The Centers for Medicare & Medicaid Services (CMS) announced updates coming in April 2019 to Nursing Home Compare and the Five-Star Quality Rating System. These updates are part of larger efforts over the last several years that include revisions to the inspection process, enhancement of staffing information, and implementation of new quality measures. These changes mean added pressure on nursing homes as the star ratings are often viewed by consumers and referral sources and used as criteria in selecting facilities for participation in value-based payment programs (e.g., 3-star requirement for waiver of three-day hospitalization requirement for Medicare).

Health Inspections

The forthcoming changes include a lifting of the “freeze” on the health inspection ratings. In February 2018, CMS froze the health inspection star ratings category after implementing a new survey process. The freeze was intended to allow all nursing homes to be surveyed at least once under the new survey process so the health inspection rankings in the star rating system would be consistent across all facilities.

An important implication of the lifting of the freeze is that the underlying data that makes up the state averages for the health inspection star rating will now change—possibly significantly in some cases. The state averages set the thresholds for health inspection stars, which are the most heavily weighted component for the overall rating. The degree of potential change in the state thresholds is as yet unknown.

Staffing Levels

A second change is that CMS is setting higher thresholds for nursing homes’ staffing levels. CMS previously found that as staffing levels increase, quality increases, and assigned an automatic one-star rating when a nursing home reports “no registered nurse is onsite” for seven or more days in a quarter.

In April 2019, the threshold that triggers the automatic downgrade to one star will be reduced from seven days to four days without an RN on site in a quarter, increasing the likelihood for facilities to end up with a one-star staffing rating.

In the initially released Star Ratings Technical User’s Guide, it appears the minimum thresholds for RN staffing have been increased by about 15 percent for the four- and five-star staffing rating calculation. This is significant because RN staffing levels are a big driver of overall star ratings. It will be interesting to see if these increased thresholds simply reflect higher underlying staffing or whether CMS is lifting the bar for RN staffing. We’ll know more when the full data comes out by the end of April.

Quality Measures

Finally, the updates also include: adding measures of long-stay hospitalizations and emergency room transfers, removing duplicative and less meaningful measures, and establishing separate quality ratings for short-stay and long-stay residents.

Next Steps

Taken together, these are significant changes that will affect nursing homes all over the country, some of which previously enjoyed high rankings. First, you must understand how these changes are affecting your facility. If you have been downgraded, you need an action plan to drive the star ratings back up, and need to clearly communicate to your referral sources about your plans to do so. In particular, carefully examine your RN staffing to ensure compliance with minimum regulatory requirements, as well as levels of staffing necessary to drive staffing and overall star ratings.

Health Dimensions Group can help assess your operations, including optimal staffing mix and quality improvement. For more information, visit our website or contact us at 763.537.5700 or

 Authored by:
Brian Ellsworth, MA, Vice President, Public Policy and Payment Transformation
Randi Hansen RNC, LNCC, Director of Corporate Compliance & Regulatory Affairs