Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
The actual subject title of QSO-20-34-NH is this:
Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star Quality Rating System due to the COVID19 Public Health Emergency
That’s a mouthful. Here’s the CMS-provided summary of its contents:
I’m going to point out first that CMS is ending the PBJ submission waiver. This is a critical action you need to be aware of! YOU MUST SUBMIT PBJ DATA FOR CALENDAR QUARTER 2 BY AUGUST 14, 2020. Keep reading…
CMS encourages nursing homes to submit data for Calendar Quarter 1 (January – March) 2020. Calendar Quarter 1 data will not be used to calculate staffing measures or ratings; however, CMS will continue to post the data in a public use file on data.cms.gov. Note: Because the waiver is being lifted, staffing measures and ratings will be updated in October 2020 based on data submitted by August 14, 2020.
With the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, CMS waived the requirements at 42 CFR 483.70(q), which require nursing home providers to submit staffing data through the Payroll-Based Journal (PBJ) system. Because of the waiver, many facilities did not submit staffing data, and thus, CMS will not be able to update the PBJ staffing measures and staffing domain star ratings at the next regularly scheduled update in July 2020. Of note, approximately 60% of facilities still submitted their data (kudos to you from me!).
Therefore, on July 29, 2020, staffing measures and ratings will be held constant, and based on data submitted for Calendar Quarter 4 (October – December) 2019. In addition, (CMS) recognizes that the waiver of the requirement prevented some facilities from improving their rating from their previous quarter’s submission. Specifically, facilities whose staffing rating was automatically downgraded to one-star due to missing the deadline for the previous submission, or for reporting four or more days in the quarter with no registered nurse, now will not have the opportunity to correct and improve their staffing rating since the ratings will be held constant. Therefore, CMS will remove the one-star staffing rating downgrade, and instead, these facilities will have their measures and ratings temporarily suppressed.
Here are the additional, important changes for you to review:
- The MDS waiver (completion & submission) related to the PHE also created some issues for data. CMS believes that data from resident assessments conducted prior to January 1, 2020, can still be used to calculate quality measures. However, CMS is concerned that data from resident assessments conducted after January 1, 2020 are impacted by the waiver and the PHE. Therefore, beginning July 29, 2020, quality measures based on data collection period ending December 31, 2019 will be held constant.
Quality measures that are based on a data collection period prior to December 31, 2019 (e.g., ending September 30, 2019); however, will continue to be updated until the underlying data reaches December 31, 2019. CMS is not holding quality measure ratings constant, as a facility’s quality measure rating can still be updated by a quality measure with underlying data that is earlier than December 31, 2019.
- CMS continues to monitor inspections, including the restarting of certain inspections (i.e., surveys) per CMS memorandum QSO-20-31-ALL. CMS will restart the inspection ratings as soon as possible and will communicate any changes to stakeholder in advance of updating the Nursing Home Compare website.
The Press Release announcing the plans to end the emergency blanket waiver requiring all nursing homes to resume submitting staffing data through the Payroll-Based Journal (PBJ) system by August 14, 2020 can be viewed here.
I strongly encourage you to share this memorandum with your team and especially those colleagues charged with PBJ reporting. August 14th is about 1.5 months from now and you know how fast summer goes by!