Long-Term Care Survey Alert

Published on Mon Feb 16, 2009 PDF

Public reporting initiative spotlights challenges to rating true quality.

Nursing facilities' star ratings are now posted on Nursing Home Compare, but the industry isn't exactly glowing about the Centers for Medicare & Medicaid Services' new public quality reporting system. Long-term care leaders and providers have identified numerous problems with the initiative, as well as suggested ways to give consumers a more accurate reflection of a facility's capabilities.

How the reporting program works: Each nursing home receives from one to five stars (with three being average) based on its performance in three areas: a subset of existing quality measures, its previous three years of survey performance, and nurse staffing data.

The survey domain is the most important one in determining the overall rating, according to CMS.

To some, the rating system seems well intentioned enough, although many providers walked away from their initial ratings puzzled about why they didn't get as many stars as more lackluster or even troubled nursing facilities.

Key example: One facility asked CMS in a Q&A why it got one star when a Special Focus Facility down the road got three. The SFF initiative is for chronic poor performers at risk of getting booted from Medicare and/or Medicaid if they don't improve sufficiently. In response, CMS noted that a SFF with a poor survey record could increase its overall number of stars by having higher ratings on nursing home staffing or quality measures. "However, a nursing home that is designated as a SFF will not receive an overall star rating higher than three stars based on their status as an SFF," CMS writes. (You can download the Q&A at www.cms.hhs.gov/CertificationandComplianc/Downloads/QsandAsFinal.pdf.)

Another example: Higher acuity, more sophisticated Illinois nursing facilities have lower star ratings than more low or intermediate level-of-care facilities that don't admit people with pressure ulcers or serious pain, observes Terry Sullivan, executive director of the Illinois Council on Long-Term Care.

"To really understand each nursing facility, you have to know the type of patients they care for," says Peter Clendenin, executive VP of the National Association for the Support of Long Term Care, who knows of a number of "fabulous" facilities that have a three-star rating.

Providers want to know how the rating system works, but they don't have the software data specs to duplicate their scoring, says Rena Shephard, MHA, RN, RAC-MT, CE-NE, president and CEO of RRS Healthcare Consulting in San Diego. And the calculation is very complex, she adds

For example, "the calculation weights the most recent surveys more so than previous surveys, but it also assigns a weight to scope and severity," Shephard notes. Staffing data are adjusted based on a facility's RUG case-mix, she adds. "And facilities don't calculate RUG scores for all residents."

Another problem: So much of the rating depends on survey results, which continue to be arbitrary, varying from state to state and from survey team to survey team, says David Hunter, CEO of Mary Wade Home in New Haven, Conn.

Some providers found their star ratings included deficiencies that they had eliminated or downgraded at IDR or through appeals, reports Joseph Bianculli, an attorney in private practice in Arlington, Va. Illinois Council's Sullivan also talked to a provider to whom that had happened. (CMS did give providers a hotline number in their preview materials to call about inaccuracies, and promised to talk to state survey agencies to correct any inaccuracies.)

Long-term care organizations don't plan to take CMS' public reporting system lying down.

The American Health Care Association will be meeting with CMS about the system "from a database standpoint" to make sure the agency understands it and ways to improve it. "In effect, we are going to see if we can work something out [with CMS]," AHCA president and CEO Bruce Yarwood told Eli an an interview. "If not, we will look at the legal side -- is there some facility jeopardized because it got one star based on erroneous information, and now the facility is a pariah in the community?" Yarwood says he doesn't know if that will happen to facilities as a result of the rating system, although a lot of people are worried about that type of scenario. AHCA also plans to talk to federal lawmakers about the system, Yarwood adds.

The American Association of Homes & Services for the Aging has asked for the following changes:

• Immediate development of a data collection tool around staffing;

• Coordination of the rating system with the Advancing Excellence in America's Nursing Homes campaign;

• Overhaul of the survey and certification system with funding provided for a new system;

• Medicaid and Medicare reimbursement that flow through directly for caregiving.

In addition, CMS and providers need to provide guidance to consumers on other factors for evaluating a nursing home, said AAHSA president and CEO Larry Minnix in a press statement.

Examples include a "five-senses test when visiting a nursing home, relying on community reputation, observation of staff-resident interactions -- and availability of senior management to address resident and family concerns."

Looking on the Bright Side