Since the advent of Payroll Based Journal (PBJ) reporting by CMS in 2016, facilities have struggled with preparing and submitting accurate PBJ data. Penalties applied for a failure to submit complete and accurate data can result in defaulting to a one-star rating and negatively impacting overall 5-star ratings.
Recently, CMS released new guidelines for PBJ calculations based on the release of MDS 3.0 Version 1.18.11 and subsequent removal of Section G. This necessitated a change to the staffing case-mix adjustment method since RUG-IV levels can no longer be applied utilizing the STRIVE study for expected minutes by job code. Additionally, CMS will freeze the staffing measures for three months starting in April 2024 during this transition. So given this changing landscape, what are the risks to you and your organization?
Let’s start with the submission of your payroll data. Remember first and foremost, the MEASURES are frozen, not the data submission. Everyone is still required to submit their fourth quarter staffing data for 2023 by 11:59 PM eastern time on February 14. Failure to do so will result in a default to a one-star rating for your facility; but that’s not where the trouble ends.
In the past, failure to submit staffing data also meant that turnover data could not be accurately calculated for six quarters. In that situation, turnover measures were excluded and the remaining staffing points re-scaled (points for turnover re-assigned to the staffing measures) for subsequent quarters until the data caught up. Facilities who missed a reporting quarter often benefitted from the re-scaling that occurred.
Starting in April 2024, CMS will be changing the rating methodology so that providers that failed to submit staffing data or submitted erroneous data will now receive the lowest score possible for the corresponding turnover measures. That means of the possible 130 points available in the turnover measures, the provider will be locked into 20 points for six quarters. That’s a heavy impact to your staffing rating potential for a prolonged period of time, so this should serve as a pretty big incentive to submit accurate staffing data timely.
RUG to PDPM Case-Mix Adjustments
The Staff Time and Resource Intensity Verification (STRIVE) study has been the basis for risk adjusted staffing utilizing RUG levels and average staffing time in minutes by job code. The removal of section G from the MDS necessitated conversion to nursing case-mix groups (CMG) and case-mix indexes (CMI) from the Patient Driven Payment Model (PDPM) in order to calculate “case-mix hours.” The new formula relies on the distribution of nursing case-mix groups within each facility, the corresponding case-mix index and the reported national average staffing level to arrive at expected staffing hours.
So how different is this from the prior method? Well, since RUG and STRIVE are gone, there are no tables to directly reference that indicate expected or average staffing levels by job code. Instead, the case-mix values for each nursing home are based on the daily distribution of residents by PDPM nursing groups in the quarter covered by the PBJ reported staffing and the CMIs for the corresponding nursing groups.
Specifically, case-mix nurse staffing hours are calculated as follows:
- Start by counting the number of residents in each of the 25 PDPM nursing groups for each day in the quarter
- Multiply the total number of resident days in each nursing group by the corresponding CMI value
- Now take those values, add them all up and divide by the total resident days in the quarter – this value represents the facility CMI score
- Similarly, CMS will calculate a national weighted-average CMI score utilizing the same steps above for ALL nursing homes
- For each nursing home, a relative nursing CMI ratio is calculated as the ratio of its weighted-average nursing CMI to the national weighted-average nursing CMI
- Now you can calculate the case-mix hours (total nursing, RN or weekend) by multiplying the facility nursing CMI ratio by the national mean of reported hours per resident day
One of the key benefits in the revised methodology would be breaking the dependence on the STRIVE study data to assign case-mix hours. The age of the data in the study notwithstanding, the table represented a static value that was not updated with changes to core staffing, increases in resident acuity, adjustments to the PDPM methodology, etc., whereas the new methodology is much more fluid and represented by adjustments seen across the nursing home base.
While PBJ data and submission has been a key focus for facilities and organizations since its inception, the revised rules and methodology carry additional incentives and penalties that raise the stakes on timely and accurate reporting.