Nursing home quality scores drop in new federal ratings

Pete Eisler and Christopher Schnaars, USA TODAY | USAToday

WASHINGTON – Nearly a third of the nation's nursing homes are getting lower scores on the government's five-star quality scale, a reflection of tougher standards for ratings used by nearly 1.5 million consumers to assess care at more than 15,000 facilities.

The new ratings, posted Friday on the government's Nursing Home Compare website and in USA TODAY, are the result of sweeping changes in the way facilities are evaluated. Among other things, the revamped assessments include measures of facilities' use of anti-psychotic drugs, which can pose serious risks for older adults, especially those with dementia. They also use more refined metrics to check for adequate staffing, a critical component of good care.

About 61% of all nursing homes got lower quality-of-care scores as a result of the changes, but the declines weren't dramatic enough in most cases to affect a facility's overall rating, a USA TODAY analysis shows. About 28% of nursing homes dropped one star in their overall ratings, including more than 1,200 that lost coveted five-star status. About 3% of facilities fell two stars.

The ratings are a closely followed measure of nursing home quality. About 1.4 million people used the Nursing Home Compare website last year to help check facility ratings. Nursing homes use the scores to gauge their stature and performance, and those with high ratings often incorporate them into marketing materials.

The new scoring is "raising the standards for nursing homes to achieve a high rating," says Patrick Conway, deputy administrator and chief medical officer at the federal Centers for Medicare and Medicaid Services, which regulates nursing homes and runs the Nursing Home Compare website. Lower ratings for a particular facility "do not necessarily indicate a change in the care provided."

Conway says the ratings system must evolve to drive "continuous improvements" in nursing home care, but the standards haven't changed since 2008, even as most facilities have reached five-star status. So "CMS has raised the bar for performance that should be recognized as high quality."

Feds toughen nursing home ratings, thousands of facilities get lower scores Nearly a third of the nation's nursing homes are getting lower scores on the government's revamped five-star quality scale, which is using tougher standards to determine the ratings used by consumers to assess care at more than 15,000 facilitiies.

USA TODAY reviewed ratings data for the more than 15,000 nursing homes included on the Nursing Home Compare website, which covers all facilities that participate in Medicare and Medicaid. Each nursing home has an overall rating based on scores in several distinct categories: performance in state inspections, staffing levels and quality of care. Among the findings:

•The average overall rating among all nursing homes dropped from 3.46 stars to 3.14 stars. Only 341 homes, or 2.3%, saw their overall ratings increase under the new measurement system.

•The biggest drops came in scores for quality of care, where the average for all nursing homes fell from 4.18 stars to 3.3 stars. No ratings category changed more, not only because it reflects the addition of data on anti-psychotic drugs, but also because other quality measures were made tougher.

•Nearly 20% of all nursing homes got the lowest possible score on the new measure of anti-psychotic drug use — CMS scored them on a curve, giving one star to homes ranked in the bottom fifth. Facilities were docked for using the drugs on residents unless they were indicated for specific conditions, such as schizophrenia, Huntington's Disease or Tourette's Syndrome.

•The new staffing measures, which distinguish between nursing staff and lesser-trained aides, had little effect on overall staffing ratings. As many as 12% would have lost a star had they not beefed up their staffing. Fewer than 8% lost a star on the staffing measure.

•There was no change in the calculation of facilities' scores in government inspections, the most heavily weighted assessment category in determining a nursing home's overall rating. The average inspection score across all facilities remained 2.81 stars.

Consumer groups representing nursing home residents and their families generally welcomed the new standards.

"We've been concerned for quite some time that the ratings have been over-inflated, particularly as they relate to quality and staffing," says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, an advocacy group for nursing home residents. "Rescaling the quality measures is going to result in more accurate reflections of the quality of care."

Nursing home operators worry that consumers will see lower ratings and won't realize the standards have changed – and the new measures were put in place because many facilities have improved their quality.

"We are concerned the public won't know what to make of these new rankings," says Mark Parkinson, president and CEO of the American Health Care Association, a nursing home industry group. "If centers across the country start losing star ratings overnight, it sends a signal to families and residents that quality is on the decline when in fact it has improved in a meaningful way."

The data used for the quality measures, including use of anti-psychotics, are self-reported by nursing homes, which has caused some consumer groups to call for more government verification. Other quality measures include the prevalence of bed sores, the rate at which residents are injured in falls and the use of physical restraints.

Conway says the ratings system will be updated more regularly in the years ahead. Additional quality measures will be incorporated in 2016, he adds, including data on hospital readmissions for nursing home residents who have had off-site medical treatment. CMS also is ramping up audits to help ensure that the quality data self-reported by facilities is accurate, Conway says.

Advocates for nursing home residents were especially happy about the decision to add measures on the use of anti-psychotics.

"High rates of anti-psychotic use can indicate serious care problems, because they're using them (to drug residents), instead of having adequate staffing and truly meeting residents' needs," Grant says. "When you're using anti-psychotics, your residents could be suffering increased falls, they're immobile, so you can see increases in pressure ulcers. They're very problematic."

While the new quality ratings are meant to give consumers a more refined picture of the care that specific nursing homes provide, Conway stresses that they are only one tool. He urges people shopping for a nursing home to tap other resources, such as local long-term care ombudsmen, and to get feedback from residents and their relatives when considering a facility.

The most important thing is to spend time in the building, Conway adds. "There is no substitute for a visit."

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