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TN nursing homes rank fifth worst in U.S.
Staffing levels are less than half what Medicare suggests
By Christina E. Sanchez
Poorly staffed http://health.state.tn.us/NursingHomes/index.htm">nursing homes have put Tennessee among the worst in the nation for quality of long-term care for a second year, a federal report shows.
Only four states had worse standings, according to a Tennessean data analysis.
That's because Tennessee has one of the lowest staffing requirements in the country — less than half of what Medicare recommends.
"We don't think the standard is enough," said Traci O'Kelley, assistant administrator at West Meade Place, one of only two nursing homes in the Nashville area to earn top marks in the survey.
But it is unlikely that facilities' staffing will get better anytime soon, in part because state law would have to require higher staffing levels, and funding for nursing homes would have to increase.
60% got low ratings
About 15,000 nursing homes nationwide got ratings of one to five stars, with five being the best, from the U.S. http://www.medicare.gov/NHCompare">Centers for Medicare and Medicaid Services. The ratings are based on inspections, complaint investigations, staffing levels and other nursing home survey data collected in 2008 and 2009.
More than 60 percent of Tennessee's 319 nursing homes got low ratings — one or two stars — for staffing by registered nurses.
Overall, the state ranked in the bottom five. Only West Virginia, Texas, Georgia and Louisiana had lower average scores. However, Tennessee fared better than it did a year ago, when the star ratings earned the state's nursing homes a third-worst designation.
Tennessee's results were better this year in quality of care, which measures such factors as the number of patients developing bedsores and infections. Staffing levels remained the biggest problem.
"We have 319 nursing homes in the state. To have one out of four rated just as one star is a sign we are not doing our job in Tennessee," said Patrick Willard, AARP advocacy director.
Staffing law faulted
Advocates say the staffing level required by state law is not enough to care for nursing home residents, and that carries consequences: ignored bedside calls, medication errors and unanswered questions.
Under Tennessee law, each patient should have at least two hours of direct care each day, including 24 minutes of a licensed nurse's time. Standards in neighboring states vary, with Mississippi requiring 2.8 hours of direct care and Arkansas mandating more than 3.8 hours.
Medicare's standard of staffing is higher: four hours of care for each patient daily, including 55 minutes from a registered nurse.
"If you increase the minimum number of hours, then you are going to be pushing those nursing homes that are trying just to get by, and by doing that, you will improve the quality of care in nursing homes," Willard said.
To get a five-star rating for staffing, a nursing home must meet Medicare's standard. No nursing home in the Nashville area achieved five stars in that category.
West Meade Place earned four stars for staffing by registered nurses and three stars for overall staffing. O'Kelley, its assistant administrator, said the home strives to have more staff than is required. The 120-bed facility, which is usually 86 percent full, adjusts staffing based on patient volume and hires more nurses if needed.
"Because of acute care and patient needs, I don't think the job would be done effectively at that minimum staffing level," O'Kelley said.
Star system has flaws
The star system is useful as a starting point for families but should not be an end in itself, O'Kelley said.
"I am always amazed at how many people show up here just because we are a five-star facility, and had never stepped foot in here," she said. "People should visit, get to know the staff and ask around."
Proponents and critics of the star system say it is a useful tool, but it has flaws. Medicare tries to streamline the standards of all states into a one-size-fits-all scenario, they say.
"You have differences between states, different ideas about what constitutes a deficiency, and a lot of information is provided by the nursing homes themselves," Willard said. "It is a worthwhile measuring stick, but it is not the only tool for finding a facility for a loved one."
'A good first glance'
Medicare officials say a one-star rating does not mean a nursing home is a bad facility. All homes must meet baseline Medicare conditions, which are often higher than state standards.
"It's a good first glance for people," said Lee Millman, spokeswoman for the Centers for Medicare and Medicaid Services' Atlanta region, which includes Tennessee.
The agency even states on its own Web site that the report has limitations, noting that state requirements vary and that some data are self-reported and may reflect only a two-week period.
Medicare "uses a system of ranking for staffing that is based on desired staffing levels, not a required or mandated level," said Ron Taylor, executive director of the Tennessee Health Care Association. "Using that staffing level, a lot of facilities that have good, quality service don't rank really high because they don't meet (Medicare's) standard. But they meet the state standard."
Keith Smith, administrator and CEO of Spring Meadows Health Care Center in Clarksville, said it's good that the government tried to keep the ratings simple, but the program needs serious work.
"The whole system was very prematurely implemented and fundamentally flawed," Smith said. "But we try to work with it."
Spring Meadows received an overall one-star rating. It moved up in the area of quality from one star to three.
The ratings for staffing and surveys focus on regulatory compliance, not quality of care and outcomes, he said.
"I'm all about the public having a good tool to evaluate, but this is not it," he said.