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CMS Announces Updates to Five Star Quality Rating System

The Centers for Medicare and Medicaid Services (CMS) announced (QSO-21-06-NH) on December 4 that the Five Star Quality Rating system will resume all updates with the January 2021 refresh. Due to the public health emergency (PHE) first issued in March 2020, the 3 domains of the rating system had previously been held constant at varying times throughout the past 9 months as a result of changes to health inspections and certain temporary regulatory waivers. During this time, CMS also unveiled the new Care Compare site, which officially replaced all legacy sites, including Nursing Home Compare, on December 1, 2020. Complete updates to the Five Star Quality Rating system will be available at the new Care Compare site on January 27, 2021.

Updates to the specific domains are as follows:

Health Inspections Domain

In March, CMS issued memos suspending and reprioritizing survey activity for nursing homes. Infection control-focused surveys were also introduced at this time. As a result, CMS announced on April 24 that the health inspection domain would be held constant beginning with the April 29, 2020 refresh and would not include data for surveys conducted after March 4, 2020.

States were recommended in May to begin reintegrating health inspections as part of a phased reopening. In June, recommendations around surveys were revised to more clearly direct the survey activity that should be taking place. Additionally, CMS began posting data from the infection control-focused surveys in a separate location on the Nursing Home Compare site in June and has continued to update these files regularly. Finally, nursing home surveys were once again re-prioritized on Aug. 17 to authorize normal survey activity, though the health inspection domain remained frozen at the time.

On Dec. 4, CMS announced that the health inspection domain would be unfrozen with the Jan. 27, 2021 quarterly refresh. Domain ratings will be recalculated and will include data from infection control-focused surveys. The method for calculating these data will be consistent with methodology for calculating complaint surveys and will be available in an updated Five Star Technical Users’ Guide expected by January 15, 2021. Of note, this domain update will impact certain related programs. Facilities will see changes to the Special Focus Facility (SFF) program, including SFF candidates, as well as the abuse icon.

Quality Measures Domain

In March 2020, as a result of the public health emergency (PHE), CMS issued a number of temporary regulatory waivers, including a waiver granting flexibility around required timeframes for submitting Minimum Data Set (MDS) data. Delayed MDS data submissions had the potential to impact the calculation of individual quality measures. CMS announced on June 25 that individual quality measures for which the underlying data collection periods ending Dec. 31, 2019 would be held constant and quality measures for which the underlying data collection periods ended prior to Dec. 31, 2019 (i.e. Sept. 30, 2019) would continue to update until the data collection period end reached Dec. 31, 2019. Once a quality measures’ underlying data collection period reached Dec. 31, 2019, it too would be held constant.

Over time, CMS has noted that the majority of providers continue to submit MDS data within a reasonable timeframe, even if submissions are outside the normal regulatory requirement. For this reason, CMS feels that sufficient data exists to accurately calculate quality measures and announced on Dec. 4 that all quality measures will resume updates with the Jan. 27, 2021 quarterly refresh. The overall quality measures domain rating, which was not held constant, will continue to update. Quality measures will be calculated using an underlying data collection period ending June 30, 2020 and methodology will be included in the updated Five Star Technical Users’ Guide expected Jan. 15, 2021. CMS notes that these changes do not apply to the quality measures included in the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).

Staffing Domain

Though PBJ staffing data submissions were initially included in the temporary regulatory waivers, this waiver was terminated in June 2020 and providers were required to submit data for calendar quarter 2 (April – June 2020) by Aug. 2020. This domain has continued to update accordingly and there are no changes to the staffing domain at this time.

What This Means for Providers

As each of the 3 domains updates, providers may see changes to their domain ratings and overall Five Star Quality Rating system rating. Additionally, related programs, such as the Special Focus Facility (SFF) program and the Consumer Alert Icon (“abuse icon”) will be updated. Providers may find themselves newly included or excluded from these special designations, including the SFF candidate list.

Lastly, note that a number of regulatory waivers that remain in effect either impact or could be impacted by this announcement. For example, the Inspection, Testing, and Maintenance waiver may impact fire safety inspections. Will CMS re-evaluate the necessity of the MDS submission waiver?

CMS has not indicated plans to pre-emptively terminate any regulatory waivers at this time. Remember that all waivers remain in effect until the end of the PHE, currently set to expire in Jan. 2021. The PHE has previously been extended 3 times (April, July, and Oct.) and may be extended again at the discretion of HHS Secretary Alex Azar.

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