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
  • 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. Reporting for the new measure is anticipated October 2020.

SNF Provider Preview Reports

 

Before QM data is publicly reported on Nursing Home Compare, SNFs have an opportunity to review and correct, as well as preview, their data. A Review and Correct Report is available for providers to access in the CMS reporting system, which will assist them in identifying whether there are any issues with the data already collected and submitted before the applicable quarterly data submission deadlines. Correction of any errors identified by the facility must be submitted by the final submission deadlines found in the Downloads section of the CMS SNF QRP Data Submission Deadlines web page CMS SNF QRP Data Submission Deadlines web page

A quarterly Provider Preview Report issued by CMS displays the data that will be publicly. 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

 

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).

SNF Quality Reporting Archives

Page Last Modified:
03/13/2020 10:13 AM