Yet More Problems with Nursing Home “Quality Ratings” in Arizona: Part 3 of a Series

This is the third in a series of posts on problems with the “quality rating” system used by the Arizona Department of Health Services [ADHS]. Last time I explained how many medication errors did not have any effect on a nursing home’s “quality rating” because the standards were revised in 2003 to ignore all but “significant medication errors” that resulted in “actual harm.”

That is not the only place where an “actual harm” requirement was added to the standards.

One long-standing flaw in the Arizona quality rating standards is that the focus is almost entirely on deficiencies discovered during the nursing home’s more-or-less annual license renewal inspection (called a “relicensure survey”). But ADHS also conducts complaint investigations (called “complaint surveys”) at any time.

As the name suggests, a complaint survey is triggered by someone--including a resident, a resident’s family member, or a hospital emergency room nurse or doctor--contacting ADHS to report a specific problem or set of problems. If ADHS considers the problem serious enough, it will be investigated within a few days (problems that ADHS considers less serious might not be investigated until months later, however). If conducted quickly and thoroughly enough, a complaint survey can reveal significant problems in a nursing home, including on-going deficiencies that the ADHS surveyors missed during a previous relicensure survey.

Prior to 2003, the standards ignored anything that was discovered during a complaint survey. A nursing home could get marked down only if it had “any current licensure deficiencies that were cited during the last licensure survey.” Thus, if ADHS cited a nursing home for a particular deficiency during its relicensure survey in 2001, and cited the nursing home for that same deficiency during its relicensure survey in 2002, the nursing home’s quality rating would be affected. But deficiencies cited in the intervening compliant surveys--no matter how serious--would have no effect whatsoever.

The 2003 revisions rewrote this standard to include repeat deficiencies cited in a complaint surveys--a positive change--but then added language that all but ensures that such repeat deficiencies will never affect a facility’s quality rating. Instead deducting points for “any repeat deficiency,” the repeat deficiency now must have “resulted in actual harm or immediate jeopardy to residents” (emphasis added).

In other words, repeat deficiencies that do not cause “actual harm or immediate jeopardy” no longer count as repeat deficiencies at all, no matter how many times they occur.

Nor is that the only drawback to the revised standard.

While “actual harm” seems fairly self-explanatory, the meaning of “immediate jeopardy” is not. As defined by a federal regulation, 42 C.F.R. § 489.3: “Immediate jeopardy means a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” A little clearer, but not much.

The true test, however, is to look at how ADHS uses those terms. The results are surprising.

For example, this was not a deficiency “that resulted in actual harm or immediate jeopardy”:

Failure to provide a resident with fall assessments that were accurate and complete, prior to a fall that resulted in a fractured hip.

A violation of the regulations that caused a broken hip is not “actual harm or immediate jeopardy,” even though (according to the ADHS Statement of Deficiencies) the facility staff admitted that “the Post Fall Evaluation and Fall Risk Assessments were inaccurate and incomplete”? Amazing.

Some other deficiencies that ADHS has not deemed to constitute “actual harm” or “immediate jeopardy” are:

• Failure to store, prepare, and serve food under sanitary conditions.
• Failure to ensure that all allegations of abuse involving a resident are reported immediately to ADHS and are thoroughly investigated by the nursing home.
• Failure to ensure that licensed staff administered medications according to professional standards and that a resident received care according to physician orders.
• Failure to ensure that residents received restorative nursing services to improve strength and range of motion in upper and lower extremities as prescribed by their physicians.
• Failure to provide care to prevent potential accidents.
• Failure to ensure residents’ medical records are accurate and maintained in accordance with accepted professional standards.
• Failure to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment.
• Failure to establish an infection control program that identified, investigated, controlled, and prevented the spread of infections.

Because none of these deficiencies constitute “actual harm” or “immediate jeopardy,” a facility could be cited multiple times for any (or all) of them without losing any quality rating points for repeat deficiencies.

This is yet another reason why a “quality rating” of “A” is no indication that a nursing home is free from significant or recurring problems, and why the ADHS “quality rating” is worthless when choosing a nursing home for a family member.

I’ll continue to post more on this topic next week. As always, your comments are welcome. Also, check out our website form more information about our firm and neglect, abuse, and negligence in Arizona group homes and nursing homes: http://solomonrelihan.com/

Other Problems with Arizona Nursing Home “Quality Ratings”: Part 2

This is the second in a series of posts on problems with the “quality rating” system used by the Arizona Department of Health Services [ADHS]. Today’s topic: How most medication errors were ignored in the revisions that watered down the “quality rating” standards in 2003.

The previous post mentioned a nursing home that received an “A” quality rating even though it had violated nineteen federal and state regulations. One of those violations was a medication error rate greater than 5% (the actual error rate, as determined by ADHS, was actually 9.5%).

Prior to 2003, a facility would lose points on its quality rating for “significant medication errors that may adversely affect the resident’s health, safety, and well-being” (emphasis added). After the standards were revised in 2003, a facility loses points only for “significant medication errors that resulted in actual harm” (emphasis added).

A bit of background to make the significance of this change a little clearer.

Federal and state regulations require nursing homes to keep their medication error rates below 5%. See 42 C.F.R. § 483.25(m)(1); Ariz. Admin. Code R9-10-911(B)(3). “Medication errors” include failing to give an ordered medication, giving a medication that was not ordered, administering the wrong dosage, and giving an ordered medication at the wrong time or by an incorrect method of administration (e.g., intravenously instead of intramuscularly, or vice versa).

A “medication error” need not cause harm, or even create a risk of harm, and the regulations reflect that by allowing a facility to make a few medication errors without penalty--the facility just has to get it right at least 95% of the time.

That’s not true with a “significant medication error,” which is a medication error that “endangers the health or safety of a resident,” see Ariz. Admin. Code R9-10-101(87) (until 2003, the Arizona regulations mirrored the federal definition of a “significant medication error” as one “which causes the resident severe discomfort or jeopardizes a resident’s health and safety,” but the “severe discomfort” part of the definition was junked at the same time the quality rating standards were revised).

Unlike “medication errors,” federal and state regulations do not allow a 5% error rate for a “significant medication errors.” Instead, federal and state regulations require that residents be totally free from significant medication errors. See 42 C.F.R. § 483.25(m)(2); Ariz. Admin. Code R9-10-906(B)(14). This zero-tolerance rule makes sense because any “significant medication error” could--though not necessarily--have serious consequences for the resident’s health and safety.

Prior to the 2003 revision of the ADHS quality rating system, only a “significant medication error”--one that jeopardized a resident’s health and safety, even if it did not cause any actual harm--could affect the facility’s quality rating. Now, however, a facility can violate both sets of regulations by having a medication error rate above 5% and having a significant medication error that endangered a resident’s health or safety without any effect on the facility’s quality rating.

Under the current standard, the facility loses points only if someone actually becomes ill or dies from a significant medication error. Even then, the penalty is only five points on the 100-point rating scale--not enough, by itself, to drop the facility a full letter grade.

While it might make sense to penalize a nursing home only five points simply for having a medication error rate above 5% or a significant medication error that did not cause actual harm, knocking off only five points for errors that do cause illness or death seems rather lenient, especially in light of the scope and severity of the problem. In Preventing Medication Errors (2007), the Institute of Medicine of the National Academies estimates:

Between 350,000 and 1.9 million ADEs [adverse drug events] occur each year among the 1.6 million U.S. nursing home residents, about 40-50 percent of which are preventable. Of the estimated 20,000-86,000 fatal or life-threatening ADEs, about 70-80 percent are preventable.

Eliminating medication errors--whether “significant” or not--should be a priority for nursing homes and regulators alike. But the current quality rating system does not provide much incentive for nursing homes to address the problem of medication errors.

After the 2003 revisions, a facility loses five points only in the unlikely event that (1) evidence of actual harm (2) from a significant medication error (3) is discovered by ADHS (4) while ADHS is conducting a relicensure survey (as mentioned in a previous post, the quality rating scores are based only on deficiencies cited during the facility’s license renewal survey, not the cumulative total of deficiencies cited on all interim complaint investigations).

Thus, a “quality rating” of “A” is no indication that a nursing home is free from significant medication errors--or other serious problems--that could seriously harm a vulnerable nursing home resident. This is one reason why the ADHS “quality rating” is worthless for choosing a nursing home for a family member.

I’ll continue to post more on this topic next week. As always, your comments are welcome. For more information, see our website: http://solomonrelihan.com/

Worthless Arizona Nursing Home “Quality Ratings”: Part 1

Arizona Administrative Code R9-10-919 requires the Arizona Department of Health Services [ADHS] to give Arizona nursing homes a “quality rating” based on the results of the nursing home’s license renewal inspection. While such “quality ratings” might seem to be a reliable, objective measure of the quality of care provided in a nursing home, and a useful guide to how well a loved one will be treated, these “quality ratings” are worthless at best; at worst, they can be dangerously misleading.

Currently, the “quality rating” is a letter grade (A, B, C, or D, with D being the lowest rating possible) based on a 100-point scale, with 90-100 points equal to an A, 80-89 points for a B, 70-79 points for a C, and 69 points or less for a D. With one exception (discussed later), the score is based solely on deficiencies discovered during the facility’s license renewal survey, not the cumulative total of deficiencies cited on any complaint investigation surveys conducted since the last relicensure inspection.

As a result, a facility could have serious deficiencies and still receive a high score–-it all depends on what the ADHS surveyors do or do not discover at the time.

Nor does the quality rating evaluate a facility’s compliance with all federal and state regulations; instead, the rating is based on only about 10% of the state regulations–and not even the most important 10%.

For example, in discussing a proposal for the Centers for Medicare and Medicaid Services [CMS] to implement a “Five-Star Ranking System” for nursing homes, the National Citizens’ Coalition for Nursing Home Reform [NCCNHR] notes that five quality measures are strongly indicative of quality of care:

• The percentage of high-risk residents with pressure ulcers;
• The percentage of residents with long-term catheters;
• The percentage of residents with restraints;
• The percentage of residents with urinary tract infections [UTIs]; and
• The percentage of residents with a significant weight loss.

The ADHS “quality rating” system ignores four of them (pressure ulcers, catheters, UTIs, and weight loss).

What this means is that a nursing home can receive a high “quality rating” even though significant and potentially dangerous problems exist at the facility. For example, I recently reviewed the file of a nursing home that received an “A” rating, even though it was cited for violating nineteen federal and state regulations, based on such findings as:

• A medication error rate greater than 5% and failing to ensure that staff administered medications according to professional standards;
• Failing to ensure residents received care according to physician orders;
• Failing to ensure that residents had accurate and complete assessments and that residents’ clinical records were accurate;
• Failing to provide care to prevent potential accidents;
• Failing to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment; and
• Failing to store, prepare, and serve food under sanitary conditions.

How could a facility violate nineteen regulations and still receive an “A”? Easily, because only two of those nineteen federal and state regulations are scored by the ADHS “quality rating” system. The most serious violations–-the medication errors, the incomplete and inaccurate clinical records, and the failure to follow physician orders–-did not affect the facility’s score at all.

I’ll post more on this topic next week–-please check back and let me know what you think. You can also learn more by going to our website: http://solomonrelihan.com/