The Center for Medicare and Medicaid Services, (CMS), has ranked nursing homes using the 5-star system since 2008. The information is made available on the Nursing Home Compare website, originally designed to inform consumers. This distinction has grown in importance since its inception. Today, the rating is looked not just by consumers, but by providers and practitioners, insurers, accountable care organizations (ACOs), and lenders and investors. In the future, facilities with less than a 3-star rating may not receive sufficient referrals or obtain Medicare or Medicaid funding.
The 5-star rating is derived from a very complicated scoring system: (1) Health Inspections which looks at the last 3 years of on-site inspections, including both standard inspections and complaint surveys;(2) Staffing which is based on the number of Licensed Nurses (RN and LPN) and Certified Nursing Assistant (CNA) hours per resident day; and (3) the Quality Measures (QM) rating based on 16 different physical and clinical measures for the nursing home residents.
The Health Inspections (or State Surveys) account for about 50% of the 5-Star Rating. Each survey and complaint inspection is weighted, the most recent survey affecting the rating the most. Annual Surveys are conducted by employees of the Department of Quality Assurance for Centers for Medicaid and Medicare Services (CMS). A facility Pine Valley’s size typically is surveyed by 3 to 5 state surveyors over the course of 3 to 4 days. Annual Surveys are conducted every 9 to15 months and are unannounced. They survey the environment, each department’s services; observe nursing care and treatments, as well as review documentation and medical records dating back to the last survey. Citations are weighted based on their scope (number of residents potentially affected) and severity. While the surveys are not the only measure of a good facility, it is often thought of as the facility’s annual “report card”.
Staffing accounts for another percentage of the 5-star rating. Staffing patterns are posted daily in nursing homes. CMS has identified minimum staffing requirements for both licensed and non-licensed staff. Staffing is also based on the acuity (the care needs) of our residents and is also scrutinized as they relate to resident care outcomes, QMs, and overall satisfaction. Resident and families are interviewed during the course of the surveys to gain this insight.
Finally, there are the Quality Measures. QMs are judged using assessments that are completed for each resident at least quarterly and more often, when needed. Some of the 16 areas that are measured and affect the 5-star rating are unintended weight loss, declines in physical function, pressure ulcers, restraint use, and medication use. They are compiled and compared to facilities within Wisconsin and nationally. Pine Valley’s Quality Assurance and Process Improvement (QAPI) team use this information to drive quality improvement projects within our facility and measure the success of our efforts.
Health Inspections are essentially “graded on a curve” and only the top 10% of facilities are awarded a 5-star rating. To achieve an overall 5-star rating, the Health Inspection rating is adjusted upward for a 4 or 5 star Staffing rating or a 5-star QM, or downward for a 1-star rating in either Staffing or QMs.
Pine Valley is proud to have had no clinical citations in our recent annual survey, which has allowed us to maintain our 5-Star rating in Health Inspections and an overall 5-Star rating, as well. This accomplishment is possible because of the many dedicated employees of Pine Valley Community Village and the support of our community. While complicated, it is a system that must be closely monitored by Nursing Home Administration and the QAPI team as it can have a profound effect on our Pine Valley’s future referrals, business relationships, and finances.