Alert: Nursing Home Compare Is NOT Accurate

Nursing Home Compare is a government run site. It provides information to the public about nursing facilities. These facilities participate in the Medicare and Medicaid programs.

As a nurse I have worked in the long-term care industry. In fact, I worked for several large organizations. This article rang true for me. We are a culture living longer. But, not healthier. Those in nursing homes are very sick. The census of a nursing home has gone from independent seniors being able to take care of themselves to... the most frail and medically compromised in our society. There is need for reform to increase the staffing to meet the needs of this frail population. Decide for yourself.

The Center for Medicare Advocacy recently released this report:

“The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again

A report by the Department of Health and Human Services’ Inspector General found ... that a third-of nursing home resident suffered an adverse event or other harm in August 2011. These occurred in Medicare approved facilities. Most of the events were preventable and caused by problems in staffing. Yet the nursing home industry claims that nursing home quality of care has improved.

The Center for Medicare Advocacy has written about this issue before... despite clear evidence he care for residents is not improving,

The Center for Medicare Advocacy continues to report…

Nursing home “Industry Claims...

In its 2013 Quality Report... the American Health Care Association (AHCA), reports that quality of care in nursing facilities is improving. The AHCA cites improvements in almost all of the quality measures from 2011 to 2012 . AHCA reports that between 2009 and 2013, the proportion of five star facilities increased from 11.8% to 19.6% . The proportion of one-star facilities decreased from 22.5% to 13.5%.”

The Center for Medicare Advocacy continues to report…

‘Improved Star Ratings Do Not Necessarily Demonstrate Improved Quality of Care for Residents

Increase in a star rating does not reflect any improvement in a residents’ quality of care, nor their quality of life. Rather, they likely reflect facilities’ self-reported and unaudited claims. These claims report that staffing and quality measures have improved.

Abt Associates, a CMS contractor, analyzed the first three years of the Five-Star Quality Rating System. They noted that the health survey measure remained constant due to self-reporting by the facilities. The improved overall ratings may “reflect changes in reporting practices... rather than real changes in quality.”

Nursing Home Compare

Since the Clinton Administration, the federal government has maintained a website called Nursing Home Compare

This site provides information to the public about nursing facilities. These facilities participate in the Medicare and Medicaid programs.

Over the years, the type and the amount of information available on Nursing Home Compare have increased. CMS uses the website to post information reflecting state survey results. And, as reported by the facilities themselves, staffing levels and quality measures (QMs).

The website also reports federal sanctions that CMS imposes against facilities. These facilities are cited with deficiencies for violating federal standards of care. Sanctions imposed under state licensing laws. However, these are not included in Nursing Home Compare.

Since 2008, CMS has rated facilities separately on each of three domains... health inspections, staffing, and quality measures. They are also rated on a composite measure. This combines the three individual measures.

In calculating the overall measure, CMS begins with the survey measure. This may increase or decrease by one star in either direction. This is based on very high or very low star ratings in the self-reported staffing levels. They are also self-reported Quality Measures, or both.

As a result, the higher ratings are reflected by a facilities’ self-reported data on staffing and Quality Measures.

Health Inspections

Nursing facilities that take part in the Medicare or Medicaid programs have an unannounced survey each year. Surveys are conducted by state survey agencies. These are located in the state department of health. They use a survey protocol that has been ... developed, tested, and validated by the federal government.

The Government Accountability Office has issued many reports over the past 15 years. They consider state survey results, complaints filed and deficiencies and self reporting.

The top 10% of facilities in a state receive five stars; the bottom 20%, one star. The middle 70%, two, three, or four stars (23.33% each). One star, the lowest score, is defined as “much below average,”. And five stars, the highest score, defined as “much above average.”

CMS has used this scoring mechanism since the Five Star Quality Rating System was first introduced in 2008. “The distribution of ratings for health inspections is essentially fixed.”

Quality Measures On Nursing Home Compare

CMS publicly reports 18 different quality measures. These are derived from resident assessments. These are conducted by the facilities themselves and electronically submitted to CMS.

Nine of the 18 measures are included in the rating system for the QM domain. CMS assigns stars in quality measures. They use resident assessment information that facilities report to CMS. CMS does not “formally check” the assessment information. They do not “ ensure accuracy” for purposes of this measure.

CMS’s rating system for QMs is extremely complex.

Half of the 18 measures are not used at all in calculating the publicly-reported QMs. Significantly, unlike health inspections, the distribution of ratings is fixed. When these remain constant, the distribution of ratings for QMs is “allowed to shift.”

The accuracy of QM information is a matter of concern to CMS. I CMS reports that facilities’ late submission or non-submission of data on discharges affects “QM data integrity.

Improved Star Ratings Reflect Facilities’ Self-Reported Quality Measures

Since health survey ratings have remained constant. While both staffing and QMs are “allowed to shift,”, facilities’ changing star ratings. These reflect improved ratings in the self-reported staffing and quality measures. Neither the staffing data nor the assessment data are audited by CMS. This should be done for purposes of public reporting.

Abt Associates’ analysis found that improved overall ratings were the result of improvements reported by facilities in... staffing and QMs. They may “reflect changes in reporting practices rather than real changes in quality”.

In January 2009, 22.7 percent of facilities had a one-star rating while 35.2 percent had a four- or five-star rating. By December 2011, the proportion with a one-star rating had declined to 15.6 percent, while 43.2 percent had a rating of four or five stars.

The Center for Medicare Advocacy Analyses Have Shown that Poor Quality Facilities... Report High Staffing and QMs, Boosting Their Overall Star Ratings

In September 2013, the Center showed that facilities with one star in health surveys still report high quality measures. The Center found that facilities with one-star ratings in health surveys in three geographically diverse states ... Georgia, Illinois, and Oregon. All had high quality measures.

In Georgia, 29 of 57 one-star facilities (51%) had four stars in quality measures. In Illinois, 33 of 93 one-star facilities (35%) had four stars in quality measures. and in Oregon, two of five facilities (40%) had four stars in quality measures. The Center found similar results with Special Focus Facilities (SFFs). These are facilities that are identified as among those providing the worst care in the country.

CMS requires that survey agencies conduct additional surveys in SFFs. And that more intensive enforcement action is imposed against SFFs.

The Center’s analysis of SFFs found that 17 of 47 facilities added to the SFF list (36%). As of May 16, 2011, reported quality measures leading to four- and five-star ratings in the QM domain.

On April 15, 2014, the Center did another analysis of the facilities on the SFF list. This time, looking at facilities that had not improved, as of March 20, 2014. The analysis shows similar disparities between... the overall measure, the health survey measure, staffing, and the QMs.

Nineteen facilities on the list of Special Focus Facilities had not improved. They had been on the list for 12 to 40 months.

* 11 of the 19 (58%) had overall ratings that exceeded their health survey

* 9 of the 19 (47%) had overall ratings of 2 stars, but health surveys of 1 star

* Staffing measure * 1 of the 19 (5%) had 5 stars in staffing

* 10 of 19 (53%) had 4 stars in staffing.

* 3 of 19 (16%) had 3 stars in staffing

* 2 of 19 (10%) had 2 stars in staffing

* 2 of 19 (10%) had 1 star in staffing

* 1 of 19 (5%) had staffing not reported

* Quality measures

* 1 of 19 (5%) had 5 stars in QMs

* 9 of 19 (47 ) had 4 stars in QMs

* 7 of 19 (37%) had 3 stars in QMs

* 1 of 19 (5%) had 2 stars in QMs

* 1 of 19 (5%) had 1 star in QM

A recent example... of a Special Focus Facility in Texas clearly illustrates the point. Poor facilities can report high quality measures… and improve their overall star rating as a result.

Southaven Nursing Center, a Dallas nursing facility, lost its Medicare and Medicaid certification in March 2014,. This was following 39 months on CMS’s SFF list. The facility received two stars in health inspections, yet five stars in QMs. Boosting its overall rating to three stars.

Advocacy for Nursing Home Residents

Conclusion... The Inspector General found that nearly one-third of Medicare residents experienced very poor care in August 2011. Much of which it considered avoidable because of inadequate staffing. Industry claims of improving care are based on self-reported data. This self reporting is highly suspect.