The federal agency that oversees nursing homes said Wednesday facilities on a newly released list of candidates for an improvement program get there by being the among most problematic in the state, based on rankings from facility inspections.
Nursing homes in Montana on the list, as well as the state's lone home already in the Special Focus Facility program, objected to how the federal government determines who is a poor performer.
On Monday, a report from two U.S. senators included for the first time the names of more than 400 nursing homes across the country that are candidates for SFF program, including five facilities in Montana. There are 88 nursing homes nationwide already in the program, including one in Montana.
The number of slots is limited by available federal funding, said Dr. Kate Goodrich, the director of the Centers for Medicare and Medicaid's Center for Clinical Standards and Quality and CMS' chief medical officer.
In a call with reporters Wednesday, Goodrich said each CMS provides states with the names of about five nursing homes that are the "poorest performers" on health inspection surveys. The agency scores facilities based on the scope and severity of citations found during annual health inspections and surveys done in response to complaints.
In Montana, that list includes Big Sky Care Center in Helena, Heritage Place in Kalispell, Montana Mental Health Nursing Home in Lewistown, Awe Kualawaache Care Center in Crow Agency and a facility called Deer Lodge in the town of the same name.
Goodrich said facilities selected by CMS are ones with "systematic issues with quality and safety." From the list of five, states pick one facility to recommend to CMS for a slot in the SFF program if one is available.
"The reason we do that is because states certainly know their communities, they know the nursing homes better than we do," Goodrich said.
CMS has final approval, however, which Goodrich says protects against any conflict of interest when a state also runs a facility on the list, like the Montana Mental Health Nursing Home in Lewistown.
Some Montana facilities, however, say the information used to develop the list of candidates for SFF can be out of date.
"It takes three years for past surveys to be removed from the calculations, so the survey data is not always an accurate reflection of the care provided," said Lori Mayer, a spokesperson for the Deer Lodge facility, in an emailed statement. "With that said, we are committed to providing high-quality care to our patients and residents and are always striving to improve quality and performance at the center."
About 90% of facilities that have gone into the SFF program since 2005 have graduated, Goodrich said. Generally, to get out of the program a facility has to pass two consecutive surveys about six months apart, according to Goodrich.
The other 10% of facilities are terminated from Medicare and Medicaid because they were unable to graduate. Spots open up when a facility graduates or is terminated.
"The number of slots we have available really is limited by our budget," Goodrich said. Budget constraints and sequestration have lowered the number of slots in the program in recent years, Goodrich said.
The presidential budget has a $45 million request for additional CMS inspections. Goodrich didn't have specifics about how much of that would go toward nursing homes, which make up about 80% of the agency's work in surveys and certifications.
Other facilities like hospitals have accrediting organizations, but there is not something like that for nursing homes, so CMS plays a larger role, Goodrich said.
The lone nursing home in Montana on the SFF program, Crest Nursing Home in Butte, has been there for 23 months. A recent CMS report categorized the facility as not improved. The most recent May 2 inspection was not available Wednesday.
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Goodrich said facilities are usually in the program anywhere between 12-18 months.
Staci Bercier, administrator for Crest, said Tuesday the process to get on and off the program is "subjective" and unfair.
"There is no strict criteria that anybody can find," Bercier said. "If you look at nursing homes around that are scoring far worse than us in surveys, it's not cut and dry. There's more to it."
Goodrich said CMS has implemented a standardized survey process and is posting surveyor training online to clarify what is required. The agency also strengthened guidelines for surveyors on how to detect immediate jeopardy, a situation when a serious harm or death to a resident is possible.
For Bercier, though, the path out of the program is still not clear.
“It feels really punitive when it’s very subjective," Bercier said. "You will have four surveyors sitting in a room arguing about if you get tagged or not."
Issues with website
The report released Monday from Pennsylvania U.S. Sens. Bob Casey, a Democrat, and Pat Toomey, a Republican, raised issue with how a website operated by CMS displays information about the quality of nursing homes, saying that consumers can tell if a facility like Crest is in the SFF program but can't tell if programs are on the candidate list.
That will change going forward, Goodrich said.
Mayer, of the Deer Lodge facility, said the website already gives people a chance to determine the quality of a nursing home, with more detail than if the facility is a candidate for SFF. She said while the Deer Lodge facility has just one star on its overall rating and one star on its health inspection, it has two stars for a staff rating, two starts on quality measures ratings and 3.5 stars for customer satisfaction.
The highest rating is five stars.
"We support making relevant, transparent information available to patients, residents and their families to make informed care decisions. The public already has access to information that helps them identify facilities at risk of quality problems or issues related to staffing, quality outcomes or other problems," Mayer said.
Of about 15,000 nursing homes in the U.S., roughly 3,000 have one-star ratings. Montana has 73 nursing homes and 10 facilities here have a one-star rating. Three of those facilities are also on the SFF candidate list, but the others with the same star ranking are not.
The 10 one-star facilities are Aspen Meadows Health and Rehabilitation Center in Billings, the Deer Lodge facility in the town of Deer Lodge, Invigorate Post Acute of Butte, Beartooth Manor in Columbus, Immanuel Skilled Care Center in Kalispell, Heritage Place in Kalispell, Hi-Line Retirement Center in Malta, Valley View Home in Glasgow, Laurel Health and Rehabilitation Center and Awe Kaulawaache Care Center in Crow Agency.
Twenty-four nursing homes have a five-star rating.