2020 was anything but normal in terms of survey processes and 5-Star rating system updates. All three of the 5-Star rating system domains were temporarily held constant at some point during 2020.  On Jan. 27, 2021, CMS resumed calculating nursing home 5-Star ratings in all three domains.

January 2021 5-Star Revisions

      • Health Inspection Rating: In January, CMS resumed calculating the health inspection rating. Current health inspection ratings include citations received during the last three standard surveys and from all complaint surveys and focused infections control surveys from the past 36 months, including all surveys that occurred after March 3, 2020. Citations from the focused infection control surveys count towards the total weighted health inspection score (similar to how complaint survey citations are counted).
      • Quality Measures: For the January 2021 update, CMS used data for July 2019- June 2020 for all of the measures that were updated. The two QMs that are part of the Skilled Nursing Facility Quality Reporting Program (Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened and Rate of successful return to home and community from a SNF) were not updated in January 2021.
      • Staff Rating: Current staffing ratings are calculated based on data submitted for the Nov. 14, 2020 payroll-based journal (PBJ) deadline. Facilities that did not report staffing for the November 14, 2020 deadline or that reported four or more days in the quarter with no registered nurse currently show the staffing rating as “Not Available” with the January, February, and March refreshes. Starting with the April 2021 refresh of Care Compare, when staffing data submitted by the February 14, 2021 deadline will be reported and used for the five-star ratings, nursing homes that do not report staffing data for October – December 2020 or that report four or more days in the quarter with no registered nurse will have their staffing ratings reduced to one star.

Care Compare Website

On December 1, 2020 CMS retired the Nursing Home Compare website that had first started in 2008. It has been replaced with CMS’s new Care Compare website. CMS states “Care Compare provides a single user-friendly interface that patients and caregivers can use to make informed decisions about healthcare based on cost, quality of care, volume of services, and other data.”

 Keys to Driving 5-Star rating improvements in 2021:

  1. Establish a robust Survey Preparedness and Management plan
      • Facilities should establish processes to use the LTC Survey Pathways tools, including the Infection Control Pathway, to routinely 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.
  1. 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 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.
  1. Understand Resident Quality Measures (QMs)
      • Monitor and routinely assess QMs through use of Certification and Survey Provider Enhanced Reports (CASPER).
      • Incorporate QM systems reviews into facility processes and 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 expedites progress and promotes sustained gains. Contact us today for more information regarding our proven Five-Star Improvement partnerships set up on a pre-budgeted project installment plan.



Blog by Angie Hamer, RN, RAC-CT, Proactive Medical Review

Click here to learn more about Angie and the rest of the Proactive team.