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Nursing Home Staffing Measures Transitioning to PBJ Data

In a letter issued on April 6th, the Centers for Medicare and Medicaid Services (CMS) confirms that it is shifting the data source used to calculate the staffing measures of the nursing home quality rating system this month. When the transition occurs, the staffing measures displayed on the Nursing Home Compare website, as well as the staffing ratings used in the 5-Star rating system, will be based on quarterly, auditable data that providers submit through the Payroll Based Journal (PBJ) system rather than on self-reported data collected at the time of survey. The initial PBJ-based staffing measures and staffing star ratings will be based on data for the fourth quarter of 2017 that homes submitted by the Feb. 14, 2018 deadline.

As has been the case prior to this transition, Nursing Home Compare will display the number of hours per resident per day for RNs, LPNs, Aides, and physical therapists (PTs), while the 5-Star staffing rating will continue to be based solely on nursing staff. CMS will continue to calculate the staffing rating by combining a total nursing staffing rating (RN, LPN, Aide) with an RN rating. However, CMS is changing the way in which they adjust the staffing measures to reflect resident acuity.

Until now, the adjustment compared actual staffing to predicted staffing based on RUG-III categories. After this transition, CMS will use predicted staffing based on RUG-IV categories to calculate adjusted staffing levels. CMS notes that while the number of nursing homes in each rating category will be approximately the same as before, some homes will see a change in their rating based on differences in the data they submitted between the old and new process, as well as the new adjustment methodology. By May 1, 2018, CMS intends to post the link to a forthcoming Technical Users Guide detailing the methodology here.

Nursing homes have been required to make quarterly staffing data submissions through the PBJ system indicating the number of hours that staff are paid to work each day of that quarter since July 2016. CMS matches PBJ data with data from Minimum Data Set (MDS) assessments homes submit to determine the number of residents on each day of the quarter as well as the RUG category for each resident. An icon has been added to the Nursing Home Compare site indicating whether a home is in compliance with the PBJ reporting requirements.

While CMS indicates that preliminary audits have found that homes are submitting their data in good faith, they did announce several discrepancy scenarios under which a home would be awarded a one-star staffing rating for one quarter, which would also reduce the composite 5-Star score by one star. These include cases where a home:

  • is found to have "significant inaccuracies" (i.e., large enough to change the star rating) between submitted and verified hours;
  • fails to submit data by the deadline;
  • does not respond or provides inadequate information in response to an audit request; or
  • after July 2018, fails to meet the requirement to have an RN onsite for at least eight consecutive hours, seven days per week (prior to July 2018, homes failing to meet the requirement will be flagged on the Nursing Home Compare website).

Based on their observation of common PBJ errors from preliminary audits, CMS recommends that homes pay special attention to the following issues:

  • exclude meal break time (paid or unpaid) when reporting hours;
  • ensure each employee has their own unique identifier;
  • complete and transmit MDS assessments, including discharge assessments, in a timely manner;
  • respond to audit notices promptly; and
  • multi-service organizations should exclude staff hours dedicated to serving anyone other than nursing home residents. 

While CMS intends to eventually revise the CMS-671 form to delete the staffing data collection section, beginning on June 1, 2018, homes will no longer be required to complete the staffing portion of CMS-671. The Agency is also indicating that they do intend to develop additional PBJ-based measures, such as staff turnover, for posting on Nursing Home Compare.

CMS recommends that homes that believe that their publicized staffing data does not accurately reflect their submitted data are encouraged to review the provider preview reports made available to each home and to run CASPER reports 1700D (Employee Report), 1702D (Individual Daily Staffing Report), and 1702S (Staffing Summary Report) to ensure PBJ data was submitted correctly. If a home believes that their data is reported inaccurately after checking these resources, the home should send an email to NHstaffing@cms.hhs.gov.

In addition to these reports, CMS suggests that homes may want to contact their Quality Innovation Network-Quality Improvement Organizations (QIN-QIO) or access tools developed by CMS on conducting facility assessments that may assist in making staffing decisions. The PBJ Policy Manual and associated Frequently Asked Questions are available here, while the link to the April 6th notification letter, which also includes a brief FAQ section, is here.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841