Published April 11, 2018

Five Star Staffing Rating: The Transition to PBJ

Last week, CMS sent out a memorandum to State Survey Directors providing much anticipated information on the transition to Payroll Based Journal (PBJ) Staffing Measures on the Nursing Home Compare Five Star Rating. Facilities have been submitting staffing data electronically through PBJ since July 2016 and many have anxiously awaited this change in hopes of a more accurate staffing star rating than the current method produced from the CMS 671 & 672 during annual survey.

In this memorandum, CMS reminds providers of the significance of staffing in nursing homes and the direct relationship between staffing, RN staffing and quality of care and resident outcomes. Historically, staffing data has been provided at the time of standard survey. The method used to provide this data typically involves a frenzied attempt day one of DOH survey to manually tally up hours worked over the past 14 days, as well as provide census data for that day. Here’s the problem, you are stuck with the staffing star rating produced by this methodology until your next survey.

PBJ data is submitted quarterly, it is verified by payroll (and other sources), it will result in a more accurate depiction of staffing patterns overtime and will allow quarterly updates to the staffing star ratings. Through PBJ, the sum of hours for each job category (i.e. RN, LPN, CNA) for each day of the quarter will be divided by the sum of each day’s census to give Hours Per Resident Per Day (HPRPD). Similar to the current methodology, the HPRPD will be adjusted based on expected staffing levels given a facilities census and acuity level. However, CMS announced in this memorandum that to set this adjusted level they will update the staffing domain rating methodology using RUGs IV criteria. With this new risk adjustment, CMS will establish new rating thresholds based on the existing distribution of ratings among facilities. More details will be made available by CMS some time on or before May 1, 2018 in the Technical Users Guide found through Medicare.gov. 

Here’s what we do know:

• When reporting hours worked through PBJ, do not count meal breaks, paid or unpaid.

• Each employee must have their own ID number.

• Submit MDS’s timely, including discharge assessments. Facility census will be calculated using this MDS data.

• Do not count hours worked for staff providing care to patients in non-certified areas/beds.

• CMS will continue to audit this area so respond promptly to audit requests.

• Facilities found to have significant discrepancies between submitted and verified hours will be presumed to have lower staffing levels and will result in a one star staffing rating, which will reduce facilities overall star rating by one star for a quarter.

• CMS requires RN staffing for a minimum of 8 consecutive hours per day, 7 days per week. Therefore, facilities reporting 7 or more days per quarter with no RN hours will receive a one star staffing rating dropping their overall rating by one star. This action will be implemented in July 2018 after the May 15th submission deadline for first quarter staffing data.

Future CMS plans include:

• Beginning June 1, 2018, the CMS 671 staffing portion will no longer be required. The form will ultimately be revised and all other data fields on the CMS 671 will still need to be completed (i.e. address, ownership type, etc.).

• CMS’s Public Use Files (PUF) are posed and contain information on nursing hours and census data. CMS plans to add other data elements to this file (i.e. therapy hours worked).

• CMS plans to add other staffing measures, i.e. staff turnover, with the goal of posting information stakeholders can use to better understand the type of care and quality that nursing homes provide.

What facilities can do:

• Run and review CASPER Reports prior to PBJ submission, before quarterly deadlines and ensure accuracy.

o 1700D Employee Report

o 1702D Individual Daily Staffing Report

o 1702S Staffing Summary Report

• Stay informed! CMS will continue to provide guidance through stakeholder calls (SNF Open Door Forum) and memoranda.

• Facilities can contact CMS if they require technical support or find errors in their data at NHstaffing@cms.hhs.gov

Contact us if you have questions or need assistance with your PBJ staffing data or to identify opportunities to enhance or sustain your staffing Five Star Rating on NHC.

Sarah Ragone, MSPT, RAC-CT
VP of Reimbursement and Education