How Skilled Nursing Facilities Can Win Under the New Five-Star System

The federal government hit skilled nursing facilities with a flurry of changes to its quality rating system earlier this year, but by diving into their own data, SNFs can pinpoint how to do better — while making the best use of their limited resources.

Some key steps include scrutinizing a facility’s Certification and Survey Provider Enhanced Reporting (CASPER) reports, keeping track of payroll-based journal (PBJ) data, and identifying education opportunities for staff.

But SNFs need to make sure that they’re being careful to target the right areas for improvement in the Five-Star Quality Rating System, Amy Stewart, vice president of curriculum development at the *American Association of Post-Acute Care Nursing, said on a webinar hosted by Skilled Nursing News last week.


“Think about what areas you’re struggling with the most under the Five Star,” she said on the webinar. “Is it health inspection? Is it staffing? Is it quality measures? And [whether] you say it’s only one or it’s all three, start making a list of those areas under each of these domains where you need the most improvement. Then you can use the CASPER reports to help you really pinpoint your specific facility concerns.”

The Centers for Medicare & Medicaid Services (CMS) announced stricter standards for its nursing home ratings in March, which included automatic one-star staffing ratings for buildings that have four or more days a quarter with no registered nurse (RN) on site; the threshold had previously been seven or more. In addition, on the quality measure metric, the star thresholds will be adjusted every six months to track each SNF’s position relative to others, in order to ensure constant improvement even among high performers.

And the health inspection ratings, which were temporarily frozen in February 2018 due to a change in survey requirements and resulting differences in timing, were reactivated.


The changes took effect in April, with roughly 36% of SNFs seeing a drop in their overall star ratings as a result, according to analyses from the American Health Care Association (AHCA) — a trade group representing nursing homes — and CarePort, a firm that provides software aimed at improving transitions of care between the acute and post-acute setting.

For many providers, the changes in star ratings came with many questions about what happened, and what exactly led to the changes across the various domains, Stewart said.

A breakdown of rating changes, courtesy of Quality Rehab Management

After providing a recap of the methodology changes for the Five Star rating system that took effect in April, Stewart dove into how facilities can take control of their star destiny by probing their own data.

“There are a number of CASPER reports available to facility leaders, and these are going to provide you with a wealth of information,” she stressed.

Specifically, the reports have information on survey history and quality measure statistics, including those that go down to the resident level. In addition, CMS provides documents related to PBJ and the Minimum Data Set (MDS), which can show missing assessments or census data, Stewart said.

She also particularly emphasized the importance of accessing MDS quality measure (QM) reports.

“The QM piece is where most providers lost the most stars, and that’s why I’m spending a little bit more time here on this area,” Stewart explained. “Accessing these MDS 3.0 QM reports is vital. These reports provide you with insight into what areas the facility is doing well in, and what areas you need to improve upon.”

These QM reports can be used to check for proper MDS coding and evaluate internal processes and systems; if certain measures stand out, providers can then zero in on efforts to improve them.

Stewart also pointed to the availability of PBJ reports — particularly the 1702D Individual Daily Staffing Report, which shows the staffing hours logged for a given day, and the 1704S Daily MDS Census Summary, which offers insight into the daily facility census over a given period, and whether or not it’s accurate.

Given the importance of correct PBJ reporting to the final star rating, facilities should use the daily staffing report to check that all workforce data has been submitted and accepted -— and is accurate. Stewart advised taking this step before the end of the reporting quarter to make sure that SNFs aren’t discovering inaccuracies after submission.

It’s also crucial for SNFs to examine their census information for the same reason, Stewart added. If a facility’s census information isn’t accurately captured, it could look like the SNF has less staff than the acuity of the patient population requires. The census report allows facilities to audit the accuracy of the daily census used for staffing calculations, she explained.

Finally, facilities have another key resource: their own staff.

“Ask staff that are closest to the work for input,” Stewart recommended. “They often have the greatest ideas, and their input can be valuable because they can tell you why something doesn’t work, why something does work, or how it could be a little bit better.”

*This article originally misstated Stewart’s title as “vice president of curriculum development at Quality Rehab Management.” SNN regrets the error.

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