Feds rate US nursing homes

[cougarnurse]

OK...how do you stack up, according to the Feds? Feds rate U.S. nursing homes - USATODAY.com

An analysis of nearly 16,000 nursing homes reveals for-profit homes are more likely to provide inferior care than their non-profit rivals, according to a USA TODAY examination of the federal government's first ratings of the homes' performance.

The new Zagat-like rating system, released today by the Centers for Medicare & Medicaid Services, assigns homes one to five stars for quality, staffing and health inspections, plus an overall score.


DATABASE: Find a specific nursing home's rating
CHART: The best and worst nursing homes
MORE: Nursing homes talk new ratings


The scores reflect tens of thousands of inspection records, complaint investigations and quality measures, such as how many nursing staff hours were provided each day to patients, how many patients developed bedsores and how many were placed in restraints. Much of the data were collected in 2008.

Acting Medicare Administrator Kerry Weems says offering the data in a simple five-star format should prompt "a national conversation about nursing home quality" and spur homes to improve.

FIND MORE STORIES IN: Congress | Aging | University of California-San Francisco

USA TODAY's analysis of the data found:

• Twenty-seven percent of the USA's 10,542 for-profit homes were one-star, compared with 13% of the 4,182 non-profits.

• Nineteen percent of non-profit facilities got five stars, compared with 9% of for-profits. Most non-profits are owned by corporations, while about one-fifth are run by faith-based groups.

The USA TODAY analysis is consistent with other research, says Charlene Harrington, professor emeritus of nursing at the University of California-San Francisco and a member of Medicare's technical advisory committee for the ratings. Studies show "a lot of the for-profit homes have low staffing, and it shows up in their quality," she says.

View our searchable database of ranked nursing homes

Thomas Hamilton of Medicare, who led development of the rating system, says agency researchers worked for years to develop their formula
and assembled the advisory panel over the summer to help finalize the ratings. Results will be updated at least quarterly.

Janet Wells, of the National Citizen Coalition for Nursing Home Reform, a consumer group, says members initially opposed ratings, fearing they would be inaccurate. Now, she says, her members give the agency "high marks" for helping to distinguish bad homes from good. "It's probably going to be most useful at the extremes," she says.

Nursing home groups say they welcome efforts to spotlight good and bad performers. But the American Health Care Association, a trade group whose members include for-profit homes, asked Congress in November to urge Medicare to delay release, saying the data were "flawed."

"The public is accustomed to looking at star ratings for restaurants or hotels," says Lyn Bentley, the association's director of regulatory services. "This is way more complex than that."

Bentley would not discuss why for-profits tend to score lower than non-profits. "I don't think poor quality is acceptable regardless of who provides it," she said.

Larry Minnix, head of the American Association of Homes and Services for the Aging, which represents non-profit homes, says the ratings reflect often-subjective information but are still a good idea. "Our goal is that you should not have to worry that your mother is in a good place," he says.

[cougarnurse]

Also related: Nursing home industry worries about new ratings - Yahoo! News

Rating systems help people decide which restaurants to go to or hotels to stay at. So why not something similar from the federal government for the nation's 16,000 nursing homes?

Such a simple rating for so complex a task as caring for the elderly is leading to much anxiety in the nursing home industry. Home operators worry about the ramifications for their business if they get one or two stars — when five is the best.

The Centers for Medicare and Medicaid Services was to let everyone know Thursday just how many stars each home is getting. Already the industry is questioning the validity of the rankings. To operators, the five-star system is a great idea whose time has not yet come.

The system "is poorly planned, prematurely implemented and hamhandedly rolled out," said Larry Minnix, president and chief executive officer of the American Association of Homes and Services for the Aging, an industry trade group.

Federal officials say the rankings will put nursing homes "on the path to improvement" because they know family members will think twice before putting someone in a one-star home.

The ratings are based on state inspections, staffing levels and quality measures, such as the percentage of residents with pressure sores. The nursing homes will receive stars for each of those categories as well as for their overall quality.

Consumer groups like the concept, but they agreed there are some potential problems with the data. For example, the staffing data is self-reported just before state surveys and is widely recognized as unreliable.

"From a consumer viewpoint, it's not stringent enough," said Alice H. Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform. "It's basically taking information already available on Medicare's Nursing Home Compare Web site and pulling it into an easier system for consumers to use, and that is a good thing."

Hedt said consumers should consider the star ratings, but not solely rely on them when comparing facilities. Her organization also issued a press release warning that nursing homes may appear in the ratings to give better care than they actually do.

"Our initial reaction is that consumers should probably avoid any facility with a one- or two-star rating and even a three-star rating unless people they trust convince them that the rating is inaccurate or unfair," she said.

But, in Indiana, eight nonprofit nursing homes have reported they got one star for staffing even though they have some of the highest staffing levels in the states, said Jim Leich, president and chief executive officer of the Indiana Association of Homes for the Aging. He believes the one-star rating is the result of a records glitch particular to any nursing home that is part of a campus that includes housing for residents with less intensive care needs.

"It's really going to be an injustice for some of our best facilities," he said.
The Jennings Center for Older Adults in Garfield Heights, Ohio, got four stars for its nursing home, said Martha Kutik, the center's president and CEO. Still, she's worried that the rating system relies on surveys that measure cracks in the ceiling but don't measure patient and family satisfaction.

"Any system that's going to measure quality for consumers should keep satisfaction high on the list," Kutik said.

[cougarnurse]

Do a search of this, and it sounds like many homes that were considered good by families were rated low. What all do you think/have to say?

[OldSquidNewNurse]

Once place that I thought very highly of did when. Another that I thought was good did poorly, but it was on the survery part only. They must weigh the survery part more than others, which if you have nothing to compare to can hurt results.

[gdpawel]

Washington, DC-based Carlyle Group owns Synagro Technologies, the company that processes municipal waste products, transports the resulting "sewer sludge" and distributes it for land application. Residents from around Pennsylvania have been calling for the expanded testing of Synagro sewer sludge and public reporting on its toxicity and disposal. Communities don't know everything that is in the sludge dumped on nearby lands. Without more information, there are possible health effects and diminished quality-of-life issues.

Concerns about the safety of Synagro sludge have intensified since the company's April 2007 buyout by The Carlyle Group. By taking Synagro private in a leveraged buyout last year, Carlyle is able to avoid requirements that Synagro provide federal agencies with certain information about its business practices and avoid publicly disclosing the existence of regulatory inquiries or legal complaints against the company resulting from health hazards caused by Synagro products and product distribution.

This has been happening with The Carlyle Group's take-over of Manor Care nursing homes earlier this year. Manor Care's restructure could obscure ownership and make it more difficult to regulate care. You can't see how they are wasting money, short-staffing, under-paying workers, or understand all the intricate inter-relations they have with supposedly outsourced services such as therapy.

All 46 Manor Care nursing homes in Pennsylvania staff below a standard recommend in a Centers for Medicare and Medicaid Services (CMS) study as putting residents at risk (Schnelle, et all. Appropriatness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II final report, December 2001).

The steady cash flows nursing home operators produce is a big attraction for private-equity firms that need the cash to pay down borrowed debt. Beverly, Extendicare, Genesis and Vencor/Kindred went private, and now Manor Care. Private firms keep all their dirty deeds from the public, especially consumers.

Ownership structures with multiple stakeholders have been used by other private-equity firms to minimize liabilities and shield them from regulator inquiries. They use these kinds of structures to avoid taking responsibility when taking control of businesses. Private-equity buyout firms such as the Carlyle Group are not required to publicly disclose information about the business practices of the companies they own.

The Carlyle Group, one of the world's largest private-equity funds with more than $75 billion under management, owns Manor Care, the largest nursing home chain, and Synagro, the largest sludge company in the United States. Perhaps they'll process all their municipal waste products, and distribute it to the lawns and gardens of all their nursing homes and add to the significant health complaints at the homes?

[Grandma-RN]

Once place that I thought very highly of did when. Another that I thought was good did poorly, but it was on the survery part only. They must weigh the survery part more than others, which if you have nothing to compare to can hurt results.

Yes, same with me, OldSquidNewNurse. Our facility for example, had 4 and 3 stars on Staffing, and RN, and Quality but 1 on Survey because of complaints. But all of the complaints except 1was justified. The one justified was a D after the survey. So, it is all relative. This is this time for survey. So, the ratings now is for previous survey. Right.

It really can be confusing to the public and some of us working in it.

[gdpawel]

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 present administration, they wanted, among other things, the "quality indicator" process to eventually replace traditional annual surverys because it relies upon self-reported, unaudited data supplied by the facilities themselves and is without consequences for failures. But it still relies upon self-reported, unaudited data supplied by the facilities themselves.

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.

[gdpawel]

Lack of Oversight

The outbreak of salmonella linked to peanut butter made at the Blakely, Georgia plant had sickened more than 500 people in 43 states and caused the deaths of eight. Three of the dead were nursing home residents, sickened before the source was found or identified.

The state performs inspections of peanut butter plants on behalf of the Food and Drug Administration (FDA), as part of a contractual agreement with the federal agency. The FDA had never inspected the plant in Georgia, delegating that duty under contract to the State Department of Agriculture. The FDA says it does not have enough inspectors to visit the country's 65,520 domestic food production facilities.

The state performs inspections of nursing homes on behalf of the Centers for Medicare and Medicaid Services (CMS), as part of a contractual agreement with the federal agency. The CMS says it does not have enough inspectors to visit the country's over 16,000 nursing home facilities. It delegates that duty under contract to the State Department of Health.

The health inspector who toured the peanut butter plant in Georgia at the center of the national salmonella outbreak noted only two minor violations in October. Less than three months later, federal inspectors found roaches, mold, a leaking roof and other sanitation problems. It's not surprising that many major deficiencies were observed at one time, and none of them were picked up previously.

In a state inspection at a nursing home in Pennsylvania, surveyors gave a "clean bill of health" to the home administrators. Four months after the state surveyors passed the home in their inspection, CMS comes in and does a federal complaint inspection of its own and cites them with 13 violations.

It's not surprising that many major deficiencies were observed, however, none of the 13 violations, which were ultimately the responsibility of management, were addressed by the oversight agency, and these were not issues with which the administration of the home was unaware or uninformed.

The president of the peanut company linked to the nationwide salmonella outbread serves on an industry advisory board that helps the U.S. Department of Agriculture set quality standards for peanuts. The board is charged with helping set quality and handling standards for domestic and imported peanuts.

Surprise nursing home inspections are in reality seldom random and their level of predictability allows nursing homes to conceal the evidence of abuse and neglect. They almost always know when an inspector is coming, and employees are instructed to clean up the facility in time for the inspection.

The nursing homes even seem to have seen to it that people at the oversight agencies are people who are loyal to the nursing home industry, such as former nursing home administrators. The number one problem in nursing homes is understaffing and regluators cannot get the for-profit agencies to comply with mandatory staffing requirements. Instead, they go to great lengths to conceal to inspectors when it comes to staffing.

Usually this is done by keeping two separate work schedules. One is shown to inspectors, with names of people who are supposed to be working at the home, and the true schedule that shows understaffing is rampant.

The Georgia peanut plant knowingly shipped out contaminated peanut butter 12 times in the past two years. The FDA and the CDC have found salmonella in internal tests a dozen times in 2007 and 2008 but the company sold the products anyway, sometimes after getting a negative finding from a different laboratory.

State inspection records showed a pattern of unsanitary conditions over several years. In each case, inspectors flagged the problems but never required routine follow-up. There was no evidence that the company was ever closed by the state or otherwise penalized.

During the federal complaint survey with the Administrator and the Director of Nursing at the nursing home in Pennsylvania, the Administrator acknowledged that the Monthly Infection Control Summary Tools reflected an extremely high infection rate within the facility (almost double to five times as high as the national average).

There were numerous Clinical Record violations, Accidents & Supervisory violations, Infection Control violations and others at various scope and severity levels, but no Administration violations were cited.

The lack of oversight also translates into even more taxpayer dollars down the drain because of the health problems and costly hospitalizations that wouldn't have been necessary as a result of it. But loopholes in state laws and the lack of federal oversight have allowed these kinds of events to skirt regulation.