Are Your Stars in Alignment? CMS 671 & 672: Data Accuracy and Their Role in the Five-Star Quality Rating System

Today s Star Chart Introductions Overview of Today s Program Coding and auditing Forms 671/672 Investigating the impact of Forms 671/672 on CMS Five-Star Staffing Score 2

Welcome and Introductions Jean Scott, Dr.PH, RN, Technical Director, CMS/CMSO/SCG Division of Nursing Homes Nancy Augustine, RN, MSN, NHA, Director of Quality Improvement and Risk Management, PointRight Inc. Steven Littlehale, MS, GCNS-BC, Executive Vice President Chief Clinical Officer, PointRight Inc. 3

Today s Objectives 1. Accurately code forms 671 and 672, and audit for accuracy 2. Review how 671/672 data contributes to CMS s Five-Star Staffing score 3. Articulate how Five-Star staffing data impacts overall Five Star score 4

What is the CMS 672? The CMS 672, Resident Census and Condition of Residents, reports: The total census at the time of survey Current condition of residents at the time of survey Facility defined as any bed that is Medicare and/or Medicaid certified 8

What is the CMS 672? Residents defined as residents in certified beds at the time of survey Total residents = all residents in Medicare and Medicaid certified beds + the number of residents with a bed hold 9

CMS 672 Accuracy Incorrectly gathering and reporting the census on the CMS 672 may impact the staffing component of Five-Star If the census is overstated and staffing is reported correctly, potentially, the staffing level might be under reported If the census is understated and the staffing is reported correctly, potentially, the staffing might be over reported 10

What is the CMS 671? CMS 671, Long Term Care Facility Application for Medicare and Medicaid Completed by every facility that participates in the Medicare and Medicaid programs at the time of every standard/annual survey Consists of two pages First page collects facility specific information related to type of services provided and facility characteristics The second page is all about staffing 11

Form 671 Hour Breakdown Full-time hours need to be reported separately from part-time hours and contract hours Full-time hours are defined as 35 hours or more per week and excludes meal breaks of a half hour or more Contract Staff includes staff not necessarily on the facility payroll but may be under contract by the organization to provide specific services 17

671 Definition of Services (Staff) Examples of Staff included: RN hours: Includes registered nurses F41, RN Director of Nursing F39, and Nurses with administrative duties F40 LPN hours: Includes licensed practical/licensed vocational Nurses F42 Nurse aide hours: Includes Certified Nurse Aides F43, aides in training F44, and medication aides/technicians F45 20

671 Definition of Services (Staff) Staff not included: Private duty nursing staff who are reimbursed by a resident s family Hospice staff and feeding assistants Volunteers 21

Staff Collection for the 671 Facility staff hours defined as actual hours worked in a 2-week pay period To include: overtime calculations Not to inlcude: non-work related hours and leaves, nonproductive work hours Use worked time information only, preferably from a payroll run or automated time keeping system 22

Staff Collection for the 671 Contract Hours (column D) collects any agency/contract staff for the same 2-week pay period Payroll data will not capture contract staff hours 23

Staff Collection for the 671 Staffing data collected for the 14-day period prior to the survey date Adhere to the 14-day period regardless of the facility s standard pay periods Is your payroll is weekly, bi-weekly or monthly? 24

Staff Collection for the 671 If the employee provides service in more than one capacity (job category), separate the hours by each service performed, for example: CNA works 50 hours as a CNA and 30 hours as an Activity Aide The information should be correctly allocated to the CNA F43 and Other Activities Staff F60 columns 25

26 Staff Collection for the 671

Correct Facility Example Correct Case example: RN Director of Nursing: 84 hours Nurses with Admin duties RN, LPN, LVN: 256 (includes, Staff Development position, MDS Coordinator, Nursing Supervisors) Registered Nurses: FT 280; PT 56; Contract - 120 Licensed Practical/Vocation Nurses: FT 1200; PT 256 Certified Nursing Aides: FT 5200; PT 736 Nurse Aides in Training: FT 320 Medication Aides/Technicians: FT - 224 27

28 Correct Facility Example

Incorrect Facility Example Incorrect Case example: RN Director of Nursing: 84 hours Nurses with Admin duties RN, LPN, LVN: 0 (includes, Staff Development position, MDS Coordinator, Nursing Supervisors) Registered Nurses: FT 656; PT 56; Contract - 0 Licensed Practical/Vocation Nurses: FT 0; PT 256 Certified Nursing Aides: FT 5520; PT 736 Nurse Aides in Training: 0 Medication Aides/Technicians: FT - 224 29

30 Incorrect Facility Example

Who should complete the CMS 671? A person with the ability to provide the detail needed and who knows where to retrieve accurate information The Administrator should review the form before it is signed 31

Ensuring CMS 671 Accuracy Consistency Align job positions with definitions for the positions identified Example: provide a guide that identifies the facility job positions and the crosswalk to the CMS 671, MDS Coordinator F40 Ensure an automated method or good manual method to capture and track worked hours on a daily basis Assign completion of the 671 to a person that understands how to collect the requested staffing information Check/audit the entries on the form before they are given to the surveyors 32

Ensuring CMS 671 Accuracy Consistency Check Nursing Home Compare (NHC) or your state website for data accuracy ALERTS: Some facilities may have no staffing data reported CMS applies exclusion criteria to identify facilities with unreliable data or outlier staffing levels Compare other support documents with the CMS- 671 Double check/verify staffing entries Sample one category and compare time card entries with the hours on the CMS-671 Calculate the nursing hours from the CMS 671 and compare to other in-house nursing hour calculations 33

Questions You Have Asked CMS

Questions for CMS If someone from corporate is at my facility performing activities that fit into a job category as defined in the CMS-671, then their hours could be included? If yes, does the corporate person need to be on facility s payroll? How does information get from State to OSCAR database and what about quality control? Is there a process for correcting staffing data in the database? Does the process differ if it was an entry error made by survey team verses facility filling out the form? 35

Questions for CMS I just heard that Hospice staff cannot be included in 671. I need to confirm that this is true. Is there a way to include them? When we complete the 672 do we only count heads in the bed or do we need to include those residents out of building but with a bed hold? 36

Questions for CMS I have a Vent Unit and my respiratory therapists are critical to the care that is provided. How can I get them included in the Star Rating? We employ what we call Universal Workers who are cross trained as CNAs. How can we account for their hours? 37

Five-Star Staffing Domain

Today s Objectives 1. Accurately code form 671 and 672 and audit for accuracy 2. Review how 671/672 data contributes to CMS s Five-Star Staffing score 3. Articulate how Five-Star staffing data impacts overall Five Star score 39

Five Star Staffing What is Five-Star Overview Components of Five-Star Survey Staffing Quality 40

The primary goal (of Five-Star) is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes. CMS s Technical Users Guide July 2009 41

Five Star Staffing What is Five-Star Overview Components of Five-Star Survey Staffing Quality 42

Staffing Domain Studies describe the relationship between nursing home staffing levels, staffing stability, and resident outcomes A CMS Staffing Study found a clear association between Nurse staffing ratios and nursing home quality of care, identifying specific ratios of staff to residents below which residents are at substantially higher risk of quality problems 43

Two Measures Comprise the Staffing Domain The Five-Star Rating for staffing is based on two case-mix adjusted measures: 1. Total nursing hours per resident day RN + LPN + Nurse Aide hours 2. RN hours per resident day 44

Only Specific Staff are Counted in the Staffing Domain Nurse aide hours: Includes certified Nurse aides F43 Aides in training F44 Medication aides/technicians F45 LPN hours: Includes licensed practical/licensed vocational Nurses F42 RN hours: Includes Registered Nurses F41 RN Director of Nursing F39 Nurses with administrative duties F40 45

Review of Staff Who are Included in Five-Star 47 Who is Counted? OSCAR (671) staffing data include both facility employees (full time and part time) and agency staff Who is NOT Counted? The OSCAR staffing data does not include private duty nursing staff who are reimbursed by a resident s family Also not included are hospice staff and feeding assistants Therapy, therapy aides, social services, recreational therapy

Ultimately the Staffing Domain Speaks to the Proportion of Staff to Residents per resident day Resident census used in the denominator of the staffing calculations is pulled from F78 of CMS- 672 form. This includes: Total number of nursing facility s certified Medicare or Medicaid beds that are occupied Either currently occupied or, On a bed hold 48

49 Form 672 Tells Us About Your Residents

Quick Review From the 671 we know about facility s staff From the 672 we know about resident census From these data we can calculate the amount of staff hours (or minutes) provided on average to each resident in the facility 50

Quick Review From the 671 we know about facility s staff From the 672 we know about resident census But Do All Residents Require the Same Amount of Nursing and Nursing Assistant time? From these data we can calculate the amount of staff hours (or minutes) provided on average to each resident in the facility 51

Not All Residents are the Same Staff/Resident Ratios are adjusted based on residents case-mix To do this CMS uses: 1. Resource Utilization Group (RUG-III) case-mix system 2. CMS Staff Time Measurement Studies Measure the number of RN, LPN, and nurse aide minutes associated with each RUG-III group 52

Staff/Resident Ratios are Adjusted Case-mix adjusted measures of hours per resident day are calculated for each facility for each staff type using this formula: Hours Adjusted = (Hours Reported / Hours Expected) x Hours National Average 53

Staff/Resident Ratios are Adjusted Hours National Average is the mean across all facilities for a given staff type. Hours Expected are based on the distribution of residents by RUG-III group in the quarter closest to the date of the most recent standard survey. How does CMS know about your residents casemix? 54

Staff/Resident Ratios are Adjusted Hours National Average is the mean across all facilities for a given staff type. The distribution of residents by RUG-III Hours Expected are based on the distribution of group is determined using the most recent residents by RUG-III group in the quarter MDS closest assessment to the date for of the current most residents recent of the standard nursing survey. home on the last day of the quarter. How does CMS know about your residents casemix? Hours Adjusted = (Hours Reported /Hours Expected ) * Hours National Average 55

Hours Expected Sum the nursing times (from the CMS Time Study) connected to each RUG category across all residents in the category and across all categories. The hours are then divided by the number of residents reported though your MDS data for that time period. The result is the expected number of hours for the nursing home. 56 Hours Adjusted = (Hours Reported /Hours Expected ) * Hours National Average

National Average National average hours represent the unadjusted national mean of the reported hours across all facilities for December, 2008. These national averages will be held constant for an initial two-year period, after which CMS will review this decision. 58 Hours Adjusted = (Hours Reported /Hours Expected ) * Hours National Average

National Average National average hours per resident per day Total nursing staff 3.83862 Registered nurses 0.63989 59

Other A set of exclusion criteria are used to identify facilities with unreliable OSCAR staffing data. Neither staffing data nor a staffing rating are reported for these facilities. August 09 Five-Star data revealed 624 of 15,713 facilities (4%) did not have a star rating for staffing. Of the 624, 163 did not have ANY star rating identified. 60

Calculating a Staffing Score Total nursing hours per resident day and RN hours per resident day are given equal weight For both measures a 1 to 5 rating is assigned based on a combination of the percentile-based method Percentiles are based on the distribution for freestanding facilities and staffing thresholds identified in the CMS staffing study For each facility a total staffing score is assigned based on the combination of the two staffing ratings 61

62 Scoring Method and Thresholds for Staffing Measures

65 Getting to a STAR

66 Getting to a STAR

Today s Objectives 1. Accurately code forms 671 and 672, and audit for accuracy What Role Does Staffing Domain Play in Overall Nursing Home 2. Review how 671/672 data contributes to CMS s Five-Star Five-Star Staffing Rating? score 3. Articulate how Five-Star staffing data impacts overall Five Star score 68

Step 1: Start with Initial Health Inspection Rating. Add 1 Star to Overall Overall No Change Minus 1 Star to Overall 4 or 5 and > health inspection rating 2 or 3 1 Step 2: If you Staffing Rating is equal to Step 3: If your QM Rating is equal to 5 2, 3 or 4 1 Add 1 Star to Overall Overall No Change Minus 1 Star to Overall Overall No Change Limit Overall to 2 Stars 2, 3, 4 or 5 1 Step 4: If you Health Inspection Rating is equal to No Overall No Change 69 Step 5: If Facility is a Special Focus Facility (SFF) Yes Limit Overall to 3 Stars

Questions You Have Asked CMS

Questions for CMS How will the new updated STRIVE study impact Five Star Staffing Domain? I haven t had a survey in a while but my staffing rating has changed. How can that be? My DON was out for the two weeks that are included on my 671. How can I make my 671 (and Staffing Star) look reasonable? 71

Conclusion Understand the written directions for completing 671/672 as provided by CMS Don t confuse your facility s policies and folklore with CMS 671/672 coding definitions The Five-Star Staffing Domain is mostly influenced by self-reported data Step One is to ensure accuracy of your staffing data Step Two is to respond to these findings with possible changes to staffing practices 72

Contact Information Email Questions to CMS: Bettercare@cms.hhs.gov Email Questions to AHCA: Lyn Bently lbentley@ahca.org Email Questions to PointRight Email Nancy Augustine Nancy.Augustine@pointright.com Email Steven Littlehale Steven.Littlehale@pointright.com CMS Five-Star Webpage http://www.cms.hhs.gov/certificationandcomplianc/13_fsqrs.asp CMS Forms http://www.cms.hhs.gov/cmsforms/cmsforms/ 73