Steps to Take in Response to Nursing Home Rankings and "Report Cards"

Open your doors to the community.
Invite community leaders, the media, residents' families and the public at large to see for themselves the kind of quality care you provide. Gearing up for an open house, publicizing it, and ensuring a good turnout on short notice in the wake of a sudden negative media report is no easy task. But remember that a large turnout is less important than your willingness to show that your home has nothing to hide, even it its inspection report was less than perfect.

That last point is important. Frankness usually plays well in the public arena. Nursing homes are human organizations, and most people accept that to err occasionally is human - as long as residents' health and safety are not threatened and corrective steps are taken as soon as possible. If you are questioned about a deficiency, be straightforward. Explain the circumstances, tell how it was corrected, or emphasize that you are working diligently toward compliance and will stick with the job until it is finished. The home that makes this point, makes it strongly (and means it!) may well emerge with a better community image and acceptance than before.

Review your facility's most recent survey report.
Know your most recent survey results and, if the report released about you is an outdated one, review what has happened in the interim. Even excellent homes sometimes have less than perfect inspections for a variety of reasons. A report of initial survey findings, unfortunately, does not take into account follow-up corrections or appeals, a point you may wish to make to the media or residents' families.

Discuss the survey report with your board and staff. They are your best ambassadors in the community and can help you educate the public about the quality of care in your home. Involve board members and volunteers in your open house plans.

Plan your media response.
Whenever survey data are released, you may be contacted by the media, or you may choose to initiate such contact even before these types of reports come out. Either way, designate a principal spokesperson and a back-up who can be reached at all times. Make sure staff and board members are fully briefed on how press contacts are to be handled.

Inform other "internal" constituencies.
These are the prime disseminators of messages about your facility: employees (whose influence extends to their families, another 2.5 persons per employee); residents (they have families, too); volunteers, who reach a great many people and should clearly understand your objectives; and visitors, who carry away and communicate important messages about your organization. All these people should be informed about any information that is being released publicly about you, before they find out from another source that might not give the whole story. Give them an opportunity to raise questions and have them answered satisfactorily. Whenever there is press coverage about nursing homes, your constituents will be curious about your home's status in comparison. Lay the groundwork early for responding to questions you may receive.

National headlines, whether carried on the wire services or featured on morning and evening news broadcasts, are usually short-lived. Coverage at the state and local levels, however, often follows shortly on the heels of national reports. This is really more critical to the individual nursing home, as the state and local follow-up reports tend to focus more specifically on the perceived standards of care in individual facilities.

Your reaction to these kinds of reports can either enhance or detract from your home's reputation in the community. To a great extent, your message will be communicated to external audiences by word of mouth, particularly by staff, volunteers, residents and family members. It is critical that all of your internal constituents understand the data, your home's standing and your response. However, the major way to convey your message to the community at large will be through the news media.

Each nursing home cited or singled out will have to decide whether its desired profile in the media is to be essentially high, low, or somewhere in between. Do not assume your home will escape comment when a nursing home report card is issued. A reporter may not be interested in the story initially, but as it gets national attention or coverage at the state level and in nearby communities, reporters will be more likely to contact you.

Before that happens, make sure your spokesperson(s) have reviewed the home's survey results thoroughly, understand the uses and limitations of survey data and nursing home report cards, and can answer any questions that might be raised about your facility's report. Anticipate questions the public and press might ask, and make sure your spokesperson is prepared to respond effectively to those questions. Possible questions and suggested answers are included below. You can add others pertinent to your own circumstances. In all cases, make clear that your number one priority is your residents and their quality of care and life.

The chief responsibilities of your spokesperson will be:
1. To cooperate fully with the media and place any negative aspects of the story in the proper perspective.
2. To be immediately available to the media when they call.
3. To maintain credibility at all times.
4. To be available to the news media until they determine that the story is over.

While we are confident that nonprofit facilities as a whole will always fare well whenever nursing home report cards are issued, it is inevitable that some homes will not be happy with what these reports say about them. The potential for inaccuracies is high, the information is dated, etc. We can also be fairly certain that much of the ensuing publicity will be negative, despite facilities' best efforts to represent themselves positively. These report cards, after all, focus on deficiencies, not on compliance levels. Unfortunately, the former are news far more often than the latter.

One of the laws of public opinion states that opinion formed as a result of broad events does not stabilize until people feel their self-interest is acutely involved. This makes response at the local level (the level of greatest self-interest) all the more vital. By focusing public attention and opinion on nursing homes, the release of a nursing home report card provides each facility a prime opportunity for public education about itself and long-term care in general.

Given the growing number of people who are turning to Internet sources of information, such as Medicare.gov and state web sites, and newspaper reports of nursing home report cards, etc., you may not want to wait for news - good or bad - before making a preemptive "public relations strike." Instead, think of ways to stay ahead of the story and have an impact on the resulting coverage.

To do so, you may want to contact the local press and offer to do a background briefing on what the nursing home survey process is all about. (The Q and A series below will be helpful in this regard.) If you do contact the press, be prepared to share your latest survey results with them and explain what has transpired since.

In some cases, laying groundwork can mean the difference between a reasoned news story and a sensational one. On the other hand, you may draw attention to a story that hadn't especially interested the local press before now. However you choose to approach this issue, make sure that each audience important to your organization understands what the survey data mean - and what they do not mean. The message you convey should be consistent for both internal and external audiences, differing only in the level of detail for each group.

Activities to Pursue When You Know a Report Card is Coming
1. Convene your board and/or staff to discuss a response strategy for your home.
2. Mount a positive press campaign to showcase the best about your home - even before a report card is announced. Showcase your staff and residents engaged in positive events. Do any residents have unusual or noteworthy backgrounds worthy of newspaper or TV feature stories? Do you have any upcoming events scheduled that would lend themselves to news coverage or a photo op? Do you offer a wellness program, state-of-the-art therapy, Alzheimer's care center, intergenerational day care or other program that the public should know about?
3. Write a letter to the editor informing the community that a nursing home report card is coming out and that your doors are open to the public. Explain some of the limitations of these reports and invite readers to contact you or your web site for information on what to look for in choosing a nursing home.
4. Submit an editorial to the local newspaper, and public service announcements to radio and TV stations, offering advice on choosing a nursing home. If you do not already have consumer handouts, LeadingAge has low-cost consumer brochures that you can buy in bulk by calling 1-800-508-9442.
5. Be available to help reporters interpret the data and understand its uses and limitations (see Q and A series below). Offer your facility as an authoritative resource on nursing home matters. Identify reporters and talk show hosts in your community who have covered long-term care and aging issues before; they are the ones most likely to cover the subject again. Monitor web sites or message boards where these matters may be discussed, and respectfully correct any misinformation you read.
6. Editorials can be immensely helpful in generating public understanding of a complex subject. Emphasize that deficiency information is a measure of compliance or noncompliance with particular requirements and is not a direct measure of the quality of care provided. Remember, your overriding concern should be consumer education. Do not be overly defensive. To question the report card issuer's motives or the state surveyors' professionalism will do no good and will only damage your own credibility. Instead, position yourself as a helpful resource on the survey's uses and limitations and suggest additional, better ways for consumers to judge a nursing home's quality of care. (See consumer checklist below.)
7. Update your media and key contacts list. Include not only reporters and editors but also civic and political figures and other opinion leaders in your community. Contact each, and urge their participation in an upcoming open house. If you feel you cannot manage an open house immediately, then pick the closest convenient date. Either way, confirm invitees' availability and participation by e-mail or telephone. Divide your invitation list, and assign staff or volunteers to stand by to do the necessary telephoning.
8. As an authority on quality of care, you and your organization can make a valuable contribution, and you will want to make sure that the not-for-profit point of view is represented in the ensuing discussion in your community. We suggest you contact civic and fraternal organizations, such as Rotary, Lions, Civitan, Kiwanis, Business and Professional Woman, Chamber of Commerce, etc., that customarily hold monthly chapter meetings with guest speakers. Suggest to the leaders of these groups that long-term care is a topical issue they might want to learn more about and that your organization can provide an expert speaker. Provide fact sheets and speaker supports (for consistent messages) to assist staff and board members in making presentations.
9. Look for community relations opportunities at every turn. For example, by building relationships with local schools, scout groups, sports clubs and other youth organizations, you not only help these young people become informed, you also reach their parents, grandparents, neighbors and friends. Those who get to know you will not automatically assign guilt by association when the news is unfavorable.

Background and Guide to Uses and Limitations of Survey Data
This Q and A format has been prepared to help nonprofit nursing homes anticipate inquiries they may receive from residents, families, the media or others as a result of the release of nursing home "report cards" based on survey findings. These questions and suggested answers will also be useful background briefing material for reporters covering the release of nursing home rankings or report cards.
Q. Describe the nursing home inspection process.
A. The process of qualifying nursing homes for participation in the Medicare and Medicaid programs is known as survey and certification. Nursing homes that are approved to take part in Medicare and Medicaid, and therefore qualified to receive federal and state funds, are required to meet standards set by federal regulations. These standards are the way the federal and state governments make sure that nursing homes that receive public monies provide quality care to residents. The standards are developed by the Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services. The state survey agency in each state inspects homes to make sure they meet health, safety and quality standards. CMS reimburses states for this survey activity. Information from these surveys is stored in a centralized computer system in Baltimore, Md., at CMS' headquarters. The information published in various nursing home "report cards" is usually obtained from this system.
Q. What do nursing home surveyors look for when they inspect a home?
A. Surveyors observe how care is actually given to residents. They interview a sample of the residents and review their medical records. They evaluate the care and services provided, including preparation of meals and eating assistance techniques. They check whether residents get prescribed medications in the proper dosage at the proper times. Surveyors also review nursing home records, interview staff, and observe the home for cleanliness, comfort and safety, quality of life and respect for residents' rights. The surveyors record their findings on federal forms. When the survey is completed, they meet with the nursing home's managers to discuss their findings.
Q. What happens if the surveyors find problems at the home?
A. If the surveyors find a problem, the nursing home has to submit a written plan or correction telling how it plans to remedy the problem and a target date for compliance. State survey agencies use various methods of follow-up review, including revisiting the home, to ensure that the needed correction has taken place.
Q. What about more serious problems, or problems that are not corrected?
A. If the problems are serious enough to threaten the health and safety of residents, and/or a nursing home fails to correct the problems, the home maybe barred from further participation in Medicare and Medicaid. Short of this action, CMS and the states can also employ an array of other enforcement methods to bring about compliance with state and federal requirements. Examples of possible actions include monetary fines, bans on new resident admissions, transfer of residents to other facilities, or placement of the facility in a receivership (temporary government-ordered management). The steps that can be taken, and the degree to which they are employed, vary from state to state. All survey agencies have tools for immediate response when residents' health and safety are in immediate jeopardy.
Q. If a facility is listed as having met all of the performance indicators, does that mean it is a "good" home?
A. It means the home was found to be in compliance with those items on its most recent inspection by surveyors working for Medicare and Medicaid. The information is thus a snapshot of conditions in the facility on a particular day. The report can indicate whether a home met minimum standards at the time of the survey, but the report alone cannot identify homes that are providing an outstanding quality of care.
Q. If a home has some deficiencies, does that mean it is a "bad" home?
A. No. Further inquiry would be needed to make a fair determination. The raw survey findings offer no explanation for what the numbers may mean, and they do not indicate whether the home has taken corrective action. Nor does the report reflect whether the home appealed the surveyor's judgment and whether the deficiency finding was subsequently overturned.
The report also does not take into account the fact that the information, as a whole, comprises the individual judgments of thousands of surveyors in 50 separate state survey agencies. Surveyors in different states, even within the same state, interpret and apply the requirements differently, which can lead to variability in survey results. The survey report, then, is not particularly reliable for comparing one facility's performance to another or the performance of facilities in one state to those in another state.
Q. How old is the information in these report cards? Should their accuracy be trusted?
A. Consumers should check with a nursing home to determine which information is current and which is out of date. This is particularly true regarding deficiencies that may have been corrected or overturned.
Q. Are all performance indicators in a survey report equally serious?
A. Nursing homes must meet several hundred separate requirements. Taken together, the survey results may be reflective of the home's quality of care, but not all requirements are directly related to conditions that, if not met, would jeopardize the health or safety of residents.
Q. How can a person tell what services a home offers?
A. The nursing home profiles in various report cards do not enumerate any specific services nursing homes offer beyond those required by Medicare and Medicaid. Consumers should ask homes individually about specialized services and care, such as nutrition therapy, various rehabilitative therapies, or dementia care, for example.
Q. What questions about nursing homes are not answered by survey data?
A. What types of specialized services and care does each home provide? Are residents receiving appropriate care? Is the environment a pleasant one? Are residents and their families satisfied with the home? Is there good staff morale? What types of activities are offered for residents? How does the home meet the spiritual, cultural or ethnic needs of its residents?
Q. If someone discovers that the nursing home his or her relative is in has deficiencies, what should that person do?
A. Find out from the home exactly what the deficiencies mean, how severe they were, how long they lasted, and whether they represent an ongoing problem or a single occurrence. Find out if and how the deficiencies have been corrected. Understand that even the best homes receive an occasional deficiency; what counts most is the nature, degree and duration of any problems the surveyor noted. If family members have questions and concerns, they should not hesitate to bring them to the attention of the nursing home's administrative staff and ask for an explanation.
Q. If families need to look for nursing home care, when should they start, and how can they find out what is available?
A. Start as soon as possible, even before the need for long-term care becomes apparent. With the help of a physician, determine the kind of care that might be needed in the future, and check into organizations in the area that provide that type of care. The person may be able to supported at home with home and community-based services, such as home health care or adult day health services. Assisted living may be the answer. Or, it may be time to consider a nursing home.
Many agencies and organizations retain information about long-term care in order to make referrals to the public. Rarely, however, will a referral agency openly endorse one provider over another. Often the referral will be in the form of a list of agencies or facilities serving a particular area, perhaps with a brief description of their services and specialties. Some general and public sources of information are long-term care provider associations, city or county social services departments, religious organizations; state health departments; local government agencies on aging; and consumer organizations. Other valuable resources include physicians, social workers, clergy, and friends or relatives whose family members have used long-term care services or been in a nursing home. One valuable source of information and referral is the toll-free Eldercare Locator, 1-800-677-1116. In addition, ombudsmen, who act as advocates for nursing home residents, are found in every state and may be helpful.
Q. Why do some homes have more bed sores [or some other characteristic from the nursing home report card in question, if applicable] than the state or national averages?
A. An above-average percentage of bed sores should raise questions on the part of consumers. It is regrettable but true that bed sores can result from poor care, and poor care is inexcusable. In other situations, however, a home may have special experience in handling skin problems, which may lead physicians to refer their patients there for specialized skin care. A home may also have more residents whose extraordinary frailty makes them more susceptible to skin breakdown and require special attention. Again, any survey finding that raises questions deserves to be explored. Consumers should ask about this or any aspect of the report that concerns them.
Q. Why doesn't the government just shut down deficient homes?
A. Not all deficiencies indicate ongoing, serious problems that could lead to harm of the residents. Some deficiencies are the result of one isolated occurrence that the facility can quickly remedy. It is in the best interests of both the government and beneficiaries to improve a facility and bring it into compliance with federal and state standards, whenever possible, than to simply close a home and displace residents in need of ongoing care. However, if the government believes the health or safety of residents is in immediate jeopardy, it can and should close the nursing home or take other enforcement action. (See "What about more serious violations?" above.)
Q. [For homes with deficiencies reflected in the nursing home report card] Do the deficiencies for your facility still exist?
A. Once deficiencies are noted on a survey form, the facility must submit a plan of correction for remedying them. The plan must include a method of correction and a target date. Homes may then be resurveyed to determine whether the deficiency still exists, whether the noncompliant practice has been corrected, or whether substantial progress toward compliance has been made. Implementation of the plan of correction must be verified by the survey agency. If corrections are not made within a specified period of time, the facility can be subject to further sanctions and closure. [Note: Be prepared to give a straightforward response to this question corresponding to your facility's status. This is a likely question you will get if approached by the media.]
Q. Should health care professionals use the information in a nursing home survey report to recommend nursing homes for their patients, and should family caregivers rely on it in selecting long-term care for their loved ones?
A. Survey results represent just one tool that can be used as a point of further inquiry into the quality of nursing home care, but health care professionals and consumers should look beyond this data to judge whether a particular facility meets an individual's needs. Visiting a nursing home, where you can ask questions and observe closely the environment and the interaction between staff and residents, remains an indispensable tool in making a good decision. In all likelihood, health care professionals, clergy, social workers and other referral sources are already well aware of the quality of services delivered by nursing homes in their communities.

Open House Announcement
Fax, e-mail or, better yet, hand deliver the PSA below to the public service directors of local TV and radio stations. Explain in a cover note and in person that you are opening your doors to the community in response to the release of the nursing home report card, to demonstrate the kind of quality care and services you provide and to permit the public to ask questions about your facility and nursing care in general.

Because you value your special relationship with your community, you will want to open your doors as a gesture to counteract any negative publicity generated by state and local coverage of deficiencies documented in the various report cards that now exist, or are anticipated.

An open house is an opportunity to demonstrate the kind of care and service you provide and an occasion that will permit the public to ask questions about your facility and even the needs of the home. Remember, a large turnout in this case is less important than your willingness to demonstrate that your home does not fear public scrutiny. Nevertheless, you will want to publicize the open house as widely as possible in the days and weeks leading up to the event.

Ideas for publicizing an open house include:

Certification for Medicare and Medicaid if these programs are important to you now or in the future.