The Centers for Medicare and Medicaid Services (CMS) launched its Nursing Home Compare website in 1998 to help consumers and their families make decisions about nursing center placement and to encourage centers to achieve higher quality through public reporting of nursing center performance. The Five Star Rating System comprises three rating domains: Health Inspections, Staffing, and Quality Measures (QM).
Since then, Nursing Home Compare has undergone a series of changes and enhancements over the years. In 2008, CMS modified the website to provide more user-friendly star ratings based on quality scores for all Medicare and Medicaid skilled nursing centers in 2008. In 2012, the agency improved the design and usability of the website. CMS once again modified the star rating system in 2015 to include measures of antipsychotic use and adjusted the QM and staffing ratings methodology to incentivize quality improvement. In 2018, CMS replaced the traditional staffing data with data collected through the Payroll-Based Journal (PBJ) system and then froze the survey portion of the star ratings after the new survey was implemented in 2018.
The most recent changes will take effect April 2019. CMS recently released QSO Letter 19-08-NH which summarizes the changes and include the following:
Ending the Freeze on Health Inspection Star Ratings
Inspections occurring on or after November 28, 2017, will be included in each center’s rating. CMS will resume the traditional method of calculating health inspection scores by using three cycles of inspections.
Quality Measure (QM) Domain Improvements
There will be separate ratings for short- and long-stay measures to reflect the level of quality provided for these two patient categories in skilled nursing centers. CMS has also revised the thresholds for ratings, added a system for regular updates to thresholds every six months, and is weighting and scoring individual QMs differently. In addition, CMS added the long-stay hospitalization measure and a measure of long-stay emergency department transfers to the rating system. Two measures from the Skilled Nursing Facility Quality Reporting Program (QRP) will be adopted to replace duplicative existing measures.
Staffing Domain Improvements
CMS adjusted the thresholds for staffing ratings and the threshold for the number of days without an RN onsite that triggers an automatic downgrade to one star, which will be reduced from seven to four days.
Health Inspection Rating Domain
Ratings will again be based on three cycles of inspections – the most recent standard inspections and any complaint inspections occurring within the past three years. The cycles will return to pre “freeze” weightings, with the most recent period assigned a weighting factor of 1/2, the previous period with a weighting factor of 1/3 and a third period having a weighting factor of 1/6 of the health inspection score.
Implement a process for continual improvement of QM thresholds
Every six months, QM thresholds will be increased by 50% of the average rate of improvement in QM scores.
QM weighting and scorings
Two different weighting levels are being established which are high and medium. The full details of this methodology are available in the Five-Star Quality Rating System Technical Users’ Guide.
Other QM Changes
The measure of long-stay hospitalizations has been added to the rating system. There will also be a new measure of emergency department transfers added to the rating system.
As a result of these changes in the thresholds and methodology for performance on both Quality Measures and Staffing domains, some skilled nursing centers may see a decline in their rating.