Things are moving at a breakneck pace already and we are only just a few weeks into the new year. As we noted in our last update, CMS has decided to use Care Compare to publicly report weekend staffing hours and staff turnover. They have also indicated that these new measures will affect individual facility 5-Star rating starting with the July Care Compare refresh. On Friday Jan. 14th, CMS posted the revised 5-Star user’s guide which details these changes.
It seems odd, in some, ways that CMS would create and implement these measures now. Nursing facilities are currently facing a staffing crisis like no other. With COVID cases climbing and the recent SCOTUS ruling validating the CMS vaccine mandate for healthcare workers, the current staffing issue may only continue and possibly worsen.
Nonetheless, CMS is moving forward with these new measures. Effective with the January 2022 refresh, CMS will begin posting the following information for each nursing home on the Medicare.gov Care Compare website:
- Weekend Staffing: The level of total nurse and registered nurse (RN) staffing on weekends (Saturdays and Sundays) provided by each nursing home over a quarter.
- Staff Turnover: The percentage of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period.
While this information will be publicly reported starting in January, it will not be used in the Five-Star Quality Rating System until July 2022. However, it is important to familiarize yourself with these measures now so that there will not be 5-Star surprises this summer.
The revised 5-Star user’s guide contains all of the technical specifications for each of these measures. Here is a synopsis.
Specifications for Turnover Measures
- Note that the calculation of the annual turnover measures requires six consecutive quarters of PBJ data (See Figure 1). Data from a baseline quarter (prior to the first quarter covered by the turnover measures) along with the first two quarters covered by the turnover measures are used for identifying employees who are eligible to be included in the turnover measure. Data from the quarter after the four-quarter period covered by the turnover measures are used to identify the gaps in days worked in the last 60 days of the fourth quarter used for the turnover measure.
- Nurse staff turnover measures are constructed using the daily staffing information submitted through the PBJ system. Turnover is identified based on gaps in days worked.
- Denominator: The turnover measures include only individuals who work at least 120 hours in a 90-day period across a baseline quarter and the first two quarters used in the turnover calculation.
- This specification excludes individuals who work infrequently (e.g., occasionally covering shifts at a nursing home). Note that both regular employees and agency staff are included in the turnover measure if they work sufficient hours to be eligible for the denominator.
- Numerator: Individuals who no longer work at the nursing home who are defined as eligible individuals who have a period of at least 60 consecutive days in which they do not work at all that started during the during the period covered by the turnover measure. Data from the quarter after the period covered by the turnover measure are required to identify gaps that start within 60 days of the end of the period covered by the turnover measure.
- Exclusions: Several types of nursing-home level exclusion criteria are applied
- Nursing homes that are not included in the PBJ public use file (PUF) for one or more of the quarters of data used to calculate the turnover measures, are excluded.
- Nursing homes are excluded from the total nurse staffing and RN turnover measures if they have fewer than five eligible nurses (RNs, LPNs and nurse aides) in the denominator.
- For the total nurse staffing and RN turnover measures, nursing homes with 100 percent daily total nurse staffing turnover for any day in the study period on which there were at least five eligible nurse staff are excluded.
- For the administrator turnover measure, nursing homes that submitted no administrator data for one or more of the six required quarters are excluded.
- Turnover calculation
- For the total nurse and RN turnover measures, the annual turnover percentage is calculated using this formula: (Total number of employment spells that ended in turnover)/(Total number of eligible employment spells)
- Nursing home administrator turnover is measured as the total number of administrators that left the nursing home during the period covered by the turnover measures which is equivalent to the numerator of the total nurse and RN turnover measures
Specifications for Weekend Staffing Measures
Two measures will be posted: total number of nurse staff hours per resident day on the weekend and total number of RN hours per resident day on the weekend. Weekend total nurse staffing and weekend RN staffing are calculated, and case mix adjusted in a similar way to the full-week staffing levels that are currently reported. This is described in detail id the 5-Star User’s guide. The primary difference is that only Saturday and Sunday staffing and census will be taken into account.
Two notes of interest with regard to this measure are as follows:
- The exclusion criteria are not applied separately for weekdays and weekends in these calculations. In other words, if the staffing is reported as excessively high for either weekdays or weekends both weekend and weekday staffing data will be excluded.
- The case-mix adjustment of weekend nurse staffing levels uses the weekend reported staffing levels and the full-week distribution of resident case-mix since CMS found that the resident RUG-IV distribution on weekends was almost identical to that for the full week .
Finally, of note in the revised 5-Star User’s Guide, CMS also updated the set of exclusion criteria to identify facilities with highly improbable PBJ staffing data and staffing data are not reported for these facilities (“Not Available” is displayed on the Care Compare website). Some of these nursing homes will also not receive a staffing rating; however, some will receive a one-star staffing rating due to existing scoring exceptions. The revised exclusion criteria are as follows (italicized are new exclusion criteria):
- Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is zero (0 hours per resident per day). These nursing homes will receive a one-star rating due to having 4 or more days with no RN hours. Existing scoring exceptions apply.
- Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is zero (0 hours per resident per day). These nursing homes will receive a one-star rating due to having 4 or more days with no RN hours (see scoring exceptions below). This exclusion went into effect with the January 2022 update.
- Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is excessively high (>12 hours per resident day).
- Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>12 hours per resident day). This exclusion went into effect with the January 2022 update.
- Nurse aide staffing (job codes 10-12), aggregated over all days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day).
- Nurse aide staffing (job codes 10-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day). This exclusion went into effect with the January 2022 update.
Staffing has been and is in CMS’ crosshairs, and this will be a challenging set of criteria that will begin affecting 5-Star ratings in July this year. The specific way in which these measures will be incorporated into the 5-star calculation remains to be seen. Since they are new measures, they will most certainly have their own set of cut points and point values that will contribute to the overall quality score and quality stars. A spring/summer update to the 5-Star User’s guide will undoubtedly point us in the right direction.
As we have noted in other postings, the new SNF VBP/QRP combined incentive program contains a staffing measure under consideration and CMS has hinted that they would like to see staff turnover in that list of QMs as well. This spring and summer are sure to be one where staffing will take center stage. How we prepare now will pay dividends when our stars and VBP incentives begin to reflect these new initiatives.