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Focused Infection Control Considerations Following the Care Compare Refresh

Focused Infection Control (FIC) survey activity requirements were revised in Centers for Medicare and Medicaid Services (CMS) memo QSO 20-31-All-REVISED, including revised criteria for triggering a FIC survey. One of the criteria is “low staffing,” which CMS defines as scoring a one-star in the staffing domain of the Five-Star Quality Rating System. Below is an example of how the criteria work:

Any nursing home with three or more new confirmed COVID-19 cases since the last National Healthcare Safety Network (NHSN) COVID-19 report, or one confirmed resident case in a facility that was previously COVID-free, AND that has not had a FIC survey in the last three weeks, AND that has a staffing rating of one star, meets the criteria for having a FIC survey in the next three to five days.

CMS refreshed the nursing home data on Jan. 27th using new methodologies for calculating Five-Star ratings. The new methodologies are contained in the updated Five-Star Technical Users’ Guide. In summary, the health inspection rating freeze has ended and includes surveys after March 3, 2020. Infection control survey deficiency data are included in the rating calculation similar to how complaint surveys are counted. Staffing data and ratings are based on Payroll-Based Journal (PBJ) data for third quarter 2020 (July, August, September) that were due by Nov. 14th. Facilities that did not meet that deadline or that qualified for the one-star staffing penalty will have their staffing rating suppressed. The quality measures rating is updated using all the quality measures except the short-stay pressure ulcer and discharge to community measures. The quality measure ratings reflect data from July 2019 through June 2020.

One more reason to stay informed of your Five-Star ratings: Look for an email link to your Five-Star Analysis Report due following the January refresh. If you have questions regarding how your Five-Star rating was calculated, contact Susan Chenail at schenail@leadingageny.org.

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