Feds announce changes in nursing home rating system

Center investigation found widespread discrepancies in reported data




The Centers for Medicare and Medicaid Services (CMS) announced changes Friday to its often-critiqued five-star rating system for nursing home quality —- changes that are likely to negatively affect the ratings for thousands of facilities.

Among the adjustments: the agency is altering how it calculates the staffing figures that are one component of the all-encompassing quality score on the Nursing Home Compare website. That website is widely used by the pubic in evaluating and comparing 15,000 nursing homes nationwide, and is thus crucial to family decisions about where to place a loved one who needs care.  

Whereas it was previously possible for a facility to receive less than four stars in both the registered nurse and total staffing sub-categories and still earn a four-star ranking for staffing overall, now nursing homes must receive the four-star level mark in at least one of those sub-categories in order to receive the four-star staffing rating, according to Patrick Conway, chief medical officer for CMS, the federal agency responsible for overseeing nursing homes. Conway added that homes also must receive at least three stars in both the registered nurse and total staffing components in order to achieve the overall four-star rating for staffing.

Thomas Hamilton, director of the agency’s survey and certification group, said 13 percent, or about 2,000, of the nation’s nursing homes will lose one or two stars on staffing as a result of these policy changes, and other changes in the data underlying nursing homes’ staffing ratings. He explained that the staffing and other changes are part of the agency’s effort to promote continuous improvement in the industry that he said has occurred since the launch of the five-star rating system in December 2008. Staffing is but one criteria used to determine the broader quality score; among the others are health inspections and the percent of residents who are physically restrained.      

In all, about one in three, or about 5,000 nursing homes, will see their broader quality star rating decrease as a result of the changes, according to Conway.    

“We view these changes as part of our continuing journey of quality improvement for the Nursing Home Compare website,” Conway said.

A Center for Public Integrity investigation published in November found widespread gaps between staffing levels reported by nursing homes and staffing levels calculated through an analysis of the homes’ annual financial documents, called cost reports.

The gaps occurred in both nonprofit and for-profit nursing homes, and for all types of direct care staffing positions, though the gaps were greatest for reported levels of registered nurses.

In 2012 the self-reported staffing levels for registered nurses were higher than the average daily level calculated through cost reports in more than 80 percent of nursing homes, the Center found.  

The Affordable Care Act required that nursing homes transition from the self-reported staffing method to a payroll-based system with audited information by March 2012. Officials have said that a payroll-based system for calculating staffing would be the most accurate of all. Hamilton said $11 million in funding awarded to CMS in October 2014 though the IMPACT Act would allow it to complete the process by the end of 2016.  He acknowledged that the variation in payroll systems in nursing homes across the country makes the task a steep one, but said the agency is committed to accomplishing it.

“We’re working hard to make it a reality,” Hamilton said.

Robyn Grant, director of public policy for the National Consumer Voice, the nation's largest nursing homes advocacy group, applauded the changes announced by CMS, but said they do not go far enough.

“We have seen inflation of scores,” Grant said. “The methodology will help bring it more in line with what staffing may actually be like: however, there’s nothing that’s going to help as much as basing the information on payroll data.”

The accuracy of the Nursing Home Compare website has been the subject of significant controversy. The Center's pieces followed the publication in August of a story by The New York Times that found much of the improvement in nursing home performance came on staffing levels and quality measures, two criteria that relied on self-reported data that were not audited by the federal government.

Advocates also welcomed another change announced by CMS: assessing a nursing home’s use of antipsychotic drugs administered to residents as an additional criteria in for measuring quality.   

Cheryl Phillips, senior vice president of advocacy and public policy at LeadingAge, an organization that represents non-profit nursing homes, said the group supports the staffing and quality measure changes, but expressed concern that the public might not understand the reason why quality ratings for many facilities will suddenly drop.

“If we’re really doing all of this to help consumers, all of a sudden changing a nursing home from a four-star to a two-star, is that really helpful in explaining the quality of the care?” Phillips asked.  

Mark Parkinson, president and CEO of the American Health Care Association, an organization that represents for-profit facilities, concurred with Phillips.  

“We are concerned the public won’t know what to make of these new rankings,” Parkinson said in an email.  

CMS is saying on the Compare website itself said that many nursing homes will see a lower quality measure rating as a result of the changes, even though the underlying data may not have changed in individual cases. As a result, the agency said it is not appropriate to compare a facility’s quality measure rating for February with those in previous months.  

Hamilton said the agency has held open forums for nursing home owners and sent notifications about the changes to all of the states.  

Rep. Jan Schakowsky (D-Illinois)  has been among those arguing that higher levels of registered nurse staffing are critical to residents’ quality of care.  Earlier this month, she reintroduced legislation that would require nursing homes to increase registered nurse levels from 8 to 24 hours per day. 

“The need for at least one RN could not be more urgent,” Schakowsky said in a statement when she introduced the initial bill. “Over the past two decades, the medical intensity and complexity of care for nursing facility residents has increased dramatically.”

Five Democrats, including Rep. Charles Rangel (D-New York) and Lucille Roybal-Allard (D-California), have signed on as co-sponsors for the measure.  

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