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Are Your Stars in Alignment?

CMS 671 & 672: Data Accuracy and Their Role in the Five-Star Quality Rating System

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Today’s Star Chart

►Introductions

►Overview of Today’s Program

►Coding and auditing Forms 671/672

►Investigating the impact of Forms 671/672 on CMS’

Five-Star Staffing Score

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Welcome and Introductions

►Jean Scott, Dr.PH, RN, Technical Director, CMS/CMSO/SCG Division of Nursing Homes

►Nancy Augustine, RN, MSN, NHA, Director of Quality Improvement and Risk Management, PointRight Inc.

►Steven Littlehale, MS, GCNS-BC, Executive Vice President Chief Clinical Officer, PointRight Inc.

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Today’s Objectives

1.

Accurately code forms

671 and 672, and audit for accuracy

2.

Review how 671/672 data contributes to CMS’s Five-Star Staffing score

3.

Articulate how Five-Star staffing data impacts overall Five Star score

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Today’s Objectives

1.

Accurately code forms 671 and 672, and audit for accuracy

2.

Review how 671/672 data contributes to CMS’s Five-Star Staffing score

3.

Articulate how Five-Star staffing data impacts overall Five Star score

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What is the CMS 672?

►The CMS 672, Resident Census and Condition of Residents, reports:

The total census at the time of surveyCurrent condition of residents at the time of survey

►“Facility”

defined as any bed that is Medicare and/or Medicaid certified

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What is the CMS 672?

►“Residents”

defined as residents in certified beds at the time of survey

►Total residents = all residents in Medicare and Medicaid certified beds + the number of residents with a bed hold

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CMS 672 Accuracy

►Incorrectly gathering and reporting the census on the CMS 672 may impact the staffing component of Five-Star

If the census is overstated and staffing is reported correctly, potentially, the staffing level might be under reportedIf the census is understated and the staffing is reported correctly, potentially, the staffing might be over reported

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What is the CMS 671?

►

CMS 671, Long Term Care Facility Application for Medicare and Medicaid

Completed by every facility that participates in the Medicare and Medicaid programs at the time of every standard/annual surveyConsists of two pages◊

First page collects facility specific information related to type of services provided and facility characteristics

◊

The second page is all about staffing

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Form 671 Hour Breakdown

►

Full-time hours need to be reported separately from part-time hours and contract hours

►

Full-time hours are defined as 35 hours or more per week and excludes meal breaks of a half hour or more

►

Contract Staff includes staff not necessarily on the facility payroll but may be under contract by the organization to provide specific services

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671 Definition of Services (Staff)

►Examples of Staff included:RN hours: Includes registered nurses F41, RN Director of Nursing F39, and Nurses with administrative duties F40LPN hours: Includes licensed practical/licensed vocational Nurses F42Nurse aide hours: Includes Certified Nurse Aides F43, aides in training F44, and medication aides/technicians F45

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671 Definition of Services (Staff)

►Staff not included:“Private duty” nursing staff who are reimbursed by a resident’s familyHospice staff and feeding assistantsVolunteers

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Staff Collection for the 671

►

Facility staff hours defined as actual hours worked in a 2-week pay period

To include: overtime calculationsNot to inlcude: non-work related hours and leaves, nonproductive work hours

►

Use worked time information only, preferably from a payroll run or automated time keeping system

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Staff Collection for the 671

►

“Contract Hours”

(column D) collects any agency/contract staff for the same 2-week pay period

Payroll data will not capture contract staff hours

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Staff Collection for the 671

►

Staffing data collected for the 14-day period prior to the survey date

Adhere to the 14-day period regardless of the facility’s standard pay periods

Is your payroll is weekly, bi-weekly or monthly?

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Staff Collection for the 671

►

If the employee provides service in more than one capacity (job category), separate the hours by each service performed, for example:

CNA works 50 hours as a CNA and 30 hours as an Activity AideThe information should be correctly allocated to the CNA F43 and Other Activities Staff F60columns

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Staff Collection for the 671

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Correct Facility Example

► “Correct”

Case example:RN Director of Nursing: 84 hoursNurses with Admin duties – RN, LPN, LVN: 256 (includes, Staff Development position, MDS Coordinator, Nursing Supervisors)Registered Nurses: FT – 280; PT – 56; Contract - 120Licensed Practical/Vocation Nurses: FT – 1200; PT – 256Certified Nursing Aides: FT – 5200; PT – 736Nurse Aides in Training: FT – 320Medication Aides/Technicians: FT - 224

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Correct Facility Example

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Incorrect Facility Example

► Incorrect Case example:RN Director of Nursing: 84 hoursNurses with Admin duties – RN, LPN, LVN: 0 (includes, Staff Development position, MDS Coordinator, Nursing Supervisors)Registered Nurses: FT – 656; PT – 56; Contract - 0Licensed Practical/Vocation Nurses: FT – 0; PT – 256Certified Nursing Aides: FT – 5520; PT – 736Nurse Aides in Training: 0Medication Aides/Technicians: FT - 224

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Incorrect Facility Example

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Who should complete the CMS 671?

►

A person with the ability to provide the detail needed and who knows where to retrieve accurate information

►

The Administrator should review the form before it is signed

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Ensuring CMS 671 Accuracy Consistency

►Align job positions with definitions for the positions identified

Example: provide a guide that identifies the facility job positions and the crosswalk to the CMS 671, MDS Coordinator – F40

►Ensure an automated method or good manual method to capture and track worked hours on a daily basis

►Assign completion of the 671 to a person that understands how to collect the requested staffing information

►Check/audit the entries on the form before they are given to the surveyors

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Ensuring CMS 671 Accuracy Consistency

►

Check Nursing Home Compare (NHC) or your state website for data accuracy

ALERTS:◊

Some facilities may have no staffing data reported ◊

CMS applies “exclusion”

criteria to identify facilities with unreliable data or outlier staffing levels

►

Compare other support documents with the CMS- 671

Double check/verify staffing entriesSample one category and compare time card entries with the hours on the CMS-671Calculate the nursing hours from the CMS 671 and compare to other in-house nursing hour calculations

Questions You Have Asked CMS

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Questions for CMS

► If someone from corporate is at my facility performing activities that fit into a job category as defined in the CMS-671, then their hours could be included? If yes, does the corporate person need to be on facility’s payroll?

►How does information get from State to OSCAR database and what about quality control?

► Is there a process for correcting staffing data in the database?

Does the process differ if it was an entry error made by survey team verses facility filling out the form?

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Questions for CMS

►I just heard that Hospice staff cannot be included in 671. I need to confirm that this is true. Is there a way to include them?

►When we complete the 672 do we only count “heads in the bed”

or do we need to include

those residents out of building but with a “bed hold”?

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Questions for CMS

►I have a “Vent Unit”

and my respiratory therapists are critical to the care that is provided. How can I get them included in the Star Rating?

►We employ what we call “Universal Workers” who are cross trained as CNAs. How can we

account for their hours?

Five-Star Staffing Domain

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Today’s Objectives

1.

Accurately code form 671 and 672 and audit for accuracy

2.

Review how 671/672 data contributes to CMS’s Five-Star Staffing score

3.

Articulate how Five-Star staffing data impacts overall Five Star score

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Five Star Staffing

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What is Five-StarOverview

Components of Five-Star◊

Survey◊

Staffing◊

Quality

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“The primary goal (of Five-Star) is to provide residents and their families with an easy way to understand assessment of nursing home quality, making meaningful distinctions between high and low performing nursing homes.”

CMS’s Technical Users’

Guide July 2009

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Five Star Staffing

►

What is Five-StarOverview

Components of Five-Star◊

Survey◊

Staffing◊

Quality

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Staffing Domain

►Studies describe the relationship between nursing home staffing levels, staffing stability, and resident outcomes

►A CMS Staffing Study found a clear association between Nurse staffing ratios

and

nursing home quality of care, identifying specific ratios of staff to residents below which residents are at substantially higher risk of quality problems

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Two Measures Comprise the Staffing Domain

►

The Five-Star Rating for staffing is based on two case-mix adjusted

measures:

1.

Total nursing hours per resident dayRN + LPN + Nurse Aide hours

2.

RN hours per resident day

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Only Specific Staff are Counted in the Staffing Domain►

Nurse aide hours:

Includes certified Nurse aides F43Aides in training F44Medication aides/technicians F45

►

LPN hours: Includes licensed practical/licensed vocational Nurses F42

►

RN hours:Includes Registered Nurses F41RN Director of Nursing F39Nurses with administrative duties F40

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Review of Staff Who are Included in Five-Star

►Who is Counted?OSCAR (671) staffing data include both facility employees (full time and part time) and agency staff

►Who is NOT Counted?The OSCAR staffing data does not include “private duty” nursing staff who are reimbursed by a resident’s familyAlso not included are hospice staff and feeding assistantsTherapy, therapy aides, social services, recreational therapy

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Ultimately the Staffing Domain Speaks to the Proportion of Staff to Residents

►“…per resident day”Resident census used in the denominator of the staffing calculations is pulled from F78 of CMS-672 form. This includes:◊

Total number of nursing facility’s certified Medicare or Medicaid beds that are occupied

•

Either currently occupied or,•

On a bed hold

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Form 672 Tells Us About Your Residents

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Quick Review

►From the 671 we know about facility’s staff

►From the 672 we know about resident census

►From these data we can calculate the amount of staff hours (or minutes) provided on average to each resident in the facility

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Quick Review

►From the 671 we know about facility’s staff

►From the 672 we know about resident census

►From these data we can calculate the amount of staff hours (or minutes) provided on average to each resident in the facility

But Do All Residents Require the Same Amount of Nursing and Nursing Assistant time?

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Not All Residents are the Same

►

Staff/Resident Ratios are adjusted based on residents’

case-mix

►

To do this CMS uses:1.

Resource Utilization Group (RUG-III) case-mix system

2.

CMS Staff Time Measurement Studies Measure the number of RN, LPN, and nurse aide minutes associated with each RUG-III group

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Staff/Resident Ratios are Adjusted

►Case-mix adjusted measures of “hours per resident day” are calculated for each facility for each staff type using this formula:

Hours Adjusted =(Hours Reported /

Hours Expected) x

Hours National Average

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Staff/Resident Ratios are Adjusted

►Hours National Average

is the mean across all facilities for a given staff type.

►Hours Expected

are based on the distribution of residents by RUG-III group in the quarter closest to the date of the most recent standard survey.

How does CMS know about your residents’ case-mix?

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Staff/Resident Ratios are Adjusted

►Hours National Average

is the mean across all facilities for a given staff type.

►Hours Expected

are based on the distribution of residents by RUG-III group in the quarter closest to the date of the most recent standard survey.

How does CMS know about your residents’ case-mix?

The distribution of residents by RUG-III group is determined using the most recent MDS assessment for current residents of the nursing home on the last day of the quarter.

Hours Adjusted = (Hours Reported /Hours Expected ) * Hours National Average

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Hours Expected

►Sum the nursing times (from the CMS Time Study) connected to each RUG category across all residents in the category and across all categories.

►The hours are then divided by the number of residents reported though your MDS data for that time period.

►The result is the “expected”

number of hours for the nursing home.

Hours Adjusted

= (Hours Reported

/Hours Expected

) * Hours National Average

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National Average

►“National average”

hours represent the unadjusted national mean of the reported hours across all facilities for December, 2008.

►These national averages will be held constant for an initial two-year period, after which CMS will review this decision.

Hours Adjusted

= (Hours Reported

/Hours Expected

) * Hours National Average

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National Average

National average hours per resident per day

Total nursing staff 3.83862

Registered nurses 0.63989

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Other

►A set of exclusion criteria are used to identify facilities with unreliable OSCAR staffing data.

►Neither staffing data nor a staffing rating are reported for these facilities.

►August 09 Five-Star data revealed624 of 15,713 facilities (4%) did not have a star rating for staffing. Of the 624, 163 did not have ANY star rating identified.

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Calculating a Staffing Score

►Total nursing hours per resident day and RN hours per resident day are given equal weight

►For both measures a 1 to 5 rating is assigned based on a combination of the percentile-based method

Percentiles are based on the distribution for freestanding facilities and staffing thresholds identified in the CMS staffing studyFor each facility a total staffing score is assigned based on the combination of the two staffing ratings

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Scoring Method and Thresholds for Staffing Measures

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Scoring Method and Thresholds for Staffing Measures

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Scoring Method and Thresholds for Staffing Measures

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Getting to a STAR

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Getting to a STAR

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Today’s Objectives

1.

Accurately code forms 671 and 672, and audit for accuracy

2.

Review how 671/672 data contributes to CMS’s Five-Star Staffing score

3.

Articulate how Five-Star staffing data impacts overall Five Star score

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Today’s Objectives

1.

Accurately code forms 671 and 672, and audit for accuracy

2.

Review how 671/672 data contributes to CMS’s Five-Star Staffing score

3.

Articulate how Five-Star staffing data impacts overall Five Star score

What Role Does Staffing Domain Play in Overall Nursing Home

Five-Star Rating?

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Step 1:Start with Initial Health

Inspection Rating.

Step 2:If you Staffing Rating

is equal to…

Add 1 Star to Overall

Overall No Change

Minus 1 Star to Overall1

2 or 3

4 or 5 and > health inspection rating

Step 3:If your QM Rating

is equal to…

Add 1 Star to Overall

Overall No Change

Minus 1 Star to Overall

5

2, 3 or 4

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Step 4:If you Health Inspection Rating

is equal to…Limit Overall to 2 Stars

Overall No Change2, 3, 4 or 5

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Step 5:If Facility is a Special Focus Facility (SFF)…

Limit Overall to 3 Stars

Overall No Change

Yes

No

Questions You Have Asked CMS

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Questions for CMS

►How will the new updated STRIVE study impact Five Star Staffing Domain?

► I haven’t had a survey in a while but my staffing rating has changed. How can that be?

►My DON was out for the two weeks that are included on my 671. How can I make my 671 (and Staffing Star) look reasonable?

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Conclusion

►Understand the written directions for completing 671/672 as provided by CMS

►Don’t confuse your facility’s policies and folklore with CMS 671/672 coding definitions

►The Five-Star Staffing Domain is mostly influenced by self-reported data

►Step One is to ensure accuracy of your staffing data►Step Two is to respond to these findings with

possible changes to staffing practices

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Contact Information

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Email Questions to CMS: Bettercare@cms.hhs.gov

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Email Questions to AHCA:Lyn Bentlylbentley@AHCA.org

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Email Questions to PointRightEmail Nancy AugustineNancy.Augustine@pointright.comEmail Steven LittlehaleSteven.Littlehale@pointright.com

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CMS Five-Star Webpagehttp://www.cms.hhs.gov/CertificationandComplianc/13_FSQRS.asp

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CMS Formshttp://www.cms.hhs.gov/CMSForms/CMSForms/