Last fall, the Centers for Medicare & Medicaid Services (CMS) released two new CASPER reports for the Payroll-Based Journal (PBJ) system that went under the radar at many nursing homes. However, these reports are worth paying attention to because nurse assessment coordinators (NACs) can use them to help assess the accuracy and timeliness of MDS census data, says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.
“Since CMS changed the staffing census to MDS data instead of data submitted to PBJ, many facilities have seen their staffing stars decrease in the Five-Star Quality Rating System,” says Maher. “But a lot of providers haven’t connected that decrease to the change to MDS census data—they seem to think it’s a mystery.”
The reports went live in conjunction with the news that CMS has begun informing state survey agencies when providers either have significantly low nurse staffing levels on weekends or several days in a quarter without an RN onsite, according to CMS Quality, Safety & Oversight (QSO) memo QSO 19-02-NH. The two reports are:
The MDS Census Summary Report. This report “allows users to retrieve the daily MDS-based resident census (i.e., count of residents) for each day in a quarter,” says CMS.
The MDS Census Detail Report. This report “allows users to retrieve a list of the residents that the MDS-based census is comprised of on a given date or dates,” says CMS.
“These reports use the same methodology CMS uses to calculate each facility’s census, which is then used to calculate the number of staff hours per resident per day posted on the Nursing Home Compare website,” the agency points out.
The most helpful of the two new reports is the MDS Census Summary Report, which should be run monthly, suggests Maher. This report can be run for the prior fiscal quarter, which is the default setting, or for the quarter to date, according to section 12, “PBJ Reports,” of the CASPER Reporting User’s Guide for PBJ Providers.
“For example, if you run the report for the prior fiscal quarter, it shows your actual census from your MDS data for each day in that quarter,” explains Maher. “It’s possible your MDS census may be off by one or two residents. The concern would be if you are off by a significant number. For example, if you have a 100-bed facility and the MDS census says you have 150 residents, you know that something is wrong. The most likely problem is that either your Discharge assessments or Death in Facility tracking forms weren’t completed and submitted timely.”
CMS tracks discharges using MDS item A0310F (federal OBRA & PPS entry/discharge reporting) = 10 (Discharge assessment-return not anticipated), 11 (Discharge assessment-return anticipated), or 12 (Death in Facility tracking record).
Discharge assessments must be completed (item Z0500B) within 14 days after the OBRA discharge date (A2000 + 14 calendar days) and then submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days), points out Maher. Death in Facility tracking records have a tighter time frame. They must be completed within seven days after the discharge (death) date (A2000 + 7 calendar days) and then submitted within 14 days after the discharge (death) date (A2000 + 14 calendar days).
“PBJ staffing calculations are done by quarter, and providers have 45 days after the close of each quarter to submit all of the required data. For example, the submission deadline for Jan. 1 – March 31 data is 11:59 p.m. eastern standard time on May 15,” says Maher. “So all of the Discharge assessments and Death in Facility tracking forms for residents who discharged or died in that quarter certainly should have been completed, transmitted, and accepted into the National Submissions Database well before that 45-day time frame is over.”
The MDS census isn’t connected to the number of certified beds, says Maher. “CMS connects the census to how many residents the MDS assessments indicate are still active. So if the Discharge assessments are late, it appears like those residents are still in your facility. For example, I have seen reports for a 100-bed facility that had a census of 300 residents because they didn’t do their Discharge assessments. Even though the facility had sufficient staffing for 100 residents, it obviously didn’t have enough staff for 300 residents, and its staffing star dropped as a result.”
So when the MDS Census Summary Report shows more residents than beds or more residents than are known to be in the building each day, it’s time to investigate further, says Maher. “The MDS Census Detail Report shows which MDSs were used in the calculation for that quarter, but honestly I find this report difficult to understand.”
NACs may find it easier to determine where the problem is by reviewing a report from the MDS side of CASPER: the MDS 3.0 Roster Report, suggests Maher. “This report, which can be found under the Nursing Home Provider Reports, will show you, according to the data in the federal database, which residents appear to be active residents in the nursing home. If there are names of people on that list who are no longer active residents—if they have discharged or died and they are still showing up—it usually is because the Discharge assessment or Death in Facility tracking record has not been completed. The Roster Report actually has resident names on it, so it’s a little easier to look at it and figure out, ‘Why is this person still on here?’”
Late MDS assessments have always been a survey issue, but now they are also a Five-Star issue, says Maher. “So MDS assessments not only need to be accurate for the quality measures, they also need to be timely because that staffing star is so important in the facility’s overall Five-Star rating.”
How to get reports
In mid-March, the QIES Technical Support Office (QTSO) at CMS announced that the Quality Improvement and Evaluation System (QIES) will be modernized, and that providers will be transitioned to the Internet Quality Improvement and Evaluation System (iQIES). Users will have to set up accounts in the Healthcare Quality Information System (HCQIS) Access Roles and Profile Management (HARP) system to access iQIES, but after that, iQIES should be easier to access and provide stronger reporting than QIES. (How providers actually submit data to CMS won’t change under iQIES.)
Long-term care hospitals have already made the switch to iQIES. In the fiscal year (FY) 2020 Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule (CMS-1718-P), CMS revealed plans to transition nursing homes to iQIES no later than October 1, 2021. While the switch could come earlier, nursing homes are scheduled to receive a critical QIES network update this June 30. Therefore, the process for obtaining reports as described below is likely to remain in place for a while.
Under the current process, unless providers (1) work with a third-party vendor that allows expanded access to the CASPER Reporting application, (2) have additional access via a corporate user account, or (3) have been approved by the QTSO to have a valid need for additional individual users, they are limited to two individual user accounts for MDS and PBJ combined, says Maher. “So usually the NAC or whoever submits MDSs and the staff member who submits PBJ data are the only two people in a facility who have access to CASPER reports.”
Users can only see the CASPER reports for systems they have permission to access. For example, if a facility gives the NAC access to both the MDS and PBJ systems, the NAC will be able to access both MDS and PBJ CASPER reports. However, if the NAC only has access to the MDS system, they will not be able to see PBJ reports in the CASPER reporting application and will need to either get access to PBJ or obtain PBJ reports from the PBJ staff person or a corporate user.
The QIES ASAP System Walkthrough and the Key CASPER Management and QM Reports charts provide:
(1) A comprehensive walkthrough of the MDS and PBJ data submission components of the QIES ASAP (Assessment Submission And Processing) system, and
(2) The full range of currently available CASPER nursing home and PBJ management reports and quality measure reports, including the traditional CASPER QMs used in Nursing Home Compare and Five-Star, the Skilled Nursing Facility Quality Reporting Program (SNF QRP) QMs, and the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) measure.
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