Providers should audit their PBJ submissions, RN scheduling documentation, and quality measure data to understand their exposure under the new methodology.
QSO Memo 19-08-NH
Technical Users’ Guide – April 2019
CMS Improving Nursing Home Compare in April 2019:
“CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports ‘no registered nurse is onsite.’ Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days.”
— Centers for Medicare & Medicaid Services, March 5, 2019
Staffing takes a front seat when driving quality of care
In this way, not only does CMS penalize facilities for going without a RN for three days, but it is demonstrating significant preference for RNs by leveraging RN staffing scores to directly influence the facility’s overall rating.
It’s clear that if nursing facilities want to score high on their staffing domain, they will need to keep their RN staffing levels as level as possible. In 2020, it’s expected that nursing facilities will increasingly push to staff more RNs in order to maintain adequate ratings.
— McKnights, December 12, 2019
How Skilled Nursing Facilities Can Win Under the New Five-Star System:
“The changes took effect in April, with roughly 36% of SNFs seeing a drop in their overall star ratings as a result, according to analyses from the American Health Care Association (AHCA) and CarePort… Some key steps include scrutinizing a facility’s Certification and Survey Provider Enhanced Reporting (CASPER) reports, keeping track of payroll-based journal (PBJ) data, and identifying education opportunities for staff… Given the importance of correct PBJ reporting to the final star rating, facilities should use the daily staffing report to check that all workforce data has been submitted and accepted — and is accurate. Stewart advised taking this step before the end of the reporting quarter to make sure that SNFs aren’t discovering inaccuracies after submission.”
— Skilled Nursing News, June 12, 2019
Nursing Homes Star Ratings Significantly Impacted by New CMS Updates:
“Since the changes have taken effect, we have analyzed swings within specific domains as nursing home ratings rise and drop based on the new criteria… A total of 7,937 nursing homes’ ratings were positively or negatively impacted. Under the new methodology, 2,387 nursing homes increased their ratings by one or more stars, while 5,550 lost at least one or more stars. Overall, 53 percent of all facilities’ stars ratings were impacted under the new change. Following CMS’ changes, 1,159 additional facilities dropped to the lowest ranking of one star. In addition, 1,210 fewer facilities held the highest ranking of five stars.”
— CLA (CliftonLarsonAllen), 2019
CMS Moves the Goalposts for Staffing Five-Star Ratings:
“Less obvious is the shift in RN cut points and stars in the Staffing Five-Star table. The focus on RN staffing comes from: A major shift in RN cut points — from 18% to 31% higher HPRD per star level… These changes are RETROACTIVE. The Oct. 1 to Dec. 31 PBJ report (submitted by Feb. 14) will be the first to use these new cut points when the Staffing Five-Star ratings come out next week. We recommend you assess your staffing levels and use ezPBJ to monitor your real-time Hours Per Resident Day metrics.”
— SimpleLTC, April 18, 2019
CMS Launches ‘Comprehensive Review’ of Nursing Homes Regulation:
“In April 2018, we incorporated data on nursing home staffing based from a new payroll-based journal (PBJ) system into Nursing Home Compare and the Nursing Home Five-Star Quality Rating System. The new PBJ data allows CMS to more accurately track staffing levels in nursing homes… SSAs are conducting a portion of their unannounced after-hours and weekend inspections to focus on staffing problems during those times. SSAs will take appropriate enforcement actions against those facilities that fail to provide the required nurse staffing.”
— HealthLeaders Media, April 16, 2019
CMS Using Data to Better Monitor Nursing Home Performance:
“The agency also is collecting staffing data from nursing facilities, based on payroll and other verifiable and auditable data, and will share it with SSAs so they know which nursing homes may have staffing issues and can target their reviews. SSAs also are conducting some inspections after hours or on weekends to assess any staffing problems at those times… Adding this data to Nursing Home Compare provides an entirely new and key source of quality information to nursing home residents, their families and caregivers.”
— Health Data Management, April 16, 2019
CMS: Hundreds More Buildings Could Receive One-Star Staffing Ratings Under New Rules:
“The most recent quarter showed roughly 550 providers who reported no RN hours for seven days in a quarter, a CMS spokesperson told SNN Tuesday. Given that the threshold is being lowered to four days, the number slated for downgrade could expand by a few hundred… ‘The CMS approach to standardize PBJ data and remove loopholes make sense,’ [Don Feige] said. ‘But many facilities are forced to rely on exempt RN staff for more than 40 hours a week and don’t know how to reconcile the PBJ “exempt bonus rules” against Department of Labor and FLSA regulations.'”
— Skilled Nursing News, March 12, 2019
Nursing Homes Subject to One Star Rating if They Go More Than Four Days Without an RN Onsite:
“Currently, facilities that report seven or more days in a quarter without a registered nurse onsite are assigned a one-star staffing rating. Starting next month, it will only take four days to trigger the automatic downgrade to one-star. CMS is also establishing separate quality ratings for short-stay and long-stay residents and is revising the rating thresholds. The agency is adding measures of long-stay hospitalizations and emergency room transfers and is removing duplicative and less meaningful measures.”
— Healthcare Finance News, March 8, 2019
CMS to Crack Down on Staffing, Separate Short- and Long-Term Stays in SNF Star Rating Overhaul:
“For the quality measure metric, CMS will increase the star thresholds to better reflect each SNF’s position relative to the crowd every six months. The exact gain will be set at 50% of the average improvement rate across all SNFs… A building’s five-star rating on Nursing Home Compare, CMS’s website for nursing home residents and their families, can be vital in securing referrals from hospital partners and attracting potential patients organically; preferred provider networks, accountable care organizations (ACOs), and other new payment models also frequently enforce certain star-rating thresholds when looking for new designated skilled nursing partners.”
— Skilled Nursing News, March 5, 2019
Investing in Staffing Doesn’t Necessarily Lead to Skilled Nursing Profits:
“Regulators have cracked down on the industry over staffing levels, hitting several facilities with one-star staffing ratings in 2018 after payroll-based journal data showed fluctuating workforce numbers. But a data dive by accounting firm CliftonLarsonAllen (CLA) found that investing in staffing star ratings may not actually correlate with profitability… ‘That sweet spot, in my view, is having survey of four or five, quality metrics of four or five, and staffing in the three to four range,’ Rutledge said on the webinar.”
— Skilled Nursing News, February 27, 2019
A New Focus on Nursing Facility Staffing:
“CMS has identified two areas of concern: 1.) nursing facilities with several days in a quarter without a registered nurse (RN) present; and 2.) significantly low nurse staffing levels on weekends. To address these concerns, CMS will begin notifying State Survey Agencies of nursing facilities that meet either or both of these criteria… OIG will be examining nursing staffing levels that are reported by facilities electronically to CMS’ Payroll-Based Journal (PBJ). In addition, the review will address the efforts by CMS to ensure data accuracy and improve quality of care by examining the enforcement of minimum requirements and encouraging the hire of high-quality staff above required levels.”
— Provider Magazine, January 2019
