Guest Columns

Moving beyond the ZIP code

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Steven Littlehale
Steven Littlehale

Seriously? Can't we move beyond ZIP code?

In the March edition of McKnight's Long-Term Care News, I wrote that over the past two years, the average total number of deficiencies, standard survey and complaint combined, has improved slightly to 6.86. 

However, there is clearly some variation between Centers for Medicare & Medicaid Services Regions in total deficiency averages, from a high of 10.38 in Region 9 to a low of 4.76 in Region 1.

Naturally, you'd conclude that there are obvious issues in Region 9 nursing homes, right? Well, maybe not. Dig deeper. 

Within Region 9 there are significant variations as well, ranging from Arizona having an average of 7.77 to Nevada at 12.77. California is close behind the number one spot with 10.68. So it's a Nevada/California issue right? Well, maybe not.

Put away that broad brush and pick up a finer one. When you do, something interesting emerges in California. There are 18 Survey Districts in this very large state. The difference between the districts with the lowest average number of deficiencies to the highest is 12.5!

In fact, when we looked at states with a higher number of districts, this same variability was evident. Washington has a difference of 8 deficiencies and Texas 7.6 when comparing high and low survey district performance. However, this was not the case in every state with several districts. Take, for example, Florida and Pennsylvania, where the difference was 3 and 4.9 average deficiencies, respectively. 

Geographic differences are apparent across state lines within the CMS regions, as well.  For example, in Region 3, Pennsylvania's average for deficiencies is 5.02, while Delaware's average is 15.32.

In 2013 throughout the country, 17% of facilities received a G-level citation; this is a slight improvement from 19% just two years ago. Hats off to Region 4 for improving to well below the national average (10%). Region 5: thanks for lowering your rate to 21%, though there is more work to do. 

While the nation improved, Region 9 has seen a 3% rise in facilities cited at the G level over the last two years. The source of many of these deficiencies is complaint surveys in concentrated survey districts in California.

California has seen a rise in the number of homes cited, jumping from 2% in the first quarter of 2012, while the rate was 7% in the fourth quarter of 2013. Across survey districts in California, the percentage of facilities that received G-level complaints varied from 0% to 18%.    

Why is there greater disparity occurring in some states but not all? Is it about the size of the state or the number of survey districts?

Why are there significant differences between states that have the same CMS Regional Office? Why are there such differences between CMS Regional Offices?

Despite the best efforts of CMS and state agencies, it does appear that in some instances, survey performance may be affected by ZIP code! But frankly, it's not enough to stop there; we must consider other things that influence the nursing home's success during survey.

We've all seen facility practice altered by a regional consultant spouting misinformation from the podium, or by corporations that put policies in place that unintentionally conflict with CMS regulations. We are required to provide evidence-based care, what happens when the evidence changes?

So how did you do? How did you compare to the nation? How about your CMS region or state or survey district (yes, district)?

To be competitive, you must have benchmarks for all of the above. If you fared better on standard surveys, which are anticipated and planned for, but had more complaint deficiencies, the response is clear. Identify the catalysts for the complaints and your overall complaint management process.

Consider expanding relationships with the community and integration with other healthcare environments, as well as managing expectations and fostering relationships with family.

In addition, it should be noted that the No. 1 deficiency generated at complaint surveys is F-309, accidents/hazards. Often, this is self-reported, but just as often it results from a slip between the care plan and the actual care provided. Consider whether your education and training programs use a performance-based measurement. This could be a perfect QAPI opportunity!

Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc. 


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Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.