AANAC RAC-CT Certification TheFiveStarQualityRatingSystem

Learning Objectives
Describe how the annual licensing and
certification survey impacts the Five-Star
Quality Rating System
Explain how the rating for staffing is computed
Review the role of Quality Measures in the
Five-Star system
Detail how to proactively institute quality
assurance activities to assist in enhancing the
Five-Star rating

The Five-Star Quality Rating System

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Background

Implemented 2008
Enhancement of the Nursing Home Compare
website at www.medicare.gov/nhcompare
Same site where Quality Measures are posted

BACKGROUND
Five-Star Quality Rating System

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What do the stars mean? The Goal

Much above average To provide the public with an easy way to

understand assessment of nursing home quality,
Above average making meaningful distinctions between high and
low performing nursing homes
Average
Below average
Much below average

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Overview Overview
Stars calculation are based on:
1. State Health Inspections Facility receives 4 star ratings
This is the foundation for your final rating
One for each domain
Facility must have had at least 2 standard surveys
or they will have no rating Overall, cumulative rating
2. Staffing
Level of staffing can pull basic score in one
direction or the other
3. Quality Measures 9 of 18 on NHC site
QM score can pull star rating in one direction or
the other

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THE DOMAINS STATE HEALTH INSPECTIONS

Five-Star Quality Rating System Survey and Enforcement

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State Health Inspections

Points are assigned to deficiencies found

during the 3 most recent annual inspection
surveys
Each deficiency weighted by scope and
severity

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State Health Inspections State Health Inspections

More recent annual surveys weighted more Substantiated complaint investigations
heavily than earlier surveys Assigned to time period based on calendar
Most recent = 1/2 year in which they occurred
1st prior = 1/3 Includes the most recent 36 months of
2nd prior = 1/6 complaint investigations
If there are only two surveys completed then Weights
the weighted points are as follows Within most recent 12 months = 1/2
Most recent = 60% 13-24 months ago = 1/3
Prior survey = 40% 25-36 months ago = 1/6

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State Health Inspections State Health Inspections

Takes into account number of revisits after the
first one
If deficiency occurs in both a standard and
complaint survey: Weights for Repeat Visits
Revisit Number Noncompliance Points
Counted only once if the complaint survey was
First 0
within 15 days of the standard survey Second 50% health inspection score
If scope & severity differ, highest is used Third 70% health inspection score
Fourth 85% health inspection score

Points from complaint deficiencies are added to

health inspection score before calculating
revisit points

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State Health Inspections

Star rating
Based on relative performance within the state
The 10% with lowest deficiency scores = 5 stars
Middle 70% = 2, 3, or 4 stars, with equal number
(~23.22%) in each category
The 20% with highest deficiency scores = 1 star
A facilitys rating does not change because of new STAFFING
surveys in other facilities that affect the statewide
distribution

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Staffing Staffing
Staffing numbers come from CMS-671 form
(Medicare & Medicaid application)
Two separate nurse staffing measures
Part time employees
RN staffing hours per patient day
Full time employees
Total nurse staffing hours per patient day
Contracted staff
Equal weight, score based on combination
Not included
Family-funded private duty staff
Hospice staff
Feeding assistants

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Staffing Staffing
RN hours per patient day Total staffing hours per patient day includes
RNs RN (as described on previous slide)
RN director of nursing LPN/LVN
Nurses with administrative duties: Nurse aide hours
RNs, LPNs, LVNs: Certified nurse aides
Who perform RAI function and do not perform direct Aides in training
care functions Medication aides/technicians
Whose principal duties are spent conducting
administrative functions

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Staffing
Census from the CMS-672 form (Resident
Census and Conditions of Residents) Total
Residents
Census includes total residents in the facility +
bed holds on the day the survey began
Staffing
Ratings based on expected staffing levels
calculated based on resident acuity using
RUGs
Staffing is case-mix adjusted based on RUG-
III (53-group version) categories
RUG-III groups calculated on last business day of
each quarter for each resident there; uses quarter in
which the staffing data was collected
Uses most recent info - can be composite from most
recent comprehensive, full, quarterly, & PPS
assessments for a particular resident

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Staffing Staffing

Hours adjusted = (Hours reported/Hours expected) * Hours national average

Five-Star rating is based on facilitys percentile
Reported: Hours reported during annual survey ranking compared to all other facilities nationwide
Expected: Reported hours based on RUG-III
National average: Mean across all facilities
Total nursing staff: 4.0309
Registered nurses: 0.7472

Total Nursing Staffing Example

3 reported 6 expected = x national average 4.0309 =
2.0154 adjusted hours

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Staffing Staffing
Adjusted Hours

Example: Adjusted RN Hours = 0.445 Example: 3-star RN + 4-star Total = 4-Star Staffing Rating

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Quality Measures
9 of 18 on Nursing Home Compare site
7 Long Stay 2 Short Stay
ADL decline New or worsened
High-risk residents with pressure ulcers
pressure ulcers Self-report moderate to
Indwelling catheter severe pain

QUALITY MEASURES Physically restrained

UTI
Self-report moderate to
severe pain
Fall with major injury

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Quality Measures Quality Measures

Uses 3 most recent quarters available Possible point range for 9 QMs is 9 - 900
Points are assigned for each QM based on
facilitys performance Five-Star Rating
Best possible score per QM: 100 points (0% of 5 stars: 616
residents have the QM condition)
Other facilities get 1-99 points based on national 4 stars: 508-615
distribution of percentiles for each QM (poorest 1% 3 stars: 436-507
get 1 point, best 1% get 99 points) 2 stars: 356-435
Based on national distribution except the ADL 1 star: 355
QM is based on state distribution

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Overall Rating

1. Start with health inspection star rating

2. Add 1 star if staffing is 4 or 5 stars and

greater than the health inspection rating

OVERALL RATING 3. Subtract one star if staffing is one star

(THE COMPOSITE MEASURE)
4. Add one star if QM is 5 stars

5. Subtract 1 star if QM is 1 star

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Overall Rating

If Health Inspection is one star, the Overall

rating cannot be upgraded by more than one
star based on Staffing and QM
For a Special Focus Facility that has not
graduated, maximum Overall rating is 3 stars
REACHING FOR THE STARS

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Reaching for the Stars Reaching for the Stars

Any new inspection survey or complaint
investigation can change the rating
CASPER staffing data added annually after
annual health inspection survey
Casemix adjustment may change quarterly
QMs are updated quarterly
Mid-month in January, April, July, October
Analyzing Five-Star-related scores point-by-
point may not be best use of time
Focus efforts on bottom-line issues up front
Quality of care
Staffing levels consistent with acuity
Accurate MDS coding

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Reaching for the Stars Reaching for the Stars

Establish effective Continuous Quality Continuous Quality Improvement

Improvement programs Rather than reacting to issues as they occur,
Improves care, surveys, resident and staff identify problems proactively before they become
satisfaction, and oh-by-the-way Five-Star significant
rating

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Reaching for the Stars Reaching for the Stars

Continuous Quality Improvement Continuous Quality Improvement

Rather than fixing just the immediate problem, Analyze and improve processes in teams rather
analyze underlying processes and root causes, than as the work of one or two people
leading to improvement in the system as a whole

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Reaching for the Stars Reaching for the Stars

Continuous Quality Improvement
Continuous Quality Improvement Develop a formal QI plan
Instead of fixing the problem and leaving it at that, Purpose
monitor key aspects of systems and processes on Mission
a regular basis to continue to be able to identify Goals
any need for improvement How issues will be prioritized for
attention/action
QI committee
System of subcommittees

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Reaching for the Stars Resources

Continuous Quality Improvement Nursing Home Compare
Identify process for improvement www.medicare.gov/NHCompare
QIs and QMs
Internal quality variance reports CMS Five-Star Quality Rating site
(skin, weight, falls, etc.) www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/FSQRS.htm
Survey history
Resident satisfaction surveys
Safety committee issues
Resident, family, staff, physician complaints
Etc.

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Resources
Five-Star Technical Users Guide
www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/use
rsguide.pdf

CMS Quality Measures site

www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment- QUESTIONS
Instruments/NursingHomeQualityInits/NHQIQualityMea
sures.html

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