COVID-19 swept through nursing homes, leaving a terrible wake in its path. At least 130,000 U.S. nursing home residents and workers died from the disease. U.S. nursing homes are rated on a star scale from 1 to 5, with five indicating the highest quality.
Those seeking nursing home care for their loved ones rely on the ratings system to ensure the best care possible. The pandemic and its dire effect on nursing home residents has shown the star system had little effect on COVID-19 outcomes. The New York Times investigation reveals that residents of 5-star facilities were as likely to develop COVID-19 as those residing in 1-star nursing homes.
The Ratings System
The ratings system went into effect in 2008. It was put into place at the time because private equity firms were on a nursing home buying binge, and legislators were concerned about quality of care deterioration. Today, about 70 percent of nursing homes are owned by for-profit companies. Higher-rated nursing homes earn considerably more money than those with low ratings.
The Centers for Medicare and Medicare Services (CMMS) evaluates nursing homes based on self-reported data from the facilities and examinations by state health inspectors. The ratings system includes separate ratings for health inspections, staffing, and quality measures. The latter consists of 15 different physical and clinical measures regarding how the facilities care for their residents’ needs.
A research letter published in The JAMA Network in August 2020 using data from eight state health departments found “there was no significant association between high- vs. low-performing nursing homes in the health inspections or quality measures domains with COVID-19 cases.”
Just Plain Wrong
According to the New York Times investigation, the primary reason the ratings system misleads the public is that much of its information is just plain wrong. Because facilities self-report, they tend to submit incorrect information regarding their cleanliness and safety.
Many accidents are not reported. The number of patients on dangerous antipsychotic medications is underreported. In 2019, a report issued by the acting Inspector General of the Department of Health and Human Services stated nursing homes reported only 16 percent of incidents of residents hospitalized for potential abuse and neglect.
Staffing levels are often deliberately inflated. Short staffing levels equate to a drop of one to two stars. Nursing homes may count employees on vacation as working during a particular period. Some may count administrators as caregivers.
It is not uncommon for nursing homes receiving high ratings for their written submissions to fail in-person inspections. Between 2017 and 2019, health inspectors cited more than one-third of the country’s nursing home for misreporting data, a figure including 800 facilities with 5-star ratings. However, government audits of the data are rare.
It also appears that in some instances, nursing homes are tipped off in advance of so-called “surprise” inspections.
Not Ready for the Pandemic
The ratings system is based on the scoring of high grades. It is not based on the upgrading of facilities. Because so many nursing homes focused on improving ratings, not the quality of care, they were less prepared for the pandemic.
The difference in death rates from COVID-19 between 5-star and lower facilities was only .5 percent. Two-star facilities actually had lower death rates than those with four stars. What appeared to matter when it came to COVID-19 in nursing homes was the facility’s location and the community infection rate, as well as the race of the nursing home residents. Star ratings had little to do with it.
COVID nursing home deaths are mostly preventable. If a loved one died in a nursing home or assisted living facility because of coronavirus or coronavirus complications, we can help.
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