Senior LIVING Magazine has received several news alerts on the issue of quality care at our Nursing Homes, both in California and our nation. Most recently we were informed that nearly a quarter of nursing homes, in our nation, were rated as much below average.

Los Angeles County
Michael D. Antonovich, Los Angeles County Supervisor, unveils and demonstrate Los Angeles County’s Online Nursing Home Grading System. To ensure the health and well-being of the County’s senior population, the Los Angeles County Board of Supervisors approved Supervisor Antonovich’s motion to provide the Federal Government’s grading reports of area nursing homes on the Los Angeles County website. The motion also encourages the State to require that nursing homes post their five-star rating issued by the Federal Government’s Centers for Medicare and Medicaid Services to allow the consumer to make an informed decision about care. “This vital information will equip families to make informed decisions about the care for their loved ones. It also provides incentives for facilities to establish higher quality standards and compliance,” said Antonovich.

Aging Services of California Criticizes CMS
Twenty-four Aging Services of California’s members rated five stars in the Centers for Medicare and Medicaid Services’ new rating system.  The facilities are among the 12 percent nationally that received the highest rating. Aging Services of California has always acknowledged the valuable role of government in measuring quality in nursing facilities. However there are concerns that CMS’s system has been implemented prematurely and major methodology issues still need to be addressed.  Despite the good intentions of developing a system which consumers could use to rank nursing home quality, CMS’s five star rating system falls short of that goal. CMS acknowledged in a recent skilled nursing facility forum call that there were issues with the methodology that needed to be addressed, but continued with the launch of the system at the end of last year.
The American Association of Homes and Services for the Aging’s recent report, Broken and Beyond Repair, makes several recommendations for changes to the survey system.In addition, CMS has acknowledged that the survey staffing data is questionable. Staffing data concentration on certain classifications of workers fails to recognize critical members of the quality improvement team in a nursing facility. The problems with risk adjustment or partial risk adjustment of the quality measures still have not been resolved. Yet these are the data used for the quality ratings.

Aside from the data, the methodology of the system has problems. There is no process for adjusting insufficient quality measure data; consequently smaller facilities cannot possibly become a five star facility.  Quality measurements are imputed. Timeliness and reliability of the data, intermixing of national and state benchmarks, various methodologies for weighting the data, utilization of different time periods, and aggregating the results for the three areas of the system in an ad hoc fashion without any type of validation are all issues which need to be addressed.

Of significance is the absence of clear definition of quality in the rating system; recognition in the system for recent quality improvement efforts of providers in the area of culture change, Quality First and Advancing Excellence; and resident, family and employee satisfaction is absent. Because of the flaws of this arbitrary rating system, consumers may draw inappropriate conclusions as to the quality of a facility. Quality improvement is a dynamic process and any quality rating system must reflect the many variants that go into the delivery of care. Regulatory compliance is but one of those variables.  CMS should be a leader in better “evidence-based” quality definition, analysis and tools for nursing facilities.
Comments with regard to the rating system should be directed to bettercare@cms.hhs.gov. Problems with regard to individual ratings.