Should Nursing Homes Play By a 'Three Strikes' Rule?


Nursing home quality regulation is an issue that causes great angst in the elder care industry. Texas State Senator Charles Schwertner has proposed skilled nursing facilities be forced to play by the same rule that governs the great American pastime—three strikes, and you're out.

During a meeting of the Texas Sunset Advisory Commission, a panel aimed at eliminating waste in state government agencies, Schwertner proposed a simple, yet radical measure for holding facilities accountable: any nursing home that repeatedly put their residents in danger by violating high-level federal quality standards on three distinct occasions during a 24 month period would have its license stripped by the state Department of Aging and Disability Services.

The proposed law, which would only go into effect in Texas, was approved by the Commission, but faces a vote by state lawmakers before it can go into effect. "We've got to be able to take action against bad nursing homes," Schwertner said in an interview with an Austin-based ABC News affiliate.

Nursing homes' high marks may be undeserved

Schwertner's "Three strikes" plan coincidentally coincides with an investigation by the "New York Times," that questioned the accuracy of an important public source of nursing home quality information, Medicare's Nursing Home Compare website.

The site, which is run by the Centers for Medicare and Medicaid Services (CMS), has been the go-to place for rankings and information on the country's nearly 15,500 Medicare and Medicaid-certified nursing homes, since its launch in December 2008.

Consumers and medical professionals alike have used the information on Nursing Home Compare to determine where the frailest members of America's aging population can go to obtain optimal care, and facilities across the country have been chasing Medicare's coveted five-star, highest-quality, ranking.

On the surface, the incentive appears to be working. In January 2009, fewer than 12 percent of nursing homes garnered top marks. By July 2013, that percentage had nearly doubled, topping out at just over 22 percent. But this meteoric rise in the number of five-star nursing homes has led to some speculation among elder care experts.

Are America's nursing homes truly taking steps to enhance their quality, or have some just figured out how to game the system?

A fault in Medicare's stars?

In the Nursing Home Compare program, facilities are rated on a scale from one (below average quality) to five (above average quality) stars, based on their performance in three key areas: annual health inspections, how many staff hours are provided per patient, and quality measures that gauge the status of residents' health (e.g. bed sores, mobility, etc.).

The problem is, only the health inspections are conducted by an independent party. The rest of the information is self-reported by the nursing homes. The ratings also overlook other important factors, such as state-based sanctions and complaints against the facilities.

CMS stands by their methodology, saying "We believe the Five-Star quality rating system on Nursing Home Compare continues to offer valuable and comprehensible information to consumers based on the best data currently available."

However, CMS just announced plans to ramp up the rating system's strictness by implementing additional inspections, verifiable staffing reports and additional quality measures (e.g. how much antipsychotic medication is prescribed to people in a given facility).

In the meantime, Medicare's Nursing Home Compare website is still a solid reference point for families of aging adults who are searching or a suitable housing and care situation for their loved one.

For more information on searching, interviewing, deciding on and paying for care for an older adult, see the Senior Living section.

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There is no way the nursing home should be able to rate their selves. We have one in our town, and everybody laughs at the rating because they know how bad the home is, yet they have five stars. By allowing the home to rate their selves, it makes the survey useless and nobody will give it any credit.
The whole survey process is conducted by individuals, and therefore subject to their interpretation. One year you may have a team with some really "hard" sticklers who will cite the facility for some very slight infraction, and another year you may have a team, who turn their heads to some things they know are difficult to enforce every single minute of every day.
For instance: residents are not supposed to have any "drugs" in their rooms, including body powders or lotions, etc. because some demented patient may enter their room and injest the substance. However some family members may sneak in Mom's favorite scented powder and put it in her drawer. If the team finds this, some will cite you regardless of how it got there, and other teams will listen if you tell them that the family sneaks things in, in spite of every attempt to control the situation, and will understand that while you are trying to enforce every rule, you cannot control every single person at every minute of the day.
I say "no" to the 3 strikes rule, as there are already steps in place to put nursing homes under state control until they bring their operation up to standards.
Good for Texas. Here in Michigan the Nursing Home Association threw big bucks into Gov. Snyder's campaign and now do whatever they please.