The quality of nursing home care is an important concern for the 1.3 million individuals receiving daily care across more than 15,500 facilities in the United States. These nursing homes must meet some quality standards to receive Medicare and Medicaid payments. Despite efforts to improve care quality, including laws from 1987 and a rating system launched by the Centers for Medicare and Medicaid Services (CMS) in 2008, challenges remain. Problems like understaffing, bedsores, and safety hazards persist, raising concerns for the well-being of nursing home residents.
This blog will explore how the introduction of the CMS 5-star rating system was a step forward in making nursing home quality more transparent.
- What is the CMS 5-Star Rating System for Nursing Homes?
- Recent Revisions in the CMS Star Ratings
- Three Components of CMS Ratings for Nursing Homes
- How are the CMS Ratings for Nursing Homes Calculated?
- 8 Strategies for Healthcare Providers to Improve CMS Ratings
- Conclusion: A Tool to Drive Quality of Care
What is the CMS 5-Star Rating System for Nursing Homes?
The Centers for Medicare and Medicaid Services (CMS) introduced the Five-Star Quality Rating System in 2008. The CMS rating for nursing homes is an invaluable tool designed to simplify the process of comparing nursing homes for consumers, their families, and caregivers. By providing an easy-to-understand rating system, it aims to facilitate informed decision-making when it comes to selecting a nursing home that meets the needs of a loved one.
The CMS ratings for nursing homes evaluate nursing homes on a scale from 1 to 5 stars. Each nursing home receives an overall rating, as well as separate ratings in three key areas: health inspections, staffing, and quality measures. We’ll discuss these components in detail later in the blog.
A significant number of nursing homes score poorly on the CMS evaluation. Specifically, over one-third of nursing homes receive 1 or 2 stars. This affects 39% of nursing home residents. On the other hand, 45% of nursing homes score well, with 4 or 5 stars, covering 41% of residents. The system shows that for-profit nursing homes often score lower than non-profit ones, and size matters too—smaller homes tend to do better. – Now that we’ve highlighted the prevalent quality issues in nursing homes, we’ll explore effective strategies to improve your CMS ratings for nursing homes and ensure optimal care for residents.
The ratings also reveal that nursing homes report better scores on self-assessed measures than on those checked by state inspections. Interestingly, the geographical distribution of nursing homes adds another layer of complexity. It means the quality of nursing homes varies widely by state, with some states having a high number of low-scoring homes and others boasting a majority of high-scoring ones. This variation suggests that income levels and state policies might influence nursing home quality.
Nursing homes rated with 5 stars are recognized for their above-average quality, whereas those with 1 star are noted for quality much below average. This tiered system is designed to highlight the differences in care and services provided by nursing homes.
Recent Revisions in the CMS Star Ratings
The CMS 5-Star Rating System, a cornerstone in assessing the quality of care provided by nursing homes across the United States, has undergone several revisions to ensure its accuracy, relevance, and fairness. The timeline below provides an overview of the significant updates and methodological adjustments over the last couple of years.
September 2023 Revisions and Beyond
Looking ahead to April 2024, CMS plans to update the staffing level case-mix adjustment methodology and freeze certain Quality Measures (QMs) to accommodate updates to the Minimum Data Set (MDS). These changes, including the transition to a model based on the Patient-Driven Payment Model (PDPM) for staffing case-mix adjustments, signal CMS’s ongoing efforts to refine and adapt the rating system to reflect current practices and technologies in patient care.
July 2023 Revisions
Adjustments in July 2023 refined the exclusion criteria for the administrator turnover measure. It targets inaccuracies and ensures a fairer assessment of nursing home administration stability. This revision aimed to better reflect the operational and management consistency within nursing facilities, recognizing the impact of administrative stability on overall care quality.
January 2023 Revisions
The beginning of 2023 saw CMS taking action against erroneous schizophrenia coding within the Minimum Data Set (MDS) data. Nursing facilities identified with inaccuracies in schizophrenia coding faced downgraded Quality Measure (QM) ratings, impacting their overall star rating. This move underscored CMS’s commitment to data integrity and accurate reporting, essential for the reliability of the 5-Star Rating System.
October 2022 Revisions
In October 2022, CMS implemented planned increases to the Quality Measure (QM) rating thresholds. This adjustment, based on the average improvement in QM scores since the last revision period, sought to continually raise the bar for quality care expectations. The new thresholds were established to encourage facilities to strive for better outcomes and quality improvements, keeping pace with the sector’s overall progress.
July 2022 Revisions
In July 2022, CMS introduced significant changes to both the Staffing and Overall Quality Rating methodologies. The Staffing star rating was recalibrated to be based on six distinct measures, incorporating case-mix adjusted staffing levels across different categories, including RN, LPN/LVN, aide staffing levels, and turnover rates for total nurses, RNs, and administrators. This approach aimed to provide a more nuanced view of staffing adequacy and stability within facilities. Concurrently, the methodology for assigning the overall quality star rating was refined. Previously, a four- or five-star staffing rating contributed to an uplift in the overall star rating. Post-revision, only nursing homes with a five-star staffing rating would see an enhancement in their overall star rating, tightening the criteria for excellence in care delivery.
Impact of Staffing Metrics on Ratings
The new staffing metrics have led to a tangible impact on the ratings of nursing homes across the country. Formation Healthcare’s analysis highlighted a stark reality: 4,850 providers, or 33%, saw a decline in their staffing rating, with 939 facilities losing two or more stars. This reflects the increased emphasis on staffing quality and its direct correlation with patient care standards.
The CMS now incorporates several specific factors into staffing ratings, including total nurse staffing hours per resident per weekend day, nurse and administrator turnover rates, and the accuracy of data submissions. Nursing facilities failing to meet these enhanced criteria face the risk of receiving automatic one-star staffing ratings for issues like data submission errors or insufficient RN hours.
April 2022 Revisions
In April 2022, CMS implemented planned, regular increases to the Quality Measure (QM) rating thresholds. This adjustment was based on the average improvement in QM scores from April 2019 through January 2022. The intent behind this update was to encourage continuous improvement in the quality of care provided by nursing homes.
By increasing the rating thresholds, CMS aimed to reflect the overall progress in care quality across the sector and to motivate facilities to strive for higher standards of care. The new rating thresholds were set to incrementally elevate the benchmarks for achieving each star level within the QM domain, without altering the point thresholds for individual QMs.
Three Components of CMS Ratings for Nursing Homes
Nursing Home Compare provides a five-star rating for each of the following three components:
1. Health Inspections
State health inspection score is the foundation of the CMS 5-Star Rating System. Nursing homes participating in Medicare and/or Medicaid programs undergo unannounced comprehensive inspections annually on average. These state health inspections are unannounced and conducted by a team of healthcare professionals. The CMS has entered into an agreement with state governments to do these state health inspections.
2. Staffing Ratings
A critical component of a nursing home’s overall quality is its staffing levels, particularly the ratio of nursing staff to residents. The CMS rating system evaluates staffing based on the number of hours of care provided on average to each resident daily by nursing staff.
3. Quality Measures (QMs)
It is based on specific clinical and physical measures that indicate the quality of care and services provided to residents. These measures cover a broad range of care aspects, including chronic care, short-stay outcomes, and resident satisfaction. Data for QMs are collected from clinical records and reflect how well a nursing home cares for its residents’ physical and clinical needs.
How are the CMS Ratings for Nursing Homes Calculated?
Here’s a detailed look into the methodology behind these ratings:
- Health Inspection Ratings
Health inspection ratings are derived from the outcomes of state health inspections over a three-year period, including both standard and complaint surveys, with more recent inspections carrying greater weight. The areas scrutinized include resident rights, quality of life, medication management, skin care, resident assessment, and more. It also takes into account the three most recent recertification surveys, complaint deficiencies over the most recent three-year period, deficiencies from focused infection control surveys in the same timeframe, and any repeated visits to ensure compliance corrections. This domain alone uses nearly 400,000 records to establish its ratings.
The scoring process involves assigning points based on the severity, scope, and number of health deficiencies identified. A nursing home’s score increases with the severity and number of deficiencies, meaning a lower score indicates better performance and a higher star rating. Nursing homes are ranked within their state, with the top 10% receiving 5 stars and the bottom 20% receiving 1 star.
- Quality Measure Ratings
The Quality Measure ratings focus on a nursing home’s performance across 10 specific QMs, including 7 long-stay and 3 short-stay resident care domains.
| Long-Stay QMs | Short-Stay QMs |
| ADL Decline | Pressure Ulcers |
| Mobility Decline | Moderate to Severe Pain – Delirium |
| Catheter | |
| High-Risk Pressure Ulcers | |
| Physical Restraints | |
| Urinary Tract Infections | |
| Moderate to Severe Pain |
These measures are crucial for assessing the effectiveness of care in areas significant to residents’ well-being, such as mobility and activities of daily living (ADL). It assigns points based on a facility’s quintile ranking for each QM, both at a state level (for ADL-related measures) and nationally (for the other measures), with higher rankings yielding better star ratings. The distribution follows a fixed quintile boundary system, ensuring consistency over time, and like Health Inspection ratings, the top 10% of facilities receive 5 stars, whereas the bottom 20% receive 1 star.
- Staffing Ratings
Staffing ratings are calculated using data on the registered nurse (RN) hours per resident day and total staffing hours (including RNs, licensed practical nurses (LPNs), and nurse aides) per resident day. This approach recognizes the critical impact of staffing levels on the quality of care and resident outcomes. Nursing facilities are evaluated against national benchmarks and optimal staffing levels identified by the CMS Staffing Study. Achieving a 5-star rating requires meeting or exceeding these benchmarks.
Calculation of Overall Ratings
The overall rating is a combination of the above components, calculated in five steps:
- STEP 1
Start with the health inspection rating.
- STEP 2
If the staffing rating is 4 or 5 stars and higher than the health inspection rating, add one star. Subtract one star if the staffing rating is 1 star. The overall rating cannot exceed 5 stars or fall below 1 star.
- STEP 3
Add one star if the quality measure rating is 5 stars; subtract one star if it is 1 star, with the same constraints on the overall rating’s limits.
- STEP 4
If the health inspection rating is 1 star, the Overall Quality rating cannot be increased by more than one star based on staffing and quality measures.
- STEP 5
If a nursing home is designated as a special focus facility that has not graduated is capped at a maximum Overall Quality rating of 3 stars.
8 Strategies for Healthcare Providers to Improve CMS Ratings
An investigation conducted by The Times, which involved the analysis of millions of payroll records of over 373,000 state inspector reports, and financial statements from more than 10,000 nursing homes, has cast a shadow over the reliability of these ratings.
A key finding was that a significant portion of the information submitted by nursing homes to CMS was inaccurate, often portraying nursing homes as cleaner and safer than they truly are. For instance, it was discovered that staffing levels are sometimes artificially inflated by counting employees who are not present because they are on vacation. Similarly, the usage of antipsychotic medications and the occurrence of residents’ accidents and health problems are frequently underreported.
Additionally, there were indications that some nursing homes may have advanced knowledge of supposedly surprise inspections, undermining the integrity of these evaluations. Even more concerning is that health inspectors, despite identifying issues related to abuse and neglect at these top-rated facilities, seldom deem these violations severe enough to warrant a downgrade in their ratings.
Nursing homes or any healthcare facility shouldn’t have to rely on presenting inaccurate data and other malpractices to get a higher CMS rating. That’s why we have created a list of some strategies that can actually help them gain higher 5-star ratings:
1. Understand How CMS 5-Star Rating Work
CMS 5-Star Ratings evaluate healthcare facilities based on three key areas: health inspections, staffing, and quality measures. Facilities are awarded stars ranging from one to five, with five indicating above-average quality. These ratings are crucial for consumer choice, professional recommendations, and financial assessments. Understanding the rating system’s intricacies is the first step toward improvement.
2. Use QAPI to Identify Areas of Improvement
Quality Assurance and Performance Improvement (QAPI) programs are essential for identifying and addressing areas needing improvement. QAPI involves comprehensive data analysis and ongoing quality improvement projects, focusing on enhancing care quality and patient safety. Implementing effective QAPI measures can directly impact CMS star ratings by improving performance in the key areas CMS evaluates.
GoAudits offers the following checklists you can use to implement QAPI:
Explore our extensive library of healthcare checklists to ensure compliance and improve the quality of care.
3. Assess Compliance
Regularly assessing compliance with healthcare regulations and standards is vital. Non-compliance can negatively affect CMS star ratings, particularly in health inspections and staffing. Facilities should ensure adherence to all regulatory requirements, including those related to patient care, safety, and staff qualifications.
4. Prioritize Quality Measures
Quality measures, which assess the outcomes of patient care, are a significant component of the CMS rating system. Prioritizing initiatives that improve patient outcomes, such as reducing hospital readmissions, improving pain management, and enhancing mental health services, can positively affect a facility’s quality measures rating.
5. Prevent Patient Abuse
Preventing patient abuse is critical for maintaining high CMS star ratings. Facilities must have strict policies and training programs in place to prevent abuse, neglect, and exploitation. Regular staff training, patient education, and a robust reporting and investigation process are essential components of an effective abuse prevention strategy.
6. Adopt a Broad Quality Improvement Strategy
A broad quality improvement strategy encompasses all aspects of healthcare delivery, from patient care and safety to staff training and facility management. Such a strategy should include regular performance evaluations, targeted improvement projects, and a culture that promotes continuous quality improvement. Engaging staff at all levels in quality improvement efforts can foster a sense of ownership and accountability, leading to sustained improvements.
7. Stay on Top of Regulatory Changes
Healthcare regulations and standards are continually evolving. Staying informed about changes and adapting practices accordingly is crucial for maintaining or improving CMS star ratings. Facilities should have a process in place for monitoring regulatory updates and implementing necessary changes in a timely manner.
8. Invest in Technology and Analytics Tools – Healthcare Compliance Software
Healthcare organizations constantly strive to improve their quality measures and attain higher 5-star ratings. Investing in technology and analytics tools can significantly support these goals.
The GoAudits Healthcare Compliance Software enables healthcare organizations to streamline their auditing processes, enhance collaboration, and drive continuous quality improvement efforts.
- Streamlined Auditing Process:
GoAudits’ auditing software enables nursing home staff to conduct inspections conveniently using their preferred mobile devices. This feature ensures real-time data collection, reduces paperwork, and enhances accuracy. By efficiently capturing information about resident care, safety protocols, and facility conditions, nursing homes can identify areas for improvement and implement corrective measures promptly.
- Insightful Instant Reports:
With the instant reports generation feature, nursing homes can generate professional-looking reports with just a few clicks. These reports provide a comprehensive view of audit findings, highlighting strengths and areas that require attention. Nursing homes can analyze these reports to identify recurring weaknesses, track progress, and address compliance issues promptly. Through the use of visual data, nursing homes gain valuable insights into their performance, enabling them to make informed decisions for quality improvement.
- Advanced Analytics for Performance Tracking:
GoAudits’ advanced analytics feature provides nursing homes with real-time visibility into their compliance status, key performance indicators (KPIs), and quality metrics. By tracking and analyzing data trends, nursing homes can proactively address potential compliance issues and continuously improve their operations. Nursing homes also gain deeper insights into their performance, identify patterns, and benchmark against industry standards. It can guide their quality improvement initiatives and align their practices with best-in-class care models that positively impact their CMS 5-Star Ratings.
Efficient Workflows and Task Management:
GoAudits task management and workflow functionality helps nursing homes streamline corrective action processes. By assigning follow-up tasks to the appropriate staff members, nursing homes can ensure accountability and track the resolution of identified issues. Administrators can also monitor task completion, track overdue actions, and ensure that necessary steps are taken to rectify deficiencies promptly.
Conclusion: A Tool to Drive Quality of Care
Achieving and maintaining a high CMS rating for nursing homes is proof of commitment to excellence in patient care, staff engagement, and overall outcomes. This rating system not only helps consumers make informed decisions when selecting healthcare services but also acts as a catalyst for continuous improvement among healthcare providers.
The significance of the CMS 5-star rating system for nursing homes in promoting quality, transparency, and excellence in healthcare remains undiminished. It encourages healthcare organizations to persistently strive for excellence, ensuring that patient care and satisfaction are always at the forefront of their mission. Understanding and using the insights provided by this rating system is crucial for healthcare providers aiming to enhance their service quality.
