LTCH Quality Reporting

Overview

Section 3004 of the Affordable Care Act directs the Secretary to establish quality reporting requirements for long-term care hospitals (LTCHs).

Quality Reporting

Section 3004 (see link below) requires the Secretary to publish, no later than October 1, 2012 the selected quality measures that must be reported by LTCHs.

Penalties for Failure to Report

For fiscal year 2014, and each subsequent year, failure to submit required quality data shall result in a 2% reduction in the annual payment update.

Public Availability of Reported Data

Section 3004 requires the Secretary to establish procedures for making data available to the public and requires the Secretary to establish procedures to ensure each LTCH has the opportunity to review the data that are to be made public with respect to that facility prior to such data being made public. No date has been specified to begin public reporting of quality data.

To read more about Section 3004 (Quality Reporting for Long-Term Care Hospitals, Inpatient Rehabilitation Facilities, and Hospice Programs) please note the link below for P.L. Public Law No: 111-148, the Patient Protection and Affordable Care Act.

Announcements

March 14, 2013 – IMPORTANT ANNOUNCEMENT

A change has been made to the LTCH data submission specifications and is scheduled to take effect as of April 21, 2013.  An errata document for V1.00.3 of the data submission specifications has been posted and is available under the Downloads section of the LTCH Quality Reporting Technical Information Page, which is accessible by selecting the link of the same name in the upper left hand corner of this webpage. 

Long-Term Care Hospital (LTCH) Quality Reporting Program Requirements for Payment Update Determination for Fiscal Years 2014 and 2015

Long-term care hospitals (LTCHs) are certified as acute-care hospitals that treat patients requiring extended hospital-level care, typically following initial treatment at a general acute-care hospital. If a hospital is classified as an LTCH for purposes of Medicare payments (as denoted by the last four digits of its six-digit CMS Certification Number [CCN] in the range of 2000–2299), it is subject to the requirements of the LTCH Quality Reporting (LTCHQR) Program.  As required by the LTCHQR Program, LTCH providers should currently be engaging in two types of activities: data submission for the Payment Year 2014 cycle and data collection and submission for the Payment Year 2015 cycle. Current activities for each cycle are detailed below.

Fiscal Year 2014 Payment Update Determination—Deadline for Data Submission: May 15, 2013

In the FY 2012 IPPS/LTCH PPS Final Rule (76 FR 51743 through 51756, and 51780 through 51781), three measures were adopted for data collection and reporting for October 1, 2012, through December 31, 2012, for the Fiscal Year (FY) 2014 Payment Update Determination: Percent of Residents with Pressure Ulcers That Are New or Worsened (NQF #0678), Urinary Catheter-Associated Urinary Tract Infection (CAUTI) (NQF #0138), and Central Line Catheter-Associated Bloodstream Infection (CLABSI) (NQF #0139). The deadline for submission of data for these three measures is May 15, 2013; to avoid a 2-percentage-point reduction in their Annual Payment Update, providers must submit data for all three measures by this deadline.  For most current definitions for the three LTCH quality measures, please refer to the LTCHQR Program Manual available under the Downloads section of this web page

The Percent of Residents with Pressure Ulcers That Are New or Worsened (NQF #0678) measure requires use of the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set Version 1.01, approved on April 24, 2012, by the Office of Management and Budget (OMB) in accordance with the Paperwork Reduction Act.  The OMB Control Number is 0938-1163, Expiration Date April 30, 2013. Details on the LTCH CARE Data Set technical submission specifications can be found at LTCH Quality Reporting Program Technical Information page, which is accessible by accessing the link of the same name in the upper left hand corner of this web page.

For the submission of data for CAUTI and CLABSI measures, the deadline for enrollment in Centers for Disease Control and Prevention’s (CDC’s) National Health Safety Network (NHSN) was December 31, 2012. If you have not registered with the NHSN, please visit the NHSN LTCH page, and contact the NHSN at NHSN@cdc.gov for additional guidance. Frequently asked questions about the NHSN enrollment process are available on the CDC website. 

Fiscal Year 2015 Payment Update Determination

In addition to engaging in data submission activities for the FY 2014 payment update determination, LTCHs should be engaging in data collection and submission activities for three measures for the FY 2015 payment update determination. Per the FY 2013 IPPS/LTCH PPS Final Rule (77 FR 53614 through 53637, and 53667 through 53672), data on the three measures, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678), NHSN CAUTI Outcome Measure (NQF #0138), and NHSN CLABSI Outcome Measure (NQF #0139), will be collected from January 1, 2013, through December 31, 2013.  For the four quarters in Calendar Year 2013 (i.e., January–March 2013, April–June 2013, July–September 2013, and October–December 2013), final submission deadline for data submission is August 15, 2013, November 15, 2013, February 15, 2014, and May 15, 2014, respectively, for FY 2015 payment update determination.

December 21, 2012

ATTENTION – IMPORTANT ANNOUNCEMENT FOR LTCH PROVIDERS!!

CMS has updated Appendix E of the LTCH QR Program Manual, which outlines which LTCH CARE Data Set items are required versus which items are voluntary.  Specifically, CMS has made a decision to require the submission of each patient’s social security number and first name.  Initially these two items were listed as voluntary, however, lack of submission of this data has led to inaccuracies related to patient record matching.  Please note that the required items will accept a default response, such as a dash (-) providing the data is unavailable to providers.  The use of a default response on required LTCH CARE Data Set items may lead to a 2 percentage point reduction in the facility’s annual payment update determination.  The updated version of Appendix E or the LTCH QR Program manual is available for download under the Downloads section of this web page below by selecting the link titled Appendix E version 1.1.

Quality Measure Submissions

It has come to the attention of CMS that a number of LTCHs are not submitting quality data to either the QIES ASAP system or the CDC’s National Health Safety Network.  If you are unsure of you CMS-certified LTCH provider status, or you are an LTCH provider that needs assistance with the submission of quality data, we urge you to contact CMS through the LTCH Quality help desk.  Access to the CMS LTCH help desk is available by selecting the link Email:  LTCHQualityQuestions under the Related Links section of this web page below.

Frequently Asked Questions

CMS has updated the Frequently Asked Questions (FAQ) document.  This version includes the questions and responses from the October 18, 2012 Special Open Door Forum as well as several question and responses from the LTCH Quality Questions help desk.  You can access the update FAQ document by selecting the link titled FAQs – LTCH QR version 3.0 December 21, 2012 under the Downloads section of this web page below.

October 18, 2012 LTCH Special Open Door Forum

The transcript from the October 18, 2012 LTCH Special Open Door Forum (SODF) is now available for download.  You can access the transcript by selecting the link titled October 18, 2012 LTCH SODF Transcript under the Downloads section of this web page below.  Information on how to access the MP3 audio from the SODF is available within the transcript document.  The transcript and audio file are also available on the CMS SODF website, which you can access by selecting the link titled Special Open Door Forums under the Related Links section of this web page below.

October 16, 2012

CMS will hold a Special Open Door Forum for LTCHs on October 18, 2012 from 2:30 p.m. – 4:00 p.m.  Topics will include updates from the Division of National Systems related to the submission of LTCH quality data, recent Frequently Asked Questions (FAQs), and a provider question and answer session.  The presentation materials that will be used during this SODF are now available for download.  The slide deck is accessible by selecting the link titled October 18, 2012 SODF Slide Deck under the Downloads section of this web page below; the FAQ document is accessible by selecting the link titled FAQs – LTCH QR Program v2.0 under the Downloads section of this web page below.  Please note that all FAQs presented during previous open door forums have been incorporated into this updated version.  We encourage all LTCHs to join us for this important call.  The call-in information is as follows:

10/18/12 Call Details:  Conference held from 2:30 p.m. – 4:00 p.m.

Conference ID: 25080375

Participant Dial-In Number(s): 
*Operator Assisted Toll-Free Dial-In Number:     (800) 603-1774

The transcript from the September 20, 2012 LTCH Special Open Door Forum (SODF) is now posted.  You can access the 9-20-2012 SODF transcript by selecting the link titled September 20, 2012 SODF Transcript under the Downloads section of this webpage below.  The 9-20-2012 SODF transcript is also available on the CMS Special Open Door Forum website along with the MP3 audio file from the SODF.  You can access the CMS SODF website by selecting the link titled Special Open Door Forums under the Related Links section of this web page below.

September 26, 2012

Attention all LTCHs!  Please make sure that your facility has registered with the Centers for Disease Control and Prevention’s (CDC) National Health Safety Network (NHSN) system, and that you have completed the requisite online trainings related to submitting data through the NHSN.  You must register with NHSN in order to submit the required quality data related to the CAUTI and CLABSI measures as outlined in the CMS FY 2013 IPPS/LTCH PPS Final Rule.  LTCHs can find additional information, including important CDC links and contact information in Chapter 5 of the LTCH QRP Manual, which is accessible by selecting the link titled “LTCH QRP Manual 1.1 [ZIP, 3MB]” under the Downloads section of this web page.

The Frequently Asked Questions (FAQ) document used during the LTCH Special Open Door Forum held on Thursday, September 20, 2012 is now posted.  The document contains FAQ’s received through the LTCHQualityQuestions mailbox as well as questions raised during previous LTCH open door forums.  The document is accessible by selecting the link titled “FAQ September 26, 2012” under the Downloads section of this web page.  The transcript and the audio file (MP3) from the September 20, 2012 LTCH SODF will be made available on the LTCH QRP website as well as the CMS Special Open Door Forum website in the near future.  CMS has additionally posted a Q & A document related to the QIES ASAP system, submissions, and processes which can be found at www.qtso.com/vendor.html (under LTCH Q & A). 

CMS has made a slight revision to Appendix E of the LTCH QR Program Manual in order to provide clarification.  CMS has replaced the previous version of Appendix E with the revised version of Appendix E in the LTCH QR Program manual.  In addition to this, we have posted an errata sheet outlining the changes made to Appendix E.  The errata sheet is accessible by selecting the link titled “Appendix E Errata Sheet – September 26, 2012” under the Downloads section of this webpage. The revised version of Appendix E is available by downloading the LTCH QRP Manual v1.1, which is accessible by selecting the link of the same name under the Downloads section of this web page.

September 17, 2012

CMS RELEASE OF LASER – LTCH Assessment Submission Entry and Reporting

LASER (LTCH Assessment Submission Entry and Reporting) is a java based application that allows Long-Term Care Hospital (LTCH) providers to collect and submit the LTCH Continuity Assessment Record & Evaluation (CARE) Data Set to the CMS national repository.  The software maintains facility, patient and assessment information.  LASER is free software.  Consult the LASER Installation Guide and LASER User Guide for further information.  These guides are contained within the downloadable software and are additionally available at www.qtso.com .  The LASER software is accessible by selecting the link titled “LTCH Assessment Submission Entry & Reporting (LASER) Software” under the Related Links section of this web page below.  For further information on WebEx trainings related to LASER, please go to the LTCH QRP Technical web page, which is accessible by selecting the link of the same name in the upper left hand corner of this web page.  Links to the LTCH Technical helpdesk mailbox are also located on the LTCH QRP Technical web page. 

The audio file (MP3 format) from the August 30, 2012 LTCH SODF is now available on the LTCH QRP webpage as well as the CMS Special Open Door Forum Web page.  The audio file is accessible by selecting the link titled “LTCH SODF Audio – August 30, 2012” under the Related Links section of this web page below.

September 10, 2012

The CMS LASER (LTCH Assessment Submission Entry Reporting) software will be posted in the very near future.  Please continue to monitor the LTCH QRP website frequently for the posting of this downloadable software.

The slides used during the August 30, 2012 LTCH Special Open Door Forum (SODF), during which we reviewed section M of the LTCH QRP Manual, as well as FAQs, are now available for download.  These slides contain the presentation used during the SODF as well as the most frequently asked questions (FAQs) that are submitted to the LTCH QRP help desk mailbox.  Please use this slide deck as a resource to review the FAQs associated with the LTCH QR Program.  Additional FAQs will be posted on the CMS LTCH QR Program web page in the near future.  The transcript of this SODF will be posted on the CMS LTCH QRP web page as well as the CMS Special Open Door Forums web page in the near future.  The audio file from this LTCH SODF has now been made available.  It is accessible by going to the CMS Special Open Door Forums Web Page (http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/index.html?redirect=/opendoorforums). 

An updated version of the CMS LTCH QRP manual will be posted quarterly on the CMS LTCH QRP website.  In order to inform providers of errors or changes to the content of the manual prior to those quarterly manual postings, we will periodically be posting an errata sheet that outlines corrections or updated language.  The first of these errata sheets is now available for download on this web page.  You can access the errata document by selecting the link under the Downloads section of this web page titled “LTCH QRP Manual Errata Sheet – Sept 2012”.  Any questions pertaining to the changes outlined in the errata document should be forwarded to www.LTCHQualityQuestions.com.

August 24, 2012:

• Please note updates to the technical trainings related to the LTCH CARE Data Submission and LASER that are available for downloading on www.qtso.com. (Information  provided on this page )
• The LTCH QRP Manual 1.1 has been updated:

The LTCH CARE Data Set with the new OMB Control number of  0938-1163  will replace Appendix C of the V 1.1 of the Manual posted on August 10, 2012.  The only change that was made to these data sets was to replace the old OMB Control number (0938-1037) with the new OMB Control number. These changes appear as follows:

The LTCH Quality Reporting Manual file titled LTCH QRP Manual Version 1.1 zip file has been replaced with the LTCH Quality Reporting Manual file titled LTCHQRP_Manual_V1.1_August_22_2012 so as to include the updated Appendix C.

No other changes were made to this file. This file can be found under downloads below.

• On August 1, 2012:  the National Quality Forum expanded the endorsement of the measure: Percent of Residents with Pressure Ulcers that are New or Worsened, to the LTCH setting.

August 10, 2012  

Please note that the “March 8 2012 LTCH Guidance” document previously available on this website is now included in the manual as an Appendix F.  Additionally, the specifications for the measure "Percent of Pressure Ulcers That are New or Have Worsened" are also included in the manual on the last page of Appendix F. 

Providers will be notified of any subsequent changes to the LTCH QRP Manual through the posting of an errata notice on the LTCH QRP Website and we will include these changes in our revisions to the manual. We intend post the manual’s revisions in a cyclical manner.  Please note that CMS will post an announcement related to any “high priority” changes that are included in the errata notice, and subsequently made  to the LTCH QRP Manual.

July 18, 2012

The LTCH CARE Data Submission Specifications have been updated and posted. The new version is V1.00.3.  This version addresses all of the issues that were addressed in the errata document that was posted in June, 2012.  These data specifications are effective for October, 2012 and are located on the LTCH Quality Reporting Technical Information page (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCHTechnicalInformation.html). You can also access The LTCH Technical web page is accessible by selecting the link of the same name in the upper left hand corner of this web page.   Additional information pertaining to the submission specifications is found on the LTCH Quality Reporting Technical Information page. LTCH software developers/vendors are encouraged to review specifications and submit questions specific to the LTCH CARE October, 2012 release to the LTCH Tech Issues mailbox (LTCHTechIssues@cms.hhs.gov). 

LTCH Quality Reporting  Program Training:

• The power point slide training materials from the May 1 & 2, 2012, National Train-the-Trainer Conference are now posted and are located under downloads. Video footage will be provided in the near future as well.

The following Power Point Slide files are provided in the two Zip Files located in Downloads:

• LTCH CARE Data Submission and LASER Trainings:

Training related obtaining user identification, data submission, data submission reports as well as the LASER tool  is now  being posted. CMS wants to ensure that LTCHs are aware of the following technical trainings related to the LTCH CARE Data Submission and LASER that are available for downloading on Quality Improvement and Evaluation System (QIES) Technical Support Office (QTSO) website (www.qtso.com):

LTCH Quality Reporting Data Submission Details

Percent of Residents with Pressure Ulcers That Are New or Worsened

Providers can find specifics related to the submission of the LTCH Quality Reporting Program's quality measures in the LTCH Quality Reporting Program Manual. This document is available below, under the Downloads section of this page. Details in this download include important information related to submission timing and deadlines for all three required quality measures. Additionally, this document includes the measure specifications for the measure titled Percent of Residents with Pressure Ulcers That Are New or Worsened.

HAI EVENT PERPORTING TO THE CDC VIA THE NHSN:

Urinary Catheter-Associated Urinary Tract Infections (CAUTI)

Central Line-Associated Blood Stream Infections (CLABSI)

In order to access details regarding data submission and reporting requirements for the two required Healthcare-Acquired Infection (HAI) measures, Urinary Catheter-Associated Urinary Tract Infections (CAUTI) and Central Line-Associated Blood Stream Infections (CLABSI), please access the CDC-NHSN link below, under Related Links. The CDC will be ready to appropriately enroll LTCHs in NHSN, and provide the correct annual facility survey for completion and specific locations for setup, beginning on Monday, February 6, 2012. Further guidance can be found on the NHSN website link below, under Related Links.

If you have feedback, comments or questions, regarding quality measurement for the long term care hospital, inpatient rehabilitation hospitals or hospice programs, please send your comments to our staffed email at LTCHQualityQuestions@cms.hhs.gov. Please note that this email has changed. In an attempt to better serve the public, CMS has created a separate web page for each of the quality reporting programs. Comments and questions can also be submitted by selecting the link titled Submit Feedback at the bottom of this page. LTCH-IRF-Hospice-Quality-ReportingComments@cms.hhs.gov.

If you would like sign up to receive listserv notices, please follow the link below, under Related Links, titled 'All Open Door Forum Mailing List Sign-up'.