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Team Newsletter

June 2022

Kelly’s Quality Corner

Demystifying the 5-Star Staffing Domain

The rating for staffing is based on two quarterly case-mix adjusted measures:

  • Total nursing hours per resident day (RN + LPN + nurse aide hours)
  • RN hours per resident day

The source for reported staffing hours is the Payroll-Based Journal (PBJ) system. These data are submitted quarterly and are due 45 days after the end of each reporting period. Only data submitted and accepted by the deadline are used by CMS for staffing calculations and in the Five-Star Rating System.

The resident census is based on a daily resident census measure that is calculated by CMS using MDS assessments. The specific PBJ job codes that are used in the RN, LPN, and nurse aide hour calculations:

  • RN hours: Includes RN director of nursing (job code 5), registered nurses with administrative duties (job code 6), and registered nurses (job code 7).
  • LPN hours: Includes licensed practical/licensed vocational nurses with administrative duties (job code 8) and licensed practical/vocational nurses (job code 9)
  • Nurse aide hours: Includes certified nurse aides (job code 10), aides in training (job code 11), and medication aides/technicians (job code 12)

Note that the PBJ staffing data include both facility employees (full-time and part-time) and individuals under an organization (agency) contract or an individual contract. The PBJ staffing data do not include “private duty” nursing staff reimbursed by a resident or his/her family. Also not included are hospice staff and feeding assistants.

The nurse staffing hours reported through PBJ and the daily MDS census are both aggregated (summed) across the quarterly reporting period. The quarterly reported nurse staffing hours per resident day are then calculated by dividing the aggregate reported hours by the aggregate resident census. Only days that have at least one resident are included in the calculations.

Exclusion Criteria

CMS uses a set of exclusion criteria to identify facilities with highly improbable PBJ staffing data and staffing data are not reported for these facilities (“Not Available” is displayed on the Care Compare website). Some of these nursing homes will also not receive a staffing rating; however, some will receive a one-star staffing rating due to scoring exceptions.

The exclusion criteria are as follows:

  • Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is zero (0 hours per resident per day).
  • Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is zero (0 hours per resident per day).
  • Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with at least one resident, is excessively high (>12 hours per resident day).
  • Total nurse staffing (job codes 5-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>12 hours per resident day).
  • Nurse aide staffing (job codes 10-12), aggregated over all days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day).
  • Nurse aide staffing (job codes 10-12), aggregated over all weekend days in the quarter with at least one resident, is excessively high (>5.25 hours per resident day).

Scoring Rules

For both RN staffing and total staffing, a rating of 1 to 5 stars is assigned. Rating cut points are set using a percentile-based method that was developed taking account of clinical evidence on the relationship between staffing and quality (Table 3). For each nursing home, the overall staffing rating is assigned based on the combination of the total and RN staffing ratings (Table 4).

Rating Methodology

The overall staffing rating is based on the combination of RN and total nurse staffing ratings as shown in Table 4. In most cases the overall staffing rating is the arithmetic average of the RN and total nurse staffing rating. However, in cases where this average is not a whole number, the overall staffing rating “rounds towards” the RN staffing rating. For example, if a nursing home earns 4 stars on total staffing and 5 stars on RN staffing, the average 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. These rules are reflected in Table 4.

Scoring Exceptions

The following exceptions to the scoring rules described above for assigning the staffing rating and RN staffing rating are made:

  • Providers that fail to submit any staffing data by the required deadline will receive a one-star rating for overall staffing and RN staffing for the quarter.
  • Providers that submit staffing data indicating that there were four or more days in the quarter with no RN staffing hours (job codes 5-7) on days when there were one or more residents in the nursing home will receive a one-star rating for overall staffing and RN staffing for the quarter.
  • CMS conducts audits of nursing homes to verify the data submitted and to ensure accuracy. Facilities that fail to respond to these audits and those for which the audit identifies significant discrepancies between the hours reported and the hours verified will receive a one star rating for overall staffing and RN staffing for three months from the time at which the deadline to respond to audit requests passes or discrepancies are identified. If repeat audits identify the same discrepancy, the timeframe for the staffing rating downgrade may be extended.

Specifications for Weekend Staffing Measures

In January 2022, CMS will begin posting information on the level of total nurse and registered nurse (RN) staffing in weekends provided by each nursing home over a quarter on the https://www.medicare.gov/care-compare/ website. Two measures will be posted: total number of nurse staff hours per resident day on the weekend and total number of RN hours per residemt day on the weekend.

More detailed information about the PBJ system is available at: https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

Kelly Dines
Vice President of Clinical Operations