What is the CMS Five-Star Quality Rating System?
In 2008, the Centers for Medicare & Medicaid Services (CMS) introduced the Five-Star Quality Rating System to help consumers compare nursing homes more easily. The system provides a rating from one (much below average) to five stars (much above average) for each Medicare and Medicaid-certified nursing home in the United States. These ratings are prominently displayed on the Medicare Care Compare website and are based on three key performance categories.
How are nursing homes rated? The three key domains
Each nursing home's rating is calculated using a complex formula that weighs three different domains of performance. While the rating offers a helpful summary, it is essential to understand what factors contribute to the overall score to make a truly informed decision. The three categories are:
- Health Inspections: This rating is based on the three most recent comprehensive (annual) health inspections, as well as any complaint-driven inspections over the last three years. More recent inspection results are weighted more heavily, and points are assigned based on the number and severity of deficiencies found. Facilities are ranked against others in their state to determine the star rating for this category, with the top 10% receiving five stars.
- Staffing: The staffing rating reflects the number of hours of nursing care provided to each resident per day. This includes time from registered nurses (RNs), licensed practical nurses (LPNs), and certified nurse aides (CNAs). CMS uses facility-reported data from the Payroll-Based Journal (PBJ) system, which is case-mix adjusted to account for the varying needs of residents. It also incorporates data on staffing turnover to provide a more complete picture.
- Quality Measures (QMs): This rating is derived from clinical data collected on the nursing home's residents. It evaluates a set of specific physical and clinical measures for both short-stay and long-stay residents. Key quality metrics include rates of resident falls, pressure ulcers, physical function, and use of antipsychotic medications. A facility’s QM performance is measured against national averages to determine its star rating for this category.
Understanding the overall rating calculation
The overall star rating is not a simple average of the three component ratings. Instead, CMS uses a specific process to arrive at the final number. It starts with the health inspection rating and then adjusts it based on the staffing and quality measure scores. A one-star health inspection rating significantly limits the potential for a high overall rating, regardless of performance in the other two categories.
How to use nursing home ratings effectively
While the CMS rating system is an invaluable resource, it has certain limitations. The data on staffing and quality measures is self-reported by facilities, which can be a source of inaccuracies. Therefore, it is essential for families to use the star ratings as a starting point, not the sole deciding factor. Always supplement your research with personal visits and conversations with staff, residents, and other family members. The ratings also cannot capture every important factor, such as facility culture, specialized care for conditions like dementia, or the quality of food and activities.
| Rating Component | Data Source | Rating Calculation | Potential Limitation |
|---|---|---|---|
| Health Inspections | State surveyor inspections (annual & complaint) over 3 years | Based on the frequency and severity of deficiencies relative to other facilities in the same state. | State-specific variations in survey processes can make cross-state comparisons difficult. |
| Staffing | Facility-reported hours via Payroll-Based Journal (PBJ) | Compares RN and total staffing hours per resident-day, case-mix adjusted for resident needs. | Relies on self-reported data, though CMS uses audits to ensure accuracy. |
| Quality Measures | Clinical data submitted by facilities (MDS) and claims data | Performance on various clinical metrics (e.g., pressure ulcers, falls) compared to national averages. | Some metrics, like antipsychotic medication use, may not reflect individual resident needs. |
| Overall Rating | A combined score derived from the three component ratings | Starts with the health inspection score and is adjusted up or down based on staffing and quality measures. | Heavily weighted towards the inspection score, which may not reflect current operational improvements. |
Conclusion
Yes, there is a comprehensive rating system for nursing homes, and it is a powerful tool for consumer research. The Centers for Medicare & Medicaid Services (CMS) operates the Five-Star Quality Rating System, which is published on the official Medicare website. By providing ratings for health inspections, staffing, and quality measures, CMS gives families a transparent starting point for comparing facilities. However, ratings should be used in conjunction with other sources, such as facility tours and interviews, to get a complete picture. By understanding the strengths and limitations of the rating system, families can make a more confident and informed decision for their loved ones. For more details, consult the official Medicare Care Compare website.
