Analyzing Nursing Home Complaints: From Substantiated Allegation to Deficiency Citations

Abstract Complaints provide important information to consumers about nursing homes (NHs). Complaints that are substantiated often lead to an investigation and potentially a deficiency citation. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Because a complaint may contain multiple allegations, and the data do not identify which allegation(s) lead to a complaint’s substantiation, we identified all substantiated single allegation complaints for NHs in 2017. Our data were drawn from federally collected NH complaint and inspection records. Among the 369 substantiated single-allegation complaints, we found most were categorized as quality of care (31.7%), resident abuse (17.3%), or resident neglect (14.1%). Of the deficiency citations resulting from complaints in our sample, 27.9% were categorized as quality of care and 19.5% were in the category of resident behavior and facility practices, which includes abuse and neglect. While two-thirds (N=239) of the substantiated complaints generated from 1 to 19 deficiency citations, nearly one third had no citations. Surprisingly, 28% of substantiated abuse and neglect allegations resulted in no deficiency citations. More surprisingly, a fifth of complaints that were categorized as “immediate jeopardy” at intake did not result in any deficiency citations. We also found a number of asymmetries in the allegation categories suggesting different processes by Centers for Medicare and Medicaid Services (CMS) region. These results suggest that the compliant investigation process warrants further investigation. Other policy and practice implications, including the need for better and more uniform investigation processes and staff training, will be discussed.

older people consume prescription medications, with high rates of polypharmacy. The aim was to analyze the factors related to the recommendation of a less expensive prescription by a medical doctor in US older adults. A cross-sectional analysis using the data from The National Poll on Healthy Aging (NPHA) 2017 was conducted, with a total sample of 1666 adults age 50 to 80 residing in the US. People were asked if they have received a less expensive prescription by a medical doctor in the last two years (yes/no). Sociodemographic and health variables, active patient medication-cost behaviors, and doctor active medication-costs actions were measured as covariates. Weighted and stratified by region logistic regression model was conducted in a 70% random sample. The model was validated in the 30% remaining using ROC curve and AUC. In the parsimonious model, ≥4 visits to the doctor (OR=2.06, 1.33 -3.18), perception of medication costs as a burden (OR=1.76, 1.25 -2.47), the doctor talked about medication costs (OR=5.54, 3.90 -7.88), doctor awareness of medication costs (OR=1.81, 1.34 -2.46), and being Non-Hispanic Black (OR=1.90, 1.20 -3.03) were linked to a higher odd to receive a less expensive prescription. The model presented a moderate-high fit (AUC:0.71; sensitivity:84.4%, specificity:49.8%). Awareness and training in the active prescription of less expensive medications by the medical doctor seem fundamental to reduce drug costs burden in older adults.

A COMPARISON OF HOME HEALTH CARE BETWEEN FINLAND AND SOUTH KOREA IN LONG-TERM CARE SERVICES
Jihyun Park, 1 and suhyun kim, 2 1. Yonsei University, Seoul, Republic of Korea,2. Kyungpook National University,Daegu,Republic of Korea Population aging is one of the significant global issues. Long-term care is emphasized as "aging in place," and it is known that home and community-based service is a cost-effective way to achieve this. Over ten years have passed since the introduction of long-term care insurance in Korea, and it is necessary to improve home health care in long-term care. The aim of this study was to identify the measures that must be undertaken for enhancing home health care in Korea by comparing it to the home health care in Finland. The data were collected via a literature review, expert interview, and field survey in Kuopio, Eastern Finland, from March 16 to 23, 2018. Based on the comparison between Korean and Finnish home health care, some issues related to home health care in Korea that need to be resolved were identified: the complex process involved in availing home health care, low utilization rate, higher cost than home health aide services in long-term care, and undifferentiated roles in home health care between registered nurses and nurse assistants. Several strategies could be utilized to enhance home health care in Korea, such as a simplified procedure to use home health care, clarification of roles between registered nurses and nurse assistants in home care, supervision of the integration of home care services by registered nurses, and an expansion of home health care into comprehensive assessment and nursing activities for chronic illness care and health promotion. Growing demand for care for Alzheimer's Disease and related Dementia (ADRD) has resulted in rising use of adult day health centers (ADHCs), which employ teams of professionals including licensed nurses, nursing aides, social workers, and activity directors. This study evaluates the scope of services and staffing models of ADHCs that provide care to persons with ADRD compared to ADHCs that do not, and examines whether there is an association between staffing and client outcomes, measured as rates of hospitalizations, falls, and emergency department visits. We used facility-level data from the 2014 National Study of Long-Term Care Providers (NSLTCP) Adult Day Services Center module. We conducted bivariate comparisons and estimated multivariate regressions to identify ADHC characteristics associated with staffing and client outcomes. ADHCs that offered ADRD services had higher average daily attendance, greater shares of revenue from Medicaid and self-payment, and greater proportions of Blacks and females. They also had greater percentages of enrollees with depression, cardiovascular disease, diabetes, and needing assistance with activities of daily living. There were also greater numbers of registered nurse, licensed practical nurse, and social worker hours per enrollee day, but fewer activity staff hours per enrollee day. Multivariate regressions focused on ADHCs that offered skilled nursing services and revealed that total staff hours per enrollee day were not higher in ADHCs that provided ADRD services, controlling for other characteristics. However, staffing was greater in chain-affiliated ADHCs. Higher staffing levels were associated with lower rates of falls and emergency department visits. Complaints provide important information to consumers about nursing homes (NHs). Complaints that are substantiated often lead to an investigation and potentially a deficiency citation. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Because a complaint may contain multiple allegations, and the data do not identify which allegation(s) lead to a complaint's substantiation, we identified all substantiated single allegation complaints for NHs in 2017. Our data were drawn from federally collected NH complaint and inspection records. Among the 369 substantiated singleallegation complaints, we found most were categorized as quality of care (31.7%), resident abuse (17.3%), or resident neglect (14.1%). Of the deficiency citations resulting from complaints in our sample, 27.9% were categorized as quality of care and 19.5% were in the category of resident behavior and facility practices, which includes abuse and neglect. While two-thirds (N=239) of the substantiated complaints generated from 1 to 19 deficiency citations, nearly one third had no citations. Surprisingly, 28% of substantiated abuse and neglect allegations resulted in no deficiency citations. More surprisingly, a fifth of complaints that were categorized as "immediate jeopardy" at intake did not result in any deficiency citations. We also found a number of asymmetries in the allegation categories suggesting different processes by Centers for Medicare and Medicaid Services (CMS) region. These results suggest that the compliant investigation process warrants further investigation. Other policy and practice implications, including the need for better and more uniform investigation processes and staff training, will be discussed.

AVAILABILITY OF AUDIOLOGY SERVICES IN ASSISTED LIVING COMMUNITIES IN FLORIDA Daniel Pupo, Hillary Rouse, Lindsay Peterson, and Kathryn Hyer, University of South Florida, Tampa, Florida, United States
Florida has one of the largest populations of older adults in the U.S., and as a result the state also has a high prevalence of hearing loss. Given the growth of assisted living as a housing option for older adults, the purpose of this study was to determine the availability of audiology services in assisted living communities (ALCs) across Florida. Data on ALC location, characteristics and audiology service availability were collected from the Florida Agency for Health Care Administration (AHCA). County socioeconomic data were collected from the U.S. Department of Labor. Logistic regression and chi2 tests were used to examine the relationship between county socioeconomics and whether an ALC provided audiology services. We found that of the 3090 ALCs in Florida, audiology services were present in only 57 (3.2%). ALCs with audiology services were significantly more likely to be located in counties with a higher education level and a higher average income. This suggests a shortage of ALCs with audiology services in counties where residents have fewer resources. The results are concerning, given that individuals with fewer resources are less able to pay for audiology services on their own and evidence showing that poor hearing health late in life impacts individuals' health and quality of life. Policy implications will be discussed, including the need for more ALCs to provide audiology services in counties with fewer resources. One possible solution is teleaudiology, which would enable a single audiologist to diagnose and prescribe hearing aids to patients in underserved areas.

CORRELATES OF SKILLED NURSING FACILITY (SNF) PERFORMANCE IN THE SNF VALUE-BASED PURCHASING PROGRAM
Dan Andersen, 1 Sherly Binu, 2 and Mike Sacca, 3 1. RELI Group,Sykesville,Maryland,United States,2. RELI Group,Baltimore,Maryland,United States,3. RELI Group,Baltimore,United States We examined the results of the 2020 skilled nursing facility (SNF) value-based purchasing (SNF VBP) program to identify correlates and potential drivers of SNF performance in this program. The SNF VBP program provides incentive payments to SNFs based on their performance on a risk-adjusted hospital readmission measure (i.e., the rate at which SNF residents are admitted back to the hospital within 30-days of being admitted to the SNF). SNFs are assessed on this measure for both improvement compared to their historical baseline and overall achievement compared to their peers. All SNFs that are covered under Medicare's prospective payment system are included in the SNF VBP program. We performed analyses to assess the correlation between individual SNFs' performance in the 2020 SNF VBP (n=15,201), which is based on actual performance in fiscal year 2018, with contemporaneous matched data related to SNF health inspection results, staffing, and performance on quality measures (these data form the basis of the five-star quality rating system on the Nursing Home Compare website). We also examined longitudinal trends in these non-SNF VBP program variables and their association with changes in SNF performance in the SNF VBP program. We controlled for important SNF-specific factors (e.g., for-profit status, connected to a hospital). We found strong contemporaneous and longitudinal associations between SNF VBP program performance and some, but not all, of these factors. Our findings are supported by decades of empirical research in SNF quality and highlight potential policy alternatives that could further incentivize high quality care in SNFs.

DEPRESCRIBING AND POLYPHARMACY FOR MEDICARE BENEFICIARIES UNDER GUARDIANSHIP IN LONG-TERM CARE FACILITIES Tami Swenson, Des Moines University, Des Moines, Iowa, United States
Local judicial courts vary in the amount of supervision they provide guardians, which makes the practice of guardianship uneven. To begin to address the evidence gap to inform best practices for persons under guardianship care, this study examines the issues of polypharmacy and prescribing patterns for four therapeutic classes most commonly targeted for deprescribing for older adults. The Medicare Current Beneficiary Survey (MCBS) for 2015 and 2016 is used to examine facility-dwelling Medicare beneficiaries under guardianship compared with those that are not. Logistic regression is used to examine association of polypharmacy outcomes and guardianship care controlling for patient and facility characteristics. Statistical models are adjusted using Fay's Method with replicate weights for the MCBS complex survey design. Approximately 12% of the facility-dwelling Medicare population in 2015 and 2016 are persons under guardianship care. Persons under guardianship were more likely to have polypharmacy or to be prescribed 5 or more medications (Odd Ratio (OR)=1.168, 95% Confidence Interval (CI)=1.156 to 1.180, p<0.001) than facility-dwelling Medicare beneficiaries not under guardianship care. Medicare beneficiaries under guardianship were more likely to be prescribed PPIs (OR=1.229, 95% CI=1.222 to 1.237, p<0.001) or antipsychotic medications (OR=1.240, 95% CI=1.232 to 1.247, p<0.001) but less likely to be prescribed benzodiazepines (OR=0.920, 95% CI=0.913 to 0.927, p<0.001) or antihyperglycemics (OR-0.726, 95% CI=0.721 to 0.731, p<0.001). Medical decision support services, such as guardianship care, are increasing in importance as shared decision