Stars for Staffing

CMS released revisions to the staffing methodology in July through an updated Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users’ Guide July 2022. The staffing star rating includes expanded from two to six compenents and introduced a new scoring calculation. 


The updated Five Star rating is calculated from the following six staffing measures… 

  • Case-mix adjusted total nurse (RN, LPN/LVN, aide) staffing levels (hours per resident per day)  
  • Case-mix adjusted RN staffing levels (hours per resident per day)  
  • Case-mix adjusted total nurse (RN, LPN/LVN, aide) staffing levels (hours per resident per day) on the weekend  
  • Total nurse turnover, defined as the percentage of nursing staff that left the nursing home over a twelve-month period  
  • Registered Nurse (RN) turnover, defined as the percentage of RN staff that left the nursing home over a twelve-month period  
  • Administrator turnover, defined as the number of administrators who left the nursing home over a twelve-month period  


Each measure is assigned points “based on the performance” by the facility, then the points from the six measures are summed. The summed score makes up the organization’s “total staffing score.” The total staffing score is “compared to staffing rating point thresholds to assign a rating of one to five stars.” The revised staffing measure compilation mirrors the quality measure star rating in configuration.  


Another change is the impact of the staffing star rating on the overall Five Star for an organization. The staffing star rating needs to be a five-star to potentially add a star to the organization’s overall rating (unless already at an overall five-star). This is a change from prior rules, when a 4 star or 5 star rating would add a star to the overall score. 


The case-mix adjusted staffing measures continue to use the daily resident census derived from the minimum data set (MDS) and the Resource Utilization Group (RUG-IV) case-mix system. A review of how all the components work together to turn the case-mix adjusted hours into stars is covered in the technical user guide.  


The Payroll-Based Journal (PBJ) system continues to be the source of reported staffing hours. The Centers for Medicare and Medicaid Services (CMS) has required nursing homes to submit data using the PBJ since 2016. 


In addition to the most recent release of the July 2022 Technical User Guide, the memorandum QSO-22-08-NH is worth a read to review ways to ensure accurate PBJ data and linked employee IDs – which could negatively affect turnover measures used in the Five Star rating. 


We recommend that a review of an organization’s star ratings should be part of the organization’s QAPI/QAA process. A systematic systemic review of the nursing home’s star rating by the QAPI/QAA committee might include:

  • Identify an interdisciplinary team to review the data now and on a scheduled time determined by the team’s analysis of the initial review. 
  • Conduct a review of each component’s configuration and the organizational practices to support the data. 
  • Update any practices found deficient in accurately reporting data and implement a plan for monitoring. 
  • Evaluate the need for a performance improvement project (PIP) if staffing in the organization needs improvement. 
  • Ensuring CMS has accurate data is only the beginning. Building an organizational culture that focuses on and understands how staffing is measured in the nursing home industry will be key moving forward.