“Some … families select what appears to be a high quality, well-staffed nursing home based on the self-reported data, only to learn after some avoidable complication or deterioration in their loved ones’ condition that the nursing home was understaffed,” said Schakowsky, who authored a provision of the Affordable Care Act that required a transition from self-reported data to payroll data that CMS has said is close to a ‘gold standard.’
Under the law, a transition to the more accurate payroll method was supposed to occur by March 2012 under CMS’ supervision. But it hasn’t happened yet — and may not for another two years. The agency said in a statement that recent legislation gives it the necessary, multi-year funding to complete the required process. Meanwhile, hundreds of homes throughout the country are also below minimum state staffing standards, according to the Center’s analysis.
The self-reporting process
State inspectors are contracted by CMS to conduct onsite inspections about once each year to determine whether its nursing homes meet minimum Medicare and Medicaid quality and performance standards. Opinion is divided about the extent to which facilities know the precise dates of surveyor visits and inflate staffing levels in anticipation of those arrivals. Although a report in the early part of last decade prepared for CMS did not find evidence of systematic “staffing up” in advance of the surveyor visits, a 2007 academic paper found significant levels of over-reporting in Texas nursing homes that could suggest preparing for inspectors’ visits by raising staffing levels did indeed take place.
But there was little ambiguity in an internal communication sent by Administrator David Fielding of Medford Multicare Center for Living in Medford, New York.
In response to an email from owner Mordechai Klein complaining about the amount of overtime pay during one pay period, Fielding wrote the following, according to a civil complaint filed in February 2014 by New York Attorney General Eric Schneiderman:
Survey. All hands on deck during survey. It’s our super bowl and only lasts one week. The staffing hours will be a little high this week but will drop the following week.
Klein responded by calling the amount of overtime “ridiculous,” the complaint said.
The two men are among the owners, workers and administrators charged in a suit, still pending, that alleges widespread physical and financial abuse at the Medford home. Fielding’s lawyer Brian Griffin, said Fielding pled not guilty and is adamant that he violated neither criminal nor civil statutes. In a statement, Medford Multicare ownership asserted its commitment to “delivering exceptional care while maintaining fiscal responsibility,” and asserted that it consistently provided hundred of overtime hours of care per week.
Edward Mortimore, technical director of the survey and certification group within CMS, suggested that the registered nurse over-reporting could be explained in part by the inclusion in the Nursing Home Compare data of nursing staff like directors of nursing who do not provide direct care. Mortimore also said that Compare’s two-week snapshot might not give as accurate information as an average daily basis.
The Center for Public Integrity performed its analysis using a second data set with quarterly staffing information that only included nurses providing direct care.
The findings remained nearly identical. More than 80 percent of the facilities self-reported higher registered-nurse staffing levels than those calculated through the cost reports, and in 26 percent the level was at least double the cost reports level.
Advocates say this gap is critical to resolve as it is occurring at a time when the nation is bracing for a “silver tsunami,” as baby boomers reach senior citizen status.
The number of standard state nursing home inspections dropped each year from 2008 to 2012, falling 6 percent from more than 15,700 to more than 14,700 during those years, the Center’s analysis of federal data found. The number of nursing homes fell just 1 percent during those years.
The lower number of inspections only heightens the importance of accurate information, says Richard Mollot, executive director of the New York advocacy group the Long Term Care Community Coalition.
“The federal government and the state are there so that people are supposed to be able to make choices,” Mollot said. “If the information is poor, that’s not helpful at all. You have all these tools now, you’re letting the marketplace rather than enforcement play a bigger role."
“The data are entirely unreliable,” he said.