Two MDS/Staffing Focused Surveys in Virginia, THIS MAKE 3. WE ARE LOOKING FOR TWO MORE.

First Virginia MDS Survey:
2 deficiencies – 
1 tag ---unnecessary med (resident sent out to hospital x 2 days and when he returned we failed to reactivate behavior monitoring on the MARs for his Seroquel, 
another tag ADM – incomplete, inaccurate medical record tag on same resident for having the seroquel listed as PO on MARs when it was given via PEG

Second Virginia MDS Survey:
Three citations:
F278 MDS Accuracy:  
Missed coding a UTI on a quarterly. The surveyor correctly identified the four criteria for coding UTI and they were all in the chart.  It was just missed by the MDSC.
Coded an indwelling catheter when it was discontinued prior to the lookback
Incorrectly coded a pressure ulcer as unstageable when it was Stage IV.  It had been unstageable prior to  lookback but was stage 4 in lookback.

F329  unnecessary drugs
failed to monitor for effectiveness,  side effects, interventions and behaviors for Seroquel on two residents. Seroquel with inadequate reason for one resident.

F356:   Didn't post staffing per requirements

Judy's opinion on this one:  These MDS citations suggest to me that they may have been copying and pasting previous MDSs without verifying accuracy for lookback


THIS IS THREE VIRGINIA SURVEYS NOW.  WE ARE LOOKING FOR TWO MORE THEN WE ARE DONE FOR THIS FY.  IF ANYONE KNOWS OF THE OTHER TWO,  PLEASE LET ME KNOW.  

Report of an MDS/Staffing Focused Survey

This is a report of an MDS Focused Survey from the Aanac list serve.  This is one person's experience.  Her advice is just that,  and not all of her advice is based in regulatory requirements.  I am printing this for the walk through of her experience:  

They walked into the facility and got right to it. One of them went out on the floor with the MDS Coordinator while the other spoke with the DON/Administrator. They handed out the letter to the administrator (found  on AANAC, I believe).

-They didn't hand out any surprises. What is available on AANAC is what they handed to us. They did request that the MDS Worksheet be handwritten. They wanted a policy for each column on the worksheet (except Skilled, LTC, Extensive Asist of Two). We didn't have a policy for UTIs, but the Infection Control policy was given instead and they "were fine with it" per the DON.

- The "Extensive Assist of Two" column - the MDS Coordinator went by the resident's most recent MDS.

- They wanted to know why Sig Changes were done, so if you're not noting the reasons why in the nurse's notes, I'd suggest starting...

- Overall, they weren't *as* focused on the MDS as I'd thought they would be. They zeroed in on psychotropics and catheters, making sure each resident had documented justification for the catheter, making sure dose reductions and behaviors were documented for the psychotropics.

- They did ask specifically (per the MDS Coordinator) for "MD Documented Behaviors" for residents on psychotropics. In this case, the MDS Coordinator was able to find an MD progress note that did document on behaviors. But honestly, I've not heard of any requirement that the MD documents on behaviors....usually it is the nurse who documents on the behaviors, sends that fax to the MD, and s/he decides what to do. So, we'll have to start doing something different in all of our facilities. This was not an issue at all with the regular state survey we had at a different facility last week.

- Remember that per current best practices, foley caths should be changed PRN, not monthly. If the MD orders otherwise, we should educate the MD as to current best practices, and the MD can decide what to do.

- Make sure that if a resident has a catheter, any pertinent diagnosis are captured in Section I.

- They did watch some pressure ulcer dressing changes. They were very happy with weekly wound documentation, which clearly shows the wound progress.

- This may not even be worth mentioning, it was just a hunch the MDS Coordinator got. The surveyors seemed to want to know how well the MDS Coordinator knew the CNAs. They asked her to go out on the floor and introduce them to CNAs, and they'd ask her, "Now what's her last name...?" Maybe they were just honest questions. But the MDS Coordinator said her radar went up. It "felt" to her like they wanted to make sure the MDS Coordinator had a relationship with the CNAs.

- Staffing was a big part of the survey. Per the staff, it felt like two different surveys - one was the MDS Focused Survey, the other was the Staffing Survey. The staff kept on trying to figure out the relationship between the two. But, nobody knows what that relationship is.  Just make sure your staffing sheets and staffing ratio sheets are updated...

- I heard that for some MDS Focused surveys, the surveyors had obviously just learned the MDS process themselves. That was definitely NOT the case here.

- The surveyors were extremely kind and understanding, and I'm not just saying that on the offchance they are reading this ha. Coffee and rolls were provided to them, and they were appreciative of that. I only mention it because it's such a small gesture - why not do it? We did *not* do that with the surveyors we had in our facility last week, and the atmosphere was 100% different. I'm not saying coffee and rolls make all the difference, but I think it may play a small role in making them feel appreciated and welcome, rather than unwanted and in a hostile environment. 

CMS adds new portal in QAPI webpage highlighting adverse drug events in NHs

Adverse Events in Nursing Homes

Office of Inspector General Report: Adverse Events in SNFs:  National Incidence among Medicare Beneficiaries

In February 2014, the Office of Inspector General (OIG) released its report Adverse Events in SNFs:  National Incidence among Medicare Beneficiaries.   It reported that one in three skilled nursing facility (SNF) beneficiaries were harmed by an adverse event or temporary harm event within the first 35 days of their skilled stay.  The OIG determined that nearly 60 percent of those events were preventable.

Click here to access the OIG report - Adverse Events in SNFs:  National Incidence among Medicare Beneficiaries

Potentially Preventable Adverse Events in Nursing Homes

In its report on adverse events, the OIG recommended that CMS collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop and promote a listing of potential events that occur in nursing homes to raise awareness of adverse events that harm to nursing home residents.  Using the OIG study, CMS and AHRQ worked together to create a list of the most common potentially preventable adverse events.

Click here to access a listing of Potentially Preventable Adverse Events

Adverse Drug Events in Nursing Homes

Of all the events identified in the OIG report, 37 percent were related to medication.  The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use causing harm ranging from hospitalization to death.
These findings are further supported by Propublica data reported in a recent Washington Post article which stated, “…from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin. It is clear that adverse events related to high risk medications continue to be pervasive with devastating effects to nursing home residents.

During its collaboration with AHRQ, CMS began work to develop and test a Focused Survey on Medication Safety Systems that looks at nursing home practice around high-risk and problem prone medications, such as warfarin.  One of the foundational tools for the survey grew from the listing of potentially preventable adverse events.  CMS envisions this tool as a resource document containing necessary information for evaluating high risk medications.  It was designed to be a crosswalk that lists:

• common potentially preventable adverse drug events
       • risk factors related to those events,
       • triggers – signs, symptoms, or clinical interventions which could indicate that the adverse drug event has occurred, and
       • probes which would assist surveyors in evaluating systems around high risk medications.

Click here to access the CMS Adverse Drug Event Trigger Tool

Click here to access the Washington Post article: Popular blood thinner causing deaths, injuries in nursing homes.

Adverse Events Tools and Resources

CMS will add resources and tools as they become available, which may assist nursing home providers to identify, track, and systematically investigate adverse events that have occurred; as well as develop and implement systemic interventions that will help prevent adverse events.

• Page last Modified: 08/25/2015 11:18 AM

Updated Information for Payroll Based Journal

August 27, 2015

Updated Information for PBJ Electronic Staffing Data Submission

The following documents are now available in the “Downloads” section below:

     - “PBJ QTSO Registration and Training 8-4-15”: Instructions on how to register for voluntary submission and other PBJ training information.  Registration is OPEN and ALL Long-term Care facilities are encouraged to register for the voluntary submission period beginning October 1, 2015.

     - “PBJ Policy Manual DRAFT (V1.1) 8-25-15”: The draft policy manual has been updated to reflect recent changes to submission guidelines. Changes are indicated in red text.

     - “PBJ Policy Manual FAQ 8-25-15”: A list of frequently asked questions and answers about PBJ instructions and policies.

• PBJ QTSO Registration and Training 8-4-15 [PDF, 77KB]
• PBJ Policy Manual Draft (V1.1) 8-25-15 [PDF, 845KB]
• PBJ Policy Manual FAQ 8-25-15 [PDF, 99KB]

 Or

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

CMS Moves Forward with a Payment Model called the "Initiative to Reduce Avoidable Hospitalizations"

The Centers for Medicare & Medicaid Services (CMS) today announced a new funding opportunity designed to enhance the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The funding opportunity will allow the organizations currently participating in the Initiative to apply to test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by nursing facility residents.

For the past three years, CMS has partnered with seven Enhanced Care and Coordination Providers (ECCPs) to test a model to improve care for long-stay nursing facility residents. The ECCPs collaborate with 144 nursing facilities across seven states—Alabama, Indiana, Missouri, Nebraska, New York, Nevada, and Pennsylvania—to provide on-site staff for training, to provide preventive services, and to improve the assessment and management of medical conditions (see fact sheet).

The intent of the new payment model is to reduce avoidable hospitalizations by funding higher-intensity interventions in nursing facilities for residents who may otherwise be hospitalized upon an acute change in condition. Improving the capacity of nursing facilities to treat medical conditions as effectively as possible within the facility has the potential to improve the residents’ care experience at lower cost than a hospital admission. The model also includes payments to practitioners (i.e., physicians, nurse practitioners and physician assistants) similar to the payments they would receive for treating beneficiaries in a hospital. Practitioners would also receive new payments for engagement in multidisciplinary care planning activities.

“This Initiative has the potential to improve the care for the most frail, most vulnerable Medicare-Medicaid enrollees—long term residents of nursing facilities,” said Tim Engelhardt, Director of the Medicare Medicaid Coordination Office. “By aligning financial incentives, we can improve the quality of on-site care in nursing facilities and the assessment and management of conditions that too often now lead to unnecessary and costly hospitalizations.”

This new four-year payment phase of the Initiative, slated to begin October 2016, will be subject to a rigorous external evaluation to determine the effects on cost and quality of care. Successful ECCP applicants would implement the payment model with both their existing partner facilities, where they provide training and clinical interventions, and in a comparable number of newly recruited facilities.

The Initiative is a collaboration of the CMS Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation, both created by the Affordable Care Act to improve health care quality and reduce costs in the Medicare and Medicaid programs. The Initiative complements broader administration efforts to improve long term care facilities, including proposed updates to the conditions of participation for nursing homes, improvements to the five star rating system for consumers, and implementation of the new Skilled Nursing Facility Quality Reporting Program that ties skilled nursing facility payment to the reporting of quality measures.

Click here to view the CMS Fact sheet issued: http://cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-27.html

Florida MDS focus survey result

last week:  One D F278 left anti anxiety Med off quarterly.

VIRGINIA CCRC CHARGED WITH DISCRIMINATION UNDER THE FEDERAL FAIR HOUSING ACT: BALANCING RESTRICTIONS AND RESIDENT RIGHTS August 18th, 2015

This is a client advisory from my business attorney, Peter Mellette:

Peter's contact information:

Mellette PC

428 McLaws Circle
Suite 200Williamsburg, VA 23185

Phone: (757) 259-9200

Toll-Free: (877) 635-5388

Fax: (757) 259-9201

Email: inquiry@mellettepc.com

Introduction

A recent case may require residential health care providers—particularly continuing care retirement communities (CCRCs)—to carefully evaluate policies that could restrict resident access to facility amenities based on a resident’s level of care. In a recent consent order with the U.S. Department of Justice (DOJ), Harbor’s Edge, a Norfolk, Virginia CCRC, settled allegations that the facility was in violation of the federal Fair Housing Act (FHA). 1

The Complaint alleged that the facility employed discriminatory policies and practices in violation of the FHA by restricting assisted living and nursing facility residents’ access to independent living dining rooms and limiting attendance by such residents at marketing and other events. DOJ also alleged discrimination against non-ambulatory residents due to the CCRC’s requirement of a non-refundable deposit and purchase of liability insurance for the use of motorized wheelchairs and scooters. The CCRC defended its policies as reasonable to ensure the health and safety of its residents. Nevertheless, Harbor’s Edge agreed as part of the settlement to adopt new policies that would balance the facility’s health and safety concerns with FHA requirements and the protection of residents’ rights to the satisfaction of DOJ. 2

Although Harbor’s Edge is a CCRC, the issues involved could apply in any healthcare setting where residents of different levels of care congregate or in any facility that has policies permitting or limiting the use of motorized mobility devices.

Dining Rooms & Events

DOJ’s allegations stemmed from a 2011 Harbor’s Edge policy that limited assisted living, memory care, and nursing facility (collectively “healthcare center”) residents’ access to dining facilities and events located in the independent living portion of its community. The facility revised this policy several times following initial implementation, but all versions restricted access by at least some healthcare center residents to varying degrees.

The DOJ cited all four variations of the policy in its complaint against Harbor’s Edge. The most restrictive version of the policy prohibited all healthcare center residents and their guests from eating in any of the independent living dining rooms and from attending any events held in the independent living building. The least restrictive policy variation—and the one in place at the time of the Complaint—allowed any resident of the healthcare center to take meals and attend non-marketing events in the independent living building if they passed a health screening, obtained physician consent, and signed a release of liability. The facility asserted that it implemented the policy in response to “medical incidents involving Assisted Living and Nursing residents in the [independent living] dining room ….” DOJ alleged that the policies violated FHA’s prohibition of discrimination in the provision of services or facilities on the basis of disability. Such discrimination could include “a refusal to make reasonable accommodations in rules, policies, practices, or services, when such accommodations may be necessary to afford such person equal opportunity to use and enjoy a dwelling.” 3

As a remedy for the alleged violations, DOJ required Harbor’s Edge to adopt new policies governing resident access to amenities. The Harbor’s Edge Consent Order and the newly imposed policy demonstrates that the DOJ is mindful of the particular challenges of balancing FHA rights with the need to protect residents from preventable harm and comply with regulatory requirements. Dining rooms are often operated and staffed in accordance with regulatory criteria applicable to a particular level of care. The potential risk to residents requiring assistance or supervision with meals is especially heightened with regard to independent living dining rooms, which may be largely unmonitored. The policy also explains that special diets are not offered in all dining rooms, and intake cannot be appropriately monitored and documented. 4

The Consent Order policy attempts to balance these concerns with residents’ rights to equal access to services by acknowledging a baseline right to eat in a dining room and participate in facility events, but subjecting that right to reasonable conditions and restrictions. Conditions to dining room access and use contained in the Order’s policy include:

• Abiding by any required dress code, adhering to reservation and guest policies, and complying with all other applicable rules and regulations;
• Notifying the resident’s assigned dining room of the intent to eat in a different dining room no later than during the preceding meal; and
• Arranging for a private duty aide to accompany and assist the resident, as needed.

The new policy also allows Harbor’s Edge to require all residents to execute a Release of Responsibility for Leave of Absence form prior to using a residential dining room or attending a residential event, and residents may be required to sign an Against Medical Advice (AMA) form and Liability Release. The policy also provides that the facility may restrict dining room and/or event access for reasons such as contagion or infection or based on other medical conditions that limit the resident’s ability to eat in a particular dining room or attend an event in a safe and non-disruptive manner. A nurse, physician, or the Level of Care Committee may impose the restriction but must promptly refer the resident to the FHA Compliance Officer, who is required to assist the resident in identifying potential reasonable accommodations and coordinate a follow-up review with the Committee or individual who imposed the restriction.

Establishment of FHA Compliance Officer & Level of Care Committee

The Order further requires that Harbor’s Edge establish a Fair Housing Act Compliance Officer and a Level of Care Committee to ensure both the monitoring and enforcement of FHA standards and appropriate safeguards based on the level of care individual residents require. The facility must now document all evaluations of a resident’s abilities related to dining, attending events, and operating motorized wheelchairs or scooters and any requests for reasonable accommodations.

Motorized Mobility Devices

The Consent Order also addressed Harbor’s Edge’s concerns involving motorized wheelchairs; it provides that Harbor’s Edge may not require residents to pay a non-refundable deposit or purchase liability insurance as a condition to operating a motorized wheelchair or scooter on the premises. The facility may, however, require a resident to pay for any injury or damage actually caused by a failure to operate the device safely or otherwise in accordance with facility policies. Under the Consent Order policy, the facility may prohibit motorized devices from an area of the facility only if “they pose a direct threat to either the safety of the individual or others or would result in physical damage to the property of others, including Harbor’s Edge.” The policy also outlines safety provisions a resident must follow, including adhering to speed limits, maintaining safe distances, following parking requirements, and keeping entrances and exits clear. Finally, the policy requires that residents sign a Motorized Mobility Aid Agreement, acknowledging their understanding and willingness to abide by all of the policies and procedures governing the use of these devices.

The facility cannot require a resident to prove the need for a motorized mobility device, but the Consent Order policy outlines certain events that allow the facility to require the resident to prove his/her ability to safely operate such a device.

Conclusion

Long-term care facilities should consider reviewing their current written policies and/or unwritten practices related to any restrictions on residents’ movement and access to common areas within the facility. The policies and procedures described and included in the Harbor’s Edge Consent Order may serve as helpful guides for facilities in reviewing and updating their own practices, but adoption of such policies and procedures does not guarantee FHA compliance. Legal counsel can also assist facilities in assessing the relative risks to resident health and safety, on the one hand, and claims of discriminatory or overly restrictive practices, on the other. 5

Should you or your organization have any questions regarding FHA compliance in the patient care setting, please contact Peter Mellette (Peter@mellettepc.com), Harrison Gibbs (Harrison@mellettepc.com), Nathan Mortier (Nathan@mellettepc.com), or Nicole Hartz (Nicole@mellettepc.com) or call Mellette PC at (757) 259-9200.

Thanks to Cait Riccobono, University of Richmond Law ’15 for her assistance in preparing this advisory.

This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice.

_________________________________________________________________________________________________

1 42 U.S.C. § 3604(f).

2 The Consent Order is available through the DOJ website and by clicking here.  

3 42 U.S.C. § 3604(f)(3)(B).

4 Additional risks and complications facilities should consider may include whether information regarding dietary restrictions, allergies, and other relevant conditions for all residents are readily accessible by staff in all parts of the facility or community. Residents also have the right to enjoy meals and social events free from disturbance and disruption by inappropriate behavior.

5 In light of violations cited by DOJ at Harbor’s Edge, it is prudent to also keep in mind Section 1557 of the Affordable Care Act, which may permit an individual to bring a private right of action if facility policies have a disparate impact on them. Before Section 1557, the U.S. Supreme Court held an individual member of a protected class could only bring a claim for intentional discrimination and not disparate impact (i.e., circumstances that result in treating individuals differently even if the discrimination is not intended). The practical effect of this distinction is that an individual could not bring a claim against a facility for facially neutral policies, even if those policies had the unintended consequence of treating people differently on the basis of factors such as disability, race, or payor source. Facilities might now be liable strictly on the basis of how their policies affect individual residents whether they intend discrimination or not. Cases regarding the scope of Section 1557 in the lower courts have reached different conclusions about whether and to what extent Section 1557 modifies existing case law. The issue is likely to reach the U.S. Supreme Court in the foreseeable future.

Categories: Client Advisory

MDS Focused Survey Results: Illinois Actual Harm Citation (G) for F323

Our facility received F 279, F 280, F314, F323, F 278 and F 356. Centered around care plan, revising care plans (especially falls), development of pressure ulcer with low risk, accidents and supervision for not completing a root cause analysis on ALL falls and posting of nurse staffing.

Spent a lot of time on the floor, watched wound care and reviewed 10 medical charts with a census of 96. Reviewed mixture of Medicaid and Medicare. Requested multiple policies (staffing posting, restraint, pressure ulcers, catheters, indwelling catheters, care of UTIs, antipsychotics, gradual dose reduction of antipsychotics, non-pharm interventions of antipsychotics and fall prevention.

Requested immediately:

Facility data sheet, resident roster, list of catheters (insertion and diagnosis), restraints (dates initiated), log of pressure sores, UTIs for past 6 months and accident/incidents since Jan 2015.

It was as stressful as an annual survey. Was interesting because they were not well versed on the MDS, e.g. tried to tell us that the when the NAC signs the MDS she is responsible for accuracy of all sections of the MDS. Pulled references to show they were wrong.

From Judy:  They got a G in F323,  for a fall with injury.  Facility did not update/review the care plan after each fall so could not prove they reviewed and revisied care plan to prevent further injury from falls."

More MDS Focused Survey Results Florida

We got 2 Ds and 1 F.  D in F278 for not coding neurogenic bladder for a foley cath.  One Care Plan D for not having a chair alarm on the care plan.  An F for not having the staffing sheet in readily accessible view in the right format.  We got a CMP for the staffing sheet.  When questioned,  they said the 3 tags together justified the CMP.  They were unorganized and definitely did not have it all together.  Hope this helps some other poor victim.

----it does and we thank you,  Judy Brandt

MDS Focused Survey Results

Mississippi: two citations, missed Sig Change and MDS accuracy

MDS focused survey Tennessee

One deficiency: didn't code Abilify as an antipsychotic

MDS Focused Survey Results Maine and New York

New York:  One citation on posting staffing
Maine  Two citations:  Posting staffing and MDS error

New MDS sections posted; Effective Oct 1 2016

July 30, 2015

The Minimum Data Set (MDS) final 2016 Part A Discharge (End of Stay) (NPE/SPE) item set and a document containing the final MDS 3.0 Sections A and GG can be found in the Downloads section below. Additionally, the final SNF QRP specifications for the quality measures adopted through the FY 2016 final rule can be found in the Downloads section at the bottom of this page.

• MDS 3.0 SECTIONS A AND GG DOCUMENT [PDF, 351KB]
• Part A PPS d/c [PDF, 397KB] (this is the NPE/SPE item set)
• SNF specs [PDF, 472KB] (this is the final SNF QRP specifications)

or

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html

There is also an archive page now where they put the older outdated materials: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting-Archives.html

Recent MDS Focused Survey Results

California:
"We did have 2 deficiency and its under F278
1. ...when the facility did not code an active diagnosis in the MDS ( this is in regard to foley catheter we have the diagnosis of Urinary Retention but was not coded in Section I1800 other active diagnosis)
2. The facility failed to develop policy and procedures for the coordination of coding and completion of MDS assessment"

North Carolina:
2 more deficiency free.  That makes three deficiency free surveys in NC.  None of those teams had the state RAI coordinator present.  She is on the other team and all of them have had citations.

SNF Final Rule Published

To be clear, there are two 'rules' now that impact our industry.  This is the usual, expected, SNF Final Rule that is published every year at the end of July for FY16.  The OTHER proposed final rule to overhaul the LTC regulations (survey book)  is still a proposed final rule.  That one is the greatest change to our regulations since OBRA 87.  It is life changing.  

Here is the direct link to the SNF Final Rule for FY16:

https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-18950.pdf

Final fiscal year 2016 payment and policy changes for Medicare Skilled Nursing Facilities

Overview

On July 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1622-F] outlining Fiscal Year (FY) 2016 Medicare payment rates for skilled nursing facilities (SNFs). The FY 2016 rates and other issues discussed in the final rule are summarized below.

The final rule promotes policies that continue to shift Medicare payments from volume to value. The Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. The final rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.

Changes to Payment Rates under the SNF Prospective Payment System (PPS)

Based on final changes contained within this final rule, CMS projects that aggregate payments in FY 2016 to SNFs will increase by $430 million, or 1.2 percent, from payments in FY 2015. This estimated increase is attributable to a 2.3 percent market basket increase, reduced by a 0.6 percentage point forecast error adjustment and further reduced by 0.5 percentage point, in accordance with the multifactor productivity adjustment required by law.

SNF Quality Reporting Program (QRP)

The Improving Medicare Post-Acute Care Transformation Act of 2014 (P.L. 113-185) (IMPACT Act), enacted on October 6, 2014, requires the implementation of a quality reporting program for SNFs and standardized data reporting across four post-acute care settings, including home health agencies, inpatient rehabilitation facilities, skilled nursing facilities and long term care hospitals.

Beginning with FY 2018, SNFs that do not satisfactorily report required quality data to CMS under the SNF QRP will have their market basket percentage updates reduced by two percentage points.

For the FY 2018 SNF QRP and subsequent years, CMS proposed and is finalizing the adoption of three measures addressing three quality domains identified in the IMPACT Act: (1) skin integrity and changes in skin integrity; (2) incidence of major falls; and (3) functional status, cognitive function, and changes in function and cognitive function.    

The finalized measures are identified below in the Summary Table of Domains and Finalized Measures for the SNF QRP. CMS intends to propose additional quality measures and resource use measures in future rulemaking.

Summary Table of Domains and Finalized Measures for SNF Quality Reporting Program

Domain	Finalized Measures
Skin Integrity and Changes in Skin Integrity	Outcome Measure: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-Stay) (NQF #0678; Measure Steward: CMS)
Incidence of Major Falls	Outcome Measure: Application of Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674; Measure Steward: CMS)
Functional Status, Cognitive Function, and Changes in Function and Cognitive Function	Process Measure: Application of Percent of Patients or Residents With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF#2631) (Endorsed on July 23, 2015; Measure Steward: CMS)

SNF VBP Program

Section 215 of the Protecting Access to Medicare Act of 2014 added new subsections (g) and (h) to section 1888 to the Social Security Act (Act). New subsection 1888(h) authorizes the establishment of a Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program beginning with FY 2019 under which value-based incentive payments are made to SNFs in a fiscal year based on their performance on an adopted hospital readmission measure for this program.

Measures

The rule finalizes adoption of the Skilled Nursing Facility 30-Day All-Cause Readmission Measure, (SNFRM) (NQF #2510), as the all-cause, all-condition readmission measure that will be used in the SNF VBP Program. This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for SNF Medicare beneficiaries within 30 days of their prior proximal short-stay acute hospital discharge.

The Act also requires CMS to replace this measure with an all-condition, risk-adjusted potentially preventable hospital readmission rate. CMS intends to address this topic in future rulemaking.

Future Policy Considerations

In the proposed rule, CMS sought public comments on numerous issues related to the SNF VBP Program’s policies.  CMS intends to propose additional details of the SNF VBP in the FY 2017 SNF PPS proposed rule.

Staffing Data Collection

The Affordable Care Act of 2010 (Pub. L. 111-148, March 23, 2010) added a new section 1128I to the Act to promote greater accountability for LTC facilities (defined as skilled nursing facilities and nursing facilities pursuant to new subsection 1128I(a) of the Act). As added by the Affordable Care Act, subsection 1128I(g) pertains to the submission of staffing data by LTC facilities, and specifies that the Secretary, after consulting with state long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives and other parties the Secretary deems appropriate, shall require a facility to electronically submit to the Secretary direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Secretary in consultation with such programs, groups, and parties.

For more information

The final rule is on display at the Federal Register’s Public Inspection Desk at https://www.federalregister.gov/public-inspection#special-filing

For further information, see http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html.