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Nursing Homes are Improving – Or Are They?

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Nursing home quality

Do you have a family member in an American nursing home? Or, perhaps, are you looking at the prospect of moving someone to a facility soon? You might reasonably worry about the quality of nursing home care in the U.S. There’s good news (and ambiguous news) about the quality of nursing home care this week.

Nursing Home Compare

First of all, you might not care as much about the overall quality of facilities. You might reasonably be more concerned about the quality of the facility you are contemplating, or the one where your family member resides.

Perhaps you want to compare the various facilities available in your community, or just gauge the relative local quality. In any of those cases, you can should must use the federal government’s Nursing Home Compare website. It is simple, and the results are informative. It is far from perfect, but it is a truly useful tool for evaluating local nursing home choices.

Nursing Home Compare is run by the Medicare program, which is in turn administered by the Centers for Medicare and Medicaid Services. The Centers are, inexplicably, known as CMS (we’ve long suspected that the Paperwork Reduction Act is somehow involved in the loss of the second “M”). In any event, it is an invaluable resource for evaluating local nursing homes.

Nursing Home Compare, however, has limitations. It relies on state agency data, which means that the quality of the information varies. States, in turn, often rely on facility reports without double-checking. The results can be uncertain, but they are at least a good starting point.

Overall quality seems to be improving

The U.S. Government Accountability Office (the GAO) is a nonpartisan and independent office funded by Congress. It reviews other government agencies and reports to Congress about its findings. It is not beholden to CMS or any other government agency.

What does that have to do with nursing homes? Nothing — or at least not directly. GAO Health Care Director John E. Dicken did, however, testify before Congress last week on general trends in nursing home quality. His report has some reassuring news. Spoiler alert: the GAO says that it appears that nursing home quality may be improving. The CMS oversight role also appears to be improving.

The GAO still has lots of concerns and questions. In his testimony, Mr. Dicken pointed out that the GAO reported on inadequate care — and inadequate government oversight — beginning in at least 1998. Several times since then, the GAO has insisted that the government should be more closely monitoring nursing homes.

The recent testimony acknowledges that nursing home quality appears to be improving. In fact, the GAO authored a 2015 study on nursing home quality that recognized that improvement. It also called for better — and more consistent — CMS oversight.

Instead, CMS has reduced its oversight. It also has continued to rely on self-reported information from the facilities. It has directed the states to use tax withholding information to calculate staffing levels.

“Special focus” facilities

One way CMS tries to monitor troublesome nursing homes is to put them on a special kind of probation: the “Special Focus Facilities” program. The number of nursing homes in the program was reduced from 152 to 62 in 2014. That reduction, though, was primarily accomplished by dropping facilities from Medicare and Medicaid reimbursement if they had not improved after 18 months in the special focus program.

In 2015, CMS complained that it could not improve the oversight of special focus facilities due to budget and staffing cuts. Still, it began to add new facilities — though slowly — and there are about 85 special focus nursing homes today.

Mr. Dicken’s GAO testimony noted that nursing home quality seemed to be improving. He also noted, though, that it is not clear that the improvement is real, since there is so little oversight of the data or its validity.

What about Arizona?

It is worth pointing out that nursing home quality in Arizona seems to be better than in many states. One indicator: the number of Arizona nursing homes in the Special Focus Facilities program. The only such facility is Ridgecrest Healthcare, in Phoenix. It has been on the special focus list for almost two years, but is listed as having shown improvement.

No other nursing home in Arizona is on the special focus list. Ratings for Tucson-area nursing homes, particularly, seem generally favorable — though four receive “below average” or “much below average” reviews. Nursing Home Compare tool is very helpful to families looking for a nursing home. Be sure to ask around after you have reviewed the ratings, however — more than a few ratings (both good and bad) appear to us to be undeserved. Better CMS oversight of the reviewing system would indeed be welcome. In the meantime, nursing home quality would be a good topic to submit to a Tucson elder law attorney.

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Robert B. Fleming


Robert Fleming is a Fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. He has been certified as a Specialist in Estate and Trust Law by the State Bar of Arizona‘s Board of Legal Specialization, and he is also a Certified Elder Law Attorney by the National Elder Law Foundation. Robert has a long history of involvement in local, state and national organizations. He is most proud of his instrumental involvement in the Special Needs Alliance, the premier national organization for lawyers dealing with special needs trusts and planning.

Robert has two adult children, two young grandchildren and a wife of over fifty years. He is devoted to all of them. He is also very fond of Rosalind Franklin (his office companion corgi), and his homebound cat Muninn. He just likes people, their pets and their stories.

Elizabeth N.R. Friman


Elizabeth Noble Rollings Friman is a principal and licensed fiduciary at Fleming & Curti, PLC. Elizabeth enjoys estate planning and helping families navigate trust and probate administrations. She is passionate about the fiduciary work that she performs as a trustee, personal representative, guardian, and conservator. Elizabeth works with CPAs, financial professionals, case managers, and medical providers to tailor solutions to complex family challenges. Elizabeth is often called upon to serve as a neutral party so that families can avoid protracted legal conflict. Elizabeth relies on the expertise of her team at Fleming & Curti, and as the Firm approaches its third decade, she is proud of the culture of care and consideration that the Firm embodies. Finding workable solutions to sensitive and complex family challenges is something that Elizabeth and the Fleming & Curti team do well.

Amy F. Matheson


Amy Farrell Matheson has worked as an attorney at Fleming & Curti since 2006. A member of the Southern Arizona Estate Planning Council, she is primarily responsible for estate planning and probate matters.

Amy graduated from Wellesley College with a double major in political science and English. She is an honors graduate of Suffolk University Law School and has been admitted to practice in Arizona, Massachusetts, New York, and the District of Columbia.

Prior to joining Fleming & Curti, Amy worked for American Public Television in Boston, and with the international trade group at White & Case, LLP, in Washington, D.C.

Amy’s husband, Tom, is an astronomer at NOIRLab and the Head of Time Domain Services, whose main project is ANTARES. Sadly, this does not involve actual time travel. Amy’s twin daughters are high school students; Finn, her Irish Red and White Setter, remains a puppy at heart.

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Matthew M. Mansour


Matthew is a law clerk who recently earned his law degree from the University of Arizona James E. Rogers College of Law. His undergraduate degree is in psychology from the University of California, Santa Barbara. Matthew has had a passion for advocacy in the Tucson community since his time as a law student representative in the Workers’ Rights Clinic. He also has worked in both the Pima County Attorney’s Office and the Pima County Public Defender’s Office. He enjoys playing basketball, caring for his cat, and listening to audiobooks narrated by the authors.