CalQualityCare Rating (Data Source: CA OSHPD FIN 08/12/2016)

CalQualityCare.org provides “Performance Ratings” on important measures of long term care quality. Ratings will help users assess the quality of care available and serve as a guide when comparing and choosing care providers.

The Staffing Performance Rating for nursing homes takes into account three measures: RN staffing levels, total nursing hours, and nursing staff turnover rates. Research shows that adequate staffing levels and lower staff turnover have a positive effect on the health of nursing home residents.

In addition, scores are adjusted to account for varying levels of resident care needs. Facilities should adjust staffing levels to ensure adequate staff to meet the needs of all the residents living in a facility. Because Medicare residents are often in nursing homes immediately following an acute hospital stay, facilities with a high percentage of Medicare days are expected to have higher RN and total staffing hours to meet the greater needs of these residents.

RN staffing levels. RN staffing levels are the average number of hours of RN time available to care for residents per day over a one-year period. The threshold was set at 0.55 RN hours per resident day for facilities with a “low” number of Medicare days and at 3.0 hours for facilities with a “high” number of Medicare days.

Total nursing hours. Total nursing hours includes all RNs, licensed vocational or practical nurses (LVNs), nursing assistants (NAs), and nursing supervisors. The measure shows the average number of hours of nursing staff time available to care for residents per day over a year.

Nursing staff turnover rates. High turnover rates may result in poor quality and coordination of care. Low turnover rates may reflect better management, staff wages and benefits, or other enhanced employment conditions.

The Staffing Performance Rating was based on the combination of RN and total staffing (RNs, LPNs/ LVNs, CNAs) ratings for each facility with equal weights given to the RN and the total staffing ratings. To receive a Superior rating, facilities must meet both RN and total nursing thresholds. In addition to meeting those thresholds, nursing homes with turnover rates greater than 90% during the most recent year received a reduction of one degree.

For the specific information on a nursing home, see the California Department of Public Health’s Licensing and Certification Program (L&C).

Medicare Days of Care (Data Source: CA OSHPD FIN 08/12/2016)

To account for differences in resident care needs, nursing homes are divided into two groups: those with a highpercentage of Medicare days (25% or more resident days paid by Medicare) and those with a low percentage of Medicare days (less than 25% of resident days paid by Medicare). This difference is important because Medicare residents tend to have short but care-intensive stays (usually following an acute hospital admission) in nursing homes. Therefore facilities with high Medicare days are expected to need higher nurse staffing hours to meet the greater care needs of residents.

Nursing Staff Turnover (Data Source: CA OSHPD FIN 08/12/2016)

The page shows the percentage of all nurses (not including supervisors) who leave the facility during the year (turnover rate) prior to the day the facility completed its most recent cost report for the Office of Statewide Health Planning and Development (OSHPD). Nursing facilities with low rates of change in nursing staff may provide better quality care than facilities with high turnover rates.

When nursing staff is constantly changing, it may be stressful and disruptive for residents. They have to keep getting used to new people who are not familiar with their routines or special needs.

The lower the nursing staff turnover rate at a nursing facility, the better the quality, continuity, and stability of care. If the turnover rate is high, it could mean there is low employee morale. High employee morale and continuity of care help create a pleasant environment that is more likely to result in high-quality care.

Nursing Hours per Resident Day (Data Source: CA OSHPD FIN 08/12/2016)

Nurse staffing level information is reported as hours per resident day (HPRD). The state of California requires nursing facilities to provide at least 3.2 HPRD of direct nursing care. This measure shows the average number of hours of nursing staff time available to care for residents each day. The total includes all licensed nurses, nursing assistants, and directors of nursing, including part-time, full time, and temporary employees. HPRD is calculated by dividing the total nursing hours worked (excluding time for vacations, sick time, disability, and other paid time off) by the total resident days of care during the year. It does not indicate the number of nurses working at any given time, how well they are organized, or the amount of care given to each resident. Nurse staffing is usually lower on evenings, nights, weekends, and holidays.

Having an adequate number of each type of nurse in a facility is important to provide quality care. It is most important to have a high number of registered nurses, because they have the most education and expertise. The different types of nurses are:

• Supervisors and Registered Nurses (RN): Facilities should have at least .75 HPRD (45 minutes) of RN time. Some experts recommend a ratio of one RN or LVN to every 15 residents during the day, one to every 20 residents in the evening, and one to every 30 residents at night. RNs have two to six years of professional education and are trained in the management and care of patients. Only RNs can complete resident assessments and care plans. RNs have the training to give complex nursing care and treatments and provide supervision to other nursing staff. They can evaluate acute and chronic conditions and determine when medical attention is needed.

• Licensed Vocational/Practical Nurses (LVN/LPN): Facilities should have at least .55 HPRD (33 minutes) of LVN/LPN time. LVN/LPNs have one year of training. They work with RNs to assess the needs of residents, to develop treatment plans, and to evaluate residents’ responses to care. They often give medications and treatment and may serve as unit supervisors.

• Nursing Assistants: Facilities should have 2.8 to 3.2 HPRD (168 to 192 minutes) of nursing assistant time. This is about one nursing assistant for every 6 to 8 residents during the day and evening shifts, and one nursing assistant for every 20 residents on the night shift. Nursing assistants (NAs) provide most of the direct resident care, such as bathing, dressing, toileting, and eating. Some NAs are called orderlies or technicians. They work under the direction of a licensed nurse (RN or LVN). All NAs must become certified (CNAs) within four months of employment. In California, they must take 160 hours of training and pass an exam.

Physical Therapist Hours per Resident Day (Data Source: CA OSHPD FIN 08/12/2016)

Physical therapist (PT) staffing level information is reported as hours per resident day (HPRD). This measure does not indicate the number of physical therapists working at any given time or the amount of care given to any one resident. The amount of physical therapy given depends on the needs of each resident. All PTs are licensed with the state of California.

Physical therapists help residents improve their movement and manage their pain. PTs test muscle strength, joint flexibility, and the ability to walk or move. PTs often work with doctors, nurses, and occupational therapists (OTs) to create customized plans to improve a resident’s physical function and well-being.

Nursing Wages per Hour (Data Source: CA OSHPD FIN 08/12/2016)

Wages are important for recruiting qualified, experienced staff and keeping them. The more staff who remain, the lower the rate of staff changes at a facility. Facilities with low turnover rates may have higher employee morale than those with frequent changes in staff. High morale could result in better quality care.

Many jobs at nursing facilities pay low wages and sometimes the wages for nursing assistants are below the federal poverty level or less than a living wage. Generally, wages are well below those of hospital employees, workers in the fast food industry, and many other local businesses. Wages may be low because the owners decide to concentrate on increasing profits or because the facility is having financial problems. They may be kept low in facilities with a high percentage of Medi-Cal residents because Medi-Cal reimbursement rates are typically lower than those for all other payers. Low wages can result in staffing shortages and unfilled vacancies.

Benefits per Hour (All Employees) (Data Source: CA OSHPD FIN 08/12/2016)

CalQualityCare Rating (Data Source: CMS NH COMPARE 06/22/2016)

CalQualityCare.org provides “Performance Ratings” on important measures of long term care quality. Ratings will help users assess the quality of care available and serve as a guide when comparing and choosing care providers.

The Quality of Facility Performance Rating for nursing homes is based on three measures: (1) federal deficiencies, (2) state citations, and (3) substantiated complaint and incident reports. The rating uses the three most recent standard surveys for each nursing home and any complaint investigations during the most recent three-year period. More recent surveys are weighted more heavily than earlier surveys.

Because facilities with more beds and nursing home residents may have more complaints, the number of substantiated complaints and incidents are standardized by the total number of beds.

• Superior: Facility scored in the best 10%
• Above Average: Facility scored in the 66.7–90% range
• Average: Facility scored in the 43.4–66.6% range
• Below Average: Facility scored in the 20.1–43.3% range
• Poor: Facility scored in the worst 20%

For the specific information on a nursing home, see the California Department of Public Health’s Licensing and Certification Program (L&C).

CalQualityCare Rating (Data Source: CMS NH COMPARE 06/22/2016)

CalQualityCare.org provides “Performance Ratings” on important measures of long term care quality. Ratings will help users assess the quality of care available and serve as a guide when comparing and choosing care providers.

The Quality of Care Performance Rating for nursing homes is based on the system used by the federal government (Centers for Medicare & Medicaid Services). The quality of care rating is based on nine measures that show how well a nursing home cares for residents’ needs. The rating is based on seven measures for long-stay residents (101 days or more) and two measures for short-stay residents (100 days or fewer).

For each measure, points are assigned (see details under About the Ratings).

Once the summary Quality of Care score is computed for each facility, a rating is assigned based on the nationwide distribution of the scores:

• Superior: Facility scored 616 or more points (16%)
• Above Average: Facility scored 508–615 points (31%)
• Average: Facility scored 436–507 points (24%)
• Below Average: Facility scored 356–435 points (18%)
• Poor: Facility scored 355 or fewer points (11%)

The Quality of Care section displays 11 measures: eight for long-stay residents and three for short-stay residents, as discussed below. The long-stay and short-stay antipsychotic use measures are not included in the Quality of Care rating.

For the specific information on a nursing home, see the California Department of Public Health’s Licensing and Certification Program (L&C).

The short-stay quality measures apply to residents in a facility 100 or fewer days.

Pressure Sores (Data Source: CMS NH COMPARE 06/22/2016)

The page shows the percentage of short-stay residents recently admitted to the nursing home following a hospital stay who have developed pressure sores, or who had pressure sores that did not get better between their 5-day and 14-day assessments in the nursing home. Residents who are confined to bed or have difficulty moving around are at a greater risk of developing pressure ulcers. A pressure ulcer (or bed sore) is an injury caused by constant pressure to the skin and muscle. Pressure ulcers may cause pain, infection, decreased social interaction, a decline in self-care activities, and a longer stay in the nursing facility. Residents may die from complications directly related to severe pressure ulcers. If residents are turned or repositioned every two or three hours, eat adequate amounts of food and liquids, and are kept clean and dry, most pressure ulcers are preventable. The chances of developing pressure ulcers may also be reduced through the use of pressure reducing devices like air pads, gel flotation pads or special padding on beds and wheelchairs. These devices do not replace moving (repositioning) or turning residents frequently.

Moderate to Severe Pain (Data Source: CMS NH COMPARE 06/22/2016)

The page shows the percentage of short-stay residents experiencing moderate to severe pain. Staff should check residents regularly for pain, find the cause, and try make the resident more comfortable. If pain is not treated, a resident may not be able to perform daily routines, may become depressed, or have an overall poor quality of life. This percentage may include some residents who are getting or have been prescribed treatment for their pain, but who refuse pain medicines or choose to take less. Some residents may choose to accept a certain level of pain so they can stay more alert.

Improvements in Function
(higher is better) (Data Source: CMS NH COMPARE 06/22/2016)

Short-stay residents frequently have limitations in their physical functioning because of illness, hospitalization, or surgery. Nursing homes help residents improve physical functioning. The page shows the percentage of short-stay residents who improved their independence during their stay in these functions (i.e., transfer: self-performance; locomotion on unit: self-performance; walk in corridor: self-performance).

Emergency Department Visit (Data Source: CMS NH COMPARE 06/22/2016)

Emergency Departments provide necessary care for many residents of nursing homes. However, if a nursing home regularly sends many residents to the emergency room, it may indicate that the nursing home isn’t properly assessing or taking care of its residents to prevent the development of conditions that require emergency treatment. The page shows the percentage of short-stay residents who had an emergency room visit.

Rehospitalized After Nursing Home Admission (Data Source: CMS NH COMPARE 06/22/2016)

Nursing homes help residents recuperate from a hospital stay and avoid going back to the hospital. Sometimes it’s necessary for a resident to return to the hospital. However, if a nursing home sends many residents back to the hospital, it may indicate that the nursing home isn’t properly assessing or taking care of its residents who are admitted to the nursing home from a hospital. The page shows the percentage of short-stay residents who were rehospitalized.

Successful Discharge
(higher is better) (Data Source: CMS NH COMPARE 06/22/2016)

High rates of successful discharge, or a resident remaining in the community for at least a month, indicate that the nursing home is restoring a resident’s function so that she or he may successfully return to the community. The page shows the percentage of short-stay residents who were successfully discharge to the community.

Antipsychotic Use (Data Source: CMS NH COMPARE 06/22/2016)

The page shows the percentage of short-stay residents being treated with antipsychotic medications. While an important treatment for patients with certain mental health conditions, antipsychotic medications have serious side effects and are associated with an increased risk of death when used in elderly patients with dementia. Interventions that do not involve medications, such as increased staffing, many and varied activities, and consistent staff assignment, can work and should be tried first. Use of antipsychotics should be carefully monitored. Consumers should ask about a nursing home’s approach to managing behavior. The federal Centers for Medicare & Medicaid Services (CMS) is developing a national action plan to improve behavioral health management and to safeguard nursing home residents from unnecessary antipsychotic drug use.

Average Total Expenditures per Resident Day (Data Source: CA OSHPD FIN 08/12/2016)

The page shows the average amount spent on each resident per day.

Expenditures as a Percent of Revenues (Data Source: CA OSHPD FIN 08/12/2016)

The page shows the percentage for each category of the total facility expense. The category expense is divided by the total number of resident days which is divided by the total expenditure. This allows for a fair comparison across facilities. Expenditures per resident day is not available for hospital-based facilities as the cost reporting data for long term care business for expenses are not separated from the general hospital expenses.

• Direct care: Includes nursing care, nursing staff costs, social services, activities, and ancillary expenses, such as diagnostic and therapy services, patient supplies, physical therapy, respiratory therapy, occupational therapy, speech therapy, pharmacy, laboratory, and other clinical services.

• Other care: Includes building and facility maintenance and renovations, housekeeping, laundry, and dietary expenses such as food, storage, and preparation.

• Administrative services: Includes general accounting, communication systems, data processing, patient admissions, public relations, professional liability and non-property related insurance, licenses and taxes, medical record activities, in-service education for nursing staff, and supplies and equipment.

• Capital expenses: Includes expenses for leases and rental, interest and depreciation include the expenses for use of the building and equipment for the facility including leases and the rental of property related to the building, equipment, and improvements.

Average Charges per Resident Day (Data Source: CA OSHPD FIN 08/12/2016)

Nursing facilities are reimbursed differently for similar services depending on each payer. Reimbursement rates affect quality of care. California sets Medi-Cal reimbursement rates and keeps them low. This may result in low staffing levels in nursing facilities with mostly Medi-Cal residents.

Medicare reimbursement rates are much higher than Medi-Cal rates. Medicare rates are set by the federal government based on a system that takes into account the care needs of residents. Therefore, staffing levels and quality of care are generally better at nursing facilities with a high percentage of Medicare residents.

Self-pay rates are not regulated. Nursing facilities may charge their self-pay residents as much as they want to. Facilities that accept only self-pay residents may charge higher rates and may have more money to spend on staff and other improvements.

Managed care plans negotiate with facilities for rates they are willing to pay.

Resident Care Days by Payments Source (Data Source: CA OSHPD FIN 08/12/2016)

This reflects the percentage of the facility’s total days of care that is paid by each payer. It is calculated by dividing the number of resident days paid for by each payer by the total number of resident days. “Other” includes private health insurance, managed care plans, and other payers.

Net Operating Income or Loss (Data Source: CA OSHPD FIN 08/12/2016)

This is the total amount of money earned from health care operations plus non-operating revenue — after nonoperating expenses have been deducted — excluding taxes and extraordinary items. If it is a positive amount, the facility made a profit. If it is a negative amount, the facility is operating at a loss.

Facilities operating at a loss may have quality of care problems. Conversely, for-profit facilities with very high profits may be taking profits they could be using to pay for resident care. For-profit facilities may pay the profits to owners or stockholders, while nonprofit facilities must reinvest profits in the facility or related activities.

Operating Margin (Data Source: CA OSHPD FIN 08/12/2016)

The operating margin is net income divided by health care operating revenue. This is another way of showing the percentage of profits or losses in a facility. Negative numbers indicate a net loss for the reporting period. Values shown for different agencies can range widely. Profit margins over 9% in for-profit facilities may be excessive and could result in poor quality of care.