Staffing measures used to calculate nursing homes’ federal ratings will freeze in April, further complicating a system based on often outdated and constantly changing metrics, experts warned last week.

The temporary freeze will run through July, when the Centers for Medicare & Medicaid Services will refresh its rating system to include a staffing measure based on the Patient Driven Payment Model’s case mix methodology.

The refresh also will incorporate a new penalty for providers that failed to submit accurate staffing data, a change that is supposed to incentivize providers to participate fully, said Melanie Tribe-Scott, RN, vice president of quality and regulatory compliance for Zimmet Healthcare Services Group.

“Previous to this, there was almost like a scale or an adjustment for turnover measures if you had not submitted all of your turnover information,” she said during a webinar last week. “Now they’re telling us that if you don’t submit all of your turnover information that you will be receiving a 1-star in staffing.”

Earning a 5-star staffing rating is one of the few ways providers can move their overall star-rating upward, Tribe-Scott explained. Yet only about 10% earn a bonus overall star from their staffing score.

Still, a pause or a penalty in staffing could be detrimental, especially considering ongoing, nationwide delays in routine health inspections.

Those inspections, Zimmet research found, are most strongly tied to facilities’ overall scores.

“Most of us, more than half of the facilities, anyway, are receiving the same overall 5-star rating as their health inspection,” Tribe-Scott said. “So it is definitely weighted the heaviest here.”

Because the health inspection actually begins with an off-site review of data — including current CMS star ratings — prior to the on-site survey, a low rating can create a negative feedback loop. Seeing poor findings possibly based on a site visit from up to three years ago may skew an inspector’s opinion of a facility. Even quality measures that aren’t used to calculate the five-star score can be influential.

“They are still published on Care Compare, and they’re still important because they still may shape an opinion — fair or not — about your facility,” Tribe-Scott said. “It’s important to take a look at those.”

New staffing details

Given the focus on staffing by both the national media and the Biden administration, however, staffing scores remain a top concern.

Because of the April freeze, providers will carry whatever rating they have right now with them into summer. The new methodology will use the nursing component of PDPM to calculate acuity for the case-mix adjusted hours, Tribe-Scott noted.

She also told attendees that a surveyor training last year encouraged inspectors to note facilities with excessively low weekend staffing. That and having more than four days without RN coverage can trigger an off-hours survey, conducted on weekends or evenings when providers are less likely to anticipate it.

“In order to code these, surveyors will review the quality of life and care, concerns, complaints and staff training competencies to meet the residents’ needs,” Tribe-Scott added. “And that’s especially true for the ‘sufficient’ staff. It needs to kind of go along with another quality of care tag to prove that there was not sufficient staff to provide care for the residents.”

She suggested providers prepare for those kinds of survey activities to help tell the story they want to show up through the Five-Star system.

“That’s where doing your own rounding, asking your own questions, possibly hiring an outside consultant to come in and ask those questions can really help you out [and] deter some of these citations that might come as a result,” she said.

Delays continue 

One thing providers can’t deter: survey delays that leave them saddled with findings from early 2023, 2022 or even late 2021. CMS last year acknowledged ongoing struggles to bring survey frequency back up to the annual requirement after the public health emergency, with some states still as far as three years behind.

Last week, Zimmet Chief Innovation Officer Steven Littlehale asked the head of the American Health Care Association to talk with CMS about decoupling some survey data from national rating programs in acknowledgement of ongoing inspection backlogs.

“So many folks haven’t been surveyed in three years,” Littlehale said. “The ripple effect that’s felt in SFF [the Special Focus Facility program] and Five-Star programmatically is very significant.”

Littlehale noted that negative ratings that stick longer than they should can impact borrowing, referrals and the ability to move out of federal oversight programs.

AHCA President and CEO Mark Parkinson told an audience at the eCap Summit in Miami last week that decoupling would be a logical approach, although his association had until now been pushing CMS to do a better job when it comes to survey frequency. More common as-scheduled surveys allow providers to see “bad” reviews lopped off of a three-year look back and earn ratings based on their more recent efforts.

As of now, CMS has said it would test an expedited survey for some providers, but it has yet to announce details of that pilot program or explain how it might reduce average length of time between surveys.