Coming Soon to QRP – Healthcare Acquired Infections

Infection control is most definitely the theme of the day. SNFs are under scrutiny like never before related to infection control and prevention. In a recent Regulatory Reminder, we detailed the recent Interim Final rule related to increased COVID testing requirements and the resulting changes to the COVID-19 Focused Survey pathways. In a recent McKnight’s LTC news one of the lead stories is titled, “Provider faces $315K fine for failing to isolate residents, warn staff of COVID-19 outbreak”. Facilities are and will continue to bear the brunt of this renewed focus with a renewed effort to prevent and mitigate issues related to infection control with a continued expectation of positive outcomes related to care provided in a SNF, and penalties when those outcomes are not achieved.

Indeed, Infection control, though always part of every facility’s daily protocols as well as the survey process, is under an intense spotlight due to the current Public Health Emergency and will be moving forward. Also in a recent in McKnight’s, buried in the “Also In the News” section, there is announcement from CMS related to a new Quality Reporting (QRP) measure. CMS has contracted with Acumen to develop a claims-based quality measure of healthcare-associated infections (HAIs) for the SNF QRP. The official title of the new SNF QRP measure is, “Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAIs) Requiring Hospitalizations Measure for the Skilled Nursing Facility Quality Reporting Program (SNF QRP).” In the announcement, CMS indicated that one of the stated objectives of this new measure development project is to, “Develop 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.”  CMS is soliciting comments on this new measure through Oct. 14, 2020. Comments may be submitted at

In a nutshell,

This new measure, “…will estimate the risk-standardized rate of HAIs that are acquired during SNF care and result in hospitalization. SNF HAIs that are acquired during SNF care and result in hospitalization will be identified using the principal diagnosis on the Medicare hospital claims for SNF residents, during the time window beginning on day four after SNF admission and within day three after SNF discharge. The measure is risk adjusted to “level the playing field” to allow comparison based on residents with similar characteristics between SNFs.”

With the implementation of Care Connect, which we detailed in our last Regulatory Reminders BLOG, it is clear that CMS is increasingly placing the attention squarely on, “…the highest priorities for quality measurement and improvement, …assessing those core issues that are the most critical to providing high-quality care and improving individual outcomes. The Meaningful Measures serve as the connectors between CMS strategic goals and individual measures/initiatives that demonstrate how high-quality outcomes for our beneficiaries are being achieved.” More and More we are faced with the reality that, as SNF providers, we are living in a value-based purchasing, pay for performance, quality driven, outcome-based world. Measuring Healthcare-Associated Infections is just the latest CMS initiative to further enhance that reality. And, if I were a betting man, I would lay odds that this particular measure will be fast tracked. Look for it to be validated and implemented and posted to Care Connect in the not too distant future.