Subject: FW: 5 Star Report- February 2019
From: Kim Grogan <[email-masked]>
To: Kathy Gaughran <[email-masked]>
Date: Tue, 19 Feb 2019 11:06:18 -0500

Hi Kathy,

FYI – please share with whoever needs this info.

Thanks!
Kim

From: Tracie Fairman <[email-masked]>
Date: Monday, February 18, 2019 at 3:25 PM
To: Kim Grogan <[email-masked]>
Subject: FW: 5 Star Report- February 2019 

Good afternoon!

Please see attached 5 star report for February 2019.  Thank you!

A Message from Angela Cooper:

GCHC’s average for February, 2019 is 4.48 out of 5 stars.   Congratulations!     There are no changes from last month.   The next major change will most likely be in April, 2019 which is the next QM and Staffing Rating changes.

The Nursing Home Compare website will be updated to reflect these star ratings next week on Wednesday, 2/27/2019.

There is new data in these reports related to weekday vs weekend staffing levels!   Please see below for further information.

Please remember that the health inspection star ratings are frozen currently and won’t “thaw” until “Spring 2019” per the Provider Rating Reports.   This is all due to the RoP Phase 2 Survey changes.  At this time, we don’t know if CMS  will change back to 3 years of survey data or keep the calculation at 2 years as it is currently (without any survey data since 11/27/2017).

From the February, 2019 Provider Rating Reports:

The February 2019 Five-Star ratings provided above will be displayed for your nursing home on the Nursing Home Compare (NHC) website February 27, 2019. The Quality Measure (QM) Rating that will be posted is based on MDS 3.0 quality measures using data from the fourth quarter of 2017 and first, second and third quarters of 2018, re-hospitalization and emergency department claims-based quality measures using data from 7/1/2017 through 6/30/2018 and the community discharge claims-based quality measure using data from 4/1/2017 through 3/31/2018. The Staffing and RN Staffing Ratings are based on Payroll-based journal staffing data reported for the third calendar quarter of 2018.

Helpline

The Five-Star Helpline will operate Monday - Friday, February 25 - March 1, 2019. Hours of operation will be from 9 am - 5 pm ET, 8 am - 4 pm CT, 7 am - 3 pm MT, and 6 am - 2 pm PT. The Helpline number is 1-800-839-9290. The Helpline will be available again March 25 - March 29, 2019. During other times, direct inquiries to [email-masked] as Helpline staff help respond to e-mail inquiries when the telephone Helpline is not operational.

Important News

As of February 2018, standard surveys and complaint surveys that occurred on or after November 28, 2017 (under the new survey process) have been displayed on the Nursing Home Compare website but  have not been utilized to calculate the health inspection rating. Please watch for additional information in upcoming provider preview reports for the specific methodology that will be used to calculate the health inspection rating once the data from the new survey process are included.

Please note: while the new surveys (on or after November 28, 2017) will not be included in the health inspection rating calculation, there may be slight changes in the total weighted health inspection score for some facilities based on data from older surveys. For cycle 2 complaint surveys only – if the date of a complaint survey is outside of three years from when the data are uploaded then it will be dropped from the system and will no longer be included in the health inspection rating calculation. For the month of February 2019 this would include complaint surveys that occurred in January 2016 or months prior. If the total weighted score for an individual facility changes then it will be compared to the state distribution that month (potentially reflecting a change in the health inspection rating). Please see the health inspection section of this report for more details on the specific surveys used to calculate the health inspection rating for your facility.

This report contains some new staffing information related to weekday and weekend staffing levels for nursing staff. The weekday and weekend staffing levels are provided for informational purposes and will not be displayed on the Nursing Home Compare website at this time. Please see the table located in the Staffing section of this report for the specific data for your facility.

 

Health Inspections

As of February 2018, the Five-Star health inspection rating listed above is based on two cycles of survey data. Cycle 1 (weighted 60%) includes the most recent standard survey that occurred before November 28, 2017 and complaint surveys from November 28, 2016 through November 27, 2017. Cycle 2 (weighted 40%) includes the previous standard survey and complaint surveys that occurred between February 1, 2016 and November 27, 2016. If a complaint survey from cycle 2 occurred in January 2016 or months prior, then it is no longer included in the health inspection rating calculation. Surveys that occurred on or after November 28, 2017 (under the new survey process) will be published on NHC but are not yet being incorporated into the calculation of the Five-Star ratings. Facilities with only one standard survey prior to November 28, 2017 will not receive a rating on the Nursing Home Compare website.

Additional Notes Regarding the Quality Measure Tables

"d<20". For individual quarters for the MDS-based QMs, d<20 means the denominator for the measure (the number of eligible resident assessments) is too small to report. A four quarter average may be displayed if there are at least 20 eligible resident assessments summed across the four quarters.

"NA". "NA" will be reported for quality measures not including in the QM Rating: 1) for which data are not available or 2) for which the total number of eligible resident assessments summed across the four quarters is less than 20.

For measures included in the QM rating, "NA" will be reported if data on this measure for your facility are not used in the calculation of your QM rating. This will happen if your facility does not have enough short-stay or long-stay measures upon which to base your rating and may occur even through your facility's data for this measure is reported on Nursing Home Compare.

Staffing

PBJ data for July 1, 2018 to September 30, 2018 (submitted and accepted by the November 2018 deadline) are being used to calculate the staffing ratings for three months starting with the January 2019 website update. The data listed below include the reported, expected and adjusted staffing levels for your facility, using the PBJ data for July 1, 2018 to September 30, 2018 and the average MDS-based resident census for your facility. The expected staffing values are based on resident acuity levels using RUG-IV data. The Five-Star Rating Technical Users' Guide contains a detailed explanation of the staffing rating and the case-mix adjustment methodology.

Scoring Exceptions for the Staffing Rating

The following criteria have been added to the usual scoring rules for assigning the staffing rating and the RN staffing rating.

1.         Providers that fail to submit any staffing data by the required deadline will receive a one-star rating for overall staff and RN staffing for the quarter.

2.         Providers that submit staffing data indicating that there were seven or more days in the quarter with no RN staffing (job codes 5-7) but on which there were one or more residents in the facility, regardless of reported staffing levels, will receive a one-star rating for overall staff and RN staffing for the quarter.

3.         CMS conducts audits of nursing homes to verify the data submitted and to ensure accuracy. Facilities for which the audit identifies significant discrepancies between the hours reported and the hours verified or those who fail to respond to an audit request will receive a one-star rating for overall staff and RN staffing for three months.

 

Availability of Reported Staffing Data

Some providers will see 'Not Available' for the reported hours per resident per day in the table above and a staffing rating may not be displayed for these facilities. There are several reasons this could occur:

1.         No MDS census data were available for the facility.

2.         No on-time PBJ staffing data were submitted for the facility. As a result, the staffing ratings will be set to one star (unless the facility is listed as 'Too New to  Rate').

3.         The facility had 5 or more days with no nurse (RN, LPN, or nurse aide) staffing hours on days when there were residents in the facility.

4.  The total reported staffing hours per resident per day (HRD) were excessively low (<1.5 HRD).

5.  The total reported staffing HRD were excessively high (>12.0 HRD).

6.  The total reported nurse aide HRD were excessively high (>5.25 HRD).

7.         A CMS audit identified significant discrepancies between the hours reported and the hours verified, or the nursing home failed to respond to an audit request.

8.  Other reason.

Scoring Exceptions for the Staffing Rating

The following criteria have been added to the usual scoring rules for assigning the staffing rating and the RN staffing rating.

4.         Providers that fail to submit any staffing data by the required deadline will receive a one-star rating for overall staff and RN staffing for the quarter.

5.         Providers that submit staffing data indicating that there were seven or more days in the quarter with no RN staffing (job codes 5-7) but on which there were one or more residents in the facility, regardless of reported staffing levels, will receive a one-star rating for overall staff and RN staffing for the quarter.

6.         CMS conducts audits of nursing homes to verify the data submitted and to ensure accuracy. Facilities for which the audit identifies significant discrepancies between the hours reported and the hours verified or those who fail to respond to an audit request will receive a one-star rating for overall staff and RN staffing

for three months.

 

Each Center has a table on their Provider Rating Report that shows comparisons between weekday and weekend staffing as compared to state and nation.

The table below shows the reported nurse staffing for your facility as well as the state and national averages. Although only the overall (All Days) staffing levels are displayed on Nursing Home Compare, the table also shows weekday and weekend staffing levels.   (If you want to see your center’s data, please ask Tracie Fairman to send.)

Please let me know if you have any questions.  I’m happy to help!

Angela Cooper, BSN, RN, RAC-CT

Director of Clinical Services

Gulf Coast Health Care, LLC

Office:  850-430-0096

Cell:  850-602-8010

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