LeadingAge Meets with CMS SNF QRP Staff

Regulation | September 12, 2018 | by Nicole Fallon

LeadingAge staff met with lead CMS staff regarding the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) to discuss the FY2019 SNF QRP noncompliance experience, understand the causes for noncompliance, and identify ways we could work together to improve the process in order to reduce the number of SNFs who are noncompliant in future years.

CMS staff shared that less than 2% of the 15,191 Skilled Nursing Facilities(SNFs) received a noncompliance letter and of those that did, roughly 50% submitted a request for reconsideration and supporting documentation. CMS granted reconsideration for about half of those SNFs who requested it stating they had made a compelling argument demonstrating that they had been using the CASPER system reports but fell short in meeting the 80% threshold reporting requirement. Those SNFs who were granted reconsideration will not be penalized the 2% off their Medicare Fee-For-Service(FFS) rates. SNFs whose noncompliance was upheld still have an opportunity to appeal and are encouraged to do so.

The main reason (90% of SNFs) for noncompliance was related to the functional assessment measure which is tied to completion of MDS items in Section GG. [See A Crosswalk of the MDS items to the SNF QRP measures for more information about which MDS items can impact reporting on this and other MDS-based measures] When these sections are completed with a dash, they are considered not completed and therefore not counted as reporting this information. 

The CMS SNF QRP staff also shared that they are creating a new report in CASPER that will be released early Winter (likely January 2019), called an "APU Threshold Report". This report will show, by MDS quality measure, the number of MDS assessments submitted and the number considered to be completed with a valid value so SNFs can better understand whether they are meeting or exceeding the required 80% reporting threshold.  SNFs will be able to run these reports at any time.  Each time the report is run it will capture the most recent data so if a SNF makes corrections to its MDS submissions it will show up the next time the report is run. CMS reminds SNFs that they will have 4 ½ months from the end of a quarter to submit missing data or late MDS forms for that quarter.  For example, MDS assessments submitted in the fourth quarter of 2018 will be able to corrected, submitted or updated until May 15, 2019.

CMS recently held some training related to the SNF QRP program in July that was recorded and is expected to be posted to the SNF QRP website soon.  One particularly helpful portion of the training walked through the available reports in the CASPER system, where to find them and how they might be useful.  We will publish more information when this recorded training is released.