NH Citations Across US: Wide Variation in Scope, Severity

By Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP; David Hoffman, JD, FCPP

ProPublica published a report¹ at the end of 2017 examining the trend in deficiency citations for long-term care facilities across the country. The interactive map found on the ProPublica website utilized inspection reports from 2014-2017, focused on the severity of penalties, concluding that there exists a significant geographical variability in the number of deficiencies and the imposition of Civil Monetary Penalties (CMPs).

The range in the number of significant deficiencies was 1-1272. The states with the greatest number of CMPs include New Mexico followed by Kentucky, Texas, Montana, Arkansas, Kansas, Tennessee, Georgia, South Carolina and South Dakota. Of these 10 states, 60% are located in the southern region of the United States. 

The states with the least number of CMPs include New Hampshire, Delaware, North Dakota, Maine, Nevada, Wyoming, Vermont, Virginia, Pennsylvania, and Minnesota.

The table below compares the number of facilities per state with significant Scope and Severity deficiencies (Level I-L):

  State        Number of I-J-K-L Deficiencies          Number Facilities            Serious Def/NH

What accounts to the variability between states regarding the number of serious deficiencies? Could the variation be attributed to differences in the inspection process; the education/experience of nursing home personnel; the level of staffing; the degree of corporate support provided to facilities; budget issues; geography or the degree of knowledge to make appropriate interventions to comply with federal regulations? Is the determination of serious violations consistently being applied across state agencies?

Examining the myriad of reasons for the variance in survey data from state to state should be a priority for CMS and the long-term care industry. Being able to compare the delivery of care from facility to facility, across regions and across the country is necessary in order to ensure the definitions of quality are being applied appropriately across these settings.  It is also necessary for consumers to have confidence in the inspection process.

Response from David Hoffman, JD, FCPP, Owner, David Hoffman & Associates and Hospital & Health Care Consultant

Dr Warner-Maron raises some important questions regarding the regulatory enforcement system associated with nursing homes. It has been my experience that state surveyors from state agencies from one area of the country may cite deficiencies in a more aggressive fashion than others. While there is no clear answer as to why, several relevant factors should be mentioned. 

The first factor is the approach of the CMS regional office. If the regional office mandates aggressive enforcement, the state will follow. The next relevant factor is the inherent difference in clinical expertise and judgement amongst nursing home surveyors, ie, one set of facts/observations could lead one surveyor to conclude that a lesser level of actual harm is more appropriate than another. For example, the “I” level deficiency is identified as “widespread” actual harm that is not immediate jeopardy. Usually this scope and severity citation means that greater than 75% of the residents could, or have in fact, been impacted by this deficient conduct. Therefore, there is inherently great latitude in determining the number of residents that could be impacted by the deficient conduct and, as a result, a lesser scope and severity citation may be issued.

The plan of correction must get at the root cause for the deficiency, regardless of its scope and severity, in order to ensure that the deficient type of conduct is remedied and not repeated.

Reference

1. ProPublica. Nursing home inspect. https://projects.propublica.org/nursing-homes/. Published November 2017. Updated April 2018. Accessed April 30, 2018.

Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.

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