Updated Five Star Staffing Measure and RoP Phase 3 Sufficient Staffing

July 28, 2022


The Five Star Quality Rating System has undergone a significant change to the Staffing Star portion of the Quality Rating. The weekend staffing and the staff turnover begin affecting the calculation of the Staffing Star portion of the Quality Rating in July of 2022. Additionally, the overall Five Star Quality Rating can be impacted by the new calculation that prevents a “4 star” rating in the staffing component from increasing the facility’s overall staffing rating. This change will impact many nursing homes. This webinar will review the new weekend staffing and staff turnover qualifications and the overall Staffing calculation impacted by these changes

The second part of this webinar will include information from the newly released Phase 3 Requirements of Participation related to Sufficient Staffing. The surveyors will begin to use the Phase 3 Requirements of Participation related to Sufficient Staffing in October of 2022. The nursing home administrator will need time to ensure his/her staffing is sufficient to meet the new requirements of participation.

Learning Objectives:
1. State how a “4 star” rating in staffing impacts the overall Five Star Quality Rating.
2. Explain how staff turnover impacts the Staffing Star calculation.
3. Report how weekend staffing impacts the Staffing calculation.
4. Give one example of F725 Sufficient Staff, Level 4, immediate jeopardy to resident health and safety.



Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter, providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

  • 1.5 hours for Licensed Nurses
  • 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on July 28, 2024.


Hansen Hunter & Co. P.C. clients are invited to access any of our webinars for free by contacting Allison Johnson at our office at 503.244.2134 to receive your free registration code.


  • This nursing continuing professional development activity was approved by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Enduring material: To meet the requirements for these contact hours, you must watch the entire recorded presentation as well as answer and submit the post-test evaluation that is provided as a link along with the link to your webinar which you will receive via email after completing your purchase.