Five-Star Quality Rating

For the first time in the 43-year history of Medicare, The Centers for Medicare & Medicaid Services (CMS) released a quality rating system for the nation's 15,800 nursing homes. Rolled out to consumers in December of 2008, the 5-Star Rating system was designed to make it easier to compare one nursing home to another.

"Our goal in developing this unprecedented quality rating system is to provide families a straightforward assessment of nursing home quality, with meaningful distinctions between high and low performing homes," said CMS Acting Administrator Kerry Weems . "The new information will also help consumers and families identify important questions to ask nursing homes and challenge nursing homes to improve their quality of care."

Under the 5-Star Rating system, nursing care communities are rated on three sets of information:

  • Health Inspections - Any nursing care community that accepts Medicare and/or Medicaid is regulated by both the federal and the state government. Communities are given an annual survey by the state, on average, every 12 - 15 months. State surveyors also investigate complaints from staff, residents or families. The surveyors review and evaluate the community based on over 180 items. These items include a wide range of standards from adherence to residents' rights to protecting residents from physical and mental abuse, to food preparation and storage. The health inspection portion of the rating system is based on the last three years of surveys, including both the annual and complaint surveys. The most recent year's surveys are weighted more heavily than the previous two years.
  • Staffing - Staffing is often considered the key criteria for evaluating quality of care. If a care community is understaffed, residents do not receive quality care. The staffing rating has information about the number of hours of care on average that is provided to each resident each day by nursing staff. This is broken down in to an overall average, in addition to the type of caregiver (Registered Nurse, Licensed Practical Nurse, Licensed Vocational Nurse, and Certified Nurse Aide). This rating also factors in the differences in needs of residents and their medical conditions. So, a nursing home with residents who had more complex illnesses would be expected to have higher staffing than those will less serious conditions.
  • Quality Measures - In this area of the rating, CMS looks at 10 different measures for nursing care community residents. These measures are both physical and clinical indicators of how well a resident is being cared for by the community. Some examples include looking to see if there has been decrease in residents' mobility or an increase in residents' pain. It also looks at the prevalence of pressure sores among residents.

How Ratings Are Calculated

A February 6, 2009 AARP Bulletin article, New Five-Star Rankings: One Way to Check Out a Nursing Home best explains how the 5-Star ratings are actually calculated:

5 star ratings

CMS uses a three-step formula to decide how many stars a nursing home should receive as an overall rating of its quality of care.

Step 1 A nursing home is first assigned a number of stars (1 through 5) according to information from health inspections of the home over three years. This number is the base rating.

Step 2 Stars are added or deducted according to the home's staff rating, which is based on the average number of hours of care per day residents receive. If the home's staff rating is 4 or 5 stars, one star is added to the base rating. If staff rating is only one star, then one star is subtracted from the base rating. If staff rating is 2 or 3 stars, the base rating remains the same.

Step 3 Stars are added or subtracted according to how well or poorly the home scores on 10 key quality measures (QM). If its QM rating is 5 stars, one star is added to the rating derived from steps 1 and 2. If the QM rating is only one star, then one star is subtracted from this rating. If the QM measure is 2, 3 or 4 stars, the rating remains the same.

Strengths and Limitations of the Five-Star Ratings

As with any rating system, there are strengths and weaknesses of the review system. The strengths and limitations below are taken from the government's www.medicare.gov website.

Health Inspection Results

Strengths:

  • Comprehensive: The nursing home health inspection process looks at all major aspects of care in a nursing home (about 180 different items).

  • Onsite Visits by Trained Inspectors: It is the only source of information that comes from a trained team of objective surveyors who visit each nursing home to check on the quality of care, inspect medical records, and talk with residents about their care.

  • Federal Quality Checks: Federal surveyors check on the state surveyors' work to make sure they are following the national process and that any differences between states stay within reasonable bounds.

Limits:

  • Variation between States: There are some differences in how different states carry out the inspection process, even though the standards are the same across the country.

  • Medicaid Program Differences: There are also differences in state licensing requirements that affect quality, and in state Medicaid programs that pay for much of the care in nursing homes.

Staffing

Strengths:

  • Overall Staffing: The quality ratings look at the overall number of staff compared to the number of residents and how many of the staff are trained nurses.

  • Adjusted for the Population: The ratings consider differences in how sick the nursing home residents are in each nursing home, since that will make a difference in how many staff is needed.

Limits:

  • Self-Reported: The staffing data are self-reported by the nursing home, rather than collected and reported by an independent agency.

  • Snap-Shot in Time: Staffing data are reported just once a year and reflect staffing over a 2 week period of time.

Quality Measures

Strengths:

  • In-Depth Look: The quality measures provide an important in-depth look at how well each nursing home performs on ten important aspects of care. For example, these measures show how well the nursing home helps people keep their ability to dress and eat, or how well the nursing home prevents and treats skin ulcers.

  • National Measures: The ten quality measures we use in the Five-Star rating are used in all nursing homes.

Limits:

  • Self-Reported Data: The quality measures are self-reported by the nursing home, rather than collected and reported by an independent agency.

  • Just a Few Aspects of Care: The quality measures represent only a few of the many aspects of care that may be important to you.

The 5-Star Rating system is not meant to be a family's sole method of selecting a nursing care community. CMS does caution that this information should be used in conjunction with personal visits and research.