Steven Littlehale

Operators, owners, and clinicians have more on their plates right now than delving into the recent Centers for Medicare & Medicaid changes to the Five-Star rating system. CMS itself, too, has far more pressing concerns to contend with. I cannot imagine a consumer who is dealing with their own personal challenges with COVID-19 turning to Nursing Home Compare for updates. So, truthfully, I did not anticipate writing about Five-Star during this pandemic.

But I was wrong.

Just as the sun continues to rise, the need to objectively monitor and evaluate care in nursing homes has not ceased, nor has the need for providers to continuously work on quality improvement initiatives. In fact, if it did not make my skin crawl to hear the overused marketing slogan “now more than ever …” I might toss it in right around here. “Now more than ever,” “during these unprecedented times,” we all deeply care about the well-being of those we serve.

I have clocked an unexpected 40 hours over the last few weeks helping providers and their external stakeholders (lenders, REITs, insurers) understand the current Five-Star scores and the impact of recent CMS changes. Most of those conversations also looked to the future and attempted to model various scenarios of what will happen when Five-Star reverts to normal. Sharing some of these conversations may help you understand your current score and anticipate the future. 

Imagine that every nursing home has its own “data story” on file at the state agency and CMS. The data that narrates that story is constantly being updated by the individual facility and by its state and national peers. When any of the data changes, so does the story.

CMS has said that data from the new targeted inspection plan that began on March 4 would not count in Five-Star. Its rationale was clear: post March 3, surveys have not been the traditional annual inspection but instead focused on infection control and other urgencies. CMS was right to identify that it is unfair and misleading to change some nursing homes’ stories when not all nursing homes would have had the same data as of quarter one’s Five-Star calculation. 

Remember, any changes to survey results that were conducted on or before March 3 that enter the national database will be included in the Health Inspection (HI) rating calculation, and that could change your data story.

“Citations from complaint surveys will not be moving between rating cycles (or dropping out of the calculation) while new health inspections are not being included in the health inspection rating calculation,” according to CMS’s May 2020 provider preview report. In other words, the old complaint that you were expecting to “age out” will not do so.

By July 31, 2020, CMS hopes that all nursing homes will have had a focused infection control survey. This is unlikely, but hopefully it’s a goal that could be met soon thereafter, especially since it affects a state’s access to CARES Act supplemental funding. Currently, 54.1% of nursing homes have had this focused survey. Once there is a level playing field and all nursing homes have focused survey data on file — following CMS’s previous logic — this data could be entered into Five-Star. We must wait to see.  

When speaking about the HI Five-Star domain, many use the word “frozen,” but I do not. Why? Any alteration of your data might change your data story and ultimately your Five-Star score. The unusual circumstances brought on by COVID-19 have altered the Five-Star rules, and some providers benefit while others do not. 

I work with many exceptional nursing homes across the country, but Sterling Health Management, a facility in Indiana, stands out. It is extraordinary in that the people there have really changed their data story. Their staffing (4) and quality (5) are noteworthy. Their HI domain was right on the brink of awesomeness … and then COVID-19 hit. 

State health inspectors entered that facility for their annual inspection on March 2 and exited on March 6. Their inspection was the traditional survey and not the new focused inspection on urgent patient safety threats and infection control. Sterling performed well above average, but will this inspection count? (The suspense is killing you, right?) The answer is that we don’t know! Ultimately, it is up to the state survey agency to select the date to be associated with the survey. Only a date prior to March 4 would change this facility’s data story in the eyes of CMS, at least for now. 

“Obviously, we are hoping to have this survey counted,” shared Shalom Menora, president of Sterling Healthcare Management, “but regardless, we are very proud of this facility. They have worked diligently with their residents and family to ensure quality care happens 24/7, regardless of survey windows, pandemics or any other challenges that come our way.”

COVID-19’s impact on the Staffing domain and Quality Measure domains was minimal for the first quarter. The planned cut point recalibration of the Quality Measures was postponed, and MDS data used for case-mix adjustment of PBJ staffing came from quarter three 2019 MDS data, not quarter four. (Only a true eraser head like me would find that worthy of comment, so just read on.) The quarter one Five-Star calculations for Staffing and Quality Measures came from quarter four 2019 data: business as usual. However, in quarter two, and likely quarter three, the waiver of the MDS and PBJ submission deadlines will impact the 2020 Five-Star calculations for the Staffing and Quality Measure domains. Please do collect this data as you can. No doubt at some point you will need to either submit or otherwise reference it.

Certainly, operators, owners, and clinicians care deeply about the quality of the care they provide and how it is measured by Five-Star. I’ve witnessed firsthand how other stakeholders also care and rely on Five-Star as their barometer. You have reminded me that the implications of these changes are far reaching and that understanding their ripple effect on the healthcare delivery system is essential.

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.