Distinguishing quality of nursing facility long-term care from stringency of enforcement

Nursing facility inspections routinely produce statistics revealing sharp disparities in care at both the facility and the state level. But whether high rates of deficiencies are more indicative of stringent enforcement of standards, leading to improved care, or ongoing poor quality care remains unclear. Until this question is answered, families of nursing facility residents, responsible public officials and interested professionals, are all unable to make sound decisions about long-term care quality. We employ cross-sectional, panel data to compare states on multiple indices of both care quality and enforcement stringency. We use the multi-method-multi-trait approach to distinguish these concepts. We find that low rates of deficiencies are positively associated with independent measures of high quality care. But, a prominent nursing facility enforcement index likely registers poor quality care more than stringency of enforcement since it is associated positively with independent indices of poor quality care and negatively with independent measures of enforcement. Attentive publics can have reasonable confidence that low rates of deficiencies indicate high quality care. High rates tend to reflect glaring deterioration in care quality. They are less signals of stringent enforcement than of obviously poor care which prompts more visible enforcement activities. Sadly, there is little evidence suggesting that these enforcement measures improve state-level care quality and thus reduce cross-state disparities in the quality of nursing facility long-term care. However, at least some of the factors responsible for sharp disparities in nursing facility care lie within the capacity of states to rectify even in the short term.