CMS Freezes Five Star Health Inspections Rating and Answers Frequently Asked Questions

CMS recently released Quality Safety and Oversight Memorandum QSO-20-28-NH, addressing a number of questions relating to nursing homes and the fight against COVID-19. This article shares the highlights, and we encourage you to review the entire memo and share it with your teams.  

CMS Is Freezing Health Inspections Ratings

Starting with the April 29th update to Nursing Home Compare, CMS will temporarily freeze the health inspection domain of the Five Star quality rating system.  Specifically, results of health inspections conducted on or after March 4, 2020, will be posted publicly, but will not be used to calculate a nursing home’s health inspection rating.  Because standard surveys are currently suspended, CMS explains, “many nursing homes that would normally be inspected, will not, thereby over-weighting and impacting the ratings of those facilities that are inspected.”  CMS does not say when it will lift the freeze or when it will resume standard survey activities.

The April 29th updates to the Quality Measures and Staffing domains will proceed as scheduled, because the underlying data for those updates is based on time periods prior to the COVID-19 crisis. CMS is prepared to make appropriate adjustments to future updates in order to ensure facilities’ ratings are fair and accurate, while still providing valuable information to consumers.

CMS Is Releasing Nursing Home Staffing Information

CMS is releasing information that shows the average number of staff (nursing and total staff) each nursing home had onsite during 2019 calendar quarter 4, based on PBJ data submitted for that time period.  CMS acknowledges this will not reflect the actual conditions in facilities currently, but states that transparency is important and that the information can be used to identify approximate facility needs (such as PPE and testing), and help support local, state, and federal agencies’ COVID response.

Frequently Asked Questions (FAQs)

Most of the memo is a list of FAQs intended to provide additional information on key topics.  CMS notes that guidance can’t address every scenario, and it advises providers to follow these principles: 

It is incumbent upon nursing homes to comply with Medicare and Medicaid’s essential health and safety standards to keep residents safe.  It is also each nursing home’s responsibility to work with individual patients and residents, along with their families and other caregivers and health care providers to support decisions that are best for that patient or resident. Each nursing home should use the information in this FAQs to make decisions based on the needs of each resident, the actions needed to prevent the transmission of the COVID-19, and the circumstances of each situation.

Admissions from Hospitals:  CMS clarified that a negative COVID-19 test is not required for admission to a nursing home. CMS recommends following CDC guidance for the discontinuation of transmission-based precautions, and while CDC states a negative test is preferred for determining when to discontinue transmission-based precautions for individuals discharging from a hospital to a nursing home, CMS clarifies that a test-based strategy is not required in making this determination. When admitting from the hospital, nursing homes should consider the following:

  • When transmission-based precautions remain in place, the individual should transfer to a nursing home that has adequate space, staff, and PPE to implement these precautions.
  • When transmission-based precautions have been discontinued but symptoms persist, the individual should be admitted to a single room, restricted to the room, and where a facemask during care.
  • When transmission-based precautions have been discontinued and no symptoms are present, no additional restrictions are needed. Recall previous guidance by CMS, however, that states that all residents should be covering their mouths and noses when staff are in their rooms. Though CMS has not been clear, one should assume that this requirement remains in effect.
  • For individuals who were in the hospital for a reason not related to COVID-19, these individuals should be admitted to a private room and placed on transmission-based precautions for a period of 14 days to monitor for the development of COVID-19 symptoms. This information is consistent with previous CMS guidance related to the admissions of individuals for whom COVID-19 status is unknown.

Staying Connected: To support efforts to keep residents connected, CMS has authorized the use of Civil Money Penalty (CMP) funds. Nursing homes can apply for CMP funds through their state CMP contact and while CMS cautions judicious use of these limited funds, funds can be used to purchase communication devices such as tablets or webcams for connecting residents with family and friends during this time of visitor restriction, and for telehealth purposes. In Minnesota CMP funds are distributed through a Committee staffed and organized by the Minnesota Department of Human Services (DHS), and LeadingAge Minnesota has a representative on that Committee.  DHS is already working with the Committee to evaluate this new information CMS, and we will provide more detail as soon as we have it.

Visiting Healthcare Workers and Essential Personnel: Over the weeks since tightening visitor restrictions and protocols, nursing homes have been left with a number of questions about who comes in and who stays out. In effort to address these questions, CMS reminded nursing homes that all visitors and staff must be screened for symptoms and must wear appropriate PPE. CMS stated that the emphasis should be on resident safety, continuing only critical services with only the personnel who are essential to provide those services. In making these decisions, CMS recommends considering the following:

  • What are the resident’s needs?
  • What services are necessary to meet those needs?
  • Who are the individuals who can meet those needs?

LeadingAge cautions that this framework should not result in restrictions of critical and necessary services. Nursing homes should carefully evaluate the resident’s needs, incorporating needs identified in the resident’s individual care plan, and work with visiting healthcare workers to ensure that these services are provided in the safest way possible. Safe service provision includes both COVID-19 precautions as well as scope of practice and specialty considerations. Providers such as hospice and palliative care workers, lab and radiology technicians, and dialysis technicians all provide a specialized type of care and nursing homes should coordinate with these and other healthcare workers to ensure that the residents have access to needed services.

Off-Site Appointments: CMS recommends cancelling or postponing non-essential appointments. Residents who go out for appointments should wear masks and both transportation providers and receiving providers must be notified of the resident’s COVID-19 status. Residents should be screened for the development of symptoms upon return for a period of 14 days; CMS states that screening in a designated location (cohorting) is preferred.

Cohorting: CMS offered further clarification around resident cohorting. Nursing homes should designate separate space, such as wings or units, for residents diagnosed with COVID-19. Additionally, CMS recommends developing a plan for other considerations. Nursing homes should attempt to cohort according to the following:

  • Residents with suspected or confirmed COVID-19 diagnoses.
  • Residents who are newly admitted, recently readmitted or returning, or whose COVID-19 status is otherwise unknown.
  • Residents who are showing signs/symptoms of COVID-19 but have not yet received a COVID-19 diagnosis.

Recall that 1135 federal blanket waivers allow for transfer, discharge, and relocation of residents to meet these recommendations.

Communal Dining: Q. Are all residents forced to eat in their room? A: Residents are not forced to eat in their rooms. Residents may still eat in dining rooms, however, nursing homes should adhere to social distancing, such as being seated at separate tables at least six feet apart. We note that social distancing should be practiced at all times (not just while dining). We further note that eating in dining areas with appropriate social distancing only applies to residents without signs or symptoms of a respiratory infection, and without a confirmed diagnosis of COVID-19. Facilities should refer to CDC guidelines for managing residents with signs or symptoms of a respiratory illness.

Surveys and Infection Control:  CMS also addresses several survey and infection control related questions, including this surveillance recommendation:

  • Q: Section four of the COVID-19 Focused Survey for Nursing Homes tool includes a probe under Infection Surveillance of: “Has the facility established/implemented a surveillance plan, based on a facility assessment, for identifying (i.e., screening), tracking, monitoring and/or reporting of fever (at a minimum, vital signs are taken per shift), respiratory illness, and/or other signs/symptoms of COVID-19 and immediately isolate anyone who is symptomatic?” Does this mean that blood pressure must be checked every shift on every resident?
  • A: Section four, infection surveillance, of the COVID-19 Focused Survey for Nursing Homes tool is referring to the surveillance required to identify cases of COVID-19 and does not necessarily require blood pressure monitoring of each resident in the facility on every shift. Individual resident assessments should be resident-centered, focused on the individual resident’s current health status, and balanced on the need for assessment data with risk of disease transmission. Practitioners have the discretion regarding which residents require their blood pressure to be taken every shift. Facilities should designate vital sign equipment (including blood pressure cuff) to either individual residents or to specific wings or units, and 12 clean and disinfect appropriately according to the equipment and disinfectant manufacturers’ instructions, using an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant.

What This Means for Members: As noted above, many questions remain. LeadingAge has routinely requested more information from CMS regarding federal waivers including MDS submissions, PBJ submissions, 3-day qualifying stay, and the interplay of COVID-19 needs and skilled care. LeadingAge will continue advocacy efforts with CMS and Congress to give nursing homes the support they need and deserve as they continue to provide safe, quality care to residents during this national pandemic.

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