In 1998, the Centers for Medicare and Medicaid Services (CMS) launched a website called Nursing Home Compare that assists the elderly and their loved ones in locating and comparing the quality of care provided by nursing homes that accept Medicare and / or Medicaid. There are approximately 16,000 nursing homes which do so and in any given geographic area of the US, there are hundreds or at least tens of nursing homes to choose from. This tool serves two purposes:
1. It provides an easy-to-use method for families to find and compare nursing home care quality.
2. It makes individual nursing homes accountable for the level of care they provide and can motivate them to increase their quality of care by pointing out areas in which improvement is needed.
While the tool is easy to use and provides much information, it is important for families to understand more than the simple Five-Star rating system when choosing a nursing home. What do the Quality Measures mean and to whom are they relevant? How should one interpret Health Inspection History? What is meant by Staffing Ratio and how is it calculated?
What is the Five-Star Nursing Home Quality Rating System?
The Five-Star Nursing Home Quality Rating System is also referred to as Nursing Home Quality Measures. In December of 2008, a nursing home five star quality rating system was added to CMS’ Nursing Home Compare website to simplify the comparison of the quality of nursing homes for website users. Although perhaps self-explanatory, this quality rating system rates the quality of care provided by a nursing home from below average to above average. A score of 1, the lowest quality score, indicates a nursing home provides below average care, a score of 3 is considered average, and a score of 5, the highest quality score, is regarded as above average.
Each nursing home is given four individualized star ratings from one to five stars.
1) Overall Rating
2) Heath Inspection Results
3) Staffing Levels
4) Quality Measure Data (of Resident Care)
What are Nursing Home Quality Measures?
The overall rating is a summary of the three other quality measures. It provides an at-a-glance view of how a nursing home performs (and compares) but families should be hesitant to use only this metric when considering different residences for a loved one. Each of the three contributing measures are weighted differently within the Overall Rating with the Health Inspections rating weighing most heavily.
Health Inspection Results
Health inspection history gives consumers information about health and safety risks within a given nursing home. A nursing home’s star rating is based on the findings from its most recent three state health inspections. State health inspections, also called state health surveys or standard health inspections, are unannounced, occur approximately once a year and take a few days to complete. The most current inspection carries more weight, meaning it will impact the rating more than an older health inspection.
The areas of assessment are extensive. They include the nursing home environment, resident rights, staff and resident interaction, skin care, medication management, quality of life, nursing home administration, and proper preparation and storage of food. Furthermore, resident medical records are reviewed and interviews are conducted with some residents (including their relatives) and administrative staff. This is all done to determine if a nursing home is meeting federal regulations.
As mentioned above, the health inspection five-star rating utilizes a nursing home’s most recent three state health surveys. However, the rating is based on the number (how many), extent (how many residents does it impact), and seriousness (serious risk versus low risk) of any “deficiencies” (areas in which a nursing home fails to follow federally set standards, also known as non-compliance). If “deficiencies” have been identified during a state health survey, the number of times the surveyors need to return to the nursing home to ensure the nursing home is now in compliance is factored in. Furthermore, findings from complaint investigations within the last 3 years are also taken into consideration. (Complaint investigations occur when a resident and / or their family call to report that the nursing home has / is providing poor care).
In addition, nursing home ratings for this performance measure are compared for all Medicaid and / or Medicare-certified nursing homes within the same state. The top 10% of rated nursing homes are given five-stars, while the lowest 20% receive just one-star. The remaining 70% of nursing homes are given a star rating of two, three, or four.
The higher the number of stars a nursing home residence receives for health inspection results, the lower the number of health and safety risks at a nursing home residence. Stated differently, a nursing home with a one-star rating carries more risk to one’s health and safety than a nursing home with a five-star rating. This rating is extremely helpful when considering the quality of care you, or a loved one, might receive at any given nursing home. Of course, one wants to choose a nursing home that will provide a level of care that equates to minimal risk to a resident’s health and safety.
Full health inspection reports and complaint investigations completed within the last three years for Medicaid and / or Medicare certified nursing homes can be found on Nursing Home Compare. Please note that these reports can be difficult to understand, as they are not intended for a consumer audience.
The second quality measure, nursing home staffing ratio (staffing level), is utilized in determining if a nursing home has a sufficient number of nursing staff, which includes registered nurses, licensed practical nurses, licensed vocational nurses, and nurse aides, to properly care for its residents. While there is no federal regulation that requires a specific number of nursing professionals per nursing home residents, regulation does state that a nursing home must employ enough nursing staff to “safely care” for its residents.
When determining the staffing ratio rating, the average total number of hours that nursing staff provide care for each resident on a daily basis is considered. (Essentially, the number of staff hours is divided by the number of nursing home residents to get a staffing ratio). This is looked at in two ways. First, the total hours of all nursing staff is calculated, and second, only the total hours worked by registered nurses is considered. Furthermore, the level of care required by the nursing home residents is factored in. This means that nursing homes that house a higher number of residents who require extensive care, whether it be due to more extensive health problems or a cognitive issue related to Alzheimer’s disease, should have a higher staff ratio than a nursing home with residents that require a lower level of care.
The more nursing staff hours available per resident per day, the higher the level of patient care that should be provided. It means a resident who needs assistance can generally be attended to more quickly and the frequency of supervision / care provided altogether should be greater. To be clear, the greater the number of stars a nursing home receives, the higher the number of staff hours per resident per day in that given nursing home. Therefore, a nursing home with a one-star staffing rating would provide significantly lower nursing hours per resident than one with a five-star rating.
Quality Measures (of Resident Care)
The Quality of Resident Care Measures looks at how well the physical and medical needs of nursing home residents are being met. For this rating, CMS utilizes 15 quality measures, 6 for short-stay (temporary) residents, and 9 for long-stay (long-term) residents. “Short-stay” is defined as nursing home residents whose care is covered by Medicare Part A or whose stay was fewer than 100 days. “Long-stay” residents are those who have resided for 100 days or more in the nursing home.
An overall star rating is given for quality of resident care, as well as two separate star-ratings; one for quality of resident care for short-stay residents and one for quality of resident care for long-stay residents.
6 Quality Measures for Short-Stay Residents
The following performance measures are used by CMS to calculate the star rating for temporary nursing home residents. Though the measurements below only refer to “residents”, all of these measures are strictly for short-stay nursing home residents.
1. Hospitalization – The percentage of residents who were previously hospitalized prior to nursing home placement and were re-hospitalized (unplanned) within 30 days.
2. Emergency Room – The percentage of residents who within 30 days of nursing home placement had to go to the emergency room for outpatient care.
3. Antipsychotics – The percentage of residents who were given an antipsychotic medication and hadn’t previously been given such a medication. According to the FDA, utilizing such medications in seniors with dementia show the risk of death is greater. Therefore, it is vital that these medications be used appropriately and only when necessary. If at all possible, it is ideal to manage behavior in other ways, such as with a higher staff to patient ratio.
4. Bed Sores – The percentage of residents who have new pressure ulcers (also called bed sores) or who already had them, but they got worse. A pressure ulcer is an area of skin that is damaged due to long-term pressure. It often occurs when one does not change positions frequently enough.
5. Independence – The percentage of nursing home residents who showed improvement in their ability to move around independently. This includes walking, transferring (i.e., getting out of bed and sitting in a chair), and the ability to move about within the nursing home.
6. Transitions – The rate in which residents were successfully transitioned back to living at home or in the community. A successful transition is no unexpected hospitalizations or death within 31 days of nursing home discharge.
9 Quality Measures for Long-Stay Residents
CMS utilizes the following performance measures to calculate the star rating for long-term nursing home residents. Although the measurements below mention “residents”, all of these measures are strictly for long-stay nursing home residents.
1. Activities of Daily Living – The percentage of residents whose need for assistance with activities of daily living (i.e., bathing, dressing, eating, using the toilet) has increased.
2. Hospitalization – The number of unplanned hospitalizations that occurred per 1,000 long-stay resident days. Long-stay resident days are the days following a resident’s 100th day in the nursing home.
3. Emergency Room – The number of outpatient emergency room visits per 1,000 long-stay resident days.
4. Movement – Percentage of residents whose ability to move about without assistance has become more difficult.
5. Bed Sores – Percentage of high-risk residents who have pressure ulcers (bed sores).
6. Catheters – Percentage of residents who either have or had a catheter inserted and left in within the last seven days. A catheter is a tube that is inserted into the bladder in order to drain urine.
7. Urinary Tract Infections – Percentage of residents, within the last 30 days, who had a urinary tract infection.
8. Falls – Percentage of residents, within one full calendar year, that had a major injury due to a fall.
9. Antipsychotics – Percentage of residents who were given an antipsychotic medication. Per the FDA, elderly persons with dementia who take antipsychotic medications have a greater risk of death. Ideally, problematic behavior should try to be managed in other ways.
Using Quality Measures to Choose a Nursing Home
While the five-star nursing home quality rating system, and its performance measures, are helpful in choosing a nursing home, one should not rely solely on these findings. Nursing Home Compare is not a replacement for doing nursing home site visits, and rather, should serve as a tool for initiating further conversation with potential nursing homes. One’s particular needs and situation must be taken into account and a quality rating of above average does not automatically mean that a nursing home will be a good fit. This is partially because the nursing home quality indicators do not take into account specialized care and other personal factors. For example, a person with Alzheimer’s disease or a related dementia might thrive in a nursing home with dementia-specific care and this is not addressed in the star rating.