Inside the Tighter CMS Requirements for the Nursing Home Quality Reporting Program

The Centers for Medicare & Medicaid Services (CMS) hosted a webinar Tuesday focused on data submission related to quality reporting requirements for nursing homes.

To remain compliant, skilled nursing facilities (SNFs) must meet or exceed two data submission thresholds. From October 1 to December 31, SNFs must submit 80% of data containing 100% of required measures, with a higher threshold of 90% from January 1 to September 30. Failure to meet these thresholds may result in a 2% point reduction in the Annual Payment Update (APU), CMS officials said during the session.

The session centered on three primary data sources: Minimum Data Set (MDS), Medicare Fee-for-Service claims, and the CDC’s National Healthcare Safety Network (NHSN).


CMS also wants to incentivize innovation and technology adoption to drive care improvements, said Heidi McGladrey, program coordinator at CMS.

“The CMS National Quality Strategy has four priority areas, each with two goals,” said McGladrey. “These eight focused and interrelated goals include embedding quality into the care journey, advancing health equity, promoting safety to achieve zero preventable harm, fostering engagement to improve quality and build trust, strengthening resiliency in the health care system.”

McGladrey kicked off the webinar by providing an overview of the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and explained that the program, established in fiscal year 2016, was a result of the IMPACT Act of 2014, which had aimed to enhance Medicare post-acute care transformation.


Data Sources and submission requirements

Teresa Mota, associate scientist and nurse researcher with Abt Associates, discussed the critical role played by NHSN – CDC’s most widely used infection tracking system for monitoring infections and vaccinations among healthcare personnel.

There are new deadlines related to reporting data through NHSN for healthcare personnel influenza and COVID-19 vaccination coverage measures, she said.

Providers are required to submit one report May 15 covering the entire influenza season from October 1, 2023, to October 31, 2024. Reporting for healthcare personnel who are up to date with their COVID-19 vaccination began in the fourth quarter of last year, and subsequent data collection runs from January to December.

Quality Measures derived from Medicare FFS claims

Mota also delved into key quality measures derived from Medicare Fee-for-Service claims, including discharge to the community, post-discharge readmission rates, and healthcare-associated infections requiring hospitalization.

She said operators should monitor these measures closely to improve care coordination and efficiency.

With regard to Medicare FFS claims, Mota and McGladrey said that when it comes to the discharge to the community measure, the CMS goal is to see higher percentages for successful discharges back to the community without subsequent unplanned hospitalizations, and that a higher percentage will indicate successful transitions and better outcomes for residents.

With 30-Day post-discharge readmission rates, McGladrey and Mota said that lower readmission rates are desirable as they suggest that issues or conditions leading to readmissions may have been preventable, and monitoring and reducing readmission rates can help with care continuity.

Regarding the quality measure related to Medicare Spending Per Beneficiary, they explained that this measure compares Medicare spending on care episodes or residents in a specific skilled nursing facility with the national average. 

They noted that a spending ratio equal to the national average signifies comparable spending, while a higher or lower ratio indicates either higher or lower spending, respectively.

Mota said it is important to track and understand spending patterns to support care coordination, efficiency, and resource allocation within skilled nursing facilities.

“The Medicare Spending Per Beneficiary quality measure is a measure that’s displayed as a way to measure itself. [It] reflects where the Medicare spends about the same, more or less on an episode of care or resident in a specific SNF compared to all SNFs in the nation,” Mota said. “To interpret the ratio, you need to understand that ratio that is equal to the national average means that Medicare spending was about the same as all sickness in the nation.”

Annual Payment Update (APU) data submission requirements

McGladrey and Mota also discussed the new Annual Payment Update (APU) data submission requirements.

The new SNF QRP operates as a pay-for-reporting program rather than pay-for-performance, and the APU determination will be based on the submission of data and the subsequent calculation of quality measures.

They outlined the timeline for data collection and application of APU, noting a two-year delay between data collection and fiscal year application. For instance, data collected in 2023 will support fiscal year 2025 APU calculations.

McGladrey and Mota also delved into accessing and understanding IQ Reports for HQRP. Confidential reports aid providers in monitoring progress and APU compliance. The Provider Preview Reports offer a preview of measures that will be publicly reported, bridging confidential and public reporting realms, they said.

They noted that the Review and Correct report will have a vital role in assessing facility and resident-level quality measures, and stressed the importance of timely corrections and data accuracy to maintain compliance.

Addressing non-compliance, McGladrey said SNFs failing to meet compliance receive notifications and have the opportunity to request reconsideration within 30 days, subject to evidence and documentation guidelines.

In the Q&A portion, an operator asked about challenges with completing interviews related to unplanned discharges, particularly regarding the use of dashes and potential penalties, and if CMS would allow more time for completion and fair treatment in the future.

McGladrey said CMS does not plan to adjust the timeframes outlined in the MDS 3.0 User’s Manual.

“If the unplanned discharge assessment is combined with a PPS assessment, the use of a dash can have a negative impact on the facility Skilled Nursing Facility Quality Reporting Program compliance,” she said. “If this is a common occurrence, the facility may wish to adjust its practices to ensure the interviews are conducted as part of the admission assessment process.”

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