An Analysis of the Quality Dimension in the Nursing Homes Across the United States

Understanding Nursing Homes (NHs) Quality ratings can be complicated. Medicare has three sets of criteria to assess NHs to be identified as Medicare or Medicaid or as dual-certified, and for a single final “overall star rating” that can be used to compare NH quality locally and nationally. Out of the three criteria, Health Inspections (surveys) as a criterion is like a foundation or a roof to the house whichever analogy you like the most. It forms the basis from which NHs are evaluated for the other two criteria in arriving at a cumulative final overall star rating. Further adding another dimension to the quality ratings, health inspections are also the basis for tagging NHs into two categories-Special Focus Facility (SFF)-these nursing homes have a prolonged history of serious patient safety and quality problems and the more recent, controversial Abuse Icon-these facilities have been cited for abuse where patients were actually harmed and or for having conditions for potential harm either in the past 12 months or for a longer duration

CMS identifies and places NHs with a history of serious problems on a list of SFF Candidates who then assume the SFF status when officially enrolled in a program to address and remediate these issues or face progressive steps including termination of Medicare and Medicaid contracts.

NHs with an SFF status (enrolled in the program) do not receive star ratings in any of the three criterion domains and will not have an overall star rating either

The analysis presented henceforth will generally follow the following roadmap-

1. All counties (in 38 states and 173 counties) in the United States with an average health inspection star rating of a 1 and an average overall star rating of a 1 or a 2

2. Counties (in 47 states and 81 counties) with a single NH provider and no star ratings (no health inspection and overall star ratings)-SFF

3. Counties (in 34 states and 123 counties) with a single NH provider and an average health inspection star rating of 1

4. Counties (13 states and 17 counties) with a single NH provider, with an average health inspection star rating of a 1 and either on SFF (none) or SFF candidate status

5. Counties (in 1 state and 1 county) with a single NH provider, with an average health inspection star rating of 1, either on SFF or SFF candidate status and a 20% or less average available bed capacity

6. Current NHs (524 NHs in 49 states) on SFF / Candidate status (and States with multiple counties where NH providers on SFF or SFF candidate Status)

7. Future potential SFF / candidate NHs (2505 NHs in 50 states)

8. Counties (in 37 states and 156 counties) with the best of the best NHs (a 5-star average health inspection star rating)

9. Counties with an average NH bed size of under 100 count (in 34 states and 109 counties) and with an average NH bed count of over 100 beds (in 24 states and 64 counties) and an average health inspection star rating of 1

The 2,946 NHs with the lowest health inspection survey scores, with a single star could be the ones that the

1. Patients and families need to be aware of when making choices

2. Insurers, hospitals (health systems, ACOs) and providers need to be aware of when referring patients. If your current goals are to improve expected patient clinical outcomes at the best possible cost and avoid harm, being informed and acting on that information timely is the key to attaining that outcome.