April 2019 Changes to CMS Five-Star Quality Rating System Hello everyone and thanks for attending the updates for the Five-Star Rating System April 2019. Jim asked me to put these slides together so we can discuss the changes. Please stop me if you have questions along the way. Susan Chenail RN, CCM, RAC-CT Senior Quality Improvement Analyst LeadingAge NY

Health Inspection Domain Return to three surveys used to calculate the rating Return to 36 months of complaints used to calculate rating Return of the Aging of Complaints Using surveys both before and after the new survey process In April 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected all domains of the rating system. Health Inspection Domain: The rating methodology for the health inspection rating returns to what it was prior to February 2018. Specifically, results from the three most recent standard health inspections and 36 months of complaint inspections are used to calculate the health inspection score and determine the health inspection rating. Surveys occurring both before and after the implementation of the new survey process (November 28, 2017) are used to determine health inspection scores and rating and are treated in the same way. The goal is to have the top 10 percent of facilities be 5 star 70 percent in 2,3,4 star range 23.3 percent in each rate And 20 percent in 1 star The State level HI cut point table is updated monthly about the same time as NHC is updated, about the third Wednesday of every month. 10 70 20

These are the areas that determine the total weighted survey score – Deficiency, Complaint, and Revisits are tallied for each cycle. This tally is then subject to weighting. All weighted scores are tallied to determine the Total weighted survey score. This score is translated into a star rating using the State Level Cut Point Table.

Staffing Cut Points Staffing Domain New RN threshold for 1 Star rating New Cut point table RN incentivized weighting Staffing Domain: The staffing rating thresholds are changing, with the staffing level required to receive a 5-star rating determined based on analyses of the relationship between staffing levels and measures of nursing home quality. In recognition of the importance of RN staffing, the method by which the RN staffing rating and the total nurse staffing rating are combined to generate the overall staffing rating is changing to provide more emphasis on RN staffing. Additionally, the overall and RN staffing ratings are set to one star for nursing homes that report four or more days in the quarter with no RN onsite. Prior to April 2019 RN and Total nurse staffing were given equal weight. For April CMS is recognizing the importance of RN’s and incentivizing the use of RN’s in the facility by rewarding with additional stars in columns 1 and 2 and 4 above.

PBJ data needs to be accurate and timely PBJ data needs to be accurate and timely. This is a calendar of PBJ reporting deadlines and what data is used to calculate the staffing five-star rating. The deadline for submitting 1st ¼ 2019 PBJ data is May 15.

NHC Staffing Domain Footnotes Footnote 1 Too New to Rate - Newly certified nursing home with less than 12 – 15 months of data available. Footnote 2 Not Available – Not enough data available to calculate a star rating. Footnote 6 Not Available – This facility didn’t submit staffing data, or submitted data that didn’t meet the criteria required to calculate a staffing measure. Footnote 8 Not Available – Not available Footnote 12 One star rating– This facility either didn’t submit staffing data, has reported a high number of days without a registered nurse onsite, or submitted data that couldn’t be verified through an audit. Finally, staffing ratings are no longer being suppressed for nursing homes that have five or more days with residents and no nurse staffing hours reported. Since CMS will no longer suppress staffing rating based on incomplete or unavailable data, footnotes 2,6,8 will be deleted. Staffing ratings are no longer being suppressed

Quality Measure Domain Changes: Reports Long and Short-Stay Rating and an Overall Rating Scoring, Weighting and Points Threshold New Measures Retired Measures Replaced Measures Specification Changes Quality Measures Domain: The Nursing Home Compare website reports separate ratings for short-stay quality of resident care and long-stay quality of resident care in addition to an overall quality of resident care rating. The scoring rules for the quality measures are changing to give more weight to measures with greater opportunity for improvement. Given the changes in measures and weights, there are also new point thresholds. Also measures have been added, retired and changed. I will provide details of all these changes in the next few slides.

Quality Measure Domain Short-Stay Rating Measures used to calculate the Short-Stay Rating: MDS-Based Percent of Short Stay Residents- Who Made Improvements in Function Who Self-Report Moderate to Severe Pain Who Newly Received an Antipsychotic Claims-Based or Medicare A FFS Stays- Discharge to the Community Re-Hospitalized After a NH Admission Out-Patient ED Visit Pressure Ulcer New or Worsened Quality Measure Domain Short-Stay Rating The measures used to calculate the Short-Stay Rating are: MDS-Based Percent of Short Stay Residents- Who Made Improvements in Function Who Self-Report Moderate to Severe Pain Who Newly Received an Antipsychotic Claims-Based Medicare A FFS Stays- Discharge to the Community Re-Hospitalized After a NH Admission Out-Patient ED Visit Pressure Ulcer New or Worsened

Quality Measure Domain Long-Stay Rating Measures used to calculate the Long-Stay Rating: MDS-Based Percent of Long-Stay Residents- Whose Need for Help with ADL’s Worsened Who Self-Report Moderate to Severe Pain Who Received an Antipsychotic Whose Ability to Move Independently Worsened High-Risk Pressure Ulcers Catheter Inserted and Left in Their Bladder UTI Falls With Major Injury Claims-Based Medicare A FFS Stays- Hospitalizations per 1,000 Resident Days Out-Patient ED Visits per 1,000 Resident Days Quality Measure Domain Long-Stay Rating The Long-Stay measures used to calculate the Long-Stay rating are: MDS-Based Percent of Long-Stay Residents- Whose Need for Help with ADL’s Worsened Who Self-Report Moderate to Severe Pain Who Received an Antipsychotic Whose Ability to Move Independently Worsened High-Risk Pressure Ulcers Catheter Inserted and Left in Their Bladder UTI Falls With Major Injury Claims-Based Medicare A FFS Stays- Hospitalizations per 1,000 Resident Days Out-Patient ED Visits per 1,000 Resident Days

This is a quick reference to the quality measures and where they are reported.

Quality Measure Domain Ranges for Point Values for Quality Measures Weighting Changes Nine measures with point range 15-150: Successful Discharge Need for Help with ADL’s has Increased Antipsychotic Medication Use (LS) Ability to Move Independently Worsened Improvement in Function Rehospitalization After a NH Stay (SS) ED Visits (SS) Hospitalizations Per 1,000 Resident Days ED Visits Per 1,000 Resident Days Of the 17 measures used to calculate the quality measure domain, 9 have 150 points available for scoring. Those measures are: Successful Discharge Need for Help with ADL’s has Increased Antipsychotic Medication Use (LS) Ability to Move Independently Worsened Improvement in Function Rehospitalization After a NH Stay (SS) ED Visits (SS) Hospitalizations Per 1,000 Resident Days ED Visits Per 1,000 Resident Days

Quality Measure Domain Ranges for Point Values for Quality Measures Weighting Changes Eight Measures with Point Range 20 -100 Pressure Ulcers That are New or Worsened Self-Reported Pain (LS and SS) Catheter Use UTI’s Falls With Major Injury Newly Received Antipsychotics High-Risk Pressure Ulcers Of the 17 measures used to calculate the quality measure domain, 8 have 100 points available for scoring. Those measures are: Pressure Ulcers That are New or Worsened Self-Reported Pain (LS and SS) Catheter Use UTI’s Falls With Major Injury Newly Received Antipsychotics High-Risk Pressure Ulcers

Point Ranges for the Quality Measures Ratings Here is a comparison of the prior cut point tables to the April cut point table in the quality measures domain. These two tables side by side show the true picture. Never before has the low end threshold for 5 stars start out the high threshold for 1 star it was always 3 stars, so what does that mean? If a facility was 5 stars for the quality measure domain at a score of 1055 then in April that same facility would be a 1 star with the penalty of losing an overall star instead of gaining one. Never before has a high end threshold for 5 star be higher than the previous high end threshold. Prior it was bested by 250 points. What does that mean? If a facility was maxed out in points and was 5 stars with adding a star overall then in April that same facility would be a 4 star and not qualify to score an additional overall star.

Quality Measure Domain Two New Measures SS PU & LS ED Use One Retired Measure LS Restraints Two Replaced Measures SS PU – QRP & SS D/C – QRP Measures Added, Retired and Replaced Quality measures have been changed: Two new - SS PU & LS ED Use One retired - LS Restraints Two replaced - SS PU – QRP & SS D/C – QRP

Quality Measure Domain The LS PU now captures Unstageable Ulcers New Measure Specifications Measures that changed specs – LS PU captures Unstageable Ulcers

NHC Quality Measure Domain Footnotes Footnote 13 Not Available – Footnote 15 – Footnote 14, 16, 8 Not Available – NHC quality measure footnotes explaining when data is not available to report. The number of cases is too small to report a rate, the results are based on a smaller amt of data than usual, and data suppressed.

Special Focus Facilities Special Focus Facility (“SFF”) Initiative Special Focus Facilities Will not be given a rating on NHC Special Focus Facilities: Nursing Home Compare no longer displays overall quality ratings or ratings in any domain for nursing homes currently participating in the Special Focus Facility program.

NHC Special Focus Facility ICON If a nursing home has a history of persistent poor quality of care, as indicated by the findings of state or federal inspection teams, it can be considered a Special Focus Facility (SFF). This means that the facility is subjected to more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid. This is the SFF icon on NHC.

Any Questions?

Resources Minimum /data Set (MDS) 3.0 RAI Manual Version 1.16 October 2018 https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf Design for NHC Five-Star Rating System Technical Users’ Guide https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Five-Star-Users-Guide-April-2019.pdf Quality Measures User’s Manuals https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqiqualitymeasures.html Claims Based Quality Measures User’s Manual