Is Simpler Better in Rating a Nursing Home?

State Surveys are independent evaluations of nursing facility performance. Annual surveys are conducted by state survey agencies, usually the state's department of health, using protocols, procedures, and forms developed by the Centers for Medicare & Medicaid Services (CMS).

A consumer concern about surveys is the repeated finding by the Government Accountability Office (GAO), in a series of reports issued since 1998, that surveys understate deficiencies and cite deficiencies as less serious than they actually are.

The survey component of CMS's proposed ranking system provides a more positive statement about quality than justified. States are increasingly using their state enforcement systems, instead of the federal system, to sanction facilities for noncompliance with standards of care. State enforcement actions do not appear on Nursing Home Compare.

The National Senior Citizens Law Center recommends that consumers use the new rating system with caution, and only as an aid while also pursuing other information and strategies. Consumers need to understand that the five-star system is a beginning, not an end.

A nursing home's quality can shift from month to month, so you have to be savvy in asking the right questions. Existing residents and their family members should be asked for their opinions.

Inspection data is mostly based on a once-a-year survey and may not accurately reflect the nursing home's performance today. Staffing information and quality measures are "self-reported" data by the nursing homes themselves. Self-reported data makes nursing home quality "appear" to be better than it actually is. It cannot easily be reduced to a star rating.

A recent GAO study found that nursing homes over-report staffing levels compared with staffing reported on audited Medicaid cost reports. Over-reporting of nursing coverage is associated with for-profit ownership of nursing homes.

Researchers recommend more careful scrutiny of staffing levels in for-profit facilties during the survey process and that improvements be made to the process of public reporting of staffing levels.

CMS should provide more and better information on Nursing Home Compare, including links to the actual survey forms and information about staff turnover. Also, CMS should use payroll data to report staffing information.

Anything to do with "quality indicators" is bogus. When de-regulation failed under the Bush administration, they wanted, among other things, the "quality indicator" process to eventually replace traditional annual surverys.

Either way, whether Traditional Survey or Quality Indicator Survey, what appears on the CMS nursing home Compare website that is labled "quality measures" is based on self-reported, unaudited data, data reported by the facilities themselves and unverified by any oversight agency to ensure it is even true. This still leads nursing staff to do charting by rote, instead of charting care that they're actually giving.

It leaves you with that warm-n-fuzzy "we'll-help-them-fix-their-problems," even though 99% of their failures are failures of practices they should already be experienced in before they are granted a license. It is part of the "kid-gloves," don't be-so-hard-on-the-poor-poor-nursing-homes" from the Bush administration.

Gregory D. Pawelski of PA 7:30PM December 26, 2008