Staffing Star Rating


Numerous studies point to the correlation between higher staffing levels and better patient outcomes, so it was important to CMS to report on facilities’ staffing levels as part of the Five-Star rating process.  To this end, each facility collects and submits staffing information to CMS using a system call Payroll-Based Journal or PBJ.   The raw staffing hours are then adjusted based on the count and clinical complexity of the residents in the home, then the adjusted figure is used to determine their Staffing Star Rating. 

Staffing Hours

CMS assigns stars based on a facility’s achievement in two different areas, each of which also receive their own sub-Star Rating: Registered Nurse or RN Staffing and Total Nurse Staffing.  RN Staffing includes only hours for Registered Nurses, where Total Nurse Staffing includes hours for RNs, plus Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs):

  • RN Staffing – Registered Nurse (RN) Hours only
  • Total Nurse Staffing – RNs + LPNs + CNAs

Note: Most facilities know that therapists, doctors and Nurse Practitioners cannot be included in these totals, but some are unaware that RNs and Nursing Directors with administrative duties can and should be included.  This potential blind spot is one area where StarNow Real-Time Staffing can help.

Staffing Hours for the categories above are then divided by the number of residents in the facility for a given quarter to arrive at the Hours per Resident Day (HRD), which some facilities also call Per Patient Day, or PPD.  The number of residents, also called Census, is determined based on patient data collected on MDS (Minimum Data Set) assessments.  For more detail on how the census data is collected and used, read CMS’s documentation.

Going Beyond "Reported" Hours

The HRD calculated above by dividing Staffing Hours over Census is called the Reported HRD, and it represents the average number of actual nursing hours per resident per day, as reported by the facility via PBJ. 

But CMS takes staffing a step further: Staffing Star Ratings are determined based on another value called Adjusted HRD, which is calculated using the formula below:

(Reported HRD / Case-Mix HRD) * National Average HRD = Adjusted HRD

Essentially, CMS understands that residents have diverse needs, including clinical conditions that require extra care.  As a result, based on the MDS Assessments of its residents, each facility receives a Case-Mix HRD.  This value is shorthand for what the expected staffing level is for a facility, given the case mix, or clinical complexity, of its resident population.

CMS also releases a figure called the National Average HRD each quarter, which is an average of the Case-Mix HRDs of all 15,000+ Nursing Homes in the country, and is used in the formula to assess a given facility’s staffing levels against their peers.

So how does this all come together?  Let’s look at RN hours for sample facility over a given 91-day quarter:

Total RN Hours=Reported HRD
Total Resident Days
(46.74 RN Hrs/Day)
(Reported HRD)
(Approx 68 Residents/Day)

Now given a Case-Mix HRD of 0.6018 and a National Average HRD of 0.3783, let’s calculate the Adjusted HRD:


Reported HRD
National Avg HRD
Adjusted HRD
Case-Mix HRD

Next, let’s see how the Adjusted HRD gets used to calculate the Star Rating.


Calculating The Staffing Star Rating

Similar to Survey and Quality, Staffing also has a set of cutpoints in a matrix to determine Star Ratings.  Since Staffing has two components, RN Staffing and Total Nurse Staffing, there are two matrices:



Because the Staffing Rating is based on both RN Staffing and Total Nurse Staffing, there is a second matrix that determines the “Overall” Staffing Rating:



Within StarPRO, we strive to simplify.  That’s why we create color-coded visuals that let you see a facility’s performance at a glance:



On the right, we can see the facility’s relative performance in all of the Staffing Star Ratings.  To the left, there are key compliance checks.  Read on for further detail on PBJ data submission and these compliance checks. 

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PBJ & Compliance

As mentioned above, Staffing data must be submitted each quarter via Payroll-Based Journal or PBJ.  Some operators submit staffing data automatically from their payroll systems, others fill out an Excel template provided by CMS, and others use third parties to extract, compile, and submit their data.  What’s key in this process is to ensure both the accuracy and completeness of this data.  CMS runs several compliance checks to ensure that staffing hours fall within reasonable ranges:

  • Excessive Total Nurse Staffing  ( > 12 HRD)
  • Insufficient Total Nurse Staffing ( < 1.5 HRD)
  • Excessive Nurse Aid/CNA Staffing ( > 5.25 HRD)

If a facility submits data with one or more of these problems, their Staffing Rating is removed and the message “Data Not Available” is displayed prominently. 

Additionally, there are other compliance checks that carry a harsher penalty — being downgraded to 1 Staffing Star:

  • Failure to submit PBJ data by the deadline
  • More than 4 days in a row without RN Staffing hours
  • Failure to respond to, submit documentation for, or failure to pass a CMS audit designed to discover discrepancies in PBJ data

Needless to say, a 1 star rating has an even wider impact than “Data Not Available”, so facilities need to ensure that their staffing levels are being reported in a timely and accurate fashion.

As such, it helps to get a handle on your Staffing situation well before it needs to be submitted.  Since the lag in time between data submission and publication on CMS ranges anywhere between 3 and 6 months, facilities with access to real-time data are at an advantage when it comes to avoiding penalties, and knowing what will be published.  With StarNow for Staffing, operators can gain that visibility.

How Can StarNow Staffing Help?

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