The Not-So-Surprising Unannounced Nursing Home Inspection

An ongoing problem that nursing home residents, their families, and consumers have expressed for years is the belief that facilities are “overly prepared” for routine annual inspections[1].

Their complaints generally sound something like this:

“Over the past several months, this nursing home has had a lot of problems answering call lights, has served food that’s, at best, barely palatable; has neglected to hire enough staff to cover the evening and weekend shifts; and has this permeating stench of urine and feces.  But, then, out of the blue one day, there’s extra staff walking the hallways, many people of whom we have never seen before; the food goes from deplorable to tasty; call lights are responded to in minutes, not hours; and the aroma smells of flowers and fresh baked bread.”

Residents, families, and advocates have repeatedly claimed that the underlying reason for this sudden and short-lived change from bad to good nursing home quality is the nursing home’s apparent awareness of the not-so-surprising, unannounced inspection–“that the state is coming in soon for their survey.”

And more often than not, they’re right.  The timing seems to be uncanny.

Unfortunately for the residents, once the inspectors leave, the daily awfulness returns, leaving residents and families scratching their heads, frustrated by what appears to be a compromised inspection process.

While much of the evidence about their claim has historically been anecdotal, a closer look at the inspection histories of the nursing homes most recently added to the Center for Medicare and Medicaid’s Special Focus Facility list gives credence to their argument.

Of the nine nursing homes added to the list this month, more than two-thirds of the cited severe deficiencies in those homes were discovered during random complaint investigations[2] (see graph below).
The sample data shows when inspections are untethered from restrictive timeframes and occur randomly, a nursing home’s ability to undertake advanced preparations for the surveyor’s visit is diminished–yielding more serious problems that need immediate attention.  And when this happens, surveyors are more apt to pinpoint those problems so they can can quickly negotiate a prompt remedy before violations become catastrophic for residents.

Fortunately, federal and state officials are aware of this overall concern and have taken some steps to enhance the integrity of the inspection process by, for example, coordinating a percentage of annual surveys during non-regular business hours and by standardizing additional family interviews during their surveys.

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The Not-So-Surprising Unannounced Nursing Home Inspection