Five-Star Nursing Home Quality Rating System

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1 Five-Star Nursing Home Quality Rating System This is a summary of the information contained in the CMS Technical User s Guide July The guide in its entirety can be found at CMS.gov. Since the launch of the CMS Five Stars Rating System in 2008, the percentage of homes with a five star rating has increased by 66% and the number of homes receiving only a one or two star rating has decreased by 23% (AHCA 2014). It is believed that this shift is contributed to: Nurses spending more time with our residents An increase in the Five-Star staffing ratings A decrease in the number of citations and an increase in the number of deficiency free surveys Overall improvement in our clinical care as reported in our quality measures Ratings from three domains determine the overall rating: Health Inspections (surveys) Staffing Quality Measures These three categories may or may not be related, but each one does affect the other. Understanding the Components of the Five-Star System HEALTH INSPECTION DOMAIN: The health inspection category ratings are based on the number of deficiencies cited, the scope, and the severity of the deficiencies from the three most recent annual inspection surveys, as well as, substantiated finding from the most recent 36 months of complaint surveys. More points are assigned for more serious widespread deficiencies and fewer points for less serious, isolated deficiencies. If the deficiency generates a finding of substandard quality of care, additional points are assigned. If the status of the deficiency is cited as past noncompliance (J, K, or L), the points associated with a G level deficiency are assigned. The most recent surveys are weighted more heavily. Additional points are added for revisits requiring more than one visit to correct the deficient practice. Deficiencies cited during a Federal Comparative or Life Safety surveys are not included in the calculations for the Five-Star rating. A lower survey score calculation equates to a better performance in the health inspection category of this domain. Annual surveys weighing factors: Most recent survey = 1/2 Prior survey period 1 = 1/3 Prior survey period 2 = 1/6 Complaint surveys weighting factors: Most recent 12 months = 1/ months ago = 1/ months ago = 1/6 Understanding the Five Star Nursing Home Quality Rating System Page 1

2 To avoid potential double-counting, deficiencies that appear on complaint surveys that are conducted within 15 days before or after of a standard survey are only counted once, If the scope differs on the two surveys, the highest scope-severity combination is used. Nursing homes in the top 10 percent for survey performance in each State receive a five-star rating. The middle 70 percent of homes in each State receive a rating of two, three, or four stars (with equal number or percent) in each rating category. The bottom 20 percent of homes in each state receive a one-star rating. In order to account for survey variance across the nation, five star ratings for the health inspection domain are compared to other homes within the same State and not to the Nation. The survey domain is critical as it forms the baseline for the overall star rating and the final scoring comes from adding or subtracting stars from this baseline with the Staffing and Quality Measure scores. Note: If the Health Inspection rating is one star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure rating. This is due to the Staffing and Quality Measure domains are self-reported domains and should not significantly outweigh the rating from actual onsite visits from trained surveyors who have identified serious quality of care problems. And since the health inspection rating is heavily weighted toward the most recent findings, a one-star health rating reflects both serious and recent finding. TAKE ACTION! Ensure you are survey ready every day with solid operational systems and processes that are continually monitored and reviewed utilizing staff accountability. Survey assessment includes: Medication management Skin Management Assessing of resident s needs and preferences Dietary services Residents rights and quality of life Re-examine your process for addressing incidents, grievances and complaints. Ensure it is a pro-active process that captures all concerns from residents, families and staff as well as monitors and tracks for patterns and trends. In review of Arkansas surveys, you are THREE times more likely to be cited a deficiency of a substandard quality of care nature on a Complaint survey than a Standard survey STAFFING DOMAIN: The rating for staffing is based on two measures: 1. Total nursing hours per resident day (RN + LPN + nurse aide hours) 2. RN hours per resident day Understanding the Five Star Nursing Home Quality Rating System Page 2

3 Hours are taken from the CMS-671 that is collected during the conference entrance at time of your standard survey. This form is used along with the form CMS-672 Resident Census and Conditions to determine the hours per resident day (HPRD). RN hours include Registered Nurses, RN Director of Nursing, and Nurses with administrative duties, such as RN or LPN who perform the Resident Assessment Instrument function in the home and do not perform direct care functions. Also include nurses whose principal duties are spent conducting administrative functions. For example, ADON is conducting an educational in-service or duties not considered to be direct care giving. Staffing domain addresses the distribution of Staff to Residents. The measures are evaluated in units of Hours Per Resident Day HPRD. From page 2 of the CMS-671: F39 RN Director of Nurses + F40 Nurses w Admin Duties + F41 Registered Nurses / 14 Days/ # of Residents as reported on F78 (page 1 of CMS-672) = RN HPRD Despite wide variations of required nurse staffing, your staffing is compared to the nation and not to your state. The Staff to Resident ratios are adjusted based on your Resource Utilization Group (RUG- III) case mix system. This data is based on a summary of MDS information for residents currently living in your home. Each home is assigned a target date that is 7 days prior to the most recent standard survey. CMS will compare the quarter of RUG data containing that target date to the homes reported staffing data from the CMS-671 from the most recent survey to calculate the ratios. Both RN hours and total staffing hours must be at or higher than the median, to receive an overall staffing rating of four or five stars. (RN: and Total Staff: ) TAKE ACTION! Strictly follow the directions for the CMS-671 to prevent erroneous Data from being submitted. If you find that the CMS-671 was submitted with errors, you can make ONE correction per year. Fax the corrected form to the Office of Long Term Care attention Mark Kilburn at The nursing home compare data is updated on a quarterly basis. In box F40 on the CMS-671, Nurses with Administrative Duties, be sure to include RNs & LPNs with administrative duties. If LPN is counted in this category, then do not count in the Licensed Practical Nurses category. In box F41 on the CMS-671, Registered Nurses, this is where you are going to capture every Registered Nurse working in your home that has not been accounted for in other areas, for example, contract RNs, agency RNs, Nurse Practitioners, Clinical nurse specialists, etc. (Do not include Hospice staff or paid feeding assistants.) Remember if you have an RN that is at the hospital or in the community conducting assessments for potential admissions or you have a RN consultant that is working and the hours are billed to your home, they are counted in F41. Understanding the Five Star Nursing Home Quality Rating System Page 3

4 QUALITY MEASURE DOMAIN: A set of quality measures has been developed from MDS based indicators to describe the quality of care being provided in nursing homes. There are 9 out of the 18 measures currently posted on Nursing Home Compare that make up this domain. The measures were selected based on their validity and reliability, the extent to which the measure is under the facility's control, statistical performance and importance. Long-Stay Residents: % of residents whose need for help with activities of daily living has increased % of high risk residents with pressure sores % of residents who have/had a catheter inserted and left in their bladder % of residents who were physically restrained % of residents with a urinary tract infection % of residents who self-report moderate to severe pain % of residents experiencing one or more falls with major injury Short-stay residents: % of residents with pressure sores that are new or worsened % of residents who self-report moderate to severe pain Ratings are calculated using the three most recent quarters for which data is available. Rating Methodology For each measure, 1 to 100 points are assigned based on the homes performance. Homes with measures ranking in the top 1% (meaning that they are flagging at 0%) will receive 100 points, while measures ranking in the lowest 1% (meaning they are flagging at a 90% or higher will receive 1 point. All of the 9 quality measures are given equal weight The points are summed across all measures to create a total for each home. The scores will range between 9 and 900 points. All measures are based on National distribution except for the ADL measure. This measure appears to be more affected by case-mix variation, particularly influenced by differences in State Medicaid policies governing long term care. A home must receive at least 508 points to receive a four star rating in this domain. TAKE ACTION! What your homes Administrator, DON, and Medical Director Need to Know to Make a Difference Be aware of your QM data and review in monthly QA meetings. Look for trends. Review all residents who triggered in the following areas! Understanding the Five Star Nursing Home Quality Rating System Page 4

5 Late Loss ADL (Bed Mobility, Transfer, Eating and Toileting) Request triggered list monthly from MDS Coordinator. Assure that end of life situations are well documented. Audit medical record for consistent evaluation by all, including ADL flow sheet. CNA Education is crucial! Pressure Ulcers Catheters Provide list of triggered residents for your Medical Director, request that he address ulcers that are not healing and treatments are changed every 2 weeks on those that are not responding to current treatment as indicated in F314. Minimize catheter use and duration. Provide list of triggered residents, those that have had catheters in place during the past 7 days. Monitor for clinical indication and diagnosis. Trial of catheter removal, document and care plan. Urinary Tract Infections Request list of all residents who have triggered with UTI s over the past 30 days. Ask Infection Control Nurse and MDS Coordinator to collaborate for this information. Audit to ensure that UTIs are coded appropriately according to McGeer s Criteria - (see link below) Monitor pericare and hand washing techniques. Pain (Almost constant or frequently moderate to severe) UTILIZATION OF PRN PAIN MEDICATION IS NOT AN INDICATION FOR ABOVE! Falls with Significant Injury (Bone Fracture, Subdural Hematoma, Joint Dislocation and Closed Head Injury with Altered level of Consciousness) over last 12 months Request a list of all triggered residents for review. Understanding the Five Star Nursing Home Quality Rating System Page 5

6 OVERALL NURSING HOME RATING: The home s overall score or Composite Measure is determined as follows: Step 1: Start with health inspection five-star rating as your baseline. Step 2: Add one star to the Step 1 results if staffing rating is four or five stars and greater than the health inspection rating: subtract one star if staffing is one star. The overall rating cannot be more than five stars or less than one star. Step 3: Add one star to the Step 2 result if quality measure rating is five stars; subtract one star if quality measure rating is one star. The Overall Quality rating cannot be more than five stars or less than one star. Step 4: If the Health Inspection rating is one star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings. (The rationale here is that this domain is not self-reported. This measure outweighs the other two since the data is collected from actual onsite visit from trained surveyors.) Step 5: If the nursing home is a Special Focus Facility (SFF) that has not graduated the maximum Overall Quality rating is three stars. One star rating in any of the domains severely impacts the overall rating and a One star rating in staffing and quality each lower the baseline health inspection rate and overall rate. Know the Implications of your Five-Star Quality Ratings and Be Prepared! Who else is looking at your Quality Ratings? Hospital discharge planners may be evaluating your Quality Ratings and providing information to prospective residents/families. Managed Care entities can also review the Five-Star finding and use them in setting contractual quality and performance expectations. In conclusion: CMS does caution that no rating system can address all of the important consideration that should go into a decision about which nursing home may be best for a particular person. While the Five Star Rating System can offer valuable information, the ratings are only a snapshot of the home. How a home s residents and their family members judge the care being provided in that particular home is the very best indicator of the quality of care and quality of life residents enjoy! Understanding the Five Star Nursing Home Quality Rating System Page 6

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