Improving Quality Measures for SNFs — CMS Upgrades Nursing Home Rating System

By Jason Bloome

In an effort to improve the nursing home tool that consumers use to compare the quality of skilled nursing facilities (SNFs), the Centers for Medicare & Medicaid Services (CMS) recently announced new changes to the Nursing Home Compare website and the evaluation tools used for their Five-Star Quality Rating System. The new changes were implemented in May 2019.

Nursing Home Compare is an online tool that rates the quality of an SNF using one to five stars. Five stars indicate SNFs that are above average while one star denotes those that fall below quality standards. Each SNF is given an overall rating and a separate rating for the following three subcategories:

• Health Inspections: Evaluations that reflect compliance to Medicare and Medicaid health and safety requirements from on-site surveys done by state health inspectors;

• Staffing Levels: The personnel who are available at any given time to provide care to patients; and

• Quality Measures: The standard of care as measured by resident assessment and Medicare claims data.

Changes to Nursing Home Compare include revisions to the inspection process, new staffing measurement enhancements, and the addition of new quality measures categories.

Higher Thresholds for Staffing Levels
Using staffing levels and quality outcomes, CMS found that more staff correlates with higher-quality care. CMS now automatically gives a one-star rating to SNFs where data reflect that “no registered staff is on-site” for four days of each quarter. (The previous standard was “no registered staff on-site” for seven days each quarter.) In the past, SNFs were able to game the system by self-reporting their staffing levels two weeks prior to inspection, but now CMS uses mandated daily payroll records to more accurately determine staffing levels.

Staffing levels in particular have been a focus of the federal government’s overhaul of the SNF rating system, spurred in part by a 2018 New York Times investigation that showed—using data analyzed by Kaiser Health News—the systematic overstating of nurse staffing by nursing home operators. As a result of subsequent investigations, CMS lowered the rating of 1,400 SNFs to one star.

Changes in the Quality Measures Category
Improvements to Nursing Home Compare also include measures that make it easier to identify differences in quality between SNFs, with the hope that increasing the visibility of quality measures will raise the expectation for care and promote continuous quality improvement by SNF operators. As new components that reflect long-stay hospitalization and emergency department transfers have been added, duplicative and less meaningful measures have been removed, and new separate rate categories for short-term and long-term SNF stays are now part of the update.

Star Ratings Lowered
According to the American Health Care Association, a trade group representing nursing homes, the CMS changes have resulted in 37% of SNFs nationwide losing one or more stars, 16% gaining one star, and 47% having no changes in their overall Five-Star Quality Rating System.

In the three rating subcategories, 47% of SNFs lost one star in Quality Measure, 33% lost one star in Staffing Levels, and 23% lost one star in Health Inspections.

— Jason Bloome is founder of Connections – Care Home Referral, an agency that specializes in information and referral to care homes for the elderly.