By Ashley N. Hadler
The Center for Medicare and Medicaid Services (CMS) regularly monitors and publishes comparative data for nursing homes throughout the nation. In Indiana, there are 551 facilities that receive Medicare and/or Medicaid reimbursement and are thereby subject to this regulation. The process involves publication of annual health inspections and complaint-based surveys, facility staffing information, and details of quality measures and trends including re-hospitalization rates and improvement or decline of residents’ functional status. The information is available at Medicare.gov and is intended for use by consumers in weighing personal options for skilled nursing care, and for facilities in determining how their services measure up to other facilities in the state.
How does the process work?
CMS compiles data made up of three sub-parts that are scored individually and then combined to determine an overall 1-5 “star” quality rating. Those three sub-parts are health inspections, facility staffing, and quality measures.
Health inspection findings: Inspections take place annually or upon a resident complaint. Inspections or “surveys” are performed to determine whether the facility is operating in compliance with federal regulations. This category is scored based on findings from the facility’s annual recertification survey and any complaint investigations that may have taken place over the course of the applicable timeframe. Due to changes in the underlying investigation process, the timeframe is currently the two most recent recertification periods preceding November 28, 2017, and deficiency citations during the same period. Generally, points are assigned in this sub-category based on the scope and severity of the deficiencies and the number of revisits required to cure the deficiency. Ratings for this category are assigned based on comparative performance within the state, with the 10 percent of facilities with the best health inspection scores receiving 5 stars, the middle 70 percent of facilities receiving 2-4 stars (equally distributed among the three) and the worst 20 percent of scores receiving one star.
Facility staffing: Staffing is a focus of quality assessment due to its negative correlation with unfavorable resident outcomes. Simply put, understaffing, particularly of registered nurses, is tied to lower quality care and increased accidents, rehospitalizations, and medical complications such as pressure sores and infections. Staffing is rated based on total RN hours per resident day plus total nursing hours (RNs, Licensed Practical Nurses, and nursing aides) per resident per day. These numbers are case-mix adjusted, which means that they are tailored to the patient population in the facility, by census and level of acuity. Using the daily resident census and the resident health status information provided through mandatory reporting called the Minimum Data Set (MDS), CMS determines the expected hours for RNs and all nursing staff. The actual RN and total nurse staffing hours from the quarter are submitted by the facilities to CMS through the electronic Payroll Based Journal (PBJ) system. The self-reported staffing hours are then compared to the expected staffing hours calculated by CMS. The actual RN and nursing staff hours per resident per day are attributed 1-5 stars based on predetermined parameters with the number of stars awarded increasing as staffing hours increase.
Quality measures: These quality indicators include information about health status and function of residents garnered from Medicare claims data and the MDS. Measures include information about the percentage of residents whose need for help with activities of daily living has increased, whose ability to move independently has worsened, who have developed pressure sores, who have had a catheter inserted, who were physically restrained, who developed UTIs, who self-report pain, who experience falls, who receive antipsychotic medication, who were rehospitalized, who have an outpatient ER visit, and who are successfully discharged to the community. Again, these findings are risk adjusted for resident census and acuity of the facility. The ratings are determined based on a point-range applicable nationally using calculations from the previous four quarters of data.
Using the three individual sub-parts, the overall nursing home rating is determined by starting with the health inspection rating and adding one star if the staffing rating is four or five stars and greater than the health inspection rating. If the staffing rating is one star, then one star is subtracted from the health inspection rating. Finally, one star is added if the quality measure rating is five stars. One star is subtracted if the quality measure rating is one star.
A new health inspection process, which includes new federal tags, or violations, was implemented in February 2018 and will be used to calculate health inspection and overall scores beginning in March 2019.
CMS recently began transitioning to monitoring nursing home staffing based on PBJ rather than self-reporting in April 2018. This information will be used to determine the next quarterly scores. This change allows the information to be tied to verifiable and auditable sources including payroll and tax reporting documents. Previously, the staffing hours were reported based on self-reporting of a random two-week interval during the recertification inspection. The new reporting system provides more insight into the continuum of staffing throughout the year. Additionally, details of expected and actual RN and total nursing staff data for each quarter are available on the CMS website. Additional quality measures added in late 2016 are included in current score calculations.
What are other anticipated changes?
As PBJ staffing data continue to accumulate on a quarterly basis, CMS has projected posting information regarding staff turnover. They also anticipate including additional information, such as therapy staff hours worked, alongside the nursing staff hours and resident census.
How can I use this information to the benefit of my clients?
Overall, the changes to the reporting and scoring of nursing facilities will improve accuracy of ratings and better inform the public. Attorneys representing healthcare facilities and nursing home residents alike will find the information useful in evaluating quality care indicators of specific facilities.•
• Ashley N. Hadler — email@example.com — is an associate in Cohen & Malad’s personal injury and healthcare litigation groups whose practice focuses on plaintiff’s nursing home litigation. Opinions expresses are those of the author.