• COVID-19: CMS Issues SNF QRP / SNF VBP Guidance Memo (3/20)

    Friday, March 27, 2020 | CMS

    DATE: March 27, 2020

    TO: MLN Connects Newsletter and Other Program-Specific Listserv Recipients

    FROM: [Program-Specific Listservs, Partner Listservs (e.g., NHSN), ESRD Networks, CMS Emergency web page]

    SUBJECT: Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19

     

    The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 under certain Medicare quality reporting and value-based purchasing programs for acute care hospitals, Prospective Payment System (PPS)-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, longterm care hospitals, ambulatory surgical centers, renal dialysis facilities, and Merit-based Incentive Payment System (MIPS) eligible clinicians for all providers and suppliers participating in the programs described below across the United States and its territories in response to the 2019 Novel Coronavirus (COVID-19) pandemic.

     

    On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19.2 This memorandum supplements and provides additional guidance to health care providers with regard to the announcement. The scope and duration of the exceptions under each Medicare quality reporting program and value-based purchasing program are described below. CMS is granting exceptions and extensions for certain deadlines to assist these health care providers while they direct their resources toward caring for their patients and ensuring the health and safety of patients and staff. In some instances, these exceptions and extensions are granted because the data collected may be greatly impacted by the response to COVID-19 and therefore should not be considered in the quality reporting program. CMS is closely monitoring the situation for potential adjustments and will update exception lists, exempted reporting periods, and submission deadlines accordingly as events occur.

     

    Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities (IRFs), LongTerm Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs)

    CMS is granting an exception to the Quality Reporting Program (QRP) reporting requirements for all HHAs, Hospices, IRFs, LTCHs and SNFs. In accordance with 42 C.F.R. 412.560(c), 412.634(c), 413.360(c), 484.245(c), these providers are excepted from the reporting of data on measures, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and standardized patient assessment data required under these programs for the post-acute care (PAC) quality reporting programs for calendar years (CYs) 2019 and 2020 for the following quarters specific to each program:

    • SNFs–Skilled Nursing Facility QRP
    • October 1, 2019–December 31, 2019 (Q4 2019)
    • January 1, 2020–March 31, 2020 (Q1 2020)
    • April 1, 2020–June 30, 2020 (Q2 2020)

     

    CMS finalized the SNF VBP Program’s Extraordinary Circumstances Exception (ECE) Policy in the FY 2019 SNF PPS final rule (83 FR 39280 through 39281). In accordance with § 413.338(d)(4)(iv) for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program, CMS will exclude qualifying claims from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for the following periods:

    • January 1, 2020–March 31, 2020 (Q1 2020)
    • April 1, 2020–June 30, 2020 (Q2 2020)

     

    PAC QRP Extraordinary Circumstances Exception Request Information For further information about exceptions, view the program-specific web pages:

    SNF Quality Reporting Reconsideration and Exception & Extension or email questions toSNFQRPReconsiderations@cms.hhs.gov

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  • CMS Relaxes SNF QRP Data Submission Requirement Changes, SNF VBP Data Changes Due to COVID-19 (3/20)

    Monday, March 23, 2020 | CMS

    CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. These actions are part of CMS’s response to 2019 Novel Coronavirus (COVID-19).

     

    Specifically, CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines that will impact both the SNF QRP and the SNF VBP.

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  • CASPER Reporting User’s Guide for MDS Providers UPDATED (3/20)

    Monday, March 23, 2020 | QTSO
    Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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  • Tuesday March 17: CDC WIll Hold COVID-19 Call for Nursing Homes

    Sunday, March 15, 2020 | CDC

    Coronavirus Disease 2019 (COVID-19) Update and Information for Long-term Care Facilities

    During this COCA Call, presenters will focus on current information about COVID-19 as it relates to long-term care facilities, including nursing homes. Topics will include infection prevention and control guidance, steps facilities should take to prepare, and available resources.

    Special Request: Due to the high demand we anticipate for this COCA Call, we kindly ask participants to access it in a group format, if possible, to allow for the maximum number of people to participate.

     

    Watch on Facebook: You may also participate in this COCA Call by joining COCA's Facebook Live.  

     

    Advanced registration is not required.

     

    Continuing Education will not be offered for this COCA Call. 

     

    There will only be a few slides for this COCA Call. Slides will not advance during the presentation portion of this webinar. You can find the slides under the "Call Materials" tab here.   


    Date: Tuesday, March 17, 2020

    Time: 2:00pm–3:00pm (ET)

    Please click the link below to join:
    https://zoom.us/j/148725646

    Or iPhone one-tap:
    US: +16468769923,,148725646# or +16699006833,,148725646#   

    Or Telephone:
    US: +1 646 876 9923 or +1 669 900 6833 

    Webinar ID: 148 725 646

    International numbers available: https://zoom.us/u/anixAVglV

    If you are unable to attend this live COCA Call, it will be available to view on-demand a few hours after the call. 

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  • Developing a Restful Environment Action Manual (DREAM) Toolkit From CMS (2/20)

    Tuesday, February 18, 2020 | CMS

    As many as 70% of adults with dementia experience sleep disturbances, which are associated with various negative health outcomes. High quality sleep is necessary for optimal cognitive and physical functioning, especially for residents who already experience cognitive decline due to dementia. The DREAM Toolkit provides educational material and practical tools for nursing home staff to help all residents living with dementia improve sleep quality. Nursing homes can choose from a variety of strategies in the DREAM Toolkit to help improve quality of life and quality of care, especially for residents living with dementia.

    The DREAM Toolkit consists of the following components:

    1) Implementation Guide

    2) Handbook

    3) Sleep Matters Video: https://youtu.be/2Ub55iKej84  

    4) Pocket Guide for Clinical Teams

    5) Sleep Environment Improvement Tool

    6) Resident Preferences Tool

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  • Head to Toe Infection Prevention (H2T) Toolkit From CMS (2/20)

    Tuesday, February 18, 2020 | CMS

    Infections comprise a large share of adverse events in nursing homes. The Head to Toe Infection Prevention Toolkit contains educational materials and practical tools to support the clinical team in providing person-centered care that helps prevent and control common infections like pneumonia, skin infections, and urinary tract infections. The Toolkit aims to educate licensed nurses and nurse aides on infection prevention practices and provide tools that can be integrated into their daily work.

    The H2T Toolkit consists of the following components:

    1) Implementation Guide

    2) Infection Prevention Handbook

    3) Staff Presentation

    4) Resource for Residents and Loved Ones

    5) Observation Guide

    6) Customizing Care Tool

    7) Suspected Infection Investigation Tool

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  • Do You Know Who Your New QIN-QIO Is? (2/20)

    Wednesday, February 5, 2020 | Staff

    In November 2019, the Centers for Medicare & Medicaid Services quietly implemented the 12th Statement of Work for the Quality Improvement Network Quality Improvement Organizations (QIN-QIOs).

    This five-year contract includes a shift in how/where the QIN-QIOs operate. There are now 14 Medicare-funded QIN-QIOs nationwide. For example, IPRO is a lead contractor partnering with two other QIOs to cover 11 states and the District of Columbia. IPRO will direct activities in New York, New Jersey, and Ohio; Healthcentric Advisors will cover all six New England states (Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island); and Qlarant will handle Maryland, Delaware, and the District of Columbia.

    "QIN-QIOs serving under the 12th Statement of Work will provide customized quality improvement to nursing homes and providers, serving rural communities and the most vulnerable populations. Through this body of work, CMS is focusing on results, protecting taxpayer dollars, and most importantly, ensuring the safety and quality of care delivered to every Medicare beneficiary," says HealthCentric Advisors.

     The QIN-QIOs will address nursing home and community coalition quality improvement in the following areas:

    • Improving Behavioral Health Outcomes – Including Opioid Misuse
    • Increasing Patient Safety
    • Increasing Chronic Disease Self-Management
    • Increasing the Quality of Care Transitions
    • Improving Nursing Home Quality
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  • MDS 3.0 Quality Measures (QM) User's Manual V13.0 (2/20)

    Wednesday, February 5, 2020 | CMS

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage.

    The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage. The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.
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  • Five-Star Technical User's Guide Plus Claims-Based Measures Appendix (2/20)

    Tuesday, February 4, 2020 | CMS

    CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in October 2019.


    October 2019 Revisions

    In October 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected the health inspection and quality measure domains. This section provides details on these changes.

    Ratings changes for facilities that receive the abuse icon: To make it easier for consumers to identify facilities with instances of non-compliance related to abuse, starting in October 2019, CMS added an icon to highlight facilities that meet either of the following criteria: 

    1. Harm-level abuse citation in the most recent survey cycle: Facilities cited for abuse where residents were found to be harmed (Scope/Severity of G or higher) on the most recent standard survey or on a complaint survey within the past 12 months. 
    2. Repeat abuse citations: Facilities cited for abuse where residents were found to be potentially harmed (Scope/Severity of D or higher) on the most recent standard survey or on a complaint survey within the past 12 months and on the previous (i.e., second most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13 to 24 months ago). 

    Nursing homes that receive the abuse icon have their health inspection rating capped at a maximum of two stars. Due to the methodology used to calculate the overall rating, the best overall quality rating a facility that receives the abuse icon can have is four stars. 

    Removal of quality measures related to pain: CMS removed two quality measures (QMs) from the Nursing Home Compare website and the Five-Star Quality Rating System in October 2019. These measures are: 

    • Percentage of short-stay residents who report moderate to severe pain. 
    • Percentage of long-stay residents who report moderate to severe pain. 

    As a result of dropping these two measures, the cut-points for the long-stay, short-stay, and overall QM ratings changed. These changes were made to maintain, as close as possible, the same distribution of short-stay and long-stay QM ratings as were posted on Nursing Home Compare in July 2019. 

    January 2020 addition: Technical specifications for claims-based measures

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  • CMS to Provide Consumer Portal to Nursing Home Compare, Other Compare Sites (1/20)

    Monday, January 27, 2020 | CMS

    Making it Easier to Compare Providers and Care Settings on Medicare.gov

    CMS plans to improve online comparison tools to inform health care decisions

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