Measuring Success: The Changing Landscape of Skilled Nursing Facility Ratings

Many factors contribute to the reputation of a skilled nursing facility, including consumer reviews and Department of Health rankings. When selecting a post-acute or long-term care facility for a loved one, interested family members inevitably go to the Internet for answers. One of the most popular websites visited by those consumers is “Nursing Home Compare,” a website run by the Centers for Medicare & Medicaid Services (CMS) to rank skilled nursing facilities. Historically, skilled nursing facilities (including both long-term and sub-acute residents) had a five-star rating system based upon:

1. Results from onsite inspections in the past three years;
2. Performance on eleven quality measures; and
3. Staffing levels.

While these three pillars still form the basis of the rating system, the ways CMS assesses and weighs these areas have changed.

On February 20, 2015, CMS amended its calculation of staffing levels. Previously, skilled nursing facilities would receive a four-star rating if they scored three stars on both registered-nurse hours-per-day and total staffing hours-per-day measures; with CMS’ recent changes, skilled nursing facilities must now score four stars on both of the aforementioned hours-per-day metrics in order to receive an overall four-star rating. Therefore, under this new methodology, facilities that are currently meeting or exceeding state staffing requirement might still only receive a three-star rating overall.

Other changes to the rating system focus on evaluating the quality of services provided in the facilities. To address the growing concern for over-prescription of antipsychotics for long-term and sub-acute residents, CMS now monitors and evaluates the use of antipsychotics for sub-acute residents (excluding those with schizophrenia, Huntington’s and Tourette’s) and the continued use of antipsychotics for long-term residents with schizophrenia, Huntington’s and Tourette’s. The underlying goal of adding this quality measurement focused on antipsychotics is to reduce the overall use of such drugs. CMS anticipates that this metric will result in a 30% reduction in the use of antipsychotics in skilled nursing facilities by the end of 2016.

CMS has stated that its goal in enforcing these amendments is to “include more meaningful distinctions in performance for consumers and focus skilled nursing facilities on continuously improving care focused on residents, families, and their caregivers”. Prior to launching the recent changes to their star rating calculations, CMS acknowledged the negative impact that these metrics would likely have on star ratings, estimating that two-thirds of facilities would experience a decline in their quality measure rating and one-third would note a decline in their overall star rating. These predictions proved realistic and provide a relatively accurate assessment of the declines facilities have seen in their ratings in since February 20th.

Since quality measures are self-reported by skilled nursing facilities, CMS has instituted pilot surveys in facilities across the nation to access accuracy of information provided to CMS for determination of star ratings. These surveys have included quarterly electronic reporting of staffing levels (verified through payroll data) as well as verification of M.D.’s coding accuracy (based upon record review, resident observation and staff interviews). In 2014, the pilot surveys were conducted in five states – Illinois, Maryland, Minnesota, Pennsylvania and Virginia. In April 2015, CMS will begin training individuals to conduct these surveys across the country.

When assessing these changes impacting the rating system, the key factor to examine is awareness - ensuring that post-acute and long-term care providers know and understand the new landscape and its impact. While 2015 ratings may be negatively impacted as a result of these amendments, providers affected by these changes should focus on accuracy in self-reporting and developing a predictive yet flexible compliance plan to meet these challenges head-on.