State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Texas

05/15/2003

Overview of How Texas Quality Reporting System Evaluates Medicaid-Certified Facilities12

Overview: Certified facilities are compared in QRS on the basis of four dimensions that depict some important aspects of quality. Quality has many dimensions. The quality of care provided to nursing home residents, the quality of life each resident experiences, the ability of a facility to meet all regulatory requirements, and customer satisfaction are all important aspects of quality. QRS uses four quality dimensions or axes to rate nursing facilities. Two axes reflect quality of care, and two more measure compliance with state and federal regulations.

A brief background history of QRS development as well as answers to providers' frequently asked questions are available on the QRSProvider FAQ page.

Interpret QRS ratings cautiously. QRS nursing home ratings are based on a reporting period that tends to indicate each facility's recent performance. QRS ratings do not indicate facility performance over the long term. Further, because QRS is only updated monthly, it is possible that very recent performance problems will not be reported. Even a facility that appears to have favorable QRS ratings may be under sanctions or penalties due to performance problems that occurred outside the QRS reporting period. The Regulatory Compliance History andEvents and Actions sections of each facility's quality profile contain additional historical information that can help you to better judge the consistency of facility performance over time.

Use QRS information to help you make a nursing facility selection rather than as a short-cut to finding the best nursing home. You may also contact the DHS Consumer Information Hotline at 1-800-252-8016 or via e-mail to request additional consumer information about a particular facility.

Comparisons: QRS uses comparison tables to show ratings for Medicaid-certified nursing facilities. These comparison tables include an overall rating score for each facility. Interpret this overall score with caution. The overall rating is the simple average of the four quality axis scores. It arbitrarily assigns equal importance to all the quality axes. As you read individual facility quality profiles, you will need to decide whether these axes are indeed equally important to you.

Nursing facilities are listed in the comparison tables from highest overall rating to lowest. When several facilities earn the same overall rating, they appear in alphabetical order. Thus, if facilities South Village, West Oaks and Davis Retirement Center all have the same overall rating, they will appear in the comparison table in the order Davis Retirement Center, South Village and West Oaks.

Quality of Care - the PAS and PDS Scales: QRS reports the quality of resident care using two ratings; these ratings serve as predictors of quality rather than as true measurements of quality. Both ratings are based on the Center for Health Systems Research and Analysis (CHSRA)Quality Indicators adopted by the Centers for Medicare and Medicaid Services(CMS, formerly HCFA) for use in monitoring nursing facility performance. The quality indicators are calculated from resident assessments that each facility submits to CMS. At this time, these assessments are not independently verified by either DHS or by CMS.

Each resident is reassessed at least every 90 days. The quality indicator scores that QRS uses are based on assessments submitted during the first four months of the six month interval that precedes the date on which this Web site's database is updated (see the date at the bottom of each Web page.) The Potential Advantages Score (PAS) and Potential Disadvantages Score (PDS) are the ratings that summarize a facility's quality indicator scores.

PDS: CMS uses the quality indicators to identify potential performance problems. That is, CMS advises nursing facilities to look for quality problems whenever an indicator condition is more common in that facility than in 90% of all other facilities. For three of the indicator conditions (Dehydration, Fecal Impaction, and Pressure Sores in Low Risk Residents), CMS recommends looking for quality problems on every occurrence. The PDS rates each facility based on the number of indicator conditions that suggest potential performance problems - each such condition is a potential disadvantage for residents in that facility. The most favorable PDS rating means that a facility has the fewest potential disadvantages.

PAS: Where CMS currently uses quality indicators only to identify potential quality problems, QRS also uses them to identify potentially superior performance. QRS recognizes those facilities in which indicator conditions are less common than in 90% of all other facilities. The PAS rates each facility based on the number of indicator conditions that suggest potentially superior performance - each such condition is apotential advantage for residents in that facility. The most favorable PAS rating means that a facility has the most potential advantages.

The Rating Scales topic below explains the relationship between the number of potential advantages and the PAS rating symbols as well as the relationship between the number of potential disadvantages and the PDS rating symbols. Because the purpose of the PAS and PDS ratings is to summarize and highlight the differences among resident groups from different facilities, DHS may periodically revise these relationships.

When considering PAS, it is important to remember that it is based on quality indicator conditions that may be less common in a particular facility simply because the residents in that facility are more healthy or less prone to those conditions. Low quality indicator scores that create a favorable PAS do not always imply higher quality services. Similarly, PDS is based on quality indicator conditions that may be more common in a particular facility simply because the residents in that facility are less healthy or more prone to those conditions. High quality indicator scores that create an unfavorable PDS do not always imply lower quality services.

Facility Surveys: Unlike PAS and PDS, the QRS Investigations and Survey scores are direct measurements of quality. The scores rate the facility's compliance with all applicable regulations and requirements.

Investigations Score: DHS investigates all complaints that come to its attention concerning nursing homes. Substantiated complaint allegations that constitute a violation of state or federal regulations are usually cited by DHS as nursing home deficiencies. The Investigations Score is based on the nature, severity and scope of the deficiencies cited in each home during the preceding six months.

Survey Score: A DHS survey team also inspects each nursing home at least once every 15 months (every 12 months on the average). The results of the most recent routine survey determine the Survey Score. This rating may not be a sensitive quality measure if the most recent survey occurred many months earlier; the quality of any service can change markedly over the course of a year.

NOTE CAREFULLY: The number of deficiencies does not determine the compliance score; it is the nature, scope, and severity of the most severe deficiency that determines the score. A nursing home cited for a deficiency has a right to appeal the citation, and there are occasions on which such appeals lead to the reversal of even the most severe deficiencies. Therefore, both the Complaint and Survey ratings can appear to be poor only to suddenly improve as the result of such a reversal. In order to provide the most accurate ratings possible, all ratings are recalculated each month.

Quality Profiles: QRS can show a quality profile that explains the facts behind the ratings assigned to a facility. This additional information may help you decide whether the facility is one that you want to consider further. The profile is a written report that includes the following:

  • Identifying Information: the facility name, address, county, phone number, and E-mail link.
  • Ownership Information: the name of the individual or entity that appears as the owner, the type of ownership (individual, corporation, profit or non-profit) and related information.
  • Facility Description: the payment sources that the facility is licensed and/or certified to accept, and the number of licensed beds, Medicaid beds, Medicare beds and beds dually certified for Medicaid and Medicare use. Note that licensed-only beds are approved only for private payment or insurance whereas Medicaid and Medicare beds are approved for those payment sources as well as for private payment and insurance.
  • Special Services: beds or units designated by the facility for residents with conditions such as Alzheimer's disease. Services such as a family or resident council are also listed here.
  • Overall Rating: a comparison of the facility's overall score to the statewide average for all facilities.
  • PAS - Potential Advantages Score: a list of the quality indicator conditions that appear to be less common among residents in the facility than they are among residents in 90% of all other facilities.
  • PDS - Potential Disadvantages Score: a list of the quality indicator conditions that appear to be more common among residents in the facility than they are among residents in 90% of all other facilities.
  • Nursing Facility Investigations: a detailed list of the regulatory deficiencies that led to the six-month compliance rating.
  • Nursing Facility Survey: a detailed list of regulatory deficiencies that led to the compliance rating assigned for the most recent routine survey.
  • Regulatory Compliance History: a yearly summary of overall compliance going back to the beginning of the facility's history or 1998 - whichever is most recent.
  • Events and Actions: a summary of past facility performance including a chronological list of significant actions such as ownership changes and sanctions that have occurred at this facility. This information only goes back to September 2000.

Rating Scales: Each QRS rating scale consists of five rating symbols. A sixth symbol, NR, is used to show that the facility could not be rated for lack of information. The rating symbols range from - the most favorable rating to - the least favorable rating. Holding the mouse pointer over any rating symbol for a few seconds will show a brief description of a rating symbol on any QRS page. Most Web browsers will show the text explanation for any picture when this is done. The precise meaning of each symbol in each rating scale is given in the tables below.

PAS is rated according to the following scale.

Most Advantages. Five or more quality indicators suggest potentially superior performance.
More Advantages. Three or four quality indicators suggest potentially superior performance.
Some Advantages. Two quality indicators suggest potentially superior performance.
Fewer Advantages. One quality indicator suggest potentially superior performance.
Fewest Advantages. No quality indicators suggest potentially superior performance.
NR No Rating Available.

PDS is rated according to the following scale.

Fewest Disadvantages. No more than one quality indicator suggests potential performance problems.
Few Disadvantages. Two or three quality indicator suggest potential performance problems.
Some Disadvantages. Four or five quality indicators suggest potential performance problems.
More Disadvantages. Six or seven quality indicators suggest potential performance problems.
Most Disadvantages. Eight or more quality indicators suggest potential performance problems.
NR No Rating Available.

The complaint and survey scores are based on the following scale.

In total compliance with regulations. No deficiencies were cited.
In substantial compliance with regulations. No cited deficiency resulted in actual resident harm or immediate jeopardy or had more than potential for minimal resident harm.
Not in substantial compliance with regulations. A cited deficiency had the potential for more than minimal harm but did not cause residents either actual harm or immediate jeopardy and did not constitute Substandard Quality of Care.
Not in substantial compliance with regulations and having at least one deficiency that caused actual resident harm or jeopardy to resident health or safety. A cited deficiency either caused actual resident harm or constituted immediate jeopardy to the Health or Safety of residents but did not constitute Substandard Quality of Care.
Substandard Quality of Care. A cited deficiency involved regulations that govern Quality of Care, Quality of Life, or Resident Behavior and Facility Practices such that: 1) there was a widespread occurrence with more than the potential for minimal harm, 2) there was a pattern or widespread occurrence of actual harm, or 3) there was immediate jeopardy to the Health or Safety of at least one resident.
NR No Rating Available.
Caution: This web site does not reflect recommendations of any specific provider by TDHS. It is simply a tool that you can use to help you make a selection. Because QRS shows information from a limited time period and is updated only once each month, it may not include some important events that are either older or more recent. QRS rating systems are developed in collaboration with long term care providers and consumer advocates and may include some self-declared and unverified information. TDHS strongly encourages you to visit any provider that you consider, to talk with its clients or client ombudsman, and to contact the TDHS Consumer Information Hotline at 1-800-458-9858 or via e-mail to obtain the most recent information concerning that provider.

12. Source: http://facilityquality.dhs.state.tx.us/ltcqrs_public/nq1/jsp2/qrsHowQRSRatesMA_nh1en.jsp?MODE=P&LANGCD=en, 4/1/2003.

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