Short-Staffed Nursing Homes See Drop In Medicare Ratings

The authorities accelerated its crackdown on nursing facilities that go days with no rn by downgrading the rankings of a tenth of the nation's homes on Medicare's consumer website, new records show.

In its update in April to Nursing Home Compare, the Centers for Medicare & Medicaid Services gave its lowest star rating for staffing – one star on its five-star scale – to at least one,638 homes. Most were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder didn't submit their payroll records or sent data that couldn't be verified with an audit.

“Once you're past four days [without registered nursing], it should be beyond bringing in sick,” said David Grabowski, any adverse health policy professor at Harvard School of medicine. “It's probably a systemic problem.”

It was a tougher standard than Medicare had previously applied, when it demoted nursing facilities with seven or more days with no rn.

“Nurse staffing has got the greatest effect on the caliber of care nursing homes deliver, and that's why CMS analyzed the relationship between staffing levels and outcomes,” the company announced in March. “CMS discovered that as staffing levels increase, quality increases.”

The latest batch of payroll records, released in April, shows that much more nursing homes fell short of Medicare's requirement that a registered nurse be on-site at least eight hours every day. Over the final 3 months of 2021, 2,633 of the nation's 15,563 nursing homes reported that for four or more days, rns worked fewer than 8 hours, based on a Kaiser Health News analysis. Those facilities didn't meet Medicare's requirement even after counting nurses whose jobs are primarily administrative.

CMS continues to be alarmed in the frequency of understaffing of registered nurses – the most highly trained category of nurses in a home – because the government last year began requiring homes to submit payroll records to verify staffing levels. Before that, Nursing Home Compare trusted two-week snapshots nursing homes reported to health inspectors once they visited – a method officials worried was too simple to manipulate. The records show staffing on weekends is usually particularly anemic.

CMS' demotion of ratings on staffing isn't as severe as it might seem, however. Over fifty percent of those homes were given a higher rating than a single star for his or her overall assessment after CMS weighed inspection results and the facilities' own measurement of residents' health improvements.

That overall rating is the one which garners the most attention on Nursing Home Compare and that some hospitals use when recommending where discharged patients might go. From the 1,638 demoted nursing facilities, 277 were rated as average in overall quality (three stars), 175 received four stars, and 48 received the very best rating of five stars.

Still, CMS' overall changes to the way the government assigns stars drew protests from nursing home groups. The American Healthcare Association, a trade group for nursing homes, calculated that 36% of homes saw a stop by their ratings while 15% received improved ratings.

“By moving the scoring 'goal posts' for 2 aspects of the Five-Star system,” the association wrote, “CMS will cause more than 30 percent of nursing centers nationwide to get rid of a number of stars overnight – despite the fact that nothing changed in staffing levels and in quality of care, which is still being practiced and delivered every single day.”

The association said within an email that the payroll records might exaggerate the absence of staff through unintentional omissions that homes make when submitting the information or because of problems on the government's end. The association said hello had raised concerns that salaried nurses face obstacles in recording time they worked above 40 hours per week. Also, the association added, homes must deduct a half-hour for each eight-hour shift for a meal break, whether or not the nurse worked through it.

“Some of our member nursing homes have told us their data is not turning up correctly on Elderly care Compare, which makes it appear they do not have the nurses along with other staff that they in fact do have on duty,” LeadingAge, an association of nonprofit medical providers including nursing homes, said last year.

Kaiser Health News has updated its interactive nursing home staffing tool using the latest data. You should use the tool to see the rating Medicare assigns to each facility for its rn staffing and overall staffing levels. The tool also shows KHN-calculated ratios of patients to direct-care nurses and aides on the best- and worst-staffed days.