CMS Changes to Nursing Home Compare and Five-Star Ratings Explained

Angie SzumlinskiCompliance, News

A recent blog post from provides a brief overview of the 2019 changes to Nursing Home Compare and the Five-Star Quality Rating System. Following is a summary of that blog. To read the entire blog, please click HERE.

Health Inspection Domain:
The methodology for the health inspection rating returned to what it was prior to February 2018. Specifically, results from the three most recent standard health inspections and 36 months of complaint inspections will be used to calculate the health inspection score and determine the health inspection rating.

Staffing Domain:
The method by which the RN staffing rating and the total nurse staffing rating are combined is changing to provide more emphasis on RN staffing. The overall staffing rating is assigned based on the combination of the total staffing and RN staffing ratings. The Five-Star staffing category will now be calculated by figuring the total staffing Hours Per Resident Day (HPRD) and RN Staffing HPRD, with CMS prioritizing RN staffing levels by rounding the Five-Star staffing toward the RN Staffing rating.

The threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. Click To Tweet

Previously, facilities that reported seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days.

Quality Measures Domain:
The scoring rules for the quality measures were changed to give more weight to those measures with greater opportunity for improvement. There are also new point thresholds for the overall quality measure rating as well as the short-stay and long-stay ratings. 

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. Measures of long-stay hospitalizations and long-stay emergency department (ED) visits were added to the quality measure rating, and the long-stay physical restraints measure was dropped from the quality measure rating.

How Might Your Rating Be Affected?

Health Inspection Rating Changes:
Health inspection data will be included as soon as they become part of the CMS database so additional inspection data may be added to the database at any time. Events that could change the health inspection score include:

  • A new health inspection;
  • New complaint deficiencies;
  • A second, third, or fourth revisit;
  • Resolution of Informal Dispute Resolutions (IDR) or Independent Informal Dispute Resolutions (IIDR) resulting in changes to the scope and/or severity of deficiencies; or
  • The “aging” of complaint deficiencies. Specifically, complaint investigations are assigned to a time period based on the most recent month period in which the complaint investigation occurred. Thus, when a complaint deficiency ages into a prior period, it receives less weight in the scoring process.

Staffing Rating Changes:
CMS is highly focused on the positive correlation between nursing home staffing levels and resident outcomes. Staffing data are reported quarterly, so new staffing measures and ratings are calculated and posted quarterly. Changes in a nursing home’s staffing measure or rating may be due to differences in the number of hours submitted for staff, changes in the daily census, or changes in the resident case-mix from the previous quarter.

Quality Measure Rating Changes:
A set of quality measures (QMs) has been developed from Minimum Data Set (MDS) and Medicare claims data to describe the quality of care provided in nursing homes. These measures address a broad range of function and health status indicators. Data for the MDS-based QMs and the claims-based hospitalization and ED visit measures are updated quarterly, and the QM rating is updated at the same time. The updates typically occur in January, April, July, and October at the time of the Nursing Home Compare website refresh.