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The world of long-term care is on the cusp of transformation – and no, PDPM isn’t the only shift to come. This month (April 2019), the Centers for Medicare & Medicaid Services (CMS) will enforce a few key changes to the Five-Star Quality Rating system.

CMS’s quality rating system operates on a scale of one to five stars, accounting for criteria across three domains: Health Inspections, Staffing, and Quality Measures. First, CMS calculates star ratings with data from state surveys, the Payroll-Based Journal (PBJ), the Minimum Data Set (MDS), and claims. Then, they post the results on Nursing Home Compare, which is part of To keep the public informed on their long-term care options while encouraging SNFs to continuously improve, anyone can look up a facility’s star rating. And CMS periodically refines the rating system to ensure data and calculations align and encompass residents’ best interests. The changes going into effect this April will impact all U.S.-based SNFs, and may cause many of them to lose a star.

Change #1: CMS will cease its freeze on the health inspection domain.

  • Why? The freeze, which took place in February 2018 following the implementation of a new survey process, allowed CMS to bide time until all facilities had been surveyed under the new model. According to CMS, “Without placing a ‘freeze’ on health inspection star ratings, the facilities would have been scored using two different evaluation processes, making the outcomes misaligned and the data inaccurate.” But CMS has hit “resume” to ensure customers can access facilities’ most accurate and up-to-date health inspection ratings. CMS will continue posting citations in October 2019.
  • The impact: To determine compliance with Medicare/Medicaid health and safety requirements, state survey agencies conduct onsite visits bi-annually. SNFs lacking a clear process to prepare for these surveys – let alone keep up with the regulations themselves – will feel the pain. Many facilities operate without any dedicated personnel to triage potential safety and health concerns, align improvement efforts with regulatory standards, or garner the appropriate data to prove compliance. Luckily, it’s possible for facilities to outsource the burden of safety and health management so internal staff can focus on providing exceptional care.

Change #2: CMS has raised the bar on staffing measures. Currently, facilities without an RN on site for seven or more days in a quarter automatically get a one-star staffing rating. Come April 24, that seven-day threshold will fall to four.

  • Why? CMS considers an ever-presence of qualified nursing staff to be the greatest determinate for quality care.
  • The impact: The turnover rate in long-term care has scaled to above 50%, which some refer to as a “national crisis” of low retention. Skilled nursing facilities face an urgent call to improve working conditions for employees by 1. minimizing wasted resources and marketing strategically to liberate funds for more competitive wages; 2. empowering nurses to spend more time on care and less time on administrative tasks; 3. cultivating a modern work environment to attract a younger generation of employees.

Change #3: CMS will introduce separate ratings for short/long-stay measures as well as add additional “long-stay hospitalization” and “long-stay emergency department” benchmarks. In tandem, quality measures thresholds will increase every six months.

  • Why? These adjustments come from CMS’s ongoing mission to sharpen the precision of quality ratings, their “Meaningful Measures” framework, which aims to award scores based upon factors that truly impact care. By compartmentalizing short vs long-stay measures, CMS can tighten the connection between a SNF’s care domain and its quality score.
  • The impact: The Meaningful Measures initiative is beneficial for SNFs as it helps establish an integrous evaluation matrix. It also helps tight-budgeted SNFs isolate specific areas for improvement. But CMS’s increasingly empirical approach to ratings presents a challenge. With cut-point calculations moving to a sixth-month calibration cycle, SNFs need to take a more proactive approach to securing future compliance.

Can star ratings make or break a SNF’s business health? Increasingly so, as younger generations seek housing options for their senior family members. Millennials and GenZers often make buying decisions based upon online review forums. Any member of the public can look up star ratings on Nursing Home Compare, so five-star SNFs will have a clear advantage. This competitive edge is critical for SNFs to secure now as the long-term care market continues to polarize.

So, how can you foster quality care and create a better experience for your caregivers, ultimately heightening your start count? Start by streamlining your operations, from collecting transition of care documents electronically to systematizing your quality improvement program. Identify inefficiencies in your workflows (paper-based processes!) and embrace automation to fraction administrative time sinks.

Need help? Cantata Health offers a quality improvement program through our professional services that’s tailored to help facilities achieve five stars. With 40+ years of experience in the long-term care industry, we bring in a depth and breadth of clinical, regulatory, and operational expertise to remediate your pitfalls. Contact us to learn more.