To be considered compliant with the skilled nursing facility quality reporting program (SNF QRP), skilled facilities must meet two requirements to avoid a 2% cut in their annual payment update (APU) in an applicable fiscal year. The first requirement is a 90% compliance for submitted 5-day prospective payment system (PPS) Minimum Data Set (MDS) assessments and Medicare Part A PPS Discharge assessments, indicating they contain 100% of the required MDS data elements answered on the MDS. The second requirement is 100% compliance with submission of healthcare provider (HCP) COVID-19 vaccinations at least one week during a month for a quarter and HCP influenza vaccinations at least annually to the National Healthcare Safety Network (NHSN). The reporting period for the influenza vaccination is for the flu season of October 1 to March 31. Providers are required to submit at least a summary of vaccination status of all eligible HCPs by the May 15 submission deadline.
Reports Recommended for Monitoring Compliance
The following reports are recommended to be downloaded from the Internet Quality Improvement and Evaluation System (iQIES) and reviewed on a routine basis to monitor compliance and make appropriate corrections throughout each quarter so that a SNF will meet the cumulative compliance rate for the entire year.
MDS 3.0 Final Validation Reports are generated and received with each MDS submission it makes to the iQIES database. It is important to review these reports carefully when received. Any assessment missing data elements will have a message of “Payment Reduction Warning.” It will also indicate what MDS item(s) are causing the warning. This allows the facility the opportunity to review the assessment and correct as appropriate.
The SNF QRP Provider Threshold Report (PTR) is a user-requested, on-demand report in iQIES that allows SNFs the opportunity to monitor compliance in real time as it is updated as soon as assessments are received in the database. It is critical for tracking MDS/NHSN compliance and APU eligibility. This report shows the number and percent of noncompliant assessments. It is important for the SNF to run this report routinely on the same schedule as MDS submission to monitor compliance and adjustments to the MDS threshold. NHSN values are also represented on this report with HCP COVID-19 vaccination measure updated quarterly and the HCP influenza vaccination measure updated twice a year. Data collection end dates are represented along with compliance/noncompliance with monthly submissions. NHSN updates occur soon after the data collection deadlines.
The MDS 3.0 Nursing Home Error Detail Report will assist in identifying which MDS assessments in the iQIES database contain errors. This report displays assessment and error message details of missing data elements identified as “Payment Reduction Warning” with submissions within a requested date range. Error messages of -3897 (5-day assessments) and -3908 (PPS Discharge assessments) will need to be entered when running the report in iQIES. The report will display the date of submission, resident’s name, data element(s) causing the error, and the data value that was submitted for the affected item(s) for any assessment with the warning. This allows the facility to research and correct any errors and resubmit the PPS 5-day or PPS Discharge assessment before the current final submission deadline of 4.5 months after the close of the reporting quarter.
NHSN Data Verification
When submitting NHSN data, it is important to make sure the information entered is complete and accurate. The best way to verify your current NHSN data submission is by running the CMS report located in the Analysis Reports section of NHSN. Detailed guidance on how to run and interpret the reports can be found on the Centers for Disease Control and Prevention (CDC) NHSN homepage. It is also recommended to run and maintain a copy of the data screen entry record.
CMS has contracted with Swingtech to send notifications to SNFs that are failing to meet the MDS submission threshold and/or the NHSN submission threshold in advance of each quarterly final submission deadline.
SNFs considered to be noncompliant with data submission will receive a noncompliant notification in iQIES, by email, or U.S. Postal Service. This notification is usually sent at the end of July and will inform the SNF of its need to submit a request for reconsideration or a request for extension of a request for consideration within 30 days of the date on the noncompliance letter. All requests for reconsideration must be communicated by email to [email protected].
How Forvis Mazars Can Help
As the U.S. population ages rapidly, senior living and long-term care organizations face mounting pressures, from workforce shortages and regulatory shifts to evolving reimbursement models and rising acuity levels. Our dedicated professionals can help providers navigate this complexity with confidence, agility, and purpose. If you have any questions or need assistance, please contact us.