Informing consumers through simplified nursing home evaluations

Journal of Legal Medicine

Volumn 30, Issue 4, 2009, Pages 545-562

  Parenteau, Michael A ^a  

^a SOUTHERN ILLINOIS UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EVALUATION; GOVERNMENT; HEALTH CARE FACILITY; HEALTH CARE QUALITY; HUMAN; LAW; MEDICAL INFORMATION; NURSING HOME; NURSING STAFF; RANDOM SAMPLE; RATING SCALE; REVIEW; SELF REPORT;

AGED; CONSUMER ADVOCACY; DIAGNOSIS-RELATED GROUPS; FACILITY REGULATION AND CONTROL; HOMES FOR THE AGED; HUMANS; MEDICAID; MEDICARE; NEEDS ASSESSMENT; NURSING HOMES; PERSONNEL STAFFING AND SCHEDULING; QUALITY INDICATORS, HEALTH CARE; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 72449172508     PISSN: 01947648     EISSN: 1521057X     Source Type: Journal    
DOI: 10.1080/01947640903356332     Document Type: Review

References (156)

1. Julie Appleby, Nursing Homes Talk New Ratings, USA TODAY, Dec. 18, 2008, available at http://www.usatoday.com/news/health/2008-12-18-nursinghomeinside N.htm (last visited Aug. 12, 2009).
2. Connie Cartmell, Rating Nursing Homes: Consumers Have a New Tool for Evaluating Care, MA RIETTA TIMES, Jan. 10, 2009, at B2, available at http://www.mariettatimes.com/page/content.detail/ id/509810.html (last visited Aug. 12, 2009);
3. see also Ctr. for Medicare & Medicaid Serv., Dep't of Health and Human Servs., Five-Star Quality Rating System, available at http://www.cms.hhs. gov/CertificationandComplianc/13 FSQRS.asp (last visited Aug. 12, 2009).
4. CTR. FOR MEDICARE & MEDICAID SERVS., DESIGN FOR NURSING HOME COMPARE FIVE-STA R QUALITY RAT I N G SYSTEM: TECHNICAL USERS' GUIDE, available at http://www.cms.hhs.gov/CertificationandCompliance/ Downloads/usersguide.pdf (last visited Aug. 12, 2009)
5. [hereinafter TECHNICAL USERS' GUIDE]; see also Ctr. for Medicare & Medicaid Servs., Dep't of Health and Human Serv., Nursing Home Compare, available at http://www.cms.hhs.gov/CertificationandCompliance/13FSQRS.asp (last visited Aug. 12, 2009).
6. TECHNICAL USERS' GUIDE, supra note 3, at 1. For example, a five-star rating means the nursing home's quality is well above the average of other nursing homes within the state, while a one-star rating means the home's quality is well below average.
7. Id.
8. Editorial, Federal Government Releases New Nursing Home Ratings, CITIZEN-TIMES, Jan. 9, 2009, available at http://www.citizen-times.com/apps/ pbcs.dll/article?AID=2008812190348 (last visited Aug. 12, 2009); see also Appleby, supra note 1.
9. Editorial, supra note 6; Cartmell, supra note 2; Appleby, supra note 1.
10. Editorial, supra note 6.
11. Id. Delaware has the highest proportion of five-star homes: 13 out of 45.
12. Id. In Louisiana, 285 of 731 homes received a one-star rating.
13. Appleby, supra note 1. Although many individuals who are considering a nursing home for themselves or for their loved ones do not select the home at random, they often do not have access to comprehensible information with which they can make an informed choice. Further, they may settle for a home based on geography rather than quality of care without realizing the varying degrees of quality of services offered at different nursing home facilities.
14. Id. Nursing homes have complained that the evaluation system looks only for faults rather than strengths.
15. Id.
16. Ning J. Zhang, Minimum Nurse Staffing Ratios for Nursing Homes, 24 NURSE ECON. 78, 78 (2006).
17. Id.
18. See generally CHARLENE HARRINGTON, NURSING HOME STAFFING STANDARDS IN STATE STATUTES AND REGULATIONS (2008), available at http://www.nccnhr.org/ uploads/HarringtonStatestaffingtableRevised Jan2008.pdf (last visited Aug. 12, 2009).
19. See generally Zhang, supra note 13. California has the highest overall staffing requirement, 3.2 RN hours per resident day, excluding administrative nurses.
20. HARRINGTON, supra note 15, at 8.
21. TECHNICAL USERS' GUIDE, supra note 3, at 6.
22. DEP'T OF HEALTH & HUMAN SERVS., NURSING HOMES: ABOUT NURSING HOME INSPECTIONS, available at http://www.medicare.gov/Nursing/AboutInspections.asp (last visited Aug. 12, 2009).
23. 42 U.S.C. §§ 301-1397 (2006).
24. DEP'T OF HEALTH & HUMAN SERVS., supra note 18.
25. Id.
26. Cartmell, supra note 2.
27. 42 U.S.C. §§ 1395-1396 (2006).
28. Christine Mueller, Nursing Home Staffing Standards: Their Relationship to Nurse Staffing Levels
29. GERONTOLOGIST 74, 74 (2006). For example the NHRA requires Medicare and Medicaid certified nursing homes to have an RN director of nursing (DON), an RN on duty at least 8 hours a day, 7 days a week, a licensed nurse (either an RN or LPN) on duty the rest of the time, and a minimum of 75 hours of training for nurses' aides.
30. Frederic H. Decker, Staffing of Nursing Services in Nursing Homes: Present Issues and Prospects for the Future, 9 SENIOR HOUS. & CARE J. 3, 4 (2001).
31. DEP'T OF HEALTH & HUMAN SERVS., supra note 18.
32. Liz Mitchell, Nursing Homes Blast New Federal Ratings System: Hilton Head's Facilities Peeved About Percentages, MYRTLE BEACH SUN NEWS, Jan. 10, 2007, available at http://www.myrtlebeachonline.com/news/local/story/728321.html (last visited Aug. 9, 2009).
33. See generally Mueller, supra note 24; Cartmell, supra note 2.
34. TECHNICAL USERS' GUIDE, supra note 3, at 6.
35. Mueller, supra note 24, at 75.
36. Id.
37. Editorial, supra note 6.
38. Appleby, supra note 1.
39. Cartmell, supra note 2 (questioning whether the ratings offer "apples-to-apples" comparisons of facilities in different states, given that each state has its own system for inspections and citations).
40. See generally TECHNICAL USERS' GUIDE, supra note 3.
41. Id. at 6.
42. KAISER FAMILY FOUNDATION, MEDICAID FACTS 1 (2008), available at http://www.kff.org/medicaid/upload/7235 03-2.pdf (last visited Aug. 12, 2009).
43. Cartmell, supra note 2.
44. Id.
45. Editorial, supra note 6. "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."
46. Id.
47. Id.
48. Id.
49. Cartmell, supra note 2.
50. TECHNICAL USERS' GUIDE, supra note 3, at 1.
51. Cartmell, supra note 2.
52. TECHNICAL USERS' GUIDE, supra note 3, at 1. The health inspection rating contains information from the last three years of on-site inspections, including both standard surveys and any complaint surveys. Id. at 4.
53. Id. at 1. The staffing rating calculates the number of hours of care on average provided to each resident each day by nursing staff. Id. at 6-7.
54. Id. at 1. These are physical and clinical measures for nursing home residents, such as how well a home responds to residents' declining mobility, the prevalence of pressure sores, or loss of weight. Id. at 10-11.
55. TECHNICAL USERS' GUIDE, supra note 3, at 4.
56. Id.
57. Id. at 6-7. Other types of nursing home staff, such as clerical, administrative, or housekeeping personnel, are not included in these staffing numbers. Id.
58. Appleby, supra note 1.
59. TECHNICAL USERS' GUIDE, supra note 3, at 7.
60. Appleby, supra note 1.
61. Id.
62. TECHNICAL USERS' GUIDE, supra note 3, at 15.
63. Id.
64. Id.
65. Id.
66. Id.
67. Id.
68. Id. If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum Overall Quality rating is three stars.
69. Id.
70. Id. However, because the three underlying data sources are reported and updated on different schedules, changes in the quality of care provided at another nursing facility may alter an individual facility's score even if it has not been reevaluated during that period.
71. Id.
72. Id. The Five-Star Rating System is set on a state-by-state basis to control for state-to-state variation in the laws governing nursing homes, especially in the area of deficiencies.
73. Id.
74. Id.
75. Id. A five-star rating means that a facility ranks "much above average;" a four-star rating means a facility ranks "above average;" a three-star rating means a facility ranks "about average;" a two-star rating means a facility ranks "below average;" and a one-star rating means a facility ranks "much below average." However all nursing homes, including those ranked "much below average," still meet federal health and safety requirements.
76. Id.
77. Id. at 4-6.
78. Id.
79. Id.
80. Id.
81. Id.
82. Id.
83. Id.
84. Id.
85. Id. Although weighing each type of violation separately would likely allow the most egregious citations to be accorded due weight, using the number of deficiency citations as a measure of nursing home quality has the advantage of compiling a composite measure of the nursing home as a whole. Nicholas G. Castle, Characteristics of Nursing Homes that Are Restraint Free, 38 GERONTOLOGIST 2181, 2185 (1998).
86. TECHNICAL USERS' GUIDE, supra note 3, at 6. If one set of inspection data is missing, then the calculation is reweighed accordingly. Id. Complaint points are assigned to the calendar year in which the complaint occurred. Id.
87. See generally Nelda Wray, Case-Mix Adjustment Using Administrative Databases: A Paradigm to Guide Future Research, 54 MED. CARE RES. & REV. 326 (1997).
88. TECHNICAL USERS' GUIDE, supra note 3, at 6.
89. Id.
90. Id.
91. Id.
92. See generally Nicholas Castle, Further Examination of the Influence of Caregiver Staffing Levels on Nursing Home Quality, 48 GERONTOLOGIST 464 (2008).
93. Zhang, supra note 13, at 79. Specifically, the NHRA requires that Medicare and Medicaid certified nursing homes have: an RN director of nursing (DON); an RN on duty at least 8 hours a day, 7 days a week; and a licensed nurse (RN or LPN) on duty the rest of the time.
94. See generally Zhang, supra note 13.
95. Id. at 78.
96. See generally Castle, supra note 87. Other important factors include: (a) what is done; (b) how well it is done; (c) when it is done; and (d) by whom it is done.
97. See generally, e.g., Castle, supra note 60;
98. Nicholas Castle, Staff Turnover and Quality of Care in Nursing Homes, 43 MED. CARE 616 (2005);
99. Nicholas G. Castle, Administrators' Opinions of Nursing Home Compare, 45 GERONTOLOGIST 299 (2005).
100. TECHNICAL USERS' GUIDE, supra note 3, at 11;
101. see also ANDREW M. KRAMER, APPROPRIATENESS OF MINIMUM NURSE STAFFING RAT I O S I N NURSING HOMES: PHASE II FINAL REPORT (2001).
102. TECHNICAL USERS' GUIDE, supra note 3, at 7. Case-mix adjusting allows consumers to make an "apples to apples" comparison of the staffing quality between nursing homes by accounting for differences in the level of care needed by residents with different conditions. Further, a nursing home that provides more hours of care per resident may not be as adequately staffed as one reporting lower care hours, if the residents of the nursing home providing more hours are so severely compromised that they require higher levels of individualized care.
103. Id. A case-mix index based on the Staff Time and Resource Intensity Verification (STRIVE) study will be utilized once these data are available. STRIVE is a national staff time measurement study that will provide data and analysis to update the Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS).
104. Id.
105. Id.
106. Id.
107. Gregory Arling, Risk Adjustment of Nursing Home Quality Indicators, 37 GERONTOLOGIST 757, 758 (1997).
108. Id. For example, the same nursing home may not be equally adept at providing both the more intensive rehabilitative services required for post-acute care and the supportive life-affecting models of extended care. See generally Andrew M. Kramer, Outcomes and Costs after Hip Fracture and Stroke: A Comparison of Rehabilitation Settings, 277 J.A.M.A. 396 (1997);
109. Robert L. Kane, Do Rehabilitative Nursing Homes Improve the Outcomes of Care?, 44 J. AM. GERIATRICS SOC'Y 545 (1996).
110. TECHNICAL USERS' GUIDE, supra note 3, at 7. Additionally, some of the self-reported measures are amenable to audit or statistical edits if they appear statistically suspect; hence, an investigation will occur before scores are calculated and released.
111. Nicholas G. Castle, Nursing Home Caregiver Staffing Levels and Quality of Care, 27 J. APPLIED GERONTOLOGY 375, 376 (2008).
112. Id.
113. Id.
114. INST. OF MED., IMPROVING THE QUALITY OF LONG-TERM CARE (2001).
115. Castle, supra note 87, at 465.
116. TECHNICAL USERS' GUIDE, supra note 3, at 10-11.
117. Id.
118. Id.
119. Id.
120. Id.
121. DEP'T OF HEALTH & HUMAN SERVS., NURSING HOME COMPARE: FIND AND COMPARE NURSING HOMES, available at http://www.medicare.gov/NHCompare/Include/ DataSection/Questions/SearchCriteriaNEW.asp (last visited Aug. 12, 2009); see also Cartmell, supra note 2.
122. Appleby, supra note 1.
123. NURSING HOME COMPARE, supra note 112; Cartmell, supra note 2.
124. Appleby, supra note 1.
125. Editorial, supra note 6.
126. Id.
127. TECHNICAL USERS' GUIDE, supra note 3, at 1. CMS has a dedicated e-mail address to receive comments regarding the Five-Star Rating System. It also hosted a national phone "call-in" to discuss the system and take suggestions, and met with several stakeholder groups. Id. Through this process, CMS received
128. public comments. Id.
129. Editorial, supra note 6. This concern stems from critics' beliefs that the public is accustomed to using star ratings for restaurants, hotels, and movies, but not for more complex matters such as choosing a nursing home. Id.
130. Liz Mitchell, Nursing Homes Blast New Federal Ratings System, SUN NEWS, Jan. 2, 2009, available athttp://www.myrtlebeachonline.com/news/local/story/ 728321.html (last visited Aug. 12, 2009).
131. Id.
132. Id.
133. Id.
134. Molly Hennessy-Fiske, California is Urged to Require Nursing Homes to Display Star Ratings, L.A. TIMES, Jan. 19, 2009, at A1, available at http://articles.latimes.com/2009/jan/19/local/me-nursing19 (last visited Aug. 12, 2009).
135. Industry critics use "small" to refer to the number of residents, rather than to the physical size of the facility.
136. Hennessy-Fiske, supra note 124.
137. Id.
138. TECHNICAL USERS' GUIDE, supra note 3, at 1.
139. Id. at 6.
140. Id.
141. This concern can be illustrated by the case of pediatric nursing homes. Pediatric nursing homes oftenrely on crib nets (restraints) to secure children to their wheelchairs. Because one quality measure is the use of physical restraints, pediatric nursing homes could receive an artificially low score. However, if this remains the standard practice in pediatric nursing homes, then consumers evaluating pediatric nursing homes will see similarly low scores for all facilities using these devices. Thus, the pediatric nursing home will not be disadvantaged because it is not competing with non-pediatric nursing homes that do not use these restraints, but instead is competing with similar pediatric facilities. The system implicitly relies on consumers knowing or discovering the different types of services they will require, but this can be accomplished through additional information outside the Five-Star Rating System.
142. Hennessy-Fiske, supra note 124.
143. Id.
144. If providers are being warned in advance of inspections, then this problem needs to be dealt with, but is not an inherent flaw in the Five-Star Rating System.
145. Castle, supra note 87, at 465.
146. Hennessy-Fiske, supra note 124.
147. See Editorial, supra note 6; see also Hennessy-Fiske, supra note 124.
148. Adjustment will not be easy, but probably will be the most beneficial to consumers. However, a system modeled on the current system's adjustments for case-mixes of patient conditions will probably be needed.
149. TECHNICAL USERS' GUIDE, supra note 3, at 1.
150. In making these comparisons, it will be important to keep in mind that the daily Medicaid nursing home payment rate varies by state from $108 in Texas to $225 in Delaware. Not surprisingly, Delaware also had the largest percentage of five-star facilities. Appleby, supra note 1.
151. Patricia Anstett, New National Nursing Home Rating System Compares Care: U.S. Consumer Guide Awards 1 to 5 Stars, DETROIT FREE PRESS, Dec. 18, 2008, at B1, available at http://www.freep.com/article/20081218/BUSINESS06/812180509 (last visited Aug. 12, 2009).
152. Id.
153. Salynn Boyles, New Rating System for Nursing Homes: Medicare Web Site Will Have Monthly Rankings of Thousands of Nursing Homes, WEBMD, Dec. 18, 2008, available at http://www.webmd.com/medicare/news/20081218/new-rating-system-for- nursing-homes (last visited Aug. 12, 2009).
154. Appleby, supra note 1. Prioritizing this measure may also have the added benefit of improving working conditions for nursing home staff. Id.
155. Id.
156. Hennessy-Fiske, supra note 124.