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CMS Updates Five Star, Nursing Home Compare, and Immediate Jeopardy Standards

On March 5, 2019, the Centers for Medicare and Medicaid Services (CMS) issued a press release detailing all the changes to Nursing Home Compare and the Five Star Rating System that will be occurring in April 2019. According to CMS, “The April 2019 changes include revisions to the calculation of the Health Inspection domain, enhancement of new staffing information, and implementation of new quality measures.” CMS has also issued revisions to Appendix Q of the State Operations Manual (SOM) providing updated guidance on Immediate Jeopardy (IJ) citations, which is effective as of March 5th.

With regard to the changes to Five Star, CMS provided further details in memo QSO-19-08-NH issued to State Survey Agency Directors. Per the memo, the effective date is April 24, 2019. LeadingAge NY would like to draw your attention to the following changes:

  • Survey star ratings will unfreeze in April 2019, and three surveys will be used for the star rating at the previous calculation rates. Cycle 1 will be weighted as 1/2, Cycle 2 will receive a weighting of 1/3, and Cycle 3 will have a weighting of 1/6 of the health inspection.
  • Changes are also forthcoming regarding staffing. The threshold for RN staffing will drop from seven days to four days without an RN in the building. Facilities reporting four or more days with no RN on-site during a quarter will be automatically assigned 1 star for their staffing rating.
  • The Five Star Quality Measure (QM) rating will be divided into a Long-stay star rating, a Short-stay star rating, and an overall QM star rating.
  • QM thresholds, weighting, and scoring will be updated every six months by a percentage (50 percent) of the overall improvement on each QM.
  • The Physical Restraint QM will be removed but will be reported to Nursing Home Compare.
  • New Long-stay measures will be added: Number of Hospitalizations per 1,000 Resident Days and Emergency Department Transfers. These measures will be included in Nursing Home Compare and the rating system.

Memo QSO-19-08-NH further states: “CMS also recognizes that some providers will be concerned about how the changes will impact their participation in other programs, such as CMS Center for Medicare and Medicaid Innovation (CMMI) demonstrations (e.g., accountable care organizations (ACOs), bundled payment models) and Medicare Advantage plan networks. Each of these, and other programs should review the changes described in this memorandum, so they can evaluate any potential impact, and make any changes they feel warranted.” For additional details on the changes, refer to the Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide April 2019.

The IJ guidance revisions were also the subject of a CMS memo, QSO-19-09-ALL, issued on March 5th. Appendix Q of the SOM, which provides guidance for identifying IJ, has been revised to create a Core Appendix Q that will be used by surveyors of all provider and supplier types in determining when to cite IJ. To cite IJ, surveyors must determine that noncompliance caused or created a likelihood that serious injury, harm, impairment, or death to one or more recipients would occur or recur, and that immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment, or death to one or more recipients.

Key changes from the previous version of Appendix Q include the following: (1) there must be a likelihood of harm instead of a potential for harm; (2) culpability is no longer a required component to cite IJ and has been replaced with noncompliance; (3) surveyors are instructed to consider whether noncompliance has caused or made likely serious mental or psychosocial harm to recipients; and (4) each IJ citation must be decided independently, and there are no automatic IJ citations.

For more information on the Five Star changes, please contact Sue Chenail at 518-867-8846 or schenail@leadingageny.org or Kristin Breese at kbreese@leadingageny.org. Any questions on the revised IJ guidance may be directed to Mary Wassel at mwassel@leadingageny.org or Elliott Frost at efrost@leadingageny.org.