Managing Your Five-Star Nursing Home Rating

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1 Managing Your Five-Star Nursing Home Rating The new consumer rating system launched by CMS forces facilities to investigate and address highlighted problems W h i t e p a p e r How many stars do you have? This question is now heard frequently in conversations in or between facilities. In December 2008, CMS unveiled the overhauled Nursing Home Compare Web site, introducing an intuitive five-star quality rating system that is easy to navigate and understand. This redesigned interface intends to allow meaningful distinctions between high- and low-performing facilities. by Diane L. Brown For additional information on the five-star quality rating system, contact Adrienne Trivers at or 800/ , Ext CMS new rating system provides a broad overview to consumers, residents, and family members on how nursing homes are assessed for quality and assists families in making informed decisions on which nursing home to send their loved ones to, according to CMS. The rating system uses data from health inspections or surveys, self-reported staffing hours per patient per day, and 10 of the existing quality measures (QM) to calculate five-star ratings. CMS displays the ratings on the Nursing Home Compare Web site under four categories: overall composite rating, health inspections, staffing, and QMs. More stars are better, and currently, about 43% of nursing homes have a one- or two-star rating. F E A T U R E S How many stars do you have? 1 Star ratings Definition Much above average Above average Average Below average Much below average You have your star rating, now what? 5 Who s looking at your stars? 7 Begin a process to improve or maintain your rating 7 Categories of stars 9 The data components used in the five-star ratings The ratings are derived from three different metrics. According to CMS Technical User s Guide for the Five-Star Quality Rating System, the ratings are calculated as follows: Health inspections. State health inspections are the basis for this measure. The rating is based on the number, scope, and severity of deficiencies found during the three most recent years of surveys, in addition to validated findings from the most recent three years of complaint investigations. The

2 2 Managing Your Five-Star Nursing Home Rating august 2009 number of repeat visits to ensure that the deficiencies are corrected is also taken into account. Staffing. Nursing home staffing levels reported annually by facilities on form CMS-671 (Long Term Care Facility Application for Medicare and Medicaid) to surveyors are the basis for this measure. The rating is based on two measures: The number of RN hours per resident day The total number of staffing hours per resident day, including RN, LPN, and nurse aide hours This measure does not include clerical, administrative, or housekeeping staff members. This measure does not include clerical, administrative, or housekeeping staff members. The measure is gathered from the CMS Online Survey and Certification Reporting system and case-mix adjusted based on the weighted distribution of RUG-III categories. QM. This measure is based on 10 of the 19 publicly reported QMs and includes seven long-stay and three short-stay QMs. For long-stay residents, the system evaluates what percent of a facility s residents: Experienced activities of daily living (ADL) decline Experienced decline of mobility Have high-risk pressure ulcers Have catheters Are physically restrained Have urinary tract infections Have moderate to severe pain For short-stay residents, the rating system evaluates the percentage of residents with: Pressure ulcers Delirium Moderate to severe pain Calculating your overall composite rating From the survey, staffing, and QM stars, the system uses the following calculation to determine a nursing home s overall star rating: 1. Your survey stars are your base number of stars 2. Add one star to your survey stars for each of the following conditions: A staffing rating of four or five stars A QM rating of five stars 3. Deduct one star from your survey stars for each of the following conditions: A staffing rating of one star A QM rating of one star For example, if Happy Hour Nursing Home has four stars for its survey rating and three stars for staffing, the staffing stars have no bearing on the ratings for that calculation. But if the facility had a staffing rating of four or

3 August 2009 Managing Your Five-Star Nursing Home Rating 3 five stars, one star would be added to the total number of survey stars for an overall rating of five stars. Conversely, if the survey component displays four stars, but only one star for the staffing component, then one star would be deducted for the composite rating, dropping the overall composite to three stars. A facility cannot receive more than five stars or less than one star. Additional rules apply to the rating calculation for special focus facilities that have not graduated and facilities that received a one-star health inspection rating. Consistently good survey results have the greatest effect on your five-star quality rating. Consistently good survey results have the greatest effect on your five-star quality rating. Health inspections rely on information gathered during the survey process through interviews with residents, families, and staff members; reviewing the medical record; observation of the facility and resident care; and analysis of quality measures/quality indicators (QM/QI). Indirectly, the MDS accuracy plays a significant role because the QM/QIs are derived from the MDS data collection. High focus on the health inspection stars After the decision to cite a deficiency is made, the survey team determines the severity of the deficiency as it relates to patient safety or health and how many residents are affected. The scope and severity chart below depicts the guidelines used to make those choices and the five-star rating points associated with letter category. Scope and severity chart Severity Level 4 Immediate jeopardy to resident health or safety Scope Isolated Pattern Widespread J 50 points (75 points) K 100 points (125 points) L 150 points (175 points) Level 3 Actual harm that is not immediate jeopardy G 20 points H 35 points (40 points) I 45 points (50 points) Level 2 No actual harm, with potential for more than minimal harm that is not immediate jeopardy D 4 points E 8 points F 16 points (20 points) Level 1 No actual harm, with potential for minimal harm Source: CMS. A 0 points B 0 points C 0 points Notes about the scope and severity graph Points in parentheses indicate the higher point value for deficiencies cited in the substandard quality of care categories

4 4 Managing Your Five-Star Nursing Home Rating august 2009 Shaded cells denote deficiency scope and severity levels that constitute substandard quality of care if the requirement that is not met falls under the following federal regulations: 42 CFR , Resident Behavior and Nursing Home Practices; 42 CFR , Quality of Life; 42 CFR , Quality of Care. Points for each deficiency cited (and not later overturned) are totaled in accordance with the scope and severity chart. For example, Happy Hour Nursing Home has seven deficiencies in the current year as follows: two Es, four Ds, and one B. The total points for the current year would be: (2 x 8 = 16) + (4 x 4 = 16) + (1 x 0 = 0) = 32 points. A second point source for the health inspection component is the number of revisits the survey team must make to ensure the facility s compliance with cited deficiencies. Weights for repeat revisits Revisit number Noncompliance points First 0 Second 50 Third 75 Fourth 100 Based on these formulas, CMS then totals the points for revisits and scope and severity for each of the previous three years. After weighting factors are applied, in which the current year counts the most and the prior years account for successively less, the final score for health inspections is determined. It will fall into one of the five-star category ranges calculated by CMS for each state and published in the CMS Nursing Home Compare Five-Star Quality Rating System: Technical Users Guide, State-Level Cut Point Tables. There can be some change to a facility s survey star rating on a monthly basis, even without a new survey. There can be some change to a facility s survey star rating on a monthly basis, even without a new survey, since CMS recalculates the cut point tables monthly to maintain a bell curve distribution, in which the top 10% of facilities in each state receive five stars and the bottom 20% receive one star, leaving the remaining 70% in the two-, three-, or four-star categories. Stars for staffing The self-reported data for the staffing star derive from two forms completed during the annual facility survey: CMS-671 (Long Term Care Facility Application for Medicare and Medicaid) and CMS-672 (Resident Census and Conditions of Residents). The CMS-671 reports RN, LPN, and nurse aide hours for a specified two-week period just prior to the survey. It includes facility staff members as well as contractual or agency staff members present during that period. The CMS-672 communicates the total resident or patient

5 August 2009 Managing Your Five-Star Nursing Home Rating 5 population during that same period and serves as the denominator of the staffing calculations. Using a set of exclusion criteria, CMS tries to identify facilities with unreliable or outlier staffing data. Lastly, the staffing measures are adjusted for case-mix differences based on the RUG-III 53 case-mix system. The adjustments are applied based on data drawn the last day of each quarter for active residents. Two separate staffing measures are calculated and given equal weight: RNs and all staff members delivering nursing care (e.g., RNs, LPNs, and CNAs). The cut points or data boundaries between each star category were determined using data available as of December 2008 and will remain fixed for the first two-year period, which CMS hopes will allow for better tracking of facility improvement or decline over that time period. The cut points are national benchmarks derived from free-standing facility statistics only. QMs are calculated and posted on the Nursing Home Compare Web site from MDS data routinely collected by staff members at specified times. Stars for quality measures QMs are calculated and posted on the Nursing Home Compare Web site from MDS data routinely collected by staff members at specified times. These data are transformed into QMs that suggest how well nursing homes address residents physical and clinical needs. Rather than benchmarks, QMs are based on actual care provided to facility residents collectively. They intend to inform consumers as they choose a nursing home as well as provide current residents with information on their facility and provide an opportunity for discussion about quality improvement efforts. Three of the 10 QMs are for short-stay patients who stay in the facility for a minimum of two weeks and have two assessments. One of the short-stay measures (pressure ulcers) is incidence-based or comparative and requires two distinct data points to calculate or more simply, the data from the fiveday Medicare assessment is compared to the 14-day Medicare assessment to determine improvement or decline. Both of the ADL measures, which are incidence-based, calculate only after the resident has been in the facility for more than 90 days. The cut points for assigning a star for QMs are based on the three most recent quarters of data. For each measure, points are assigned based on the facility percentile. The two ADL measures use state-specific quintile distributions because of the state-to-state variations. The remaining QMs are based on national distribution, and although the cut points for the two ADL measures will be reset quarterly, the remainder of the cut points will be fixed for two years. You have your star rating, now what? Not all facilities are happy with their star rating. It s possible that your facility received an unexpected low rating and now you want to know what steps to take for improvement and, ultimately, a better star ranking on Nursing Home Compare. If you believe an error was made when calculating your star rating, CMS has a five-star hotline for providers to report unusual findings, errors, or potential errors.

6 6 Managing Your Five-Star Nursing Home Rating august 2009 CMS will update the ratings monthly. Unfortunately, not all criteria are updated or reviewed monthly. For example, the QMs are updated quarterly. CMS provides the following suggestions for nursing homes that want to improve their ranking: Have fewer and less serious deficiencies on surveys Increase the level of RNs, LPNs, and/or CNAs Concentrate on quality improvement actions in areas reflected in the QMs Range of reactions from the provider community Most in the nursing home provider community agree in principle that a rating system is important. However, the current system is flawed by inaccurate data and inconsistencies among survey results region-to-region and state-by-state, as documented by several GAO studies. Benchmarked variations among survey results can exceed 33%, depending on the individual survey team. There is also concern that if an otherwise good facility had a poor survey three years ago based on a single incident, the number of points accumulated from that incident may prevent that good facility from attaining a good rating. the biggest miss with the five-star system is that it doesn t measure what we think is a very important measure, and that s customer satisfaction. Richard C. Bane, MBA, FACHCA Many members of the long-term care industry are also disappointed the fivestar quality rating system doesn t take customer satisfaction into account. The biggest miss with the five-star system is that it doesn t measure what we think is a very important measure, and that s customer satisfaction, says Richard C. Bane, MBA, FACHCA, president of BaneCare, LLC, which operates several nursing facilities in Massachusetts. In Massachusetts, long-term care providers worked with the state legislature and department of public health to conduct customer satisfaction surveys in 2005 and In both surveys, nine out of 10 respondents said they would recommend their nursing home to a friend or family member. To have that kind of performance and to have that not be recognized in a five-star rating is crazy, particularly because the five-star rating is intended to focus on the needs of the consumer, Bane says. Currently, the staffing component of the five-star quality ratings is based on a self-report for one two-week period just prior to the annual survey. These staffing numbers may not fairly represent the usual staffing patterns of the facility, and the CMS-671 form used to report staffing is not consistently completed by all facilities. Another major complaint voiced by facilities is that the ideal staffing level required to get five stars in staffing is unfunded by the prime payer in most states Medicaid. Another frequent provider complaint is the bell curve approach to the survey component of the ratings. Many providers are frustrated that adopting this approach is not reflective of actual quality of care provided.

7 August 2009 Managing Your Five-Star Nursing Home Rating 7 CMS has published many of the provider concerns, and although the feedback from the provider community identifies valid points, CMS contends that it will work with providers and provider organizations to improve the system in the future. This leaves many providers frustrated. Who s looking at your stars? Nursing homes aren t the only ones looking at ratings. Families and residents are also taking notice. CMS advises families to not focus solely on a facility s star rating when deciding on a nursing home for a loved one. Families should visit a facility, take a tour, and meet with staff members before they make a decision. For those families contemplating transferring their family member to a higher-star facility, they should take into account the potential effects the transfer will have on their loved one. Nursing homes can help educate family members about the benefits of their facility and the negative effects a transfer might have. One facility reports a phone call from a prospective resident asking whether it had an overall fivestar rating. When the facility responded that it was a four-star facility, the potential client was elated and proceeded to schedule a tour of the facility because she didn t think she could afford to live in a five-star facility! However, consumers aren t the only ones looking at nursing homes star ratings. Under the five-star quality rating system, nursing facilities reputations aren t the only thing on the line: SNFs ability to get loans or obtain a certificate of need could be affected by their star ratings. The U.S. Department of Housing and Urban Development (HUD), an important lender for nursing facilities, is now using star ratings as a component of its risk assessment of nursing facilities. In addition, the U.S. Department of Housing and Urban Development (HUD), an important lender for nursing facilities, is now using star ratings as a component of its risk assessment of nursing facilities. Potential and current customers and families Initially, the national press covered the introduction of the rating system extensively, bringing it to the attention of the public. However, CMS warns consumers that the ratings should be only one tool to evaluate a potential facility, along with a visit and other determining factors. Begin a process to improve or maintain your rating If you are in the 10% of facilities that have an overall rating of five stars, congratulate yourself and promote that fact. But read on if you intend to maintain your current status. If you are in the remaining 90% of facilities, the first thing you must do is determine the accuracy and validity of your ranking. If the ratings are inaccurate or do not seem valid, begin to pursue a path to correct the problems. This may involve contacting CMS officials to determine the cause of the problem. For ratings that seem accurate and valid, identify all the specifics. For example, if the facility has seven identified deficiencies that caused a poor rating,

8 8 Managing Your Five-Star Nursing Home Rating august 2009 determine the causes of the citations. Causes could range from surveyor bias to inaccurate assessments to poor documentation in the medical record to actual quality-of-care or quality-of-life issues. It s important to have systems and processes in place to complete the investigation of causes. Investigation of the specific causal factors will help the facility determine the course of action it must take to improve ratings. Perform customer satisfaction surveys and be prepared to tell your own story. Perform customer satisfaction surveys and be prepared to tell your own story. Support your story with personal customer satisfaction testimonials. The best local support for your facility comes from grateful customers who were well served. Most importantly, adhere to the principles of continuous quality improvement and transparently demonstrate your commitment to those principles. Despite federal and state oversight, only we as an industry can improve the quality of the care we deliver, maintain the dedication to our customers that will make them return again and again, and remain viable. Therefore, education on systems and process improvement must be vigilant and ongoing. n Help is available HCPro, Inc., provides assistance with the five-star quality rating in many formats, including: Five-Star Quality Rating Boot Camp for Long-Term Care Customized on-site five-star training Consulting services to help you improve your five-star rating Contact client service representative Adrienne Trivers at or at 800/ , Ext. 3207, to find out which format best fits your needs.

9 August 2009 Managing Your Five-Star Nursing Home Rating 9 Categories of stars Overall rating 1 5 stars are computed using health inspections as the base Health inspections (weighted over three years) 1 5 stars based on points and distributed by cut points Staffing (acuity, case-mix adjusted) RN hours Total hours QMs 1 5 stars adjusted from reported data for a two-week period prior to survey 1 5 stars adjusted from reported data for a twoweek period prior to survey 1 5 stars based on performance of 10 (out of 19) QMs calculated into points (1 136) Formula: Start with survey stars and add 1 star if staffing is 4 or 5 stars (and greater than survey stars) or deduct 1 star if staffing is 1 star. Then add 1 star if quality is 5 stars or deduct 1 star if quality is 1 star. Year 1 weight: 1/2 Year 2 weight: 1/3 Year 3 weight: 1/6 RN hours per patient day (RN + LPN + CNA) total per patient day Weighted by RUG score for each resident from quarter in which survey falls 7 measures: long-stay residents (n = 30 assessments) 3 measures: short-stay residents (n = 20 assessments) NH compare displays most recent quarter of QM data, but the ratings are based on the three most recent quarters of data Cut points update monthly to maintain distribution of 10% (5 stars), 70% (2, 3, 4, 5 stars), 20% (1 star) 0.55 RN threshold identified for potentially avoidable hospitalizations (shortstay measure) 4.08 threshold (2.78 CNA licensed staff for longstay measures) Cut points are constant for initial two-year period Each QM is scored and weighted based on percentile and type of QM. ADLs use state-level data; other QMs use national-level data as the comparison point Cut points are constant for initial two-year period

10 10 Managing Your Five-Star Nursing Home Rating august 2009 How does your state rank? The following graph focuses on the number of one- and two-star facilities in each state. State Facilities 1-star 2-star % 1-star % 2-star # 1-, 2-star % 1-, 2-star LA % 23.2% % GA % 23.1% % TN % 23.3% % NM % 21.4% 35 50% IL % 22.1% % WV % 20% % TX % 19.9% % OH % 20% % IN % 20.7% % NV % 18.8% % KY % 22% % OK % 20.7% % SC % 17.1% % NC % 16.5% % CA % 21.4% % WA % 16.3% % MO % 21.6% % PA % 18.3% % NY % 21.7% % SD % 25.5% % AZ % 22.2% % NJ % 19.9% % KS % 25% % AR % 18.2% % UT % 20.2% % MS % 18.3% % MI % 18.6% % DC % 16.7% % OR % 23.2% % IA % 20.1% % FL % 19.4% % MD % 17.8% % MN % 22.7% % AL % 19.4% % AK % 36.4% % MT % 19.8% % MA % 20.6% % CO % 16.1% % VT % 17.5% 14 35% WI % 17.8% % NH % 27.5% % NE % 18.7% % WY % 12.8% % ID % 19% % RI % 18.6% % HI % 25% % CT % 20.8% % DE % 15.6% % ME % 19.3% % ND % 15.7% % TOTALS % 20.3% % 08/09 SR3709

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