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CMS’ New Warning Icon for Nursing Home Compare Has Everyone Seeing Red

Ann Longterm Care. 2019;27(12):e5-e6. doi:10.25270/altc.2019.12.00092

Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD—Column Editor


Dr Stefanacci is the chief medical director for the managed markets agency of EVERSANA™.


EVERSANA™, Berkeley Heights, NJ; Atlanticare/Geisinger, Atlantic City, NJ; Thomas Jefferson University, College of Population Health, Philadelphia, PA

In an effort to crack down on nursing home (NH) quality and enhance oversight, the Centers for Medicare & Medicaid Services (CMS) has taken a number of steps. Their latest strategy was to roll out a new consumer alert icon that will be displayed on the profiles of approximately 750 of the 15,000 skilled nursing facilities (SNFs) on the Nursing Home Compare website.1

The red hand alert icon has been added to facilities listed on the Nursing Home Compare website that have been cited on inspection reports for “incidents of abuse, neglect, or exploitation” that led to harm of a resident within the past year or that could have potentially led to harm of a resident in each of the last two years.

To ensure CMS is providing the latest information, the icon designation will be updated monthly—at the same time CMS inspection results are updated. This means consumers will not have to wait for CMS’ quarterly updates to see the latest information, and NHs will not be flagged for longer than necessary if their most recent inspections indicate they have remedied the issues that caused the citations for abuse or potential for abuse and no longer meet the criteria for the icon. This icon supplements existing information, including the Nursing Home Five-Star Ratings, helping consumers develop a more complete understanding of a facility’s quality. Despite this, industry stakeholders are arguing that this icon is counterproductive.

Consumer Alert Icon: Helpful or Harmful? 

AMDA—the Society for Post-Acute and Long-Term Care Medicine has written to CMS outlining their specific objections with this approach.2 They said that this tactic represents a violation of a fundamental patient safety principle—a principle that establishes a blame-free environment where individuals and organizations work systematically to report all errors and near misses without fear of reprimand or punishment. 

The Agency for Healthcare Research and Quality has spent “hundreds of millions of dollars to establish a patient safety network responsible for education, training, and the promotion of systematic approaches to prevent adverse events, including abuse and neglect.”2 They say that the “red hand” approach a “clear violation of this principle.” Instead of creating accountability, the red hand effectively and systematically assigns blame.2 Literature on adverse drug events shows that systems that penalize reporters lead to decreased reporting.3,4 This was also apparent with the pain measures, which were recently removed from the Nursing Home Compare website and the Five-Star Quality Rating System in part for a similar reason. Because facilities were underreporting incidents, the facilities appeared to rated higher than other facilities. 

The Society thinks we should seek to increase reporting of abuse and neglect in order to help staff learn from mistakes, not perpetuate them. This type of “just culture” is critical to gaining engagement in efforts to prevent patient harm as well as improve quality. The Society cites the published work by W. Edwards Deming and others on total quality improvement.5,6 The alert symbol, they feel, is more likely to have the “reverse effect of increasing the risk of abuse, as abuse is unlikely in open, healthy work cultures.” Promoting penalties may also lead to further negativity related to a specific care setting and add to the present stigma and staff issues in US nursing facilities. 

The red hand approach is not evidence based, and concerns remain regarding the survey process. Survey findings remain subjective and highly variable despite attempts to standardize them. Implementation science has also shown that punishment rarely encourages or contributes to true behavior change in recipients. Behavior change is much more likely to occur via candid discussions of evidence-based approaches, collaborative activities, and positive reinforcement.

Undermining Preferred Provider Networks

As discussed in prior installments in this column series, many organizations, including accountable care organizations (ACOs), are establishing preferred networks of SNFs based on indicators that include staffing, quality metrics, and resident outcomes.7,8 Preferred networks are chosen and cultivated in a mutually beneficial manner to the patient, facility, and health care organization. While truly abusive situations are always unacceptable, the effect of a poor survey outcome is already considered in a network selection. With the new alert icon, however, an SNF that may otherwise have good ratings and a long history of good service may have a single abuse citation caused by a single individual that is subjective to each survey team. The red hand icon is then assigned to that facility, and ACOs must consider pulling the facility out of their preferred network and using lesser-quality facilities. This has a domino effect wherein many patients are negatively impacted (instead of just one) as well as the financial integrity of the ACO. Survey results with one adverse finding, even abuse, do not warrant a facility’s exclusion from a well thought out SNF preferred network.

Need for Strong Leadership and Transparency

The Federal Nursing Home Reform Act of 1987 (OBRA ’87) created a set of national minimum set of standards of care and rights for people living in certified nursing facilities. It required that each facility hire a clinical leader—a physician medical director tasked with overseeing both the administrative and clinical quality of the facility.9 Yet, little to no information is publicly available to patients and their families about this role or the qualifications of individuals serving in this capacity. The Society expressed concern to CMS that, despite the OBRA ’87 law on NH quality with requirements related to the medical director position, this position and the performance of those in this position does not tie directly to the quality measures of NH care.2

Providing a public information registry on individuals serving as NH medical directors may assist patients in selecting a quality facility. Providing information on the medical director could also provide CMS and other stakeholders the ability to reach out to and educate them about the latest developments and issues with NH abuse and neglect, as well as other clinical and regulatory concerns. This strategy would help avoid the negative consequences that a red hand icon brings to patients and facilities. 


SNF stakeholders should address the issue of this red alert symbol on a facility and national basis. On a facility basis, this means working to prevent your facility falling victim to being tagged with a red hand icon. If your facility does receive this tag, articulate to CMS why this is unfair and take steps to get it removed. On a national basis, facilities should work with AMDA and others to rectify this poorly thought out tactic and work to provide real tools for all stakeholders to improve care to SNF residents. 


1. Trump administration empowers nursing home patients, residents, families, and caregivers by enhancing transparency about abuse and neglect [press release]. Baltimore, MD: Centers for Medicare & Medicaid Services; October 7, 2019. Accessed December 12, 2019. 

2. AMDA—The Society for Post-Acute and Long-Term Care Medicine. AMDA comments on NH Red Hand Icon. Published November 22, 2019. Accessed December 12, 2019.

3. Wolf ZR, Hughes RG. Chapter 35, error reporting and disclosure. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

4. Adverse event analysis. In: Institute of Medicine (US) Committee on Data Standards for Patient Safety; Aspen P, Corrigan JM, Wolcott J, et al eds. Patient Safety: Achieving a New 

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