SNF Quality Reporting Requirements: Important Updates From CMS

SNF quality reporting requirements are among the many evolving regulations with which skilled nursing facilities (SNFs) must comply. In this three-part blog series, I’ve been providing highlights from AAPACN 2024 about key topics at the conference — including important regulatory updates.

In my AAPACN 2024 presentation, “Don’t Let Your Infection Control Program Live in Isolation,” I provided a comprehensive overview of the latest updates, guidelines, and regulations from the Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), and CDC’s National Healthcare Safety Network (NHSN) — as well as the latest data around infection control in SNFs and how it has impacted elderly residents.

My first post, “AAPACN 2024: Hot Topics for Skilled Nursing Facilities,” covered two common themes that were important at the conference: infection surveillance and Enhanced Barrier Precautions.

In the second post, “SNF Regulations: Important Updates for Compliance,” I discussed the latest SNF regulations from the CDC and NHSN — as well as key findings of a recent report from the U.S. Department of Health and Human Services Office of Inspector General.

In this last post, I’ll wrap up the series with a look at important CMS updates.

SNF quality reporting: QRP quality measures

Although there have been changes to vaccine-related requirements, the SNF Quality Reporting Program (QRP) still includes two staff vaccination quality measures:

• SNF QRP Measure #11: COVID-19 Vaccination Coverage among Health Care Personnel (HCP) (CBE #3636) — which is reported one week per month via NHSN
• SNF QRP Measure #12: Influenza Vaccination Coverage among Health Care Personnel (HCP) (CBE #0431) — which must be reported at least once during the October-March period and is considered late by May 15

Failure to submit the required quality data will subject the SNF to a 2% reduction in the Annual Payment Update for the applicable performance year.

An additional claims-based quality measure tied to Infection Control is the SNF Healthcare Associated Infections (HAI) Requiring Hospitalization.

SNF quality reporting: Strengthened Enhanced Enforcement for Infection Control Deficiencies and QIO

On March 30, 2023, CMS issued revised guidance for Strengthened Enhanced Enforcement for Infection Control Deficiencies. A summary of Memorandum QSO-23-10-NH notes that the updated guidance:

• Strengthens enforcement efforts for noncompliance with infection control deficiencies
• Includes enhanced enforcement actions that are more stringent for infection control deficiencies that result in actual harm or immediate jeopardy to residents
• Expands the criteria for enhanced enforcement on infection control deficiencies that result in no resident harm to include enforcement on noncompliance with Infection Prevention and Control (F880) combined with COVID-19 Vaccine Immunization Requirements for Residents and Staff (F887)

Enhanced enforcement will be applied in the following instances, with progressively significant enforcement remedies:

• Noncompliance with both Infection Prevention and Control (F880) concurrent with COVID-19 Vaccine Immunization Requirements for Residents Staff (F887) requirements cited at Scope and Severity (S/S) Level 2
• Noncompliance for Infection Prevention and Control (F880) cited at S/S Level 3
• Noncompliance for Infection Prevention and Control (F880) at S/S Level 2

The Memorandum notes that Quality Improvement Organizations (QIOs) have been refocused to provide comprehensive support and technical assistance, specifically focusing on low-performing nursing homes that have historically faced challenges related to infection control. Additionally, states can request QIO technical assistance specifically targeted to nursing homes that have experienced an outbreak.

AAPACN 2024: other hot topics

In addition to those previously mentioned, other hot topics from the AAPACN 2024 lectures and updates from CMS representatives included:

• Patient-Driven Payment Model (PDPM) audits and surveys
• New risk-based survey (RBS) approach being tested by CMS
• Revision of staffing case-mix adjustment methodology to a PDPM model
• CMS focus on SNF Quality Reporting Program (QRP) Measures #6 and #7 regarding transfer of health information and SNF QRP Measure #9 regarding COVID-19 vaccine data capture
• Revision of staffing rating methodology so that SNFs failing to submit staffing data or submitting erroneous data will be audited and automatically receive a 1-star rating for staffing for the quarter in which the data are reported. Additionally, nursing homes that fail to submit data in order to calculate staff turnover will have their staff turnover measures excluded from the staffing rating calculation.
• SNF QRP related to health equity

To learn more about how the right technology can help your facility stay on track with the latest SNF quality reporting requirements, visit our clinical solutions page for more information, and set up a demo.

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