Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases

Abstract

This study evaluates COVID-19 case rates between high- and low-performing nursing homes based on CMS quality measures.

In the US, approximately 27% of deaths due to coronavirus disease 2019 (COVID-19) have occurred among residents of nursing homes (NHs).¹ However, why some facilities have been more successful at limiting the spread of infection than others is unclear. For example, those with greater staffing or higher performance on quality measures may be better at containing the spread of COVID-19 among staff and residents.

We evaluated whether NHs rated highly by the Centers for Medicare & Medicaid Services (CMS) across 3 unique domains—health inspections, quality measures, and nurse staffing—had lower COVID-19 cases than facilities with lower ratings.

Methods

We used data from 8 state health departments (California, Connecticut, Florida, Illinois, Maryland, Massachusetts, New Jersey, and Pennsylvania) to determine the total number of COVID-19 cases occurring in NHs between January 1, 2020, and June 30, 2020. We linked these data with CMS Nursing Home Compare, which includes star ratings (range, 1 [low] to 5 [high]) that characterize performance across the 3 domains.² The health inspection rating is based on the number of deficiencies identified in the 3 most recent state surveys across several areas, including staff-resident interactions and adequate infection control protocols. The quality measures rating is based on the weighted mean of performance across 15 quality measures (eg, avoidable hospitalizations, pressure ulcers, urinary tract infections). The nurse staffing domain is based on the mean staffing hours per resident by qualified nursing staff.

Given how COVID-19 data are publicly reported across some states, we were limited to grouping NHs into 3 categories: those with 10 or fewer, 11 to 30, or more than 30 COVID-19 cases. We performed 3 separate ordinal logistic regression models to assess the odds of high-performing facilities (4- or 5-star facilities) having more than 30 cases vs 11 to 30 cases vs 10 cases or fewer relative to low-performing facilities (1- to 3-star facilities), adjusting for the number of certified beds and including county fixed effects. The study was conducted using SAS version 9.4 (SAS Institute Inc). Two-sided P values were considered significant at the P < .05 level. The Harvard T. H. Chan School of Public Health Institutional Review Board waived the need for informed consent.

Results

Of the 4254 NHs across the 8 states, 4254 (100%) had star ratings for health inspection; 4241 (99.7%), quality measures; and 4225 (99.3%), nurse staffing domains. Within each domain, 1451 (34.1%) were considered high performing for health inspection; 2974 (70.1%) for quality measures; and 1517 (35.9%) for nurse staffing (Table 1). High-performing NHs were less likely to have had more than 30 COVID-19 cases than were low-performing facilities across each domain (health inspections, 348 [24.0%] vs 948 [33.8%]; quality measures, 897 [30.2%] vs 397 [31.3%]; nurse staffing, 382 [25.2%] vs 907 [33.5%]). High-performing NHs had a lower median number of certified beds. After adjustment, NHs with high ratings on nurse staffing were less likely to have more than 30 COVID-19 cases vs facilities with 11 to 30 and vs facilities with 10 or fewer cases than were low-performing NHs (OR, 0.82; 95% CI, 0.70-0.95; P = .01) (Table 2). There was no significant association between high- vs low-performing NHs in the health inspections or quality measures domains with COVID-19 cases.

Table 1. Characteristics of High-Performing vs Low-Performing Nursing Homes Across 3 CMS Performance Domains^a.

Nursing home characteristics	Nursing homes with ratings
	All	Health inspectionb		Quality measuresc		Nurse staffingd
		High performing	Low performing	High performing	Low performing	High performing	Low performing
No. of nursing homese	4254	1451	2803	2974	1267	1517	2708
COVID-19 cases, No. (%)
≤10	2712 (63.8)	1013 (69.8)	1699 (60.6)	1900 (63.9)	801 (63.2)	1024 (67.5)	1668 (61.6)
11-30	246 (5.8)	90 (6.2)	156 (5.6)	177 (6.0)	69 (5.4)	111 (7.3)	133 (4.9)
>30	1296 (30.5)	348 (24.0)	948 (33.8)	897 (30.2)	397 (31.3)	382 (25.2)	907 (33.5)
Certified beds, median No.	116	91	120	111	120	100	120
States, %
California	23.4	22.8	23.7	27.8	13.2	17.9	26.6
Connecticut	5.0	5.2	4.9	5.3	4.4	6.2	4.4
Florida	16.1	16.3	16.1	16.4	15.2	23.6	11.8
Illinois	16.7	16.3	16.9	12.3	27.0	13.5	18.1
Maryland	5.3	5.1	5.4	5.9	3.9	5.5	5.1
Massachusetts	8.8	8.4	9.0	7.2	12.5	10.3	8.0
New Jersey	8.5	9.4	8.0	10.3	4.3	10.0	7.8
Pennsylvania	16.2	16.4	16.1	14.9	19.5	13.1	18.2
County characteristics
<High school education, %	60.6	58.3	61.8	63.1	54.4	55.2	63.6
Median income, $	58 212	59 296	57 650	59 135	56 142	60 673	56 841
White population, %	72.8	73.2	72.6	71.0	77.0	72.6	73.0

Abbreviations: CMS, Centers for Medicare & Medicaid Services; COVID-19, coronavirus disease 2019.

^aCMS ratings are based on each domain. Higher-performing facilities rank 4 or 5 stars; lower-performing facilities, 1 to 3 stars.²

^bBased on the number of deficiencies from 3 most recent standard surveys (or any complaint-triggered inspection) and assess such areas as staff-resident interactions, protection of residents from abuse, infection control, and food and medication storage and management.

^cRates for 15 equally weighted measures based on the percentage of long-stay patients whose need for help with activities of daily living has increased, whose ability to move independently worsened, who have pressure ulcers, who have had a catheter inserted and left in their bladder, who have a urinary tract infection, who have had 1 or more falls with major injury, and who received an antipsychotic medication and on the number of hospitalizations and outpatient emergency department visits per 1000 resident-days; and the percentage of short-stay residents whose function improved, who have new or worsened pressure ulcers, who newly received an antipsychotic medication, who were rehospitalized after nursing home admission, and who have had an outpatient emergency department visit and on the rate of successful return to home and community.

^dBased on 2 case mix–adjusted measures: total nursing hours per resident day and registered nurse hours per resident day. Overall nurse staffing rating is the arithmetic average of the registered nurse and total nurse staffing rating.

^eSee the Results section of text for the overall No. (%) of star ratings among sample nursing homes. Across the 8 states, the sample included the following proportion of CMS-certified nursing homes in each state: 99.2% in Massachusetts, 99.4% in New Jersey, 99.5% in Connecticut, 83.3% in California, 99.3% in Pennsylvania, 97.6% in Florida, 99.1% in Maryland, and 97.8% in Illinois. Massachusetts, New Jersey, Pennsylvania, Florida, and Maryland counted both staff and residents who contracted COVID-19 at their facilities; the other states included resident cases only.

Table 2. Association Between Nursing Home Ratings on Health Inspections, Quality Measures, and Nurse Staffing Domains With COVID-19 Cases.

High-performing vs low-performing nursing homes across CMS domains	Ordinal odds ratio of a nursing home having >30 cases vs 11 to 30 cases vs ≤10 casesa	P value
Health inspection	0.91 (0.78-1.07)	.25
Quality measures	1.05 (0.90-1.23)	.52
Nurse staffing	0.82 (0.70-0.95)	.01

Abbreviations: CMS, Centers for Medicare & Medicaid Services; COVID-19, coronavirus disease 2019.

^aSeparate ordinal logistic regression models across each rating category were used to calculate the likelihood of high-performing nursing homes (those rated 4 or 5 stars) vs low-performing nursing homes (those rated 1 to 3 stars) having more than 30 COVID-19 cases vs 11 to 30 cases vs no more than 10 cases. All models were adjusted for certified beds of each nursing home and included county fixed effects.

Discussion

Across 8 states, high-performing NHs for nurse staffing had fewer COVID-19 cases than low-performing NHs. In contrast, there was no significant difference in the burden of COVID-19 cases between high- vs low-performing NHs for health inspection or quality measure ratings. These findings suggest that poorly resourced NHs with nurse staffing shortages may be more susceptible to the spread of COVID-19.^3,4 Although guidance on best practices on infection control are important, which has been the primary strategy used by CMS to date, policies that provide immediate staffing support may be more effective at mitigating the spread of COVID-19.^5,6

This study has limitations. It included data from only 8 states; however, these states rank among those with the highest COVID-19 burden. The state-reported data used are also more reliable than the national COVID-19 data set recently released by CMS, which reports suggest is incomplete and inaccurate. In addition, high-performing NHs may have greater capacity to test and diagnose cases, which may lead to an underestimate of the association between low performance on the staffing domain and higher COVID-19 cases.

Section Editor: Jody W. Zylke, MD, Deputy Editor.