Final Updates From CMS: PBJ Data's Use In Five-Star Ratings

The Centers for Medicare & Medicaid Services (CMS) has announced it will start utilizing Payroll-Based Journal (PBJ) data to calculate the staffing measure rating for the Five-Star Quality Rating System in a recent memo.

It is critical that all skilled nursing providers are aware of these change and read CMS' new Payroll-Based Journal Technical Guide. Here are the details: 

Changes Effective April 2018

Beginning in April 2018, CMS will utilize PBJ data to calculate the staffing measure rating for the Five-Star Quality Rating System, which will be posted on Nursing Home Compare on the last week of the 2nd month following submission deadline. 

CMS will utilize calendar Q4 2017 data within PBJ report submissions and publish four measures on Nursing Home Compare, including:

• RN Hours Per Resident Day:
• Includes RN director of nursing (job code 5), registered nurses with administrative duties (job code 6), and registered nurses (job code 7)
• Total Nursing Hours Per Resident Day
• RN hours: Includes RN director of nursing (job code 5), registered nurses with administrative duties (job code 6), and registered nurses (job code 7)
• LPN hours: Includes licensed practical/licensed vocational nurses with administrative duties (job code 8) and licenses practical/vocational nurses (job code 9)
• Nurse aide hours: Includes certified nurse aides (job code 10), aides in training (job code 11), and medication aides/technicians (job code 12)
  
• Physical Therapist Hours Per Resident Day
  
  
• Average Daily Census

Calculating Five-Star Staffing Rating

The HPPD measures for nursing staff, RNs and physical therapists will be calculated by summing the number of hours for the relevant job categories submitted for each day of the quarter, and then dividing by the sum of each day's census within the same quarter. Resident census is now derived from the facility MDS submissions and not the previously required census on the last day of the month.*  The staffing measure rating is calculated by adjusting the HPPD based on the expected level of staff needed given the number and acuity of the residents in the facility.

*Note: Submitting timely and accurate MDS discharge assessments is key to having an accurately reported census. The CMS algorithm for calculating census will assume that a resident with a missing discharge assessment stayed in the facility 150 days after the last non-discharge assessment, which may lead to many centers having artificially inflated census numbers, lowering HPPD.

Switching To RUG-66 Staffing Risk Adjustment

The HPPD measures used in Five-Star ratings will continue to be risk adjusted to account for differences across facilities' resident acuity. CMS will move to using RUG-66 from RUG-53 to calculate the adjusted staffing levels. The new cut points are below.

Upcoming Penalties: April 2018 & Beyond

Significant Inaccuracies And/Or Failure To Submit PBJ Data

Providers whose audits show significant inaccuracies between hours reported and verified or those who fail to submit data by the PBJ reporting deadlines will have a one-star rating on the staffing domain, which will result in a drop by one star in their overall Five-Star rating.

Through their contractors, CMS started conducting audits of facilities where issues were identified, such as an employee working more than 300 hours in a month, etc. Based on the audits that CMS has conducted, the following five items were identified as common errors found.

1. Per the PBJ Policy Manual, providers are required to exclude meal times for employees' daily hours**
2. Providers must assign a unique identifier for each employee
3. For accurate census calculations, providers must submit timely and accurate MDS assessments for every resident in the facility
4. Providers must exclude time that staff spend providing care to individuals in non-certified beds
5. If a provider receives an audit, they must promptly respond to it

**Note: Providers who give their employees a paid meal break and then include those hours in their PBJ submission because they expect employees to ‘work’ during a compensated meal break are being flagged as non-compliant.

Reporting Zero RN Hours For Seven Or More Days In A Quarter

Similarly, those facilities that report seven or more days in a quarter with no RN hours will have a one-star rating on the staffing domain, which will result in a drop by one star in their overall Five-Star rating. This enforcement will start in July 2018, after the May 15, 2018 submission deadline for the first calendar quarter of 2018.

Prior to the July date, facilities that report seven or more days in a quarter with no RN hours will have an icon placed next to their name on Nursing Home Compare.

Why Staffing Ratings Show As 'Not Available' On Nursing Home Compare

Some providers may see 'Not Available' for the reported staffing hours. There are six reasons a staffing rating will not be calculated:

• No MDS census data were available for the facility
• No on-time PBJ nurse 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’)
• The facility had 5 or more days with no nurse staffing (on days when there were residents in the facility)
• The total reported staffing hours per resident per day (HPRD) were excessively low (<1.5 HPRD)
• The total reported staffing HPRD were excessively high (>12.0 HRD)
• The total reported nurse aide HPRD were excessively high (>5.25 HPRD)

Form-671 Discontinued Starting June 2018

Starting on June 1, CMS will stop requiring providers complete the staffing portion (page 2) of CMS Form-671.

Turnover Reporting On CMS’ Radar

CMS continues to say that at a future date they will start to report turnover and retention percentages.  The details and specific timing are yet to be determined. 

OnShift will continue to work with CMS and state and national provider associations to keep you apprised of PBJ developments as they occur. Our goal is to assist you in any way that we can and make this transition as easy as possible.