SNF Quality Reporting Program (QRP) 2021 – Q&A

On October 15th, Broad River Rehab Reflections Provided a Webinar detailing the following as well as the anticipated October 2020 Nursing Home Compare/Care Compare refresh and new quality measures.

  1. What is the IMPACT Act?

  2. The Quality Reporting Program (QRP).

  3. A history of the current QRP measures.

  4. The 6 QRP measures new to NHC/Care Compare in October.

  5. QRP process, how to manage your QRP.

The Q&A following this presentation follows below.

NOTE: The recording as well as all handouts including the slide presentation are located here.

Q1. Will the 6 new measures impact the five-star rating for quality measures?

 A1. The short answer is no. Currently there are 15 quality measures that impact the 5-Star rating listed below. Note that only two of these measures come from the QRP as indicated by the QRP icon in the list below.

Long-Stay residents MDS based measures:

  • Percent of residents whose need for help with activities of daily living has increased

  • Percent of residents whose ability to move independently worsened

  • Percent of high-risk residents with pressure ulcers

  • Percent of residents who have/had a catheter inserted and left in their bladder

  • Percent of residents with a urinary tract infection

  • Percent of residents experiencing one or more falls with major injury

  • Percent of residents who received an antipsychotic medication

Long-Stay residents claims based measures:

  • Number of hospitalizations per 1,000 long-stay resident days

  • Number of outpatient emergency department (ED) visits per 1,000 long-stay resident days

Short-Stay residents MDS based measures:

  • Percent of residents who made improvement in function

  • Percent of SNF residents with pressure ulcers that are new or worsened (Will be replaced by the QRP Measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury) QRP

  • Percent of residents who newly received an antipsychotic medication

Short-Stay residents Claims based measures:

  • Percent of short-stay residents who were re-hospitalized after a nursing home admission

  • Percent of short-stay residents who have had an outpatient emergency department (ED) visit

  • Rate of successful return to home and community from a SNF QRP

Q2. Do we know if all quality measures will be frozen or just those affecting QRP?

A2. The short answer is yes to all. Note the underlined excerpts from both the most recent 5-Star user’s guide and as the latest COVID-19 Public Reporting Tip Sheet indicate the following.

5-Star User’s Guide

Similar to the staffing data waiver, CMS waived requirements at 42 CFR 483.20 related to the timelines for completing and submitting resident assessment (minimum data set (MDS)) information. This information provides the underlying data used to calculate quality measures used on the Nursing Home Compare website and in the Five-Star Quality Ratings System. CMS believes that data from resident assessments conducted prior to January 1, 2020, can still be used to calculate quality measures (QMs). However, CMS is concerned that data from resident assessments conducted after January 1, 2020 were impacted by the waiver and the public health emergency. Therefore, beginning July 29, 2020, quality measures based on the data collection period ending December 31, 2019 will be held constant. Quality measures that were based on a data collection period prior to December 31, 2019 (e.g., ending September 30, 2019); however, will continue to be updated until the underlying data reaches December 31, 2019. We note that CMS is not holding the quality measure ratings constant, as a facility’s quality measure rating can still be updated by a quality measure with underlying data that is earlier than December 31, 2019.

 The MDS-based QMs will continue to cover 2019Q1 – 2019Q4. Four of the claims-based measures (long-stay and short-stay hospitalizations and ED visits) will be updated and will cover the time period January 1 – December 31, 2019. The short-stay QM, rate of successful return to home and community, will continue to cover October 1, 2016 – September 30, 2018.

October 2020 COVID-19 Public Reporting Tip Sheet

For Q1 2020 and Q2 2020, providers were excepted from data submissions. For this reason, CMS will hold the data constant (i.e., freeze the data) following the October 2020 refresh. The affected Compare site refreshes that were scheduled to contain CY 2020 COVID-19 data (Q1 2020, and Q2 2020) include:

  • January 2021

  • April 2021

  • July 2021

  • October 2021

After the October 2020 refresh, CMS will hold the October 2020 data constant until we resume SNF Compare site refreshes in January 2022. Refreshes will then return to normal by the April 2022 refresh of the SNF Compare site.

Q3. I’m wondering why on slide 12 there was not a star next to fall with major injury, that also affects the 5-star, correct?

A3. You will notice that the list of quality measures that impact the 5-star rating in the answer to Q1 indicates a long stay measure of the Percent of residents experiencing one or more falls with major injury. This measure reports the percent of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period. This is measure N013.02

The QRP measure, Application of Percent of Residents Experiencing One or More Falls with Major Injury is measure S013.02. This QRP measure reports the percentage of Medicare Part A SNF Stays (Type 1 SNF Stays and Type 2 SNF Stays) where one or more falls with major injury (defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) were reported during the SNF stay. This measure is a short stay measure and does not impact the 5-Star rating.

Q4. (a.) Is there any word out there that the 5-star reports will be frozen due to the QMs being currently held constant as of 12/31/2019?  Also with annual surveys just recently resuming, is there any word out if the 3 most recent survey calculation formula at 1/2; 1/3 and 1/6th  value going to be altered?

(b.) Just to be sure I have it clear – both QRP measures and 5 Star QM measures are being frozen until 2022?

A4. The 5-Star rating is a composite rating that is comprised of ratings from health inspections, staffing and certain quality measures. As noted in the answer to Q2 above, quality measure data is being held constant due to the MDS reporting waivers that were in place q1 and q2 of 2020.

Likewise, notice this language also from the July 2020 5-Star user’s guide related to the health inspection rating.

“Since the Nursing Home Compare (NHC) refresh in April 2020 and until further notice, the health inspection domain of the rating system is being held constant to include only data from surveys that occurred on or before March 3, 2020. Results of health inspections conducted on or after March 4, 2020, will be posted publicly, but not be used to calculate a nursing home’s health inspection star ratings. CMS will continue to monitor inspections, including the restarting of certain inspections (i.e., surveys) per CMS memorandum QSO-20-31-ALL. CMS will restart the inspection ratings as soon as possible and will communicate any changes to stakeholders in advance of updating the Nursing Home Compare website.”

CMS also issues a memo on August 17th that instructs states on how to restart survey enforcement for surveys that occurred prior to March 23rd and to restart the normal survey process based on the White House’s reopening guidance.  This will be an ongoing process as states reopen.

The only 5-Star data that has resumed to pre-COVID status is staffing and Q2 staffing data will be reported in the October refresh. CMS stated in a memo issued on June 25th, “Because the waiver is being lifted, staffing measures and ratings will be updated in October 2020 based on data submitted by August 14, 2020.

That said, since all 3 domains are necessary for an accurate overall 5-star rating, I believe that the 5-Star rating will be frozen until we reach a point in time when all three domains are being reported appropriately and are up to date with respect to their affect on the rating system. One caveat is that the rating could be affected by QM data that catches up to Dec. 31, 2019 and health inspection data that is added for surveys conducted before March 23rd.

Q5. Will Q1 and Q2 5 Star QM data never be calculated into the calculation for 5-Star QM domain?

A5. See response to Q2 and Q4 above. It appears from CMS’ responses that the QM freeze is intended to eliminate MDS data from those two quarters from affecting the public reported data and by proxy, the 5-Star rating.

Q6. When is nursing home compare being updated?

A6. Remember that there is a new site called Care Compare that will replace Nursing Home Compare. It will serve providers well to become familiar with this new reporting site. Review answer to Q2 above. There will be a refresh in October 2020 based on MDS QM data that is current as of Dec. 31, 2019, Survey data that was current as of March 23, 2020 and PBJ data reported for Q2 2020. After this refresh, publicly reported data will be held constant until a full refresh in April of 2022.

Q7. Does your HAI Performance Report affect your QRP?

A7. The short answer is no, not currently. The Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAIs) Requiring Hospitalizations Measure for the Skilled Nursing Facility Quality Reporting Program (SNF QRP) is currently in draft form and CMS has just completed a comment period in which stakeholders offered input on the details of this measure. As noted in the presentation this new QRP measure is being developed as a healthcare-associated infections quality measure for the SNF QRP under the Meaningful Measure domain: Making Care Safer by Reducing Harm Caused in the Delivery of Care.

While this measure has not yet been approved by the National Quality Forum (NQF) and is not currently being publicly reported CMS has made it clear that,

“… the SNF HAI measure will be a part of the Measures Under Consideration list later this year and it is our (CMS’) intention to present this measure for pre-rulemaking review at the Measure Applications Partnership Post-Acute Care/Long-Term Care Workgroup meeting in December.  (We) CMS will be providing Confidential Dry Run Reports to alert each SNF of their SNF HAI performance score based on these draft measure specifications in the coming weeks.”

That said, it appears that this measure is on the fast track to be a publicly reported measure. It is important to note, as we mentioned in the presentation, that CMS has, in fact, posted dry run HAI reports to each provider’s CASPER page in QIES and these are available for download now. While this is pure speculation at this point, given the attention that COVID-19 has place on infection control practices in nursing homes and what the hospital readmission data clearly shows related to HAIs, It would not be surprising to find that this measure does end up affecting the 5-Star rating with the April 2022 refresh.

Q8. I have a question regarding GG for OBRA assessments. Are we expected to gather data for PDPM scores, including GG data, for hospice residents?

A8. Chapter 2 page 2-2 of the current RAI Manual states, “The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable regardless of age, diagnosis, length of stay, payment source or payer source.” There are specific guidelines with respect to the MDS and Hospice patients throughout the RAI Manual.

Therefore, if a Hospice patient resides on a Medicare and/or Medicaid certified portion of a nursing facility, and an OBRA assessment is required for a resident, and the state has indicated that nursing facilities are required to complete the MDS data necessary to calculate a PDPM HIPPS on OBRA MDS assessments that are not combined with a PPS 5-day assessment, then yes, you would be expected to gather PDPM dad for those residents.