Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public

Nursing homes have manipulated the influential star system in ways that have masked deep problems — and left them unprepared for Covid-19.



By Jessica Silver-Greenberg and Robert Gebeloff

Twelve years ago, the U.S. government introduced a powerful new tool to help people make a wrenching decision: which nursing home to choose for loved ones at their most vulnerable. Using a simple star rating — one being the worst, five the best — the system promised to distill reams of information and transform an emotional process into one based on objective, government-blessed metrics.

The star system quickly became ubiquitous, a popular way for consumers to educate themselves and for nursing homes to attract new customers. During the coronavirus pandemic, with many locked-down homes unavailable for prospective residents or their families to see firsthand, the ratings seemed indispensable.

But a New York Times investigation, based on the most comprehensive analysis of the data that powers the ratings program, found that it is broken.

Despite years of warnings, the system provided a badly distorted picture of the quality of care at the nation’s nursing homes. Many relied on sleight-of-hand maneuvers to improve their ratings and hide shortcomings that contributed to the damage when the pandemic struck.

More than 130,000 nursing-home residents have died of Covid-19, and The Times’s analysis found that people at five-star facilities were roughly as likely to die of the disease as those at one-star homes.

The ratings program, run by the U.S. Centers for Medicare & Medicaid Services, relies on a mix of self-reported data from more than 15,000 nursing homes and on-site examinations by state health inspectors. Nursing homes receive scores based on how they fare in those inspections; how much time nurses spend with residents; and the quality of care that residents receive. Those three grades are then combined into an overarching star rating for each nursing home.

To evaluate the ratings’ reliability, The Times built a database to analyze millions of payroll records to determine how much hands-on care nursing homes provide residents, combed through 373,000 reports by state inspectors and examined financial statements submitted to the government by more than 10,000 nursing homes.

The Times obtained access to portions of the ratings data that aren’t publicly available from academics who had research agreements with the Centers for Medicare & Medicaid Services, or C.M.S.

Among The Times’s findings:

Much of the information submitted to C.M.S. is wrong. Almost always, that incorrect information makes the homes seem cleaner and safer than they are.

Some nursing homes inflate their staffing levels by, for example, including employees who are on vacation. The number of patients on dangerous antipsychotic medications is frequently understated. Residents’ accidents and health problems often go unreported.

In one sign of the problems with the self-reported data, nursing homes that earn five stars for their quality of care are nearly as likely to flunk in-person inspections as to ace them. But the government rarely audits the nursing homes’ data.

Data suggest that at least some nursing homes know in advance about what are supposed to be surprise inspections. Health inspectors still routinely found problems with abuse and neglect at five-star facilities, yet they rarely deemed the infractions serious enough to merit lower ratings.

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