: 278.
State: Connecticut;
Minimum: 92;
Maximum: 254.
State: Nebraska;
Minimum: 66;
Maximum: 245.
State: Wyoming;
Minimum: 50;
Maximum: 243.
State: Colorado;
Minimum: 101;
Maximum: 243.
State: Rhode Island;
Minimum: 29;
Maximum: 238.
State: Utah;
Minimum: 27;
Maximum: 230.
State: Massachusetts;
Minimum: 67;
Maximum: 229.
State: Virginia;
Minimum: 73;
Maximum: 229.
State: Arizona;
Minimum: 84;
Maximum: 210.
State: Washington;
Minimum: 112;
Maximum: 204.
State: Ohio;
Minimum: 101;
Maximum: 194.
State: Minnesota;
Minimum: 104;
Maximum: 182.
State: Pennsylvania;
Minimum: 91;
Maximum: 180.
State: Iowa;
Minimum: 99;
Maximum: 174.
State: Hawaii;
Minimum: 22;
Maximum: 173.
State: West Virginia;
Minimum: 75;
Maximum: 170.
State: Maryland;
Minimum: 81;
Maximum: 151.
State: Montana;
Minimum: 51;
Maximum: 140.
State: Delaware;
Minimum: 52;
Maximum: 126.
State: Idaho;
Minimum: 67;
Maximum: 117.
State: Nevada;
Minimum: 31;
Maximum: 111.
State: North Dakota;
Minimum: 16;
Maximum: 79.
State: South Dakota;
Minimum: 30;
Maximum: 68.
Source: GAO analysis of CMS data.
Notes: (1) This figure illustrates the range of scores for the 755 SFF
Program candidates, as of December 2008, which we determined based on
CMS's SFF methodology. There are 755 such homes because some nursing
homes in the same state had the same total score and because we
excluded nursing homes in Alaska, which does not have SFFs, and
included nursing homes in the District of Columbia, which has one SFF.
(2) The left side of the bars represents the homes with the lowest
scores, and the right side represents the homes with the highest
scores.
[End of figure]
Statistical scoring thresholds. Absent a fixed number of homes per
state, we developed statistical scoring thresholds because there was no
natural break point delineating the most poorly performing nursing
homes from all other homes.[Footnote 33] The two statistical scoring
thresholds we used were conservative, because they focused on chronic
poor performance and nonchronic, very poor performance. About 87
percent of the 580 nursing homes that we identified as the most poorly
performing exhibited chronic poor performance; that is, they had high
scores in at least two of the three cycles measured, as well as a high
total score. The remaining roughly 13 percent of nursing homes had
nonchronic but very poor performance; that is, they had very serious
poor performance in one cycle only, which resulted in a very high total
score.
Homes that met our chronic poor performance threshold had total scores
above the 93rd percentile for all nursing homes, or total scores
ranging from approximately 168 to approximately 1,017.[Footnote 34] All
of the nonchronic but very poor performing homes had total scores at or
above the 99th percentile for all nursing homes, or total scores
ranging from approximately 330 to approximately 1,577. Table 4
summarizes the compliance history of two of the most poorly performing
homes identified by our estimate, and appendix II provides a detailed
compliance history for these two homes.
Table 4: Compliance Histories over the Last Three Cycles for Two of the
Most Poorly Performing Nursing Homes, as of December 2008:
Example of a chronic poor performer (total score of about 507):
Cycle 1;
Number of deficiencies: Potential for more than minimal harm:
Number of deficiencies: Actual harm: 3;
Number of deficiencies: Immediate jeopardy: 0;
Number of complaint investigations with deficiencies[A]: 4;
Example of standard for which highest deficiency was cited[B]: Proper
treatment to prevent or heal pressure sores.
Cycle 2;
Number of deficiencies: Potential for more than minimal harm: 13;
Number of deficiencies: Actual harm: 4;
Number of deficiencies: Immediate jeopardy: 0;
Number of complaint investigations with deficiencies[A]: 5;
Example of standard for which highest deficiency was cited[B]: Facility
is free of accident hazards.
Cycle 3;
Number of deficiencies: Potential for more than minimal harm: 21;
Number of deficiencies: Actual harm: 5;
Number of deficiencies: Immediate jeopardy: 15;
Number of complaint investigations with deficiencies[A]: 5;
Example of standard for which highest deficiency was cited[B]:
Facility prohibits abuse or neglect.
Example of a nonchronic, very poor performer (total score of about
344):
Cycle 1;
Number of deficiencies: Potential for more than minimal harm: 15;
Number of deficiencies: Actual harm: 4;
Number of deficiencies: Immediate jeopardy: 7;
Number of complaint investigations with deficiencies[A]: 3;
Example of standard for which highest deficiency was cited[B]:
Resident's care supervised by a physician.
Cycle 2;
Number of deficiencies: Potential for more than minimal harm: 7;
Number of deficiencies: Actual harm: 0;
Number of deficiencies: Immediate jeopardy: 0;
Number of complaint investigations with deficiencies[A]: 1;
Example of standard for which highest deficiency was cited[B]: Facility
establishes infection control program.
Cycle 3;
Number of deficiencies: Potential for more than minimal harm: 5;
Number of deficiencies: Actual harm: 0;
Number of deficiencies: Immediate jeopardy: 0;
Number of complaint investigations with deficiencies[A]: 0;
Example of standard for which highest deficiency was cited[B]:
Medication error rates of 5 percent or more.
Source: GAO analysis of CMS data.
Notes: (1) Both homes had one revisit that contributed to their total
scores. (2) Total score incorporates our refinements to the SFF
methodology, which are discussed in the next section.
[A] This column only includes complaint investigations with
deficiencies at the D level or higher.
[B] The descriptions of the standards in this column have been
abbreviated from those that appear in CMS guidance.
[End of table]
Additional homes might have been identified as the most poorly
performing had we used different thresholds. For example, one nursing
home with a total score of about 324 did not meet our definition for
chronic poor performance and was below the threshold of 330 for
nonchronic, very poor performance. During the three-cycle period, this
nursing home had 41 D-through F-level deficiencies, 5 immediate
jeopardy deficiencies, and a second revisit that contributed to the
score, but most of the deficiencies and the revisit occurred in one
cycle.
Refinements made to CMS's SFF methodology. Our three refinements to
CMS's SFF methodology had a moderate effect on the composition of the
list of homes we identified as the most poorly performing.
* Deficiency points. We believe that the deficiency points used in the
Five-Star System are more appropriate for identifying the most poorly
performing nursing homes nationwide than those used in the SFF
methodology because they compensate somewhat for understatement and the
interstate variation in the citation of serious deficiencies. First,
given the significant disparity between immediate jeopardy (50 to 150
points) compared to lower-level deficiencies (2 to 6 points for D-
through F-level deficiencies), our use of SFF deficiency points to
identify the most poorly performing nursing homes nationwide might have
missed poorly performing nursing homes in states with significant
understatement. Second, there is considerable interstate variation in
the citation of serious deficiencies, including immediate jeopardy-
level deficiencies. For example, in 2008, about 11.3 percent of
deficiencies were at the immediate jeopardy level in one state, but
less than 1.0 percent of deficiencies were cited at that level in 26
states.[Footnote 35] The Five-Star System, on average, doubles the
points assigned to deficiencies below the immediate jeopardy level,
giving a D-level deficiency 4 points and a G-level deficiency 20
points, compared to 2 and 10 points, respectively, using the SFF
deficiency methodology. As a result, using the Five-Star System
deficiency points, homes with numerous D-through I-level deficiencies
are more likely to be identified as the most poorly performing. CMS
officials told us that they planned to evaluate the effect of using the
Five-Star System deficiency points on identifying SFF candidates; our
analysis showed that it changed the composition of SFF Program
candidates by an average of about 2.5 candidates per state.
* Substandard quality of care. In comparison with the SFF methodology
and the Five-Star System, we assigned 5 more points to G-level
deficiencies that occurred in any of the three categories of standards
that CMS considers to be SQC.[Footnote 36] As noted earlier, CMS does
not classify any G-level deficiencies as SQC. Without this
modification, an F-level deficiency in an SQC area is assigned the same
number of points as a G-level deficiency even if the G-level deficiency
is in an SQC standard--10 and 20 points, respectively, under the SFF or
Five-Star System methodologies. (See table 2.) This adjustment was
important because approximately 45 percent of all nursing homes had one
or more G-level deficiencies in an SQC category during the three cycles
used for calculating SFF scores. Therefore, assigning SQC points to G-
level deficiencies had an effect on total scores for the nursing homes,
which we used to determine the most poorly performing homes nationwide,
and would have an effect on the composition of CMS's SFF candidate
list. For example, about 4 percent of the SFF Program candidates--or
less than one candidate per state on average--would change if CMS
assigned SQC points to G-level deficiencies.
* Technical status changes. While the SFF methodology does not consider
all deficiencies and revisits identified within the three-cycle period
that occurred before the nursing home's technical status change, we
incorporated the full histories of nursing homes that underwent a
technical status change.[Footnote 37] At the time of a technical status
change, a new provider identification number is assigned, and the
nursing home's complete history under the old number is not combined
with that of the new provider number. For example, a nursing home with
a status change on January 1, 2008, might have a compliance history for
only 1 year at the time we did our work instead of the three cycles
called for in the SFF methodology. The SFF scores for nursing homes
that have undergone technical status changes within the last three
cycles are almost always lower than would be the case if three cycles
of deficiency history were included and, therefore, more favorable than
would be justified by the complete history. We found that almost 1
percent of all nursing homes (148), including 11 of the 580 we
identified as the most poorly performing, had a technical status change
during the last three cycles that affected their SFF scores.[Footnote
38] For most states, this change would not have affected their SFF
candidate lists.
Key Characteristics, such as Chain Affiliation and For-Profit Status
Differentiated the Most Poorly Performing Nursing Homes:
Compared to all other nursing homes, the most poorly performing nursing
homes in the nation averaged notably more deficiencies at the D level
or higher, more serious deficiencies, and more revisits. They were also
more likely to be for-profit and part of a chain and have more beds and
residents. In addition, they had an average of almost 24 percent fewer
registered nurse hours per resident per day.
Actual Harm and Immediate Jeopardy Deficiencies Occurred Significantly
More Often for the Most Poorly Performing Nursing Homes:
Compared to all other nursing homes, deficiencies over the last three
cycles at the actual harm (G through I) level occurred over 5 times as
often, and deficiencies at the immediate jeopardy (J through L) level
occurred 15 times as often for the most poorly performing
homes.[Footnote 39] (See table 5.) Furthermore, we found that revisits
were made to the most poorly performing nursing homes 6 times as often
as to all other nursing homes.
Table 5: Compliance History over Last Three Cycles for the Most Poorly
Performing Nursing Homes and All Other Nursing Homes, as of December
2008:
Compliance history: Total deficiencies at the D level or higher;
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 55.7;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 20.3.
Compliance history: Deficiencies by scope and severity level (D-L):
Deficiencies at the potential for more than minimal harm level (D-F);
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 47.3;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 19.1.
Compliance history: Deficiencies by scope and severity level (D-L):
Deficiencies at the actual harm level (G-I);
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 5.4;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 1.0.
Compliance history: Deficiencies by scope and severity level (D-L):
Deficiencies at the immediate jeopardy level (J-L);
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 3.0;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 0.2.
Compliance history: Deficiencies by survey type (D-L): Deficiencies
cited on standard surveys;
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 40.8;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 17.3.
Compliance history: Deficiencies by survey type (D-L): Deficiencies
cited on complaint investigations;
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 14.9;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 3.0.
Compliance history: Number of revisits;
Average number of deficiencies and revisits in the last three cycles:
Most poorly performing nursing homes: 2.4;
Average number of deficiencies and revisits in the last three cycles:
All other nursing homes: 0.4.
Source: GAO analysis of CMS data.
Note: All differences between groups are significant at the 0.05 level.
[End of table]
The most poorly performing nursing homes were more frequently cited for
deficiencies in important care areas and specific standards related to
the delivery of care compared to all other nursing homes. Seven of the
10 most frequently cited deficiencies at the immediate jeopardy level
involved standards in the categories of care that CMS considers to be
SQC and four of the 10 are related to abuse or neglect. For example,
about 42 percent of the most poorly performing nursing homes had at
least one immediate jeopardy deficiency related to being free of
accident hazards in the last three cycles, compared with about 5
percent for all other nursing homes. (See table 6.) A larger proportion
of the most poorly performing nursing homes were cited for actual harm
in each of the three SQC areas--about 90 percent in Quality of Care,
about 31 percent in Resident Behavior and Facility Practices, and about
17 percent in Quality of Life. In comparison, a smaller proportion of
all other nursing homes were cited for actual harm in those same
categories of care--about 42 percent in Quality of Care, about 6
percent in Resident Behavior and Facility Practices, and about 2
percent in Quality of Life. (See appendix III.)
Table 6: The 10 Standards Most Often Cited at the Immediate Jeopardy
Level in the Last Three Cycles among the Most Poorly Performing Homes
Compared to All Other Nursing Homes, as of December 2008:
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility is free of
accident hazards;
Federal quality standard category: Quality of Care[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 42.1;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 5.4.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility is administered
effectively to obtain highest practicable physical, mental, and
psychosocial well-being of each resident;
Federal quality standard category: Administration;
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 28.6;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 2.1.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Provides necessary care
for highest practicable physical, mental, and psychosocial well-being;
Federal quality standard category: Quality of Care[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 25.7;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 2.5.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility prohibits abuse
or neglect;
Federal quality standard category: Resident Behavior and Facility
Practices[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 15.3;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 1.2.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Policies and procedures
prohibit abuse or neglect;
Federal quality standard category: Resident Behavior and Facility
Practices[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 12.6;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.7.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility must inform
resident, resident's physician, and family of any accidents; changes in
the resident's physical, mental, or psychosocial status, or treatment;
or of a decision to transfer or discharge resident;
Federal quality standard category: Resident Rights;
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 11.9;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.8.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Proper treatment to
prevent or heal pressure sores;
Federal quality standard category: Quality of Care[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 10.9;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.6.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility must not employ
persons guilty of abuse, neglect, or mistreatment, and must investigate
and report alleged violations involving abuse, neglect, or
mistreatment;
Federal quality standard category: Resident Behavior and Facility
Practices[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 10.0;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.6.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Facility maintains a
quality assessment and assurance committee;
Federal quality standard category: Administration;
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 9.5;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.5.
Ten standards most often cited at the immediate jeopardy level among
the most poorly performing nursing homes[A]: Residents have a right to
be free from abuse;
Federal quality standard category: Resident Behavior and Facility
Practices[B];
Percentage of the most poorly performing nursing homes with at least
one immediate jeopardy citation: 8.6;
Percentage of all other nursing homes with at least one immediate
jeopardy citation: 0.8.
Source: GAO analysis of CMS data.
Note: All differences between groups are significant at the 0.05 level.
[A] The descriptions of the standards in this column have been
abbreviated from those that appear in CMS guidance.
[B] Deficiencies cited at the immediate jeopardy level in these
standards are considered to be SQC.
[End of table]
We also found that from fiscal years 2006 through 2008 the most poorly
performing nursing homes were much more likely to have had deficiencies
that could have resulted in the imposition of at least one immediate
sanction compared to all other nursing homes.[Footnote 40] For example,
in fiscal year 2008, about 33 percent of the most poorly performing
homes may have been at risk of having at least one immediate sanction
imposed, compared to about 4 percent for all other nursing homes.
Nursing homes that receive at least one G-through L-level deficiency on
successive standard surveys or complaint investigations must be
referred for immediate sanctions, and about 15 percent of the
deficiencies for the most poorly performing nursing homes, on average
over the last three cycles, were at the actual harm or immediate
jeopardy level.
The Most Poorly Performing Nursing Homes Differed from All Others in
Several Ways, Including Chain Affiliation and For-Profit Status:
We found that the most poorly performing nursing homes differed from
all other nursing homes in terms of the proportion of each group that
was chain affiliated, for-profit, or both. They also differed in size
and nurse staffing.[Footnote 41]
Type of organization. We found that the most poorly performing nursing
homes were less likely to be hospital based compared to all other
nursing homes. Additionally, compared to all other nursing homes, we
found that the most poorly performing nursing homes were more likely to
be part of for-profit organizations, more likely to be affiliated with
a chain organization, and more likely to be both for-profit and
affiliated with a chain organization. About 55 percent of the most
poorly performing nursing homes were for-profit and chain affiliated,
compared to about 41 percent of all other homes. (See table 7.)
Table 7: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Type of Organization, as of December 2008:
Type of organization: Facility type: Hospital based;
Percentage of the most poorly performing nursing homes: 1.9;
Percentage of all other nursing homes: 7.8.
Type of organization: Facility type: Freestanding;
Percentage of the most poorly performing nursing homes: 98.1;
Percentage of all other nursing homes: 92.2.
Type of organization: Ownership type: For-profit (individual,
partnership, or corporation);
Percentage of the most poorly
performing nursing homes: 84.1; Percentage of all other nursing homes:
67.0.
Type of organization: Ownership type: Nonprofit (corporation, church,
or other); Percentage of the most poorly performing nursing homes:
11.6; Percentage of all other nursing homes: 27.1.
Type of organization: Ownership type: Government owned;
Percentage of the most poorly performing nursing homes: 4.3[A];
Percentage of all other nursing homes: 5.9[A].
Type of organization: Chain affiliation;
Percentage of the most poorly performing nursing homes: 61.9;
Percentage of all other nursing homes: 53.2.
Type of organization: For-profit and chain affiliated;
Percentage of the most poorly performing nursing homes: 54.5;
Percentage of all other nursing homes: 41.4.
Type of organization: Nonprofit and chain affiliated;
Percentage of the most poorly performing nursing homes: 6.6;
Percentage of all other nursing homes: 11.2.
Type of organization: Government owned and chain affiliated;
Percentage of the most poorly performing nursing homes: 0.9[A];
Percentage of all other nursing homes: 0.7[A].
Source: GAO analysis of CMS data.
Notes: Unless otherwise noted, all differences between groups are
significant at the 0.05 level. Individual entries may not sum to totals
because of rounding.
[A] The difference between most poorly performing and all other nursing
homes for this variable is not significant.
[End of table]
Participation in Medicare and Medicaid. We found that a higher
percentage of the most poorly performing homes participated in both
Medicare and Medicaid, and a smaller percentage of such homes
participated only in Medicare or only in Medicaid, compared to all
other nursing homes. (See table 8.)
Table 8: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Medicare and Medicaid Participation, as of
December 2008:
Medicare and Medicaid participation: Medicare and Medicaid;
Percentage of the most poorly performing nursing homes: 96.2;
Percentage of all other nursing homes: 90.2.
Medicare and Medicaid participation: Medicare only;
Percentage of the most poorly performing nursing homes: 0.2;
Percentage of all other nursing homes: 5.3.
Medicare and Medicaid participation: Medicaid only;
Percentage of the most poorly performing nursing homes: 3.6;
Percentage of all other nursing homes: 4.5.
Source: GAO analysis of CMS data.
Note: All differences between groups are significant at the 0.05 level.
[End of table]
Beds and residents. We found that a larger percentage of the most
poorly performing homes had more than 100 beds, compared to all other
nursing homes.[Footnote 42] On average, the most poorly performing
nursing homes had about 23 percent more beds than all other nursing
homes. Additionally, our analysis found that on average, the most
poorly performing homes had almost 14 percent more residents, a lower
occupancy rate, and a greater share of Medicaid patients. (See table
9.)
Table 9: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Beds and Residents, as of December 2008:
Beds and residents: Average number of beds per home[A];
Most poorly performing nursing homes: 129.7;
All other nursing homes: 105.3.
Beds and residents: Bed size (percentage): 0 to 49 beds;
Most poorly performing nursing homes: 3.4;
All other nursing homes: 14.1.
Beds and residents: Bed size (percentage): 50 to 99 beds;
Most poorly performing nursing homes: 28.8;
All other nursing homes: 36.6.
Beds and residents: Bed size (percentage): 100 to 199 beds;
Most poorly performing nursing homes: 57.2;
All other nursing homes: 43.0.
Beds and residents: Bed size (percentage): More than 199 beds;
Most poorly performing nursing homes: 10.5;
All other nursing homes: 6.2.
Beds and residents: Average number of residents per home;
Most poorly performing nursing homes: 101.7;
All other nursing homes: 89.4.
Beds and residents: Average occupancy rate (percentage)[B];
Most poorly performing nursing homes: 78.3;
All other nursing homes: 84.6.
Beds and residents: Average share of resident type (percentage):
Medicare;
Most poorly performing nursing homes: 12.2;
All other nursing homes: 15.8.
Beds and residents: Average share of resident type (percentage):
Medicaid;
Most poorly performing nursing homes: 69.5;
All other nursing homes: 59.5.
Beds and residents: Average share of resident type (percentage): Other;
Most poorly performing nursing homes: 18.3;
All other nursing homes: 24.7.
Source: GAO analysis of CMS data.
Notes: All differences between groups are significant at the 0.05
level. Individual entries may not sum to totals because of rounding.
[A] We analyzed the number of certified beds, which is the number of
Medicare beds, Medicaid beds, or both.
[B] Average occupancy rate is the average of the number of residents
per home divided by the number of certified beds per home.
[End of table]
Nurse staffing levels. Compared to all other nursing homes, the most
poorly performing homes had almost 24 percent fewer registered nurse
hours per resident per day on average.[Footnote 43] One effect of this
difference is that the most poorly performing nursing homes averaged
fewer registered nurse hours per resident per day as a share of total
nursing hours. Specifically, registered nurse hours made up about 8
percent of total nurse staffing hours in the most poorly performing
nursing homes, compared to about 10 percent in all other nursing homes.
(See table 10.)
Table 10: Distribution of the Most Poorly Performing Nursing Homes and
All Other Nursing Homes by Case-Mix-Adjusted Nurse Staffing Levels, as
of November 2008:
Type of staff (average hours per resident per day):
Nurse staffing levels[A]: Registered nurse;
Most poorly performing nursing homes: 0.28;
All other nursing homes: 0.36;
Percentage difference[B]: -23.51.
Nurse staffing levels[A]: Licensed practical and vocational nurses;
Most poorly performing nursing homes: 1.03;
All other nursing homes: 0.98;
Percentage difference[B]: 4.16.
Nurse staffing levels[A]: Nurse aide;
Most poorly performing nursing homes: 2.37[C];
All other nursing homes: 2.40[C];
Percentage difference[B]: -1.13.
Nurse staffing levels[A]: Total;
Most poorly performing nursing homes: 3.42;
All other nursing homes: 3.55;
Percentage difference[B]: -3.76.
Nurse staffing levels[A]: Registered nurse hours as a share of total
nurse staffing hours (percentage)[D];
Most poorly performing nursing homes: 8.15;
All other nursing homes: 10.07;
Percentage difference[B]: n/a.
Source: GAO analysis of CMS data.
Note: Unless otherwise noted, all differences between groups are
significant at the 0.05 level.
[A] The staffing data we analyzed were case-mix adjusted by CMS for use
in the Five-Star System.
[B] Percentage differences were calculated using unrounded data and
therefore differ slightly from percentage differences calculated
directly from this table.
[C] The difference between most poorly performing and all other nursing
homes for this variable is not significant.
[D] Registered nurse hours as a share of total nurse staffing hours is
an average across all homes in each group; therefore, the percentages
differ slightly from those as calculated directly from this table.
[End of table]
Conclusions:
Our estimate of the most poorly performing nursing homes nationwide is
more than four times greater than the 136 homes that receive enhanced
scrutiny under CMS's SFF Program. We believe that our estimate is
conservative, because we focused only on those nursing homes with
chronic poor performance over time or with very poor performance in one
survey cycle. Because of resource constraints, CMS limits the size of
the SFF Program, requiring every state except Alaska to select from 1
to 6 homes--an allocation based on the number of nursing homes in each
state--from a list of 15 candidates. The homes selected are not
necessarily the most poorly performing homes in the nation but rather
are among the poorest performers in each state. In contrast, the 580
homes we identified have more deficiencies at the potential for more
than minimal harm level or higher and more revisits on average than the
755 homes identified as potential SFF candidates using CMS's SFF
methodology. Our estimate also revealed that the state-by-state
distribution of the most poorly performing homes nationwide is uneven,
calling into question the approach CMS uses to allocate SFFs across
states.
Furthermore, we believe that CMS's SFF Program and the Five-Star System
could be strengthened by incorporating the three enhancements we made
to identify the most poorly performing homes nationwide:
* First, we adopted the deficiency points that CMS developed for its
Five-Star System because they compensate somewhat for understatement
and the interstate variation in the citation of serious deficiencies,
an important consideration for our nationwide estimate of the most
poorly performing nursing homes. Currently, CMS uses a different set of
deficiency points for the SFF methodology, but agency officials told us
that they planned to study the effect of using a common set of numeric
points--the Five-Star System deficiency points--for both methodologies.
* Second, we added points for G-level deficiencies in the three
standard areas that CMS considers to be an indication of SQC. We found
that about 4 percent of the SFF candidates--or less than 1 candidate
per state, on average--would change if CMS assigned SQC points to G-
level deficiencies when they were cited in an SQC area. Without such an
adjustment, an F-level deficiency in an SQC area would receive the same
number of deficiency points as a G-level deficiency in the same
standard area. Approximately 45 percent of all nursing homes had one or
more G-level deficiencies in an SQC category during the three cycles
used for calculating SFF scores.
* Third, we incorporated the full compliance history of homes that
underwent technical status changes. For example, a nursing home with a
technical status change on January 1, 2008, might have a compliance
history for only 1 year at the time we did our work instead of the
three cycles called for by the SFF methodology. The SFF scores of homes
that have undergone technical status changes within the last three
cycles are almost always lower than if all three cycles were
considered. We also found that the Five-Star System does not accurately
take into consideration technical status changes because it imputes a
total score to account for one missing standard survey rather than
using actual survey results.
Recommendations for Executive Action:
To improve the targeting of scarce survey resources, the Administrator
of CMS should consider an alternative approach for allocating the 136
SFFs across states, by placing more emphasis on the relative
performance of homes nationally rather than on a state-by-state basis,
which could result in some states having only one or not any SFFs and
other states having more than they are currently allocated.
To improve the SFF methodology's ability to identify the most poorly
performing nursing homes, the Administrator of CMS should make the
following three modifications:
1. Consider using a common set of numeric points for identifying poorly
performing nursing homes by determining the effect of adopting those
associated with the Five-Star System for the SFF methodology.
2. Assign points to G-level deficiencies in SQC areas equivalent to
those additional points assigned to H-and I-level deficiencies in SQC
areas.
3. Account for a nursing home's full compliance history regardless of
technical status changes.
To ensure consistency with the SFF methodology, CMS should also
consider making two of these modifications--the SQC and full compliance
history changes--to its Five-Star System.
Agency Comments and Our Evaluation:
We obtained written comments on our draft report from CMS, which are
reprinted in appendix IV. CMS noted that our report adds value
regarding the methods that CMS and the nursing home industry should use
to address the issue of homes that consistently demonstrate quality of
care problems and indicated that the agency would seriously consider
all of our recommendations. CMS generally agreed in principle with our
recommendations.
In response to our first recommendation, CMS noted that it would
evaluate a "hybrid" approach that would assign some SFFs using homes'
performance in each state and other SFFs on their relative national
ranking. If implemented, CMS's proposed hybrid approach would address
our recommendation that it consider placing more emphasis on the
relative performance of homes nationally, which might result in some
states having fewer SFFs and others having more than their current
allocation. We did not recommend that CMS allocate SFFs solely on the
basis of the relative performance of homes nationally, an approach CMS
would disagree with according to its comments.
CMS agreed in principle with our remaining recommendations--intended to
improve the SFF methodology's ability to identify the most poorly
performing nursing homes and ensure its consistency with the agency's
Five-Star System--and noted that it would evaluate the effects of
adopting them. The agency explained that there might be technical
barriers to fully implementing our recommendation that it account for a
nursing home's full compliance history regardless of technical status
changes, but noted that it would implement the recommended adjustment
to the maximum extent practicable. CMS agreed that although this change
would affect a small number of providers, it would improve the accuracy
of ratings for those providers.
CMS also provided technical comments, which we incorporated as
appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies to the
Administrator of the Centers for Medicare & Medicaid Services and
appropriate congressional committees. The report will also be available
at no charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or at dickenj@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix V.
Signed by:
John E. Dicken:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
This appendix provides a more detailed description of our scope and
methodology.
Determining the Number and Comparing the Performance of the Most Poorly
Performing Nursing Homes:
To determine the number of most poorly performing nursing homes in the
nation and compare their performance to that of homes identified using
the Centers for Medicare & Medicaid Services' (CMS) approach, we began
by interviewing agency officials about the Special Focus Facility (SFF)
Program and methodology and by reviewing documentation related to the
methodology. In addition, we interviewed officials in all 10 CMS
regional offices and 14 state survey agencies regarding their
impressions of the SFF methodology and also asked the state survey
agencies what they consider to be indicators of poor performance.
[Footnote 44] To ensure that we calculated the scores for each nursing
home consistent with CMS's SFF methodology, we obtained a copy of the
computer programming that CMS used to score and rank nursing homes,
verified that our use of CMS's program generated results that were
consistent with output on scores that CMS provided to states, and used
the program as the basis for our estimate of the most poorly performing
nursing homes in the United States. The SFF methodology creates a total
score for each nursing home over three cycles by assigning points to
the following data, which we obtained from CMS's On-Line Survey,
Certification, and Reporting system (OSCAR) database: (1) deficiencies
cited on the three most recent standard surveys, (2) deficiencies cited
on the last 3 years of complaint investigations, and (3) revisits
associated with the three most recent standard surveys.[Footnote 45]
Additional points are assigned to deficiencies classified as
substandard quality of care (SQC). Each cycle consists of one standard
survey, revisits associated with the standard survey, and 12 months of
complaint investigations. We extracted these data from OSCAR in
December 2008.[Footnote 46]
To learn about methods used to rate nursing home performance, we
interviewed officials of two nursing home associations--the American
Health Care Association and the American Association of Homes and
Services for the Aging, interviewed experts in long-term care research,
attended meetings that CMS held to seek input from long-term care
researchers on the development of the agency's Five-Star Quality Rating
System (Five-Star System), analyzed information available at CMS's
Providing Data Quickly Web site, reviewed prior GAO reports, and
interviewed officials from some states with nursing home rating
systems. We also reviewed documentation describing additional
approaches to rating nursing home performance. Specifically, we
reviewed eight nursing home rating systems, which considered a variety
of rating factors.[Footnote 47]
Examination of the SFF Methodology:
To determine the adequacy of the SFF methodology, we compared the
methodology to other compliance-based measures of poor performance and
tested the sensitivity of the methodology to variations, such as
weighting.
We compared the SFF methodology to two other compliance-based measures
of poor performance--SQC and immediate sanctions.[Footnote 48] We found
that those nursing homes with the worst total scores in the nation were
much more likely to have met the criteria for SQC in the last 1, 2, and
3 years compared to all other nursing homes. Similarly, we found that
the same nursing homes were much more likely to have had deficiencies
that could have resulted in the imposition of at least one immediate
sanction in the last 1, 2, and 3 years compared to all other nursing
homes.[Footnote 49] In addition, we tested the sensitivity of CMS's SFF
methodology to several variations, some of which led us to consider
making modifications to the methodology that affected facility scores.
For example, in one variation, we modified the SFF methodology so that
the cycle scores were no longer weighted--CMS began weighting the cycle
scores in June 2008. We concluded from this test that the SFF
methodology was sensitive to weighting, which influenced our decision
to impose a requirement in our scoring thresholds such that the most
poorly performing nursing homes have high scores in at least two of
three cycles or a very high score overall.
Based on our examinations of the SFF methodology, document review, and
interviews, we concluded that the SFF methodology is reasonable and
comprehensive because it uses multiple years of data, includes all
deficiencies as opposed to a subset of deficiencies, includes
deficiencies from standard surveys and complaint investigations, and
accounts for the scope and severity of deficiencies and the number of
revisits. Furthermore, CMS has refined the SFF methodology over time.
Development of the Nationwide Statistical Scoring Thresholds:
Although we concluded that estimating the number of the most poorly
performing nursing homes on a state-by-state rather than on a national
basis would yield inconsistent results, we determined that there was no
natural break point that differentiated the most poorly performing
nursing homes from all other homes. As a result, we investigated
several statistical approaches and determined that Tukey's method was
appropriate because the distribution of nursing homes' total scores is
highly skewed.[Footnote 50] Tukey's method is meant to identify the
extreme ends of the distribution. It labels an observation as a
potential outlier if its value is greater than the threshold identified
by the following equation:[Footnote 51]
Potential Outlier Threshold = Q3 + 1.5 * (Q3 - Q1);
Where: Q3 = 75th percentile and;
Q1 = 25th percentile:
The range identified by (Q3 - Q1), called the interquartile range,
covers 50 percent of the observations in the center of the
distribution. We applied this method by identifying nursing homes that
had scores that were above the potential outlier threshold.
We then explored several options to identify the most poorly performing
nursing homes using Tukey's method as a basis. For each option, we
analyzed the group of resulting nursing homes identified as poor
performers and those missed by the thresholds. As the result of our
examination of the SFF methodology and prior work in which we
classified nursing homes as low, moderately, or high performing, we
knew that nursing homes that have serious deficiencies in one year may
not demonstrate consistent poor performance--what we term chronic poor
performance in this report.[Footnote 52] Thus, another option we
considered was to identify as a poor performer any nursing home that
had a total score that (1) was above the potential outlier threshold
and (2) was also above the potential outlier threshold for at least two
of its three cycle scores. This option identified 507 nursing homes.
Because these nursing homes had poor performance in at least two of
three cycles as well as high total scores, we concluded that this
threshold identified chronic poor performance. However, we found that
when we limited the most poorly performing nursing homes to this group
of chronic poor performers we missed some nursing homes with very poor
performance that was not chronic. Therefore, we established a second
threshold to identify those very poor performers--those nursing homes
that were at or above the 99th percentile--or approximately 330--of
total score.[Footnote 53] This threshold added another 73 nursing
homes.[Footnote 54]
Determining the Characteristics of the Most Poorly Performing Nursing
Homes:
To determine the characteristics of the most poorly performing nursing
homes that distinguish them from all other nursing homes, we analyzed
deficiencies and revisits from the three most recent cycles--that is,
the three most recent standard surveys as of the date of our data
extract (December 17, 2008) and any associated revisits, as well as
deficiencies cited on complaint investigations conducted 3 years before
our data extract. We also analyzed other data that describe the
characteristics of nursing homes: a December 17, 2008, extract of other
OSCAR variables; case-mix-adjusted nurse staffing hours available from
CMS's Five-Star System, which were dated November 2008; and a list
developed by CMS of nursing homes whose deficiency histories could have
subjected them to immediate sanctions, which we obtained from CMS in
October 2008[Footnote 55].:
Following are highlights of how we analyzed certain characteristics:
* We calculated the number of nursing homes in each fiscal year that
had deficiencies that could have resulted in the imposition of at least
one immediate sanction.
* Nursing homes self-report their ownership type. We created the
ownership type of for-profit by combining three categories of for-
profit nursing homes designated in CMS's data (individual, partnership,
and corporation) and the category of limited liability corporation.
Similarly, we created the ownership type of nonprofit by combining
three categories of nonprofit nursing homes (corporation, church
related, and other), and the ownership type of government from the six
designations made in CMS data (state, county, city, city/county,
hospital district, and federal).
* CMS maintains a variable in its data called multi-nursing home
(chain) ownership, which is self-reported by nursing homes and which we
refer to as chain affiliation. According to CMS, multi-nursing home
chains have two or more homes under one ownership or operation. We
determined the percentage of nursing homes that were for-profit and
chain affiliated, nonprofit and chain affiliated, or government owned
and chain affiliated by combining the ownership type described above
with CMS's designation of multi-nursing home (chain) ownership.
* We used the number of beds certified for payment for Medicare,
Medicaid, or both to calculate the following: the average number of
beds per nursing home and the percentage of nursing homes by bed size
category (0 to 49, 50 to 99, 100 to 199, and more than 199 beds).
* We calculated the percentage share of residents by resident type
(Medicare, Medicaid, or other) by dividing the number of Medicare,
Medicaid, and other patients by the number of total residents.
* We calculated the occupancy rate by dividing the total number of
residents by the number of certified beds. We used certified beds to
calculate the occupancy rate instead of total beds because CMS
officials told us that certified beds provided more reliable
information.
* We analyzed the following nurse staffing hours, which were case-mix
adjusted by CMS for use in its Five-Star System: registered nurse hours
per resident per day, licensed practical nurse and vocational nurse
hours per resident per day, nurse aide hours per resident per day, and
total staffing hours per resident per day.[Footnote 56] We calculated
resident nurse hours as a share of the total. Unadjusted nurse staffing
hours data are collected by CMS, self-reported by nursing homes, and
represent staffing levels for a 2-week period before the state
inspection. CMS case-mix adjusted the staffing data using the average
minutes of nursing care used to care for residents in a given resource
utilization group category as reflected in the Medicare skilled nursing
facility prospective payment system.[Footnote 57] CMS acknowledges that
the staff hours collected from nursing homes have certain limitations.
In order to increase the accuracy and comprehensiveness of the staffing
data, CMS has been investigating whether it can use nursing home
payroll data to report staffing levels on the Nursing Home Compare Web
site.
[End of section]
Appendix II: Detailed Compliance History for Two of the Most Poorly
Performing Nursing Homes, as of December 2008 :
The following table provides the detailed compliance history over three
cycles for two of the most poorly performing homes in the nation.
Table 11: Detailed Compliance History over Three Cycles for Two of the
Most Poorly Performing Nursing Homes in the Nation, as of December
2008:
Example A: Chronic poor performer: Cycle 1:
10/29/2008;
Standard survey;
2G-I;
24 D-F.
G: Proper treatment to prevent or heal pressure sores;
G: Proper care and services for residents with naso-gastric tube.
8/20/2008;
Complaint survey;
1 D-F;
5/19/2008;
Complaint survey;
1 G-I;
1 D-F;
G: Facility is free of accident hazards.
3/25/2008;
Complaint survey;
4 D-F;
12/20/2007;
Complaint survey;
2 D-F.
Example A: Chronic poor performer: Cycle 2;
12/6/2007;
Standard survey;
7 D-F;
8/31/2007;
Complaint survey;
1 D-F;
8/1/2007;
Complaint survey;
2 G-I;
2 D-F;
G: Proper treatment to prevent or heal pressure sores;
G: Facility provides sufficient fluid intake.
7/3/2007;
Complaint survey;
1 D-F;
6/14/2007;
Complaint survey;
1 G-I;
1 D-F.
G: Facility is free of accident hazards.
1/26/2007;
Complaint survey;
1 G-I;
1 D-F.
G: Proper treatment to prevent or heal pressure sores.
Example A: Chronic poor performer: Cycle 3[A];
11/14/2006;
Standard survey;
1 G-I;
9 D-F;
G: Facility is free of accident hazards.
8/4/2006;
Complaint survey;
6 J-L;
2 D-F;
L: Facility is administered effectively to obtain highest practicable
physical, mental, and psychosocial well-being of each resident;
L: Plans to meet emergencies/disasters;
K: Resident not catheterized unless unavoidable;
K: Facility provides sufficient fluid intake;
J: Facility prohibits abuse or neglect;
J: Provides necessary care for highest practicable physical, mental,
and psychosocial well-being.
7/14/2006;
Complaint survey;
1 G-I;
2 D-F;
G: Resident not catheterized unless unavoidable.
6/16/2006;
Complaint survey;
1 D-F.
6/8/2006;
Complaint survey;
3 J-L;
1 G-I;
2 D-F;
J: Facility prohibits abuse or neglect;
J: Provides necessary care for highest practicable physical, mental,
and psychosocial well-being;
J: Facility is free of accident hazards;
G: Proper treatment to prevent or heal pressure sores.
5/4/2006;
Complaint survey;
6 J-L;
2 G-I;
5 D-F;
L: Facility prohibits abuse or neglect;
L: Facility is administered effectively to obtain highest practicable
physical, mental, and psychosocial well-being of each resident;
K: Provides necessary care for highest practicable physical, mental,
and psychosocial well-being;
K: Proper treatment to prevent or heal pressure sores;
J: Facility is free of accident hazards;
J: Proper treatment/care for special care needs;
G: Facility must inform resident, resident's physician, and family of
any accidents; changes in the resident's physical, mental, or
psychosocial status, or treatment; or of a decision to transfer or
discharge resident;
G: Residents have a right to be free from abuse.
Example B: Nonchronic very poor performer; Cycle 1[B]:
8/5/2008;
Complaint survey;
2 D-F.
5/8/2008;
Complaint survey;
2 G-I;
2 D-F;
G: Proper treatment to prevent or heal pressure sores;
G: Accuracy of assessments/coordination with professionals.
4/3/2008;
Complaint survey;
5 J-L;
2 G-I;
1 D-F;
J: Residents' care supervised by a physician;
J: Facility must inform resident, resident's physician, and family of
any accidents; changes in the resident's physical, mental, or
psychosocial status, or treatment; or of a decision to transfer or
discharge resident;
J: Services by qualified persons in accordance with care plan;
J: Proper treatment to prevent or heal pressure sores;
J: Facility is administered effectively to obtain highest practicable
physical, mental, and psychosocial well-being of each resident;
G: Responsibilities of medical director;
G: Physician promptly notified of lab results.
1/25/2008;
Standard survey;
2 J-L;
10 D-F;
J: Services by qualified persons in accordance with care plan;
J: Proper treatment to prevent or heal pressure sores.
Example B: Nonchronic very poor performer; Cycle 2:
11/28/2007;
Complaint survey;
2 D-F.
4/25/2007;
Standard survey;
5 D-F.
Example B: Nonchronic very poor performer; Cycle 3:
5/18/2006;
Standard survey;
5 D-F.
Source: GAO analysis of CMS data.
Note: The descriptions of standards are provided only for deficiencies
cited at the G level or higher. The descriptions of the standards have
been abbreviated from those that appear in CMS guidance.
[A] The chronic poor performer had one revisit that contributed to its
total score during cycle 3.
[B] The nonchronic, very poor performer had one revisit that
contributed to its total score during cycle 1.
[End of table]
[End of section]
Appendix III: Performance by Standard Area for the Most Poorly
Performing and All Other Nursing Homes, as of December 2008:
The following table provides the percentages of the most poorly
performing and all other nursing homes that were cited for actual harm
or immediate jeopardy by standards area over three cycles.
Table 12: Percentage of the Most Poorly Performing and All Other
Nursing Homes Cited for Actual Harm or Immediate Jeopardy, by Standards
Area, in the Last Three Cycles as of December 2008:
Standards area: Administration;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 15.5;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 2.0;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 31.4;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 2.5.
Standards area: Admission, Transfer, and Discharge Rights;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 0.5[A];
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.2[A];
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 0.2[A];
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.0[A].
Standards area: Dental Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 1.0;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 0.0[A];
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.0[A].
Standards area: Dietary Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 0.9;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 4.3;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.4.
Standards area: Infection Control;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 2.1;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.3;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 2.8;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.2.
Standards area: Nursing Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 5.9;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.5;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 4.5;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.1.
Standards area: Pharmacy Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 2.6;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.4;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 3.4;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.3.
Standards area: Physical Environment;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 1.2;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 3.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.3.
Standards area: Physicians Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 1.4;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.3;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 0.7;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.0.
Standards area: Quality of Care;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 89.7;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 42.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 67.2;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 9.1.
Standards area: Quality of Life;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 17.4;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 2.4;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 4.3;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.2.
Standards area: Resident Assessment;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 20.3;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 5.8;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 16.0;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 1.3.
Standards area: Resident Behavior and Facility Practices;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 30.9;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 5.9;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 28.8;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 2.4.
Standards area: Resident Rights;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 18.8;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 3.7;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 13.3;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 1.0.
Standards area: Specialized Rehabilitative Services;
Percentage with at least one actual harm deficiency (G through I
level): Most poorly performing nursing homes: 1.9;
Percentage with at least one actual harm deficiency (G through I
level): All other nursing homes: 0.1;
Percentage with at least one immediate jeopardy deficiency (J through L
level): Most poorly performing nursing homes: 0.5;
Percentage with at least one immediate jeopardy deficiency (J through L
level): All other nursing homes: 0.0.
Source: GAO analysis of CMS data.
Note: Unless otherwise noted, all differences between groups are
significant at the 0.05 level.
[A] The difference between the most poorly performing and all other
nursing homes for this variable is not significant.
[End of table]
[End of section]
Appendix IV: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
August 18, 2009:
John Dicken:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Dicken:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's draft report entitled, "Nursing Homes: CMS's
Special Focus Facility Methodology Should Better Target the Most Poorly
Performing Homes, Which Tended to be Chain Affiliated and For Profit"
(GAO-09-689).
The Department appreciates the opportunity to review and comment on
this draft report before its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Enclosure:
[End of letter]
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: August 14, 2009:
T0: Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Office of the Secretary
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Draft Report: "Nursing
homes: CMS's Special Focus Facility Methodology Should Better Target
The Most Poorly Performing homes, Which Tended to Be Chain Affiliated
and For Profit" (GAO-09-689):
The Centers for Medicare & Medicaid Services (CMS) appreciates the
opportunity to review and comment on the above-mentioned draft report.
GAO was asked to examine CMS' efforts to improve the quality of care in
poorly performing nursing homes. GAO examined the ability of CMS'
Special Focus Facility (SFF) algorithm to identify poorly performing
nursing homes and compared CMS's method with a variant method for
identifying poorly performing nursing homes. GAO issued two basic
recommendations: I) that CMS use a national, rather than State-
specific, algorithm for identifying SFF; and 2) that CMS revise its
methodology slightly to more heavily emphasize certain types of
deficiencies and to include a longer compliance history for providers
that have changed certification type.
The GAO compared CMS' SFF methodology with a similar method that GAO
constructed based on the SFF methods, some elements of CMS' Five Star
Quality Rating System, and other GAO adjustments. GAO concluded that
CMS' SFF methodology is "reasonable and comprehensive," but that it
misses a number of poorly performing nursing homes because it is
restricted to identifying only 15 nursing homes in each State. GAO
states that if CMS made SFF selections on a national (rather than State-
by-State) basis, then scarce resources could more effectively target
survey activity on the worst-performing nursing homes in the country.
As evidence, the GAO identifies several States in which no nursing
homes meet its criteria for poor performance.
We believe that the GAO study adds value to the important public policy
debate regarding methods by which CMS and the nursing home industry
ought to address the problem of nursing homes that consistently
evidence serious quality of care problems. We will seriously consider
all of the GAO recommendations and convey to GAO the results of our
further study.
GAO Recommendation 1:
To improve the targeting of scarce survey resources, the Administrator
of CMS should consider an alternative approach for allocating the 136
SFFs across States, by placing more emphasis on the relative
performance of homes nationally rather than on a State-by-State basis,
which could result in some States having only one or not any SFFs and
other States having more than they are currently allocated.
CMS Response:
We disagree with the approach of adopting a totally national ranking
system because it would ignore important differences between States.
Instead, we will evaluate a hybrid approach in which the current State-
by-State assignments are used for part of the SFF selections, while a
portion of the selections are made on a national basis. The current
system has the advantage of both controlling for State-to-State
variation and creating a process by which additional State survey
agency knowledge is brought to bear on the final selections. Examples
of such knowledge include the facility's track record of making and
sustaining their prior problem correction efforts, the track record of
the owner in both the SFF nursing home and other nursing homes, and the
track record of the operator. On the other hand, a national pool may
permit greater recognition of the fact that there are important
differences in quality of care between nursing homes in different
States.
GAO Recommendation 2:
To improve the SFF methodology's ability to identify the most poorly
performing nursing homes, the Administrator of CMS should make the
following three modifications:
(1) Consider using a common set of numeric points for identifying
poorly performing nursing homes by determining the effect of adopting
those associated with the FiveStar System for the SFF methodology.
(2) Assign points to G-level deficiencies in substandard quality of
care (SQC) areas equivalent to those additional points assigned to H-
and I-level deficiencies in SQC areas.
(3) Account for a nursing home's full compliance history regardless of
technical status changes.
CMS Response:
(1) Consider using a common set of numeric points for identifying
poorly performing nursing homes by determining the effect of adopting
those associated with the Five-Star System for the SFF methodology.
We agree in principle. We appreciate the value of harmonizing SFF and
Five-Star methodologies to the extent appropriate and will evaluate the
effect of using the Five-Star methodology.
(2) Consider using a common set of numeric points for identifying
poorly performing nursing homes by determining the effect of adopting
those associated with the Five-Star System for the SFF methodology.
We agree in principle. We will evaluate the effect of such a
methodological change in both the SFF and the Five-Star system.
(3) Account for a nursing home's full compliance history regardless of
technical status changes.
We agree to the extent practicable. This recommendation would require
linking providers that have had a change in certification, and hence a
change in provider number, to their earlier provider numbers. In this
way, a longer compliance history could be used to calculate ratings.
Although this affects a small number of providers, it would improve the
accuracy of ratings for those providers. We will evaluate the technical
barriers involved in this change and implement the recommended
adjustment to the maximum extent practicable.
GAO Recommendation 3:
To ensure consistency with the SFF methodology, CMS should also
consider making two of these modifications-the SQC and full compliance
history changes-to the Five-Star System.
CMS Response:
We agree in principle. We appreciate the value of consistent SFF and
Five-Star methodologies and will evaluate the effect of making these
changes to both the SFF and Five-Star systems.
We appreciate the efforts that went into this report and look forward
to working with the GAO on this and other issues.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
John E. Dicken, (202) 512-7114 or d [Hyperlink, dickenj@gao.gov]
ickenj@gao.gov.
Acknowledgments:
In addition to the contact named above, Walter Ochinko, Assistant
Director; Ramsey Asaly; Daniel Lee; Shannon Slawter Legeer; Jessica
Morris; Jessica Nysenbaum; Dae Park; Roseanne Price; Jennifer Rellick;
Kathryn Richter; and Jessica Smith made key contributions to this
report.
[End of section]
Related GAO Products:
Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine
Its Approach for Funding State Oversight of Health Care Facilities.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-64. Washington,
D.C.: February 13, 2009.
Nursing Homes: Federal Monitoring Surveys Demonstrate Continued
Understatement of Serious Care Problems and CMS Oversight Weaknesses.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-517]. Washington,
D.C.: May 9, 2008.
Nursing Home Reform: Continued Attention Is Needed to Improve Quality
of Care in Small but Significant Share of Homes. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-794T]. Washington, D.C.: May
2, 2007.
Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not
Deterred Some Homes from Repeatedly Harming Residents. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-241]. Washington, D.C.: March
26, 2007.
Nursing Homes: Despite Increased Oversight, Challenges Remain in
Ensuring High-Quality Care and Resident Safety. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-117]. Washington, D.C.:
December 28, 2005.
Nursing Home Quality: Prevalence of Serious Problems, While Declining,
Reinforces Importance of Enhanced Oversight. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-561]. Washington, D.C.: July
15, 2003.
Nursing Homes: Public Reporting of Quality Indicators Has Merit, but
National Implementation Is Premature. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-187]. Washington, D.C.:
October 31, 2002.
Nursing Homes: Federal Efforts to Monitor Resident Assessment Data
Should Complement State Activities. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-02-279]. Washington, D.C.:
February 15, 2002.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of
the Quality Initiatives. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-197]. Washington, D.C.:
September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-6]. Washington, D.C.:
November 4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That
Regulatory Actions Were Unreasonable. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-154R]. Washington, D.C.:
August 13, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing Homes
Has Merit. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-157]. Washington, D.C.:
June 30, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to
Protect Residents. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-80]. Washington, D.C.:
March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of
Federal Quality Standards. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-99-46]. Washington, D.C.:
March 18, 1999.
California Nursing Homes: Care Problems Persist Despite Federal and
State Oversight. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-98-202]. Washington, D.C.:
July 27, 1998.
[End of section]
Footnotes:
[1] Medicare is the federal health care program for elderly and
disabled individuals. Medicaid is the joint federal-state health care
financing program for certain categories of low-income individuals.
Combined Medicare and Medicaid payments for nursing home services were
about $78 billion in 2007, including a federal share of about $54
billion.
[2] Such nursing homes often have a pattern of cycling in and out of
compliance. See GAO, Nursing Homes: Additional Steps Needed to
Strengthen Enforcement of Federal Quality Standards, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-46] (Washington, D.C.: Mar. 18,
1999), and Nursing Homes: Proposal to Enhance Oversight of Poorly
Performing Homes Has Merit, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-99-157] (Washington, D.C.: June
30, 1999).
[3] In a 2007 report, we recommended that the Administrator of CMS
consider further expanding the SFF Program to include all homes that
met a certain threshold established by CMS to qualify as poorly
performing. CMS agreed with the concept of expanding the program, but
indicated that it lacked the resources needed to expand the number of
surveys. See GAO, Nursing Homes: Efforts to Strengthen Federal
Enforcement Have Not Deterred Some Homes from Repeatedly Harming
Residents, [hyperlink, http://www.gao.gov/products/GAO-07-241]
(Washington, D.C.: Mar. 26, 2007).
[4] See [hyperlink, http://www.gao.gov/products/GAO-07-241], and GAO,
Nursing Homes: Federal Actions Needed to Improve Targeting and
Evaluation of Assistance by Quality Improvement Organizations,
[hyperlink, http://www.gao.gov/products/GAO-07-373] (Washington, D.C.:
May 29, 2007).
[5] Each cycle consists of a standard survey, which occurs roughly
annually, revisits associated with the standard survey, and 12 months
of complaint investigations. Multiple revisits are an indicator of more
serious problems in achieving or sustaining compliance.
[6] OSCAR data change continually as new surveys are conducted and
entered into the database, but there can be a lag time. As a result,
the data we analyzed did not necessarily include all surveys conducted
through December 2008. The number and composition of our estimates of
the most poorly performing nursing homes and the SFF Program candidates
will change over time as new surveys and revisits are conducted and
considered.
[7] One characteristic we analyzed, "multi-nursing home (chain)
ownership," is self-reported by nursing homes. According to CMS, multi-
nursing home chains have two or more homes under one ownership or
operation. In this report, we refer to nursing homes that have
indicated that they operate under multi-nursing home (chain) ownership
as having chain affiliation.
[8] Pub. L. No. 100-203, §§ 4201, 4211, 101 Stat. 1330, 1330-160, 1330-
182 (codified in pertinent part at 42 U.S.C. § 1395i-3 and 42 U.S.C. §
1396r).
[9] Nursing Home Compare is available at [hyperlink,
http://www.medicare.gov/NHCompare].
[10] Every nursing home receiving Medicare or Medicaid payment must
undergo a standard survey not less than once every 15 months, and the
statewide average interval for these surveys must not exceed 12 months.
See 42 U.S.C. § 1395i-3(g)(2)(A)(iii); 42 U.S.C. § 1396r(g)(2)(A)(iii).
CMS generally interprets these requirements to permit a statewide
average interval of 12.9 months and a maximum interval of 15.9 months
for each home.
[11] The standard survey also includes an assessment of federal fire
safety standards. The fire safety portion of a standard survey is not
always conducted concurrently with the assessment of other standards.
[12] Other areas include Admission, Transfer and Discharge Rights;
Resident Assessment; Pharmacy Services; Administration; Nursing
Services; Dietary Services; Physician Services; Specialized
Rehabilitative Services; Dental Services; Infection Control; and
Physical Environment.
[13] In this report, we use the term states, including the District of
Columbia, to refer to state survey agencies.
[14] A revisit is required for deficiencies at the G through L levels
as well as certain F-level deficiencies.
[15] See GAO, Nursing Homes: Federal Monitoring Surveys Demonstrate
Continued Understatement of Serious Care Problems and CMS Oversight
Weaknesses, [hyperlink, http://www.gao.gov/products/GAO-08-517]
(Washington, D.C.: May 9, 2008).
[16] In a federal comparative survey, federal surveyors independently
evaluate state surveys by resurveying a home recently inspected by
state surveyors and comparing the deficiencies identified during the
two surveys. In our May 2008 report, we analyzed the results of 976
comparative surveys conducted by federal surveyors from fiscal years
2002 through 2007. See [hyperlink,
http://www.gao.gov/products/GAO-08-517].
[17] The scope and severity of a deficiency is one of the factors that
CMS may take into account when imposing sanctions. CMS may also
consider a home's compliance history, desired corrective action and
long-term compliance, and the number and severity of all the home's
deficiencies.
[18] See [hyperlink, http://www.gao.gov/products/GAO-07-241].
[19] In addition to deficiencies cited during standard surveys and
complaint investigations, quality of care measures are also indicators
of nursing home quality. Nursing homes participating in Medicare and
Medicaid are required to submit clinical assessment data--known as the
Minimum Data Set--on all of their residents. Data are collected on the
residents' health, physical functioning, mental status, and general
well-being and are used to compute quality of care measures, which
indicate potential problem areas that need further review and
investigation.
[20] Alaska does not have any SFFs because it has few nursing homes--
only 15 in fiscal year 2008.
[21] The criteria for an SFF to graduate are two consecutive standard
surveys and no intervening complaint investigations with deficiencies
higher than an E level. In addition, an SFF may not have a deficiency
at the G level or higher on the fire safety portion of its most recent
standard survey.
[22] To avoid potential double-counting, deficiencies that appear on
complaint surveys that are conducted within 15 days of a standard
survey (either before or after the standard survey) are only counted
once. If the scope or severity differs on the two surveys, the highest
scope-severity combination is used.
[23] The SFF methodology does not assign points to revisits associated
with deficiencies cited on complaint investigations.
[24] The most recent score is assigned a weighting factor of one-half,
the second most recent score is assigned a weighting factor of one-
third, and the third most recent score (from the earliest period) is
assigned a weighting factor of one-sixth.
[25] A two-star rating means a facility ranks "below average;" a three-
star rating means "about average;" and a four-star rating means "above
average."
[26] To determine the overall quality rating, CMS starts with a nursing
home's rating from the health inspections component. One star is then
added to the rating for very high component ratings or subtracted from
the rating for very low component ratings. The overall quality rating
is capped in two circumstances. First, if any nursing home's health
inspections rating is one star, then the overall quality rating cannot
exceed two stars. Second, nursing homes currently in the SFF Program
have their overall quality rating capped at three stars even if they
have high ratings in individual components.
[27] The Five-Star System assigns the same number of additional points
to SQC deficiencies and revisits as the SFF methodology does. According
to CMS officials, CMS has not adopted the deficiency points used in
CMS's Five-Star System for the SFF methodology because it has not yet
analyzed the effects of that change.
[28] Total nursing hours includes hours for registered nurses, licensed
practical nurses/licensed vocational nurses (LPN/LVN), and nurse aides.
In general, registered nurses have more training than LPNs/LVNs. Nurse
aides include certified nursing assistants, who work under the
direction of licensed nurses.
[29] The quality of care measures component uses 10 measures--7
measures for long-term residents of a facility and 3 measures for
individuals who enter a nursing home for a short stay. The 7 measures
for long-term residents are the percentage of residents who have an
increasing need for help with daily activities, have a worsened ability
to move about in and around their rooms, are high risk and have
pressure sores, have catheters inserted and left in their bladders,
were physically restrained, have urinary tract infections, and have
moderate to severe pain. The 3 short-stay measures are the percentage
of residents with pressure sores, moderate to severe pain, and
delirium.
[30] CMS generally identifies SFF Program candidates on a quarterly
basis. Because the December 2008 time frame when we conducted our
analysis did not coincide with CMS's quarterly cycle, we use the term
SFF Program candidates to refer to the nursing homes in each state with
the 15 worst scores at the time that we conducted our analysis. We
determined the SFF Program candidates using CMS's SFF methodology,
without our refinements. There are 755 SFF Program candidates because
some nursing homes in the same state shared the same total score and
because we excluded nursing homes in Alaska, which does not have SFFs,
and included nursing homes in the District of Columbia, which has one
SFF.
[31] One reason that additional SFFs were not identified as the most
poorly performing by our methodology may be that the homes' performance
improved since entering the program. Our estimate included another 13
nursing homes that were no longer active SFFs as of February 2009.
[32] Some of this variation could be attributed to understatement. Our
estimate did not adjust for state variation because we do not know
which nursing homes are potentially affected. However, we know that
nursing homes cited for many serious deficiencies or those that require
multiple revisits have quality problems and therefore deserve federal
and state attention.
[33] Because the distribution of nursing home scores is highly skewed,
we identified a statistical approach that focuses on identifying
outliers.
[34] As noted earlier, our estimate of the most poorly performing
nursing homes incorporated several refinements to the SFF methodology,
which are discussed in the next section. These refinements had a
moderate effect on the composition of the list of most poorly
performing homes we identified. Not all nursing homes with total scores
above the 93rd percentile are included in our estimate, just those that
were also chronic poor performers.
[35] About 1.7 percent of all deficiencies cited in 2008 were at the
immediate jeopardy (J-L) level, about 4.9 percent were at the actual
harm (G-I) level, and about 84.6 percent were at the D through F
levels.
[36] This is the same number of additional points that CMS assigns to H-
and I-level deficiencies if they occur in areas considered to be SQC.
(See table 2.)
[37] We developed a list of all provider numbers--the identification
numbers used by CMS to identify nursing homes--associated with any
nursing homes that were indicated by CMS's data as having made such a
change to their provider numbers from October 1, 2004 (i.e., the
beginning of fiscal year 2005), through December 17, 2008. We did so by
using a field that identifies the new provider number after a home
undergoes a technical status change, or in two instances, using the
nursing home's address to link provider numbers. In the health
inspections component of its Five-Star System, CMS adjusts for any
nursing home with only two standard surveys by imputing a total score
to account for the missing survey. This adjustment is less precise
because it imputes the results instead of using a home's actual
performance history. CMS does not report star ratings for nursing homes
with only one standard health inspection.
[38] In 6 of the 11 nursing homes, this modification increased their
total score by less than about 8 percent; however, the total score of
the other 5 nursing homes increased from about 10 to about 370 percent.
[39] The OSCAR data we analyzed were as of December 2008. We analyzed
only D-through L-level deficiencies because nursing homes with
deficiencies at the A, B, or C levels are considered to be in
substantial compliance with federal quality standards.
[40] We analyzed a CMS file that identifies nursing homes whose
deficiency histories could have subjected them to immediate sanctions.
A CMS official told us that the file is not used by states to refer
homes for immediate sanction. As a result, the file does not indicate
that immediate sanctions were imposed on homes but represents CMS's
analysis of probable instances of immediate sanctions.
[41] The data we analyzed were as of December 2008, except for the data
on nurse staffing, which were as of November 2008.
[42] For this section, we analyzed the number of certified beds, which
is the number of Medicare beds, Medicaid beds, or both.
[43] The staffing data we analyzed were case-mix adjusted by CMS for
use in the Five-Star System.
[44] We interviewed officials in a nongeneralizable sample of 14 state
survey agencies, which were selected based on a combination of factors,
including the number of SFFs allocated to the state and SFF scores.
[45] Points are only assigned to facilities that require more than one
revisit before being able to demonstrate substantial compliance.
[46] OSCAR data change continually as new surveys are conducted and
entered into the database, but there can be a lag time. As a result,
the data we analyzed did not necessarily include all surveys conducted
through the date of our data extract.
[47] We reviewed materials describing systems that rate nursing homes
in the following states: California, Florida, Indiana, Massachusetts,
Minnesota, New Jersey, Ohio, and Texas. We did not conduct a
comprehensive review to identify all states that have nursing home
rating systems. New Jersey no longer maintains its own rating system
and refers individuals instead to CMS's Five-Star System.
[48] For these analyses, we compared the 766 nursing homes in the
nation with the highest total scores to all other nursing homes. The
number 765 is equal to 50 states (including Alaska) and the District of
Columbia multiplied by 15 nursing homes per state, and there was a tie
in total score among these homes, for a total of 766 nursing homes.
[49] We analyzed a CMS file that identifies nursing homes whose
deficiency histories would have subjected them to immediate sanctions.
A CMS official told us that the file is not used by states to refer
homes for immediate sanction. As a result, the file does not indicate
that immediate sanctions were imposed on homes but represents CMS's
analysis of probable instances of immediate sanctions. We did not
determine which nursing homes were sanctioned in this way.
[50] See John W. Tukey, Exploratory Data Analysis (Reading, Mass.:
Addison-Wesley Publishing Company, 1977), 39-47. See also, John M.
Chambers, William S. Cleveland, Beat Kleiner, and Paul A. Tukey,
Graphical Methods for Data Analysis (Boston, Mass.: Wadsworth
International Group and Duxbury Press, 1983), 21-22.
[51] If there is no observation exactly at the value identified by the
equation, the observation with the next lower value would be the
threshold.
[52] For a prior report, using deficiencies from three standard surveys
from January 1, 1999, through November 1, 2002, we classified 15
percent of nursing homes as low performing, 65 percent as moderately
performing, and 20 percent as high performing. See GAO-07-373.
[53] We explored using the 95th percentile of total score to identify
nonchronic but very poor performance, but decided that the 99th
percentile was a more conservative approach because it limited this
group to those with extremely high total scores.
[54] We considered additional thresholds that would have identified
additional poor performers with many D-level or higher or many G-level
or higher deficiencies. For example, 50 additional nursing homes would
have been identified as poor performers if we had also included nursing
homes with a large number of D-level or higher deficiencies (greater
than or equal to the 99th percentile of the number of D-level or higher
deficiencies). An additional 25 nursing homes would have been
identified as poor performers if we had also included nursing homes
with a large number of G-level or higher deficiencies (greater than or
equal to the 99th percentile of the number of G-level or higher
deficiencies).
[55] As previously noted, this file is not used by states to refer
homes for immediate sanction and does not indicate that immediate
sanctions were imposed on homes but represents CMS's analysis of
probable instances of immediate sanctions.
[56] Nurse staffing hours were not available for 6.9 percent of nursing
homes we determined were the most poorly performing and for 6.1 percent
of all other nursing homes. Reasons these data were not available
include that CMS deemed the data to be unreliable (e.g., very high
nursing hours per resident per day) or that CMS newly certified the
nursing home.
[57] See Centers for Medicare & Medicaid Services, Design for Nursing
Home Compare Five-Star Quality Rating System: Technical Users' Guide,
revised April 1, 2009, [hyperlink,
http://www.cms.hhs.gov/CertificationandComplianc/Downloads/usersguide.pd
f] (accessed June 17, 2009).
[End of section]
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