Bill would enforce IOM oversight of state of care

At a glance…

Legislation has been introduced that would require the Institutes of Medicine to review care at nursing homes as well as the federal and state oversight system.

Legislation that would require the Institutes of Medicine (IOM) to review the current state of care at nursing homes as well as the federal and state oversight system has been introduced by Sen. Russ Feingold (D-Wisc.), in response to concerns expressed by members of the Wisconsin Association of Homes and Services for the Aging (WAHSA).

The legislation follows a report last August that said 580, or nearly 4% of the nation’s 16,000 nursing homes, could be considered “the most poorly performing” in the nation, far more than those cited by the Centers for Medicare & Medicaid Services (CMS) under its Special Focus Facility (SFF) program.

S. 3407, the Improving the Quality of Care in Nursing Homes Act of 2010, requires the U.S. Department of Health and Human Services to work with IOM and conduct a study on the current state of nursing home oversight.

“After hearing from members of WAHSA, it is clear it’s time for a fundamental review of how far the nursing home field has come, and where we must improve to ensure our seniors are receiving the highest quality of care,” Feingold said. “This legislation will help bring nursing home quality assurance into the 21st century and ensure a better quality of life for current and future nursing home residents.”

In a news release announcing his bill, Feingold said WAHSA expressed several concerns to him regarding nursing home oversight and enforcement of quality standards. Under his bill, the IOM will recommend ways that Congress can improve the law.

AAHSA welcomes bill

The American Association of Homes and Services for the Aging (AAHSA) welcomed Feingold’s bill and urged its members to co-sponsor the legislation. In a memo to members, AAHSA said, “We are confident that the objective, in-depth evaluation of the oversight process for which S. 3407 provides would lead to a nursing home quality assurance process that is better for both residents and providers.”

“The current system too often impedes comprehensive quality improvement initiatives while at the same time hampering the ability of nursing home regulators to target facilities with frequent and serious care issues,” said WAHSA Executive Director John Sauer. “Our hope is that the IOM study will encourage innovative regulatory reforms and enable the system to recognize facilities that provide exemplary care and services.”

The study provided by the legislation would cover:

  • The current structure and methods for surveying and evaluating nursing homes.

  • The relationship between CMS and nursing homes and how the relationship affects quality.

  • The relationship between CMS and state agencies.

  • The CMS methodology in surveying and evaluating nursing homes.

  • The effectiveness of the current enforcement system.

  • Whether the current system effectively allows states and other stakeholders to engage in innovative ways to pursue quality improvement.

  • Alternatives to the current system.

The OEM’s report containing recommendations for policy and procedural changes to improve the survey and certification process would be due to the Secretary of Health and Human Services and Congress within 18 months of the bill’s passage.

The Government Accountability Office’s (GAO) report last August said methods CMS uses to determine which nursing homes are designated as SFFs needs to better target the most poorly performing homes, which GAO said tended to be chain-affiliated and for-profit facilities.

The GAO study said the 580 homes it identified as the most poorly performing overlap somewhat with the 755 SFF program candidates, which are the 15 worst homes in each state, and the 136 homes actually selected by states as SFFs.

GAO pointed out that the SFF program is structured 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. Under GAO’s methodology, eight states had no such homes, while 20 others had from 21 to 52.

“The most poorly performing homes identified by GAO averaged over 46% more serious deficiencies that placed residents at risk of death or serious injury (immediate jeopardy), compared to the 755 SFF program candidates identified under CMS’s approach,” the GAO’s report said.

GAO said it 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 report noted, the most poorly performing nursing homes averaged about 56 such deficiencies and two revisits, compared to about 20 such deficiencies and less than one 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,” the report said.

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.

Poor performers

GAO said the scoring thresholds were necessary because there were no natural break points that delineated the most poorly performing homes from others. They were conservative, GAO said, focusing on chronic poor performance generally over a two- or three-year period or very poor performance over about one year.

GAO said it used deficiency points from CMS’s Five-Star Quality Rating System because they decreased the disparity between immediate jeopardy and lower-level deficiencies, such as those with the potential for more than minimal harm.

In addition, homes received extra points when certain actual harm deficiencies occurred in standards areas that CMS categorizes as substandard quality of care. That, the agency said, was important because it found many homes with at least one such deficiency.

Deficiency history

Finally, GAO said the “full deficiency history of homes” was included, noting that 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 said it believes its estimate that 580 homes are the most poorly performing is conservative because the study focused only on those homes with chronic poor performance over time or with very poor performance in one year.

In response to the recommendations, CMS said it would consider a “hybrid” approach that would assign some SFFs using homes’ performance in each state and other SFFs on their relative national ranking. GAO recommended that CMS place more emphasis on relative performance of homes nationally, rather than on a state-by-state basis.

CMS also agreed in principle with GAO recommendations that were intended to improve the SFF methodology’s ability to identify the most poorly performing nursing homes and ensure its consistency with the Five-Star Quality Rating System.

Bob Gatty has covered governmental developments of the trade and business press for more than 30 years. He is founder and president of G-Net Strategic Communications, Sykesville, Maryland.

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Long-Term Living 2010 July;59(7):10-13

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