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Nursing Home Care Levels May Be Much Lower Than Families Think

Edna Irvin in her bed at the Arkansas Health Center in Benton, Ark. In 2010, one quarter of the residents in the facility were black, according to data compiled at Brown University. A Center for Public Integrity analysis of more than 10,000 nursing homes across the country found that nursing homes where the majority of residents were black or Latino received much less registered nurse care than those facilities where most residents were white. Jon Lowenstein / NOOR via CPI

This story was published by The Center for Public Integrity, a nonprofit, nonpartisan investigative news organization in Washington, D.C.

Many U.S. nursing home patients may not be receiving the level of care their loved ones believe they're getting, a Center for Public Integrity probe has found.

Staffing levels reported by thousands of nursing homes on a widely-used government website were higher than the staff levels calculated by the Center for Public Integrity through an analysis of annual financial reports submitted by the homes, suggesting that consumers in those facilities may not be getting as many hours of skilled care as they expect. Experts have shown that the amount of care provided by nursing homes is linked to the quality of care.

The discrepancies raise profound questions about the accuracy of the information in the so-called Nursing Home Compare website that many consumers use to pick a nursing home for family members. The reporting discrepancies occurred for all types of positions, but were particularly high for registered nurses, the most skilled and highest paid workers.

More than 80 percent of the facilities reported higher registered nurse staffing levels on the public website than those the Center calculated through its analysis of the cost reports. In more than 25 percent of nursing homes nationwide, the amount of staff listed on the public website was at least double the level in the cost reports.

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Close to 100 peer-reviewed, academic studies have shown that the amount of care, particularly that provided by registered nurses, is most strongly connected with residents’ quality of care. Lower levels of care are associated with a higher likelihood of injury and even death.

Eight of the 10 states with the largest levels of discrepancies in the reporting of registered nurse staffing levels were southern. Among them: Louisiana and Arkansas, where the average self-reported levels were at least twice the amount calculated through the cost reports analysis.

Edna Irvin lies in her bed at the Arkansas Health Center in Benton, Ark. A Center for Public Integrity analysis of more than 10,000 nursing homes across the country found that Arkansas was one of two states where the daily level of registered nurse care listed on public website Nursing Home Compare was at least twice the level the Center calculated from an analysis of annual financial cost reports. The Arkansas Health Center was not included in the analysis. Jon Lowenstein / NOOR

A systematic problem

Data on the publicly available Nursing Home Compare website, which is promoted by the government for comparison shopping, reflects staffing levels self-reported by nursing homes during a two-week period before annual inspections. Advocates say many homes work hard to prepare for these visits. As a result, critics say, those staffing levels may be artificially inflated.

In 2005, the Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for overseeing nursing homes, said cost reports to the Medicaid program, which are harder for the public to locate and understand, are a more accurate source of information than Nursing Home Compare. The Center analyzed staffing levels in Medicare cost reports that contain largely the same information as the Medicaid documents, and compared them to those reported by Nursing Home Compare.

CMS declined to comment on this issue since it had not seen the Center’s analysis. Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, the nursing home industry’s largest professional organization, said he is “not surprised by these findings since the way the cost reports collect information on staffing is different than [Compare].” He added in a statement that daily direct care nursing hours have increased for residents at all levels of nursing staff from 2008 to 2013.

But Robyn Grant, director of public policy for the Washington, D.C.-based advocacy group the National Consumer Voice, said the Center’s analysis was shocking.

“We all recognize the data is flawed, but I am truly stunned by [the] findings and appalled that you’re finding this level of over-reporting” Grant said.

Rep. Jan Schakowsky (D-Ill.), said the self-reported data included on the Nursing Home Compare website shows an “extreme overestimation.”

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“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 to more accurate data by March 2012—a transition that still has not occurred.

The Affordable Care Act mandated that CMS implement by March 2012 an electronic data collection system by which facilities would submit payroll-based, verifiable staffing information about registered nurses, licensed practical nurses and certified nursing assistants. That information about the amount of staffing by position and staff turnover was to be published on the Nursing Home Compare website.

But on Dec. 9, 2011, Thomas Hamilton, director of the agency’s survey and certification group, wrote a memo saying that CMS would not make that deadline due to fiscal constraints.

Little progress has been made since. A pilot program to capture payroll data tested less than 1 percent of homes, according to the agency. In October, CMS said it would complete the implementation of the payroll system by the end of 2016 after receiving $11 million in funding from bipartisan legislation.

Sen. Charles Grassley (R-Iowa) and Schakowsky, expressed disappointment at the agency’s failure to complete its mandated task.

Grant of the National Consumer Voice called the implementation of the payroll data collection system “long overdue” and said her organization would remain vigilant.

“We will continue our advocacy to ensure the system is implemented appropriately and within the stated time frame,” Grant said.

A lack of oversight

Patient advocates like Richard Mollot, executive director of the New York advocacy group the Long Term Care Community Coalition, say accurate staffing data is more important than ever because nursing home inspections are falling. A Center analysis found that the number of standard state nursing home inspections fell 6 percent from 2008 to 2012— even though the number of nursing homes fell just 1 percent during those years.

“If the information is poor, that’s not helpful at all,” Mollot said. “You have all these tools now, you’re letting the marketplace rather than enforcement play a bigger role."

Other data indicates that hundreds of nursing homes have had staffing levels that are lower than those mandated by state laws.

Thirty-three states and Washington, DC had daily direct care staffing requirements that in 2010 ranged from .44 hours per resident in Arizona to 3.9 hours per resident in Florida, according to a survey conducted by Charlene Harrington, emeritus professor of nursing at the University of California, San Francisco.

But in 2012, more than 700 facilities, including more than 250 nursing homes in Illinois, had daily care levels that were lower than the levels required by those state laws, according to the Center’s cost report analysis.

Lisa Creamer contributed reporting to this story.

This story was written with support from the Fund for Investigative Journalism.

The Center for Public Integrity is a nonprofit, nonpartisan investigative news organization in Washington, D.C.