Assessment of Consumer Complaint Investigation Scores, Recertification Survey Scores, and Overall Nursing Home Health Inspection Star Quality Rating

Abstract

ImportanceThe Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System combines results from nursing home recertification surveys and complaint investigations into a single indicator for health inspections. This combination may mask complaint investigation results.ObjectiveTo construct and compare star ratings specific to recertification surveys and specific to complaint investigations to discern whether they provide different information.Design, Setting, and ParticipantsIn this quality improvement study, the Nursing Home Compare Five-Star Quality Rating System was used to calculate three 5-star ratings: 1 overall health inspection rating combining recertification survey scores and complaint investigation scores, 1 using only recertification scores, and 1 using only complaint investigation scores. The study included US nursing homes. The sample calculated star ratings for nursing homes in November 2017. This sample included all whose most recent recertification surveys occurred in 2016 up to and including November 2017, and those with 36 months of data from the ASPEN Complaints/Incidents Tracking System and the Certification and Survey Provider Enhanced Reports. Data analyses were completed on different days in 2022, depending on which questions were being addressed.Main Outcomes and MeasuresComparison of the 3 star rating distributions. The recertification survey and complaint investigation star ratings were compared with respect to the overall health investigation rating. The recertification and complaint star ratings were cross-tabulated.ResultsAmong the 15 499 nursing homes, 19.8% had 1 overall health inspection star, 23.2% had 2, 23.2% had 3, 23.2% had 4, and 9.8% had 5 overall health inspection stars. Most had the same overall and recertification star ratings; for example, 79.4% had 5 overall stars and 5 recertification survey stars. However, overall and complaint-based star ratings were discordant, with a relatively large proportion of nursing homes (25.7%) having no complaint deficiencies and therefore high star ratings.Conclusions and RelevanceIn this quality improvement study assessing the 2 components of the Five-Star Quality Rating System, results of recertification surveys were largely similar to health inspection star ratings. However, recertification survey scores differed from complaint inspection scores, suggesting health inspection ratings may not reflect consumers’ views of care, services, or other valued amenities. A complaint-focused metric may have utility. However, research is needed concerning the many nursing homes with no or very few complaint deficiencies.

The Importance of Zero-Deficiency Complaints in Nursing Homes: A Mere Consequence or Serious Concern?

“…A complaint results in no deficiencies (zero-deficiency complaints [ZDCs]) when 1) the complaint allegations are determined to be unsubstantiated, that is, not being valid, 2) the complaint is valid, and hence substantiated but complaint investigators are unable to find evidence of a regulatory violation, and 3) the complaint is substantiated but involves an issue that is not addressed in the federal regulations (see Figure 1; Peterson & Bowblis, 2023). The purpose of this paper is to examine the second and third scenarios above: complaints that are substantiated but do not yield deficiencies (referred hereafter as zero-deficiency substantiated complaints [ZDSCs]).

Figure 1.Schematic diagram of complaint investigation process.Note: SSA: state survey agency; NH: nursing home.

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“…Several research studies have been conducted in the last few years considering NH deficiencies as overall quality measures (Alexander & Madsen, 2017; Harrington et al, 2016; Lerner et al, 2014). Research has also examined the role of complaints in quality assessment (Bhattacharyya et al, 2023b; Peterson & Bowblis, 2023; Troyer & Sause, 2011) and the changing number of complaints over the past several decades (Hansen et al, 2019; Peterson et al, 2020). Stevenson was among the first to use NH complaints to estimate the quality of NH care; he reported that 35% of NHs had no complaints, and 18% had five/more complaints during 1998–2002 (Stevenson, 2006).…”