CLIENT ADVISORY: Recent Changes to the CMS Nursing Home Compare Five Star Quality Rating System

Effective April 2019, CMS made changes in the Five Star Quality Rating System of the Nursing Home Compare website that affected all domains of the rating system. This advisory provides a brief description of these changes, how they will directly impact nursing homes, and what nursing homes should do in reaction to these changes.

Changes to the Quality Rating System

The quality rating system still focuses on three domains: Health Inspection, Staffing, and Quality Measures. The Health Inspection Domain now focuses on the last three annual recertification inspections and the last three years of complaint investigations. The three tracked periods are weighted with the most recent period given 1/2 weight, the second most recent period 1/3 weight, and the most distant tracked period 1/6 weight. CMS assesses different point penalties based on the number of re-inspections required to confirm that a deficiency or complaint has been remediated. The Staffing Domain takes two measures into account: Registered Nurse (RN) hours and total nurse staffing hours. This new standard puts a much higher emphasis on RN hours. If any quarter passes where a nursing home reports no RN staffing hours for four or more days, that facility will automatically be given a one-star rating for this Domain. The Quality Measure Domain tracks the nursing home’s performance on seventeen of the Quality Measures on the CMS website. CMS added long stay hospitalizations and long stay Emergency Department visits to this Domain and removed the long stay physical restraints measure. Additionally, CMS reports separate ratings for the quality of care given both short-stay and long-stay residents.

A nursing facility can estimate the final, composite rating by starting with the health inspection and staffing ratings. Add one star if the staffing rating is four or five stars and higher than the health inspection rating; subtract one star if the staffing rating is one star. Then, add one star if the quality measure rating is five stars and subtract one if it is one star. At no point in the calculation can the rating go above five or below one star and if the health inspection rating is one star then the overall rating cannot be upgraded beyond two stars. Nursing homes that are current Special Focus Facility (SFF) program participants will not be assigned an overall rating or any domain ratings.

Immediate Impacts of the Rating Update

These changes herald a significant update in the scoring and tracking of both the Staffing and Quality Measure Domains. Now, it is much harder for nursing homes to achieve top ratings in these Domains as the new rating system grades and tracks these domains much more stringently. This may cause a significant number of nursing homes to lose stars in these two Domains and, as a result, lose stars in their overall rating.

Residents and families who track the rating system may be confused by the sudden change to the rating of their, or their loved one’s, nursing home. Those same people may come to nursing home staff and ask questions as to why the rating of their facility recently dropped and what it means about the quality of services rendered by the nursing home.

In addition, some facilities have their quality rating affected by the use of universal workers. Incomplete instructions on how to allocate staff hours in PBJ reports has led to one star ratings for staffing by highly staffed facilities.

Actions SNFs Should Take in Response to the Ratings Overhaul

First, don’t panic if the new guidelines cause your facility’s star rating to drop. A rating drop due to a changing measuring stick does not necessarily mean that the facility’s care has changed.

Second, it is increasingly important to ensure that a facility has sufficient RN staff. The new system puts heightened emphasis on RN staffing and you do not want to lose stars in your rating because you do not have a sufficient RN staff according to the new scoring guidelines.

Third, nursing home administrators will need to make sure facility staff is educated on the changes to the rating system. As discussed above, worried family members and residents may be coming to you asking questions about why the star rating on your facility dropped. Administrators will need to be able to explain to concerned individuals that it was caused by a moving of the goalposts to assuage the concerns of residents and families about the quality of care in their facility.

Finally, even under the new system, the ratings start with, and are heavily influenced by, a nursing home’s performance on the Health Inspection Domain. Nursing homes need to ensure that they are prepared for their recertification inspections and that they address deficiencies and complaints that arise in their facilities as quickly as possible to ensure that the rating for this Domain is as high as possible. Should you have questions concerning the above proposal, please contact Peter Mellette, Harrison Gibbs, or Elizabeth Dahl at Mellette PC.

If you would like to look at the CMS Technical User’s Guide detailing at this information, the document is at:

This client advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up-to-date ad fact-specific advice.

Categories: Client Advisory