powered by LeadingAge New York

CMS Extends Its Staffing Focus to Publicly Reported Data on Care Compare

On Jan. 26, 2022, the Centers for Medicare and Medicaid Services (CMS) will add five new measures to the staffing domain on Care Compare for nursing homes. The new measures include data on weekend staffing and staff turnover derived from Payroll-Based Journal (PBJ) data. The new measures are:

  • Average number of registered nurse (RN) hours worked per resident per day on weekends – (job codes 5, 6, 7)
  • Average number of total nurse hours worked per resident per day on weekends – (job codes 5-12)
  • The percent of RN staff that left the facility over the last year – (job codes 5, 6, 7)
  • The percent of total nurse staff that have left the facility over the last year – (job codes 5-12)
  • The number of administrators that have left the facility over the last year – (job code 1)

While this new data is publicly reported, it will not be used to calculate the staffing star rating until July. The PBJ data that will be used for the July refresh to calculate the staffing star rating is quarter 1 2022 (Jan. 1st to March 31st), with a submission deadline of May 15th. That means there is time to prepare for the changes. There are three things that can be done now:

  1. Analyze current weekend staffing. Data from LeadingAge NY is coming soon.
  2. Confirm that PBJ data is accurate and submitted timely by reviewing Certification and Survey Provider Enhanced Reporting (CASPER) 1700 series reports to audit PBJ data. The current PBJ User Manual can be found here, and the CASPER Reporting User’s Guide is here (see Section 12 for PBJ reports).
  • PBJ On Demand Final File Validation Report
  • PBJ Submitter Final File Validation Report
  • 1700D Employee Report
  • 1702D Individual Daily Staffing Report
  • 1702S Staffing Summary Report
  • 1703D Job Title Report
  • 1704D Daily Minimum Data Set (MDS) Census Detail Report
  • 1704S Daily MDS Summary Report
  1. Ensure that the methodology to link employee identifiers is in use. CMS’s changing employee identifiers document can be found here.

Contact: Susan Chenail, schenail@leadingageny.org, 518-867-8383 ext. 116