Medicare 5 Star Nursing Home Rating System Explained

Medicare 5 Star Nursing Home Rating System Explained

There has been a lot of press lately regarding the perils of nursing home care. Often facilities are chastised or praised based on their Medicare star rating.
Five star facilities are considered to be “much above average”. Four, three, two and one star facilities are considered “above average”, “average”, “below average” and “much below average” respectively.
As we will expose below this might not be an accurate or realistic way to measure nursing home quality. In fact many patients and their families can be misled by both high and low rankings.
As consumers our main point of reference for a star system comes from the hotel, resort and vacation industry. We associate 5 stars with room service, posh living conditions, gourmet food and no expense spared luxury.
However, patients and families are often disappointed when a 5 star nursing home in no way resembles the five star hotel or cruise from last summer’s vacation. Conversely many are surprised by the quality of a lower star facility following a tour.
Regardless of the rating, families and patients must have realistic expectations. Nursing Homes provide highly skilled care, often to very sick patients; luxury and amenities can only be provided to the extent that is medically safe and prudent. .
It is important to remember the facility you choose is first and foremost a medical center with the goal of providing quality healthcare.
More and more families are consulting the Medicare Star rating system found at www.medicare.gov. Be it for a short rehab stay or a long term situation the star rating system can provide valuable insight.
However, this should not be the only factor your decision is based on. This system can be misleading and is not always an accurate representation of a facilities true quality or ability.
A government rating system should never be a substitute for your own due diligence and intuition. We will attempt to explain in layman’s terms what comprises a facilities rating and outline ways to ensure you loved one finds a facility that best meets their individual needs.
Most families simply don’t understand what goes into a one star or a five star rating. This rating is not developed by a complicated algorithm or high tech computer. Rather the rating is doled out by human beings following a standard set by CMS (govt. Center for Medicaid and Medicare Services).
More specifically government survey teams, these teams like all humans are fallible and operate with preconceived notions and their own interpretations of the standards laid out by CMS. Because of the possibility of human error there can be no true standard of measurement, in short two survey teams could come up with two different ratings for the same facility.
Each facility gets an overall rating based on their performance in three individual categories. The first of these three categories is Health Inspections performed by state survey teams on behalf of CMS (for a detailed non layman’s overview click here: http://www.medicare.gov/NursingHomeCompare/About/Ratings/HowWeCalculate....)
These survey teams check to see how adequately each facility has met the minimum standards required by the government. These surveys take place every 12 to 15 months and also following complaints made by families, patients, and members of the healthcare community.
The survey team has a check list of more than 180 different categories ranging from food preparation, to infection control and skin care. The problem with this particular category is that facilities are often unfairly judged by patient ailments outside the scope of their control.
Often patients come to facilities with infections, skin sores and other “health inspection” issues. Obviously a facility should not be penalized for a preexisting condition that happens to coincide with their annual survey.
One patient with a particularly bad skin condition or infection suffered as a result of a prolonged hospital stay could literally affect the star rating of the facility. This randomness can also explain why ratings are constantly changing.
Often facilities achieve a five star rating only to lose it based on an isolated incidence beyond their control. A one or two star facility could have been a five star option a month earlier.
The same staff, activities, and amenities are still available as when they had the coveted five star ranking. The only change is a sub-par survey resulting in a deficiency that was immediately corrected and more often than not resulted in no harm to their patients.
The second category is Staffing, according to www.cms.gov this category relates to the number of hours of nursing care provided per patient per day. This number is also determined by the number of and type of nurses (RN, LPN, Nursing Asst) employed by the facility two weeks before the survey. A 52 week year is judged by the number of nurses and the hours those nurses worked in a single two week period.
According to CMA each patient needs to have four hours of nursing attention per day with 33 minutes of that care via an RN. It stands to reason that certain patient nursing needs will vary based on their own personal abilities and overall health. It is not reasonable to apply a blanket 4 hour minimum to every patient and situation.
The third category is Quality Measures. This category is dependent on the facility sending CMS clinical data on every Medicare and Medicaid patient from the most recent three quarters. There are 19 separate categories including the number of patients restrained to keep from falling, the overall pain level of individual patients, bed sores, urinary tract infections and patient mobility levels.
All of these above mentioned items are common issues affecting nursing home patients. Moreover patients generally come to the nursing home with these conditions. This category also punishes facilities treating medically complex patients. The condition and ability of the current patient load is not necessarily indicative of the care provided by that facility.
While this article points out obvious flaws in the Medicare Star system it is by no means condemning it. Rather we are simply stating it should be only one of many factors effecting your decision.
We feel a better indicator of quality can be found by interviewing current staff members and residents. Ask to speak to current patients; this will give you a true understanding of the facility and its residents. Take both scheduled and unscheduled tours.
Ask about key personnel and how long they have been with the facility. Key members include the Directors of Nursing, Therapy Directors and Facility Administrators. Look for facilities with long term employees, especially in the positions mentioned above.
If you are seeking a short term rehab stay ask about their therapy results and average length of stay. Insist on seeing data to support their claims.
If a facility does have a below average star rating inquire as to why. More often than not the rating is the result of an isolated incident that has since been corrected.
Facilities should also be convenient for family and friends. Visitors boost morale and progress. Look for facilities in nearby or familiar neighborhoods that will be conducive to frequent visitors.
This is a difficult decision and one that should not be taken lightly. It is important to do your homework and when possible plan in advance, tour several facilities before making a choice. If you need further assistance reach out to a professional in your community.