State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Aspects of Florida's Quality Improvement Programs Noted to be Less Successful


Although some discussion participants praised the Quality Monitoring program, consumer advocates voiced some concerns, primarily because of the changes that were made to the original role and responsibilities as laid out in HB 1971 in 1999. The program as initially enacted was seen as separate from the survey agency and allowed the monitors to focus on the more problematic facilities. In SB1202, the quality monitors' roles and responsibilities were expanded. It required the Quality Monitors to provide quarterly visits to each facility in his/her region, oversee the risk management program, verify that facilities were meeting the minimum staffing requirements and perform various surveyor activities as needed. Quality monitors are now responsible for monitoring facilities that were closing or in immediate jeopardy and provide orientation for new surveyors. By taking on surveyor tasks, the separation between quality monitoring and enforcement became less distinct. Provider association members reported that since the Quality Monitors are seen more as part of the risk management effort now, providers rarely think anymore about how they can use them for quality improvement.

Consumer advocates were concerned that the close ties between Quality Monitors and surveyors would lead to one group putting pressure on the other so that the information they presented about facilities was consistent between them. For example, a poor survey outcome could lead to the conclusion that the Quality Monitor was not providing effective oversight.

There was some concern expressed that Quality Monitors hired as a result of SB 1202 were not as qualified as the former surveyors hired in the first round, and that there was great variability in the quality of quality monitoring depending on region of the state. Providers noted that often they were asked to provide information for the Quality Monitors who did not necessarily have a background in long term care. They also stated that a problem existed with inconsistency between information being disseminated by Quality Monitors and surveyors. Some providers complained that visits were not occurring on a quarterly basis because of Quality Monitors being overwhelmed and the position experiencing high turnover rates. They also noted that often a survey followed a quality monitoring visit, focusing on the same issues that the monitor had raised, causing them to question whether the Quality Monitors were maintaining confidentiality of the visits.

Consumer advocates objected to the promotion of the best surveyors out of the enforcement agency, saying it weakened survey. They also stated that they did not agree that taxpayer funds should be used to provide advice to multi-facility chains on how to deliver care, likening it to the government providing training to Fed-Ex on how to deliver packages on time. They agreed that small, independent facilities often needed and should be entitled to such support, but it made more sense to shut down large for-profit chains if they provided poor quality care to residents. Concern was also expressed that because Quality Monitors must now oversee the risk management programs, visits are no longer always unannounced, since the Quality Monitor must meet with the facility's designated risk manager.

Respondents were critical of the Gold Seal program because the strict criteria eliminated the majority of facilities. The expense of a financial audit, which is required, was also a negative. Providers noted that there was not much incentive to seek a Gold Seal, as there was no change to the survey cycle, no immunity from lawsuits and no change in reimbursement.

Although some facilities praised the risk management process as teaching them how to critically evaluate their protocols, the reporting of adverse incidents and the confusion around the reporting requirements has put providers in a difficult situation. Facilities have been over reporting adverse incidents because they have trouble identifying incidents that are in their control and because the stakes for not reporting are so high. The failure to report an adverse incident to the survey agency can result in a G-level deficiency. A G-level deficiency citation results in placement on the Watch list. Two G-level deficiency citations may result in a six-month survey cycle and imposition of fines. Reporting of adverse incidents was intended to distinguish better performing facilities from problem facilities, thus encouraging insurance companies to come back into the state. In part because of the over-reporting issue, however, no progress has been made in improving the insurance situation. Participants also noted that no credentials or qualifications were mandated for the facility risk manager. Requiring credentialing was seen as one way to improve the program.

Both the Nursing Home Watch List and Nursing Home Guide are based on survey outcomes and were thus criticized because of the recognized inconsistency of survey results. Participants noted that information in both areas was often not available in a timely manner. The website star system is based on 45 months of data and participants noted that, "a lot can happen in 45 months." Consumer advocates did not agree with the star system, maintaining that giving the worst facilities in the state even a one-star rating was misleading. They also did not agree with the agency's practice of not posting information until appeals had been resolved. Advocates also recommended that the website should contain information on lawsuits and fines. Providers also noted that Florida consumers now have access to three types of sites with nursing home quality of care information--the CMS site, the proprietary sites and the AHCA site. Since information varies from site to site, they use different ratings, and show different levels of compliance, they question how this helps consumers.

Providers were very concerned that the mandated increase in nurse aide staffing to 2.9 ppd (due in January 2004) is going to be virtually impossible to attain. They are concerned that it will force facilities to compete with one another by offering bonuses and incentives. There was disagreement as to the adequacy of the workforce needed to meet the future requirements. Consumer advocates stated that there were plenty of nurse aides available in the state, with 250,000 on the registry and 10,000 new grads each year. They saw nurse aide shortages as the result of the poor conditions, benefit and pay provided by facilities and stated that improving working conditions and giving nurse aides 40 hour work weeks would go a long way to remedying the situation. Provider representatives, however, said that there was not an adequate supply to meet the demand "without significant wage pressure." Two-thirds of Florida's nursing homes are paid for by Medicaid and they will not be able to increase wages to engage in competition for employees.

Provider representatives also noted that they would like the State to relax the requirement that facilities self-impose an admission moratorium when unable to meet the staffing minimums. They would also like to see the staffing requirement relaxed for smaller facilities. Facilities are being forced to use temporary agency staff to meet the requirements. The cost is prohibitive and providers complain that they are not being reimbursed for it. They also fear that the legislature will not pass the funding necessary to increase the nurse aide hours, but that facilities will still be expected to meet the required staffing minimums.

Consumer advocates noted that they would prefer that staffing minimums be designated by shift rather than for a 24 hour period. They are also concerned that the industry circumvents the staffing requirements by shifting tasks and duties to nursing assistants. Provider association staff also expressed concern that some facilities were eliminating housekeeping positions and shifting housekeeping duties to nursing assistants.

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