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


Although there was agreement that nursing facilities appreciated recognition for good performance, there was concern expressed by the Ombudsman that these awards gave consumers a false sense of security. In their experience, they noted that consumers seeing a Best Practice icon on the website or a Deficiency Free Certificate assumed that the facility was performing well in all care areas on a consistent basis. In fact, as they pointed out, a Deficiency Free Certificate only attested to the facilities' ability to meet minimal standards for the days that the surveyors were in the building. Likewise, recognition of one good area of practice did not mean that all practice areas were exemplary. HFD surveyor trainers noted that advocacy groups had been critical that these award programs were seen as bringing the regulatory agency too close to the entity they were supposed to be regulating.

The Ombudsman also noted that the requirement that the Best Practice be reported and evaluated during the survey was burdensome for facilities. They recommended that the recognition of Best Practices not be tied to a particular facility, but listed separately on the website.

One of the most difficult situations for all parties to contend with concerned those facilities that had received recognition for a practice or deficiency free survey and then later had compliance problems. These situations had been widely reported in the news media by an individual reporter who focused on long-term care issues. Initial praise and recognition of a facility that subsequently falls into disfavor was reported by participants as making the whole process look suspect. Another very controversial issue concerned the posting of all deficiencies on the web site, including those that were under appeal. The HFD policy is to post them two days after they are mailed to facilities and if appealed by the facility to mark them as such on the website. Both provider associations had unsuccessfully attempted to block the posting of deficiencies under appeal. Provider associations stated that even when deficiencies were later overturned, the damage from the initial posting and subsequent publication in the media was not readily reversed. Appealed postings are noted as pending appeal. The third most widely expressed concern with the Nursing Home Report Card posting of deficiencies is that it is claimed by some industry representatives to have had an impact on nursing home liability insurance rates. According to the AHCA representative, based on the number of deficiencies, some insurance companies were not writing policies and others had increased rates to the point that they were unaffordable by facilities. According to the department's Deputy Director, the governor convened a task force to examine insurance issues generally. The Task Force report does not note any connection between rates/availability of insurance and the web site report card postings.

Other more minor issues with the Nursing Home Report Card concerned the ease of consumer use. The Ombudsman pointed out that consumers were confused by the listing of complaints that were found unsubstantiated. Complaints that are not substantiated are not written out in their entirety. They recommended that all complaints be posted so that trends over time could be evaluated. The provider associations also felt that more collateral materials should be included on the website to aide consumer understanding of the information posted. They also disagreed with the inclusion of the names of directors of nursing and administrators in several years worth of data, noting that if these individuals are no longer employed because of poor performance their information remains on the web site.

Participants were mixed in their impressions as to how widely the Report Card was used by consumers. Consumer advocates noted that many consumers do not know that it is out there and that especially in many rural situations, there may only be one facility within a reasonable distance of family members and in this situation there could be little benefit to using the report card for facility selection.

There was widespread agreement from all participants that the Quality-Based Inspections program had not been successful as the application process was generally too burdensome for the majority of facilities to complete. Only ten nursing facilities are state-only licensed and even though the program had been modified in an attempt to streamline the process, only one had applied to participate in the program. Additionally, the benefits from applying for the quality-based inspections were reported as, "not worth the effort." The potential benefit is that the survey cycle could be extended to as long as 30 months. And, even for facilities that qualify for an extended survey cycle, some type of annual follow-up (a validation review) is required to make sure that the facility is still performing at the high level required to justify the longer survey cycle. The validation review involves one or two surveyors on site for no more than two days and involves a quality assessment based on the program's criteria. The State's Ombudsman reported that the philosophy of the quality-based inspection program "scared them." They believed that there could be large changes in provider quality after the inspection (i.e., in the case of "yo-yo compliance") and are opposed to any program that would increase the length of time between inspections.

Provider representatives reported that facilities were not convinced that responses on the survey questionnaire were completely anonymous. Even though the forms are sent to the Iowa Foundation for Medical Care for tabulation, providers are fearful that surveyors have access to the survey feedback information. Provider associations reported that comments they received from facilities regarding surveys were not consistent with the survey results that they had received from HFD. Either facilities were not completing the survey or were being overly generous to HFD in their rankings. The provider association also believed that individual surveyors should be named on the questionnaire rather than be reported at the coordinator/supervisor level. In their opinion, the naming of individual surveyors would lead to individual employment counseling where indicated. IHCA has developed and begun distributing its own questionnaire, which is similar to that used by DIA (except that it includes surveyor-specific questions) so that the association may compare its results with those obtained from the department questionnaires.

Joint provider/surveyor training was praised for providing access for both groups to up-to-date clinical information although progress toward its secondary goal of opening up communication between the two groups was seen as marginal. Participants noted reluctance on the part of both groups to asking questions in the group setting, as providers did not want to share areas of facility weakness and surveyors did not want to look uninformed in front of providers. Surveyor trainers also noted that by providing these joint training sessions, they necessarily had to cut back on the number of surveyor-only meetings for budgetary reasons. Also, provider associations initially objected to the issuing of continuing education units for these programs, as the income from offering educational programs has traditionally made up a major part of their revenue.

View full report


"statenh.pdf" (pdf, 822.35Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®