Nursing home surveyor conducting a site visit

Medicare’s Care Compare site did not accurately reflect nursing home deficiencies in two-thirds of listings reviewed by a federal watchdog agency, a finding that implies more than 10,000 health, life safety or emergency preparedness violations may have been left out of view of consumers.

The report, issued early Wednesday by the Department of Health and Human Services Office of Inspector General, also found that the Centers for Medicare & Medicaid Services sometimes reported deficiencies to Care Compare that were not found in survey documentation. Scope and severity levels were also inaccurate for one out of every three nursing homes reviewed in a small sample, the OIG said.

While the OIG’s attention was trained on CMS, the findings also stand to malign nursing homes by reinforcing the idea that deficiencies are widespread in the sector. It could also lead to renewed CMS attention to public reporting accuracy, which in some cases could benefit consumers and nursing homes.

“Consumers rely on the information they find on Care Compare to make informed healthcare decisions and expect it to be accurate; the information can set the expectation for a consumer’s experience with a particular nursing home,” the OIG said in a report reviewed exclusively by McKnight’s Long-Term Care News Tuesday. 

“The findings in this report demonstrate the need for CMS to take additional measures to ensure that the information it reports on Care Compare for nursing homes is accurate.”

OIG said CMS’ processes for reviewing inspection results both before and after they were reported on Care Compare “were not adequate.” Though CMS hires contractors to upload deficiency information to Care Compare, OIG found the agency relied on state survey staff to confirm accuracy after posting and on nursing homes to self-report inaccuracies.

CMS had not replied to a McKnight’s request for comment by deadline.

The OIG audit was based on a sample of 100 nursing homes and their Care Compare listings. Overall, the watchdog found that there were missed deficiencies in 67 cases.

Those included missed health deficiencies for 34 nursing homes — one of which was a J-level deficiency issued during a complaint inspection following the fire-related death of a patient who used in-room oxygen. 

OIG also found missing fire safety deficiencies for 52 nursing homes, and emergency preparedness deficiencies missing for two nursing homes. In addition, for 42 of the 100 sampled nursing homes, CMS did not report results on Care Compare about the yearly fire safety and emergency preparedness inspections. Each sample was compared to deficiencies documented in state surveyors’ inspection and complaint reports dating back three years.

Extrapolating that, OIG estimated inaccurate deficiency listings for 10,303 of the nation’s 15,377 nursing homes at the time the samples were pulled in December 2020.

Care Compare accuracy getting worse?

The audit comes nearly 20 years after a similar investigation. This version appears to show that CMS lapses have increased. 

In June 2004, OIG found that Nursing Home Compare, as it was then known, was missing one or more deficiencies in 11% of nursing homes and was missing inspection results for one or more of the three most recent inspections in 19% of nursing homes. 

At that time, the audit showed deficiencies that were not identified in inspection reports were appearing on public pages for 15% of nursing homes.

That problem continues, especially after facilities use the independent dispute resolution process. Inaccurate reporting that could harm nursing homes’ reputations even after appeals is still getting through to Care Compare. In this report, among a subsample of 34 nursing homes, nine had 23 health deficiencies posted for which the OIG could not find any supporting deficiency documented in an inspection report. That represents more than a quarter of the subsample.

In another alarming section, OIG related extensive concerns about fire and life safety reporting into Care Compare. In a look at 52 nursing homes, the watchdog found 231 deficiencies were missing across 41 of the facilities. In 18 of the 41 nursing homes, all of the fire safety deficiencies identified during inspections were missing from Care Compare. 

Those deficiencies ranged from D-level to F-level and included deficiencies for failure to test and maintain the fire alarm and sprinkler systems, conduct fire drills, to keep full and empty oxygen tanks separated, and install and maintain portable fire extinguishers.

CMS officials told OIG auditors that programming it used to export data from CASPER to Care Compare was not correct and caused approximately 35,000 fire safety deficiencies from three years of annual and complaint inspections not to be reported, the report said.

After the OIG’s work began, CMS updated the coding error and changed some information to reflect shortcomings in the nursing homes included in the sample.

Otherwise, OIG said CMS and its contractors’ data validation checks were not adequate for ensuring accuracy. The OIG found that a manual quality assurance check CMS used to verify that Care Compare reflected updated information was triggered largely by a change to a nursing home’s quality rating and was performed for only a small number of nursing homes. It “was not designed to verify whether nursing home deficiencies reported on the website were accurate.”

CMS responds to concerns

Among several process-driven changes recommend by OIG was a call for CMS to strengthen review of Care Compare data by:

  • Requiring state survey agencies to verify that deficiencies shown in the Automated Survey Processing Environment (ASPEN) are also shown in CASPER when they are preparing to conduct an inspection,
  • Providing technical assistance and additional training to state survey agencies that are not following procedures in the State Operations Manual and ASPEN Central Office Procedures Guide for reporting deficiencies in ASPEN, and
  • Including in its manual quality assurance check a verification that nursing home inspection results are accurately reported.

In its response included in the report, CMS said that it already offers surveyor training through its website but that it “will explore ways to provide additional technical assistance and training.”

CMS also said that it had discovered several primary causes for issues identified in the audit and had “worked expeditiously to resolve them.”

Regarding health deficiencies, CMS said one reason for data discrepancies was a system issue that caused inspection results to overwrite previously entered inspections that were performed on the same day but entered into the system on different days. CMS stated that it corrected the issue with a coding update. CMS also said “it found a few instances of human error” during its review of the findings but “does not believe these occasional instances heavily impact the Five-Star Quality Rating System.”

CMS also noted that several of the findings were related to data that is no longer factored into current Care Compare data.