Jennifer L. Boen

Jun. 27, 2008 (McClatchy-Tribune Regional News delivered by Newstex) -- Searching for a good hotel leads many travelers to look at the number of stars they've received in ratings by hospitality industry organizations. Choosing a five-star hotel sets up expectations of comfortable beds, excellent food, a clean-as-a-whistle environment and top-notch service.

The federal Centers for Medicare and Medicaid Services plans to roll out a five-star rating system for nursing homes in January, officials announced earlier this month, calling it a groundbreaking ranking system of America's nursing homes.

While the goal is to help consumers evaluate care, some senior advocate and provider organizations are concerned that assigning stars to rate places where more than 3 million of the nation's most vulnerable people live reduces the significance of the issue.

"I'm concerned that they could oversimplify things. I guess that's our biggest concern," said Jim Leich, president of Indiana Association of Homes and Services for the Aging Inc. (IAHSA), a long-term-care industry organization representing the nonprofit sector.

"It's more looking at the negatives. A limited number of bad things define a five-star facility, but we have to have something that defines the good things -- where are they excelling." Resident and family satisfaction should be part of the data, he suggests.

The rating system, which will provide a composite view of quality and safety information on every Medicare-certified nursing home, is still in development, and Centers for Medicare and Medicaid Services (CMS) wants input from the public by the end of July before firming up details.

All of Allen County's 25 nursing homes are Medicare-certified, but even if a resident's care is not covered by Medicare -- as is the case for most -- CMS regulations apply to all residents in the facilities.

One to five stars will be given based on three data sources: survey, or inspection, results from the three most recent years; nurse staffing information from the most recent inspection; and data based on how well the facility has performed on specific quality measures.

Most of this information is already available on CMS' Nursing Home Compare Web site, but it is difficult for the public to interpret the data, said Kerry Weems, acting administrator of CMS, at a recent news conference.

The Washington, D.C.-based Center for Medicare Advocacy, a nonpartisan group working to increase access to Medicare and quality care for recipients, is concerned much of the data for the rating system is self-reported by facilities.

"Two of the three criteria that CMS plans to use -- quality measure and staffing data -- are self-reported by nursing facilities and are inaccurate," said Toby S. Edelman, senior policy attorney with the center. "Relying on nursing homes to describe accurately how well they are doing -- and reporting that information as fact -- just doesn't make sense."

Staffing data posted on Nursing Home Compare represent the average number of hours and minutes per day of care provided each resident in that facility. Data are usually based on the staff levels found during the annual inspection.

Although surveys are not scheduled, Edelman is aware of situations in which some nursing homes add staff around the time the annual survey is anticipated. CMS, she said, knows the self-reporting of staffing levels is flawed, and a better system would be based on payroll data for the year.

Indeed, in the description of how the five-star system will work, the CMS Web site states: "While these data are informative, this raw form of display has limited ability to address whether the facility seems to be adequately staffed or not."

One method CMS is considering for evaluating adequacy of staffing levels is based on case mix of residents. Medicare residents are already assigned to a Resource Utilization Group (RUG) based on the amount of resources required to meet the resident's needs. Nursing homes are reimbursed by Medicare based on the RUGs, and staffing scores would be more individualized if based on the RUGs.

Staffing is not just about numbers, Edelman said, explaining, "Most people focus on the number of nurses and the fact there are not enough nurse aides, but a lot of people are concerned about the lack of professional level of staffing."

A nursing home is required to have a registered nurse on site at least eight of every 24 hours, but in most facilities, licensed practical nurses outweigh registered nurses, who have double or more the education of LPNs.

Currently, 19 quality measures are part of the nursing home survey and scoring system in CMS' Nursing Home Compare site. Deficiencies or problems are scored according to the number of people affected and the level of harm or injury to a resident or group of residents.

"Right now, the quality outcome measures are better than anything we've ever had, but from a pure research point of view, they're not going to tell you everything you need to know," Leich said, noting, "I always tell people to visit several times, at different times of day. Use your nose."

He also maintains Indiana surveyors dole out more deficiencies than surveyors in other states. Although the same CMS regulations are used in every state, he said, "Sometimes we're concerned about consistency. If Indiana averages more deficiencies overall, how does that compare to states where fewer deficiencies are given?"

The Center for Medicare Advocacy has asked CMS to delay reporting facilities' ranks until additional systems are in place that ensure facility-reported data are accurate, Edelman said.

While the rating system is still a work in progress, Weems said in a media conference call, "I don't think we'll see very many people who are going to be anxious to put a loved one into a one-star home."

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