The Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT Act) required standardized data across the continuum of care from long-term care hospitals (LTCH), inpatient rehab facilities (IRFS), skilled nursing facilities (SNFs), and home health agencies (HHAs). SNFs that fail to report the required data will have a 2% reduction in their Prospective Payment System (PPS) payments.

It is important to remember the Quality Reporting Program (QRP) Measures should not be confused with the Five-Star Quality Measures. The QRP Measures are reported through the Minimum Data Set (MDS) and claims. Entering a dash (-) on the MDS in any of the sections below is considered a failure to report. CMS expects dashes for these MDS items to occur rarely.

Currently there are eight quality reporting measures that are reported on the MDS:

1. Section J - Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
2. Section GG - Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and Care Plan that Addresses Function
3. Section N – Drug Regimen Review Conducted with Follow-up that Addressed Any Issues
4. Section M – Changes in Skin Integrity Post-Acute: Pressure Ulcer/Injury

The last four are based on MDS section GG scores at discharge, and whether the scores have changed from admission to discharge. These scores measure the effectiveness of the interdisciplinary team efforts to improve the patient’s self-care and mobility.

5. Section GG – SNF Functional Outcome Measure: Discharge Self-Care Score for SNF Residents
6. Section GG – SNF Functional Outcome Measure: Discharge Mobility Score for SNF Residents
7. Section GG – SNF Functional Outcome Measure: Change in Self-Care Score for SNF Residents
8. Section GG – SNF Functional Outcome Measure: Change in Mobility Score for SNF Residents

Facilities must “report” this information on 80% of the total MDS assessments they transmit.

There are four claims-based measures:

1. Potentially Preventable 30-Day Post-Discharge Readmission Measure for Skilled Nursing Facilities
2. Discharge to Community – Post-Acute Skilled Nursing Facilities
3. Medicare Spending Per Beneficiary (MSPB) for Skilled Nursing Facilities
4. SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization Quality Measure

On October 1, 2021, CMS required facilities to begin submitting COVID-19 vaccination coverage among health care personnel (HCP) through the CDC/National Healthcare Safety Network (NHSN) web-based surveillance system. The numerator is the number of health care personnel who received a complete vaccination course against COVID-19 and worked in the facility at least one day during the reporting period. The denominator is the cumulative number of HCP eligible to work in the facility for at least one day during the reporting period. HCP with contraindications preventing COVID-19 vaccinations are excluded from the denominator. Facilities must report this information at least one week each month, and the CDC will report to CMS quarterly.

While CMS requires that 80% of the MDS assessments submitted include the QRP information, the CDC/NHSN requirement is 100%. Therefore, if a facility fails to report in either instance, they will receive a 2% reduction in their PPS payment.

The Department of Health and Human Services and CMS will continue to push the requirements of the IMPACT Act to measure quality of services across care providers. In the recent Code of Federal Regulations released on August 3, 2022, CMS laid out their plans to expand the QRP for FY 2024, which indicates data collection will begin on October 1, 2023. The recent release of the MDS Data Set Version 1.18.11 reflects significant change to meet the Impact Act goal to have Standardized Patient Assessment Data Elements (SPADES) across the care settings. These changes will also impact the Five-Star Measures. As of October 1, 2023, the MDS will no longer include Section G.

Stay Up-to-Date with Richter

Richter anticipates the RAI Manual V1.18.11 with coding rules for these changes will be released in January 2023. Continue to check back on our website for updates, as we assist and prepare your organization for these changes. To learn more about our customized clinical consulting services, contact us here or call us at 866.806.0799.

References:

• MDS Data Set Version 1.18.11 retrieved from: MDS 3.0 Nursing Home Comprehensive (NC) Item Set (cms.gov), September 16, 2022.
• SNF Quality Measure Calculations and Reporting User’s Manual 4.0 retrieved from Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Change Table Version 4.0 (cms.gov) September 16, 2022.
• Department of Health and Human Services, Centers for Medicare & Medicaid Services, 42 CFR Vol. 87, No. 148 Wednesday August 3, 2022.
• Department of Health and Human Services, Centers for Medicare & Medicaid Services, 42 CFR Vol. 86, No. 147 Wednesday August 4, 2021.
• Department of Health and Human Services, Centers for Medicare & Medicaid Services, 42 CFR Vol. 84, No. 152 Wednesday August 7, 2019.