A patient in a North Carolina nursing home was allowed to fall by a nurse aide. The aide and her friends/coworkers covered it up and for two weeks the patient was untreated for a hip fracture. She was eventually taken to a hospital and there it was found she had a broken hip. Shocked by the news, the family eventually was able to find out what happened. The resident’s family learned what happened only by reviewing follow-up reports from state inspectors.

As we know, rules and regulations get through “channels” and many times they do so without anyone noticing. That has happened again. A recent change in federal rules on nursing home inspections makes it nearly impossible for families to get the information they need to protect their loved ones.

According to the associated press, the changes were put into effect in October 2008 with little notice and without a public comment period. The change is getting sharp criticism for closing off critically important information. Under the new rules, the state inspector follow-up reports can’t be released without specific approval from the chief of CMS.

“It’s an extremely troubling development – it puts a lot of information related to nursing-home inspections off-limits,” said Eric Carlson, director of the Long-Term Care Project of the National Senior Citizens Law Center, a California-based nonprofit group funded in part by the federal Administration on Aging. “I think it’s certainly bad for consumers and the folks who represent them.”

The change bars nursing home surveyors from releasing privileged information to the public without approval from the Director of the Centers for Medicare and Medicaid Services. State employees (the nursing home and hospital surveyors) who perform inspections for the federal government have been reclassified as federal employees as part of the revision. This reclassification is only for this purpose, and not for wages/benefits or other purposes. The surveyors are still state employees. They contract to the Federal government to perform the surey and certification work and as such are required to follow federal standards and procedures, and in this case, are required to follow the federal procedures for the release or non-release of privileged resident/patient information.

Officials at the Department of Health and Human Services said employees have been too burdened by requests for information. Under the rule change, state employees who inspect nursing homes for the federal government are reclassified as federal employees who aren’t allowed to provide “privileged” information or documents to the public without approval from the head of the Centers for Medicare and Medicaid Services.

Requests were diverting employees from certification responsibilities, Michael Leavitt, secretary of the Department of Health and Human Services, said in announcing the change.

Lawyers are now finding out that the new rule has already slowed efforts to represent their clients. It is slowing down the process to get the information they need.

How does this affect you, the consumer? – You can see, it is putting a wall in your path to ensuring your loved ones are getting safe care.

What about those of you who are administrators and staff of nursing homes – now is it affecting you? You might think at first, that it is a good thing, but really, getting information out to the public about both GOOD and BAD state inspections is beneficial to the facility and to those who are wanting to look at where to place their loved ones.  I would think even those who administer nursing homes find the change in rules, without a public comment period, to be a poor decision.

Then look at who has to give the permission – the head of CMS – the head of a federal agency is going to review and provide permission for the hundreds of requests in every state? That sounds like an impossible task, the permission is either going to be given or withheld willy-nilly. What determines who gets permission to see the documents and who doesn’t? Will there be criteria? Who is developing that criteria? What patient rights are being stepped on here?



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Last week Medicare’s Nursing Home Compare website ( launched a five-star rating system for all nursing homes nationwide. Accordig to CMS, individual nursing homes will receive one to five stars in three categories — quality measures, nurse staffing and health inspections — as well as an overall rating. It will be the first time the Centers for Medicare & Medicaid Services (CMS) has used such a rating system. According to CMS the five-star rating system provides a new, simple, easy-to-understand approach to making what might be the hardest decision ever — putting a loved one in a nursing home.

I’ve taken a look at some information about this and want to share it with you. I will review the site more and we can discuss it more later. This has been such a busy month, and sometimes I get home so exhausted from surveys – I don’t get to writing like I should!

So the information, which has been sent to me by what I believe is a firm helping CMS to get the word out, is in the form of an adobe powerpoint slide presentation. The presentation explains that all nursing homes that are Medicare & Medicaid Certified (16,000 in the nation – and counting!) will receive a 1 to 5 star rating (I imagine it is something similar to rating systems used in many other avenues of life.)  The five star rating summarizes specific information for each nursing home. These areas are: 1. An Overall rating, 2. Health Inspections, 3. Quality Measures, and 4. Staffing.

For the health inspections, the star rating takes into account the 3 most recent annual inspections, with the most recent having the most weight, and all complaint investigations for the last three years. The rating considers the number and the Severity and Scope of the deficiencies, with the more serious ones lowering the star rating. If you remember, in July, we discussed Severity & Scope.

CMS selected 10 Quality Measures (we have not yet discussed this, but I will address that in a future post), which are basically what they sound like, measures of the quality of care in a facility. CMS selected the 10 measures with the highest reliability ans uses the three most recent quarters of data to help determine the star rating. I do want to point out that the quality measure data is dependent on the nursing home providing accurate data. The 10 that CMS selected to assist in determining the star rating for nursing homes are: ADL (Activities of Daily Living) change, Mobility change, High Risk Pressure Ulcers, Long Term Catheters, Physical Restraints, Urinary Tract Infections, Pain (for both Long Stay and Short stay), Delirium, and Short Stay Pressure Ulcers.

For staffing data, the star rating takes into account the number of hours of care on average provided to each resdient each day, the nursing staff (meaning RNs, LVN/LPNs and CNAs). CMS has adjusted these to account for differences in the level of care resident of different nursing homes may need.

5 Stars = Much above average, 4 Stars = Above Average, 3 Stars = Average, 2 Stars = Below Average, and 1 star = Much Below Average.

For the Overall rating it appears the calculation of the number of stars is in steps and Step 1 starts with the health inspection rating. Step 2 takes into account the staffing, and they add 1 star for a 4 or 5 star staffing and subtract a star for 1 star rating. The 3rd step adds 1 star for 5 Star Quality Measures and subtracts a star for 1 star Quality Measures.

So it appears each item has its own stars and then an over all star system is also determined.

I’ll take some more time to help you understand the system, and if you have any questions you’d like me to ask, feel free. The group who sent me the information stated I could talk to a CMS spokesperson if there were questions. Although this information is mostly for consumers, I can see an Nursing Home and Hospital Surveyor taking a look at this information during their offsite preparation for a survey.


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