CMS to Crack Down on Staffing, Separate Short- and Long-Term Stays in SNF Star Rating Overhaul

The Centers for Medicare & Medicaid Services (CMS) on Tuesday announced stricter standards for its consumer-facing nursing home ratings, including a lower threshold for staffing penalties and new separate ratings for short-term and long-term stays.

Starting April 24, CMS will automatically hand out one-star staffing ratings to buildings that have four or more days in a quarter with no registered nurse on site, down from the current seven-day standard.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” the agency said in a Tuesday statement announcing the new rules for the Five-Star Quality Rating System. “CMS found that as staffing levels increase, quality increases.”


CMS will also lift a temporary freeze on health inspection ratings initially implemented in February 2018 amid a shift in survey requirements; due to differences in timing, federal officials had stopped updating the category until all of the facilities could be assessed under the new rules.

“Ending the freeze is critical for consumers,” CMS noted. “In April, they will be able 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.”

Long and short of it

In addition to these new requirements, CMS will also develop separate quality ratings for short-stay and long-stay residents, and adjust the star thresholds “to better identify the differences in quality among nursing homes, making it easier for consumers to find the right information needed to make decisions.”


With the move, CMS acknowledged what many industry-watchers have long insisted: Caring for short-stay, post-acute residents is a fundamentally different service than housing long-term, custodial patients.

“While every nursing home resident has their own individual needs and goals, the overarching goal of the short-stay residents is typically aimed at improving their health status so they can return to their previous setting,” CMS wrote in its extended guidance on the new rules. “Conversely, 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.”

CMS will still provide an overall score for each facility, with short- and long-term performance ranked equally in the ultimate calculation.

U.S. News & World Report, which has compiled its own separate list of top American nursing homes since 2009, introduced individual short- and long-term ratings in its 2018 edition, released last fall — specifically questioning the utility of CMS’s one-size-fits-all quality metric.

“They’re just looking to produce a single summary of each nursing home’s care, whereas our long-term vision might be closer to: If you have a stroke, and you’ve just been discharged from a hospital, which skilled nursing facility might be right for you?” Ben Harder, the publication’s chief of health analysis, told Skilled Nursing News at the time.

Multiple academic inquiries have also taken aim at the correlation between a facility’s star ratings and overall consumer satisfaction. A November 2018 study from the University of Chicago found very few safety differences among facilities in the middle of the star-rating pack, while other researchers determined that more stars didn’t necessarily lead to fewer re-hospitalizations.

Moving goalposts

The changes will come with a new overall formula designed to constantly push skilled nursing facilities to improve. For the quality measure metric, CMS will increase the star thresholds to better reflect each SNF’s position relative to the crowd every six months.

The exact gain will be set at 50% of the average improvement rate across all SNFs.

“For example, if there is an average rate of improvement of 2%, the QM threshold would be raised 1%,” CMS wrote. “Similar to setting new thresholds, this action also aims to incentivize continuous quality improvement. Additionally, it will reduce the need to have larger adjustments to the thresholds in the future.”

Stressing staffing

A building’s five-star rating on Nursing Home Compare, CMS’s website for nursing home residents and their families, can be vital in securing referrals from hospital partners and attracting potential patients organically; preferred provider networks, accountable care organizations (ACOs), and other new payment models also frequently enforce certain star-rating thresholds when looking for new designated skilled nursing partners.

Staffing issues took center stage in the public discourse around Nursing Home Compare last summer, when the New York Times and Kaiser Health News published an expose on the widespread inflation of nursing home staffing coverage in CMS’s data. In response, CMS slapped nearly 1,400 nursing homes with a one-star rating in the staffing category because they had seven or more days per quarter with no RN hours.

The federal agency also announced in November that it would begin using Payroll-Based Journal data — which replaced nursing homes’ previously self-reported staffing information — to direct state-level inspections of properties deemed to have insufficient staffing.

Part of the issue was the transition period from the self-reported data to the beefier PBJ statistics, a shift that the Times acknowledged in its article.

“Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day to day,” the publication reported.

The April 2019 changes will also include adjustments to the inspection process, the addition of data on long-stay hospitalizations and transfers to emergency rooms, and the removal of “duplicative and less meaningful measures.”

“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,” CMS administrator Seema Verma said in a statement. “Our goal is to drive quality improvements across the industry and empower consumers to make decisions, with more confidence, for their loved ones.”

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