Effective July 27, the Centers for Medicare & Medicaid Services (CMS) has overhauled the methodology for the Staffing domain’s star rating calculations in the Five-Star Quality Rating System on Care Compare, says Jessie McGill, RN, RAC-MTA, RAC-MT, a curriculum development specialist with AAPACN. “Staffing star ratings—and potentially overall Five-Star ratings as well—may have changed for some facilities, and it’s important to understand why so that providers can be proactive and make process improvements rather than get caught up in the details of what may have happened up to 12 months ago in some cases.”
Note: Some initial news reports indicate that one-third of nursing homes may have seen a decline in their staffing star ratings, while one-quarter may have experienced a drop in their overall Five-Star ratings.
Payroll-Based Journal (PBJ) electronic staffing data drives the Five-Star Staffing domain, so nurse assessment coordinators (NACs) typically play a background role with these measures, points out McGill. “However, as the facility Five-Star expert, NACs have an opportunity to help directors of nursing services (DNSs) understand the basics of why the facility’s staffing star rating or overall star rating may have changed.”
What it all means
Critical information needed to interpret the new calculation methodology includes the following:
* The staffing star rating’s impact on the overall star rating. Facilities that have a 5-star staffing rating can gain an additional 1-star increase to their overall star rating (up to 5 stars total). Previously, a 4-star staffing rating also could achieve this as long as the staffing rating was higher than the health inspection rating. “This revision to the rules could negatively impact your overall star rating even if your staffing rating didn’t change,” points out McGill.
* Six measures vs. two measures. “CMS kept the two measures that were already in the Staffing domain: Total Number of Nurse Staff Hours per Resident per Day and Registered Nurse (RN) Hours per Resident per Day,” says McGill. “The agency also added four new measures. There is one new nurse staffing level measure, which is the case-mix-adjusted Total Number of Nurse Staff Hours per Resident per Day on the Weekend. And there are three new turnover measures: Total Nursing Staff Turnover, RN Staff Turnover, and the Number of Administrators Who Have Left the Nursing Home.”
* Scoring rules: A weighted system with points assigned on the decile. In addition to tripling the number of measures used in the Staffing domain to calculate staffing star ratings, CMS is assigning points based on deciles for five of the six measures (administrator turnover is the lone exception)—similar to how the quality measures (QMs) are calculated in the QM domain, says McGill. “CMS is still using a weighted system in conjunction with the decile-based point assignments.”
The six measures, which can combine for up to 380 points maximum, are weighted as follows, according to the Nursing Home Five-Star Quality Rating System Technical Users’ Guide:
- Higher staffing levels gain higher points:
- Total Number of Nurse Staff Hours per Resident per Day: 10 points minimum and 100 points maximum, with 10 deciles that go up in 10-point increments.
- RN Hours per Resident per Day: 10 points minimum and 100 points maximum, with 10 deciles that go up in 10-point increments.
- Total Number of Nurse Staff Hours per Resident per Day on the Weekend: 5 points minimum and 50 points maximum, with deciles going up in 5-point increments.
- Higher turnover rates gain lower points:
- Total Nursing Staff Turnover: 5 points minimum and 50 points maximum, with deciles going up in 5-point increments.
- RN Turnover: 5 points minimum and 50 points maximum, with deciles going up in 5-point increments.
- Number of Administrators Who Have Left the Nursing Home: Three groups of points (30, 25, or 10). No administrator turnover qualifies for 30 points, one administrator leaving qualifies for 25 points, and two or more leaving qualifies for 10 points.
Note: Table A2, Ranges for Point Values for Staffing Measures, in the Five-Star Technical Users’ Guide shows what performance ranges are associated with which point totals for each measure, while Table 3, Point Ranges for the Staffing Rating, assigns star ratings based on the cumulative point totals up to 380.
Also, check out AAPACN’s Five-Star Staffing Measures Scoring and Methodology tool for a visual overview of these measures, their maximum points, methodology details, and their data periods.
* Turnover measures use six quarters to calculate 12 months of data. The three turnover measures report 12 months of data that will be updated quarterly, says McGill. “While quarters 1 – 4 are used to calculate the actual 12-month turnover in the numerator, six quarters of data, including quarters 0 and 5, are used to identify employees who met the criteria of (1) working at least 120 hours in 90 days across the baseline period of quarters 0, 1, and 2 for the denominator, and (2) having a period of at least 60 consecutive days—a gap that must have started during the 12-month period covered by the turnover measure—in which they did not work at all for the numerator. Meeting those criteria is what will cause the employee to trigger a turnover measure.”
* Turnover definition criteria are broad. Key points include the following, according to McGill:
- Any staff, including agency staff and other temporary staff, counts as an eligible employee for a turnover measure if they worked 120 hours in 90 days during the three-quarter baseline period.
- For eligible employees, all employment gaps of at least 60 consecutive days that occur or start during the 12-month period covered by a turnover measure count as turnover, meaning that:
- One employee can have multiple instances of turnover over those 12 months.
- Staff members who have extended medical or family leave or who work odd schedules over holidays or weekends—and may not be considered turnover according to facility policy—will count as turnover if they meet the Five-Star criteria.
* Turnover exclusions could cause havoc for unprepared facilities. Missing or invalid data for any one of the six required quarters will exclude those turnover measures from the staffing star rating, points out McGill. “For example, invalid data for the Total Nursing Staff Turnover and RN Turnover measures includes having fewer than five eligible nurses (RNs, LPNs/LVNs, and nurse aides) in the denominator, or having 100 percent turnover for any one day in a six-month period.”
While NACs can offer some insights into the rationale behind these six measures, their true strength is on the MDS side. Taking the following steps can help NACs ensure that the MDS plays a strong supporting role for the Five-Star Staffing domain:
Learn how the MDS impacts staffing measures
“NACs need to be aware that all three of the nurse staffing level measures that look at hours per resident per day—RN Hours per Resident per Day, Total Number of Nurse Staff Hours per Resident per Day, and Total Number of Nurse Staff Hours per Resident per Day on the Weekend—use MDS data,” says McGill.
This MDS data is used in two key ways:
* Case-mix adjustments. “The three nurse staffing level measures are case-mix-adjusted,” says McGill. “The case-mix adjustments still use the CMS Staff Time Resource Intensity Verification (STRIVE) study estimates of daily RN, LPN/LVN, and nurse aide hours, as well as the facility’s own MDS data that were submitted for the measure time period, to identify the nursing hours needed based on the case-mix for that facility (using the 66-group Resource Utilization Group IV (RUG-IV) case-mix model).” Note: For details on how this works, see the section, Case-Mix Adjustment, in the Five-Star Technical Users’ Guide.
Before the July refresh, only two nurse staffing level measures were case-mix-adjusted, notes McGill. “Now that three measures have this case-mix adjustment piece that uses MDS data, it’s even more important that you ensure that accurate MDS data is going into the RUG-IV group assignments to capture resident acuity for these measures.”
* Census. CMS uses MDS data to calculate a daily resident census that affects the denominator of the three nurse staffing level measures, says McGill. “To have an accurate census, you must have timely completion of assessments, particularly entry records, Discharge assessments, and death in facility records because those will change the census per day. You need accurate calculation of residents per day in the facility because these measures are based on hours per resident per day.” Note: For more information about how the census is calculated and what can negatively affect data accuracy, see the section, Specifications for the Nurse Staffing Level Measures, in the Five-Star Technical Users’ Guide.
Do MDS accuracy audits
The case-mix adjustments for the three nurse staffing level measures are just one in a long list of reasons to do MDS accuracy audits on a routine basis, says McGill. “You want to have some kind of auditing system in place, whether it’s internal or through a consultant, to verify MDS accuracy. You need checks and balances.”
Monitor with MDS CASPER reports
NACs also need to make sure that the MDS scheduling system is in place and adequately monitored, says McGill. “If you are severely deficient in completing assessments, that can affect both case-mix and census. The CASPER Reporting application in the QIES ASAP MDS data submission system provides NACs with access to a number of MDS 3.0 management reports that can assist with monitoring. Pulling key reports at least monthly if not weekly can help you ensure that you are not missing any MDS assessments or tracking records and that your MDS census matches your active census.”
Section 6, “MDS 3.0 Nursing Home Provider Reports,” of the CASPER Reporting User’s Guide for MDS Providers lists the available management reports and how to access and interpret them. Key reports to review include the following:
* The MDS 3.0 Missing OBRA Assessment report. “This report can help you determine whether you have missed a Discharge assessment or another assessment because it looks at the gap between the prior submitted assessment and what assessment CMS expected to see next,” says McGill. “So, if no MDS or tracking record has been accepted into QIES ASAP in that time frame, this report will indicate that an MDS is missing on this resident, whether it’s a Quarterly, Annual, or Discharge assessment.”
* The MDS 3.0 Roster report. “If you identify discharged residents who are still on this report, you will need to do a Discharge assessment to ensure that the census is correct,” says McGill. “For late Discharge assessments, the assessment reference date (ARD) still must be the date of discharge, and the completion will be out of compliance since you are completing this MDS late.”
However, having a late assessment is better than having that resident remain on the facility’s roster, stresses McGill. “That will inadvertently increase your census—and negatively impact the three nurse staffing level measures that are based on hours per resident per day.”
When completing missed assessments late, such as a missed Discharge assessment, NACs may have to dash MDS items that do not have supporting documentation available in the medical record, adds McGill. “Overall, though, submitting that late assessment, even with dashes, is a better choice than having that assessment remain missing because the resident still will be counted in your census.”
Collaborate with the facility’s PBJ point person
After the facility’s PBJ point person enters PBJ data into the QIES ASAP data submission system (e.g., on a monthly basis), that staff member can use the CASPER Reporting application to access PBJ management reports that can be used to monitor the accuracy of the submitted PBJ data, says McGill. Note: NACs typically don’t have access to PBJ management reports. They must be generated by the staff member who submits data on the PBJ side of QIES ASAP.
Section 12, “PBJ Reports,” of the CASPER Reporting User’s Guide for PBJ Providers lists the available management reports and how to access and interpret them. Two of these reports provide information on submitted MDS census: the Daily MDS Census Detail Report, which lists by ID the residents included in daily facility census counts for a requested period, and the Daily MDS Census Summary Report, which lists daily facility census counts for a requested period.
“NACs should collaborate with the PBJ point person to use these MDS census reports as a final check and balance to look for discrepancies in the submitted MDS census data,” suggests McGill.
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