Managing Your Five-Star Nursing
Home Rating
The new consumer rating system launched by CMS forces facilities to investigate and address
highlighted problems
W h i t e pa p e r
How many stars do you have?
T
his question is now heard frequently in conversations in or between facilities. In December 2008, CMS unveiled the overhauled Nursing Home
Compare Web site, introducing an intuitive five-star quality rating system
that is easy to navigate and understand. This redesigned interface intends to
allow meaningful distinctions between high- and low-performing facilities.
CMS’ new rating system provides a broad overview to consumers, residents,
and family members on how nursing homes are assessed for quality and
assists families in making informed decisions on which nursing home to
send their loved ones to, according to CMS.
by Diane L. Brown
The rating system uses data from health inspections or surveys, self-reported
staffing hours per patient per day, and 10 of the existing quality measures
(QM) to calculate five-star ratings. CMS displays the ratings on the Nursing
Home Compare Web site under four categories: overall composite rating,
health inspections, staffing, and QMs. More stars are better, and currently,
about 43% of nursing homes have a one- or two-star rating.
For additional information
on the five-star quality
rating system, contact
Adrienne Trivers at
[email protected] or
800/650-6787, Ext. 3207.
FEATURES
■■ How many stars do you
have?
1
■■ You have your star rating,
now what?
5
■■ Who’s looking at your
stars?
7
■■ Begin a process to improve
or maintain your rating 7
■■ Categories of stars
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9
Star ratings
Definition
✮
✮
✮
✮
✮
Much above average
✮✮✮✮
✮✮✮
✮✮
✮
Above average
Average
Below average
Much below average
The data components used in the five-star ratings
The ratings are derived from three different metrics. According to CMS’
Technical User’s Guide for the Five-Star Quality Rating System, the ratings are
calculated as follows:
■■ Health inspections. State health inspections are the basis for this measure. The rating is based on the number, scope, and severity of deficiencies
found during the three most recent years of surveys, in addition to validated
findings from the most recent three years of complaint investigations. The
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Managing Your Five-Star N urs ing Ho me Rating August 2009
number of repeat visits to ensure that the deficiencies are corrected is also
taken into account.
Staffing. Nursing home staffing levels reported annually by facilities on
form CMS-671 (Long Term Care Facility Application for Medicare and Medicaid)
to surveyors are the basis for this measure. The rating is based on two
measures:
– The number of RN hours per resident day
– The total number of staffing hours per resident day, including RN, LPN,
and nurse aide hours
■■
This measure does
not include clerical,
administrative, or
housekeeping staff
members.
This measure does not include clerical, administrative, or housekeeping
staff members. The measure is gathered from the CMS Online Survey and
Certification Reporting system and case-mix adjusted based on the weighted
distribution of RUG-III categories.
QM. This measure is based on 10 of the 19 publicly reported QMs and
includes seven long-stay and three short-stay QMs. For long-stay residents,
the system evaluates what percent of a facility’s ­residents:
– Experienced activities of daily living (ADL) decline
– Experienced decline of mobility
– Have high-risk pressure ulcers
– Have catheters
– Are physically restrained
– Have urinary tract infections
– Have moderate to severe pain
■■
For short-stay residents, the rating system evaluates the percentage of residents with:
– Pressure ulcers
– Delirium
– Moderate to severe pain
Calculating your overall composite rating
From the survey, staffing, and QM stars, the system uses the following
calculation to determine a nursing home’s overall star rating:
1. Your survey stars are your base number of stars
2. Add one star to your survey stars for each of the following conditions:
– A staffing rating of four or five stars
– A QM rating of five stars
3. Deduct one star from your survey stars for each of the following ­conditions:
– A staffing rating of one star
– A QM rating of one star
For example, if Happy Hour Nursing Home has four stars for its survey
rating and three stars for staffing, the staffing stars have no bearing on the
ratings for that calculation. But if the facility had a staffing rating of four or
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Managing Your Five-Star Nur sing Home Rating ­3
five stars, one star would be added to the total number of survey stars for
an overall rating of five stars. Conversely, if the survey component displays
four stars, but only one star for the staffing component, then one star would
be deducted for the composite rating, dropping the overall composite to
three stars.
A facility cannot receive more than five stars or less than one star. Additional
rules apply to the rating calculation for special focus facilities that have not
graduated and facilities that received a one-star health inspection rating.
Consistently good survey
results have the greatest
effect on your five-star
quality rating.
Consistently good survey results have the greatest effect on your five-star
quality rating. Health inspections rely on information gathered during the
survey process through interviews with residents, families, and staff members; reviewing the medical record; observation of the facility and resident
care; and analysis of quality measures/quality indicators (QM/QI). Indirectly,
the MDS accuracy plays a significant role because the QM/QIs are derived
from the MDS data collection.
High focus on the health inspection stars
After the decision to cite a deficiency is made, the survey team determines
the severity of the deficiency as it relates to patient safety or health and how
many residents are affected. The scope and severity chart below depicts the
guidelines used to make those choices and the five-star rating points associated with letter category.
Scope and severity chart
Severity
Scope
Isolated
Pattern
Widespread
Level 4
Immediate jeopardy to
resident health or safety
J
50 points
(75 points)
K
100 points
(125 points)
L
150 points
(175 points)
Level 3
Actual harm that is not
immediate jeopardy
G
20 points
H
35 points
(40 points)
I
45 points
(50 points)
Level 2
No actual harm, with
potential for more than
minimal harm that is not
immediate jeopardy
D
4 points
E
8 points
F
16 points
(20 points)
Level 1
No actual harm, with
potential for minimal harm
A
0 points
B
0 points
C
0 points
Source: CMS.
Notes about the scope and severity graph
■■ Points in parentheses indicate the higher point value for deficiencies cited in the substandard quality of care categories
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­4 Managing Your Five-Star N urs ing Ho me Rating August 2009
■■
Shaded cells denote deficiency scope and severity levels that constitute substandard quality of care if the requirement that is not
met falls under the following federal regulations: 42 CFR 483.13,
Resident Behavior and Nursing Home Practices; 42 CFR 483.15,
Quality of Life; 42 CFR 483.25, Quality of Care.
Points for each deficiency cited (and not later overturned) are totaled in accordance with the scope and severity chart. For example, Happy Hour Nursing
Home has seven deficiencies in the current year as follows: two Es, four Ds,
and one B. The total points for the current year would be: (2 x 8 = 16) + (4 x 4
= 16) + (1 x 0 = 0) = 32 points.
A second point source for the health inspection component is the number of
revisits the survey team must make to ensure the facility’s compliance with
cited deficiencies.
Weights for repeat revisits
Revisit number
Noncompliance points
First
0
Second
50
Third
75
Fourth
100
Based on these formulas, CMS then totals the points for revisits and scope
and severity for each of the previous three years. After weighting factors
are applied, in which the current year counts the most and the prior years
account for successively less, the final score for health inspections is determined. It will fall into one of the five-star category ranges calculated by CMS
for each state and published in the CMS Nursing Home Compare Five-Star
Quality Rating System: Technical Users’ Guide, State-Level Cut Point Tables.
There can be some change
to a facility’s survey star
rating on a monthly basis,
even without a new survey.
There can be some change to a facility’s survey star rating on a monthly
basis, even without a new survey, since CMS recalculates the cut point tables
monthly to maintain a bell curve distribution, in which the top 10% of facilities in each state receive five stars and the bottom 20% receive one star, leaving the remaining 70% in the two-, three-, or four-star categories.
Stars for staffing
The self-reported data for the staffing star derive from two forms completed during the annual facility survey: CMS-671 (Long Term Care Facility
Application for Medicare and Medicaid) and CMS-672 (Resident Census
and Conditions of Residents). The CMS-671 reports RN, LPN, and nurse
aide hours for a specified two-week period just prior to the survey. It includes
facility staff members as well as contractual or agency staff members present
during that period. The CMS-672 communicates the total resident or patient
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Managing Your Five-Star Nur sing Home Rating ­5
population during that same period and serves as the denominator of the
staffing calculations. Using a set of exclusion criteria, CMS tries to identify
facilities with unreliable or outlier staffing data. Lastly, the staffing measures
are adjusted for case-mix differences based on the RUG-III 53 case-mix system. The adjustments are applied based on data drawn the last day of each
quarter for active residents.
Two separate staffing measures are calculated and given equal weight: RNs
and all staff members delivering nursing care (e.g., RNs, LPNs, and CNAs).
The cut points or data boundaries between each star category were determined using data available as of December 2008 and will remain fixed for the
first two-year period, which CMS hopes will allow for better tracking of facility improvement or decline over that time period. The cut points are national
benchmarks derived from free-standing facility statistics only.
QMs are calculated and
posted on the Nursing
Home Compare Web site
from MDS data routinely
collected by staff members
at specified times.
Stars for quality measures
QMs are calculated and posted on the Nursing Home Compare Web site
from MDS data routinely collected by staff members at specified times.
These data are transformed into QMs that suggest how well nursing homes
address residents’ physical and clinical needs. Rather than benchmarks,
QMs are based on actual care provided to facility residents collectively.
They intend to inform consumers as they choose a nursing home as well as
provide current residents with information on their facility and provide an
opportunity for discussion about quality improvement efforts.
Three of the 10 QMs are for short-stay patients who stay in the facility for
a minimum of two weeks and have two assessments. One of the short-stay
measures (pressure ulcers) is incidence-based or comparative and requires
two distinct data points to calculate—or more simply, the data from the fiveday Medicare assessment is compared to the 14-day Medicare assessment
to determine improvement or decline. Both of the ADL measures, which are
incidence-based, calculate only after the resident has been in the facility for
more than 90 days.
The cut points for assigning a star for QMs are based on the three most recent
quarters of data. For each measure, points are assigned based on the facility percentile. The two ADL measures use state-specific quintile distributions
because of the state-to-state variations. The remaining QMs are based on
national distribution, and although the cut points for the two ADL measures
will be reset quarterly, the remainder of the cut points will be fixed for two years.
You have your star rating, now what?
Not all facilities are happy with their star rating. It’s possible that your facility received an unexpected low rating and now you want to know what steps
to take for improvement and, ultimately, a better star ranking on Nursing
Home Compare. If you believe an error was made when calculating your star
rating, CMS has a five-star hotline for providers to report unusual findings,
errors, or potential errors.
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­6 Managing Your Five-Star N urs ing Ho me Rating August 2009
CMS will update the ratings monthly. Unfortunately, not all criteria are
updated or reviewed monthly. For example, the QMs are updated quarterly.
CMS provides the following suggestions for nursing homes that want to
improve their ranking:
■■ Have fewer and less serious deficiencies on surveys
■■ Increase the level of RNs, LPNs, and/or CNAs
■■ Concentrate on quality improvement actions in areas reflected in
the QMs
Range of reactions from the provider community
Most in the nursing home provider community agree in principle that a
rating system is important. However, the current system is flawed by inaccurate data and inconsistencies among survey results region-to-region and
state-by-state, as documented by several GAO studies. Benchmarked variations among survey results can exceed 33%, depending on the individual
survey team.
There is also concern that if an otherwise good facility had a poor survey three
years ago based on a single incident, the number of points accumulated from
that incident may prevent that good facility from attaining a good rating.
“The biggest miss with the
five-star system is that it
doesn’t measure what we
think is a very important
measure, and that’s
customer satisfaction.”
—Richard C. Bane,
MBA, FACHCA
Many members of the long-term care industry are also disappointed the fivestar quality rating system doesn’t take customer satisfaction into account.
“The biggest miss with the five-star system is that it doesn’t measure what
we think is a very important measure, and that’s customer satisfaction,” says
Richard C. Bane, MBA, FACHCA, president of BaneCare, LLC, which
operates several nursing facilities in Massachusetts.
In Massachusetts, long-term care providers worked with the state legislature
and department of public health to conduct customer satisfaction surveys in
2005 and 2007. In both surveys, nine out of 10 respondents said they would
recommend their nursing home to a friend or family member. “To have that
kind of performance and to have that not be recognized in a five-star rating
is crazy, particularly because the five-star rating is intended to focus on the
needs of the consumer,” Bane says.
Currently, the staffing component of the five-star quality ratings is based on
a self-report for one two-week period just prior to the annual survey. These
staffing numbers may not fairly represent the usual staffing patterns of the
facility, and the CMS-671 form used to report staffing is not consistently
completed by all facilities. Another major complaint voiced by facilities is that
the ideal staffing level required to get five stars in staffing is unfunded by the
prime payer in most states—Medicaid.
Another frequent provider complaint is the bell curve approach to the survey
component of the ratings. Many providers are frustrated that adopting this
approach is not reflective of actual quality of care provided.
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Managing Your Five-Star Nur sing Home Rating ­7
CMS has published many of the provider concerns, and although the feedback from the provider community identifies valid points, CMS contends
that it will work with providers and provider organizations to improve the
system in the future. This leaves many providers frustrated.
Who’s looking at your stars?
Nursing homes aren’t the only ones looking at ratings. Families and residents
are also taking notice. CMS advises families to not focus solely on a facility’s star rating when deciding on a nursing home for a loved one. Families
should visit a facility, take a tour, and meet with staff members before they
make a decision. For those families contemplating transferring their family
member to a higher-star facility, they should take into account the potential
effects the transfer will have on their loved one.
Nursing homes can help educate family members about the benefits of their
facility and the negative effects a transfer might have. One facility reports a
phone call from a prospective resident asking whether it had an overall fivestar rating. When the facility responded that it was a four-star facility, the
potential client was elated and proceeded to schedule a tour of the facility
because she didn’t think she could afford to live in a five-star facility!
However, consumers aren’t the only ones looking at nursing homes’ star
ratings. Under the five-star quality rating system, nursing facilities’ reputations aren’t the only thing on the line: SNFs’ ability to get loans or obtain a
certificate of need could be affected by their star ratings.
The U.S. Department
of Housing and Urban
Development (HUD), an
important lender for nursing
facilities, is now using star
ratings as a component of
its risk assessment of nursing
facilities.
In addition, the U.S. Department of Housing and Urban Development
(HUD), an important lender for nursing facilities, is now using star ratings
as a component of its risk assessment of nursing facilities.
Potential and current customers and families
Initially, the national press covered the introduction of the rating system
extensively, bringing it to the attention of the public. However, CMS warns
consumers that the ratings should be only one tool to evaluate a potential
facility, along with a visit and other determining factors.
Begin a process to improve or maintain your rating
If you are in the 10% of facilities that have an overall rating of five stars,
congratulate yourself and promote that fact. But read on if you intend to
maintain your current status. If you are in the remaining 90% of facilities,
the first thing you must do is determine the accuracy and validity of your
ranking. If the ratings are inaccurate or do not seem valid, begin to pursue
a path to correct the problems. This may involve contacting CMS officials to
determine the cause of the problem.
For ratings that seem accurate and valid, identify all the specifics. For example, if the facility has seven identified deficiencies that caused a poor rating,
© 2009 HCPro, Inc.
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­8 Managing Your Five-Star N urs ing Ho me Rating August 2009
determine the causes of the citations. Causes could range from surveyor bias
to inaccurate assessments to poor documentation in the medical record to
actual quality-of-care or quality-of-life issues. It’s important to have systems
and processes in place to complete the investigation of causes. Investigation
of the specific causal factors will help the facility determine the course of
action it must take to improve ratings.
Perform customer satisfaction
surveys and be prepared to
tell your own story.
Perform customer satisfaction surveys and be prepared to tell your own
story. Support your story with personal customer satisfaction testimonials.
The best local support for your facility comes from grateful customers who
were well served.
Most importantly, adhere to the principles of continuous quality improvement and transparently demonstrate your commitment to those principles.
Despite federal and state oversight, only we as an industry can improve the
quality of the care we deliver, maintain the dedication to our customers that
will make them return again and again, and remain viable.
Therefore, education on systems and process improvement must be vigilant
and ongoing. n
Help is available
HCPro, Inc., provides assistance with the five-star quality rating in many
formats, including:
■■ Five-Star Quality Rating Boot Camp for Long-Term Care
■■ Customized on-site five-star training
■■ Consulting services to help you improve your five-star rating
Contact client service representative Adrienne Trivers at [email protected]
or at 800/650-6787, Ext. 3207, to find out which format best fits your needs.
© 2009 HCPro, Inc.
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Managing Your Five-Star Nur sing Home Rating ­9
Categories of stars
Overall
rating
Health
inspections
(weighted
over three
years)
1–5 stars are
computed
using health
inspections
as the base
Formula:
Start with
survey stars
and add 1
star if staffing is 4 or 5
stars (and
greater than
survey stars)
or deduct 1
star if staffing is 1 star.
Then add 1
star if quality is 5 stars
or deduct 1
star if quality
is 1 star.
Staffing
(acuity, case-mix adjusted)
RN hours
Total hours
QMs
1–5 stars
based on
points and
distributed
by cut points
1–5 stars
adjusted from
reported data
for a two-week
period prior to
survey
1–5 stars
adjusted from
reported data
for a twoweek period
prior to survey
1–5 stars
based on performance of
10 (out of 19)
QMs calculated into points
(1–136)
Year 1
weight: 1/2
RN hours per
patient day
(RN + LPN
+ CNA)
total per
patient day
7 measures:
long-stay residents (n = 30
assessments)
3 measures:
short-stay residents (n = 20
assessments)
Weighted by RUG score for
each resident from quarter in
which survey falls
NH compare
displays most
recent quarter of QM
data, but the
ratings are
based on the
three most
recent quarters of data
Year 2
weight: 1/3
Year 3
weight: 1/6
0.55 RN
threshold
identified for
potentially
avoidable
hospitalizations (shortstay measure)
4.08 threshold
(2.78 CNA +
1.30 licensed
staff for longstay measures)
Cut points are constant for
Cut points
initial two-year period
update
monthly to
maintain distribution of
10% (5 stars),
70% (2, 3, 4,
5 stars), 20%
(1 star)
© 2009 HCPro, Inc.
Each QM is
scored and
weighted
based on
percentile
and type of
QM. ADLs use
state-level
data; other
QMs use
national-level
data as the
comparison
point
Cut points are
constant for
initial two-year
period
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­10 Managing Your Five-Star N urs ing Ho me Rating August 2009
How does your state rank?
The following graph focuses on the number of one- and two-star facilities in each state.
State
LA
GA
TN
NM
IL
WV
TX
OH
IN
NV
KY
OK
SC
NC
CA
WA
MO
PA
NY
SD
AZ
NJ
KS
AR
UT
MS
MI
DC
OR
IA
FL
MD
MN
AL
AK
MT
MA
CO
VT
WI
NH
NE
WY
ID
RI
HI
CT
DE
ME
ND
TOTALS
08/09
© 2009 HCPro, Inc.
Facilities
285
359
318
70
793
130
1143
956
511
48
286
319
175
423
1255
239
513
717
650
110
135
362
344
231
94
202
425
18
138
448
679
230
388
232
11
91
433
211
40
393
80
225
39
79
86
48
240
45
109
83
15439
1-star
115
113
98
20
221
37
320
265
129
13
68
78
46
113
268
63
107
172
132
18
26
77
55
51
18
42
87
4
21
82
126
46
55
40
0
15
68
40
7
65
5
33
8
11
12
3
21
6
8
7
3435
2-star
66
83
74
15
175
26
228
191
106
9
63
66
30
70
268
39
111
131
141
28
30
72
86
42
19
37
79
3
32
90
132
41
88
45
4
18
89
34
7
70
22
42
5
15
16
12
50
7
21
13
3141
% 1-star
40.4%
31.5%
30.8%
28.6%
27.9%
28.5%
28%
27.7%
25.2%
27.1%
23.8%
24.5%
26.3%
26.7%
21.4%
26.4%
20.9%
24%
20.3%
16.4%
19.3%
21.3%
16%
22.1%
19.1%
20.8%
20.5%
22.2%
15.2%
18.3%
18.6%
20%
14.2%
17.2%
0%
16.5%
15.7%
19%
17.5%
16.5%
6.3%
14.7%
20.5%
13.9%
14%
6.3%
8.8%
13.3%
7.3%
8.4%
22.2%
% 2-star
23.2%
23.1%
23.3%
21.4%
22.1%
20%
19.9%
20%
20.7%
18.8%
22%
20.7%
17.1%
16.5%
21.4%
16.3%
21.6%
18.3%
21.7%
25.5%
22.2%
19.9%
25%
18.2%
20.2%
18.3%
18.6%
16.7%
23.2%
20.1%
19.4%
17.8%
22.7%
19.4%
36.4%
19.8%
20.6%
16.1%
17.5%
17.8%
27.5%
18.7%
12.8%
19%
18.6%
25%
20.8%
15.6%
19.3%
15.7%
20.3%
# 1-, 2-star
181
196
172
35
396
63
548
456
235
22
131
144
76
183
536
102
218
303
273
46
56
149
141
93
37
79
166
7
53
172
258
87
143
85
4
33
157
74
14
135
27
75
13
26
28
15
71
13
29
20
6576
% 1-, 2-star
63.5%
54.6%
54.1%
50%
49.9%
48.5%
47.9%
47.7%
46%
45.8%
45.8%
45.1%
43.4%
43.3%
42.7%
42.7%
42.5%
42.3%
42%
41.8%
41.5%
41.2%
41%
40.3%
39.4%
39.1%
39.1%
38.9%
38.4%
38.4%
38%
37.8%
36.9%
36.6%
36.4%
36.3%
36.3%
35.1%
35%
34.4%
33.8%
33.3%
33.3%
32.9%
32.6%
31.3%
29.6%
28.9%
26.6%
24.1%
42.6%
SR3709
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