Staffing is difficult—that was a defining truth for nursing homes before the COVID-19 public health emergency created a full-blown staffing crisis that still is harming providers throughout healthcare. So, it may seem like the wrong time for directors of nursing services (DNSs) to pay much attention to the staffing domain in the Five-Star Quality Rating System. “However, all of the Five-Star data—the staffing, health inspections, and quality measures domains—funnels into multiple parts of a facility’s life,” says Shelly Maffia, RN, MSN, MBA, NHA, QCP, CHC, director of regulatory services for Proactive Medical Review and Consulting in Evansville, IN.
“For example, Five-Star data may impact contracts that you are trying to obtain, or it may affect your ability to bring in new residents whose families are looking at Care Compare,” points out Maffia.
What could be next?
Staffing data, as well as other Five-Star data, could soon play an even larger role, according to the Fiscal Year (FY) 2022 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule. Using data that nursing homes submit primarily via the Payroll-Based Journal (PBJ) system, the overall staffing star rating derives from two quarterly case-mix-adjusted measures:
- Registered nurse (RN) hours per resident day; and
- Total nurse hours per resident day, which is the sum of RN, licensed practical nurse (LPN), and nurse aide hours.
Note: On Care Compare, data for both measures is displayed, but star ratings are shown for overall staffing and RN hours, not for total nurse hours.
These RN and total nurse hours measures may be included in an expanded Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), according to table 30, Quality Measures Under Consideration for an Expanded SNF VBP, in the final rule. In addition, the Centers for Medicare & Medicaid Services (CMS) may throw a staff turnover measure into the SNF VBP mix because plans are already under way to “report employee turnover information [on Care Compare] in the near future.” Note: CMS first announced the development of a staff turnover measure in the April 2018 Quality, Safety, and Oversight (QSO) memo QSO-18-17-NH.
The combination of these current and potential future impacts of Five-Star staffing data means that providers don’t have any time to lose, suggests Maffia. “While staffing is extremely challenging right now, facilities should identify and implement plans for improving in any domain where the organization is below four stars, including the staffing domain. You want to be able to speak to stakeholders about why you have that rating and what plans you are implementing to improve in that domain. You can’t let a bad Five-Star rating be the elephant in the room that you are trying to avoid.”
The following practices can help DNSs drive improvement in the staffing star ratings:
Figure out why staffing is under four stars
Providers with staffing star ratings of one to three stars should review the PBJ data that they are submitting to determine exactly what the problem is, says Maffia. “Obviously, the most common reason for a staffing star rating that is under four is that the facility is not meeting those minimum levels for four-star staffing,” she explains. “For RNs, that minimum threshold for four stars is 0.731 hours per resident day, and for total nursing, it is 4.038, according to table 3, National Star Cut Points for Staffing Measures Based on Adjusted Hours per Resident Day (updated April 2019), in the Nursing Home Five-Star Quality Rating System Technical Users’ Guide.”
It’s important to understand that the overall staffing rating displayed on Care Compare, which usually is the combined average of RN and total nurse staffing ratings, rounds toward the RN rating if that average isn’t a whole number, points out Maffia. “For example, a facility that earns a four-star RN staffing rating and a three-star total nurse staffing rating will round up to a four-star overall staffing rating even though it only meets the three-star minimum threshold of 3.580 hours per resident day for total nurse staffing.”
Conversely, a facility that earns a three-star RN staffing rating and a four-star total nurse staffing rating will round down to a three-star overall staffing rating even though the facility meets the four-star minimum threshold of 4.038 hours per resident day for total nurse staffing, she explains. Note: For details, see table 4, Staffing and Rating (updated April 2019), in the Five-Star Technical Users’ Guide.
There can be other, more process-oriented issues as well, adds Maffia. “For example, some providers fail to submit complete, accurate data before the quarterly deadline. The final PBJ submission deadline for each fiscal quarter is 45 days after the quarter ends. PBJ data must be submitted successfully by the quarterly deadline, or it won’t be used in the staffing measures on Care Compare or in Five-Star calculations. And no data at all means automatic one-star ratings for that quarter.”
Note: The next upcoming reporting period is quarter 4 (July 1 – Sept. 30), which has a final submission deadline of Nov. 14. CMS maintains a PBJ data submission calendar here.
Further, providers will receive only a one-star rating for both overall staffing and RN staffing in any quarter that has four or more days with no RN staffing hours, says Maffia. “In addition, nursing homes that either don’t respond to PBJ audits or have significant discrepancies identified between reported and verified hours in those audits will get a one-star rating following the missed deadline or the identification of discrepancies.”
The key point to remember is that there are several possible reasons why a facility could have a staffing star rating of one to three stars, stresses Maffia. “Therefore, the first step is to determine why you are coming in under four stars, and then, based on that reason, you can put actions in place to get to four stars.”
Avoid waiting for the quarterly refresh preview to take action
“Facilities often ignore Five-Star ratings until they get their Five-Star Preview Report that shows what their star ratings will be on the next quarterly Care Compare refresh,” points out Maffia. “It is too late at that point to implement any corrective actions that will have an immediate impact on your star ratings for that refresh. You want to establish an ongoing system of review so that you can affect your staffing star ratings before the reporting quarter ends.”
Create a data submission process that doesn’t hinge last-minute success
Many facilities that fall short on their staffing star ratings make two critical mistakes: (1) waiting until the last minute to submit their PBJ data, and (2) not having good systems to validate the accuracy of their data before the quarterly deadline, says Maffia. Submitting right up against the quarterly final submission deadline also fails to account for the following potential submission issues:
- Weekend deadlines. Quarterly submission deadlines may fall on the weekend, noted CMS officials at the Aug. 5 Skilled Nursing Facility/Long-Term Care Open Door Forum. For example, the upcoming Nov. 14 submission deadline for Q4 (July 1 – Sept. 30) data will be on a Sunday. When providers experience submission problems, they can contact the QIES Help Desk for assistance at (800) 339-9313 or [email protected]. However, “the Help Desk is only available Monday – Friday, so providers should not wait until the last few days before the deadline to begin their submissions,” stressed officials.
- Up to 24-hour turnaround for PBJ Final File Validation Reports. Whenever a facility uploads a data file to the PBJ system, the way to verify that that file was submitted successfully is by checking the Final File Validation Report, which the system will auto-generate and make available in the provider’s Validation Report folder (which begins with the provider’s two-digit state code, then shows PBJ and the Facility ID, and ends in VR). While this validation report is often available within an hour, it may take up to 24 hours to generate.
“So, providers must allow for time to correct any errors and to resubmit if necessary,” said CMS officials at the Open Door Forum. If the facility doesn’t receive the Final File Validation Report within 24 hours, the staff member who submitted the data file should request the PBJ Submitter Final File Validation Report through the CASPER (Certification and Survey Provider Enhanced Reporting) Reports function. To do this, the staff member will need the Submission ID that the PBJ system provided on the confirmation message that was generated at the time the file was initially submitted. “This [submitter] report will indicate whether or not the files were processed successfully,” they added.
The following timeline may be helpful:
|Submit data file.||PBJ generates confirmation message on Upload Data File page that data file was received. Make note of submission ID and submission date in case they are needed to request reports in the future.||Within 24 hours, PBJ generates the Final File Validation Report to confirm whether data contained in the data file was submitted successfully. Warning messages should be reviewed, but fatal errors prevent successful data submission. Those errors must be corrected, and the data must be resubmitted before the quarterly deadline. The system purges this report after 60 days.||If the Final File Validation Report is not generated within 24 hours, the provider should request a Submitter Final File Validation Report via CASPER Reports to determine the file status. If the facility needs to access a purged Final File Validation Report, the provider should request an On Demand Final File Validation Report via CASPER Reports.|
Note: For additional information, review the following resources:
- Final File Validation Report: Section 4.3 of the PBJ Provider User’s Guide explains how and when this report is generated and describes, field by field, what the report includes. Appendix F, “Payroll-Based Journal System Edits,” identifies each error message by number, explains what type of error it is (i.e., fatal or warning), defines the error and its cause, and offers tips and action steps that may be needed.
- Submitter Final File Validation Report: Section 12, “PBJ Reports,” of the CASPER Reporting User’s Guide for PBJ Providers, provides detailed information on this report, including how to access and understand it. Section 12 also covers the ins and outs of the On Demand Final File Validation Report.
“At a minimum, you want to submit quarterly data in plenty of time before each quarter’s final submission deadline so that you can ensure that your data was submitted successfully, and then you can run the appropriate CASPER reports to make sure your data also is complete and accurate,” says Maffia.
“However, the best practice is to routinely submit your data throughout the quarter rather than waiting until close to the deadline and submitting the entire quarter at one time,” she adds. “This will allow you to use the CASPER reports to see where you are coming in on the staffing levels and understand what adjustments you may need to make to your staffing to get to four or five stars.”
Use available CASPER reports to check accuracy and set goals
The Final File Validation Report only confirms that PBJ data was submitted successfully. “It does not confirm that the data submitted is accurate or complete,” pointed out CMS officials at the Open Door Forum. To review accuracy and completeness, Maffia recommends that providers take advantage of the following three CASPER staffing reports and two MDS census reports:
- The 1700D Employee Report, which identifies a facility’s active and/or terminated employees during a specified period.
- The 1702D Individual Daily Staffing Report, which shows facility staffing information (by employee ID) during a specified period.
- The 1702S Staffing Summary Report, which summarizes a facility’s staffing information (by job title) during a specified period.
- The 1704D Daily MDS Census Detail Report, which lists residents (by ID) included in daily facility census counts for a specified period.
- The 1704S Daily MDS Census Summary Report, which identifies the daily facility census counts for a specified period. Note: To learn how to access and interpret all of these reports, see section 12, “PBJ Reports,” of the CASPER Reporting User’s Guide for PBJ Providers.
“While you should use all three staffing reports to double-check the accuracy and completeness of your submitted PBJ data, I find that the 1702S Staffing Summary Report is the most valuable from a labor management perspective,” says Maffia. “It gives you that quick overview of what your total hours are in each job ‘bucket.’”
Providers that submit data routinely throughout the quarter can run this report monthly and use that information to calculate RN and total nurse hours per resident day based on the submitted data, she recommends. “This will allow you—in real time—to see what star rating you currently qualify for and, if necessary, make staffing adjustments to reach your goal by the end of the quarter.”
In addition, providers should at least compare the 1704S Daily MDS Census Summary Report to the facility’s internal census report and investigate any variances, says Maffia. “To calculate your hours per resident day, you must have accurate census data, and that comes directly from the MDSs that are submitted during that quarter. Issues such as missing internal IDs or discharge tracking records can impact your reported census.”
Note: For additional information about the census, including how to use the MDS 3.0 Roster Report to research discrepancies, see the AAPACN article, “PBJ Reports Help Verify Your MDS Census Numbers.” Also, review the Staffing Domain section of the Five-Star Technical Users’ Guide to learn how to calculate case-mix-adjusted hours per resident day.
Providers that submit data monthly also can get feedback on their most recent submission by reviewing their Five-Star Preview Report each month instead of just once a quarter, suggested CMS officials at the Open Door Forum.
Set up a process for routing reports
“Typically, whoever is submitting PBJ data will have access to the CASPER reports that need to be reviewed and investigated. However, those staff often are not running and sharing the reports,” says Maffia. “You want to be sure that you have a timely communication process that gets the reports where they need to be.”
Often, the administrator is the best person to validate these reports because they are monitoring staffing levels and census on a routine basis, points out Maffia. “But who is doing this review is less important than ensuring that someone is regularly completing the task of verifying the PBJ data that you have submitted and making the calculations to see what hours per resident day you are running based on the data submitted.”
Not at four-star staffing levels? Consider adding QAPI to labor management
Providers that are below the minimum levels for four-star staffing ratings should set goals on what they want their reported staffing hours to be, reiterates Maffia. “Then, you need to manage staffing on a daily basis through the last day of the quarter, making adjustments as you go to reach the goals that you have set. These two parts of the process go hand in hand: You can’t set goals if you don’t know where you stand, and you can’t meet the goals you set if you aren’t actively monitoring and reviewing your data.”
However, that process is incomplete on its own, says Maffia. “Facilities need to drill down to the meat of the problem. Having staffing star ratings under four usually is due to recruitment and retention issues. So, you also have to analyze your turnover data to determine the root causes of why you are not able to hire and/or retain quality staff. For example, are new hires coming in, working two weeks, and not returning to the job? Or, are you having turnover in long-term staff?”
Presenting turnover data through the facility’s Quality Assurance and Performance Improvement (QAPI) program is a good avenue to take, she suggests. “It can be enormously helpful if you, as a team, dig into why your turnover rates are so high.”
Key questions could include the following, according to Maffia:
- What groups are most affected?
- Is it the certified nursing assistants (CNAs)?
- Is it the licensed nurses?
- What are those patterns of turnover?
- How long after hiring does turnover occur?
- Are there particular units or shifts or even supervisors with high rates of turnover?
“If you do that root-cause analysis to determine why your employees are leaving, you can put performance improvement plans in place through the QAPI team to address those root causes that you identify,” says Maffia. “For example, that could include strengthening your preceptorship program for new hires.”
Note: AAPACN members have access to several additional resources to assist them with recruitment, reducing turnover, and improving staff retention:
- AAPACN Onboarding Essentials: Welcoming Staff to Promote Retention Tool
- 10-Week Nurse Assessment Coordinator Orientation Guide Tool
- Certified Nurse Aide (CNA) Retention Tip Sheet Tool
- Reduce Turnover and Increase Staff Retention with Employee First Culture
- Staff Recruitment: How to Stand Out From the Crowd
- Hiring for Character and Talent: 4 Tips for Interviewing
- Lead CNA Programs: Learn How to Hire and Support the Best In-House Candidates
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