Saturday, February 16, 2008

Why nursing homes have poor quality

I was thinking about this last night and realized something quite obvious. JCAHO, the organization that accredits virtually every hospital in this county, has established standards for hospitals to go by. These standards are considered optimally achievable outcomes -- what a facility should aspire to be. CMS standards, the ones that nursing homes are required to comply with, are minimum standards -- the absolute bare minimum you can do to get by with. Literally every single nursing home I have worked with has regarded the CMS minimum standards as optimal achievable outcomes. The prevailing thought in the long term care industry is that a deficiency free survey is something you should aspire to. The problem with this thinking is that a deficiency free survey only means that you are providing a minimally acceptable level of care. Facilities must truly desire to go above the minimum standards, which requires blowing up the box and getting the hell away from the status quo. Unfortunately this is too scary for most providers and corporate owners. Nursing homes have the worlds worst case of "we have never done it this way before" that anyone has ever seen.


Patti said...

Now isn't this just the painful truth! I think one could ask any CNA about this and they would provide endless examples of how nursing homes do things "just to get by" and these standards are a joke. To make it worse we always seem to know when the inspectors are coming, and this is when management comes to life- making everyone miserable with their sudden attention. Passing the survey is the most important thing...even when passing it means so little.

Ryan said...

To an extent I can agree with what you have to say. There are many facilities out there that are so deeply rooted in tradition and "the way we have always done things" that over time this "one way" is the end, rather the means. About JCAHO: I also agree that standards of excellence are better than acceptable minimum standards. I believe you error though in your discussion of the CMS survey process. We (and I say this as SNF administrator myself) are held to a much higher standard than you articulate. For starters, we operate under a set of highly detailed regulations 550 pages long. How many pages of regulations do hospitals operate under? The guidance to surveyors for LTC facilities is 104 pages. The survey activity guide provided by JCAHO for hospitals? 59 pages. Keep in mind this is just the federal regulations, do hospitals have state regulations they must also adhere to like NH's do? Patti offers that "we almost always seem to know when they are coming". My last three years of surveys have been within the mandated time frame but have consistently come at irregular intervals. JCAHO just started performing unnannounced surveys in 2006. Unnannounced! as in JCAHO calls you to schedule a time to come to your facility! As in you have time to prepare, get enough staff, review your documentation, educate your people and be ready for a friggin' 3-4 day affair. Thats like going in to take an exam, and being allowed to look at the test before you take it.

Moving on.....Granted there have been many nursing facilities over the years who have totally blown it with regard to care and services. So in a way we all pay the price for what one very poor performing facility does. However as time has gone on the bar has been raised for everyone. So while they are "acceptable minimum standards" they are pretty damn tough standards to meet. I'm not sure about other states but in KS, deficiency free surveys are few and far between, with over a third receiving actual harm deficiencies. The state avg is 11 def/survey. In a study completed by the University of Kansas funded by the Kansas Department on Aging, it was found, among other things, that there are great discrepancies between regions in KS related to survey deficiency citations. In other words its a subjective process, what one surveyor views as actual harm another does not, and what one surveyor views as a deficient practice another does not. KS is also a pilot state for the Quality Improvement Survey process. Avg # of QIS deficiencies is nearly double of the traditional survey process. KS plans to move to complete QIS in the next year or two.

One final point here. If CMS wants us to pursue optimal achievable outcomes, then they should (1) revise the survey process to be work alongside providers rather than punish them and (2) reimburse us in a fashion that allows us to afford paying people a living wage. With the average elder having only 40k for retirement and a year stay in a NH being nearly 60k, those elders becoming eligible for Medicaid will surely grow. Administrators in KS must have a four year college degree. They are oftentimes the highest educated person in the facility, with the bulk having simply a 90 hour c.n.a class. Why couldn't CMS and the states come together to reimburse a proper medicaid rate? Hospitals can offset many of their costs through private insurance, Medicare stays, charging large costs (like $10 for a tylenol), and maximizing revenue centers and minimizing cost centers (like making money on heart surgeries but losing money in the ER). In LTC we can diversify somewhat but not quite as well as the hospital...and thats my two cents!

Matt Sevier said...

Ryan, I certainly appreciate your thoughts. I would like to respond to several points that you have made. First off, I am well aware of the high standards nursing homes are held to. The problem is that there is limited accountability for nursing homes failing to meet that standard. I know all about the fines and potential loss of the medicare/medicaid contract, but it isn't enough. Another problem fueling the lack of accountability is the fact that nursing homes aren't going to lose residents because there simply isn't anywhere for them to go. I know this is a bad analogy, but it reminds me of the cable company here in town that can get away with virtually non-existent customer service because the customers can't go anywhere else. When it comes to comparing hospitals and nursing homes, I am assuming that you are using the "watermelon book" from AHCA when referring to the CMS regulations. My current copy of guidance to surveyors, as published by CMS, is 414 pages. JCAHO's accreditation manual for hospitals, the 2007 copy of which is sitting on my bookshelf, is 492 pages. CMS has an additional 307 pages of minimum standards for hospitals, which are almost as nitpicky as the nursing home regs. JCAHO accreditation will give a facility deemed status with CMS, which means that they do not necessarily have to be surveyed because they are assumed by virtue of their accreditation to meet the CMS standards as well. JCAHO is not just for hospitals; they accredit nursing homes as well. The majority of the JCAHO surveys are still unannounced and occur every three years, not yearly. I disagree with your statement that JCAHO is like "going in to take an exam, and being allowed to look at the test before you take it". It is very much possible to do the same thing with CMS/state, but you have to know the rules and play by the rules.

You are very much correct in saying that the traditional survey is a very subjective process. The quality indicator survey is much more objective. I am actually getting one of my client facilities to use the forms from the QI survey to replace traditional QA work, at least on a temporary basis. I find that the stage 2 critical elements forms to be a great tool, because they actually do all the 'thinking' for surveyors. I imagine that part of the reason that the # of deficiencies went up with QI surveys is that the surveyors could no longer be quite as subjective.

You do bring up some important issues regarding reimbursement and working cooperatively with surveyors. The primary job of the survey agency is to enforce regulations, but I have always found them more than willing to answer questions regarding the process and various F tags. The state QIO is designed to assist nursing providers and they do not have a relationship with the state survey agency. I agree with you about the need for increased reimbursement. I am reminded that CMS has frequently stated that most nursings unintentionally under-bill on the MDS, and I am also reminded of cost reports. I do realize that facilities need to get paid more. I wonder if CMS is hesitant to increase reimbursement because they think that the money would only be used for the good of shareholders and not residents? Just a thought.

Anonymous said...

I have been a cna for 28 years and i think the "bare minimum" should be ALOT higher. The state of Iowa has no staff to patient ratio. This gives room for nursing homes to hire the very minimum of staff which, is usually inadequate enough to take proper care of residents. The administration has no idea of how much time resident care takes(if done correctly). who gets the blame when surveys are bad? Usually the cnas!!I asked a state worker once if they worried about the number of aides taking care of the residents and they replied "No, as long as the work is getting done" If you think about it there is no way 2 aides could take proper care of 62 people.If the state allows 15 min. per resident that is 4 residents taken care of in 1 hour. Most nursing homes start their day shift at 6 a.m. and breakfast is at 8 a.m.With 2 aides that is 16 residents and alot more to go. You also have to factor the 2 man transfers they take even more time.
Most nursing homes know about when to start expecting state to show up for their annual inspection. The state does each home each 9-12 months so they just figure when they were there last and go by that date. Around the time for them to show up nursing administraters and D.O.N.s start running around making sure everything is done right. This is the time that cna's get told this has to be done and that has to be done, other wise they arent that concerned.When state walks in the door you see all kinds of workers in the nursing home come out of the woodwork to help where they can. If the state only want to check certain residents then those are the residents that get the attention. During the year cnas are told to take care of the "squakers" (residents who can and will tell the state they are not getting the care they need. The residents who cant talk they are left til last.To sit in urine and feces until the aides can get to them.
If the administration would stop and think about how they want to be treated or how they want their family members to be treated maybe the quality of care would be alot higher.

Patti said...

Another point worth mentioning here is the infamous WAGE PASS THRU laws that have come and...gone.

Many states received special funds from the government that were supposed to go to the paychecks of CNA's. Well very few CNA's have ever seen that money- designated to them.

Where does it all go? Let's see...the states redirect the funds to the nursing homes, via the lobby and industry groups. The funds go towards "repairs" and needed building improvements and such...I call a red flag to all of this. In many nursing homes there were no building improvements or repairs. This leads us to believe the for profit homes took the money and ran with it.

Matt is correct when he cites the JCAHO- I too have the manual, along with the SOM and there are huge differences and then little differences at the same time. JCAHO focuses a lot on patients. Their true rights. Hospital patients are usually much more "with it" than nursing home residents, so they have more voice in all this. Hospital patients simply won't put up with the bulloney the average nursing home resident must endure.

The SOM reads like a technical journal: How high off the floor freezers must be in the main kitchens, for example. While much is supposed to be resident centered, it is anything but.

The old saying rules are meant to be broken is never truer than in the nursing home...where the lines of accountability are very dull.
And the people most guilty of bucking the rules are the management.

Ryan said...

Yes Patti that is so true. KS just had a Senate Bill for a nursing home bed tax, which hopefully will not pass, I believe it did not. The bill was for "quality assurance" but did not specify how exactly the the money was supposed to be spend. As patti says, this oftentimes results in the for-profits lining their pockets with more money for shareholders.

Yes Matt I agree. There must be a greater sense of accountability in ltc. As Larry Minnix at AAHSA says, "there are two kinds nursing homes, the excellent and the non-existant." How do you feel about CMS's list of poor performing facilities? What kind of feedback are you getting from those you consult with?

Matt Sevier said...

Ryan, as far as the list goes, I firmly believe that the entire list must be available to the public. I was discussing this with the administrator of a client facility about two weeks ago, and she felt the same way I do. She was also suprised that more facilities were not on the list. IMHO, releasing the full list only to AHCA was definitively unethical and probably illegal, as they are a lobbying organization.

In regards to the labor cost outlier payments, it makes me mad. There is a nursing home the next county over from me that is smack dab in the middle of the sticks -- as rural as rural can get. But because they are within 60 miles of Nashville, they are included in the metropolitan statistical area and receive a wage outlier payment, but the CNAs only make minimum wage. CMS should demand proof from facilities receiving these payments that they are actually being used to pay staff with and not to line corporate's pockets. I don't have a problem with businesses turning a profit, because that's what they're supposed to do, but they must be responsible corporate citizens.