By Thomas Goldsmith
When the time comes near to choose a nursing home for a loved one, the ideal path is to visit one or more facilities and talk with administrators, staff, and residents, according to people familiar with this transition.
But for many families, the need for a nursing home is an urgent one, precipitated by a fall or a catastrophic illness that has suddenly rendered a loved one unable to cope at home.
Several online resources can help people who are looking for the best possible care. It’s popular to “do your own research” on choices such as this, but it can be difficult to find the time and expertise to look into nursing homes, especially since many people enter the long-term care system in crisis.
Public and nonprofit experts helped North Carolina Health News compile a list of some sources of information about skilled nursing facilities across the state.
This is the last of three stories on a new report from the National Academies of Science, Engineering and Medicine.
The sweeping new report on nursing homes created by a blue-ribbon committee of the National Academies contains broad criticism on the current state of care for older people and those with disabilities.
The assembled expert members of the committee that produced the report, “The National Imperative to Improve Nursing Home Quality,” included experts from the fields of nursing, veterans affairs, health economics, family medicine, geriatrics, health care policy, vaccines, public health and cancer research.
Dr. Philip Sloane is a professor of family medicine and geriatrics at UNC-Chapel Hill and a member of the panel that created the report. Each of the experts gave a stamp of approval to each of the panel’s conclusions, Sloane said.
So, if the institution of nursing homes needs improvement, what specific steps does the report recommend to make ownership and operations more transparent for the public?
In one proposal certain to receive pushback from industry, the committee recommends that the federal Centers for Medicare and Medicaid Services should have full access to Internal Revenue Service tax returns of companies that play a role in a nursing home’s operation.
In many cases, the person or corporation in ownership of a nursing home also owns companies that supply business management, pharmacy services, food preparation, security and other needs to the facility. That can result in a convoluted structure that’s hard to assess and that makes any legal action against the nursing home hard to pursue.
The presence of legally separate businesses owned by the nursing homes parent corporation would be used by Medicare and Medicaid in an annual audit of a facility’s home office and related companies, according to the committee’s recommendation.
Additionally the committee recommends that:
- Prospective owners of a skilled nursing facility should be prevented by new regulations from buying, running or managing new facilities if records show they have a history as owners of operating other homes, in any state, that chronically had low staffing or poor quality.
- Enforcement of laws and rules on nursing homes should go beyond the widely used civil monetary penalty. These efforts should make more use of remedies that include having corporate chains enter integrity agreements, disallowing new residents, mandated courses of correction, installation of temporary managers, and ending contracts with Medicare and Medicaid.
- A new Early Detection Task Force made up of federal and state regulators, people from the Centers for Disease Control and prevention and the U.S. Justice Department should keep a continuing eye on nursing homes’ performance based on data collected on staffing levels, a record of time spent by a facility’s medical director, inspection programs and the federal justice department’s assessments. The task force would be able to send “strike teams” into nursing homes with especially urgent problems. A similar practice was used in western North Carolina early in the COVID pandemic.
In addition, the report says interested people should be able to search information on the Nursing Home Compare site not only by a facility’s name, but also by any chain or common ownership.
Look to the stars
For those beginning the process, the five-star rating system offered by the Centers for Medicare and Medicaid Services, or CMS, is worth consulting but should be supplemented from other sources, said Bill Lamb, a board member of the advocacy group FOR, or Friends of Residents in Long Term Care.
“A five-star rating means you still need to look at additional information,” Lamb said in a phone interview. “But if you’ve got a two-star or one-star or special focus facility, there’s something going on there.”
Special focus facilities are nursing homes with records that show they’ve fallen short in caring properly for residents during long periods. If federal regulators make that determination, the center in question can find itself facing more frequent inspections, ponying up to pay fines within a large range, and losing reimbursement from both Medicare and Medicaid.
A new report examining the state of the U.S.’s nursing homes from the National Academies of Science, Engineering and Medicine, “The National Imperative to Improve Nursing Home Quality,” raises questions about the value of the federal star rating system, available at the Nursing Home Compare website.
“Although the five-star composite measure seems to have face validity and predictive validity at the extremes, the evidence is mixed as to whether the star ratings are helpful to consumers choosing among nursing homes that are closer to average,” the report says, citing academic studies that raise sometimes provocative questions about the system.
There’s the unfortunate possibility that facility owners with knowledge of the system might prepare information designed to produce a specific rating.
“Part of the challenge of the current rating system is that both staffing and quality measures are based on self-reported data from nursing homes, which could allow for ‘gaming’ where nursing homes could falsify their data or use questionable strategies to improve scores,” the report says.
In other words, well-ranked homes are likely good, while poorly-ranked homes should likely be avoided. For homes ranked in the middle of the pack, the quality can be hard to determine.
See for yourself
Lamb and other experts across the board emphasize the importance of in-person visits.
“Making an appointment to visit nursing homes and talking to staff and residents is also important,” said spokeswoman Summer Tonizzo from the North Carolina Department of Health and Human Services.
Adam Sholar, CEO of the nursing home trade group North Carolina Health Care Facilities Association, is on the same page.
“Personally, I’d recommend that families make an appointment to visit nearby nursing facilities so they can see first-hand what type of care is being provided,” Sholar said. “Personal visits will tell you far more about the staff, the facilities, and the culture than anything else.”
However, people familiar with the industry caution visitors not to place much importance on amenities such as the well-appointed lobby of a nursing home. The day-to-day treatment of residents takes place out of sight of any such trappings.
Take a deeper dive into the data
The site data.medicare.gov, maintained by CMS, is likely the most informative tool, but can also be the most difficult to use. Its spreadsheet data can supply consumers with details about a facility’s level of staffing at specified jobs, rate of turnover, population, deaths from COVID-19 and much more. Those unfamiliar with Excel or other spreadsheet software will need to learn how to use it by themselves, or get help with it.
Nursing Home Compare lets visitors check possible destinations against competing facilities. It’s run by the federal Centers for Medicare and Medicaid Services and issues the 1 to 5 star ratings for facilities.
This site focuses on seeing how one facility stacks up against another, or with a few, so it’s not always the easiest place to get information. However, as noted in the National Academies report, the star rating system is a useful way to determine a general level of quality, especially in the lower and 4 to 5 star ranges.
The state NC DHHS’s Division of Health Service Regulation Nursing Home Licensure and Certification Section web page allows consumers to consult inspection reports for facilities in the state, along with statements of deficiencies that are generated when there’s a problem and the corresponding plans of correction. A no-frills list of facilities is on the DHHS site — click on “nursing homes, portable document form.”
There are also regular postings of the centers with “deficiencies.”
Go back in time
Among other resources, the state nursing home licensure and certification section, which receives about 2,000 nursing home complaints a year, maintains a list of centers that have been cited for deficiencies in care.
Those interested in a specific nursing home can examine records from the near past or going back several years. For example, someone looking into the Citadel Salisbury would find that regulators cited the nursing home in March for failing to protect a female resident who complained that a male resident had repeatedly offered her money for sex.
Residents or caregivers can file complaints about incidents that have happened in the past year and that involve problems identified in state or federal regulations. Other sorts of concerns could be handled by another agency.
Although nursing homes are licensed and operate under federal regulations, when there’s a complaint, it’s state DHHS and local county employees who carry out inspections that form the chief basis of citations and penalties from the Centers for Medicare and Medicaid Services.
Other information sources:
- The Long Term Care Community Coalition offers state-by-state spreadsheets that combine state and federal information on nursing homes. Here’s North Carolina’s.
- The Kaiser Family Foundation has reams of information about skilled nursing facilities, from nurse staffing to private and nonprofit ownership. A recent issue brief sums up what states have done to address shortages in nurses at skilled nursing facilities.
- The national non-profit investigative newsroom ProPublica also has especially robust information and prides itself on keeping its listing up to date. Their data site Nursing Home Inspect also combines information from different levels of agencies. For example, a ProPublica listing shows two North Carolina nursing homes as among the most heavily fined nationally during a three-year period. They are Citadel Salisbury with $700,000 in fines and the Carolina Rehab Center of Cumberland, with $604,000.