On-Site Ombudsmen Lead to More Skilled Nursing Deficiencies on Surveys

When an ombudsman remains on site during post-acute and long-term care facility surveys, the building’s quality scores may be negatively affected, according to a study in published this week in JAMDA, journal of AMDA — The Society for Post-Acute and Long-Term Care Medicine.

Researchers determined that ombudsmen may direct assessors to more attention to on-site problems, muddying the waters of quality ratings.

The role of an ombudsman is to be an impartial mediator and resident advocate to help assure the quality of a resident’s stay. Authors Diane Berish, Josh Bornstein, and John Bowblis looked closely at the ombudsman’s presence at the time of surveys and found that quality of life and administrative ratings were lower while deficiencies increased as compared to when an ombudsman was not on site.


Ombudsmen were present for almost 30% of visits, although that figure varied considerably from state to state: Massachusetts had the highest proportion, with one on site for 82% of facilities, while New Hampshire and Kansas brought up the rear with 0.8% and 1.5%. In addition, the officials were most often found on lower-rated sites during the time of surveys, the authors found.

The researchers’ analysis indicated that when present, a “0.2 increase in the number of deficiencies and 2.2-point increase in deficiencies occurred in the survey, which corresponds to a 3.9% and 5.9% increase” in problems associated with quality of life and administrative issues, according to the study.

More specifically, on a national level, an on-site ombudsman increased the number of deficiencies by 6.5% and increased deficiency scores by 11.3%.


Although the study contends that ombudsmen may alert surveyors to more problems, it’s possible that their presence may prompt the implementation of improvements based on poor findings — at least in the future.

“It may be the case that the presence of ombudsmen leads to long-run quality improvements. Ombudsmen present during surveys may have a better understanding of the facility-specific survey process, which they can use throughout the year to help their facilities address quality concerns,” said the authors.

Surveys play a role in the Centers for Medicare & Medicaid Services’ (CMS) all-important five-star rating system for nursing homes, which can have a direct impact on referrals and funding availability.

“If consumers use this information to select a NH, NHs that receive more deficiency citations can see reductions in demand,” the researchers observed. “Deficiencies also can lead to monetary fines and, in some states, Medicaid reimbursement rates are tied to quality of care, with more deficiencies resulting in lower reimbursement rates. Therefore, receiving multiple deficiencies can harm the bottom line for the NH and its ability to invest in quality improvement efforts.”

This past summer, CMS administrator Seema Verma touted her efforts to boost consistency among State Survey Agencies (SSAs), pointing out vast discrepancies between their methodologies and survey quality.

“As the survey results come in, we’re analyzing the data, including focusing on outliers, such as states reporting a significantly lower than average number of citations per survey,” Verma wrote in an August blog post. “We review SSAs that are outliers and when warranted, require corrective action plans to ensure they are following CMS policies and procedures as expected.”

The five-star ratings have also been in the news after the agency moved from self-reported to payroll-based staff data outcomes last year — a shift that hit the headlines when the New York Times exposed certain operators that had been reporting higher-than-actual nursing and caregiver coverage under the old system.

In turn, CMS slapped about 1,400 nursing homes with one-star ratings over their staffing figures, and introduced more stringent staffing requirements while separating ratings between long-term and short-term stays.

With more rigorous rating standards and the onset of the Patient Driven Payment Model (PDPM) on October 1 — changing clinical coding and reimbursement rules — establishing higher quality ratings has become essential for remaining financially healthy in the marketplace.

The researchers behind the study had affiliations with Penn State University’s College of Nursing and Miami (Ohio) University’s Department of Economics and Scripps Gerontology Center.

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