After a misfire, the first Skilled Nursing Facility Quality Reporting Program (SNF QRP) Review and Correct Reports for the data collection period of Jan. 1, 2017 – March 31, 2017, are now available to SNFs. (See the notice here.) This data collection period will remain open so that providers can continue to make relevant MDS submissions or corrections until the data correction deadline 4.5 months later on Aug. 15, 2017. As of that date, the MDS data for that quarter will be frozen for the purposes of meeting the SNF QRP data submission threshold for the MDS-based SNF QRP quality measures (QMs), as well as for the upcoming SNF QRP public reporting.
Providers can use the Review and Correct Reports “in conjunction with other CASPER reports to determine any reporting errors that may affect performance for those quality measures,” said officials with the Centers for Medicare & Medicaid Services (CMS) during a May 2 webinar to explain how the Review and Correct Reports work. (Access the recorded webcast here, the webcast slides here, and the participant Q&A document here.) Here are key takeaways from the webinar:
Where to find them
The Review and Correct Reports, which only include observed raw facility-level data on assessment-based QMs, are available via the CASPER reporting mechanism in the QIES ASAP system. Instructions on how to access these user-requested reports are provided in Section 13, “SNF Quality Reporting Program,” of the CASPER Reporting User’s Guide for MDS Providers. In addition, webinar Q&As #1, #11, and #49 contain useful information about requesting and then finding the reports. (See excerpt at the end of this article.)
It’s important to note that, according to webinar Q&A #1, “Providers will not receive notification when new quarterly data are available in the Review and Correct Reports. New quarterly data will be available in the Review and Correct Reports on the first day following the end of a calendar quarter (January 1, April 1, July 1, and October 1).” According to this schedule, the next quarterly Review and Correct Reports for the April 1, 2017 – June 30, 2017, data collection period will be available on July 1, 2017, and providers will subsequently have until Nov. 15, 2017, to finalize MDS submissions/corrections for that data collection period.
The Review and Correct Reports contain the following header information:
· Report title, setting, and report number;
· Report run date and number of pages;
· CMS Certification Number (CCN);
· Facility name;
· Address (street, city/state, ZIP code, county); and
· Telephone number.
“You want to carefully review the data about your facility, including your provider name and the CCN,” said CMS officials. Neither the CMS central office staff who handle the SNF QRP e-mail box nor the QIES Technical Support Office Help Desk (firstname.lastname@example.org or 877-201-4721) can check or change the facility header information. Providers must contact either their Medicare administrative contractor (MAC) or their CMS regional office to make corrections to facility-identifying information, they stressed.
The Review and Correct Reports currently cover three MDS-based SNF QRP QMs:
· Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)
o CMS Measure ID: S002.01;
· Application of Percent of Residents Experiencing One or More Falls With Major Injury (Long Stay) (NQF #0674)
o CMS Measure ID: S013.01; and
· 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)
o CMS Measure ID: S001.01.
For each of these SNF QRP QMs, the Review and Correct Reports will include the following information, according to Section 13 of the CASPER Reporting User’s Guide for MDS Providers:
· Table Legend, which provides important information for interpreting results. This states:
o Medicare Part A stay (SNF stay): A Medicare Part A stay includes consecutive time in the facility starting with the Medicare Part A Admission record (PPS 5-day assessment with A0310B = ) through the Medicare Part A Discharge record with A0310H =  and all intervening assessments.
o Dash (-): Data not available or not applicable.
· Reporting Quarter: The quarter and calendar year for which the data were collected.
· Start Date: Beginning date of the reporting quarter.
· End Date: Ending date of the reporting quarter.
· Data Correction Deadline: The date after which the data for the reporting quarter are frozen. This deadline will be one of the following dates:
o Q1 (1/1 – 3/31): August 15;
o Q2 (4/1 – 6/30): November 15;
o Q3 (7/1 – 9/30): February 15; or
o Q4 (10/1 – 12/31): May 15.
· Data Correction Period as of Report Run Date, which will be designated either open or closed:
o Open = As of the Report Run Date, the data correction deadline of the reporting quarter is either today or in the future; data may still be corrected.
o Closed = As of the Report Run Date, the data correction deadline is in the past; data can no longer be corrected and affect the QM results or the data submission thresholds.
· Number of SNF Stays Included in the Numerator for This Measure.
· Number of SNF Stays Included in the Denominator for This Measure.
· Your SNF’s Observed Performance Rate, i.e., the (numerator / denominator) x 100. This facility-level QM rate is an observed raw rate that is not risk-adjusted. Risk-adjusted QM results will be available via the upcoming Quality Measure Reports (scheduled for release in October 2017) and Provider Preview Reports (scheduled for release in June 2018).
What data will be updated when
The Review and Correct Reports will be run on a quarterly basis, but also will be updated weekly to incorporate any data submissions/corrections for the associated quarter during an open data collection period. Webinar Q&A #8 explains the update schedule:
Data for the Review and Correct Reports are updated or refreshed as follows:
· Weekly measure calculations: Performed in the early morning hours every Monday.
· Quarterly measure calculations: To allow a quarter to be displayed on the CASPER Review and Correct Report as soon as that quarter is completed, the Review and Correct quality measures are calculated and updated in the early morning hours of the first day of the following quarter. (This is essentially an extra weekly run that occurs on the first day of a new quarter.)
· End-of-quarter calculations: To “close” a quarter, the Review and Correct quality measures are calculated and updated 4.5 months after that quarter is completed; on the 16th day of February, May, August, and October, the quarter will be processed and marked as “closed.”
NOTE: New or corrected records (with target dates during the quarterly period) that were submitted after the Data Correction Deadline will not be included in the weekly quality measure calculations for the Review and Correct Report.
How much data will be available
The first quarterly Review and Correct Report for the data collection period of Jan. 1, 2017 – March 31, 2017, is the only report that will have a single quarter of data, noted officials. “After the first quarter, quarter 2 is added to that Review and Correct Report. So cumulative data is going to be displayed as we add more quarters of data. When a new reporting data year begins, the oldest quarter will drop off. So we will always have four rolling quarters once we reach that total of four quarters. Providers are able to obtain their aggregate performance for up to the past four quarters as the data are available.”
The newest quarter will always be added to the top of the Review and Correct Reports, said officials. For example, the Q1 2018 report will display in descending order: Q1 2018, Q4 2017, Q3 2017, Q2 2017, and the cumulative results for the entirety of those four quarters from the start date of April 1, 2017, to the end date of March 31, 2018.
“When you are looking at your Review and Correct Reports, you want to be careful that you are also looking at the measures that specify for that particular report that you’re running,” stressed officials.
How to interpret the results
To determine whether a high or low observed performance rate is better, providers need to consider the individual SNF QRP QM, said officials. “Lower results are better” for Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) and Application of Percent of Residents Experiencing One or More Falls With Major Injury (Long Stay). However, higher results are better for Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function.
Additional resources for understanding the SNF QRP QMs include the following:
· SNF QRP Measure Calculations and Reporting User’s Manual;
· Technical Specifications Table for Reporting Assessment-Based Measures for FY2018; and
· Technical specifications for the QMs, which are available here.
How and when to find quarterly Review and Correct Reports
The Review and Correct Reports will be available to providers on a quarterly basis.
To identify whether new quarterly data are available, providers should follow these steps:
· Login to the CMS Network using the CMSNet User ID and password.
· Access the Welcome to the CMS Quality Improvement and Evaluation System (QIES) Systems for Providers web page.
· Select the Certification and Survey Provider Enhanced Reports (CASPER) link. Enter your QIES User ID and password on the QIES National System Login page.
· On the CASPER Home page, select the Reports button from the menu bar. A list of report categories will display in the left frame of the page.
· Select the … SNF … Quality Reporting Program (QRP) link, and a list of quality measure reports will display in the right frame of the page.
· Select the … SNF … Review and Correct Report link, and the CASPER Report Submit page will display.
· Verify the quarter and year option that displays in the End Date field. The quarter and year End Date option will automatically be updated on the first day following the end of the previous calendar quarter. The most current quarter and year option will display by default; however, older quarter and year options will also be available for selection.
As with other user-requested CASPER reports, the completed reports will be automatically saved into the requester’s My Inbox folder in the CASPER Reporting application. Here are the steps to locate the completed report:
· Following a report submission request, users receive verification that the report request was placed into the queue for processing. If desired, users can select the Queue button from the CASPER toolbar to view the status of a requested report. Select the Refresh button to refresh the CASPER Report Queue page so that you can monitor the progress of your report.
· When your report is no longer listed on the CASPER Report Queue page, it is done processing. Select the Folders button, and a list of folders associated to the user will be displayed in the left frame of the web page.
· Select the My Inbox link, and a list of the completed report links will display in the right frame of the web page, with the newest report at the top. The report link names identify the type of report in the folder[, e.g., SNF Review and Correct Report].
Review and Correct Reports will remain in CASPER folders for 60 days. However, it is important that providers use the Review and Correct Reports while the Data Correction Period is still open so that they can correct information if needed. Therefore, obtaining and using the reports shortly after they become available is advised. [In addition,] providers can save this information per their facility guidelines.
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