Nursing Home Consumer Complaints and Quality of Care: A National View

The Importance of Zero-Deficiency Complaints in Nursing Homes: A Mere Consequence or Serious Concern?

Complaints represent an important metric for assessing the quality of nursing home (NH) care. Using the Automated Survey Processing Environment (ASPEN) Complaints/Incidents Tracking System dataset (2017), we examined the relationships between zero-deficiency complaints (ZDCs) and zero-deficiency substantiated complaints (ZDSCs) and the proportion of residents with dementia. NHs (N = 15,339) were separated into three groups-proportion of residents with dementia in the top, two middle, and the bottom quartiles. Negative binomial regressions assessed zero-deficiency complaint patterns in relation to NHs' proportion of residents with dementia, controlling for facility characteristics, staffing, and racial pattern. We reported average marginal effects (AMEs) and 95% confidence intervals (CIs). NHs in the top quartile yielded higher numbers of both ZDC (AME = .189, 95% CI: .102-.276, p < .001) and ZDSC (AME = .236, 95% CI: .094-.378, p = .001), than NHs in the bottom quartile. Results suggest a need for more uniform investigation processes and staff training to promote a more valid complaint process for residents with dementia.

Residents' Fear of Retaliation in America's Nursing Homes: An Exploratory Study

The phenomenon of residents' fear of staff retaliation when voicing care concern and making mistreatment complaints in nursing homes has been shown in research to be common. Despite longstanding concerns by care advocacy organizations about this phenomenon and its impact on residents (including emotional suffering, inadequate care, and mistreatment due to fear-driven lack of reporting, investigation, and resolution), little research examined it to date. Using 100 standard survey and complaint investigation reports from state survey agencies in nursing homes in 30 states, the researcher of this qualitative study aimed to improve understanding of residents' lived experience of four aspects of this phenomenon-fear of retaliation, allegations of threats of retaliation, perceived retaliation, and actual (confirmed) retaliation-and their emotional consequences. The findings could inform practice and policy changes necessary to realize residents' federal right to speak up without fear of retaliation when advocating for dignified and safe care.

Associations between Complaints and Organizational Characteristics among Ohio Nursing Homes

OBJECTIVES

In recent years, Ohio nursing homes (NHs) have received an increasing number of complaints. The current study aims to gain a better understanding of the relationship between NH organizational characteristics and the number of complaints.

DESIGN

Secondary data analysis was used.

SETTING AND PARTICIPANTS

Four data sources on Ohio NHs were merged. Ohio NH complaints data reported in 2018 and 2019 was linked with the 2017 Ohio Biennial Survey of Long-Term Care Facilities, 2017 Ohio Nursing Home Resident Satisfaction Survey, and 2018 Ohio Nursing Home Family Satisfaction Survey.

METHODS

Descriptive analysis, bivariate tests (ie, analysis of variance and χ2 test), and multinomial logistic regression analyses were conducted.

RESULTS

Findings included that urban location, NH administrator (NHA) and director of nursing (DON) turnover in the previous 3 years, NH size, occupancy rate, certified nursing assistant (CNA) retention, and overall family satisfaction were significantly associated with total complaints. NHA and DON turnover, NH size, CNA retention, and overall family satisfaction were found to be significantly associated with substantiated complaints.

CONCLUSIONS AND IMPLICATIONS

The importance of leadership (ie, NHA and DON) turnover, CNA retention, and family satisfaction indicates that specifically targeted efforts to improve in these areas can have a positive impact on NH quality.

Do nursing homes with a higher proportion of residents with dementia have greater or fewer complaints?

Objectives: Nursing home (NH) residents' capacity to communicate deteriorates with dementia. Consequently, NHs with high proportions of people living with dementia (PLWD) may receive fewer resident complaints, and/or investigating complaints may be challenging. We assessed NHs' proportion of PLWD in relation to total and substantiated complaints. Methods: Data were from the ASPEN Complaints/Incident Tracking System and the Certification and Survey Provider Enhanced Reports (2017). NHs (N = 15,499) were categorized based on high (top-10%), medium (middle-80%), and low (bottom-10%) dementia prevalence. Negative binomial Poisson regression assessed complaint patterns in relation to NHs' high/low (vs. medium) proportions of PLWD and other facility/resident characteristics. Results: Compared to NHs with medium-dementia prevalence, NHs with low proportions of PLWD had higher total (average marginal effect [AME] = 0.16, p < 0.001) and substantiated (AME = 0.30, p < 0.001) complaints, whereas NHs with high proportions of PLWD had fewer total (AME= -0.07; p < 0.05) and substantiated (AME= -0.11, p < 0.05) complaints. Also, NHs' profit status, chain-affiliation, size, staffing, and resident ethnicity were associated with total and substantiated complaints. Conclusion: The association between high proportions of PLWD and lower NH complaints suggests either that these NHs have higher overall quality or that complaints are underreported. Regardless, surveyors and families may need more involvement in monitoring higher dementia prevalence facilities.

Can Implementing Person-Centered Care Tools Reduce Complaints? Evidence from the Implementation of PELI in Ohio Nursing Homes

Nursing homes receive complaints when actual care provided to residents misaligns with desired care, suggesting that person-centered care (PCC) and honoring resident preferences in care delivery may help prevent complaints from arising. We explore whether nursing home implementation of a PCC tool, the Preferences for Everyday Living Inventory (PELI), is related to measures of complaints. Publicly available data on Ohio nursing homes was used to examine 1,339 nursing home-year observations. Regression techniques were used to evaluate the relationship between the extent of PELI implementation and four complaint outcomes: any complaint, number of complaints, any substantiated complaint, and number of substantiated complaints. Nursing homes with complete PELI implementation were less likely to have any complaints by 4.7% points (P < .05) and any substantiated complaints by 11.5% points (P < .001) as compared to partial PELI implementers. When complete PELI implementers did have complaints, they were fewer than partial PELI implementers. Complete PELI implementers were not immune from receiving complaints; however, the complaints they did receive were fewer in number and less likely to be substantiated as compared to communities who only partially implemented a PCC tool.

Consumer Complaints in Nursing Homes: Analyzing Substantiated Single-Allegation Complaints to Deficiency Citations

Complaints provide important information to consumers about nursing homes (NHs), but how substantiated complaints map onto deficiency citations is unknown. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Federally collected NH complaint and inspection records were obtained to identify all single allegation, substantiated complaints for NHs across the U.S. in 2017. Overall, the 369 complaint allegations in our sample resulted in a total of 585 deficiencies at the inspection stage; however, 35.2% of the allegations led to no deficiencies. Nearly two-thirds of the 369 substantiated single allegation complaints were categorized at the intake stage as quality of care (31.7%), resident abuse (17.3%), or resident neglect (14.1%). Further, 18% of the inspection deficiencies originated with complaint allegations that were prioritized as immediate jeopardy at intake, but of these, 71.4% were determined upon inspection to constitute "no actual harm with potential for more than minimal harm." These results provide evidence that complaints have the potential to provide unique valuable information on NH quality of care and draw regulatory attention to consumers' concerns. Future studies should include qualitative research concerning complaint processes by conducting interviews/surveys of complainants, NH staff/administrators, long-term care ombudsmen, and state officials.

Complaints, Restraint, and Seclusion in Massachusetts Inpatient Psychiatric Facilities, 2008-2018

There has been limited research on the quality of inpatient psychiatry, yet policies to expand access have increased, such as the use of Medicaid Section 1115 waivers for treatment in "Institutions for Mental Disease" (IMD). Using data from public records requests, we evaluated complaints, restraint, and seclusion from inpatient psychiatric facilities in Massachusetts occurring from 2008 to 2018, and compared differences in the rates of these events by IMD status. There were 17,962 total complaints, with 48.9% related to safety and 19.9% related to abuse (sexual, physical, verbal), and 92,670 episodes of restraint and seclusion. On average, for every 30 census days in a given facility, restraint, and seclusion occurred 7.47 and 1.81 times, respectively, and a complaint was filed 0.94 times. IMDs had 47.8%, 68.3%, 276.9%, 284.8%, 183.6%, and 236.1% greater rates of restraint, seclusion, overall complaints, substantiated complaints, safety-related complaints, and abuse-related complaints, respectively, compared to non-IMDs. This is the first known study to describe complaints from United States inpatient psychiatric facilities. Policies should strengthen the implementation of patients' rights and patient-centeredness, as well as external critical-incident-reporting systems.

Trends in Nursing Home Complaints: Prevalence and Variation Across Center for Medicare and Medicaid Services Regions

Resident complaints are vital to understanding nursing home (NH) quality. Using complaints as facility- and resident-level outcomes, this study replicates prior analyses (spanning 1998-2002 and 2007-2012) with 2013-2017 data, the phase prior to NH regulatory changes initiated in November, 2017. Advancing prior papers, we analyze the number of complaints, allegations, and deficiency citations separately. Between 2013-2017, 458,101 total complaints (5.9/NH/year) were identified, containing 949,466 allegations (12.2/NH/year), and resulting in the issuance of 156,135 deficiency citations (2.0/NH/year) in about 15,600 NHs across the country. Regarding the number of complaints, substantiated complaints, and deficiency citations, results show a steady increase compared to previous years. Furthermore, there are marked differences among the CMS survey regions on the prevalence of overall complaints, substantiated complaints, and deficiency citations. However, the average rate of substantiation of complaint allegations shows a decreasing trend over these years, suggesting that complaints may have increased due to higher care expectations.

Assessment of Consumer Complaint Investigation Scores, Recertification Survey Scores, and Overall Nursing Home Health Inspection Star Quality Rating

IMPORTANCE

The Centers for Medicare & Medicaid Services' Five-Star Quality Rating System combines results from nursing home recertification surveys and complaint investigations into a single indicator for health inspections. This combination may mask complaint investigation results.

OBJECTIVE

To construct and compare star ratings specific to recertification surveys and specific to complaint investigations to discern whether they provide different information.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study, the Nursing Home Compare Five-Star Quality Rating System was used to calculate three 5-star ratings: 1 overall health inspection rating combining recertification survey scores and complaint investigation scores, 1 using only recertification scores, and 1 using only complaint investigation scores. The study included US nursing homes. The sample calculated star ratings for nursing homes in November 2017. This sample included all whose most recent recertification surveys occurred in 2016 up to and including November 2017, and those with 36 months of data from the ASPEN Complaints/Incidents Tracking System and the Certification and Survey Provider Enhanced Reports. Data analyses were completed on different days in 2022, depending on which questions were being addressed.

MAIN OUTCOMES AND MEASURES

Comparison of the 3 star rating distributions. The recertification survey and complaint investigation star ratings were compared with respect to the overall health investigation rating. The recertification and complaint star ratings were cross-tabulated.

RESULTS

Among the 15 499 nursing homes, 19.8% had 1 overall health inspection star, 23.2% had 2, 23.2% had 3, 23.2% had 4, and 9.8% had 5 overall health inspection stars. Most had the same overall and recertification star ratings; for example, 79.4% had 5 overall stars and 5 recertification survey stars. However, overall and complaint-based star ratings were discordant, with a relatively large proportion of nursing homes (25.7%) having no complaint deficiencies and therefore high star ratings.

CONCLUSIONS AND RELEVANCE

In this quality improvement study assessing the 2 components of the Five-Star Quality Rating System, results of recertification surveys were largely similar to health inspection star ratings. However, recertification survey scores differed from complaint inspection scores, suggesting health inspection ratings may not reflect consumers' views of care, services, or other valued amenities. A complaint-focused metric may have utility. However, research is needed concerning the many nursing homes with no or very few complaint deficiencies.

Does Higher Worker Retention Buffer Against Consumer Complaints? Evidence From Ohio Nursing Homes

BACKGROUND AND OBJECTIVES

This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs (n = 691).

RESEARCH DESIGN AND METHODS

Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and Centers for Medicare and Medicaid Services Automated Survey Processing Environment Complaints/Incidents Tracking System. To compare NHs, 4 quartiles of CNA retention rates were created: low (0%-48%), medium (49%-60%), high (61%-72%), and very high retention (73%-100%). Negative binomial regressions were estimated on total, substantiated, and unsubstantiated allegations and complaints. All regressions controlled for facility and county-level factors and clustered facilities by county.

RESULTS

NHs in the top 50% (high and very high) of retention received 1.92 fewer allegations than those in the bottom 50%, representing a 19% difference; this trend was significant and negative across all outcomes. Using quartiles revealed a nonlinear pattern: high-retention NHs received the fewest number of allegations and complaints. The differences between high and low retention on allegations, substantiated, and unsubstantied allegations were 33% (3.73 fewer), 34% (0.51 fewer), and 32% (3.12 fewer), respectively. Unexpectedly, very high-retention NHs received more unsubstantiated allegations than high-retention NHs.

DISCUSSION AND IMPLICATIONS

While higher-retention should result in fewer complaints, our results indicate that some turnover may be desirable because the very high-retention NHs performed slightly worse than those with high retention. Among the remaining facilities, fewer complaints may be achieved by improving CNA retention through higher wages, career advancement, and better training.

Factors Influencing Admission Decisions in Skilled Nursing Facilities: A Retrospective Quantitative Study (Preprint)

BACKGROUND

Occupancy rates within skilled nursing facilities (SNFs) in the United States have reached a record low. Understanding drivers of occupancy, including admission decisions, is critical for assessing the recovery of the long-term care sector as a whole. We provide the first comprehensive analysis of financial, clinical, and operational factors that impact whether a patient referral to an SNF is accepted or denied, using a large health informatics database.

OBJECTIVE

Our key objectives were to describe the distribution of referrals sent to SNFs in terms of key referral- and facility-level features; analyze key financial, clinical, and operational variables and their relationship to admission decisions; and identify the key potential reasons behind referral decisions in the context of learning health systems.

METHODS

We extracted and cleaned referral data from 627 SNFs from January 2020 to March 2022, including information on SNF daily operations (occupancy and nursing hours), referral-level factors (insurance type and primary diagnosis), and facility-level factors (overall 5-star rating and urban versus rural status). We computed descriptive statistics and applied regression modeling to identify and describe the relationships between these factors and referral decisions, considering them individually and controlling for other factors to understand their impact on the decision-making process.

RESULTS

When analyzing daily operation values, no significant relationship between SNF occupancy or nursing hours and referral acceptance was observed (P>.05). By analyzing referral-level factors, we found that the primary diagnosis category and insurance type of the patient were significantly related to referral acceptance (P<.05). Referrals with primary diagnoses within the category "Diseases of the Musculoskeletal System" are least often denied whereas those with diagnoses within the "Mental Illness" category are most often denied (compared with other diagnosis categories). Furthermore, private insurance holders are least often denied whereas "medicaid" holders are most often denied (compared with other insurance types). When analyzing facility-level factors, we found that the overall 5-star rating and urban versus rural status of an SNF are significantly related to referral acceptance (P<.05). We found a positive but nonmonotonic relationship between the 5-star rating and referral acceptance rates, with the highest acceptance rates found among 5-star facilities. In addition, we found that SNFs in urban areas have lower acceptance rates than their rural counterparts.

CONCLUSIONS

While many factors may influence a referral acceptance, care challenges associated with individual diagnoses and financial challenges associated with different remuneration types were found to be the strongest drivers. Understanding these drivers is essential in being more intentional in the process of accepting or denying referrals. We have interpreted our results using an adaptive leadership framework and suggested how SNFs can be more purposeful with their decisions while striving to achieve appropriate occupancy levels in ways that meet their goals and patients' needs.

Summary of the 2020 AHRQ research meeting on 'advancing methods of implementing and evaluating patient experience improvement using consumer assessment of healthcare providers and systems (CAHPS®) surveys'

BACKGROUND

The Agency for Healthcare Research and Quality held a research meeting on using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) data for quality improvement (QI) and evaluating such efforts.

TOPICS COVERED.

Meeting addressed: 1)What has been learned about organizational factors/environment needed to improve patient experience? 2)How have organizations used data to improve patient experience? 3)What can evaluations using CAHPS data teach us about implementing successful programs to improve patient experience?

KEY THEMES

Providers and stakeholders need to be engaged early and often, standardize QI processes, complement CAHPS data with other data, and compile dashboards of CAHPS scores to identify and track improvement. Rigorous study designs are valuable, but much can be learned and accomplished through practical organization-level studies.

Patient Characteristics Associated With Admission to Low-Safety Inpatient Psychiatric Facilities: Evidence for Racial Inequities

OBJECTIVE

The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities.

METHODS

Massachusetts all-payer 2017 discharge data (N=39,128 psychiatric patients) were linked to facility-level indicators of safety (N=38 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1,000 discharges (α=0.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately.

RESULTS

Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]=1.71, p<0.01; for non-Hispanic Asian, RRR=5.60, p<0.01; for non-Hispanic "other" race, RRR=2.17, p<0.01; and for Hispanic-Latinx, RRR=1.29, p<0.01) and not having private insurance (for self-pay or uninsured, RRR=2.40, p<0.01; for Medicaid, RRR=1.80, p<0.01; and for Medicare, RRR=1.31, p<0.01).

CONCLUSIONS

To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.

Complaints Matter: Seriousness of Elder Mistreatment Citations in Nursing Homes Nationwide

Mistreatment of nursing home residents is prevalent and leads to harmful consequences. The Centers for Medicare & Medicaid Services's (CMS) mission to protect residents' right to be free from mistreatment is implemented partially through state survey agencies' (SSAs) issuance of deficiency citations. The goal of this study was to compare SSA standard surveys and SSA complaint investigations with regard to the seriousness (scope and severity) of the mistreatment citations issued. A cumulative link mixed model was built to estimate the differences between standard surveys and complaint investigations in the seriousness of four core and two secondary mistreatment citations nationwide from 2014 to 2017. In all of the six mistreatment deficiency citations, complaint investigations were more likely to be determined as more serious compared with standard surveys. The findings reinforce the importance of strengthening nursing homes' and CMS/SSA response to consumers' concerns and grievances before they escalate into more harmful mistreatment.

The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes

While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.

A SBM-DEA based performance evaluation and optimization for social organizations participating in community and home-based elderly care services

The community and home-based elderly care service system has been proved an effective pattern to mitigate the elderly care dilemma under the background of accelerating aging in China. In particular, the participation of social organizations in community and home-based elderly care service has powerfully fueled the multi-supply of elderly care. As the industry of the elderly care service is in the ascendant, the management lags behind, resulting in the waste of significant social resources. Therefore, performance evaluation is proposed to resolve this problem. However, a systematic framework for evaluating performance of community and home-based elderly care service centers (CECSCs) is absent. To overcome this limitation, the SBM-DEA model is introduced in this paper to evaluate the performance of CECSCs. 186 social organizations in Nanjing were employed as an empirical study to develop the systematic framework for performance evaluation. Through holistic analysis of previous studies and interviews with experts, a systematic framework with 33 indicators of six dimensions (i.e., financial management, hardware facilities, team building, service management, service object and organization construction) was developed. Then, Sensitivity Analysis is used to screen the direction of performance optimization and specific suggestions were put forward for government, industrial associations and CECSCs to implement. The empirical study shows the proposed framework using SBM-DEA and sensitivity analysis is viable for conducting performance evaluation and improvement of CECSCs, which is conducive to the sustainable development of CECSCs.

Effects of the CMS' Public Reporting Program for Inpatient Psychiatric Facilities on Targeted and Nontargeted Safety: Differences Between For-Profits and Nonprofits

The Centers for Medicare and Medicaid Services implemented the Inpatient Psychiatric Facility Quality Reporting Program in 2012, which publicly reports facilities' performance on restraint and seclusion (R-S) measures. Using data from Massachusetts, we examined whether nonprofits and for-profits responded differently to the program on targeted indicators, and if the program had a differential spillover effect on nontargeted indicators of quality by ownership. Episodes of R-S (targeted), complaints (nontargeted), and discharges were obtained for 2008-2017 through public records requests to the Commonwealth of Massachusetts. Using difference-in-differences estimators, we found no differential changes in R-S between for-profits and nonprofits. However, for-profits had larger increases in overall complaints, safety-related complaints, abuse-related complaints, and R-S-related complaints compared with nonprofits. This is the first study to examine the effects of a national public reporting program among psychiatric facilities on nontargeted measures. Researchers and policymakers should further scrutinize intended and unintended consequences of performance-reporting programs.

Nursing home oversight during the COVID-19 pandemic

BACKGROUND/OBJECTIVES

Regulatory oversight has been a central strategy to assure nursing home quality of care for decades. In response to COVID-19, traditional elements of oversight that relate to resident care have been curtailed in favor of implementing limited infection control surveys and targeted complaint investigations. We seek to describe the state of nursing home oversight during the pandemic to facilitate a discussion of whether and how these activities should be altered going forward.

DESIGN AND SETTING

In a retrospective study, we describe national oversight activities in January-June 2020 and compare these activities to the same time period from 2019. We also examine state-level oversight activities during the peak months of the pandemic.

PARTICIPANTS

United States nursing homes.

DATA

Publicly available Quality, Certification, and Oversight Reports (QCOR) data from the Centers for Medicare and Medicaid Services (CMS).

MEASUREMENTS

Number of standard, complaint, and onsite infection surveys, number of deficiencies from standard and complaint surveys, number of citations by deficiency tag, and number and amount of civil monetary penalties.

RESULTS

The number of standard and complaint surveys declined considerably in the second quarter of 2020 relative to the same time frame in 2019. Deficiency citations generally decreased to near zero by April 2020 with the exception of infection prevention and control deficiencies and citations for failure to report COVID-19 data to the national health safety network. Related enforcement actions were down considerably in 2020, relative to 2019.

CONCLUSION

In the months since COVID-19 first impacted nursing homes, regulatory oversight efforts have fallen off considerably. While CMS implemented universal infection control surveys and targeted complaint investigations, other routine aspects of oversight dropped in light of justifiable limits on nursing home entry. Going forward, we must develop policies that allow regulators to balance the demands of the pandemic while fulfilling their responsibilities effectively.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

Objectives

To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.

Design

Retrospective cohort study from November 27, 2017 to November 27, 2019.

Setting and Participants

In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.

Methods

We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.

Results

A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.

Conclusions and Implications

As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

Appropriate Nurse Staffing Levels for U.S. Nursing Homes

US nursing homes are required to have sufficient nursing staff with the appropriate competencies to assure resident safety and attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident. Minimum nurse staffing levels have been identified in research studies and recommended by experts. Beyond the minimum levels, nursing homes must take into account the resident acuity to assure they have adequate staffing levels to meet the needs of residents. This paper presents a guide for determining whether a nursing home has adequate and appropriate nurse staffing. We propose five basic steps to: (1) determine the collective resident acuity and care needs, (2) determine the actual nurse staffing levels, (3) identify appropriate nurse staffing levels to meet residents care needs, (4) examine evidence regarding the adequacy of staffing, and (5) identify gaps between the actual staffing and the appropriate nursing staffing levels based on resident acuity. Data sources and specific methodologies are analyzed, compared, and recommended. The goal is to assist nursing home nurses and administrators to ensure adequate nursing home staffing levels that protect resident health, safety, and well-being.

Quality Indicators as Predictors of Future Inspection Performance in Ontario Nursing Homes

OBJECTIVES

There are several mechanisms for monitoring the quality of care in long-term care (LTC), including the use of quality indicators derived from resident assessments and formal inspections. The LTC inspection process is time and resource-intensive, and there may be opportunities to better target inspections. In this study, we aimed to examine whether quality indicators could predict future inspection performance in LTC homes across Ontario, Canada.

SETTING AND PARTICIPANTS

In total, 594 LTC homes across Ontario.

METHODS

Using a database compiling detailed inspection reports for the period from 2017 to 2018, we classified each home into 1 of 3 categories (in good standing, needing improvement, needing significant improvement). Machine learning techniques were used to examine whether publicly available Resident Assessment Instrument‒Minimum Data Set quality indicators for the period 2016‒2017 could predict facility classification based on inspection results.

RESULTS

After running a wide range of models, only a weak relationship was found between quality indicators and future inspection performance. The best-performing model was able to achieve a classification accuracy of 40.1%. Feature analysis was performed on the final model to identify which quality indicators were most indicative of predicted poor performance. Experiencing worsened pain, restraint use, and worsened pressure ulcers were correlated with homes predicted as needing significant improvement. Counterintuitively, improved physical functioning had an inverse relationship with homes predicted as being in good standing.

CONCLUSIONS AND IMPLICATIONS

Most quality indicators are poor predictors of inspection performance. Further work is required to explore the limited relationship between these 2 measures of LTC quality, and to identify other quality measures that may be useful as predictors of facilities facing difficulty in meeting quality standards.

Analyses of Complaints, Investigations of Allegations, and Deficiency Citations in United States Nursing Homes

Quality of care in nursing homes has been evaluated from varying perspectives, but few studies analyze complaints made to surveyors. This study analyzed complaints, investigations, and citations for nursing homes nationwide. Using the complaint and survey data sets, analyses match nursing home complaints with findings of investigations conducted. Results showed the average complaint rate was 13.3 complaints per 100 residents and that 43.2% of complaint allegations were substantiated, with complaints about care and services provided being the most prevalent. Variability was noted among the Centers for Medicare and Medicaid Services regions and, on average, 47.5% of facilities had five or more complaints in a given year. While additional research could evaluate the effect of complaint investigations on nursing home quality, results indicated that complaints and subsequent investigations provide further information regarding quality for residents. Results also suggest improvements in the training for surveyors and more consistency across Centers for Medicare and Medicaid Services survey regions.

Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery

BACKGROUND

In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored.

METHODS

To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV.

RESULTS

A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair.

CONCLUSION

The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.

Racial segregation and quality of care disparity in US nursing homes

In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality.

Are dual eligibles admitted to poorer quality skilled nursing facilities?

BACKGROUND

Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries.

OBJECTIVES

To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities (SNFs) compared with Medicare-only beneficiaries.

RESEARCH DESIGN

Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status.

SUBJECTS

A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005.

MEASURES

Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality.

RESULTS

Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home.

CONCLUSIONS

Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.

Effect of hospital-SNF referral linkages on rehospitalization

OBJECTIVE

To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage.

DATA SOURCES/COLLECTION

We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006.

STUDY DESIGN

We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument.

PRINCIPAL FINDINGS

Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge.

CONCLUSIONS

Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs.

An investigation of the effects of a nonprofit agency's investigations on quality of care in nursing homes

PROBLEM

This study examined whether an agency's investigation of complaints in 40 nursing homes is positively correlated with the quality of nursing home care.

METHODS

A quantitative methodology design using quantitative and qualitative data was used to assess the relationship between Agency X's investigation of consumers' nursing home complaints and the quality of nursing home care.

FINDINGS

Results showed fewer violations after the agency's interventions, indicating improvement in the nursing care. Analysis showed on average 0.14 fewer violations. This decrease is statistically significant (p = .015), indicating that this agency's intervention improved nursing home care.

CONCLUSIONS

Additional studies are needed to further explore the quality of care given in nursing homes. Nurses may propose to the Centers for Medicare & Medicaid Services to establish a new innovative system for ensuring high quality nursing home care by requiring the establishment of outside agencies, such as Agency X, to monitor care in addition to the annual surveys conducted by the Department of Health and Human Services.

Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia

OBJECTIVE

To determine whether international medical graduates (IMGs) have more complaints made against them to medical boards and experience more adverse disciplinary findings than Australian-trained doctors.

DESIGN AND SETTING

Data on all complaints made against doctors to medical boards in VICtoria and Western Australia over 7.5 years and 5.25 years, respectively, were extracted and linked with information on all doctors registered in those states over the same time periods. The data pertained to complaints resolved before February 2010 in Western Australia and June 2010 in VICtoria, the dates of the respective extractions. We tested for associations between IMG status and the incidence of complaints using multivariable logistic regression.

MAIN OUTCOME MEASURES

Incidences of complaints and adverse disciplinary findings.

RESULTS

Among 39 155 doctors registered in VICtoria and Western Australia in the study period, 5323 complaints were made against 3191 doctors. Thirty-seven per cent of registered doctors were IMGs. The odds of complaints were higher against IMGs than non-IMGs (odds ratio [OR], 1.24; 95% CI, 1.13-1.36; P < 0.001), as were the odds of adverse disciplinary findings (OR, 1.41; 95% CI, 1.07-1.85; P = 0.01). However, disaggregation of IMGs into their countries of qualification showed wide variation: doctors who qualified in Nigeria (OR, 4.02; 95% CI, 2.38-6.77), Egypt (OR, 2.32; 95% CI, 1.77-3.03), Poland (OR, 2.28; 95% CI, 1.43-3.61), Russia (OR, 2.21; 95% CI, 1.14-4.26), Pakistan (OR, 1.80; 95% CI, 1.09-2.98), the Philippines (OR, 1.80; 95% CI, 1.08-3.00) and India (OR, 1.61; 95% CI, 1.33-1.95) had higher odds of attracting complaints, but IMGs from the 13 other countries examined had odds that were not significantly different from Australian-trained doctors.

CONCLUSIONS

Overall, IMGs are more likely than Australian-trained doctors to attract complaints to medical boards and adverse disciplinary findings, but the risks differ markedly by country of training. Better understanding of such heterogeneity could inform a more evidence-based approach to registration and oversight rules.

Association between traditional nursing home quality measures and two sources of nursing home complaints

OBJECTIVE

To test for an association between traditional nursing home quality measures and two sources of resident- and caregiver-derived nursing home complaints.

DATA SOURCES

Nursing home complaints to the North Carolina Long-Term Care Ombudsman Program and state certification agency from October 2002 through September 2006 were matched with Online Survey Certification and Reporting data and Minimum Data Set Quality Indicators (MDS-QIs).

STUDY DESIGN

We examine the association between the number of complaints filed against a facility and measures of inspection violations, staffing levels, and MDS-QIs.

DATA EXTRACTION

One observation per facility per quarter is constructed by matching quarterly data on complaints to OSCAR data from the same or most recent prior quarter and to MDS-QIs from the same quarter. One observation per inspection is obtained by matching OSCAR data to complaint totals from both the same and the immediate prior quarter.

PRINCIPAL FINDINGS

There is little relationship between MDS-QIs and complaints. Ombudsman complaints and inspection violations are generally unrelated, but there is a positive relationship between state certification agency complaints and inspection violations.

CONCLUSIONS

Ombudsman and state certification agency complaint data are resident- and caregiver-derived quality measures that are distinctive from and complement traditional quality measures.

Interaction effect of Medicaid census and nursing home characteristics on quality of psychosocial care for residents

BACKGROUND

Numerous studies have identified disparities in nursing home quality of care. Although previous studies have found the overlap among Medicaid census, nursing home characteristics, and negative quality of care outcomes, few studies have examined how the psychosocial well-being of nursing home residents is associated with Medicaid census and other nursing home characteristics.

PURPOSE

The purpose of this study was to elucidate the intertwined relationships between Medicaid census and other important nursing home factors and its impact on psychosocial care for residents. This study examined the interactive effects of (1) nursing home ownership status and Medicaid census, (2) staffing level and Medicaid census, and (3) resident ethnic mix and Medicaid census on psychosocial well-being outcomes.

METHODOLOGY

The sample, derived from a combined data set of New York State nursing homes' Online Survey Certification and Reporting System and Minimum Data Set, included 565 nursing homes in rural and urban areas of the state.

FINDINGS

Medicaid census had no main effect on psychosocial well-being outcomes of nursing home care but had a significant interactive effect with other nursing home characteristics. High Medicaid census was associated with lower level of psychosocial symptom detection in nonprofit nursing homes and nursing homes with a higher proportion of ethnic minority residents.

PRACTICE IMPLICATIONS

Nursing staff training on better psychosocial well-being care, in particular, better psychosocial assessment, is important. To obtain the training resources, nursing homes with high Medicaid census can collaborate with other nursing homes or social service agencies. Considering that nursing homes with a high proportion of ethnic minority residents have lower level of detection rate for psychosocial well-being issues, culturally competent care should be a component of quality improvement plans.

Complaints in for-profit, non-profit and public nursing homes in two Canadian provinces

BACKGROUND

Nursing homes provide long-term housing, support and nursing care to frail elders who are no longer able to function independently. Although studies conducted in the United States have demonstrated an association between for-profit ownership and inferior quality, relatively few Canadian studies have made performance comparisons with reference to type of ownership. Complaints are one proxy measure of performance in the nursing home setting. Our study goal was to determine whether there is an association between facility ownership and the frequency of nursing home complaints.

METHODS

We analyzed publicly available data on complaints, regulatory measures, facility ownership and size for 604 facilities in Ontario over 1 year (2007/08) and 62 facilities in British Columbia (Fraser Health region) over 4 years (2004-2008). All analyses were carried out at the facility level. Negative binomial regression analysis was used to assess the association between type of facility ownership and frequency of complaints.

RESULTS

The mean (standard deviation) number of verified/substantiated complaints per 100 beds per year in Ontario and Fraser Health was 0.45 (1.10) and 0.78 (1.63) respectively. Most complaints related to resident care. Complaints were more frequent in facilities with more citations, i.e., violations of the legislation or regulations governing a home, (Ontario) and inspection violations (Fraser Health). Compared with Ontario's for-profit chain facilities, adjusted incident rate ratios and 95% confidence intervals of verified complaints were 0.56 (0.27-1.16), 0.58 (0.34-1.00), 0.43 (0.21- 0.88), and 0.50 (0.30- 0.84) for for-profit single-site, non-profit, charitable, and public facilities respectively. In Fraser Health, the adjusted incident rate ratio of substantiated complaints in non-profit facilities compared with for-profit facilities was 0.18 (0.07-0.45).

INTERPRETATION

Compared with for-profit chain facilities, non-profit, charitable and public facilities had significantly lower rates of complaints in Ontario. Likewise, in British Columbia's Fraser Health region, non-profit owned facilities had significantly lower rates of complaints compared with for-profit owned facilities.

An exploratory study of boarding home sanctions and compliance in Washington State

States vary in enforcement systems that monitor the quality of care in residential boarding homes. The growing number of people seeking long-term care services in boarding homes requires regulatory systems that are effective in quality assurance enforcement. This 6 year retrospective study describes the characteristics of 601 sanctioned and nonsanctioned homes in the state of Washington and evaluates the effectiveness of enforcement actions such as intermediate sanctions on future boarding home compliance. The intermediate sanctions evaluated are stop placement of admissions, civil fines, and conditions placed on licenses. Boarding homes that were sanctioned tended to be homes that were for-profit and had governmental contracts for Medicaid services. Homes that remained sanctioned throughout the 6 year study tended to be homes that were individual ownership corporations, had smaller numbers of licensed beds, and did not provide nursing services. Intermediate sanctions were found to vary in effectiveness. Conditions placed on licenses were the most effective intermediate sanction, and civil fines the least effective. Higher citation numbers and the most severe level of complaint types were found to be predictors of becoming a sanctioned boarding home.

Rurality and nursing home quality: evidence from the 2004 National Nursing Home Survey

PURPOSE OF THE STUDY

To evaluate the impact of rural geographic location on nursing home quality of care in the United States.

DESIGN AND METHODS

The study used cross-sectional observational design. We obtained resident- and facility-level data from 12,507 residents in 1,174 nursing homes from the 2004 National Nursing Home Survey. We used multilevel regression models to predict risk-adjusted rates of hospitalization, influenza and pneumococcal vaccination, and moderate to severe pain while controlling for resident and facility characteristics.

RESULTS

Adjusting for covariates, residents in rural facilities were more likely to experience hospitalization (odds ratio [OR] = 1.50, 95% confidence interval [CI] = 1.16-1.94) and moderate to severe pain (OR = 1.68, 95% CI = 1.35-2.09). Significant facility-level predictors of higher quality included higher percentage of Medicaid beneficiaries, accreditation status, and special care programs. Medicare payment findings were mixed. Significant resident-level predictors included dementia diagnosis and being a "long-stay" resident.

IMPLICATIONS

Rural residents were more likely to reside in facilities without accreditations or special care programs, factors that increased their odds of receiving poorer quality of care. Policy efforts to enhance Medicare payment approaches as well as increase rural facilities' accreditation status and provision of special care programs will likely reduce quality of care disparities in facilities.

Complaints against nursing homes: comparing two sources of complaint information and predictors of complaints

PURPOSE OF THE STUDY

Two consumer-derived measures of nursing home quality that have been underutilized by researchers are consumer complaints to the state certification agency between inspections and complaints to the Long-Term Care Ombudsman Program. This article describes these complaints, considers facility-level predictors of complaints, and examines how complaints to the 2 entities are related.

DESIGN AND METHODS

This article uses North Carolina complaint data from the state certification agency and Ombudsman from 2002 to 2006. First, we outline the similarities and differences in the 2 complaint sources by considering descriptive statistics and examining the structure of the 2 agencies. Second, we examine the relationship between complaints and facility characteristics that have been predictive of traditional quality measures. Finally, we examine the relationships between the 2 types of complaints.

RESULTS

We find that complaints to the 2 agencies exhibit distinct differences in substantiation rates, although the top complaint category for both agencies is quality of care. Having a higher proportion of Medicaid residents is generally not predictive of complaint volume, whereas having a higher proportion of Medicare residents is associated with higher complaint levels.

IMPLICATIONS

We find a lack of association between complaints to the 2 agencies when examining specific matched categories of complaints in many cases, suggesting that the 2 entities are not duplicating efforts in these categories.

What is nursing home quality and how is it measured?

PURPOSE

In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality.

DESIGN AND METHODS

A brief review of the history of nursing home quality is presented that provides some context and insight into currently used quality indicators. Donabedian's structure, process, and outcome (SPO) model is used to frame the discussion. Current quality indicators and quality initiatives are discussed, including those included in the Facility Quality Indicator Profile Report, Nursing Home Compare, deficiency citations included as part of Medicare/Medicaid certification, and the Advancing Excellence Campaign.

RESULTS

Current quality indicators are presented as a mix of structural, process, and outcome measures, each of which has noted advantages and disadvantages. We speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes, including report cards, pay for performance, market-based incentives, and policy developments in the certification process. Areas for future research are identified throughout the review.

IMPLICATIONS

We conclude that improvements in nursing home quality have likely occurred, but improvements are still needed.

Nursing Home Caregiver Staffing Levels and Quality of Care

In this research, the author reviewed 70 studies that had examined the relationship between staffing levels and quality in nursing homes (covering the years 1991 to 2006). The results of the review including all of this literature show that approximately 40% of the quality indicators examined show an association with nursing home staffing levels. Nevertheless, this finding is further interpreted in the context of the limitations of many of these prior studies. The author discusses the limitations of poor quality staffing data, small sample size, quality indicators used, methodological concerns, and underspecified models inherent to many prior studies. The author finds no study representing a “gold standard” exists in this area. Still, the few studies that seem methodologically most robust would seem to indicate that an association between nursing home staffing levels and quality exists. However, the author concludes that studies in this area need to be further enhanced.