In the thick of the pandemic, the predominant concern for long-term post-acute care (LTPAC) providers was ensuring the health and safety of their residents and staff. As part of its response to COVID-19, the Centers for Medicare & Medicaid Services (CMS) announced many changes in 2020 that would support LTPAC and other healthcare providers in their struggle to keep residents and patients safe and to curtail the spread of the disease.

Changes to Health Inspections in 2020

Included among the changes implemented by CMS in 2020 were the suspension of certain on-site inspections and the temporary freezing of survey data. As of March 4, 2020, non-emergency inspection activity was suspended and the focus was directed to surveys involving infection control and immediate-jeopardy situations. The change was in effect until mid-August 2020, when normal survey activity was resumed.

Because of this temporary modification and its impact on the weighting of survey data used in the calculation of ratings, CMS froze the health inspection aspect of the Five-Star Quality Rating. Survey data was held constant until January 2021 when CMS resumed calculating the health inspection domain and began to use results from surveys occurring after March 3, 2020.

Consequently, the standard annual health inspection was, for a time, not likely top of mind for many LTPAC providers. Now that there is a return to pre-COVID survey activity and health inspection ratings calculations, it’s important that providers get reacquainted with the Five-Star Quality Rating and its three components, starting with the health inspections domain.

What Makes Up the Five-Star Quality and Health Inspection Ratings?

CMS created the Five-Star Quality Rating system in order to review LTPAC providers, supply them with feedback and hold them accountable for making improvements. The Star Ratings also give residents and their loved ones a means for comparing available providers.

The Five-Star Quality Rating system is comprised of three parts, referred to as domains: health inspections (survey), quality measures and staffing. A rating of one to five stars is given to each of the three domains, which are combined into an overall quality rating.

The health inspection domain forms the basis of the ratings system. Any provider that participates in the Medicare or Medicaid program is subject to an annual on-site inspection, also called a survey, that is unannounced and comprehensive in nature.

Surveyors seek to uncover health and safety issues by inspecting all aspects of a provider, including:

• The facility. Surveyors look for facilities to be well-maintained, free from hazards, clean and sanitized. Facilities should have appropriate equipment that is in working order. Food should be stored and prepared properly and medications handled according to guidelines.
• The staff. Facilities should have adequate staffing levels based on the number of residents. Staff should be trained and have appropriate qualifications. Providers should ensure that they’ve done adequate background checks and that staff records are in order.
• The residents. Surveyors look for any signs of abuse or neglect, if treatment plans are being followed correctly and whether residents are generally being properly cared for. They will determine if the resident population is too high or whether facilities have the necessary equipment and resources to care for the needs of each resident. Surveyors will often interview residents and their loved ones to gauge their satisfaction with the care provided.

Surveyors issue deficiencies based on their findings from the annual inspection. These deficiencies, along with any deficiencies resulting from complaint investigations, form the basis of the health inspection rating.

Related Article: Infection Prevention in Skilled Nursing Facilities: Strategies for Mitigating Survey Citations

How the Health Inspection Rating is Calculated

Ratings for the health inspection domain are calculated based on deficiency findings from the three most recent annual inspection surveys, the most recent 36 months of complaint investigations and any repeat visits needed to determine that deficiencies found during the annual survey have been corrected. Currently, rating calculations also include findings from infection-control surveys done in 2020.

Step 1: Points are assigned to deficiencies.

Deficiency findings are weighted and points are assigned to each deficiency based on its scope, ranging from isolated to widespread, and its severity, ranging from no actual harm done to immediate jeopardy to resident health or safety.

Step 2: Points are weighted and scored

Deficiency points are assigned a weighting factor based on the 12-month period – cycle 1, 2 or 3 – in which the survey occurred and a score for each deficiency is calculated. The most recent annual surveys (cycle 1) are weighted more heavily than older surveys.

• Cycle 1 - assigned a weighting factor of or 0.50
• Cycle 2 - assigned a weighting factor of or 0.33
• Cycle 3 - assigned a weighting factor of or 0.16

Step 3: Weighted scores are summed and used to determine health inspection star rating

The weighted scores for cycles 1, 2 and 3 are added together to determine a total health inspection score. That score will determine the health inspection star rating.

CMS determines facility ratings using these criteria:

• The top 10 percent of facilities in each state according to their total health inspection scores receive a rating of five stars.
• The middle 70 percent of facilities receive a rating of two, three or four stars, with an equal number (approximately 23.33 percent) in each rating category.
• The worst 20 percent receive a one-star rating.

The health inspection points cut table is published monthly. This means your overall rating can change monthly as well, making it important to pay close attention to cut-off points.

How to Improve Your Health Inspection Rating

There is often an element of panic associated with inspections that may be avoided by striving to do things the right way, all the time. Rather than waiting for your survey window when you know that your inspection is imminent, implementing certain best practices may make the process less painful, including:

• Provide adequate training. Your staff should be well-informed of procedures and rules and monitored to ensure they’re following them. Constant reminders, such as wash your hands, lock your cart and check labels, are important as well as any reminders relating to the administration of medications.
• Keep good records. Surveyors typically ask for a lot of information, including both staff and patient records. They may check an employee’s file for the date of a recent physical or a patient’s file for an up-to-date TB test, making the accuracy and accessibility of records vital.
• Prepare a survey binder. Pull all of the needed documentation into one place and keep track of daily rounds by the administrative staff. Review the last annual survey and complaint surveys to ensure none of your processes have lapsed.
• Ensure that the facility is up-to-date. A regular routine should include checking for safety hazards, such as malfunctioning equipment, broken furniture, inadequate lighting and unstable pathways, and fixing them as soon as possible.  

The Bottom Line

While COVID-19 was an aberration that no one was prepared for, it was particularly disastrous for the healthcare industry and illuminated a number of inadequacies for many LTPAC providers. Now that inspections are back in full swing, providers must return to a focus on survey preparedness with an understanding, however, that pre-COVID practices may need an overhaul in order to maintain a desired Five-Star Quality Rating.

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