It’s been a while since we sent out the last Regulatory Reminder. As we have been preparing for our Reflections call today I downloaded a copy of the most recent (March) 5-Star preview report from CASPER and, to my surprise, there were a few important announcements that CMS conveyed using that format related to the April refresh. Here are the important items to remember related to the refresh that will occur to Care Compare next month.
As you may be aware, late last year, CMS announces a return to the annual survey cycle as regional and local COVID rates would allow. These had been on pause since early 2020, as had any impact to the health inspection stars in the nursing home 5-star rating, due to the COVID PHE. For the January Care Compare refresh, CMS made the following announcement in memo QSO 21-06-NH as well as in the January release of the 5-Star User’s guide.
Beginning with the January 2021 refresh, CMS resumed calculating the health inspection rating domain and began to use results from surveys that occurred after March 3, 2020. Additionally, focused infection control surveys are included in the rating calculation, with citations from these surveys counting towards the total weighted health inspection score (similar to how complaint survey citations are counted).
These changes resulted in updates to the Special Focus Facility (SFF) program, including updates to SFF candidates, and facilities’ status for receiving an icon for noncompliance related to abuse. Specifically, updates to the health inspection data due to the incorporation of surveys occurring after March 3, 2020 and the updating of the complaint periods means that the abuse icon will be removed for facilities that no longer meet the abuse icon criteria based on more recent survey findings. Once facilities no longer meet criteria for the abuse icon, their health inspection rating will no longer be capped at two stars.
This will continue with the April 2021 refresh. Facilities should be aware that the focused infection control surveys have now been incorporated into their health inspection star rating and many facilities have seen changes to their star rating as a result
As you may be aware, CMS paused PBJ reporting requirements for a brief period early in 2020 due to the constraints that COVID PHE placed on nursing facilities. PBJ reporting requirements resumed with Quarter 2 2020 reporting with data reporting deadline of August 14, 2020. With the October and January refressh to Care Compare, CMS indicated that they were giving SNFs a pass related to PBJ reporting, i.e. no penalty (staffing star reduced to one star) for non-reporting, with the following announcements.
Starting with the October 2020 refresh of Nursing Home Compare (NHC), CMS will resume updating PBJ staffing measures and staffing ratings, using the data submitted for the August 14, 2020 deadline (covering April – June 2020). During the time these data are reported on NHC (October – December 2020), facilities that did not report staffing for the August 14 deadline or that reported four or more days in the quarter with no registered nurse will have their staffing ratings suppressed. Their staffing ratings will show “Not Available”.”
“Beginning with the January 2021 refresh, facilities that did not report staffing for the November 14, 2020 deadline or that reported four or more days in the quarter with no registered nurse will have their staffing ratings suppressed. Their staffing ratings will show “Not Available” with the January, February, and March refreshes.
Regarding the upcoming April Care Compare refresh, CMS has made the following announcement.
Starting with the April 2021 refresh of Care Compare, when staffing data submitted by the February 14, 2021 deadline will be reported and used for the five-star ratings, nursing homes that do not report staffing data for October – December 2020 or that report four or more days in the quarter with no registered nurse will have their staffing ratings reduced to one star.
Facilities should be aware that there has been no leeway indicated related to the PBJ reporting requirements relative to the April Care Compare refresh. As noted in the announcement above, nursing homes that do not report staffing data for October – December 2020 or that report four or more days in the quarter with no registered nurse will have their staffing ratings reduced to one star.
As you may be aware, in early 2020 CMS waived certain MDS reporting criteria due to constraints placed on nursing facilities due to the COVID PHE. Because of this waiver, In the October 2020 update to the 5-star User’s Guide, CMS indicated that “CMS is not currently using any MDS-based or claims-based Quality Measure data after December 31, 2019 for reporting on NHC or in the Quality Measure Rating. Essentially they were indicating a freeze on the QM data and updates for the October refresh. However, in memo QSO 21-06-NH as well as in the January release of the 5-star User’s guide, CMS made the following
As previously mentioned, CMS waived the timeframes that facilities are required to submit resident assessment information through the Minimum Data Set (MDS) per 42 CFR 483.20. We note that while the timeframes for submitting data were waived, nursing homes have still been submitting the required data. Since nursing homes have continued to submit MDS data, the data can be used to update quality measures without any issues. We have also analyzed the data used to support the claims-based quality measures, and similarly, see no issues updating these measures.
Quarterly updates of most of the quality measures (QMs) posted on Care Compare and used in the Five-Star Quality Rating System resumed with the January 2021 refresh. For the January 2021 update, CMS used data for July 2019- June 2020 for all of the measures that were updated. The two QMs that are part of the Skilled Nursing Facility Quality Reporting Program (Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened and Rate of successful return to home and community from a SNF) will not be updated in January 2021.
Regarding the Upcoming April 2021 Care Compare refresh CMD has made the following announcement.
With the April 2021 refresh the QM data will return to the previous update schedule (prior to the COVID-19 Public Health Emergency). The MDS-based QMs will use data from Q1, Q2, Q3, and Q4 of 2020. Four of the claims-based QMs will use data based on the data collection period ending September 30, 2020. The two QMs that are part of the Skilled Nursing Facility Quality Reporting Program (SNF QRP), “Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened” and “Rate of successful return to home and community from a SNF”, will continue to be held constant in April 2021.
This will be a major update for which nursing facilities should be prepared. As you may be aware, for the majority of quality measures that are used to compute a nursing facility’s quality measure star rating CMS uses a 4 quarter average. The usual quarterly update to this data essentially removes the oldest of the 4 quarter’s data and adds the most recent quarter’s data to arrive at an updated 4 quarter average. Since the October update the last quarter of data that has been used has been frozen at Q3, Q4 2019 and Q1, Q2 2020, with data ending June 30th 2020. You will note from the April announcement that in the process of “catching up” the QM data on Care Compare, CMS will deviate from the normal process of removing one quarter and essentially two quarters (Q3 and Q4 2019) will be removed and 2 quarters (Q3 and Q4 2020) will be added.
Facilities should be aware of this update and be prepared for the impact this will have on their quality measure stars. With this volume of data shifting, and with the two new quarters that will be added being the fall and winter COVID surge quarters, facilities stand to see some significant impact to their quality measure stars and potentially their overall star rating.