Steven Littlehale

“Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public,” published March 13, 2021, is one of the sloppiest pieces of reporting that I have ever read from the New York Times.

It is nothing less than shameful how this lazy journalism, coupled with the need to sell advertising space, purposefully perpetuates misunderstandings about nursing homes, caregivers and government surveyors alike.

To be completely honest, I am sure most nursing home professionals would match your over 5,000 words of damnation with their own sincere and objective analysis of what is wrong with nursing homes. Some of my negative critique would include the Five-Star Quality Rating System itself — the very system you examined yet clearly misunderstood. Our industry is far from perfect, and many of us have devoted our professional lives to its improvement. But although you used phrases like “analyze[d] millions of payroll records,” “373,000 reports by state inspectors,” and “built a database” to quickly establish trust in your readers and justify your article, it’s clear you’ve published something that shouldn’t be trusted.

To authors Jessica Silver-Greenberg and Robert Gebeloff, let me point out a few examples of what I mean by “lazy journalism.” You seem convinced that the nursing home data that comprises Five-Star is “self-reported.” Some points to consider:

  1. The Five-Star domain that carries the most weight is the health index (survey findings). These are deficiencies from annual recertifications and complaint surveys. Nursing homes do not self-report this data; in fact, surveys are conducted through an elaborate data-driven process that guides on-site investigation.
  2. Staffing data comes from the Payroll-Based Journal (PBJ) — read: payroll. I’m having a hard time understanding how a nursing home could manipulate its payroll data.
  3. The quality domain has the least amount of weight in the rating system and is based mostly upon Minimum Data Set (MDS) information. If a nursing home manipulates its MDS data to “look better,” it is lowering its acuity and willfully receiving less Medicare (and, in most states, Medicaid) reimbursement. This conflicts with your characterization of how nursing homes work. If the MDS is wrong, the entire care planning, evaluation and reimbursement system falls apart. Submitted MDS assessments often have assessment issues; onsite surveyors would cite these with a deficiency.

You stated that nursing homes are “exaggerating nurses’ hours” and then demonstrated the weakness of your investigation. Two quotes from the report illustrate this: 

“Thousands of homes … derived at least half of their nursing hours from administrators who don’t care for patients. C.M.S. permits the practice, but the public sees only the total number of hours, not the breakdown between administrative nurses and registered nurses who care for patients.”

Administrators’ hours are not included in Five-Star, but nurses with administrative duties are. Who are these people? Nurses who coordinate the completion of the MDS and care plans, directors of nursing and associate directors of nursing, staff development nurses, infection control nurses — all of whom routinely interact with residents and families and often administer direct care to residents.

“In 2018, C.M.S. improved the way it collected staffing data. … With the payroll records, nursing homes’ average staffing numbers plummeted, according to the Times analysis. That suggested that homes had previously been inflating their nursing data.”

Here you are referring to the transition from CMS form 671 to PBJ. Yes, undeniably the staffing numbers dropped (though they hardly “plummeted”), but the rules for counting time also changed. PBJ does not allow nursing homes to count unpaid hours in a staff member’s time. If a salaried person works a few extra hours during the week, those hours are not counted. The same goes for staff cross-trained to provide support during key times of the day: A recreational therapist who also provides support as a certified nursing assistant (CNA) will not have their CNA time counted. Jessica and Robert, did you miss that little detail? 

Furthermore, some of your broadest statements about the Five-Star system are contradictory. Your report stated, “Researchers have determined that the better staffed a facility was, the fewer residents they lost to Covid-19.” However, this conflicts with your later statement, “The Times found that there was little if any correlation between star ratings and how homes fared during the pandemic. … A facility’s location, the infection rate of the surrounding community and the race of nursing home residents all were predictors of whether a nursing home would suffer an outbreak. The star ratings didn’t matter.” 

Finally, I’m at a dead end when it comes to how you used the Integra Med Analytics paper, which looked at data from Medicare hospital claims, to support your hypothesis that nursing homes are underreporting serious incidents such as pressure ulcers and UTIs. 

The paper’s methodology section does not clarify much, but there is something off with how Integra Med compared Medicare hospital claims to nursing home data. What data did they compare the hospital claims to? MDS? The definitions from a Medicare claim and MDS are misaligned, and a long-stay Medicaid resident would not be represented on a nursing home’s Medicare claim. Flipping the argument, it is common for nursing homes to discover unreported skin ulcers on residents admitted from the hospital. But perhaps this sounds like sour grapes. It is unclear how you can speak to the misalignment of nursing home and hospital data from this non-peer reviewed article.

New York Times, I implore you to stop perpetuating misinformation that serves to hinder, rather than improve, how we care for our country’s most vulnerable population. We are fully aware of the need for improvement, and these distractions and plaintiff attorneys circling in the sky like buzzards just waste our limited time and resources. 

The millions of residents and families who rate their nursing positively, the thousands of caregivers and surveyors who give tirelessly to our industry, also have a story to tell. It may not sell as much, but work with us and be part of the solution.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.