Changes to Nursing Home Compare and the Five Star Quality Rating System

Two-Thirds of Nursing Facilities Nationwide Will See Decline In their Quality Measures;
One-Third of Facilities Will See Decline in Their Overall Score

As promised in October 2014,[1] the Centers for Medicare & Medicaid Services (CMS) has made significant changes to Nursing Home Compare, effective February 20, 2015.  The changes recalibrate the Quality Measures (QMs), add antipsychotic drug use to the QM star rating, and adjust the criteria for the staffing measure.  In addition, CMS is expanding the focused surveys that are designed to improve the accuracy of resident assessment information.  These changes were announced February 12 at the Skilled Nursing Facility (SNF) Open Door Call and in a CMS Fact Sheet,[2] and were further described February 20 in a Survey and Certification Letter[3] and CMS Press Release.[4]

Changes to Nursing Home Compare

Nursing Home Compare is the federal website where, since 1998, CMS has published information about nursing homes.  Revisions over the years have expanded the categories of information included on the site.  In December 2008, CMS introduced the Five Star Quality Rating System to the website “to assist the public in identifying meaningful distinctions among providers.”[5] 

The Rating System provides individual ratings on three separate measures: (1) the health survey measure, which is based on unannounced annual surveys and complaint surveys conducted by state survey agencies; (2) the staffing measure, which is based on self-reported information of nurse staffing in the two weeks before the annual survey; and (3) the QMs, which are based on risk-adjusted resident assessment information.  The survey measure uses fixed percentages of facilities at each star rating level, with facilities compared to other facilities in their state.  The QMs use different scoring systems for different measures and generally national data, but, significantly for this discussion, they use fixed numeric thresholds for each star level.  At present, approximately 80% of facilities receive either four or five stars on their QMs.[6]  An overall rating combines the three individual scores.  Although the overall rating begins with the health survey, high scores on the self-reported staffing measure and QMs will increase a facility’s overall rating. 

An evaluation of the Five Star Rating System in 2014 by Abt Associates found “dramatic” changes in the QM scores between 2009 and 2013, with the percentage of facilities receiving five stars in QMs more than tripling, from 10.1% to 34.8%, and the percentage of facilities receiving one star in QMs declining, from 20.0% to 3.2%.[7]  The New York Times reported in August 2014 that there is considerable gaming on the rating system.[8] 

Here are the specific changes to Nursing Home Compare:

• Recalibration of the Quality Measures.  For the first time since the Five Star Quality Rating System was introduced six years ago, CMS has reset the scale to identify the number of points that are needed to achieve different star ratings on the five-star scale (with one star being the lowest and five stars the highest).  CMS describes the change as both raising the standard for nursing facilities and providing meaningful differences among facilities (that is, preserving sensitivity of the scale) to benefit the consumers who use the Star Rating System.

  CMS’s Press Release reports, “About two thirds of nursing homes will see a decline in their quality measures rating and about one third of nursing homes will experience a decline in their Overall Five Star Rating.”  Before the recalibration, about 80% of all nursing facilities received four or five stars on their QM rating.  After the recalibration, about 49% will receive four or five stars.  CMS has not recalibrated the scales to the distributions originally calculated in 2009, when 20.0% of facilities received one star in QMs, 22.8% received two stars, 23.2% received three stars, 24.0% received four stars, and 10.1% received five stars.[9]

• Addition of two quality measures to the Quality Measure score.  CMS is adding both short-stay and long-stay antipsychotic drug use to the measures that are used to calculate the QM score.  Reducing inappropriate use of antipsychotic drugs in nursing homes is a major subject of CMS’s Partnership to Improve Dementia Home Care in Nursing Homes.[10]

  CMS reports a total of 18 measures on Nursing Home Compare – five short-stay and 13 long-stay – but has used only nine of them to calculate the QM rating.  With the addition of the short-stay and long-stay antipsychotic drug use measures for the QM score, CMS now uses a total of 11 measures to calculate the QM rating.  Other measures will continue to be publicly reported on Nursing Home Compare but, as in the past, they will not be used to calculate a facility’s QM score.

• Staffing.  CMS now limits four-star staffing ratings to facilities that score four stars on either (or both) the registered nurse (RN) component or the staffing categories.  A facility cannot receive a four-star staffing rating if either of the individual measures is three stars.

  Prior to this recalibration of the Quality Measures, CMS awarded four-star staffing ratings to facilities that scored three stars on both the RN and staffing categories, the two components of the publicly-reported staffing measure.  As Thomas Hamilton, Director of Survey and Certification at CMS, described the change in the Open Door Call, three plus three does not equal four.

  CMS also announced in October that it would be implementing the requirement, mandated by §6106 of the Affordable Care Act, that nursing facilities electronically submit direct care staffing information (including agency and contract staff) “based on payroll and other verifiable and auditable data in a uniform format.”[11]  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) provided explicit funding for this statutory requirement.

Nationwide Expansion of Targeted Surveys

The Survey & Certification Letter also reports expansion of targeted surveys, which CMS describes as “specialized onsite surveys of a sample of nursing homes across the U.S. that assess the adequacy of resident assessments and the accuracy of information reported to CMS that is used in calculating quality measures used in the rating system.”[12]

A separate Survey & Certification Letter on the staffing focused surveys describes CMS’s plans for the nationwide expansion and a pilot survey.  In 2014, five volunteer states (Illinois, Maryland, Minnesota, Pennsylvania, and Virginia) “piloted a short-term focused survey to assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and its relationship to resident care in nursing homes.”[13] 

The evaluation of the pilot, prepared by Abt Associates, reports that the 25 pilot surveys (five surveys in each of five states) had two goals: evaluation of “adherence of MDS 3.0 reporting requirements” and evaluation of “the agreement between the MDS 3.0 assessments and the resident’s medical record.”[14] 

Abt found “high levels of compliance related to registered nurse (RN) coordination and assessment timing requirements” but “room for improvement in MDS 3.0/medical record agreement in four of seven clinical conditions reviewed, including: 1) the severity of injury associated with falls [25.5% disagreement]; 2) pressure ulcer status [18.3% disagreement]; 3) restraint use [17% disagreement]; and 4) late loss activities of daily living (ADL) status [15.4% disagreement].”[15] 

Conclusion

The changes to Nursing Home Compare and expansion of surveys are welcome, but they are not the only changes that are needed.  As the National Consumer Voice for Quality Long-Term Care and the (New York) Long Term Care Community Coalition suggest, CMS must also implement the payroll-based staffing data mandate and must strengthen the survey and enforcement systems so that inspections “identify serious care problems and adequately assess harm to residents” and enforce the standards of care.[16]

An editorial in The New York Times on February 25 calls for surveys of resident assessment information to be “as rigorous as possible” in order “to help determine if even stronger measures are needed.”[17]  The Times also describes as “the most important improvement” the electronic reporting of staffing data that is now scheduled for the end of 2016, concluding, “That will be a far more objective measure than unverifiable self-reports.”[18]

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Editor’s Note:  The author, Center for Medicare Advocacy Senior Policy Attorney Toby S. Edelman has been at the forefront of the fight for nursing home quality and enforcement for decades.  Ms. Edelman, has been quoted in the New York Times on the topic, and has been instrumental in bringing this topic to the public. Ms. Edelman also writes a monthly newsletter: Enforcement: Recent Developments in Nursing Homes.