Increased Staffing, Fewer Deficiencies at Nursing Homes but Quality Problems Persist

One in three fail to meet minimum staffing standards and only one in ten fully comply with federal standards

Several indicators of nursing home care quality in California showed improvement between 2000 and 2003, but quality problems still persist, according to the latest analysis funded by the California HealthCare Foundation (CHCF) and conducted by the University of California, San Francisco (UCSF).

Today, CHCF also launched an improved and expanded Web site that now includes additional information on California’s 834 home health agencies and 172 hospice programs. is the only comprehensive, one-stop, online source for objective quality information on long-term care options. Since 2002 CHCF has sponsored, a Web site that provides consumers with independent, objective information on the state’s 1,382 nursing homes.

“When individuals and families face difficult long-term care choices, they often don’t get the same level of guidance from health care providers as they do on other health care decisions,” said Mark D. Smith, M.D., M.B.A., president and CEO of the California HealthCare Foundation. “With the addition of home health care and hospice services to, consumers now have a reliable, easy-to-use resource for helping them decide what level of care is needed, locating nearby providers, and comparing quality.”

A key finding from the UCSF analysis shows that quality varies widely among the state’s home health agencies and hospice programs, as well as at nursing homes. All of these organizations are inspected for compliance with state and federal quality regulations. Failure to comply with regulations or standards results in a deficiency.

“Facilities or long-term care providers with the highest number of deficiencies are likely to have more quality problems,” said Lisa Payne Simon, CHCF senior program officer. “Consumers should examine deficiency rates and other quality measures on carefully when selecting a long-term care provider once they have determined which providers offer the services they need.”

In addition to deficiencies, the other quality variables used to evaluate the quality of nursing homes, home health agencies, and hospice care programs include: staffing, complaints, finances, and clinical quality measures established by the federal government. (Quality measures have not been established for hospice programs.) uses star ratings — one star (below average), two stars (average), or three stars (above average) on each variable to make comparisons with state averages.

Nursing Home Quality

Nursing home quality varies widely. Based on a review of the most current publicly available information, UCSF researchers found:

  • A total of 31 percent of freestanding nursing homes failed to meet the state’s minimum staffing standard of 3.2 nursing hours per resident per day, down from 44 percent in 2001.
  • Though average nurse staffing hours increased between 2000 and 2003, the improvement was due to increased hours from licensed practical nurses and nursing assistants, with registered nurse (RN) hours declining.
  • Nursing staff turnover rates averaged 64 percent in 2003, down from 84 percent in 2000. This means that about two-thirds of all nursing staff in an “average” nursing home leave every year. The nursing staff turnover rate ranges from 8 to 258 percent.

“While these findings indicate some progress, the number of homes with high turnover rates and low staffing is still too high,” said lead researcher Charlene Harrington, Ph.D., School of Nursing, UCSF.

According to Harrington, research has shown that RN hours have the highest relationship to good quality of care, “so a decrease in their hours can have a negative effect on the quality of nursing home care.”

Other findings include:

  • The average number of deficiencies dropped from 13.2 in 2000 to 9.7 in 2003.
  • The number of homes in substantial or full compliance with federal standards—at 9 percent—was relatively unchanged between 2000 and 2003. Deficiencies received for serious noncompliance increased 29 percent. However, those receiving deficiencies for very serious noncompliance or—worse yet—substandard care decreased 57 and 80 percent respectively. (Note: It is unknown whether the reduction in the number of deficiencies is related to changes in survey procedures or to improvements in the quality of care.)
  • The average nursing home received about one complaint per year for poor quality in 2003. The range of complaints was from one to 237 during the 2000 to 2004 time period.
  • California nursing homes fared better than national averages on seven of nine measures for quality of life and clinical care. (Use of physical restraints was higher on average in California and there is no national measure for weight loss.)
  • Clinical quality performance varies in nursing homes. For example, at some homes no residents experienced weight loss, while at others nearly all did. Similarly, at some homes few residents experienced a decline in their ability to engage in normal activities or to move around, but at other facilities 50 percent or more of residents declined in these quality measures.

    Home Health and Hospice Quality

    In 2003 the average home health agency had eight deficiencies for violations of federal or state regulations—down from 17 in the year 2000. Though it is unclear if the decline was the result of quality improvements or changes in the state’s survey process, quality does vary significantly among agencies as evidenced by a wide range of deficiencies-from five to 116.

    Average home health scores on seven of eight dimensions of quality were slightly better in California than national averages. One was the same as the national average.

    In 2003 the average hospice program also had eight deficiencies for failure to meet federal quality standards and conditions, a decline from 15 in the year 2000. Like home health agencies, it is unclear if the decline was due to quality improvements or changes in the state’s survey process. But quality does vary significantly among programs as evidenced by a range of deficiencies from three to 91 between 2000 and 2004,

    Quality of care measures have not been established by the state or federal government for hospice programs.

    Home Health and Hospice Facts and Features

    “Finding the most appropriate long-term care for a parent, a child, or a spouse can be a daunting task. now makes it even easier by offering detailed information on home health agencies and hospice programs, as well as guidance and tools necessary to make informed decisions about the type of care that is right for a family’s unique situation,” said Payne-Simon. now offers detailed information on 834 home health agencies in California. It is searchable by city, county, Zip Code, region, facility name, certification (Medi-Cal or Medicare), type of program (hospice, home infusion, or home infusion with licensed pharmacy) or by six basic services: skilled nursing; physical, occupational, or speech pathology; social services; or home health aide.

  • In 2001 home health agencies served 536,000 individuals and 53 percent were age 71 or older.
  • Agencies are located in 52 of California’s 58 counties.
  • Eighteen percent of home health agencies are non-profit organizations.
  • Thirty-three percent of agencies accept only private pay or private insurance payments.

    Detailed information on 172 hospice programs is also searchable. Types of hospice programs are freestanding, hospital-based, and home health-based. The specialized services search is by: designated inpatient facility/unit, specialized pediatric program, adult day care, and specialized palliative care program.

  • In 2001 hospice programs served over 48,000 individuals and 73 percent were age 71 or older.
  • Agencies are located in 37 counties.
  • Forty-eight percent of hospice programs are nonprofit organizations.
  • Medicare pays for 80 percent of client days in hospice care.

    Information available on home health agencies includes:

  • Agency Characteristics: type of program, availability of the six basic services (listed above as searchable items), 11 special services (AIDS/HIV; blood transfusions; enterostomal, intravenous or respiratory/pulmonary therapy; mental health counseling; pediatric; psychiatric nursing; nurse assistants, home health aides or homemakers, and continuous care nursing), and ownership.
  • Client Profile: Number of clients, diagnosis (such as cancer or heart and lung disease), care intensive diseases (HIV or Alzheimer’s), and age characteristics.
  • Quality of Agency: ratings based on the number of state and federal deficiencies, a 2000 to 2004 year-by-year summary of state and federal deficiencies compared to state averages for eight specific measures (quality of care, mistreatment, resident assessment, resident rights, environment, nutrition, pharmacy and administration), agency complaints, and accreditation (JCAHO or CHAP).
  • Quality of Care: Ratings on quality of life (such as walking around and bathing) and clinical care (such as taking medicines correctly, admitted to hospital) measures compared to state averages.
  • Staffing: Visits per patient, compared to state averages, by either skilled nurses, aides, or seven other specialists—nutritionists, social workers, speech pathologists, occupational or physical therapists, physicians, or spiritual advisors.
  • Finances: Payments sources compared to state averages: Medi-Cal, Medicare, private-pay, or other sources.

    Information available on hospice programs includes:

  • Program Characteristics: One of three program types; four specialized services; days spent in the home, hospital, skilled nursing facility, congregate living health facility, or residential care facility—compared to state averages; and ownership.
  • Client Profile: Diagnosis (cancers and blood disorders; brain nervous system and mental disorders; heart and lung diseases; digestive and urinary system diseases); length of treatment compared to state averages; and age, gender, race/ethnicity characteristics.
  • Quality of Program: Ratings based on the number of state and federal deficiencies and a 2000 to 2004 year-by-year summary of state and federal deficiencies compared to state averages for nine specific measures (quality of care, mistreatment, client assessment, client rights, environment, nutrition, pharmacy, administration, and life safety), agency complaints, and accreditation (JCAHO or CHAP).
  • Staffing: Visits per client, compared to state averages, by a registered nurse, LVN, hospice physician, social worker, home health aide and homemaker, spiritual advisor, or “other” clinical service provider.
  • Finances and Cost: (This information will be available for the next update of

    About the Department of Social and Behavioral Sciences, University of California, San Francisco
    The Department of Social and Behavioral Sciences at the University of California, San Francisco, is dedicated to advancing knowledge through theory and research, designing and evaluating the organization, financing, and delivery of health care; and examining the broad dynamics of health, healing, and the production of knowledge and its application in these domains.

    About California Nursing Home Search
    California Nursing Home Search,, is a free public service designed to provide comprehensive, consumer-friendly comparative information about the quality of the state’s nursing homes, home health agencies, and hospice programs. The Web site includes practical resources and interpretive information designed to help consumers learn more about their options for care at home and in the community.

About the California Health Care Foundation

The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.