Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

I hesitated about 24 hours on whether to share this New York Times article with this title posted March 13, 2021 then decided that we all needed to see this – to be aware of what’s “out there.”  Sit down with a cup of coffee and review the piece.  Warning: It will take a few passes to digest if that’s even possible.  It’s scathing.  You’ll likely hear that others in your community have seen it as well.  Best to be prepared as you may receive questions on how your facility looks in comparison.  The sub-heading is: Nursing homes have manipulated the influential star system in ways that have masked deep problems — and left them unprepared for Covid-19.  The piece, as you may have already deduced speaks to Nursing Home Compare, the Five-Star Rating System and Payroll Based Journal (PBJ).

“To evaluate the ratings’ reliability, The Times built a database to analyze millions of payroll records to determine how much hands-on care nursing homes provide residents, combed through 373,000 reports by state inspectors and examined financial statements submitted to the government by more than 10,000 nursing homes.

The Times obtained access to portions of the ratings data that aren’t publicly available from academics who had research agreements with the Centers for Medicare & Medicaid Services, or C.M.S.

Among the Times’ findings:

  • Much of the information submitted to C.M.S. is wrong. Almost always, that incorrect information makes the homes seem cleaner and safer than they are.
  • Some nursing homes inflate their staffing levels by, for example, including employees who are on vacation. The number of patients on dangerous antipsychotic medications is frequently understated. Residents’ accidents and health problems often go unreported.
  • In one sign of the problems with the self-reported data, nursing homes that earn five stars for their quality of care are nearly as likely to flunk in-person inspections as to ace them. But the government rarely audits the nursing homes’ data.
  • Data suggest that at least some nursing homes know in advance about what are supposed to be surprise inspections. Health inspectors still routinely found problems with abuse and neglect at five-star facilities, yet they rarely deemed the infractions serious enough to merit lower ratings.

METHODOLOGY: The Times’s analysis of the star system’s effectiveness was based in large part on data submitted to the Centers for Medicare & Medicaid Services, or C.M.S. The Times used data from January 2020, before the pandemic upended the industry and temporarily changed data-collection practices. The primary analysis examined the characteristics of homes with five-star ratings, including their staffing patterns and code violations.

The core data set was from the Nursing Home Compare system. That included the most recent set of star ratings for each facility and the underlying metrics. To see how these ratings changed over time, The Times also examined quarterly ratings and metrics going back to 2015.

The Times looked at all code violations reported in the three inspection cycles included in the January 2020 data.

The analysis also incorporated nursing homes’ 2019 payroll data (daily logs of the hours worked by nurses, aides and administrators) and Medicare cost reports (financial statements that facilities submit to the government). The cost reports were used to examine the relationship between profitability and the star system.

In addition, The Times used summary data provided by researchers who were granted access to individualized data on Medicare claims. By examining how often nursing home residents were admitted to hospitals after falls or complications from pressure ulcers, the researchers demonstrated the extent to which facilities underreported serious health incidents in data they submit for ratings purposes.”

At the time I authored this blog, there were 790 comments to the article. As expected, the NYT Picks comments were all negative; All comments fared about the same with an occasional positive remark.  Not a pretty read but one that you need to know is out there. 

Those of us who are LTC veterans (myself included), know that rarely does a “good nursing home” get positive press coverage.   If you’ve participated in my past industry webinars, you know that I’m an advocate for knowing what your facility looks like in Nursing Home Compare (now retitled as Care Compare).  What do your ratings say about you???  If you haven’t looked recently, now would be a good time to do so then check regularly – at least once a quarter.  Take a good look at your PBJ submissions as well – check for accuracy.  When was the last time you audited your MDS process?   Really reviewed your Quality Measure and other CASPER reports?  We’ve all been through a tough year and the pandemic is not done with us yet.  Don’t ignore the public-facing information that you generate – get on top of it!