Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Public Reporting

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Public Reporting

Now available! Our new Provider Data Catalog makes it easier for you to search and download publicly reported data. We’ve also improved Medicare’s Compare sites.

Background

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 modified the Social Security Act requiring that SNFs be required to submit data for public reporting. In response, the Centers for Medicare & Medicaid Services (CMS) established the SNF QRP and authorized the Secretary to report quality measures that relate to care provided by SNFs on a CMS website.

Care Compare

Care Compare formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each SNF. This tool helps families compare some key quality metrics, such as pressure ulcers and readmissions, for over 15,000 SNFs across the nation.

Quality Measures for SNF Public Reporting

  • Discharge to Community (DTC) - Post Acute Care (PAC) SNF QRP
  • Potentially Preventable 30-Days Post-Discharge Readmission Measure (PPR) for SNF QRP
  • Medicare Spending Per Beneficiary (MSPB) – PAC SNF QRP
  • Skilled Nursing Facility Healthcare-Associated Infections (HAI) Requiring Hospitalization 
  • Application of Percent of Long-Term Care Hospital Patients (LTCH) with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC SNF QRP
  • Application of IRF Functional Outcome Measure: Change in Self-Care (Consensus Based Entity [CBE] #2633)
  • Application of IRF Functional Outcome Measure: Change in Mobility (CBE #2634)
  • Application of IRF Functional Outcome Measure: Discharge Self-Care Score (CBE #2635)
  • Application of IRF Functional Outcome Measure: Discharge Mobility Score (CBE #2636)
  • COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) (CBE #3636)
  • Influenza Vaccination Coverage among Healthcare Personnel (HCP) (CBE #0431) (beginning October 2023)

SNF Provider Preview Reports

Before Quality Measure (QM) data is publicly reported on Care 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 SNF QRP Data Submission Deadlines webpage.

Following the QRP data submission deadline, a quarterly Provider Preview Report issued by CMS displays the data that will be publicly reported. 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 Care Compare. Reports are available in the SNF Internet Quality Improvement and Evaluation System (iQIES).

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 the quality measure results to be inaccurate (numerator, 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 (numerator, 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 for CMS review of data may be submitted to CMS beginning on the day the SNF Provider Preview Reports are available in the SNF Internet Quality Improvement and Evaluation System (iQIES) folders 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 CCN
  • SNF Business Name
  • SNF Business Address
  • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address, i.e. not a post-office box
  • Information supporting the SNF’s belief that the data contained within the SNF’s Provider Preview Report are erroneous, including, but not limited to quality measures affected and aspects of quality measures affected (numerator, denominator or quality metric)

After submitting a request, 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 SNF-identified errors resulting from inaccurate data submissions that a SNF failed to correct prior to the applicable quarterly data submission deadline are not acceptable reasons for granting reconsideration. Also, CMS will not consider correcting quality measure calculations that providers find to be inaccurate due to missing data that was submitted 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 Care Compare.
  • The data used to generate the SNF Provider Preview Reports are frozen for the upcoming Care 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

July 26, 2023

Care Compare July Refresh of SNF QRP Data – Now Available

The July 2023 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by SNFs to Centers for Medicare & Medicaid Services (CMS) from Quarter 4, 2021 through Quarter 3, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure reflects data from Quarter 3, 2022. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization measure, Quarter 4, 2020 through Quarter 3, 2021.

In summary, the following SNF QRP measures will be displayed on Care Compare and PDC during the July 2023 refresh:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of Percent of Long Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633)
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Discharge to Community - PAC SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization
    • Q4 2020 – Q3 2021 (10/1/2020 – 9/30/2021)
  • National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)
    • Q3 2022 (7/1/2022 – 9/30/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about SNF QRP Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

July 14, 2023

SNF Provider Preview Reports – Now Available

The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the October 2023 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by SNFs from Quarter 1, 2022 through Quarter 4, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure reflects data from Quarter 4, 2022. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) measure, from Quarter 4, 2021 through Quarter 3, 2022.

Providers have until August 14, 2023 to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (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.

SNF Provider Preview Reports can be retrieved by:

  1. Select the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage.

NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

  1. Enter your QIES user ID and password on the QIES National System Login page.
  2. Select the Login button, review the contents of the U.S. Government-Authorized Use Only Window pop-up message box and select the OK button to proceed to the “CASPER Home” webpage.
  3. Select the Folders button from the menu bar.
  4. Select your provider’s shared folder from the Folders list on the CASPER Folders page. The folder will be named in the following manner: [State Code] LTC or SB [Facility ID] Where:

State Code = your 2-character state code

LTC = Nursing Home Providers

SB = Swing Bed Units

Facility ID = CMS-assigned facility ID used for submitting Minimum Data Set (MDS) records

NOTE: The SNF Provider Preview Reports will not be in your provider’s Validation Report (VR) folder.

  1. Select the desired SNF Provider Preview report link from the list of reports displayed on the right side of the CASPER Folders page and the report will display.

NOTE: The SNF Provider Preview report links are titled “SNF Provider Preview Report”.

For questions related to accessing your facility’s provider preview report, please reach out to the iQIES helpdesk at iqies@cms.hhs.gov or call 1-877-201-4721. For questions about SNF Quality Reporting Program (QRP) Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

April 26, 2023

Care Compare April Refresh of SNF QRP Data – Now Available

The April 2023 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by SNFs to Centers for Medicare & Medicaid Services (CMS) from Quarter 3, 2021 through Quarter 2, 2022. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization measure, Quarter 4, 2020 through Quarter 3, 2021. Lastly, the Centers for Disease Control and Prevention (CDC) measure COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) reflects data from Quarter 2, 2022 for this refresh.

In summary, the following SNF QRP measures will be displayed on Care Compare and PDC during the April 2023 refresh:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (Consensus Based Entity [CBE] #0674)
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (CBE #2633)
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (CBE #2634)
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (CBE #2635)
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (CBE #2636)
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Discharge to Community - PAC SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization
    • Q4 2020 – Q3 2021 (10/1/2020 – 9/30/2021)
  • National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)
    • Q2 2022 (4/1/2022 – 6/30/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about SNF QRP Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

April 14, 2023

SNF Provider Preview Reports – Now Available

The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the July 2023 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by SNFs from Quarter 4, 2021 through Quarter 3, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure reflects data from Quarter 3, 2022. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) measure, from Quarter 4, 2020 through Quarter 3, 2021.

Providers have until May 15, 2023, to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (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 questions related to accessing your facility’s provider preview report, please reach out to the iQIES helpdesk at iqies@cms.hhs.gov or call 1-877-201-4721. For questions about SNF Quality Reporting Program (QRP) Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

January 25, 2023

Care Compare January Refresh of SNF QRP Data – Now Available

The January 2023 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

The data are based on quality assessment data submitted by SNFs to Centers for Medicare & Medicaid Services (CMS) from Quarter 2, 2021 through Quarter 1, 2022. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization measure, Quarter 4, 2020 through Quarter 3, 2021. Lastly, the Centers for Disease Control and Prevention (CDC) measure (COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)) reflect data from Quarter 1, 2022 for this refresh.

In summary, the following SNF QRP measures will be displayed on Care Compare and PDC during the January 2023 refresh:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (Consensus Based Entity [CBE] #0674)
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (CBE #2633)
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (CBE #2634)
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (CBE #2635)
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (CBE #2636)
    • Q2 2021 – Q1 2022 (4/1/2021 – 3/31/2022)
  • Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Discharge to Community - PAC SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP
    • Q3 2019 – Q4 2019; Q3 2020 – Q2 2021 (7/1/2019 – 12/31/2019; 7/1/2020 – 6/30/2021)
  • SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization
    • Q4 2020 – Q3 2021 (10/1/2020 – 9/30/2021)
  • National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)
    • Q1 2022 (1/1/2022 – 3/31/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about SNF QRP Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

January 17, 2023

SNF Provider Preview Reports – Now Available

The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the April 2023 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by SNFs from Quarter 3, 2021 through Quarter 2, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure reflects data from Quarter 2, 2022. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021 for this refresh, and for the SNF Healthcare-Associated Infections (HAI) measure, from Quarter 4, 2020 through Quarter 3, 2021.

Providers have until February 16, 2023, to review their performance data. Corrections to the underlying data will not be permitted during this time. However, providers can request Centers for Medicare & Medicaid Services (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.

To locate the SNF Provider Preview reports, please follow these steps below:

  1. Log into the CMS Network (CMSNet) using the CMSNet login credentials.
  2. Log into the Certification and Survey Provider Enhanced Reporting (CASPER) application using the Quality Improvement and Evaluation System (QIES) login credentials.
  3. Select the Folders button from the menu bar in CASPER and a list of your folders will display.
  4. Select the facility-specific, non-Validation Report (non-VR) folder.  These folders will be named in the following manner:

For Nursing Home-based SNFs:

[State Code] LTC [Facility ID] (i.e., MD LTC XYZ123)

For Swing Bed units:

[State Code] SB [Swing Bed ID] (i.e., TX SB ABC987)

  1. The Preview Reports are listed in descending order by Date Requested within this folder.
  2. Select the desired preview report link to view the report.

For questions related to accessing your facility’s provider preview report, please reach out to the iQIES helpdesk at iqies@cms.hhs.gov or call 1-877-201-4721. For questions about SNF Quality Reporting Program (QRP) Public Reporting, please email SNFQRPPRQuestions@cms.hhs.gov.

SNF Quality Reporting Program Archives

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