These changes, alongside the FY 2023 SNF PPS proposed rule’s request for comment on minimum staffing requirements, signal a sustained federal effort to use PBJ data as the foundation for both public accountability and regulatory enforcement.
QSO Memo 22-19-NH
Technical Users’ Guide – July 2022
PBJ Policy Manual – Version 2.6
Appendix PP Guidance to Surveyors for Long Term Care Facilities
CMS Revises Methodology for Calculating Staffing Star Rating
“Effective with the July 2022 refresh, the Centers for Medicare & Medicaid Services (CMS) is revising the methodology for calculating the staffing star rating. These measures, which have been posted on the CMS website for more than a decade, are used to calculate each nursing home’s star rating for the staffing section of the Nursing Home Five-Star Quality Rating System. The new rating is based on six separate staffing measures. In a system similar to the Quality Measure (QM) rating, points are assigned based on the performance on each of these six measures. The points are then summed up, and the total staffing score is compared to staffing rating point thresholds to assign a rating of one to five stars.”
— HealthLeaders Media, July 20, 2022
Five-Star Shifts Have Added Pressure to Staffing Urgency — It’s Time for a New Approach
“As skilled nursing facilities work to hire more nurses in the wake of COVID-19-related staffing shortages, the Centers for Medicare & Medicaid Services’ recent changes to its Five-Star Quality Rating System are putting additional pressure on HR and nursing leaders. The updated guidelines now include measures for staff turnover (including RNs, licensed practical nurses, nurse aids and administration) and weekend staffing levels. Reducing the time to hire will greatly improve staffing star ratings.”
— McKnight’s Long-Term Care News, November 15, 2022
1 in 3 Nursing Homes Fall in Staffing Under New CMS Five-Star Rating System
“A new quarter of staffing data was released to which CMS applied their new methodology for rating staffing that integrates staffing hours per resident day, nursing staff and administrator turnover, and weekend staffing rates. Considering these changes, 4,850 providers (33%) declined in staffing rating, with 939 losing 2 or more stars.”
— McKnight’s Long-Term Care News, July 28, 2022
CMS Officially Adds Weekend Staffing, Turnover to Five-Star Quality Ratings
“The Centers for Medicare & Medicaid Services (CMS) on Wednesday launched its enhanced Five-Star Quality Rating System – adding weekend staffing and annual turnover to the mix. The updates come at a time when the sector is experiencing a more than 14% drop in staffing levels compared to pre-pandemic. That’s a loss of nearly 229,000 caregivers since February 2020, according to the Bureau of Labor Statistics.”
— Skilled Nursing News, July 27, 2022
Lots to Learn with New Five-Star
“We now have six staffing metrics, and we no longer have the opportunity to pick up an additional star for achieving a ‘4-star’ in staffing. Without exception, whenever I review PBJ submissions in the support of nursing home legal defense, I discover staff hours that were paid and worked but never submitted.”
— McKnight’s Long-Term Care News, July 22, 2022
Thousands of Nursing Homes Face Lower Five-Star Ratings with Changes to Staffing Stars
“The added data will affect calculations beginning with a July 27 refresh, CMS said. Spencer Blackman, director of product at analytics firm StarPro, found 1,556 nursing homes, about 10%, currently earn a ‘bonus’ star for their 4-star staffing efforts. Another analysis by Formation Healthcare found 2,453 facilities, or about 16% nationwide, would lose one star from their overall rating if the new methodology maintains their 4-star nursing staffing rating.”
— McKnight’s Long-Term Care News, July 11, 2022
PBJ Data Use in Surveys Serves as ‘Breadcrumbs’ to Looming Federal Staffing Mandate
“For the first time ever, surveyors have objective staffing data in front of them, and they’re going to use it to probe and ask staff very poignant questions about specific days when they were working and frankly, I think that’s a game changer,” said Steven Littlehale, chief innovation officer for Zimmet Healthcare Services Group. Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care (NASL) sees the PBJ updates as ‘breadcrumbs,’ indications of what CMS is working toward in terms of minimum staffing requirements.”
— Skilled Nursing News, July 10, 2022
CMS: Turnover, Weekend Staffing Levels Now in Five-Star Ratings
“Additionally, to emphasize the importance of staffing, we will no longer add one star to the overall rating of nursing homes that have a four-star staffing rating,” CMS explained. “Rather, only nursing homes with a five-star staffing rating will be rewarded with an increase in their overall star rating.”
— McKnight’s Long-Term Care News, July 8, 2022
CMS Issues Guidance on Five-Star Staffing Measures
“The agency specified a maximum of 100 points can be awarded for case-mix adjusted total nurse staffing and RN staffing, 50 points max for weekend statistics, and 50 points each for annual total nurse turnover, RN turnover and administrator turnover, respectively. Generally, the additions have been seen by some as insensitive in light of a historic staffing shortage and soaring agency use.”
— Skilled Nursing News, July 7, 2022
New Employee Interviews, Deeper Dive Into PBJ Data Could Lead to More Survey Citations
“CMS now plans to incorporate Payroll Based Journal staffing figures into investigations about potential noncompliance with nurse staffing requirements. Surveyors will be looking for problems such as insufficient staffing, lack of a registered nurse for eight hours each day, and a lack of licensed nursing for 24 hours a day. Providers should also know that although the PBJ staffing data report uses four or more days without an RN coverage, surveyors are instructed to consider a citation when there is one day without coverage.”
— McKnight’s Long-Term Care News, July 1, 2022
“To begin helping address the staffing issue while the rulemaking process is underway, CMS added new requirements for surveyors to incorporate the use of Payroll Based Journal staffing data for their inspections. This will help better identify potential noncompliance with CMS’s nurse staffing requirements, such as lack of a registered nurse for eight hours each day, or lack of licensed nursing for 24 hours a day. This guidance will help to uncover instances of insufficient staffing and yield higher quality care.”
— Centers for Medicare & Medicaid Services, June 29, 2022
Updated Guidance for Nursing Home Resident Health and Safety
“Nurse Staffing (Payroll-Based Journal): Uses payroll-based staffing data to trigger deeper investigations of sufficient staffing and added examples of noncompliance. Training Resources: On June 29, 2022, CMS will provide training in the Quality, Safety, and Education Portal (QSEP) for surveyors and nursing home stakeholders to explain the updates and changes of the regulations and interpretive guidance.”
— Centers for Medicare & Medicaid Services, June 29, 2022
“When the government asks for more and more information, data collection, we’re taking that clinical leadership off the floor and away from the patient. That’s counterintuitive to the goal,” added Manuel. “Now’s the time to make sure the data you’re submitting is actually accurate, because it is being publicly reported.”
— Skilled Nursing News, June 5, 2022
Nursing Home Pay Rule Reveals CMS Strategy on Minimum Staffing
“The release of a proposed 2023 pay rule Monday afternoon reiterated the Centers for Medicare & Medicaid Services’ commitment to implementing a minimum staffing rule after more than 20 years of debate on the issue. The proposed total staffing hours VBP element wouldn’t be added until 2026. It would draw from auditable Payroll Based Journal data, and CMS expects it will be a key way to move the needle on staffing.”
— McKnight’s Long-Term Care News, April 12, 2022
Fiscal Year (FY) 2023 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1765-P)
“CMS is seeking input on establishing minimum staffing requirements for LTC facilities. The Total Nursing Hours per Resident Day is a structural measure that uses auditable electronic data to calculate total nursing hours per resident day. Given the strong evidence regarding the relationship between sufficient staffing levels and improved care for patients, inclusion of this measure in the SNF VBP Program adds an important new dimension to provide a more comprehensive assessment of and accountability for the quality of care provided to residents.”
— Centers for Medicare & Medicaid Services, April 11, 2022
