Harmony Healthcare International (HHI) Blog

Five-Star Health Inspections, Staffing (PBJ and CMI), and Quality Measures



Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency • Survey

Kris Presenting Montana-1

Five Star History

Back in December 2008, CMS enhanced the Nursing Home Compare public reporting site to include a set of quality ratings for each nursing home that participates in Medicare or Medicaid.  This Nursing Home Compare website displays a facility “star rating” for the public. 

The goal is to provide residents, families and the public with an easy way to understand nursing home quality and make informed decisions regarding high and low performing facilities.  This is the essence of value-based purchasing (metric, report and a reward).

The Overall Quality Five-Star Rating ranges between of one to five stars is based on the facility’s performance of 3 Domains:

  1. Health Inspections
  2. Staffing
  3. Quality Measures

Each of these Domains utilizes a scoring system of one to five stars, as well.

The interpretation of the Overall Quality Five-Star Quality Rating looks like this:

  • 5-Star rating = “much above average”
  • 4-Star rating = “above average”
  • 3-Star rating = “average”
  • 2-Star rating = “below average”
  • 1-Star rating = “much below average”

This nomenclature is confusing, so be sure to reference each domain when discussing Five-Star. 

For example, be clear when communicating to staff the rating:

“Our Overall Quality Five-Star Rating is a 2-Star,

our Quality Measures Domain is a 3-Star.”

The Formula for Calculating “Overall Quality 5-Star Rating” is as follows with a grid that helps for easy viewing: 

Step 1:  Start with the health inspections domain rating.

Step 2:  Add 1 star if the staffing domain rating is 4 or 5 stars and greater than the health inspections rating.  Subtract 1 star if the staffing rating is 1 star.

Step 3:  Add 1 star if the quality measures domain rating is 5 stars; subtract 1 star if the quality measures rating is 1 star.

Step 4:  If the health inspections domain rating is 1 star, then the overall rating cannot be upgraded by more than 1 star based on the staffing and quality measure ratings.

Step 5:  If a nursing home is a Special Focus Facility (SFF), the maximum overall rating is 3 stars.


Screen Shot 2020-05-29 at 12.18.45 PM


All three domains are complex, and the domain specific rating can be impacted by a multitude of variables.  The purpose of this article is to highlight some areas of opportunity that seem to be consistent across the county. 

1. Health Inspection Domain

  • The Health Inspection domain is the basis for everything.
  • Understand the survey process and be sure to write the Plan of Correction with the Team.
  • In October 2019, this domain underwent some changes including the abuse Icon.
    • Harm Level abuse citation in the most recent survey cycle: (Scope and Severity G or higher) most recent survey or on a complaint survey within last 12 months.
    • Repeat Abuse Citations: (Scope and Severity D or higher) most recent standard survey or complaint survey within last 12 months and on the Previous (2nd most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13-24 months ago).
    • A provider with Abuse Icon health inspection rating will be capped at 2 stars. The best Overall Quality rating is 4 stars.
  • Under the most recent recalibration, within a state:
    • Top 10% of all nursing facilities will receive 5 Stars
    • 33% of all nursing facilities will receive 4 Stars
    • 33% of all nursing facilities will receive 3 Stars
    • 33% of all nursing facilities will receive 2 Stars
    • Bottom 20% of all nursing facilities will receive 1 Star
  • The Health Inspection results scoring rules are assigned to individual health deficiencies according to their scope and severity. More serious, widespread deficiencies receive more points. G-level deficiencies are assigned if the status of the deficiency is “past non-compliance” or the severity is “immediate jeopardy.” 
  • To avoid potential double-counting:
    • If a deficiency appears on both standard and complaint surveys and the complaint survey is conducted within 15 days of the standard survey, it will only be counted once.
    • If scope and severity differ, the highest scope-severity combination is used.
  • The rating for a facility stays the same until there is a change in the weighted health inspection score regardless of the statewide distribution. Items that will change health inspection score include:
    • A new health inspection.
    • A complaint investigation that result in deficiencies.
    • A second, third or fourth
    • Changes in scope/severity of deficiency related to Resolution of an Informal Dispute Resolution or Independent Informal Dispute Resolution
    • “Aging” of complaint deficiencies.
  • The below Scope and Severity grid is well known to the industry, but it is always good to post, educate and share with staff.
Screen Shot 2020-05-29 at 12.32.54 PM

Red Shade Substantial Compliance 

Purple Shade Substandard Quality of Care

  • Points from complaint deficiencies from a given period are added to the health inspection score before calculating revisit points, if applicable. If only two standard surveys are available, the surveys will be weighted at 60% and 40%.
2. Staffing Domain

CMS correlates the relationship between nursing home staffing levels, staffing stability and resident outcomes with the Overall Quality of Care rendered.

  • The rating for staffing domain is based on two case-mix adjusted measures:
    1. Total Nursing Hours Per Resident Day (RN + LPN + Nurse Aide Hours)
    2. RN Hours Per Resident Day
  • The staffing data includes both facility employees (full/part time) and agency staff.
  • Only 11.1% of SNFs received a 5 Star Rating in the staffing domain this past quarter.
  • The below grid provides you with a bird’s eye visual on the calculation for this domain:

  • The below charts (Chart 1 and Chart 2 created by James E. Smerczynski) provides you with the relationship between the:
    • CMI
    • PPD RN
    • PPD Total Nurse Hours
    • Staffing Domain

Chart 1

The below generic chart demonstrates the relationship between RN Hours, Total Hours and the various Five-Star Staffing Domain levels.

Chart 2 

The second graph adds in the Case Mix Index (CMI) variable.  The two lines are the STRIVE correlation. 

The top green line (curve) shows the total hours as a function of CMI.  The bottom yellow line (curve) is the direct relationship between the CMI and the RN Hours PPD.

This suggests if the facility staffs at:

  • 1.049 RN Hours
  • 4.037 Total Hours

Then, the CMI that supports this level would be 2.25. 

  • Do your MDS’s support this case mix?
  • Do you track hours of RN?
  • Do you have respiratory therapy? (Currently, these hours do not count in the calculation, but they really should be included. The industry needs to lobby for this change.)


3. Quality Measure Domain
  • Recently, there was the Removal of 2 Quality Measures:
    • Percentage of short-stay residents who report moderate to severe
    • Percentage of long-stay residents who report moderate to severe
  • Most providers will have three Quality Measure (QM) Ratings
    • Overall
    • Long-Stay
    • Short-Stay
  • There is a total of 15 Measures:
    • 10 MDS Based
    • 5 Claims Based
  • Starting April 2020, every 6 months the QM Thresholds will be increased by half of the average rate of improvement in QM Scores.
    • Intent: Incentivize (CQI) Continuous Quality Improvement And this is what HHI dubs as “Define and Refine” all system at all times.
  • Measures for Long-Stay Residents (defined as residents who are in the nursing home for greater than 100 days) that are derived from MDS Assessments:
    1. Perfect of residents whose need for help with activities of daily living has increased.
    2. Percent of residents whose ability to move independently worsened.
    3. Percent of high-risk residents with pressure ulcers.
    4. Percent of residents who have/had a catheter inserted and left in their bladder.
    5. Percent of residents with a urinary tract infection.
    6. Percent of residents experiencing one or more falls with major injury.
    7. Percent of residents who received an antipsychotic medication.
  • Measures for Short-Stay Residents that are derived from Claims Data:
    1. Number of hospitalizations per 1,000 long-stay resident days.
    2. Number of outpatient emergency department (ED) visits per 1,000 long-stay resident days.
  • Measures for Short-Stay Residents that are derived from MDS Assessments
    1. Percent of residents who made improvement in function.
    2. Percent of SNF residents with pressure ulcers that are new or worsened.
    3. Percent of residents who newly received an antipsychotic medication.
  • Measures for Short-Stay Residents that are derived from Claims Data:
    1. Percent of short-stay residents who were re-hospitalized after a nursing home admission.
    2. Percent of short-stay residents who have had an outpatient emergency department (ED) visit.
    3. Rate of successful return to home and community for a SNF.



Be sure to audit all aspects your facility Overall Quality 5-Star Rating on an ongoing basis. Harmony Healthcare International (HHI) can help you in any of the domains.  Call us at 617.595.6032.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

 harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Five-Star

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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