SNF Quality Reporting Program Public Reporting

Background:

The IMPACT Act of 2014 modified the Social Security Act requiring that Skilled Nursing Facilities be required to submit data for public reporting. In response, CMS established the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and authorized the Secretary to report quality measures that relate to care provided by SNFs on a CMS website. The SNF QRP data will be publicly reported on NH Compare. Please  visit the NH Compare website to view the SNF QRP quality data.

 

Quality Measures for SNF Public Reporting:
  • Discharge to Community- Post Acute Care (PAC) SNF QRP
  • Potentially Preventable 30-Days Post-Discharge Readmission Measure for SNF QRP

 

  • Medicare Spending Per Beneficiary –PAC SNF QRP
  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function- NQF #2631

 

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) - NQF #0674
  • Percent of Residents or Patients with Pressure Ulcers that are New or Worsened- NQF #0678*

* As finalized in the FY 2018 SNF PPS Final Rule, the Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (NQF #0678) measure was replaced in the SNF QRP by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury. Data collection for Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (NQF #0678) ended on September 30, 2018. Therefore, facility scores and national averages displayed in the July 2019 refresh (reporting period: 10/01/2017-09/30/2018) will reflect the last updated results for this measure and will remain on Nursing Home Compare until sufficient data has been collected for the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury measure to be reported (anticipated October 2020).

SNF Provider Preview Reports

Prior to the release of SNF QRP data on NH Compare, SNFs are given the opportunity to review their quality measure results during a 30-day preview period using a SNF Provider Preview Report, which will be issued quarterly by CMS. The purpose of these reports is to give SNFs the opportunity to review their quality measure results on each quality measure prior to public display on NH Compare. Reports can be accessed via the Certification and Survey Provider Enhanced Reports (CASPER) application, which is accessible from a SNF’s “Welcome to the CMS QIES Systems for Providers” page.

Instructions on how to access the reports are available in the Download section below.

SNFs will have 30 days to preview their quality measure results beginning on the date the reports are available. SNFs reviewing their preview reports will not be able to correct any of the underlying data, as all data submission/correction deadlines for the targeted period will have passed.

A SNF may request CMS review of the data contained within their provider preview report, should they believe it to be inaccurate (denominator or quality metric). All such requests must be made during the 30-day preview period.

Procedures for requesting CMS’ Review during Preview Period:

We encourage SNFs to review their data as provided in the SNF Provider Preview Reports. If a SNF disagrees with their quality measure results (denominator or quality metric) contained within their provider preview report, they will have an opportunity to request review of that assertion by CMS. In order to make such a request, SNFs must adhere to the process outlined below:

  • Requests may be submitted to CMS beginning on the day the SNF provider preview reports are available in their CASPER folders, and may be submitted through 11:59:59 p.m. PST on day 30 of the preview period.
  • CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
  • SNFs are required to submit their request to CMS via email with the subject line: “[Provider Name] SNF Public Reporting Request for Review of Data” and include their CMS Certification Number (CCN) (e.g., ABC Skilled Nursing Facility Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: SNFQRPPRquestions@cms.hhs.gov.      

The email request must include the following information:

  • SNF CMS Certification Number (CCN)
  • SNF Agency Name and Mailing Address
  • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address
  • Information supporting the SNF’s belief that the data contained within their preview report are erroneous, including, but not limited to, quality measures affected, and aspects of quality measures affected (denominator or quality metric)

    SNFs will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.

    • CMS will review all requests and provide a response outlining the decision via email. Please note that for SNF-identified errors resulting from inaccurate data submissions that a SNF failed to correct, will not be corrected. CMS will not consider correcting quality measure calculations that SNFs find to be inaccurate due to inaccurate or missing data that was identified beyond the applicable quarterly data submission deadline. 
    • Data that CMS decides/agrees to correct will be displayed during the subsequent quarterly release of SNF quality data on NH Compare.
    • The data used to generate the SNF provider preview reports are frozen for the upcoming NH Compare refresh, and corrections submitted after the generation of the SNF provider preview report will not be reflected until the next quarterly preview report is generated.

    Please note: The only method for submitting a request to CMS for review of your preview report data is via email (SNFQRPPRquestions@cms.hhs.gov). Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations in the request being submitted to CMS.

    Resources

    Sign up for SNF QRP updates today!

    SNF Public Reporting helpdesk: SNFQRPPRquestions@cms.hhs.gov

    Please continue to check this webpage for updates.

    Updates

    October 24, 2019

    Nursing Home (NH) Compare Quarterly Refresh with Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Data

    The October 2019 Nursing Home Compare Refresh, including quality measure results based on SNF QRP data submitted to CMS, is now available. For this refresh SNF QRP assessment-based measures performance scores will be based upon data submitted to CMS between Q1 2018 – Q4 2018 (1/01/18 – 12/31/18); claims-based measures performance scores will be based upon SNF Prospective Payment System (PPS) claims dated between Q4 2016 and Q3 2018 (10/01/16 – 9/30/18).

    CMS will no longer refresh the measure Percentage of Residents/Patients with Pressure Ulcers that are New or Worsened (NQF #0678), under the SNF QRP. The October refresh, as well as all subsequent refreshes of this quality measure data will be solely related to the CMS Nursing Home 5-Star Ratings.

    We are implementing the annual refresh of the SNF QRP claims-based measures during the October 2019 refresh of NH Compare. The annual refresh will include updates to the Medicare Spending per Beneficiary (MSPB) and Discharge to Community (DTC) measures. As previously announced, we have updated the methodology used to assign provider performance categories to the DTC measure. Additionally, this refresh includes the inaugural posting of provider performance scores for the Potentially Preventable Readmissions (PPR) measure, which were previously suppressed.

    For additional information on the update to the DTC methodology, we invite you to view the associated Fact Sheet (PDF) and/or FAQ (PDF).

    For additional information on the Potentially Preventable Readmission measure, please view the associated Fact Sheet (PDF) and/or FAQ (PDF).

    Please visit the NH Compare website to view the updated quality data.

    For questions about SNF QRP Public Reporting please email SNFQRPPRQuestions@cms.hhs.gov.

    August 15, 2019

    SNF Provider Preview Reports- Now Available

    Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. The data contained within the Preview Reports is based on quality data submitted by SNF’s between Quarter 1-2018 and Quarter 4-2018 for assessment based quality measures and between Quarter 4-2016 to Quarter 3-2018 for claims based quality measures. Providers have until September 16, 2019 to review their quality measures scores prior to the October 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate. 

    CMS will be posting quality measure scores for the SNF QRP Potentially Preventable Readmissions measure for the first time during this refresh. In addition to this, CMS has updated the methodology for assigning providers to performance categories for the publicly displayed SNF QRP Discharge to Community measure for the October 2019 refresh of NH Compare and beyond.                        

    • For additional information on the SNF QRP Potentially Preventable Readmissions (PPR) measure, we invite you to view the SNF QRP PPR Fact Sheet (PDF) and FAQ (PDF) documents.
    • For additional information on the change in methodology related to the SNF QRP Discharge to Community (DTC) measure, we invite you to view the SNF QRP DTC Fact Sheet (PDF) and FAQ (PDF) documents.
    • For additional information on accessing your facility’s preview report, please review the Preview Report Access Instructions (PDF).

    May 31, 2019

    Update of the Discharge to Community Measure for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

    The DTC-PAC measure was first displayed on the Nursing Home Compare website in fall 2018 and will be refreshed in fall 2019. CMS has refined the statistical methodology for assigning providers to performance categories for public display to align with the Potentially Preventable Readmissions measures in the PAC QRPs and the Hospital-Wide Readmission measure in the Inpatient QRP. This refinement results in greater variation in provider performance categories, allowing better discernment of providers that underperform or overperform considerably compared with the national rate. The refinement will be reflected for the first time in the fall 2019 Quarterly Refresh for the Nursing Home Compare website, and the related August 2019 Provider Preview Reports.

    Background

    • The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) directed the Secretary to specify and publicly report measures reflecting successful discharge to community for use in the SNF QRP.
    • The SNF QRP DTC measure was finalized in the Fiscal Year 2017 SNF PPS Final Rule. Confidential feedback reports were distributed to SNF providers in fall 2017 and the measures were first displayed on the Nursing Home Compare website in fall 2018.
    • For the fall 2019 public display refresh of the DTC measure, and in future years, CMS has refined the method by which we assign providers to performance categories to align with the claims-based Potentially Preventable Readmissions measures in the SNF QRP and the Hospital-Wide Readmission measure in the Inpatient QRP.
    • Our revised methodology results in greater variation in performance categories, allowing better discernment of provider performance, including those that underperform or overperform considerably compared with the national rate. This refinement will be reflected in the fall 2019 Quarterly Refresh of the Nursing Home Compare website, as well as the August 2019 SNF Provider Preview Reports.

    May 30, 2019

    Publication of Potentially Preventable Readmission Measures for the Post-Acute Care Quality Reporting Programs (QRPs)

    Beginning fall 2019, CMS will publicly display measure results on Nursing Home Compare for the Potentially Preventable 30-Day Post-Discharge Readmissions Measure adopted for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). We postponed publishing this measure in late 2018 to allow more testing to ensure it provides a reliable, accurate picture of provider performance on quality, in line with CMS’s Meaningful Measures Initiative to address high-priority areas for quality measurement with measures that will help improve patient outcomes while minimizing provider burden. We have since completed this additional testing and have refined the method for assigning providers to performance categories, in which their performance level is compared to the national rate.

    Background

    • The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 directs the Secretary to specify a measure that reflects all-condition risk-adjusted potentially preventable hospital readmission rates for use in the SNF QRP. The IMPACT Act also requires the Secretary to publicly report provider performance on resource use and other measures, including measures to reflect all-condition risk-adjusted potentially preventable hospital readmission measures.
    • CMS developed a potentially preventable 30-day readmission measure for the SNF QRP to meet the resource use and other measures domain as mandated by the IMPACT Act.
    • Since potentially preventable readmission rates are relatively low, we conducted additional testing to ensure that this measure reliably assesses a provider’s performance on quality. We postponed publishing this measure while conducting this additional testing.
    • We have since completed our additional testing and will publish this measure on the Nursing Home Compare website as part of the October 2019 Nursing Home Compare Quarterly Refresh.
    • As a result of the additional testing, we have refined our method for assigning providers to performance categories, which indicate their level of performance compared to the national rate (i.e., “no different than the national rate,” “better than the national rate,” and “worse than the national rate”). This refinement will also be reflected in both the October 2019 Nursing Home Compare Quarterly Refresh and the August 2019 Provider Preview Reports.

    May 1, 2019 

    SNF Provider Preview Reports- Now Available  

    Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. The data contained within the Preview Reports is based on quality data submitted by SNFs between Quarter 4 – 2017 and Quarter 3 – 2018, for assessment-based quality measures, and between Quarter 1 – 2017 to Quarter 4 – 2017, for claims-based quality measures. Providers have until May 30, 2019 to review their quality measure scores prior to the July 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.  

    For more information:

    April 24, 2019

    Nursing Home (NH) Compare Quarterly Refresh with Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Data 

    The April 2019 NH Compare Refresh, including quality measure results based on SNF QRP data submitted to CMS, is now available. For this refresh SNF QRP assessment-based measure performance scores will be based upon data submitted to CMS between July 1, 2017 and June 30, 2018; claims-based measure performance scores will be based upon SNF Prospective Payment System (PPS) claims dated between January 1, 2017 and December 31, 2017. Please visit the NH Compare website to view the updated quality data.

    For questions about SNF QRP Public Reporting please email SNFQRPPRQuestions@cms.hhs.gov.

     

    February 1, 2019

    SNF Provider Preview Reports- Now Available

    Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. Providers have until March 4, 2019 to review their performance data prior to the April 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.  

    The data contained within the Preview Reports is based on quality data submitted by SNFs during the following quarterly timeframes: 

    1. Quarter 3 – 2017 to Quarter 2 – 2018 data
      1. Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (#0674)
      2. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
      3. Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (#2631). 
    2. Quarter 4 – 2016 to Quarter 3 – 2017 data
      1. Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure
      2. Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

    January 31, 2019

    NH Compare Quarterly Refresh with SNF QRP Data

    The January 2019 quarterly Nursing Home (NH) Compare Refresh, including updated quality measure results based on SNF QRP data submitted to CMS, is now available.

    The updated SNF quality measure results are based on data submitted to CMS between:

    1. Quarter 2 – 2017 to Quarter 1 – 2018 data
    1. Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (#0674)
    2. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
    3. Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (#2631). 

        2. Quarter 4 – 2016 to Quarter 3 – 2017 data

    1. Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure
    2. Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) 

    As a reminder, CMS announced in October 2018 that it will not publish a 6th previously posted quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time. Additional time will allow for more testing to determine if modifications to the measure and method of displaying it are needed. This additional testing will ensure that the future publicly reported measure is thoroughly evaluated so Compare users have an accurate picture of provider quality. While we conduct this additional testing, CMS will not post reportable data for this measure, including each SNF’s performance, as well as the national rate.

    Please visit the NH Compare website to view the updated quality data.

    November 1, 2018

    SNF Provider Preview Reports- Now Available

    Skilled Nursing Facility Provider Preview Reports have been updated and are now available. Providers have until November 30, 2018 to review their performance data on quality measures based on Quarter 2 -2017 to Quarter 1 - 2018 data, prior to the January 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate. For help accessing your preview report, please refer to the SNF Preview Report Access Instructions located under the Downloads section of this webpage below.

    October 24, 2018

    Attention SNF Providers: Inaugural Release of SNF QRP Data on NH Compare

    In accordance with Section 1899B(g)(1) of the Social Security Act, which requires CMS to provide for the public reporting of SNF provider performance on the quality measures, CMS is announcing the inaugural release of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) quality data on Nursing Home (NH) Compare.

    Nursing Home Compare allows you to find and compare SNFs that are certified by Medicare and nursing homes that are certified by Medicaid. This website contains quality of resident care and staffing information for more than 15,000 nursing homes around the country, and will now additionally include SNF QRP quality data that can be used to compare SNF providers by their performance on important indicators of quality, such as the percentage of patients with new or worsening pressure ulcers, or the percentage of patients that experienced a fall and sustained a major injury. Specifically, the following five SNF QRP measures are now being displayed on the NH Compare site:

    Assessment-based measures:

    1. Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (National Quality Forum #0678)
    2. Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    3. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

    Claims-based measures:

    1. Medicare Spending Per Beneficiary-PAC SNF QRP
    2. Discharge to Community-PAC SNF QRP

    CMS has decided not to publish a 6th quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time.   Additional time would allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. This additional testing will ensure that the future publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality. While we conduct this additional testing, CMS will not post reportable data for this measure, including each SNF’s performance, as well as the national rate.

    Visit the NH Compare website to view the new SNF QRP quality data.

     

    June 05, 2018

    Public Reporting of SNF QRP Data on Nursing Home Compare - Coming Soon!

    Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) quality measure scores will be publicly reported on Nursing Home (NH) Compare. CMS will report information on SNFs across the nation allowing patients, family members, and health care providers to get a snapshot of the quality of care in each facility. SNFs can be compared based on important measures of quality, such as pressure ulcers and readmissions.

    The information on NH Compare:

    • Helps consumers make more informed decisions about where they get healthcare, and
    • Encourages SNFs to improve the quality of care that they provide to patients and their families.
    Page Last Modified:
    12/06/2019 02:45 PM