CMS has updated its Five Star system to increase the emphasis on RN staffing. Providers with four or more quarterly occurrences of less than eight hours of RN coverage will automatically get one star in staffing, and subsequently, lose a star overall in their Five Star Quality Rating.

We know that finding and keeping staff is a challenge today in many U.S. industries. In healthcare, it is ever pressing in the skilled nursing space. For many, finding an RN is mathematically impossible. So, what will this change mean for SNF providers?

We set out to measure the impact of this change for providers who use our primeVIEW business intelligence dashboard and its payroll-based journal (PBJ) module.  

Based on our Q4 2018 data for nearly 600 SNFs:

  • 8% (50) locations will have their staffing star set to one for the next quarter.
  • Of these, 2.8% (14) had 4, 5, or 6 days of less than eight hours RN coverage. This was “okay” under prior Five Star rules, but not the new.  
  • If our sample is representative of approximately 15,000 U.S. SNFs, an estimated 420 facilities may decline to one staffing star, based on the April change.

Our study of our providers also found:

  • Several days were missing RN hours
  • Staff was classified in wrong PBJ job codes
  • Providers acknowledged the struggle to find RNs
  • Rural areas were unaware of rural RN waiver

Whatever the reason, finding and keeping RNs remains a challenge, putting increased pressure on staff RNs scheduled to be 100% in attendance.

Prior to PBJ, data used for staffing reflected a two-week period. Therefore, SNF providers might luckily not show incidents of short RN coverage. With PBJ, it’s quarterly. So, that’s 92 days when providers can only miss three days of RN coverage. In other words, you MUST be spot on with RN coverage 96.8% of the time.

What does that mean for the SNF with one RN scheduled on the weekend days – and that one RN calls in sick, needs to leave early, has a family emergency, etc.? It means there is a high risk of the SNF getting one star overall for the quarter.

Here is my concern, as a 30-year RN. We don’t have enough RNs anywhere to meet the new standards. In New Hampshire, we are short 1,000 nurses and due to graduate 550 in May. If we could possibly keep all of our newly graduated RNs working, we would still be looking for 450 more.

My home state of New Hampshire is not alone. We simply don’t have enough RNs to fill the vacancies. Does this mean more weekend rotations? More contract RN use? More overtime dollars placed on an already resource-starved industry? Is this really the time for CMS to put more squeeze on SNFs? Or, will we simply drive more providers from the space?

I understand studies looking at quality outcomes find that better outcomes result from having more RN hours. I also understand that regulations require eight hours of RN coverage per day. What I don’t agree with, is the expectation of near perfection or the loss of a staffing star.

For the days when RN coverage is lacking, CMS should consider requiring higher total direct care staffing before simply reassigning the SNF to one star. Five Star has such wide implications on membership in preferred or narrow networks.

Is now really the time for CMS to take this strict stance on RN labor? Are the studies between RN and LPN nurse SO predictive of quality that we are going to force poor quality scores on those with less than 96.8% on-time RN performance? Does any other industry watch staff so closely?

Since we can’t change what CMS is doing, here are some suggestions for providers:

  • Use technology to help spot vulnerabilities in your schedule.
    • Identify days with only one RN scheduled, and consider having a second RN willing to be on call for a small “bonus.” This assures in-house staff can cover a reasonable change in availability.
  • Provide Five Star education to RNs who are the only one scheduled. Make sure they know their value in patient care, as well as the Five Star puzzle.
    • Five Star predictive tools can help staff see and understand how critical they are in the success of the facility.
  • Reinforce the requirement of eight hours of direct care, plus a meal break. In addition, of course, help them see there is no opportunity to leave early.
  • If you don’t already, consider programs that reward perfect attendance, making prizes as big in value as Five Star scores are to your facility.

Cheryl Field is the Chief Product Officer for Prime Care Technologies.