The working life of a nursing home administrator can be a tough one.  There are innumerable tasks that fill up the days (and nights), and one drawback of the job is that we often suffer under a woefully underdeveloped job description.  In an effort to put out today’s fires, we can miss some pretty important pieces of information that come down the pike.  For example, I only recently got around to reading the AAHSA (American Association of Homes and Services for the Aging) report that came out this past summer, “Broken Beyond Repair: Recommendations to Reform the Survey and Certification System.” 

Life Services Network hosts a permanent link to the full report (here).  If you, like me, have been too busy to read it, I recommend giving it a glance as soon as you can.  Especially with the regulatory change winds blowing as hard as they have been in recent months, it is important for on-the-ground LNHAs to understand the issues involved so we can support the advocacy and lobby groups when they make their arguments.

At any rate, the report contains a number (31) of specific recommendations for improving the current certification and survey process (as well as its overall conclusion of OBRA ’87 needs to be completely revisited, and the surv/cert process overhauled).  One in particular has caught my imagination.  It reads as follows:


AAHSA should encourage CMS to revise the Nursing Home Compare Web site so its language is less pejorative and the data it presents is easier to understand and includes a full explanation of survey results. This can be accomplished by giving providers the opportunity to elaborate on the Statement of Deficiencies posted on Nursing Home Compare by adding specific facts related to its cited deficiencies in a standardized format established by CMS.

A major complaint I’ve heard from LNHA colleagues and read in the listserves w/r/t the Five Star Component to Nursing Home Compare is that the website does not offer enough explanation of the results, and that the results do not indicate true quality (i.e. how a resident is actually taken care of – – the compassion factor).  The above recommendation could be an excellent step towards meeting this complaint.

Imagine if you were able to address the deficiency as noted now by a  number of stars in a graph through a short narrative, properly formatted for consistency and ease of use.  I know I would feel better about my facility’s star rating (even though already good) if I could directly address some of the viewer witha  paragraph.  Further, this sort of collaborative back and forth – – adversarial tension between Surveyor and facility – – could result in a dialogue with residents and their family members regarding the appropriateness of the survey results as reported on CMS Nursing Home Compare.  Such a dialogue would help us get to a better regulatory tool (RE: Survey Process), which is the point of OBRA ’87 in the first place.

Indeed, it could go farther than just the facilities having the opportunity to comment on the Survey and Certification results as posted on Nursing Home Compare.  Would it not be empowering to residents and their families if the CMS site allowed them to post their own comments for others to see?  I think it is an idea worth exploring.  If the regulators’ survey results, the facilities’ comments, and the residents and their families’ opinions were collected in the same place, I think the true relative worth and value of a nursing home would out – – rewarding the good and encouraging the bad to improve.  What a lofty, but possible goal.




The following is a comment to my post titled: Five Star Rating Techincal Manual: Staffing Domain Accuracy.

I copy it here becuase the author makes a very good point w/r/t where the focus should be for Nursing Home Administrators, and I wouldn’t want it to get lost:

“As a member of the Technical Advisory Panel for the 5-Star system and a co-author of the paper cited in this discussion, I am in a relatively unique position to comment. The author of the posting is correct about the potential effects of errors in reporting staffing.

However, the study showed that for-profit homes tend to over-report, and it was for-profit homes that fared the worst in the 5-Star system. So, it seems that the effects of over-reporting may not be as dire as suggested.

In addition, I would suggest that instead of trying to cast doubt on the 5-Star system, which we all admit is not perfect, the industry should push for a new reporting system for staffing. That is what NCCNHR is doing. Join them. After all, the staff data are self-reported by homes. If your fellow administrators are “cheating you,” then I suggest that you advocate a reporting system that doesn’t allow them to do that.”

To Dr. Phillips I say, yes, you are absolutely right to point out that the energy should not be soley on casting doubt on the Five-Star system, but instead should be focused on the constructive work of fixing the public rating system as a whole.  The Five Star data just makes more accessible the already flawed Nursing Home Compare data.  Therefore, it is important to focus the anger we feel at being “cheated” by an innacurate  system into 1) convincing the public and legislators that this is a poor tool for researching nursing homes and 2) helping to devise a new system.  We must be careful of doom and gloom predictions and overactions like calling the Five-Star system a “travesty of justice,” as Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging said to members of Dec. 18th.

On a personal note, though, I still find my blood pressure rises when I think about how the quality of care I know my home provides is not as well reflected as I think it should be in its Five-Star rating.  Maybe the advice from older DONs than Directors of Nursing is appropriate here: (in Latin) “pace. pace. pace (peace. peace. peace.)”.  Let’s take a breath and work the problem instead of rail at it.

Like many of you, I have been pouring over the CMS Nursing Home Compare Five Star Ratings today.  The results have been . . . unexpected.  I operate a facility in Illinois, a state somewhat notorious in the Long Term Care industry, and when I looked at the ratings of facilities in my geographic region, I was truly surprised.  The variance is what got me.  Homes I know are pleasant, and seem to be well-run, scored much worse than those with bad reputations.  Many had perfect marks in the Quality Measures domain, but only one star in the Health Inspections domain.    

To try to get a handle on this new metric, I have also been pouring over the Technical Manual for the Five Star Rating System.  Entitled, “Design for Nursing Home Compare Five-Star Quality Rating System: Technical User’s Guide”, the 23 page report does  a fair to good job of laying out hte technical details of how the different domain scores are calculated.  My objection to this manual is that it does not give a very good rationale for why the score algorithms were selected over others.  I found myself wondering, ‘how did the Techincal Expert Panel (TEP) decide to score a domain this way instead of another.’  There are vague justifications: “distribution is based on CMS experience and input from the Project’s TEP” (page 5), but no real explanation or rationale.  

This Technical Manual may be (somewhat) easy to use then, but difficult to critique.  However, I would like to discuss one issue that bothered me.  First, I found it difficult to locate the study cited to on page five, “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care.”  (executive summary located here).  But, in the process of searching for this 2001 CMS staffing survey and study, I discovered the following, interesting article, first published in the scholarly journal, The Gerontologist: “Comparing Staffing Levels in the Online Survey Certification and Reporting (OSCAR) System With the Medicaid Cost Report Data: Are Differences Systematic?,” Bita A. Kash, PhD, Catherine Hawed, PhD, and Charles D. Phillips, PhD.  (abstract located here).  This article discusses some interesting results from a study of the OSCAR system.

The Techincal Manual cites the Online Survey Certification and Reporting (OSCAR) System as the source data for the staffing measures/Staffing Domain.  This is the same data used now for Nursing Home Compare, although the staffing data was not compressed into a quintile metric before the Five-Star Rating.  The OSCAR database includes essentially every piece of information a surveyor gathers during certification/licensure surveys and complaint surveys.  However, information on nursing home operational characteristics (like staffing ratios and Case-mix) are reported by the nursing homes themselves.  Inspectors review the information, but the data are not formally audited to ensure accuracy.  The study Kash, Hawes and Phillips study cited above arrives at a critical result to this operation.  The study sought to assess the validity of the OSCAR staffing data by comparing them to staffing measures from audited Medicaid Cost Reports.  The results of this study were that “[A]verage staffing levels were higher in the OSCAR than in the Medicaid Cost Report data.”  Meaning that “[C]ertain types of facilities consistently over-report staffing levels.”  This 2007 study went on to say that the implications of these findings are that “reporting errors will affect the validity of consumer information systems, regulatory activities, and health services research.”  

In other words, OSCAR data is inaccurate in reporting staffing levels and some facilities will have a lower staff-to-patient ratio than the data reflects.

What does this mean with respect to the Five-Star System?  Because the staffing ratios/RUG-III modifiers are relatively scored (i.e. a score based on how your facility matches up to other facilities in the same category), if a facility is over-reporting its staff ratios (as the above study suggests OSCAR does), then every facilities score in the Staffing Domain will be inaccurate.  If your facility happens to have a lower-ratio and higher complexity modifier than one of the innaccurate reporting facilities, your relative position will be even lower than it otherwise would have been if all facilities staffing ratios were accurately reported.  

The Staffing Domain can skew the entire star system.

Of course, it would be wrong to discard CMS’s new system based on the strength of one adverse study, but Administrators and academics need to give the whole Five-Star System a hard look.  The Staffing Domain is an important indicator of quality of care.  It should be in any comparison metric, provided the data source is accurate.  There have been a lot of criticisms leveled at the Five-Star System, but drilling down into the technical manual, I think, can provides the most salient.  

I encourage everyone reading this to do just that.  Keep this conversation going.

It turns out the main stream media has somehow received the Five Star data ahead of many nursing homes. The listserves are abuzz with Administrators complaining of having to talk to newspapers, televisions stations and the like about their five-star rating, without actually knowing the rating themselves.

Furthermore, there seems to be a lot of grumbling about the accuracy and precision of the Five Star Ratings. The five step “How the Ratings are Calculated” guide CMS sent to MDS mailboxes is pretty basic. In case you haven’t seen it, here it is:

How the Ratings are Calculated:

A nursing home’s Overall Quality rating on Nursing Home Compare ( is based on its ratings for Health Inspections, Quality Measures (QMs), and Staffing. Ratings for each domain and the overall rating range from 1 star to 5 stars, with more stars indicating higher quality. Based on these three ratings, the overall 5-star rating is assigned in 5 steps:

Step 1: Start with the Health Inspection Rating.

Step 2: Add one star if the Staffing rating is 4 or 5 stars and also greater than the Health Inspection rating. Subtract one star if the Staffing rating is 1 star. The rating cannot go above 5 stars or lower than 1 star.

Step 3: Add one star if the Quality Measure rating is 5 stars; subtract one star if the Quality Measure rating is 1 star. The rating cannot go above 5 stars or lower than 1 star.

Step 4: If the Health Inspection rating is 1 star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.

Step 5: If a nursing home is a Special Focus Facility that has not graduated, the maximum Overall Quality rating is 3 stars.

Nursing Home Compare provides a five-star rating for each of the following three components:

1) Health Inspection ratings:

• Ratings are calculated from points that are assigned to the results of nursing home surveys over the past three years, as well as complaint surveys from the past three years and survey revisits. More recent surveys are weighted more heavily.

• Points are assigned based on the number, scope and severity of a nursing home’s health deficiencies. If multiple revisits are required to ensure that major deficiencies are corrected, additional points are added to the health inspection score.

• Lower health inspection scores result in a better 5-Star rating on Nursing Home Compare.

• Nursing homes are ranked within their state based on their score, and the number of stars is based on where the nursing home falls within the state ranking.

• The top 10% of facilities get 5 stars, the bottom 20% get 1 star, and the middle 70% of nursing homes receive 2, 3 or 4 stars, with equal proportions (23.33%) in each category.

• Health Inspection ratings are re-calculated every month to account for new survey results entering into the system.

2) Quality Measure ratings:

• Ratings are calculated from a nursing home’s performance on 10 Quality Measures (QMs), which are a subset of those reported on Nursing Home Compare.

• The QMs include 7 long-stay (chronic care) QMs and 3 short-stay (post-acute care) QMs.

Long-Stay QMs Short-Stay QMs

• ADL Decline

• Mobility Decline

• Catheter

• High-Risk Pressure Ulcers • Physical Restraints

• Urinary Tract Infections

• Moderate to Severe Pain • Pressure Ulcers

• Moderate to Severe Pain

• Pressure Ulcers

• Ratings are calculated using the three most recent quarters of data.

• ADL Decline and Mobility Decline contribute more heavily (each weighted at 1.667 times) than the other QMs.

• A nursing home’s performance on the ADL Decline and Mobility Decline QMs is ranked against all other nursing homes in the state.

• A nursing home’s performance on the other 8 measures is ranked against all other nursing homes in the nation.

• Points are assigned for each QM based on what quintile the facility falls in comparison to other nursing homes. Points for each QM are added together for a total point score.

• Based on this total score, the top 10% of facilities nationwide get 5 stars, the bottom 20% get 1 star, and the middle 70% of nursing homes receive 2, 3 or 4 stars, with an equal proportion (23.33%) in each category.

3) Staffing ratings:

• Ratings are calculated from two measures: RN hours per resident day and total staffing hours (RN, LPN, nurse aide) per resident day. These two measures contribute equally to the Staffing Rating.

• Staffing measures are derived from OSCAR data that is then case mix adjusted based on the facility’s distribution of MDS assessments by RUG-III group, based on the number of RN, LPN, and nurse aide minutes associated with each RUG-III group

• Other staff, such as clerical, administrative, and housekeeping staff, are not included in the calculation of the Staffing ratings.

• For each staffing measure, a 5-Star rating is assigned based on where the facility ranks compared to the adjusted staffing hours for all freestanding facilities AND where the facility ranks compared to optimal staffing levels identified in the 2001 CMS Staffing Study.

• To earn 5 stars on the Staffing rating, the nursing home must meet or exceed the CMS staffing study thresholds for both RN and total nursing hours per resident day.

• The Nursing Home Compare website will include a “drill down” that shows the nursing home’s rating for RN Staffing.

The RN Staffing Rating for Nursing Home Name is .

Ratings are provided only for nursing homes that have had at least two standard health inspection surveys. Nursing homes that have not yet had two standard health inspection surveys are listed as ‘too new to rate,’ and no rating information is provided for the nursing home If the rating indicates ‘data not available’ then the data needed to rate the nursing home were not available.

If Your Rating Isn’t What You Think it Should Be

If your nursing home’s rating seems to be markedly different from your expectation, it may be that a recent survey has not yet been entered into the database. It may also arise from a dispute resolution or appeal decision that has not yet entered into the database. You can check the health inspection detail on Nursing Home Compare for more information about the particular deficiencies that entered into the calculation.

If your quality measure rating states “data not available,”, it means that there were too few eligible residents for us to calculate a reliable quality measure. If your staffing score says “data not available,” it means that the number of hours of staffing were found to be a value that were so extremely high or low that they were not plausible. In this case, please check with your state survey agency to confirm the staffing values you reported.

A technical manual containing additional information can be found on the CMS website (


If you have questions, please contact the 5-Star Helpline at 1-800-839-9290.

To make matters worse, as of this writing, the technical manual has not yet been published on CMS’ website (the link above). So, some Administrators are getting some pretty bad news, with no technical context in which to frame it.

Whether the Five Star Nursing Home Compare site will be a highly used tool by the public remains to be seen, but the five star system needs to accurately reflect the quality of care if it is to be a usable metric.  My fear (and I’m sure I’m not alone in this) is that the Five Star system will make a confusing, relatively difficult to use, flawed data set (the Nursing Home Compare website) less difficult to use, but still just as flawed.  I know my own facility’s overall star rating was less than I anticipated.  I intend to pour over the technical manual, looking for a way to match the Nursing Home Compare Five Star Rating with the quality of care I know my staff provides every day.

*Update: the technical manual is now online.  I’ve made the link above live.

Centers for Medicare/Medicaid Services reached out to nursing home administrators today in an attempt to quiet anxieties over next week’s roll out of the new Five Star Rating on CMS’ Nursing Home Compare website.  CMS Regional offices set up teleconferences with LTC affiliates, so member nursing homes could hear directly from CMS staff how the roll out was going to work and what last-minute changes were being made.  The key facts that made me take notice were:

1) State license and complaint surveys are going to be weighted so the five-star comparison is intra, not inter-state.

2) The Staffing tab data will be weighted across with RUG scores before being tabulated into the five-star algorithm

3) Nursing Home Compare will be kept up to date (within a quarter) and the Five Star will be updated monthly.  

I will be interested to see how this plays out next week when the Five Star rating is debuted.  As I said in my earlier post, though, I remain positive on the Five Star rating, though, it should be mentioned, this objective metric will never be able to capture the full scope of care being provided.

Today I happened to read James Berklan’s Editor’s Note in Mcknight’s concerning the coming-soon Five Star rating system on CMS’ Nursing Home Compare website.  (full article here)  

He makes some awfully good points: the Five Star comparison makes already deceptive data even more important, the promised “phase two” changes that would improve the inherent flaws have no target date — so may never actually come about, it is unclear if there are any Five Star rated homes in the country under this scheme, etc.  

I’ve been tracking this 5 star rating system for some time now.  (In fact, until very recently, I was convinced the opposition would be able to continuously delay its implementation).  In that time, I think I have heard every argument against this system, including Mr. Berklan’s well-reasoned and well-written remarks.  What I have not heard is whether this 5 star system will actually affect the way potential residents and their families use the Nursing Home Compare website tool.  

The Nursing Home Compare tool, as it currently operates, is convoluted and not very user friendly. Adminstrator colleagues at other facilities complain to me that the Five Star system will confuse potential residents because it compresses dubious data into a relatively arbitrary star system; but I wonder if the charts and spreadsheets of the current system do not leave users jsut as confused?  I know DONs and Administrators who pour over each metric on the current system, looking for ways to improve overall care, as well as ways to improve key numbers over the direct competition.  But, I’ve seen no real evidence that residents and familes use the website as diligently.  They may look closely at a few key metrics, but there is little or no guidance over which spreadsheets identify “good care.”  If the current system creates arbitrary distinctions with an overload of data, is the new system which compresses data in order to create arbitrary distinctions really all that bad?  

Maybe a familiar and generally well-understood metric like a five star system will be a better occassion for resident and family education than the mountains of data the current Compare website offers.