Sunday, September 6, 2015

Senators Propose Investigation of LTC's "Star Ratings" by CMM -- Long Overdue

Two Senators have recently called for the federal government to investigate Centers for Medicare and Medicaid Services' Five-Star Quality Rating System.

I wrote about the Minimum Data Set, mandated to be used in all Long Term Care Facilities on a regular basis and reports sent to the DHSS and Medicare/Medicaid for its negativity and misapplication.

Want to read what I wrote on December 17, 2014 on the MDS: click here

This system of "Star Ratings" by the US Government CMM has been promoted as being a reliable way of determining the quality of care and safety in Long Term Care Facilities across the US when it is actually a compilation of information whose source varies and whose information is questionable as to accuracy and dependability.

The general public deserves to have websites provided by the Federal and State Governments that are accurate and complete, especially when human lives are involved.

Unfortunately, this Star System can be detrimental to the lives of Seniors and their families with its limited and biased information.

Click here to pull up the page on the web that details what's used/included in this "review".

You actually have to click through to Nursing Home Compare to get information on specific facilities. You can put in your zip code and it will pull up several to compare.

I did and reviewed my Mom's LTC where she lived and died. Ratings were far higher than I would have expected from the actual experiences of Neglect and Abuse reported several times by our family and others.

The Key Word here is "Average" as it is the basis of the report. Let's see if we can find a definition for this word as it applies to the three categories.

For this we need to go into another site. Here you'll find the following on page 6:

"For the above reasons, Five-Star quality ratings on the health inspection domain are based on the relative performance of facilities within a state. This approach helps control for variation among states. Facility ratings are determined using these criteria: • The top 10 percent (lowest 10 percent in terms of health inspection deficiency score) in each state receive a five-star rating. • The middle 70 percent of facilities receive a rating of two, three, or four stars, with an equal number (approximately 23.33 percent) in each rating category. • The bottom 20 percent receive a one-star rating."

IMPORTANT: The information that each State sets its own standards so a 1 star in one State can be a 2 star in another and vice versa. 

Shouldn't a Long Term Care Facility in Georgia have the same basic requirements and therefore comparisons as an LTC in New York State? 

What's not being openly discussed is the broad scope of legislation and the leaving to the States individually to set their own standards and parameters for care giving for our Seniors.

Then, on Page 10  you'll find Table 5 Staffing Points and Rating (updated February 2015) 
 a table of information that's best viewed as it doesn't copy well for insertion into this blog.

What's also upsetting is the "lumping together" of RN, LPN and Nurse's Aides as though they were equally qualified to care for residents.

In Mom's facility, there was only one RN on duty and that was only during the hours of 7 AM to 5 PM Monday through Friday, not on weekends, one or two LPN's per floor depending on the number of residents at the time and usually 2 to four CNA's depending on the total number of residents and not the actual abilities of the residents or needs. All totally in line with the State of Missouri "requirements". 


If the facility administers their own tests, hires their own Doctors, requires (as Mom's did) only their facility's Hospice Care and doesn't allow any other "end of life care", please tell me how much weight we should give to the accuracy and positive intent of a facility?

These valuations were always greatly underestimated and trying to get a facility associated Dr to ensure the real level of personal assistance, mental capacity and capability were notated and recorded was never accomplished in all the time we spent there and all the reports we generated.

Most importantly when you read the report you'll notice it relies on the reports generated by the facility as to the ability level of its residents.

Sadly, those who write the reports often do not tell the truth; they do not adjust for changes and especially for lessening of abilities both mental and physical.

At Mom's facility, as I'm sure is true of many, they relied on Staff "Rounds" that were supposed to be held at the beginning of each new shift to VERBALLY inform the CNA's about the abilities and needs of the resident. 

Can't say I ever really saw a CNA checking a record of a patient. There was a recording area for them to put down what services they provided but the errors had to be extensive as it was not portable but fixed to a wall and totally dependent on the provider to leave the room walk down the hall, pull up the specific resident and record services rendered and observations. 

Imagine this scenerio:  CNA is called to Room 1 for resident who needs to be transferred to commode. CNA takes advantage of time while resident sits to give assistance to another who needs help getting wheelchair out of a corner or some other logistics need; another light goes on and another and the CNA moves from room to room.

So, if the average person can only remember 10% of anything they're taught or specific procedures they've done, how accurate can this "report" be when the CNA finally gets around to recording their actions/activities with each resident?

THAT, SENATOR CASEY AND SENATOR WYDEN, is one of the many reasons why this Star Report is inaccurate and not worthy of the time and cost.

How about a website that provides A VOICE FOR THE PEOPLE?  One where residents and families can record their concerns and their observations?  That would be a better spending of Tax Dollars -- in my opinion.

The general public deserves unbiased information and full disclosure. Some states now provide itemized reporting of ALL violations found and reports made generating visits by the State Departments of Health and Human or Senior Services.

Senators, this is the format that needs to be followed:


A federal government website that uses the reports generated by the individual States differing standards and procedures for reporting quality of care IS NOT ACCURATE when it does not include the parameters of each specific State or at least a click through for each State so we can acess directly the parameters used to judge and measure Seniors.

You cannot compare apples to oranges.

A federal government website that relies on individual interpretation and administration of measurements like the MDS, Minimum Data Set, often administered by unqualified and underqualified individuals in settings not conducive to a "controlled study" which this test and others like it should be is not reliable and should not be used to determine the "quality" of care giving in any Long Term Care Facility in any of our fifty States.

I've personally seen the questions given to residents after waking them from a nap, at the dining table, after receiving medications, etc -- all factors never reported or divulged as influencing the outcomes of the MDS-- as mentioned in the above blog entry I wrote on December 17, 2014

The Problems:  

This system uses reports generated by the State DHSS's who each have varying parameters they use to determine the specific categories covered: 

There are only three areas used to determine the Five Star Quality Rating System. 

 Health Inspections done yearly at facilities    Staffing          QM's 
How often is there a review of this "system"?  When is it updated? Let me know if you can find the answer -- I'm still looking.

My Comments:  

Reference is made to the three most recent ANNUAL health inspections. What about the inspections generated by families and residents endangerment and negligence?  They wouldn't be in this classification or examination according to the interpretation of this directive.

Three most recent surveys health inspections -- done by the government agency, the DHSS. 

Ever read one?  I have and was appalled to see severe and life threatening events portrayed with moderate and not severe language. Anyone reading this report would "judge it" according to the language as is stated above and a really poor facility could get significantly higher marks.

As someone who is very against the use of the Minimum Data Set, I challenge the Senators to review this tool as it is used on patients with Dementia, especially Lewy Body Dementia. 

According to medical experts on the Lewy Body Dementia Association website, you can't get an accurate "reading" and variances can be extreme from one hour to another as to what a resident will respond with patients who have LBD.

This "tool" shouldn't be used to measure the amount of care giving an individual needs as it is too variable in its results and not effective in the hands of the people who usually administer it at Long Term Care facilities.

The Star System needs to be changed to allow the accurate and total reporting of facilities reports generated each and every time the DHSS makes an inspection for whatever purpose and full transparency should be required. 

Forget giving ratings, give exact information or links to websites mandated for each State to contain exact information gathered from reports made by Long Term Care facilities collected by the DHSS, Medicare and Medicaid.

Let the general public see how many of each category of caregiver is actually working on a  daily basis; let us see all the details (except for the name of the exact resident) for any and all real or perceived violations and the outcomes including all fines and any other actions taken by exact date and amount.

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