Design for Care Compare - CMS

1 Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users Guide February 2018 Note: On November 28, 2017 the Centers for Medicare and Medicaid Services (CMS) instituted a new Health Inspection process along with an entirely new set of tags . Beginning in February 2018, CMS will not use deficiencies cited on surveys on or after November 28, 2017 in calculating the health inspection rating for the Nursing Home Compare Five-Star Quality Rating System for a period of 12 months to allow sufficient survey results to accumulate from the new-process surveys.

2 During that time, the health inspection rating will be based on results from the two most recent standard surveys prior to November 28, 2017 as well as deficiencies arising from complaint investigations during the two-year period prior to November 28, 2017. Standard surveys and complaint surveys that occurred on or after November 28, 2017 (under the new survey process) will be displayed on the Nursing Home Compare website but will not be utilized to calculate the health inspection rating during the twelve-month period beginning in February 2018. These changes are described in more detail in the Health Inspection Domain section of this document.

3 1 Introduction In December 2008, The Centers for Medicare & Medicaid Services (CMS) enhanced its Nursing Home Compare public reporting site to include a set of quality ratings for each nursing home that participates in Medicare or Medicaid. The ratings take the form of several star ratings for each nursing home. The primary goal of this rating system is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes. This document provides a comprehensive description of the Design for the Nursing Home Compare Five-Star Quality Rating System.

4 This Design was developed by CMS with assistance from Abt Associates, invaluable advice from leading researchers in the long-term care field who comprise the Technical Expert Panel (TEP) for this project, and numerous ideas contributed by consumer and provider groups. All of these organizations and groups have continued to contribute their input as the rating system has been refined and updated to incorporate newly available data. We believe the Five-Star Quality Rating System continues to offer valuable and comprehensible information to consumers based on the best data currently available.

5 The rating system features an Overall Quality Rating of one to five stars based on facility performance for three types of measures, each of which has its own five-star rating: Health Inspections - Measures based on outcomes from State health inspections: Facility ratings for the health inspection domain are based on the number, scope, and severity of deficiencies identified during the two most recent annual inspection surveys occurring prior to November 28, 2017, as well as substantiated findings from complaint investigations occurring in the 24 months prior to November 28, 2017.

6 All deficiency findings are weighted by scope and severity. This measure also takes into account the number of revisits required to ensure that deficiencies identified during the health inspection survey have been corrected. Staffing - Measures based on nursing home staffing levels: Facility ratings on the staffing domain are based on two measures: 1) Registered nurse (RN) hours per resident day; and 2) total staffing hours (RN+ licensed practical nurse (LPN) + nurse aide hours) per resident day. Other types of nursing home staff such as clerical or housekeeping staff are not included in these staffing numbers.

7 These staffing measures are derived from the CMS Certification and Survey Provider Enhanced Reports (CASPER) system, and are case-mix adjusted based on the distribution of Minimum Data Set, Version (MDS ) assessments by Resource utilization groups, version III (RUG-III ) group. QMs - Measures based on MDS and claims-based quality measures (QMs): Facility ratings for the quality measures are based on performance on 16 of the 24 QMs that are currently posted on the Nursing Home Compare web site, and that are based on MDS assessments as well as hospital and emergency department claims.

8 These include nine long-stay measures and seven short-stay measures. In recognition of the multi-dimensional nature of nursing home quality, Nursing Home Compare displays information on facility ratings for each of these domains alongside the overall performance rating. Further, in addition to the overall staffing five-star rating mentioned above, a five-star rating for RN staffing is also displayed separately on the Nursing Home Compare website, when users seek more information on the staffing component. 2 An example of the rating information included on Nursing Home Compare is shown in the figure below.

9 Users of the web site can drill down on each domain to obtain additional details on facility performance. A companion document to this Technical Users Guide (Nursing Home Compare Five Star Quality Rating System: Technical Users Guide State-Level Cut Point Tables) provides the data for the state-level cut points for the star ratings included in the health inspection. The data table in the companion document will be updated monthly. Cut points for the staffing ratings have been fixed and do not vary 3 monthly. Data tables giving the cut points for the staffing ratings are included in Tables 4 and 5 in this Technical Users Guide.

10 Methodology for Constructing the Ratings Health Inspection Domain Nursing homes that participate in the Medicare and/or Medicaid programs have an onsite recertification (standard) ( comprehensive ) inspection annually on average, with very rarely more than fifteen months elapsing between inspections for any one particular nursing home. Inspections are unannounced and are conducted by a team of health care professionals who spend several days in the nursing home to assess whether the nursing home is in compliance with federal requirements. These inspections provide a comprehensive assessment of the nursing home, reviewing facility practice and policies in such areas as resident rights, quality of life, medication management, skin care, resident assessment, nursing home administration, environment, and kitchen/food services.