Nursing Home Compare:  The Freeze is Lifted but the Bar is Raised 

On March 5, 2019, CMS published QSO 19-08-NH announcing several significant changes to the Five Star Quality Rating System which will take effect April 24, 2019.  The changes include adjustments to all three domains of the Five Star Quality Rating System — Health Inspections, Staffing and Quality Measures. 

The Health Inspection domain will once again be included in facilities’ overall star rating calculations. CMS had previously placed a “freeze” on the Health Inspections star rating in February 2018 due to the implementation of a new survey process related to Phase 2 of the Requirements of Participation. As a result, facilities’ star ratings remained static and changes in performance were not reflected. After a year-long analysis of survey findings, CMS determined that the average number of cited deficiencies remained consistent between the old survey process and the new survey process and that the Health Inspection star rating could resume. Like before the freeze, the star rating calculation will be based on three cycles of inspections and will now include inspections conducted on or after November 28, 2017. Scores will be determined based on pre-freeze weighting with the most recent period assigned a factor of one-half, the previous period with a weighting of one-third, and the third-oldest period with a weighting of one-sixth.  CMS also announced that star ratings will now be suppressed for facilities included in the Special Focus Facilities (SFF) program, which total approximately 90 facilities.


Changes to the Staffing domain include new staffing rating thresholds, increased weight of the registered nurse (RN) staffing in the staffing rating, and a change to the on-site RN threshold.  To incentivize improved staffing, CMS will establish new thresholds for staffing ratings and adjust the rating grid to increase the weight of RN staffing in the star rating.  Details regarding the new thresholds will be included in the “Five-Star Users’ Guide April 2019” in the Downloads section on the Five-Star Quality Rating System webpage.  Perhaps the most drastic change, facilities that report four or more days in a quarter with no RN on site will be automatically downgraded to a one-star rating in the Staffing domain, a change from the previous threshold of seven days, making internal auditing of PBJ reporting even more important.  

The Quality Measure (QM) rating domain will see several changes including: 

  • New QM rating thresholds. Thresholds will be raised, requiring facilities to show greater rates of improvement. Thresholds will also continue to increase by 50 percent every six months going forward, which mean facilities must continue to improve in order to maintain ratings.
  • QM weightings and scoring. QMs will now be identified as “high” weight and “medium” weight. For QMs of high weight, a total of 150 points will be available, awarded in 10-point increments. For QMs of medium weight, 100 total points will be available, awarded in 5-point increments.
  • Separation of short-stay and long-stay ratings. Data from short-stay residents and long-stay residents will be evaluated separately due to the differing needs and care goals of these two populations. Long-stay resident data will now include hospitalization rates and emergency department transfers, but no longer include the use of physical restraints due to consistently high performance by facilities on this measure in the past. Among short-stay resident data, CMS will replace pressure ulcers and successful discharge to community with two similar measures from the Skilled Nursing Facility Quality Reporting Program.  (More detail on the QM article changes in the article below.) 

CMS warns that as a result of these changes, many nursing homes will see a decline in their domain ratings as well as potential for a decline in the Overall Five Star Rating. Additionally, changes may impact participation in programs such as Centers for Medicare and Medicaid Innovation (CMMI) demonstrations and Medicare Advantage plan networks.  LeadingAge will be watching these developments but encourages members to share experiences with us so that we may continue to advocate on your behalf in our regular meetings with CMS.