Summary of NQHI Ranking for Comprehensive at Williamsville

New York Department of Health Nursing Home Quality Initiative

The NYS DOH Nursing Home Quality Initiative (NHQI) is an annual quality and performance evaluation project to improve the quality of care for residents in NYS Medicaid-certified nursing homes. The NHQI offers an alternative method of ranking nursing homes to CMS Nursing Home Compare. The 2020 NHQI is based on the previous calendar year’s performance in 3 component areas: Quality (quality measures); Compliance (compliance with reporting); and Efficiency (potentially avoidable hospitalizations) categories. The overall score is worth a maximum of 90 points (this is a reduction from the previous NHQI max score of 100 due to a removal of employee flu vaccination measures).101

NHQI: Quality Component (worth 65 points)

These are measured from MDS 3.0 data, CMS Payroll Based Journal Public Use Files (PBJ PUFs), and Nursing Home Compare data. The points are evenly distributed for all quality measure and include 13 quality measures each worth a maximum of 5 points.

NHQI: Compliance Component (worth 15 points)

These consist of two measures: CMS five-star quality rating for health inspections and timely submission of nursing home certified cost reports. Health inspection survey scores are downloaded directly from CMS and are scored as follows: 10 points=5 stars, 7 points=4 stars, 4 points=3 stars, 2 points=2 stars, and 0 points=1 star. Timely submission measures are specified by the Bureau of Residential Health Care Reimbursement and are worth a maximum of 5 points13 .

NHQI: Efficiency Component (worth 10 points)

This consists of one measure: potentially avoidable hospitalizations. The rate is calculated for each quarter and the averaged to create an annual average in order to stay consistent with other CMS quality measures. The measure is risk-adjusted. Scores are given as follows: Quintile 1=10 points, Quintile 2=8 points, Quintile 3=6 points, Quintile 4=2 points, and Quintile 5=0 points13 .

Any facility that was cited for a letter J, K, or L health inspection deficiency one or more times are not eligible to be ranked into overall quintiles. This is because these letter deficiencies indicate Level 4 immediate jeopardy which is the highest level of severity for health inspection deficiencies.

The total scores are grouped into five quintiles (or tiers). Facilities in the first quintile are the top performing NY nursing homes. Comprehensive at Williamsville has been ranked in the worse quintile (5) in every year of the NHQI’s existence.

101https://www.health.ny.gov/health_care/medicaid/redesign/nhqi/2020/methodology.htm