The Nursing Home Compare website is a useful tool for those looking for a good nursing home or checking the background of a nursing home where a family member lives. Although this resource and others like it are available, they can be difficult to interpret. In today’s episode, nursing home abuse attorneys Rob Schenk and Will Smith discuss the Nursing Home Compare website with guest Richard Mollot, Executive Director of The Long Term Care Community Coalition.
Schenk: Hello out there and welcome. My name is Rob Schenk.
Smith: And I’m William Smith.
Schenk: And thank you for joining us. We are co-hosts for this episode of the Nursing Home Abuse Podcast, talking about the Nursing Home Compare website.
Smith: Yeah, so there are a lot of different websites out there, A Place for Mom is one of them. There are other private organizations – US News and World Report Best Nursing Homes or Worst Nursing Homes. And what we’re going to be talking about today is the government-run Nursing Home Compare website that is funded and used by CMS, which is the Centers for Medicare and Medicaid Services. We’ve got Mr. Richard Mollot on the air. He’s the executive director of the Long-Term Care Community Coalition.
Schenk: Sixth time. Sixth time on the podcast.
Smith: Oh yeah, no, Richard – I originally met Richard at the Consumer Voice Conference back in October of last year, I think, and he was going through the rating systems and what the different data means. So this man runs a website called Nursing Home 411. He works for the LTCCC, which is the Long-Term Care Community Coalition. It’s a nonprofit organization dedicated to providing care for seniors and the disabled through legal and policy research, advocacy and education. And so we’re really lucky to have him on here taking us through the government-run Nursing Home Compare site because he’s going to explain what data is important, where they get the data and how to use this site to determine an appropriate nursing home for your loved one.
Schenk: Richard, welcome to the show.
Richard: Great, thank you very much. Thanks for having me, really excited to be speaking to you guys again and also to be talking about one of my favorite things, which is looking for quality and other important information for the public and for residents and families on Nursing Home Compare. So I thought that I would start with just a plain Google page on my website, if you can see, and just type in “Nursing Home Compare,” and show you what – it’s medicare.gov/nursinghomecompare, but for those who are not that involved every day, it may be hard to remember. So if you type in Google “Nursing Home Compare,” you’ll see what came up for me here is medicare.gov/nursinghomecompare.
I just want to mention to be very careful, like the other search results will come up – if you look down here, it’s Caregivers.org, there’s another one – A Place For Mom. Many of those places take advertising money from nursing homes and assisted living to be listed. So you want to make sure you’re going to the Medicare.gov website.
And here you see “Find a Home” – so it’s Medicare.gov on top, “Find a Home,” and you can type in really anything that you’re looking for. So what I’m typing in here is “Atlanta,” and you’ll see it comes up with Atlanta, Georgia. And if I want to, I can type in the name of a nursing home, but I don’t have to do that. I’ll just do a search and see what I come up with. And what we’re going to be looking at today is one of the Pruitt Health facilities – actually Pruitt Health Virginia Park is one of the ones we’re looking at and it comes up right here.
So for people who just in general might be searching for a nursing home in their area, I think it’s worthwhile noting that you can see here they show 55 nursing homes within 25 miles from the center of Atlanta, Georgia, but on the right hand side, you can modify your search. I can change that to within 100 miles in a more rural area, 50 miles, 10 miles, one mile if I’m in the city, etc. And I can also add the name of a nursing home if I’m interested in a specific nursing home – perhaps I have a loved one there or it’s a nursing home that the hospital told me they’re going to be sending my loved one, etc.
And just before we move on, there are also these green buttons to compare. You can compare up to three nursing homes at one time to compare to get some information on them.
Schenk: Oh, that’s fantastic, Richard. Is that a new function? Has that always been there?
Richard: Yeah, it’s always been there.
Schenk: Oh, okay. I’m just not very observant then. So you’re clicking on Pruitt Health Virginia Park as an example.
Richard: Yes, also before we move on, you can see here, they have the overall rating. So there’s the nursing home name on the left hand column. There’s the overall rating, health inspections, staffing, quality measures, and then lastly the distance from wherever you searched from if it was a geographic search. So you can see here the stars very easily, the star ratings for each one of these.
Now I think it’s important to know, as I mentioned, I do a lot of work with Nursing Home Compare and other data, and the Nursing Home Compare data are not perfect – we’ll talk about that in a little bit – but they are in my estimation by far the best information, the best data that’s out there for people who are looking at nursing homes or are looking at the nursing homes in their area.
I think it’s really important to note that in the way that nursing homes are rated, the different criteria, they are much better at identifying poorly performing facilities and highly performing facilities, meaning that in my opinion, if you have a one- or two-star facility, it’s very, very, very likely to be an extremely poorly performing facility, whereas if you have a four- or five-star facility, that doesn’t necessarily mean that it’s a great place because of the way that the rating system works. So I think it’s just very worthwhile to note that a five-star facility may be good or it may not be, but you can be reasonably certain that a one-, two- or even a three-star facility is not going to be very good.
So you can see here if you were doing just a general search looking in your area, where you want to start, and I always tell people, if they’re able to, start with a four- or five-star facility and try to eliminate one-, two-, and if possible, three-star facilities if you’re making a choice.
But we’re going to go to Pruitt Health right now in Virginia Park, and so here you can see the information that is provided. This is the general information and there are tabs here, “Health Inspections,” “Fire Safety Inspections,” “Staffing,” “Quality of Resident Care” and “Penalties.”
Schenk: Okay, Richard. So let me kind of – let me ask this. For the audience that’s actually watching this podcast versus listening to it, you’ll see there are the tabs that highlight the different categories. My question is how does the information get gathered for each of these tabs? Very quickly, can you walk us through how is this information even acquired from the nursing home before it can even be displayed on this website?
Richard: Sure, and that’s a really good question. So the health inspections are based upon the annual inspections that take place from the state as well as any complaint generated inspections, so that’s the star information and the information that we’ll talk about there based solely on that.
The fire safety inspections are also part of that, usually when a survey takes place, which is approximately annually, they’ll look at healthcare, they’ll look at fire safety.
Staffing is extremely important, you guys know and many people in the audience know, so staffing is based now, very recently, it’s based on payroll-based journal data. It’s really, really important we do a lot of work around staffing because it is such an important criteria related to resident care and quality of life. Up until November of last year, it was actually – let me restate that, sorry – up until the spring of this year, the staffing data were based upon what was self-reported by the facility once a year and not audited by either the state or the federal government, and there were long-standing concerns that nursing homes were inflating their staffing data. Starting in the spring of this year, CMS listened to us and other advocates and they started requiring that nursing homes report payroll-based, so the actual who they paid coming in for certain hours every day, and those data are collected on a quarterly basis, and those data are now included. So the staffing information on Nursing Home Compare are now, as of just a few months ago, much stronger, much more reliable.
Schenk: Oh good. That makes sense. And I ask that, Richard, because I want the audience to understand and make sure that generally when they’re searching online for services and other items, they’re going to Yelp or Google Review. I just want the audience to understand and know that this information is not consumer or the residents grading the facility. This is actually based on inspections conducted by Centers for Medicare and Medicaid Services as opposed to Yelp, if that makes sense.
Richard: Correct. And I think that’s a really good point. It’s something I’ve been thinking a lot about lately. People are rating nursing homes more on Yelp and other online reviews, and that’s fine. I think it’s really important to go back to the data as much as possible and look at what is, again, the most reliable information. But it could also be useful to find out what people are experiencing. A lot of advocates and family members complain that we’re not hearing about what residents and families want and what they’re experiencing, and those things are undoubtedly important. That’s the whole entire mission of my organization is to improve care for residents and to empower them and their families. However, I think that when a resident or a family, when we complain as customers in any setting, we tend to complain about things that we have knowledge and expertise, which is our experience, how we’re feeling, how we’re being treated, etc.
But what is extremely important, I think we’d all agree and I’ve been a family member several times as well is that is the care good? How are we measuring the quality? And I know personally, I’m not a clinician. I don’t have the expertise to do that, so I rely on staffing data, I rely on this health inspection data as well. So it’s really important. Again, I’ve been a family member, and as someone who has some expertise on these issues, I think that these are the most important things to look at, but that people’s experience can be useful as well.
Schenk: Fantastic. So we’ve gone to the Nursing Home Compare website as a family member and we’ve searched, for the sake of this particular episode, this person is looking at Atlanta. We’ve chosen out of the 55 or so options that the Nursing Home Compare website populated for us, Pruitt Health Virginia Park. We’ve clicked on that and now we’re looking at the general information is what displayed first as long as these tabs. So at this point, guide us through what we’re looking at and what other information is available for us for this particular nursing home.
Richard: Sure. So again the tabs, the first two tabs relate to the inspections. The health inspections I think are the most important terms of how the facility did in regards to their health inspections. And then our safety, staffing, quality of resident care and penalties – now quality of resident care, it sounds like it’s exactly what you’re looking for. What’s the quality of care? I don’t care if you have two people on staff or 200, my concern is quality of resident care.
Unfortunately, almost all of the indicators and all the criteria that they use are self-reported and unaudited, and a lot of them are very subjective. So although it sounds like it might be the most important, it’s actually – I completely disregard them. Yes, I do. And we work with several other advocates in our national advocacy with CMS, and we have pressed them successfully to include some what they call claims-based, insurance claims-based criteria there, but again, for the most part, it’s really based upon a subjective criteria, which unfortunately nursing homes are able to game.
So here you see this nursing home has a two-star rating. If you look down below at the star rating categories, based on the health inspection, the staffing and the quality of resident rating – but oftentimes, frankly you’ll see nursing homes that have one or two stars for inspections, one or two stars for staffing and then four or five stars for quality of nursing. It’s quite often completely out of balance, so that’s why I don’t look at it.
Before we move on a dig a little deeper, I just want to mention some of the information that’s provided here on this general page. You can see how many beds there are. You can see if they’re participating in Medicare or Medicaid. You can see if there are automatic sprinklers, whether there’s a resident council or a resident family council, so that’s useful to know as well.
Smith: And what does that mean, Richard, that a resident council only, just out of curiosity?
Richard: So that means there’s only a resident council, that there’s no family council in the facility. We’re doing more and more work, my organization, to educate and empower family councils, and part of that is based upon research that has found where there is a family council in a nursing home, there tends to be much better care, not only for the residents who have family members on the family council, but for all residents. So we’ve been focusing more and more – we’re actually starting a new project in August to work with family councils and to provide them with tools to empower them to better understand their residents’ rights and to advocate for them. So check back on our website. Put in a plug.
So let’s look at the health inspections – let me go back one second, I’m sorry. So if you look again at those three categories, health inspection ratings, safety ratings, quality measure ratings, those are the three ratings that are put together in the facility’s overall rating.
Schenk: I got you.
Richard: So that’s just worthwhile to note. That’s what CMS looks at, but the research that I’ve read, my own experience researching hundreds and hundreds of Nursing Home Compare listings and statements of deficiencies, etc., indicates to me that the quality measures, I don’t give a lot of credence to. I really look at the health inspection and the staffing ratings.
So if you go to the health inspection tab, you can see what their rating is and why. So here they have a two-star rating, which is below average. That would be, again, very alarming to me because as I mentioned before, these rating systems tend to better identify poor care than – excuse me, let me rephrase that, sorry – rating systems do not always capture when there is poor care, so if you have a one- or two-star facility, again, it’s very likely that type of facility is providing a very poor quality of care whereas if you have a four- or five-star facility, which may seem very good, like you go to a four- or five-star movie, it does not necessarily guarantee that the facility good. So when I see two stars, that says to me that they have identified generally some very serious problems in this nursing home.
Schenk: So what can we clean from this particular screen of Pruitt Health Virginia Park as of today, August 27th, Richard? Like what are we looking at?
Richard: So looking at this facility, if I was just coming to it fresh, I would see two stars – that would be significant concern to me. You can see generally the last three years of health inspections and citations, etc., on this page, so you can see their most recent health inspection was in March of this year. But the number of citations, 11, I know is high, and if you look underneath the next blue bar located at the top of the screen, the previous health inspection and the average number of health citations in Georgia is three.
Smith: Oh wow.
Richard: So this facility has almost four times.
Smith: Four times, yeah.
Schenk: So what does a citation mean, Richard?
Richard: So what a citation means is, we’re just talking about health citations here, that the facility is found to have been in violation of 11 different minimum standards of care in March of 2018. It’s really poor – I don’t want to give people too much information because I know it can be overwhelming, but think about it again. I know that families tell me this all the time, they expect to come in once a year, oftentimes the facility is at least somewhat aware of when they’re going to be inspected, so sometimes facilities will actually beef up and clean up the place, they’ll beef up staffing a little bit around that time period. And I’m not saying it’s necessarily a result of fraud – it could be that if it’s in a rural area, they see there are cars parked in other nursing homes in their community, it could be that they were inspected March of 2018 and they were inspected in February or March or April the year before, February, March, April the year before that, so now around this time is when we can expect an inspection.
So the reason why I mention that is, again, this is why these star ratings are oftentimes the tip of the iceberg, is that this is just a snapshot the inspectors have of one time they were in the facility. And you know when the inspectors come in, whether the facility is somewhat aware of them coming or not, the facilities are on their best behavior.
Schenk: All hands on deck.
Richard: Right. They’re all hands on deck. Exactly. That’s why, again, some of these ratings are, in my mind, the tip of the iceberg. So when you see 11 citations, that’s clearly a significant concern. It’s four times the number of health citations in Georgia, and almost double the number of health citations in the United States. Now just looking at those two numbers, the average number of health citations in Georgia is three, the average number of health citations in the country is 5.8, that tells you that Georgia does not identify a lot of problems in nursing homes.
Smith: Oh yeah.
Schenk: I would have said the opposite. I would have said, “Wow, Georgia is doing pretty good.”
Smith: I know we’re not.
Richard: Pardon me?
Smith: I said and I know that we’re not.
Richard: Right, right. And that’s the thing. We dig deep into the data so that others don’t have to, so hopefully this program, we’re providing you with some information that allows your audience to get a good sense and make smart decisions about their residents and about where they go for nursing home care and what they can understand or what they can do if they’re in a nursing home or have a loved one in a nursing home. But essentially I can tell you that that’s not the case – the fact that a state has low level citations is not indicative of the state providing or the state’s nursing homes providing better care unfortunately. There are a number of different criteria that we look at that I’ve studied over the years – pressure ulcer rates, antipsychotic drugging rates, staffing levels, etc., and other researchers have done this as well – that indicate that there’s not that kind of variation, especially among the bigger states. Sometimes some states like Alaska only have a very small number of nursing homes, or Puerto Rico, we see they’re much smaller, but a state like Georgia, it’s a fairly large state so it would even out in terms of quality, but it’s not evening out in terms of the ability of inspectors to identify problems.
Smith: Got you. Well they need to use this website in conjunction with yours then, the Nursing Home 411, because this one I think can be a little misleading.
Schenk: Yes, and we’ll actually visit that on another episode, your site, so that would be something…
Richard: Oh great, I actually – I did have a window open if you want, but I want to go to staffing next.
Schenk: Yeah, in the last few minutes we can talk about staffing, and Richard, once we’re done with that, I want you to actually – you told me that the quality of care is not as important – can you identify, after you’ve gone through staffing, what is the most important in terms of the information provided here in terms of a decision to place your loved one in this particular nursing home?
Richard: Sure, I would say it’s what we’re looking at right now. It’s staffing.
Smith: Got you.
Richard: Yeah, and the reason for that is, as we were just discussing with Georgia compared to the rest of the country is that our studies, government accountability office studies over the years have all shown that nursing home inspectors and state inspectors don’t do a great job at identifying problems that exist in a nursing home, and again, that goes back and is supported by a lot of data – prevalence of pressure ulcers, prevalence of antipsychotic drugs, prevalence of falls year after year after year, that we see a lot of nursing homes that have substandard care with these citations year after year after year after year, so that indicates over and over again that the state inspection systems are not adequately identifying problems and ensuring that facilities correct the problems that they do identify. That’s the heart of our mission.
So we look at staffing because the staffing is so important. Academic studies have shown that it’s one of the most important if not the most important criteria when it comes to quality of care. It’s, again, absolutely it’s not perfect but it’s absolutely critical and we’re going to talk on our next episode about the statement of deficiency, but I often say to people when I read about a deficiency whether in a news report or a lawsuit or a statement of deficiency, I can almost always see there wasn’t staffing there. There wasn’t staffing there to answer the call bell. There wasn’t staffing there ensure that someone was monitored and repositioned for pressure ulcers. There wasn’t staffing there when someone was given an antipsychotic drug rather than the care that he or she needed to address dementia-related symptoms, etc.
Schenk: So then looking at this information, what is the staff ratio that you want to see? What’s the – this obviously says two stars below average, but how I do understand that that’s actually below average? What am I looking for?
Richard: Well what you’re looking for is high staffing, of course, very, very bluntly, and high RN staffing is very important. So here you see that the RN hours per resident day, the line here, is 22 minutes per resident day. Georgia averages 24 and the national average is 40. So again, substantially below, but in terms of what studies have shown is that you really need three-quarters of an hour of RN care time per resident per day to provide decent care.
Smith: Got you.
Schenk: Wow. So you’re saying even more than the actual national average, you think it should be 45 minutes.
Richard: Yeah, so the national average is very low. The inspector general, the U.S. Inspector General for the Department of Health and Human Services basically did a study years ago, and they found that over 90 percent of nursing homes don’t have enough staff. That’s why nursing homes tend to be poor places to live and poor places to get care. That’s why my work exists and your work exists, because so much nursing home care is unfortunately substandard, and unfortunately abuse and neglect are pretty pervasive and long-standing issues, and that again comes down to essentially just not enough staff? And why is there not enough staff? Because there are no numerical standards. We know the numbers that are needed to care for a typical resident. As I said, we need about 0.75 hours over the course of an hour per resident per day in RN time, and about four-and-a-half hours in total staff time per resident per day to provide good care for a typical resident. You can see that we are nowhere near that here. They’re providing three-and-a-half hours, and the national average here is just under four.
Schenk: Well Richard, you’ve guided us through Nursing Home Compare, some of the categories of information you can gather from it, which ones are a little bit more important, which ones not necessarily to disregard but not give as much credence to. In the last couple of minutes, do you want to tell us about your website that also takes this data and analyzes this?
Richard: Sure. So very quickly, we put a lot of information on our website for consumers. This is a picture of our nursing home staffing page for the last quarter. So as I mentioned earlier, the federal government started requiring that nursing homes provide payroll-based journal data every day on a quarterly basis, and as you see here, we have it for every single state, and the file, we try to make it as easy to use as possible.
But I know it’s still a lot of information, but we have separate state files, and here I’ve highlighted the Pruitt Health Virginia Park, the same nursing home. And you can see what we did here is we took out the hours of staff that were assigned to provide care. CMS now requires nursing homes to separate who is assigned to provide care and who is assigned for administrative staff. And as far as I’m concerned, as a family member, as an advocate, I don’t care if your administrator is an RN, because he or she is not providing care to my resident. Who I care about is who is assigned to provide care.
So here we have it. You can see here we have average staffing hours per resident day for the quarter – Pruitt Health had actually 3.5 hours and their average RN care staff hours is only 0.2 hours per resident.
Schenk: Yeah, so this website in some instances is much more in depth and provides much more analysis that Nursing Home Compare.
Richard: Yeah, you can quickly go to our website and see what is my nursing home providing in terms of staff that they have assigned to provide resident care.
Schenk: Right. And what’s that website again?
Richard: It’s NursingHome411.org.
Schenk: Awesome. Well Richard, I hate to – I feel like we’ve just scratched the surface with these, but for time, we’re going to have to cut and run, but Richard, we’re going to definitely have you on next week to talk about once you’ve looked at the Nursing Home Compare and got the information, how to analyze some of that data. But we’re definitely going to have you on again to walk us through with this website, which is fantastic. But always, you’re the five-timers club, I believe, now in terms of number of appearances and we really appreciate that, Richard.
Richard: Oh, thank you very much. I appreciate the opportunity to speak to you all and the audience as well. Thank you very much.
Schenk: Thanks, Richard. Awesome, we’ll talk to you next week.
Richard: Okay, bye-bye now.
Schenk: What a great guest. Richard is a combination of just knowledge with being able to succinctly, unlike me, to provide that knowledge, which I feel like whereas I stumble, Richard can just answer the question and go right to it. He’s a great guest.
Smith: Yeah, I mean he’s a policy wonk and he’s a data guru.
Schenk: A data cruncher.
Smith: Yeah, a data cruncher, so it’s always good to have guys like that.
Schenk: Yeah. But I guess with that, that’s goingto conclude this particular episode of the Nursing Home Abuse Podcast.
Schenk: Will, you’re walking down the street. Somebody comes up to you and says, “I desperately want to listen to the latest episode of the Nursing Home Abuse Podcast, but I have zero understanding of how to do that.” What do you tell him?
Smith: Well you can go to multiple different mediums and you can watch it at www.NursingHomeAbusePodcast.com. You can go to our YouTube Channel. If you do, make sure you click the subscribe button. Or you can download it anywhere that your favorite podcasts are available.
Schenk: And he grabs you by the collar and pulls you closer and says, “Where are my favorite podcasts available?”
Smith: So you can certainly go to Stitcher or iTunes. You can go to Spotify or Podcast Puppies or Pound Puppy or whatever it is you say every time, which I don’t even think is a real thing. Anywhere where your favorite podcasts are located, you can download the audio or the MP3.
Schenk: And he breathes a sigh of relief and he continues walking down the street. And with that, everybody, we thank you for joining us and we’ll see you next time.
Smith: See you next time.
Thanks for tuning into the Nursing Home Abuse Podcast. Nothing said on this podcast, either by the hosts or the guest, should be construed as legal advice, nor is intended to create an attorney-client relationship between the hosts or their guests and the listeners. New episodes are available every Monday on Spotify, iTunes, Stitcher or on your favorite podcast app as well as on YouTube and our website, NursingHomeAbusePodcast.com. Again, that’s NursingHomeAbusePodcast.com. See you next time.