Courtesy of Carolyn L. Rosenblatt

By Carolyn L. Rosenblatt, RN, BSN, JD

The Centers for Medicare and Medicaid Services (CMS) has a rating system on its Web site to help consumers compare nursing homes. It adds an additional feature to the Nursing Home Compare component on Medicare.gov, rating nursing homes that receive Medicare or Medicaid funds according to five criteria and giving each one “stars” to indicate high or low ratings. A one-star facility would be much below average, while five stars designate far above average. With a governmental rating project in a bureaucracy this large, it is not surprising that various shortcomings exist.

Problems with the five-star rating system

Even the Medicare Web site points out that the data for the five-star rating system are limited. In giving a nursing home a rating, Medicare considers its own health inspection reports, facility staffing, and ten nationally standardized quality measures. CMS acknowledges that there are differences in state licensing requirements from state to state that affect quality. The five-star rating system is only appropriate to compare nursing homes within the same state. Health inspection reports, therefore, do not provide a reliable way to see if one nursing home is better than another if a state line happens to run between them.

Staffing is another basis for CMS’s rating system, and staffing is self-reported. What’s to keep a facility from providing incorrect information to CMS to make it look better? Nothing we can determine. Staffing data are reported just once a year and reflect staffing over a two-week period only. That report, which becomes public information, could be wildly inaccurate in describing average staffing levels over a year’s time. We consider this the worst defect in the rating system—and potentially the most dangerous if a consumer relies on it.

Another weakness of the five-star rating system is that the quality measures are also self-reported. In addition, the rating system does not measure all of the critical aspects of safety that the family of an aging parent entering a nursing home need to know. It focuses instead on a few aspects of care at a most basic level, like eating and dressing, and does not provide any information about how often things go wrong with these measures. It certainly does not provide a preview of likely safety problems.

Why these flaws are fatal

From a legal point of view, one of the glaring weaknesses of every government rating system is that consumers have no way of knowing how often or whether the nursing home has been sued for neglect or abuse of its residents. We have no national database to record how many civil lawsuits have been filed against nursing homes and to describe which homes have lost lawsuits that went to trial.

There is, of course, some relationship between below-average nursing homes and citations those facilities receive from CMS for failure to properly deliver care or meet other requirements, but this is not at all a clear indicator of how bad things could be. Facilities often fight citations through the CMS hearing process, and the degree of the violation for which a facility is cited can end up being reduced before the public even learns of it. The result can be deceiving, making a citation for poor care appear to the public as if things were not as bad as CMS originally alleged. The public record of a citation against a nursing home is often not the whole story of what happened.

How to get more accurate information on nursing homes

What’s the takeaway message here? Consumers who are searching for a nursing home should plan to spend as much time as they can investigating all sources of information about the nursing homes they are considering. Medicare.gov alone is not reliable enough for access to complete information. Newer nursing homes and poor-quality homes that have had a change of name or ownership within the fifteen months before the implementation of the five-star rating system do not even show up in Medicare’s ratings. No rating information will be stored on the Medicare site for nursing homes that have changed names and had to apply for recertification by Medicare because of the name change.

Visit your state’s Medicaid Web site to read as much as you can find before making your choice. Other Web sites can round out the picture and help the consumer find reliable data. The choice is important. Aging parents who must move more than once can be quite traumatized by the process. The effort to dig deeper into the question of which facility is best in the elder’s area is well worth it.