Chris Caulfield

The Five-Star Quality rating system, which was developed by CMS to help consumers select and compare skilled nursing care centers, assigns ratings to facilities using information from healthcare surveys (both standard and complaint), quality measures and staffing. In addition to giving consumers a tool to compare nursing homes with greater transparency, the rating system also provides an important benchmark for nursing home facilities’ operations. 

In April 2019, CMS enacted stricter staffing standards for nursing facilities, which implemented smaller windows for staffing penalties and new ratings for short-term and long-term stays. In its first week, CMS automatically handed out one-star staffing ratings to buildings that had four or more days in a quarter with no registered nurse on-site, making it clear that CMS meant business when it came to RN staffing levels. 

Facilities will need to staff more registered nurses

In CMS’s new rating methodology, facilities are rewarded for staffing more RNs — and punished when they don’t have enough. Ratings on the staffing domain are based on two measures: the number of RN hours per resident per day and total nursing hours (combined RN, LPN, and nurse aide hours) per resident per day, all pulled from quarterly Payroll-Based Journal reports. Both the RN score and the total nurse score are rated, and the two scores are averaged together to determine the total score, giving the RN score a higher weight. If the average score is not a whole number, the score will be rounded toward the RN score. CMS offers the example that “if a nursing home earns 4 stars on total staffing and 5 stars on RN staffing, the average score would be 4.5. This is rounded towards the RN rating value (i.e., 5) and the nursing home would receive a 5-star overall staffing rating.”

In this way, not only does CMS penalize facilities for going without a RN for three days, but it is demonstrating significant preference for RNs by leveraging RN staffing scores to directly influence the facility’s overall rating.

It’s clear that if nursing facilities want to score high on their staffing domain, they will need to keep their RN staffing levels as level as possible. In 2020, it’s expected that nursing facilities will increasingly push to staff more RNs in order to maintain adequate ratings. 

Better staffing standards will lead to better quality care

Improving staffing standards for facilities is universally accepted as the ultimate way to improve quality across the board. In fact, studies indicate that lower staffing levels are associated with heightened risks of poor patient outcomes. CMS believes that this push to up staffing ratios will give facilities a better chance of reducing stress and burnout among their staff and will better position staff to provide the safest care to their patients.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” the agency said in a statement following the announcement of the new rules for the Five-Star Quality Rating System. “CMS found that as staffing levels increase, quality increases.”

With the prevalence of nurse burnout, high turnover in the post-acute setting, and the rising nursing shortage in the US, it may be increasingly difficult for some nursing facilities to keep their RN quota high. The facilities that will succeed long-term — not just in terms of star-ratings, but in care quality and patient satisfaction — will be the ones that creatively tailor their staffing to these new rules. Leveraging tools like a flexible per-diem system, internal self-scheduling apps, or the implementation of an external agency to fill gaps in care will become a must-have for facilities that want to keep their star ratings, and admissions, high.