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Survey delays reduce nursing homes’ 5-star ratings and create legal and financial pitfalls
While it is widely understood that 5-star ratings for nursing homes do not always accurately reflect a facility’s true performance in real time, or even in a timely manner, less attention has been paid to the financial and legal headaches that the system classification system created for suppliers and consumers.
The complexities underpinning the 5-star rating system have to do with the process of data collection, analysis and implementation, as well as delays in inspection surveys due to a shortage of inspectors. The entire process is fraught with pitfalls, causing nursing homes with low ratings to be denied loan refinancing and incur revenue losses due to decreased occupancy.
This situation may also cause facilities to be unfairly excluded from participating in preferred networks for federal government incentive programs, which may be supported based on a facility’s star rating.
In short, an outdated classification can last for months on end, industry experts told Skilled Nursing News.
At the heart of the problem are two types of delays, those arising from survey delays and those related to the inevitable delay between data submission and its reflection in star ratings, according to industry expert Steven Littlehale, chief innovation officer at Zimmet. Healthcare Services Group. .
By definition, there is a six-month lag – or two quarters – between the time a facility submits data to the Centers for Medicare and Medicaid Services (CMS) and the time it is integrated into star ratings.
“Therefore, there is the concept of an expected delay when a facility is populating data from the minimum data set and PBJ files. AND [even as] they are submitting them on schedule to CMS – no one is late, no delays – but the operational processing of these data sets results in six months between the time a facility submits the data and the time that data is reflected in the ratings by stars,” Littlehale said.
On the other hand, there is another type of delay that is directly attributed to research delays. Due to these delays, some facilities have surveys from six years ago that are still being factored into 5-star ratings. Even though the nursing facility has made huge investments in improving quality, or even under new ownership, these outdated ratings affect the facility’s ability to refinance, he said.
Legal and financial problems
And so unintended delay, while intrinsic to the system, can have far-reaching consequences, Littlehale said.
In lawsuits, for example, lawyers often cite star ratings as evidence of a facility’s quality of care at the time of an incident. However, what they do not consider is the gap between the incident and the data reflected in the classifications. This discrepancy can significantly impact the outcome of legal proceedings, painting an inaccurate picture of a facility’s performance.
“What happens in court is that a lot of times the plaintiff’s attorneys will say, ‘Here’s the star rating that matches the date of the incident.’ And I always have to explain that if you want to talk about personnel or clinical outcomes at the time of the incident, you have to fast forward six months, or basically two quarters, in the MDS assessment and the PBJ data that reflects back to that incident period. ,” explained Littlehale.
However, if a facility undergoes an ownership change and subsequently improves its operations despite positive changes, outdated survey data continues to haunt them, influencing their eligibility for preferred networks and financial opportunities, Littlehale said.
Furthermore, there are regional variations in the timing of surveys.
“I looked at the average polling gaps between the most recent poll and the last poll and it varies a lot by state, and even within the state it varies a lot,” he said. “The problem is that if a facility has had a negative survey in the past and is not having the opportunity to update the data from that survey, that old survey, that incident that may have happened three or four years ago, is still being reflected in the latest survey. recent.”
A low rating due to a previous, already corrected citation will be reflected in the rating and work against the facility.
“Then this comes up in court where they will say, in the assessment of the premises, the rating is one and I will have to explain that whilst this is true, there has not been a surveyor in the building in over 24 months… The facility has not had the opportunity to clean its record, to get a new independent assessment – and that is very unfortunate,” said Littlehale.
In fact, being denied funding or being excluded from such preferred networks on value-based programs due to a below-average star rating can deal a severe blow to a facility’s bottom line, further compounding the financial pressure caused by regulatory delays.
Meanwhile, delays in research can often exacerbate problems related to federal and state reimbursement, according to Tina Sandri, CEO of D.C.’s Forest Hills, who also serves on the Board of Governors of the American Health Care Association (AHCA).
“Inspectors are currently spending a disproportionate amount of time, compared to pre-COVID, researching complaints. And this is taking away their time to do regular research. So they are also dealing with staff shortages the same way we deal with staff shortages, which is why people are not receiving their surveys on time,” Sandri told SNN. “This can impact funding if you are receiving Medicare-Medicaid funding and your funding is withheld because your research is not actually done on time. This impacts [the facility’s] cash flow and ability to provide services.”
Solutions to avoid headaches with a 5-star rating
Sandri’s solution to avoiding survey delays – and related 5-star problems – is to have more certified professionals assess quality per installation than is currently the norm.
“As a provider, I really think that if we could expand the accessibility of certifications and training to [quality certified professionals]especially with a focus on complaints and customer service, we could essentially hit the low-hanging fruit of quality issues,” said Sandri.
Additionally, conducting peer-based surveys is a proactive approach to avoiding later citations and maintaining consistent quality, according to Robert Hurlbut, president of Hurlbut Care Communities, which operates 11 facilities in the New York area.
“We do peer reviews where our administrators act as employees of the New York State Department of Health, and they come in twice a year to do that. [an informal] survey. And if they find something wrong, they write it down. But that doesn’t [seen as] punitive,” Hurlbut told SNN.
A peer review is simply a preventative move and is internal to the organization, with administrators and department heads, from cleaning and laundry to diet and nursing, evaluating and helping to resolve issues within 30 days, he explained.
“It works,” said Hurlbut, who said not only has he avoided citations at his facilities, but a nice side benefit has been lower turnover among his team leaders and nursing home administrators.
“We have administrators who have been with me for 15 or 20 years,” he said.
That said, although quality is not compromised and the facilities remain in good standing with research, even this solution does not guarantee profits.
“I have about three edicts: take care of residents and employees, do really good research for the state health department and then make money – [money] it’s the last one,” Hurlbut said.
Need for systemic change
At the end of the day, Littlehale emphasized the need for systemic changes to address these issues. From a policy perspective, stakeholders should work together to decouple survey results from programs like the Five-Star Quality Rating System when delays make them unreliable, he said.
Additionally, he urges facilities to leverage data-driven approaches to tell their story – to lenders, referral sources and regulatory bodies. By presenting their clinical outcomes, staffing ratios and the impact of regulatory delays, facilities can advocate for fair treatment and mitigate the financial repercussions of outdated star ratings.
“The biggest offense is that consumers are being encouraged to use the 5-star system to make placement decisions and monitor care. However, it is terribly outdated,” Littlehale said. “Nobody wants that. Residents, families and service providers want to use current, accurate data to make important decisions.”