Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
“For 67 of the 100 sampled nursing homes, CMS did not accurately report on Care Compare 1 or more deficiencies that surveyors identified during yearly and complaint inspections. The deficiencies consisted of health deficiencies for 34 nursing homes, fire safety deficiencies for 52 nursing homes, and emergency preparedness deficiencies for 2 nursing homes. In addition, for 42 of the 100 sampled nursing homes, CMS did not report on Care Compare the results of all yearly fire safety and emergency preparedness inspections.
On the basis of (OIG) sample results, (it is) estimated that 10,303 nursing homes had 1 or more deficiencies identified during inspections that were not accurately reported on Care Compare. Specifically, OIG estimated that 5,228 nursing homes had health deficiencies, 7,996 nursing homes had fire safety deficiencies, and 308 nursing homes had emergency preparedness deficiencies that were not accurately reported on Care Compare. In addition, (OIG) estimated that for 6,458 nursing homes CMS did not report on Care Compare the results of all yearly fire safety and emergency preparedness inspections.”
This OIG report – same title as this blog (44 pages) was posted Monday, April 10, 2023. OIG randomly sampled 100 nursing homes from among 15,377 nursing homes nationwide. For each sampled nursing home, OIG compared the deficiencies that had been reported on Care Compare as of December 10, 2020, with the deficiencies that State survey agency surveyors had documented in inspection reports from the three most recent yearly health, fire safety, and emergency preparedness inspections and the results of the most recent 3 years of complaint inspections.
OIG recommends that CMS: (1) correct the inaccurately reported deficiencies that we identified for the sampled nursing homes; and (2) strengthen its processes for reviewing inspection results reported on Care Compare by requiring State survey agencies to verify the deficiencies reported, providing technical assistance and additional training to State survey agencies, and verifying that nursing home inspection results are accurately reported. The report has three other procedural recommendations.
CMS concurred with the second part of our last recommendation—that it provide technical assistance and additional training to survey agencies—but it did not state whether it concurred with our remaining recommendations. CMS provided information on actions that it had taken or planned to take to address some of those recommendations. After reviewing CMS’s comments, OIG revised the first recommendation to clarify that CMS should correct the inaccurately reported deficiencies we identified for the sampled nursing homes. OIG also revised the first part of the last recommendation to clarify that the verification should be performed when a State survey agency is preparing to conduct an inspection. OIG maintains that these recommendations, as revised, are valid.
Share this OIG report with your team and your colleagues. What does your facility’s Care Compare reporting look like in the light of the OIG report? When was the last time you viewed your Care Compare report?