Medicare Annouces Changes to Nursing Home Rating System

On October 6, 2014, the Centers for Medicare and Medicaid Services (CMS) announced changes to the rating system used for nursing homes. These changes, which will start to be implemented in 2015, include focused survey inspections for a nationwide sample of nursing homes, quarterly electronic reporting of staffing data, the use of additional quality measures, improved requirements for nursing home inspections, and an improved scoring methodology.

CMS hopes that the changes will improve the rating system, leading to better care. The agency writes that the survey inspections, which will start in January, 2015, will “enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System.”

The press release states the new system for the electronic reporting of staffing data “will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing.” My past post on staffing levels mentioned that the number of staff and the hours of care they provide are important to the quality of care a resident receives. In a New York Times article, Katie Thomas quotes Brian Lee, executive director of Families for Better Care, who said, “If we are able to get better information on staffing levels, the higher the quality is going to be in the long run.”

CMS is not only looking to improve current quality measures, but also adding additional measures to the rating system. Beginning in January, 2015, the rating system with take into account the use of antipsychotic medications by residents. According to Thomas’ article, 20.3 percent of long-term residents of nursing homes are given antipsychotic medications. With the changes, instead of merely being reported, the percentage of residents given these drugs will play a role in each nursing home’s rating. In the future, ratings will also take into account other measures, including claims-based data on re-hospitalization and community discharge rates. These new inclusions, along with a revision of the scoring methodology of the rating system, could produce noticeable changes in nursing home ratings.

I have blogged about issues with the five star rating system in the past. When researching ratings, self-reporting and the manipulation of data have made it difficult to decipher the actual quality of care provided by a nursing home. It seems that CMS has proposed these changes with the goal of addressing these issues in mind. Only time will tell if the new rating system will be effective. However, these changes seem to be a step in the right direction. In addition, CMS demonstrates that they are aware of the issues and are responding to calls for change.

While writing this post, I was wondering why CMS does not have a section of their website dedicated to consumer reviews and ratings. Today, almost everything (movies, restaurants, hotels, etc.) is rated by consumers. Anyone who has access to the internet can rate and review a product in just a few minutes. While residents and family members can file complaints with the New York State Department of Health, if they have issues with a nursing home, to my knowledge, there is no option to rate or comment on the quality of a nursing home on Nursing Home Compare. A cursory Google search revealed some websites that allow individuals to rate and comment on nursing homes, including http://www.aplaceformom.com/, https://www.senioradvisor.com/, and https://www.ourparents.com/. Consumer reviews should always be taken with a grain of salt, but reviews from individuals with firsthand knowledge of nursing homes can provide a valuable insight into their quality.

Attorney General’s Hidden Camera Investigation Leads to Arrests

Two days ago, Attorney General Eric Schneiderman announced that another hidden camera investigation has resulted in the arrests of nursing home employees. Two certified nurses’ aides, who worked at Erie County Medical Center Skilled Nursing Facility (also known as Terrace View Long Term Care Facility), were arrested and charged with “Falsifying Business Records in the First Degree (class E felony), Endangering the Welfare of an Incompetent or Physically Disabled Person (class A misdemeanor) and Willful Violation of Public Health Laws (unclassified misdemeanor).”

According to video footage, the CNAs, Donna Laury and Nakeia Green, allegedly neglected to follow a 79-year-old resident’s personal care plan, “failing to use two people when performing incontinence care and failing to use a mechanical lift to transfer the resident.” The employees are accused of falsifying documents to cover up their alleged neglect.

Due to Alzheimer’s disease, dementia and the inability to get around on her own, the 79-year-old resident relies on nursing staff to assist with daily activities. Many nursing home residents are in similar situations, where their well-being depends on the care of others. While many residents do receive the care they need, there are many instances, including this one, where caretakers are neglectful or abusive, and do not provide proper care. What is it about the culture of a facility that lends itself to this type of behavior?  And is it evidence of a systemic problem?

Do Staffing Levels Affect Quality of Care?

Back in January of 2006, the Office of the Attorney General released a report titled “Staffing Levels in New York Nursing Home: Important Information for Making Choices.” This report, although dated, has some interesting information regarding nursing home staffing levels in New York State, as well as recommendations to consider when searching for a nursing home.

While there are multiple factors that determine the quality of care in a nursing home, staffing levels are an important one. The number of hours of care provided to a resident and quality of care show “a strong relationship.” In New York State, staffing levels in a nursing home are usually measured in “the average number of hours of daily care that staff members provide each resident of the home.” This measurement is commonly referred to as “hours per resident day,” and is “calculated by adding up the total number of hours worked by the nursing staff and dividing it by the number of resident-days during the reporting period.”

A study done by the Centers for Medicare and Medicaid Services (CMS) found that quality of care declined once staffing levels fell below three separate thresholds. Once the amount of care provided by Registered Nurses (RNs) fell below 0.75 hours per resident day (45 minutes), quality of care declined. If RNs and Licensed Practical Nurses (LPNs) together provided less than 1.3 hours per resident day (1 hour, 18 minutes), the quality of care suffered. In addition, quality of care started to decline when Certified Nursing Assistants (CNAs) provided less than 2.8 hours per resident day (2 hours, 48 minutes). These thresholds mean that any nursing home in New York must provide at least 4 hours and 6 minutes of total nursing care, for the quality of care not to suffer.

The level of care provided to residents also should take into account specific needs of residents. If residents have special needs, they may need additional care and a nursing home may need to employ additional staff. Additional care may be required when residents are pediatric, have suffered traumatic brain injuries, have AIDS, are on ventilators, are on respite care, or have behavioral needs. With any of these cases, additional care is necessary, and nursing homes must ensure that their staff can provide the necessary and proper care.

When considering which nursing home you or a loved one should choose, keep in mind that staffing levels are only numbers. The Office of the Attorney General also recommended prospective residents and their loved ones:

  • Visit the home and look around
  • Learn about the management and staff, including the level of turnover
  • Speak with caregivers
  • Speak with others who have experience with nursing homes, including knowledgeable professionals

These recommendations should be part of any nursing home decision.

What Does a Five-Star Rating Really Mean?

The New York Times placed Medicare’s nursing home rating system front and center in a recent, in depth article, by Katie Thomas, and a recent editorial . In the past, I have written about Medicare’s rating system, pertaining to New York State nursing homes. While The Times article mentions nursing homes in New York, it focuses on nursing homes in California, specifically Rosewood Post-Acute Rehab, which has a five-star rating despite having over 100 consumer complaints and around a dozen lawsuits filed against it.

Nursing home ratings, like Rosewood’s, cannot be taken at face value because much of the data behind them is self-reported and can be changed or misreported by facilities’ employees. The ratings are determined by three criteria, staff levels, quality statistics and health inspections. The Times editorial acknowledges that staff levels and quality statistics “are reported by the nursing homes and accepted at face value by Medicare without verification.” If this data is not authenticated by Medicare, facilities can easily get away with manipulating it for their benefit.

The data from annual health inspections, while not self-reported, can be manipulated, as well. Nursing homes often know when inspections will occur, and increase staff hours during the inspection, only to decrease them once the inspection was complete. The administrator of Medford Multicare Center for Living, a facility in New York, described the inspection period as “our Super Bowl.” The current rating system seems to shift the focus and effort of nursing home staff and administrators to obtaining high ratings, and away from providing consistent, quality care.

In an attempt to rectify part of the problem, the Affordable Care Act “requires Medicare to use payroll data to verify the accuracy of staff levels.” However, the agency, “still working on the verification system,” has not yet put this requirement into effect.

Even though the rating system is imperfect, Katie Thomas writes that, starting this year, Medicare plans to use a comparable system for hospitals, dialysis centers and home-health-care agencies. While the five-star rating system makes it easy for families and loved ones to compare facilities, these recent stories show that the data behind the ratings are not always accurate. When deciding on a nursing home, be sure to look beyond the ratings. They do not always represent the true quality of care.

Highpointe Employees Charged Following Hidden Camera Investigation

Continuing to make use of hidden cameras during investigations, Attorney General Eric T. Schneiderman announced charges against 17 employees of Highpointe on Michigan Health Care Facility in Buffalo, NY. The charges are based on video footage recorded by the Attorney General’s Office that allegedly reveals the neglect of a 56-year-old resident. According to the press release, “nurses failed to dispense pain medication and check on the resident,” and “aides neglected to check on the resident, failed to give him liquids and failed to perform incontinent care.” In addition, the video footage also revealed that the nurses and aides falsified documents to cover up their alleged neglect.

The resident of Highpointe, who had Huntington’s disease and was bedridden and unable to walk, was fully dependent on the facility’s staff. The Attorney General announced that his office “will use every tool in our arsenal…to ensure that nursing home residents receive the care they need and the respect they deserve.” Many residents of nursing homes, like the 56-year-old resident of Highpointe, do need someone to provide a watchful eye over their care. While the owners of nursing homes should be the ones to provide this oversight, many times, their lack of oversight adds to or causes neglect and abuse.

The Attorney General’s Office continues to demonstrate that it will be a watchful eye in nursing homes. In a previous blog post, I wrote about surveillance in nursing homes, and the Attorney General’s Office’s use of hidden cameras back in 2010. With advancements in technology, it is arguably becoming easier to oversee the care provided in long-term care settings. I am hopeful that the Attorney General’s commitment to oversight, coupled with his office’s willingness to use technology, will set an example for nursing home owners and the public throughout New York State.

State Rankings Paint Inaccurate Picture of Quality of Care in Nursing Homes

Previously, I blogged about the ongoing saga of Medford Multicare Center for Living, located on Long Island. A lawsuit, the highlight of which is the death and alleged cover up of an elderly woman at Medford, was filed by New York State Attorney General Eric T. Schneiderman. The Attorney General claims there is a history of neglect and mistreatment at Medford. These accusations are surprising because recent state rankings of the nursing home don’t reflect these claims of poor treatment.

According to two Newsday articles (one by Ridgely Ochs and Chau Lam and the other by Joye Brown), Medford Multicare Center for Living received an overall ranking of 3 out of 5 stars on a federal website, Medicare’s Nursing Home Compare, that provides detailed information about Medicare and Medicaid-certified nursing homes. Last year, the nursing home received a ranking of 4 out of 5 stars for health inspections and quality of care. If the Attorney General’s allegations are true, this average ranking in no way reflects the quality of care at Medford.

New York State’s Department of Health conducts inspections, collecting data used to rank nursing homes throughout the state. However, nursing homes themselves gather and report the statistics used for ranking. This data is not required to be reviewed, so the is no way to determine its accuracy. This self-reporting creates a conflict of interest that can lead nursing homes to inflate or even completely falsify the data they report.

In her Newsday article, Joye Brown quotes Charlene Harrington, a professor of nursing at the University of California, San Francisco. Harrington explains, “The rating system is based on three things: First, deficiencies: If those aren’t issued properly, then you can’t rely on that. Second, staffing: Nursing homes can gin up those numbers when they suspect surveyors are coming. Third, they can falsify quality measures.”

According to a paper by the Kaiser Commission on Medicaid and the Uninsured from 2013, the Affordable Care Act requires nursing homes to increase their transparency. The Centers for Medicaid and Medicare Services (CMS) has already implemented a number of new requirements, including improving the collection of data on owners and managers and providing links to health inspection reports. However, other important provisions have not yet gone into effect.

With the Attorney General’s surprising allegations, it may be time to rethink the way we assess and present the quality of care and safety at nursing homes. The public relies on these ratings to make difficult decisions for themselves and their loved ones. Verifiable data needs to be easily accessible and used in the ranking process, so ratings represent the truth about nursing homes throughout New York State.

3 Deaths at the Suffolk Center for Rehabilitation and Nursing

Yesterday, NBC4 New York’s Chris Glorioso and the station’s I-Team reported on their investigation into three deaths at the Suffolk Center for Rehabilitation and Nursing on Long Island. According to family members, Thomas Bischoff and Raymond Curiale, residents of the nursing home and Korean War veterans, both died as a result of neglect.

According to medical records from Brookhaven Memorial Medical Center, Mr. Bischoff died of a cardiac arrest resulting from a septic infection. The sepsis was partly caused by bedsores, which can form if nursing home staff neglect to provide basic care. You can find more information on bedsores, also referred to as pressure ulcers, here.

After being admitted to the nursing home in March 2013, part of Raymond Curiale’s care required staff members to monitor him every 15 minutes. On July 15,2013, Mr. Curiale accidentally hanged himself. Not one staff member checked on Mr. Curiale for 57 minutes, the time frame during which he died.

Glorioso’s article also mentions another Suffolk Center patient who overdosed three times on narcotic painkillers and died last May. In this matter as well, the facility’s staff failed to properly watch over the resident.

In response, the Suffolk Center released a statement stating that the nursing home provides “quality care” for its residents.

This history of neglect is unacceptable for any facility that cares for our loved ones. If you have any questions, concerns, or information about possible abuse or neglect at the Suffolk Center for Rehabilitation and Nursing, you can contact Benjamin Decker, Esq. at (518) 621-4210 or benjamin@dpsattorneys.com.

NBC4 Story on Suffolk Center for Rehabilitation and Nursing

Tonight at 11 PM, NBC4 New York will be broadcasting an investigative story concerning the Suffolk Center for Rehabilitation and Nursing, a 120 bed facility in Patchogue, NY. When considering nursing home options for loved ones, information is the key to making the right decision. If you have a loved one currently in a nursing home, or are considering nursing home options for a loved one, you should watch this report. Those of you in the New York City area can tune in to NBC4 New York to see the story. If you are outside of NBC4 New York’s broadcast area, I will post a link to the story here on the blog as soon as it is available.