The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires public reporting of quality measures (QMs) which relate to the care provided in skilled nursing facilities (SNFs), as well as the submission of standardized assessment data elements by post-acute care settings, including SNFs. The quality reporting program (QRP) promotes the delivery of person-centered, high quality and safe care by SNF’s.
The data submitted for the SNF QRP QMs are derived from two sources:
- Minimum Data Set (MDS):
- Used to capture data elements submitted in the calculation of 10 assessment-based QMs.
- Medicare fee-for-service claims:
- Provide information for three claims-based QMs.
MDS data needs to be submitted and accepted into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the acceptable threshold. The threshold for SNF data submission is as follows;
- 80% of MDS assessment data submitted must contain 100% of the required quality data elements for the eight assessment-based QMs.
- SNFs that fail to submit the required data by the data submission deadlines will be subject to a 2% point reduction in their Annual Payment Update (APU) for the affected fiscal year.
To meet SNF QRP requirements, SNFs must:
- Meet the MDS data collection requirements
- Submit MDS data on time per submission deadlines
- Ensure MDS data are accepted
The act of submitting data does not equal acceptance. The MDS Final Validation Report can verify the acceptance or rejection of MDS records.
Any SNF that does meet the requirements of the SNF QRP will be considered non-compliant and subject to the 2% point reduction in APU for the applicable fiscal year.
May 17, 2021, at 11:59 pm is the final submission deadline for data collected in the time frame of October 1-Decemeber 31, 2020, for the following QMs:.
- Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
- Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long-Stay)
- Skilled Nursing Facility (SNF) Functional Outcome Measure: Change in Self-Care Score for Skilled Nursing Facility Residents
- Skilled Nursing Facility (SNF) Functional Outcome Measure: Change in Mobility Score for Skilled Nursing Facility Residents
- Skilled Nursing Facility (SNF) Functional Outcome Measure: Discharge Self-Care Score for Skilled Nursing Facility Residents
- Skilled Nursing Facility (SNF) Functional Outcome Measure: Discharge Mobility Score for Skilled Nursing Facility Residents
- Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
- Drug Regimen Review Conducted with Follow-Up for Identified Issues- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program
Three QMs are claim based, and are actually hospital claims for Medicare beneficiaries that received post-acute care services following an inpatient stay. The clinical data from the resident’s SNF stay are used as covariates in the risk adjustment model for these measures, and the actual triggering event is driven by the hospital claim. No additional information is required to be submitted by the SNF. These quality measures are as follows:
- Medicare Spending Per Beneficiary (MSPB)- Post-Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
- Potentially Preventable 30-Day Post- Discharge Readmission Measure Skilled Nursing Facility (SNF) Quality Reporting Program
- Discharge to Community- Post-Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
The Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training Resource page can be accessed at: Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training | CMS.
CMS Quality Reporting Program Provider Training recorded webinar can be accessed at: SNF QRP: Achieving a Full APU (cms.gov)
The Skilled Nursing Facility Quality Reporting Program Data Collection & Final Submission Deadlines for the FY 2022 SNF QRP* can be accessed at: Skilled Nursing Facility Quality Reporting Program Data Collection & Final Submission Deadlines for the FY 2021 SNF QRP (cms.gov)
Issue:
Administrators, directors of nursing, and MDS Coordinators should routinely check validation reports to ensure that all submitted MDSs were accepted into the QIES data bank. The MDS should be accurate and timely. A triple check system should also be a part of the interdisciplinary and billing office routine. MDSs that are inaccurate or not submitted timely can have financial penalties and generate further investigation by inspectors and auditors.
Discussion Points:
- Evaluate your policy and procedures for MDS submission and validation reports review. Update your policy as needed.
- Train all appropriate staff on your MDS submission and validation report review policy. Document that this training occurred and file the signed document in each employee’s education file.
- Periodically review validation reports to ensure that all MDSs submitted were accepted into your QIES and any rejected MDS was corrected and resubmitted in an appropriate time frame.
