Celtic Consulting

CMS Revisions to the Five Star Rating System

Posted Sunday, March 10, 2019

The CMS revisions to the Five Star Rating system include all domains.  These domains include the Health Inspection, Quality Measure, Staffing and RN Staffing domains. In general, facilities should not see any drastic changes in their Five Star ratings.  Here is a summary of the changes and potential impacts:

1. Health Inspection domain:  Ratings for surveys will revert to its previous calculation methodology which includes 3 cycles over 36 months.  Cycles and their calculation weights –

Cycle 1 (weighted ½ or 50%) includes most recent standard survey & Complaint surveys from most recent 12 months from data upload.

Cycle 2 (weighted 1/3 or 33%) includes the previous standard survey & Complaint surveys from 13 to 24 months prior to upload date.  

Cycle 3 (weighted 1/6 or 16.6%) includes the next standard survey prior to the previous & Complaint surveys 25-36 months prior to upload date.

The potential impact of this domain depends on each facilities performance during older versus newer surveys.  Many facilities that were waiting for old surveys with high amounts of points to drop out of the calculations will see that they’ll now remain.  However, the older the survey, the less the weight. 

2. Quality Measure domain:  Several changes were made here:

  1. The Nursing Home Compare website will now report separate ratings for short-stay quality of care and long-stay quality of care in addition to the overall facility quality of resident care rating.  For facilities that excel in one over the other, this will now be evident, however it may also be misleading for facilities with smaller short or long-term censuses since their performance will appear worse mathematically.
  2. The rating point thresholds for each of the QMs have been revised for the first time since 2016 to account for quality measure improvement over time in the industry.
  3. Measures of long-stay hospitalizations and long-stay Emergency Department (ED) visits are being added and the long-stay restraints measure is being dropped.  For most facilities, the restraints measure was a “free” 100 points, but this is no longer.  The new long stay measures may negatively impact facilities who may have been only focusing on short stay hospitalizations and ED use. 
  4. The scoring rules for QMs are changing to give more weight to measures CMS believes have greater opportunity for improvement. These areas have been given more weight than other measures by expanding the range of rating points from 0-100 to 0-150. This change applies to:
  • The 3 ADL-Related QMs
    • Long Stay Increased ADL Help
    • Long Stay Ability to Move Independently Worsened
    • Short Stay Improved Function
  • Long Stay Antipsychotic Use
  • The 5 Claims-Based Measures:
    • Short & Long Stay Hospitalizations
    • Short & Long Stay ED Use
    • Short Stay Successful Discharge to the Community

3Staffing domain:  CMS has updated the staffing rating thresholds using the most current national staffing data of Quarter 4 2018.  Due to the importance of RN staffing and its relationship to quality outcomes, methodology has been changed to place more emphasis RN staffing when calculating the overall staffing stars. Additionally, the overall and RN staffing ratings are set to one star for those that report four or more days in the quarter with no RN onsite rather than seven days without an RN. Finally, staffing ratings are no longer being suppressed for nursing homes that have five or more days with residents and no nurse staffing hours reported.