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Nursing homes subject to one star rating if they go more than four days without an RN onsite

CMS is also establishing separate quality ratings for short-stay and long-stay residents.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services is updating the nursing home compare and the five-star quality rating system by dropping the threshold for RN staffing from seven to four days, adding a measure for hospitalizations among long-stay residents and lifting the freeze on health inspections.

The changes go into effect in April.

Currently, facilities that report seven or more days in a quarter without a registered nurse onsite are assigned a one-star staffing rating. Starting next month, it will only take four days to trigger the automatic downgrade to one-star.

CMS is also establishing separate quality ratings for short-stay and long-stay residents and is revising the rating thresholds. The agency is adding measures of long-stay hospitalizations and emergency room transfers and is removing duplicative and less meaningful measures, CMS said.

It is lifting a freeze on health inspection star ratings. The freeze has been in effect since February 2018, to avoid facilities from being scored using two different evaluation processes, one old and one new.

CMS had implemented a new process for onsite surveys by state survey agencies. Because these are done at different times, CMS wanted to give time for all of the facilities to get caught up to the new process for compliance. 


Nurse staffing has the greatest impact on the quality of care nursing homes deliver, CMS said. In analyzing the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases.

Inspections include the findings on compliance to Medicare and Medicaid health and safety requirements.

The quality of resident care measures are based on resident assessment and Medicare claims data. The added quality measures are consistent with the meaningful measures initiative.


The April 2019 updates to nursing home compare are part of a broad range of updates that have been under development for the last several years.

Nursing home compare has a quality rating system from one to five stars. A five is above-average quality and a one reflects below-average quality.

Each nursing home is rated and a separate rating is given for health inspections, staffing levels and quality measures.

Other periodic improvements include when, in 2012, CMS enhanced the design and usability of the website while incorporating new information.

In 2015, the compare site included measures on the use of antipsychotic drugs in the ratings' calculation and adjustments to the quality measures and staffing ratings' methodology.

Most recently, in 2018, CMS replaced the self-reported staffing data with data collected electronically through the Payroll-Based Journal (PBJ) system, which provides insight into the staffing of nursing homes.


"CMS is committed to safeguarding the health and safety of nursing home residents by ensuring they are receiving the highest quality of care possible," said CMS Administrator Seema Verma. "Our updates to nursing home compare reflect more transparent and meaningful information about the quality of care that each nursing home is giving its residents."

Twitter: @SusanJMorse
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