On Feb. 20, 2015, the Centers for Medicare & Medicaid (CMS) unveiled Version 3.0 of its Nursing Home Compare, which updates the current 5-Star Quality Rating System to reflect higher performance standards. Because of these changes, not only will it will be increasingly difficult for nursing homes to earn the much-desired four-star and five-star ratings, but also the ratings for many nursing homes may immediately fall by one or more stars. Further, the changes will also result in more survey citations for unnecessary psychotropic medication, inadequate staffing, poor resident assessment and, in all likelihood, increase civil liability.

Through the 5-Star Quality Rating System, CMS gives nursing homes up to five stars based on: (1) onsite inspections from state public health departments and CMS; (2) various quality measures, which assess patient health outcomes and processes of care; and (3) staffing levels. Industry stakeholders and the public look to a nursing home's star rating as a way to measure overall quality.

In updating the rating system, CMS has made the following changes:

• Rise in Performance Expectations. CMS raised the threshold for nursing homes to achieve a high score on quality measures.

• Addition of Two Quality Measures for Antipsychotic Medication Use in Nursing Homes. In a further attempt to reduce the inappropriate use of antipsychotic medications for nursing home residents, CMS has added two new quality measures that track antipsychotic medication use for residents without diagnoses of schizophrenia, Huntington's disease, or Tourette syndrome. One quality measure applies to short-stay residents, measuring when a nursing home begins to use antipsychotics for residents, and the other quality measure applies to long-stay residents, measuring the continued use of antipsychotics for residents.

• Adjustment to Staffing Algorithms. CMS adjusted the staffing algorithm it uses in assigning ratings to more accurately reflect staffing levels. To receive four stars on the overall staffing rating, nursing homes must now earn four stars on either the individual Registered Nurse only category or the other staffing category, or no less than a three-star rating in other staffing categories.

• New Payroll-Based Staff Reports. CMS announced that it is implementing a new quarterly reporting system for staffing levels. CMS will use the data collected under this new system to calculate quality measures for staff turnover, retention, and types and levels of staffing. To verify staffing information, these reports will be auditable back to a nursing home's payroll. CMS will begin collecting information under the new system with some nursing homes in 2015 and all nursing homes will be required to report by the end of 2016.

• Expansion of Targeted Surveys. CMS announced it will create a plan for State Survey Agencies to conduct specialized, on-site surveys of a sample of nursing homes across the United States. In addition to evaluating the adequacy of resident assessments, the surveys will also assess the accuracy of information reported to CMS by nursing homes that CMS then uses to calculate a nursing home's quality rating.

Increase in Survey Citations

These changes will inevitably lead to increased scrutiny and citations by surveyors during annual and complaint surveys. Facilities should pay particular attention to their use of psychotropic drugs (F309 and F329), resident assessments (F279), and staffing (F353 and F520). Specifically, surveyors will be examining the use of psychotropic medication to determine if: (1) there is a valid medical diagnosis to support the order for the psychotropic medication (including the use of two psychotropics); (2) there is evidence that the physician reviewed the risks and side effects of the psychotropic medication and determined that the medication was clinically necessary; (3) nursing homes are properly documenting behaviors related to the diagnosis and the effect of the psychotropic medication; and (4) nursing homes have attempted to eliminate or reduce the dosage of psychotropic medication. With regard to resident assessments, surveyors will be conducting comprehensive reviews of the adequacy of resident assessments as well as the accuracy of resident quality data. Likewise, expect surveyors to scrutinize facility staffing resulting in allegations of insufficient staffing and inaccurate reporting to CMS.

Increased Civil Liability

Nursing homes will face a difficult balancing act as they seek to reduce the use of "unnecessary" psychotropic medications, while preventing other residents from being injured by residents with aggressive behaviors. These behaviors may increase as a result of dosage reductions or the discontinuation of psychotropic medication. Also, plaintiffs' attorneys will certainly be looking forward to using government allegations of inadequate staffing to bolster their portrayals of nursing homes as heartless profit centers in their cases.

What Providers Should Do

• Review the facility policy on the use of psychotropic medication and ensure that it requires that: (1) all orders for psychotropic medication are supported by a medical diagnosis; (2) all orders include documentation of a consideration of the risks and side effects of using the psychotropic medication; (3) behaviors associated with the diagnosis are properly documented; and (4) there is a program to reduce the dosage of psychotropic medications.

• Audit the records of all residents with orders for psychotropics (including physician orders and the Medication Administration Record) to ensure that the record supports the need for the medication and the dosage. Particular attention should be paid to whether side effects are being documented and properly reported to the attending physician.

• Review the care plans for residents on psychotropic reduction plans to ensure that appropriate monitoring is in place to prevent resident injury due to increased aggressive behavior.

• Review all staffing information to ensure that all information being reported to CMS is accurate.

• Review the facility's process for assessing residents and the audit sample of resident assessments to ensure that they are timely and comprehensive.

What Providers Should Know

• Nursing homes must prepare for the possibility that their scores may decrease as a result of updates to the rating system. Nursing homes that experience an initial decrease in their ratings should explain to residents, families, and staff the reasons for the decrease. In particular, the nursing home should make clear that the decrease does not mean the nursing home's quality of care has suffered, or changed at all. Proper explanation now will avoid confusion later.

• In anticipation of new quality measures related to staff turnover, retention, and types and levels of staffing, nursing homes should begin to analyze available staffing data now and proactively identify areas needing improvement.

• CMS anticipates that scoring for quality measures will be further adjusted in the coming years. Providers must be able to raise their scores on quality measures as star-ratings become more difficult to achieve.

For More Information 

The Advisory Opinion (No. 14-01) can be found here.