COVID-19 Upended Star Rating Calculations for Nursing Homes — But Nothing is ‘Frozen’

The federal government took several steps to cut red tape in the health care system to help providers across the continuum battle the COVID-19 pandemic.

But while those changes included alterations to reporting requirements for skilled nursing facilities, providers won’t be exempt from the consumer-facing rating system — and they need to be aware of what that means.

That’s according to a webinar hosted by the New Jersey-based consulting firm Zimmet Healthcare Services Group, which examined how the COVID-19 pandemic will affect SNFs’ status on the Centers for Medicare & Medicaid Services’ (CMS) star rating system — which ranks facilities by assessing the combination of their survey results, staffing, and quality measures.


Even though this measure was first and foremost intended to give consumers make choices about facilities for their family members and monitor care, the star ratings have emerged as a tool for banks and lenders to make decisions on loans, a way for ACOs and hospitals to make network decisions, and even as a means of making a court case, Zimmet chief innovation officer Steven Littlehale noted on a Wednesday webinar.

That makes it paramount to understand what’s changed about star ratings in a regulatory landscape that’s constantly changing to combat the novel coronavirus — and what hasn’t changed.

“What’s is driving the bus is survey; it’s all about survey,” Littlehale emphasized. “When all is said and done: Survey. It’s like two-thirds of the value [of the star rating]. Second to that is staffing. Third to that is your actual quality domain.”


But the health inspection survey was one of the earliest elements upended by the COVID-19 pandemic. On March 4, CMS announced that it would immediately refocus skilled nursing inspections on infection control, and from that date until whenever the COVID-19 situation changes, survey data is not being added into a SNF’s profile for five-star calculation, Littlehale said.

“They changed the survey,” he explained. “They rightfully said: Fair’s fair. It’s not fair for people who have a new survey to be compared to people with the old survey, and vice versa.”

However, this doesn’t mean that tags from infection control surveys, for instance, will be invisible; that information will show up on CMS’s Nursing Home Compare tool. It just won’t go into the rating calculations, Littlehale noted.

But for facilities that did have a survey from January 1 to March 3, those surveys do count — and the number of SNFs that had those surveys is not small. According to calculations from Zimmet, 1,563 SNFs had a survey in this timeframe — or about 10% of the national total — and for them, it’s “business as usual.”

Even though the current surveys won’t be a part of the five-star calculation, this does not mean they aren’t happening. In fact, Sheryl Buchholtz-Rosenfield, director of clinical operations at Zimmet, provided some details on some of the most major immediate jeopardy (IJ) issues these newly focused inspections are turning up.

“One of the biggest IJs we’re hearing, more in theNortheast because we have more facilities struggling with a higher volume of patients, is the staff walking into rooms designated as COVID-positive or strict isolation — and then maintenance workers walking out and not taking off the gown immediately,” she said. “Or someone walking in and being observed putting the mask on incorrectly. There is a total procedure for how you get into your PPE.”

PBJ paused — but unclear what’s replacing it

The federal government has relaxed the requirement for SNFs to submit their payroll-based journal data (PBJ) for the first quarter; it would have been due in May. This data, based on SNF payroll records, is used by CMS to verify staffing levels for the five-star system, with strict thresholds for the requirements around the presence of registered nurses.

The staffing star rating calculations for the first quarter remain the same, since it’s based on staffing data that was submitted in the previous quarter.

With the COVID-19 emergency, however, the relaxation of the requirement to submit data means that the five-star staffing rating for the second quarter cannot be calculated by CMS, because “the nation is not giving them quarter 1 data,” Littlehale said.

“Therefore, they’re going to to have do something with five-star and staffing; they’ve acknowledged that,” he said. “They just don’t know what. I mean, what are the options? Are they going to hold staffing constant? Or drop it out? Who knows? But they cannot calculate your next five-star [for staffing].”

When it comes to quality measures, COVID-19 does affect Minimum Data Set (MDS) submissions, in that CMS relaxed some of those requirements as well. That will affect the government’s ability to calculate the quality domain consistently, meaning something will have to be done — either in terms of freezing or adjusting it, Littlehale said.

“They were going to recalibrate the QM benchmarks. They said this last year; they’re going to start doing it every six months, and they’re going to start it in April 2020,” he noted. “They didn’t start it in April 2020. They put that on hold, so the quarter-one impact is only that they didn’t recalibrate the benchmarks — which frankly is only good news for you, because the recalibration would have made the test harder, if you will.”

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