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March 11, 2019

How CMS is revamping its five-star ratings for nursing homes

Daily Briefing

    CMS on Tuesday announced that it will implement changes to its Nursing Home Compare Five-Star Quality Ratings, including lowering its threshold for penalties related to staffing levels and launching separate ratings for short-term and long-term care facilities.

    Want to see how your nursing home performed? See our interactive star rating map.

    The Nursing Home Compare Five-Star Quality Ratings system rates nursing home facilities on a scale ranging from one to five stars. Health care providers use the ratings to help decide where to refer patients when they are discharged from hospitals. In addition, the ratings often are used by investors and lenders to help decide whether to fund a nursing home.

    CMS announces Nursing Home Compare upgrades

    CMS in a memorandum sent Tuesday to state survey agency directors wrote that, as of April 24, CMS will change how it evaluates nursing homes. CMS said the changes are intended to provide patients with more accurate and comprehensive data on the quality of care at nursing homes, which can help them make informed health care decisions.

    CMS said the changes will be part of a new overall formula for evaluating nursing homes, Skills Nursing News reports. Under the new formula, CMS will use a quality measure improvement metric to reflect a nursing home's performance relative to other nursing homes, and the agency will evaluate that metric every six months. CMS explained that it will increase quality measure thresholds by 50% of the average rate of improvement across all skilled nursing facilities. "For example, if there is an average rate of improvement of 2%, the [quality measure] threshold would be raised 1%," CMS wrote.

    CMS wrote that the new formula "aims to incentivize continuous quality improvement" and "will reduce the need to have larger adjustments to the thresholds in the future."

    In addition, CMS said starting next month it will begin automatically assigning one-star ratings to nursing homes that lack a registered nurse on site for four or more days in a quarter—down from the current standard of seven days or more in a quarter. CMS said it "analyzed the relationship between staffing levels and outcomes" and found "nurse staffing has the greatest impact on" nursing homes' quality of care. 

    CMS also will lift a temporary freeze on health inspection ratings that the agency implemented in February 2018. CMS froze the ratings to ensure it assessed all nursing homes under a new survey process at least once before releasing the ratings. CMS said, "Ending the freeze is critical for consumers" because it will allow them "to see the most up-to-date status of a facility's compliance, which is a very strong reflection of a facility's ability to improve and protect each resident's health and safety."

    Further, CMS said it will establish separate quality ratings for short-term and long-term nursing facilities. The agency said it is implementing the different ratings because patients at short-term and long-term facilities typically have different goals. CMS said, "the overarching goal of the short-stay residents is typically aimed at improving their health status so they can return to their previous setting," while "the main goal of long-stay residents is typically aimed at maintaining or attaining their highest practicable well-being while residing long term in the facility."

    Further, CMS said starting next month it will:

    • Adjust the inspection process for nursing homes;
    • Add data to Nursing Home Compare on long-stay hospitalizations and transfers to emergency departments; and
    • Remove "duplicative and less meaningful measures" from Nursing Home Compare.


    CMS Administrator Seema Verma said, "Our updates to Nursing Home Compare reflect more transparent and meaningful information about the quality of care that each nursing home is giving its residents. Our goal is to drive quality improvements across the industry and empower consumers to make decisions, with more confidence, for their loved ones."

    The American Health Care Association (AHCA) said it "broadly supports" the changes, but noted that CMS could have gone further and included other providers in the evaluation of staffing levels. AHCA said, "It is important to realize it is not just registered nurses who play a critical role in ensuring patient-centered care. The staffing rating still does not include therapists, who play an important role in ensuring quality care" (Castellucci, "Transformation Hub," Modern Healthcare, 3/5; Spanko, Skills Nursing News, 3/5; Heath, PatientEngagementHIT, 3/6; Stempniak, McKnight's Long-Term Care News, 3/6).

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