By Thomas Goldsmith
With additional reporting by Rose Hoban
Since 2009, North Carolinians looking for an adult care home have used a star rating system designed to show how well these assisted-living centers look after older residents and those with disabilities.
Now a multi-disciplinary team mandated last year by the General Assembly is studying whether the four-star system should be retained, modified or scrapped.
Representatives of the assisted living industry say that the rating system relies too heavily on arbitrary and subjective information gleaned from inspections chiefly made by a county’s human services staff. Meanwhile, advocates for older people maintain that the system has value and shouldn’t be set aside, even if it needs modification.
There’s agreement among the public, private and nonprofit leaders studying the controversial system that it’s vital for potential residents and caregivers to look beyond the star rating system when picking a facility.
“I would disagree with doing away with it,” said Sharon Wilder, who retired in 2016 after 28 years with the state ombudsman program, 16 of those as head of the office.
“For many families that are caught in that quandary of trying to find a place for their relatives, it’s one useful tool. It helps them narrow down their search somewhat, but it should never be the only way that they look,” she said.
How the stars were born
The General Assembly set the table for a rating system in 2007. It debuted as a three-star ranking in 2009, with provisions to move to a four-star scale the following year. Representatives of North Carolina’s adult care home industry have said that the system doesn’t assess facilities’ quality as well as the federal database that provides data on nursing homes, Nursing Home Compare.
In North Carolina, “adult care” refers to the kind of residential care often referred to as assisted living. Assisted living centers are licensed by the state Department of Health and Human Services to care for people who don’t need skilled medical attention, but can’t live without 24-hour supervision. Residents receive room and board, some activities, medications given by staff, transportation to medical appointments and help with bathing and toileting.
A nursing home or skilled nursing facility, regulated by the federal Centers for Medicare and Medicaid Services, offers care by a registered nurse, under a doctor’s supervision, after illness or for chronic conditions. Some residents stay for shorter periods in nursing homes for speech, occupational or physical therapy.
Source: Resources for Seniors
“When they passed the law back in 2007, they really didn’t give the state much money to implement it,” said Jeff Horton, a former state official who has been executive director of the trade group NC Senior Living Association (formerly called the North Carolina Association, Long Term Care Facilities) since August. “The state pretty much had to come up with a rating system with current resources and the only data they had was inspection reports.”
Bill Lamb, president of the nonprofit advocacy organization Friends of Residents in Long Term Care, believes the star-rating system has its place.
“It’s a pretty simple, straightforward process,” he said. “The star-rating system is a rating system for adult care homes to provide consumer information to help families and residents make decisions about care, being able to compare one facility to another without having to get into all the bureaucratic stuff behind regulations.”
Horton, whose organization has a significant lobbying presence on Jones Street, said the state’s star rating works like a restaurant’s inspection-based sanitation score, whereas the federal star rankings of nursing homes considers more objective factors in a more complex algorithm.
“They look at inspection reports, they look at staffing levels and things like that to come up with a rating and it’s more comprehensive,” Horton said.
Horton also said that the system was supposed to be updated after the initial rollout almost a decade ago, but there’s been no revision since.
See for yourself, to be sure
In their advisory roles with the state Department of Health and Human Services, both Horton and Wilder, the former ombudsman, were part of the group that met to come up with the star-rating system. So was Frances Messer, a leader since 2013 of the North Carolina Assisted Living Association, another trade group.
In an interview, Messer took the position that the star-rating system could be replaced with a revamped state website that gave consumers more transparency in the form of easier access to citations, violations and fines against these living places for older people and those with disabilities.
“The star rating is not the only piece that a consumer needs or wants to look at,” Messer said.
A lower star rating can cause owners problems beyond a negative perception by potential residents or caregivers, Horton said.
“Say you have an older home, the state comes in, they do their inspection and they cite you for some physical plant issues, that decreases your star rating, say it goes down to two stars,” Horton said. “Because a lot of physical plant things you need to do, well, you don’t have the money for that, and so then you go to the bank and now banks are checking the star rating site and if you got two stars or less, they won’t even loan you money.”
While some North Carolina homes have mom-and-pop owners or are owned by small chains, many show ownership by large chains such as Brookdale and Sunrise Senior Living. In turn, chains are often owned by multi-billion-dollar corporations or private equity firms, a fact that doesn’t always emerge unless a caregiver digs deep online.
On the personal level, Messer, Wilder and Horton all pointed to the necessity of a visit to a center, with some particular guidelines on the visit.
“If you are interested in two facilities, even if you have to take time off work, go in the late afternoon or on the weekend, that’s the best time to visit a facility,” Wilder said. “On the weekend, residents’ families are there, and you can ask them.
“They’ll say, ‘Oh, they take such good care of Mama,’ or ‘It’s been rough, but we’re making it.’”
Using the state’s Adult Care Licensure website a consumer or caregiver can see more than just star ratings. One can see, for example, that North Pointe Assisted Living of Garner has a zero, or lowest ranking, and see the factors that led to the rating. The facility’s most recent inspection found that center staff put a female patient with dementia into a Geri-chair, a type of wheelchair that allows a user to be restrained, without having received a medical order for it.
Inspection records show that the resident, who was not named, had a diagnosis upon entering of “dementia without behaviors, history of falls, dysphagia, major depressive disorder, essential hypertension, history of transient ischemic attack, and prosthetic nervous system disorder.” The report gave stark, detailed information about the circumstances surrounding the citation against the home.
“Resident #4 was sitting in the dining room in her geri-chair reclined at an approximately 40 degree angle with her feet elevated awaiting feeding assistance. A black gel cushion was in the geri-chair seat under Resident #4. There was blue cushion in the geri-chair behind the back of Resident #4. Resident #4 had a large purple colored bruised swollen area in the middle of her forehead and the bruising extended down into the bridge of her nose. Resident #4 was able to point using her right arm and hand. Resident #4 required assistance with feeding from staff.
Based on observation, interview, and record review, Resident #4 was not interviewable.”