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 AHCA Urges CMS to Change Planned Consumer Alert Icon on Nursing Home Compare

Plans to add a “consumer alert icon” to the Nursing Home Compare (NHC) consumer website for skilled nursing facilities (SNFs) that have received an abuse or neglect citation have raised the objection of the American Health Care Association (AHCA), which told federal regulators in a letter on Oct. 11 that the icon would have the potential unintended effects of “creating unnecessary worry and concern among residents and their families.”

AHCA, instead, suggested that the Centers for Medicare & Medicaid Services (CMS) utilize a more cautionary symbol as the icon and not the “red stop sign” portrayed by the agency. The letter from AHCA President and Chief Executive Officer Mark Parkinson to CMS Administrator Seema Verma also objected to CMS’ plan to cap the survey Five-Star rating at two stars. 

“We appreciate you taking a personal interest in this issue and efforts to implement changes to prevent abuse and neglect. However, we feel these efforts may not be as effective without further changes to the survey system and how abuse and neglect is enforced,” Parkinson said. 

First, on the icon issue, in the letter AHCA detailed how the icon could not only have unintended consequences but also decrease access to care if patients avoid a particular SNF not experiencing “current significant problems” but which also continues to have an icon suggesting consumers avoid the facility.

The icon selected creates a strong visual recommendation ‘to stop and avoid’ going to this nursing home. A red ‘stop sign’ with a hand on it is inconsistent with the message outlined in the [CMS] press release that the information on the site should help ‘consumers develop a more complete understanding of a facility’s quality,’” Parkinson said.

Such a symbol, he explained, implies people should avoid the SNF altogether rather than use the information as a warning or caution to investigate further.

“As such, we would request that the symbol be changed to be more in align with the goals of transparency and warning to consumers to gather additional information,” Parkinson said. “We recommend using a symbol to suggest either ‘caution’ or need to investigate further, as you might see on the roadway or as you do for Special Focus Facilities (that is, a yellow triangle with an exclamation point) would be more appropriate.”

AHCA’s letter said once a facility has corrected the deficiencies that led to the citation and is back in substantial compliance with CMS regulations, then the icon should be removed as it suggests an ongoing problem that no longer exists.

There is also the matter of the severity of the citations involved and how that translates into the use of the icon. Parkinson said while providers appreciate the policy importance to highlight past episodes of abuse or neglect resulting in harm (that is, citations at a G or higher level), citations at a lower level not related to harm should not be used to assign a warning icon. “Particularly given the enormous variation in the use of deficiencies cited at a scope and severity of D between states,” he said.

“For example, the proportion of facilities cited at a D level with an abuse or neglect citation (that is, F-tags 600, 602 and 603 used to determine the icon) vary dramatically between states from 0 percent to 23 percent.”

The proportion of all abuse or neglect citations for these three F-tags cited at only a D level also varies dramatically from 0 percent in Arkansas to 87 percent in Nevada. “This enormous variation is not explained by differences in rates of abuse or neglect between states but reflects the inconsistency in how CMS inspections and interpretations of abuse and neglect are made,” Parkinson said.

As such, AHCA recommends CMS not use D-level deficiencies until such time as the reporting across states is more consistent and accurate. “Otherwise, some facilities will have an icon that does not warrant it, scaring consumers away from a facility that can meet their needs safely and others who should have an icon will not. This inconsistency of citations does not advance transparency or consumer choice,” the letter said.

On the matter of star ratings, Parkinson said using the Five-Star rating system to punish facilities by reassigning stars for not following one or two specific CMS regulations undermines the system. CMS, he said, has “numerous other enforcement mechanisms to penalize facilities and drive compliance.”

The Five-Star system is meant to provide information on a wide range of quality metrics (compliance with regulations, staffing levels, and quality outcomes), the letter said. “By reassigning stars, the importance of other measures is dramatically diminished. This reduces transparency to the consumer by masking information for other important quality concerns from impacting the Five-Star rating,” Parkinson said.

The capping of the survey component at two stars is akin to assigning two to four times more survey points to these three citations, more than any of the other 246 citations, and overwhelms the impact of staffing or quality.

“The capping of two stars results in over 95 percent of SNFs with a survey star rating of three or higher losing one, two, or three stars in their overall rating. It also:

-          Undermines the importance of staffing levels, a key driver in the efforts to address abuse and neglect;

-          Undermines the importance of other CMS priority areas to improve resident safety such as infection control, antipsychotic use, and prevention of hospitalizations and emergency room visits; and

-          Devalues improvements in these key areas,” the letter said.

Parkinson stressed that AHCA and its members “stand ready to work with you and your team to combat abuse and neglect and further improve safety and quality of care for nursing home residents. We are concerned the current icon and two-star cap will not achieve this shared goal without significant changes.”

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