Scoring Methodology - How the Score is Calculated

Scoring Methodology - How the Score is Calculated

The best possible score that a facility can achieve is 0 points. This means that no deficiencies were found in the 45 requirements used for scoring for the past three standard surveys, and there have been no findings of Substandard Quality of Care or Immediate Jeopardy for any survey during the time period covered by those three standard surveys. (A facility with a score of 0 may still have been found deficient in one or more requirements outside the set of 45 used for scoring.)

Step One: Identify the surveys to be included in the scoring process. There are three sets:

1. The most recent standard survey and any other surveys performed between it and the second most recent standard survey.
2. The second most recent standard survey and any other surveys performed between it and the third most recent standard survey.
3. The third most recent standard survey and any other surveys performed between it and the fourth most recent standard survey.

Step Two: Identify the information from each survey to be included in the scoring process:

• For the standard surveys (those that are required every 9-15 months):
• Deficiencies cited in any of the 45 requirements used for scoring, and the Scope and Severity found for each deficiency. (Each of the 45 requirements falls into one of five categories.)
• Whether or not the survey found Substandard Quality of Care
• Whether or not the survey found Immediate Jeopardy
• For any non-standard surveys (such as complaint investigations and revisit surveys):
• Whether or not the survey found Substandard Quality of Care
• Whether or not the survey found Immediate Jeopardy

Step Three: Score each of the three sets of surveys (most recent, second most recent, and third most recent):

1. For each deficiency found in the 45 requirements assign a point value according to the Scope and Severity found as indicated in the table below.
2. If Substandard Quality of Care was found on any survey in that set (regardless of the number of times), assign a point value of 6.
3. If Immediate Jeopardy was found on any survey in that set (regardless of the number of times), assign a point value of 30.
4. Add all of the above point values together. This is the score for that facility for that survey period.
 Scope and Severity Table Isolated Pattern Widespread Immediate jeopardy to resident health or safety J 60 points K 77 points L 96 points Actual harm that is not immediate jeopardy G 21 points H 32 points I 45 points No actual harm with potential for more than minimal harm that is not immediate jeopardy D 4 points E 5 points F 12 points No actual harm with potential for minimal harm A 1 point B 2 points C 3 points

Step Four: Calculate the overall score. This is the total of the scores for each of the three survey periods, weighted so that recent surveys count more than older surveys.

1. Multiply the score for the most recent survey period by 1.

Multiply the score for the second most recent survey period by 2/3.

Multiply the score for the third most recent survey period by 1/3.

1. Add the three weighted scores and multiply times 3. This is the overall score for that facility.

Example:

Facility XYZ

Most recent standard survey:

Tag F0221 scope and severity grid E scores 5 points.

Tag F0225 scope and severity grid D scores 0, as it is not in the subset of 45 tags.

Tag F0323 scope and severity grid G scores 21 points.

(Note that although there were two visits which had substandard quality of care, only one 6 point addition is added.)

Total = 26 points.

Second most recent standard survey:

Tag F0150 scope and severity grid F scores 0, as it is not in the subset of 45 tags.

Tag F0274 scope and severity grid F scores 12 points.

Tag F0324 scope and severity grid G scores 21 points.

There was a complaint investigation survey after this survey and before the most recent standard survey that had immediate jeopardy this will add 30 points to this year's score.

Total = 63 points.

Third most recent standard survey:

Tag F0272 scope and severity grid D scores 4 points.

Tag F0366 scope and severity grid F scores 12 points.

Tag F0465 scope and severity grid G scores 21 points.

Tag F0497 scope and severity grid F scores 12 points.

Total = 49 points.

Facility Total:

Most recent survey score = 26 multiplied by 1 = 26.

Second most recent survey score = 63 multiplied by 2/3 = 42

Third most recent survey score = 49 multiplied by 1/3 = 16 1/3

Total = 26 + 42 + 16 1/3 = 84 1/3 multiplied by 3 = 253 Total

In addition the points scored for each tag in the subset of 45 would have its score

accumulated within the category it is listed under, administration, nursing, etc. for

each of the three survey periods.