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.

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.

Privacy and Nursing Home Surveillance

In recent months, with revelations concerning consumer credit card theft and the National Security Agency surveillance programs, the notion of privacy has again entered the public consciousness. Now seems like a good time to discuss the debate that continues over privacy and surveillance in the world of long-term care facilities. Unfortunately, abuse and neglect occur far too often in nursing homes and assisted living facilities and, in an attempt to protect loved ones, families are turning to technology. Small, sometimes hidden, cameras, often referred to as “granny cams,” are becoming increasingly popular as families and governments seek to ensure proper care.

In a New York Times article last November, Jan Hoffman recounts the story of a nursing home resident, Eryetha Mayberry, from Oklahoma City, Oklahoma. Ms. Mayberry and her family had noticed a few personal belongings go missing and installed a hidden camera in an attempt to catch a thief. When Ms. Mayberry’s daughter finally watched the footage, however, she was astonished and horrified by what she discovered. Staff members had been abusing her mother.

As a result of the outrage that arose following the discovery of Ms. Mayberry’s abuse, Oklahoma became the third state to explicitly allow surveillance cameras to be used in the rooms of residents of long-term care facilities. New Mexico and Texas are the other two states that have passed similar legislation. Although New York has passed no specific legislation allowing individuals to maintain surveillance cameras in their rooms, the government, specifically Governor Andrew Cuomo and the Medicaid Fraud Control Unit, has been using hidden cameras in nursing home investigations throughout the state.

In March of 2010, then-Attorney General Cuomo reported that 22 arrests had been made after investigations into Northwoods Rehabilitation and Extended Care Facility in Troy, NY and Williamsville Suburban Nursing Home in Amherst, NY. Surveillance footage played key roles in both investigations, revealing instances of alleged neglect and conduct endangering residents.

Proponents of video cameras understand that, without surveillance, much of the abuse and neglect that is occurring may never be discovered. In addition to uncovering instances of mistreatment, many hope that cameras, coupled with posted notices of surveillance, will prevent abuse and neglect from occurring in the first place.

However, nursing home surveillance has encountered opposition. Opponents claim that these cameras are an invasion of privacy. A frequently used argument against the use of cameras is that the monitoring infringes not only on the rights of a loved one, but also the rights of fellow residents. Cameras may catch residents during their most intimate moments, such as when they are dressing or undressing. Some nursing home operators also believe surveillance may reduce staff morale, claiming that it may become more difficult to hire and retain caretakers if they constantly feel threatened by the monitoring of video cameras (CNA’s Cost and Benefits of Video Surveillance).

These arguments against video monitoring may be valid. But is slightly less privacy worth the potential reduction in abuse and neglect, along with the peace of mind gained by residents and their families? With the right rules and regulations, I think so.

Trapped in the Hospital Bed

A client recently forwarded a New York Times article to me that discusses the hidden dangers of older adults spending too much time in bed when hospitalized.  I asked Jeanette Sandor, a well respected former Director of Nursing at a nursing home, to comment on this article as it relates to the elderly in hospitals and long term care facilities.  Below is a link to the New York Times article along with Ms. Sandor’s comments.

http://newoldage.blogs.nytimes.com/2013/05/30/trapped-in-the-hospital-bed-2/?src=rechp

Comments by Jeanette Sandor:

I really appreciate Dr. Brown’s research. It is so consistent with what I saw as a nurse who worked in nursing homes for 20 years. There are so many elderly who end up in nursing homes due to a diagnosis that rendered them dependent such as Alzheimer’s Disease or a stroke. However, there is also a large group of elderly that end up in nursing homes with the primary diagnosis “Deconditioning”. These individuals have been hospitalized for various reasons and while receiving treatment they experienced an overall decline from immobility. Their functioning had declined. They had become incontinent. They got a bit confused. Now they need a nursing home, hopefully on a short-term basis. Although some regain previous functioning through the restorative therapies they receive in a nursing home, there is a significant group who never regain their mobility and many who suffer other consequences of the decreased functioning such as pressure ulcers, falls and depression. Once these events occurred, the likelihood of returning to previous functioning is reduced even further. Personally, I was recently hospitalized and saw firsthand that while hooked up to intravenous and donning a hospital gown, how minimally I moved each day.  Where does one go in the hospital besides walking in the hallway? And as the article suggests, who is going to walk the elderly down that hallway? If the person is blessed to have a visitor who will take on this role they will have a better outcome. Educating loved ones is a critical piece to improving outcomes. And as a society and as healthcare providers, let us not forget those individuals who have no loved ones to look out for them, to take a walk down the hall. Growing up we heard “An Apple a day keeps the doctor away!”.  Let’s coin the phrase for hospitalized elderly: “A walk down the hall keeps the nursing home away!” 

Jeanette