Print - SNF - 5 Star Ratings

Beginning December 18, 2008, the Centers for Medicare & Medicaid Services (CMS) will rate the quality of nursing homes and report the ratings on its website, Nursing Home Compare.[1] Under the new system, each facility participating in Medicare or Medicaid, or both, will receive a rating of one to five stars for each of three dimensions (health surveys, staffing, and quality measures), a composite rating that combines all three dimensions, and a separate rating for registered nurses (RNs). Visitors to Nursing Home Compare can sort facilities, by state, by the number of stars, separately for each of the three dimensions and for the composite score.

The health survey rating reflects performance on the three most recent annual health surveys that are conducted by state health departments to determine facilities' compliance with federal standards of care. More recent surveys are weighted more heavily. The health inspection rating also includes deficiencies that are cited as a result of all complaint health inspections for the previous three years. The number of deficiencies as well as their scope and severity are used to calculate the star ratings. Facilities are measured against other facilities in the state. Deficiencies identified in federal oversight surveys and Life Safety Code deficiencies are not used to calculate facility ratings.

Facilities with fewer total deficiencies, fewer serious deficiencies, and fewer revisits, compared to other facilities in their state, receive higher star ratings.[2] The top 10% of facilities in a state receive five stars; the bottom 20%, one star; and the middle 70%, two, three, or four stars (23.33% each).

The staffing rating calculates the number of hours of care by nursing staff (RN, LPN/LVN, and certified nurse assistant (CNA)), as self-reported by facilities and as adjusted by their case-mix. The RN measure includes Directors of Nursing and other RNs with administrative responsibilities. Facilities are measured against all facilities in the country,

Although staffing is not reported separately for hospital-based and freestanding facilities, CMS uses staffing in freestanding facilities to determine the ratings for staffing.[3]

CMS intends to keep the performance boundaries between the stars constant for two years so that "Nursing homes that seek to improve their staffing, for example, will be able to ascertain the increased levels at which they would be afforded a higher star rating for the staffing domain."[4]

A five-star staffing rating is limited to facilities that report that they meet the staffing standard identified by CMS in its 2002 nurse staffing report, as case-mix adjusted – 4.08 nursing hours per resident per day and .55 RN hours per resident per day. CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report (2002).

CMS considers staffing the weakest of the three data sources. Although self-reported staffing data are inaccurate and overstated[5] and payroll data are considered more accurate, CMS contends that it needs legislation or a regulation to require facilities to submit payroll data electronically. However, the Nursing Home Value-Based Purchasing Demonstration that CMS is implementing will use electronically-submitted payroll data for staffing information.[6]

Ten quality measures (QMs) (of the 19 currently reported on Nursing Home Compare), self-reported by facilities, are used to create a QM score. Seven measures reflect long-stay residents and three, short-stay measures.

The two ADL measures (ADL change and mobility change), which account for 40% of the total QM score, are based on comparisons to other facilities in the state for the three most recent quarters. The remaining eight measures, 60% of the QM score, use national data for comparisons.

To create a composite score for each facility, the rating system begins with the number of stars resulting from health inspections.

The Staffing rating is applied next, and can only affect a facility's rating at the extremes. A five- or four-star staffing rating increase a facility's composite rating by one star; a one-star staffing rating decreases a facility's composite rating by one star. Staffing ratings of two or three stars do not change the composite score.

Scores on quality measures are applied last, again affecting a facility's rating only at the extremes. A five-star QM rating increases a facility's composite rating by one star; a one-star QM rating decreases a facility's composite rating by one star.

Although the Center for Medicare Advocacy supports efforts to increase the amount of information about nursing home quality that is provided to consumers, that information must be accurate and meaningful. The Center is concerned that some facilities may receive higher ratings under the rating system than they deserve, misleading consumers. The Center also recognizes the need for a strong and effective public regulatory system that assures that all facilities provide all residents with high quality care. Market-based approaches are insufficient to assure quality.

NCCNHR (The national consumer voice for quality long-term care) praises CMS for making the complex information on Nursing Home Compare more "consumer friendly," but calls on CMS to take steps to improve the data.[8] NCCNHR points out that the staffing and QM data are self-reported and that repeated government studies have shown that "surveys frequently under-represent the seriousness of problems in nursing homes."

The nursing home industry strongly opposes the rating system. The American Health Care Association (AHCA), the trade association of for-profit nursing facilities, has been vocal in its opposition, contending that all three data sources – survey and certification results, staffing data, and quality measures (QMs) – "are flawed and do not provide useful information to the public." This opposition to the Five-Star Rating System is somewhat ironic. The quality measures used by the system include the same measures used by the industry in its own voluntary quality improvement efforts and the same measures the industry relies on to argue that quality of care has improved.[9]

The American Association of Homes and Services for the Aging (AAHSA), which represents not-for-profit facilities, describes the five-star rating system as "poorly planned, prematurely implemented and ham-handedly rolled out."[10] AAHSA is using the introduction of the rating system to call for an "overhaul of the survey and certification system with funding provided for a new system."[11]

For more information on the rating system, contact attorney Toby Edelman
(tedelman @ medicareadvocacy.org) in the Center for Medicare Advocacy's
Washington, DC office at (202) 293-5760.

[1] CMS, "CMS Issues Historic Star Quality Rating System for Nursing Homes; Next Step in Evolution of Nursing Home Compare Web Site" (Press Release, Dec. 18, 2008), http://www.cms.gov/apps/media/press/release.asp?Counter=3383&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date; CMS, "Nursing Homes – Launching of Five Star Rating System on the Nursing Home Compare Website," S&C-09-17 (Dec. 5, 2008) (Memorandum from Thomas E. Hamilton, Director, Survey and Certification Group, to State Survey Agency Directors), http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-17.pdf; see also http://www.cms.gov/CertificationandComplianc/13_FSQRS.asp.

[2] The specific scoring methodology is set out in the Technical Users' Guide, which is available at http://www.cms.gov/CertificationandComplianc/Downloads/usersguide.pdf.

[3] Until now, Nursing Home Compare has always reported staffing levels separately for hospital-based and free-standing facilities. Hospital-based SNFs historically had, and continue to have, significantly higher staffing levels than free-standing facilities. Since 1998, the Medicare prospective payment system for SNFs has paid all SNFs the same rates, based on diagnosis-related groups, and does not distinguish between hospital-based and freestanding facilities.

[4] Technical Users' Guide, page 6, http://www.cms.gov/CertificationandComplianc/Downloads/usersguide.pdf.

[5] In 2005, CMS added an edit function to improve the accuracy of the staffing data reported on Nursing Home Compare. CMS, "Nursing Homes – Changes to Staffing Data on the Nursing Home Compare Web Site," S&C-05-24 (Aprl 14, 2005), http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter05-24.pdf. Researchers also report that for-profit nursing facilities over-report nurse staffing levels, particularly registered nurse staffing levels, compared to staffing reported on audited Medicaid cost reports. Bita A. Kash, et al, "Comparing Staffing Levels in the Online Survey Certification and Reporting (OSCAR) System with the Medicaid Cost Report Data: Are Differences Systematic?" The Gerontologist, Vol. 47, No. 4, 480-489 (2007).

[6] CMS is soliciting states to participate in the Demonstration. The November 14, 2008 letter to State Medicaid Directors, with a link to the project description, is at http://www.cms.gov/SMDL/downloads/SMD111408.pdf. NHVBP Survey Electronic Payroll Submission Guidelines are at http://www.cms.gov/DemoProjectsEvalRpts/downloads/NHP4P_Data_Collection_Specs.pdf.

[7] A Special Focus Facility (SFF) is a nursing facility with a history of poor performance that receives additional surveys and enhanced enforcement. The initiative is described at http://www.cms.gov/CertificationandComplianc/Downloads/SFFList.pdf. CMS updates the lists of SFFs quarterly.

[8] NCCNHR, "Five-Star Rating System Provides New Dimension In Consumer Information about Nursing Homes" (Dec. 18, 2008), http://www.nccnhr.org/uploads/File/Five-Star_Rating_System12-17-08.pdf.

[9] See Advancing Excellence in American's Nursing Homes, http://nhqualitycampaign.org/.

[10] AAHSA, "AAHSA Statement on CMS Five-Star Rating System for Nursing Homes" (Press Release, Dec. 17, 2008). See http://aahsa.org/print.aspx?id=6196.

[11] AAHSA Task Force on Survey, Certification and Enforcement, Broken and Beyond Repair: Recommendations to Reform The Survey and Certification System (June 2008), http://search.aahsa.org/search?q=Broken%20and%20Beyond%20Repair&entqr=0&output=xml_no_dtd&sort=date%3AD%3AL%3Ad1&ud=1&client=aahsa_frontend&oe=UTF-8&ie=UTF-8&proxystylesheet=aahsa_frontend&site=default_collection.