More data is almost ready to go public on the quality of care you provide – have you reviewed it?
Let’s start with the background details:
The IMPACT act of 2014 requires Skilled Nursing Facilities (SNFs) to submit data for public reporting. CMS has establish the SNF Quality Reporting Program (SNF QRP) in response to the requirement. This has been and continues to be collected and now will be reported publically on Nursing Home Compare.
Here are the measures that are being used for public reporting:
- Discharge to Community- Post Acute Care (PAC) SNF QRP
- Potentially Preventable 30-Days Post-Discharge Readmission Measure for SNF QRP
- Medicare Spending Per Beneficiary –PAC SNF QRP
- Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function- NQF #2631
- Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) - NQF #0674
- Percent of Patients or Residents with Pressure Ulcers that are New or Worsened- NQF #0678
So now what?
The good news is that prior to this data going public, SNF operators have an opportunity to preview their data 30 days prior to go live using a SNF Provider Preview Report. This report will be issued quarterly for providers to review. Have you taken a look at your data yet? What does your data show? Are you focused on these measures? How will your partners use this data? All great questions to be answered.
The bad news is that it is now too late to correct any underlying data because all data submission/correction deadlines for the targeted period on the review report will have passed. The best to do is prepare and focus on current practice and data moving forward.
Some good news is that a SNF may request CMS review of the data contained within their provider review report if the provider believes the data is inaccurate. The requests must be made within the 30 day preview period. There is a process outlined by CMS that each provider must follow in order to request CMS review the data. CMS is urging providers to preview and submit if there are believed to be inaccuracies in the data: Here are those details on how to submit:
- Requests may be submitted to CMS beginning on the day the SNF provider preview reports are available in their CASPER folders, and may be submitted through 11:59:59 p.m. PST on day 30 of the preview period.
- CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
- SNFs are required to submit their request to CMS via email with the subject line: “[Provider Name] SNF Public Reporting Request for Review of Data” and include their CMS Certification Number (CCN) (e.g., ABC Skilled Nursing Facility Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: SNFQRPPRquestions@cms.hhs.gov.
And the request MUST include the following information:
- SNF CMS Certification Number (CCN)
- SNF Agency Name and Mailing Address
- CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
- Information supporting the SNF’s belief that the data contained within their preview report are erroneous, including, but not limited to, quality measures affected, and aspects of quality measures affected (denominator or quality metric).
SNF providers will have until July 1st, 2018 to preview their reports.
These current SNF Provider Preview Reports will include the following data:
Quarter 1 – 2017 to Quarter 4 – 2017 data
- Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (#0674)
- Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
- Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (#2631).
Quarter 4 – 2016 to Quarter 3 – 2017 data
- Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure
- Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
Quarter 4 – 2015 to Quarter 3 – 2017 data
- Potentially Preventable 30-Days Post-Discharge Readmission Measure for Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
Click HERE for instructions on how to access your SNF Provider Preview Report
Information based on Proposed Rule released by CMS on April 27, 2018.
Written by: Kristy Yoskey, MOT, OTR/L, RAC-CT, Senior Vice President
Kristy's #HigherCalling: "Everyone has a significant purpose in life, mine is to help others become aware of that purpose - every nurse, CNA, rehab professional, on person at a time."