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Navigating the Complex World of Choosing a Nursing Home

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Looking at a nursing home's ratings on the Medicare website is just one step that should be taken to evaluate a potential care facility.
Looking at a nursing home's ratings on the Medicare website is just one step that should be taken to evaluate a potential care facility. | Screenshot: Medicare.gov

This story was published in tandem with a segment for KCET's award-winning TV show "SoCal Connected." Watch it here now.

When it comes to choosing a nursing home, the overuse of anti-psychotic drugs is just one factor to consider. But finding the truth about all the vital details isn't easy. First, Medicare's star rating system, the primary tool for those who are looking into this type of senior care, came under fire recently for holes in its evaluation process.

The ratings, based on three criteria (annual health inspection results, staff levels and quality statistics), rely heavily on self-reporting by nursing homes, the New York Times reported last month. The latter two factors are accepted once reported -- Medicare does not independently verify them, nor does it consider other potentially harmful information reported by state agencies.

KCET spoke with two experts who described some of the loopholes in nursing home accountability, as well as steps families can take to avoid these pitfalls.

Mike Connors, who works with California Advocates for Nursing Home Reform, says Medicare's rating system for the nation's more than 15,000 nursing homes falls dangerously short.

KCET: What are some of the problems with the current ratings system for nursing homes?

Mike Connors: The ratings system is not really reliable to tell you if it's a quality facility or not. On the drugging side, the quality measures that factor into the ratings don't look at all at the use of anti-psychotics or other psychoactive drugs.

If you look on federal Nursing Home Compare [webpage], it shows one nursing home has not received any fines in the last three years. But that facility has probably received the largest number of fines than any facility in the country.

Is it not up-to-date?

No, it has nothing to do with that. It only provides information about enforcement under federal laws and federal standards. The federal government is contracting with state government to inspect facilities, but the public has no way of knowing what the difference is between state standards and federal standards, or state fines and federal fines.

So this says they haven't been fined by the federal government?
Right, but it doesn't clarify that, and this is the principal ratings system that the public uses to look at nursing home quality. Lawsuits and things like that don't show up. Fines and sanctions that are given by the state agency that the federal government is paying for don't show up on their website. State contractors issue citations for federal violations, too. It's the same inspectors; they enforce both laws.

For example, one California facility evicted almost overnight some 70 residents because it said it needed to clear them out to install an automated sprinkler system. The reason it needed to do that is because the federal government in December said it was about to decertify the facility for ignoring a federal requirement that it have sprinklers.

How did things get that far?

[The facility] had five years to implement that requirement, ignored the five-year requirement and months later when it got dinged for that, instead of paying the price itself it made all of its residents pay. People who have been living there for years are told in a day or two, 'you are going to go have to go to another facility because we need to clear this out so we can protect our building and our license and our certification'.

The problems at [the facility] are just one example of the myriad issues people face when placing family members in nursing homes. KCET's "SoCal Connected reported on the misuse of anti-psychotic drugs in nursing homes on September 24, 2014.

So how can they avoid this type of nightmare scenario?

One vital step in choosing the right facility is gathering as much information as possible from various websites -- not just the federal site -- to paint a comprehensive portrait, said Jocelyn Montgomery, a registered nurse who represents nursing homes and worked previously as nursing home inspector.

Are there certain staffing requirements for nursing homes?

Jocelyn Montgomery: In California there is a staffing requirement of no less than 3.2 nursing hours per patient, per day. That's the floor for our compliance; the average is 3.7 in California and if you compare that around the country we are actually are one of the better staffed states. It's part of the picture, more in other states than it is here.

The average overall may have adequate staffing, but what do you say to those particular nursing homes where the staffing is below requirement?

The state of California's department of healthcare services has been doing staffing audits for two years. Every nursing home is audited. They look at payroll records, they look at staffing records, they look at sign-in sheets. And any facility that falls below that 3.2 is written up in a statement of deficiencies and if more than five percent are falling below that they are fined money. And if it's found on the annual survey that they don't have enough staff no matter what the number is there are deficiencies written for that facility that they have to come up with a plan of correction. They don't get away with it, although there is turnover. So, sometimes the staffs are not as competent and effective or familiar with the patients, or as efficient.

Can people trust those stars and scores?

You can have a facility that has a really bad inspection and it could be happenstance. Let's say that a really good nursing home has a problem with some contaminated process that they're doing, and there's a widespread infection control problem -- it comes up in that particular season and it's caught by the inspectors. If it is widespread enough, it can take that survey way down to the most serious level, called immediate jeopardy. The survey score drives the five-star score. You can have very good staffing and quality measures and you could be dropped to one or two stars. You can't always trust that a one- or two-star rating is a problem facility.

Is there a reliable website you can use to see the quality of care your loved one will get in a given nursing home?

We have a lot of transparency in the nursing home world. There is the nursing home compare website, which is the one with the five-star rating. That's the federal website. There aren't just stars there. When I'm looking at a nursing home for a loved one, I'm looking at the stars, but I also pull up the inspection reports. They're all posted there. And I look to see how many infractions were cited. I look to see how many complaints were filed and substantiated. I think that a savvy person that knows how to do that can learn a lot from looking at the website. By looking at the stars alone...it's not perfect.

The state of California has a website called Health Facility consumer Information System. They post ownership information. They have all these state violations posted there. That's a very transparent website. There's a third website with its own rating system that looks at wages, that is through the California Healthcare Foundation. That's a lot of transparency.

But there's no substitution for visiting. We provide checklists. I would tell you to visit. Visit once on the weekend -- sit down and watch, don't just get toured -- listen to how staff are talking with residents, chat with the residents. Get a feel for the culture there. There's no substitute for that.

The New York Times recently came out with a story looking at the star system for rating nursing homes, and found that a substantial amount of the factors were self-reported. What is your take on that?

The nursing home industry was very much opposed to five-star system. It was because we saw the risk of it painting a false picture. CMS [Centers for Medicare and Medicaid Services] listened to some of our suggestions, and in some ways they altered it, but this is very much the system CMS designed. The industry didn't ask for it, didn't support it, and had very little say in how it was designed.

The five-star system is based on the inspection results. The inspection results count for 75 percent of that rating. The staffing can move you one star, up or down. That's all.

Your children go to public schools, and they have a score based on standardized testing. And there have been accusations of teachers doing things to up their scores. But for the most part you've got a profession of committed teachers trying very hard to be very successful and if part of that means teaching to the standards, then they teach to the standards so they look better on the test. Is that inappropriate? You gave us a scorecard. We've focused on those quality measures and we've tried very hard to make our care better in those areas because we're being scored. That's just human nature. Is it wrong? Is it bad? Is it fraudulent? I don't think so. It's probably what CMS wanted -- they wanted to drive improvement and they did.

NOTE: These interviews have been condensed and edited.

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