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CMS Updates the Five Star Staffing Calculation and Adds New Measures

The July 2022 CMS Five Star Rating Update included a change to the Staffing Rating. The rating will not only be calculated differently but will also include new turnover and weekend staffing measures. The most recent data release issued on July 27, 2022, includes these new measures in the calculation and are reflected on the Care Compare website.

Measures

The CMS Five Star Staffing Rating has historically been based on the case mix adjusted total nursing hours per resident day and the case mix adjusted registered nurse hours per resident day, with RN hours weighted more than total nursing hours. These measures are calculated quarterly based on data submitted through the Payroll Based Journal (PBJ). CMS is now adding four new measures to the calculation: case mix adjusted total nursing hours per resident day on weekends, nursing turnover, registered nurse turnover, and administrator turnover. The changes are in response to CMS research showing that low staffing levels and high turnover is associated with a lower quality of care. Stable leadership and long-term relationships with residents lead to better outcomes.

Calculation of New Measures

The weekend staffing measure is calculated similarly to the other staffing per resident day calculations, the only difference being that instead of averaging the hours per resident day over all days in a quarter, this measure will only average weekend days. Staffing tends to be much lower on the weekends, so providers may need to adjust if this measure ends up reducing their overall star rating. The turnover ratings are calculated using six quarters of data and measure the percent of staff that left the nursing home over a twelve-month period. Only employees working at least 120 hours in a 90-day period are counted in the turnover calculations, while employees that do not work for a period of 60 days will be counted as separated. Turnover percentages will include both employed and contracted workers. Since the employee ID number will be used to identify gaps in employment, consistent use of the same number for employees who have left and returned, as well as contracted employees, will be crucial to minimize reported turnover.

Scoring Calculation

Scoring of the staffing rating has also changed with the July 2022 update. Previously, cut points were applied to both the case mix adjusted RN and case mix adjusted total nurse staffing measures and facilities to establish the provider’s rank, with RN staffing weighted more than total nurse staffing. The new methodology assigns a maximum point value to each measure and then providers are divided into deciles

based on the national distribution of each measure. Case mix adjusted RN and total nurse staffing per resident day each have a maximum of 100 possible points. Weekend nurse staffing per resident day, total nurse turnover, and RN turnover are each worth a maximum of 50 points. Homes with no administrator turnover receive 30 points, homes with one administrator separation receive 25 points and all others receive 10 points. All points are then summed, and homes are scored using the cut points for staffing ratings shown below. If providers have invalid data for turnover measures, those measures will not be used to calculate the staffing rating and instead all available measures will be rescaled and given greater weight. Providers that fail to submit data or submit data showing that there were four or more days within a quarter with no RN hours will receive an automatic one-star rating. Additionally, providers with a four-star or higher staffing rating will no longer get an increase of one star in their overall star rating. Instead, only five-star staffed providers will get the increase.

Next Steps

Providers should review the Care Compare website to determine their five-star rating and take note of any changes to their staffing rating as compared to previous periods. Homes should review their processes for assigning employee IDs in the PBJ submissions to ensure that employees who leave and return are given the same employee ID. Continuity in employee IDs should also be applied to contracted workers to minimize reported turnover. Providers are also encouraged to review the cut points for each individual measure in the appendices of the Five Star Technical Guide to determine which measures caused any reduction in their five-star rating. It will also be more important than ever to print and review PBJ reports prior to submission to ensure that all data is properly captured and reported.

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