Effective with the April 2022 Five-Star refresh, CMS is now implementing the planned, regular increases to the Quality Measure (QM) rating thresholds, that were originally announced to begin in 2019 but were delayed due to the public health emergency. With the April 2022 update, the QM rating thresholds were increased by one-half of the average improvement in QM scores since the last time the thresholds were set. The average improvement was determined from the period of April 2019 – January 2022. The new rating thresholds can be found in Table 6 of the Five-Star Quality Rating System Technical User’s Guide (April 2022). Point thresholds for individual QMs are not changing.
Effective with the January 2022 refresh, CMS began posting the following information for each nursing home on the Medicare.gov Care Compare website:
- Weekend Staffing: The level of total nurse and registered nurse (RN) staffing on weekends (Saturdays and Sundays) provided by each nursing home over a quarter.
- Staff Turnover: The percentage of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period.
While this information is now publicly reported, it will not be used in the Five-Star Quality Rating System until July 2022. The technical specifications for the measures of weekend staffing and staff turnover are included in the appendix of the Technical Users’ Guide.
CMS also updated the exclusion criteria they use to identify facility with highly improbable PBJ staffing data, for which no staffing data are reported for facilities meeting the exclusion criteria. The exclusion criteria are as follows:
- Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is zero (0 hours per resident per day). – Previously, nursing homes with total staffing <1.5 hrs per resident day were excluded.
- Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is zero (0 hours per resident per day). – New addition to exclusions
- Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is excessively high (>12 hours per resident day).
- Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>12 hours per resident day). – New addition to exclusions
- Nurse aide staffing (job codes 10-12), aggregated over all days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day).
- Nurse aide staffing (job codes 10-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day). – New addition to exclusions
Keys to Driving 5-Star rating improvements in 2022:
- Establish a robust Survey Preparedness and Health Inspection Management plan
- Facilities should establish processes to use the LTC Survey Pathways tools, to routinely to monitor compliance with regulatory requirements. If concerns are identified through the routine monitoring, the concerns should be reviewed with the QAPI committee and performance improvements plans implemented to address the identified concerns.
- A mock survey is also an invaluable process that should be used by all facilities. A mock survey is an opportunity for you to take a fresh look at systems, procedures and processes of care to identify potential risk areas, so that you can address these risk areas through your performance improvement processes. It is also a wonderful process to “test” how your staff will perform and handle the stress associated with surveys and how your residents will respond to interviews conducted by surveyors.
- One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. Proactive Medical Review & Consulting offers mock survey services to assist providers in preparing for the annual survey process by identifying potential areas that may be at risk related to your systems, procedures and processes of care, as well as consultations on developing a plan of correction, follow-up compliance visits, staff training, and on-going regulatory compliance consultation services.
- Master Staffing and Labor Management
- Establish 5-Star staffing PPD goals to achieve a 4- or 5-star staffing rating and monitor your daily labor on to evaluate needed changes in staffing to meet established goals.
- With nursing shortages, high rates of turnover, and tight budgets, hiring and retaining the best staff can be difficult. This is a great time to review you new employee orientation and mentoring programs, as well as your recruitment and retention programs to identify areas with performance improvement opportunities.
- Establish systems to ensure that accurate PBJ data is submitted by each quarterly deadline. Evaluate the CASPER staffing reports (1700D Employee Report, 1702D Individual Daily Staffing Report, and/or 1702S Staffing Summary Report) prior to the quarterly submission deadline to review your submitted data and ensure accuracy.
- Review your monthly Provider Preview report in your (CASPER) folder for feedback on your most recent PBJ submission.
- Understand Resident Quality Measures (QMs)
- Monitor and routinely assess QMs through use of Certification and Survey Provider Enhanced Reports (CASPER).
- Incorporate QM systems review into facility processes include methods for tracking “real-time” data for the quality measures that impact your 5-Star rating.
- Review QM data routinely through your QAPI processes and establish benchmarks to trigger when additional performance improvement efforts are needed.
- Consider establishing QM focused sub-committees
Proactive Medical Review specializes in assisting facilities with Five-Star Rating Improvement plans that expedite progress and promote sustained gains. Contact us today to schedule a mock survey or for more information on our proven Five-Star Improvement partnerships.
Cowritten By: Angie Hamer, RN, RAC-CT and Shelly Maffia MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC