SNF QRP Purpose, Deadline and Quality Measures

Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

Data submitted via the MDS assessments and data submitted to CMS via the CDC NHSN for July 1, 2022 – September 30, 2022 (Q3) of calendar year (CY) 2022 are due no later than 11:59 p.m. on February 15, 2023. 

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) submission deadline refers to the date by which SNFs must submit data for certain quality measures as required by the Centers for Medicare & Medicaid Services (CMS). This data submission is a requirement for SNFs to receive their full annual payment update under the Medicare program. The SNF QRP measures assess the quality of care provided to patients in SNFs, and the information is used by CMS to publicly report on the quality of care in SNFs and to help consumers make informed decisions about their care.

The deadline is a crucial part of the program, as SNFs that fail to submit their data on time may be subject to financial penalties. To avoid these penalties, it is important for SNFs to ensure that they have completed all necessary steps and submitted their data by the deadline.

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) includes several quality measures that assess the quality of care provided to patients in SNFs.

Some of the most commonly reported measures include:

• Percentage of Residents or Patients with Pressure Ulcers
• Percentage of Residents or Patients Experiencing One or More Falls with Major Injury
• Percentage of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
• Percentage of Residents or Patients with a Urinary Tract Infection
• Percentage of Residents or Patients Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
• Percentage of Residents or Patients with a Catheter-Associated Urinary Tract Infection
• Percentage of Residents or Patients with an Unplanned Weight Loss
• Percentage of Residents or Patients Who Made Improvements in Physical Function

These measures are designed to assess various aspects of care provided in SNFs, such as the prevention of pressure ulcers, falls, infections, and unplanned weight loss, as well as the promotion of physical function. The data collected from these measures is used by CMS to publicly report on the quality of care in SNFs and to help consumers make informed decisions about their care.

Facilities should perform internal check by running reports from the below entities prior to each quarterly reporting deadline, to ensure that all required data has been submitted.

• CASPER (Certification And Survey Provider Enhanced Reports).
• iQIES (Internet Quality Improvement and Evaluation System).
• NHSN (National Healthcare Safety Network).

Where do the SNF QRP Measures come from?

Data for the SNF QRP Measures are collected and submitted through three methods:

I. Minimum Data Set (MDS) 3.0.

II. Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN).

III. Medicare Fee-For-Service Claims.

What are the SNF QRP Measures?

There are a total of 16 SNF QRP Measures used for the SNF QRP.

• 13 Measures are in effect today.
• 2 Measures will be implemented October 1, 2023 (Transfer of Health Data).
  • SNF QRP Measure #9: Transfer of Health Information to the Provider Post-Acute Care.
  • SNF QRP Measure #10: Transfer of Health Information to the Patient Post-Acute Care.
• 1 Measure is scheduled to be publicly reported for CY 2022.
  • SNF QRP Measure #16:  SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization.

There 16 SNF QRP Measures are numbered below.

I. MDS Assessment-Based Measures

Data collected using the MDS 3.0 and submitted to the Centers for Medicare & Medicaid Services (CMS) through the Assessment Submission and Processing (ASAP) system to the Quality Improvement and Evaluation System (QIES):

SNF QRP Measure #1: Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)

• This measure was finalized in the fiscal year (FY) 2016 SNF Prospective Payment System (PPS) Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46440 through 46444). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.

SNF QRP Measure #2: Application of Percent of Long Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function

• This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46444 through 46453). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.

SNF QRP Measure #3: Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP

• This measure was finalized in the FY 2017 SNF Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52034 through 52039). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #4: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

• This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36572 through 36577). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #5: Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633)

• This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36578 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #6: Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

• This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36580 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #7: Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

• This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36583 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #8: Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

• This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36584 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #9: Transfer of Health Information to the Provider Post-Acute Care

• This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38755 through 38761). Data collection for this measure will begin on October 1, 2023.

SNF QRP Measure #10: Transfer of Health Information to the Patient Post-Acute Care

• This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38761 through 38764). Data collection for this measure will begin on October 1, 2023.

II. CDC NHSN Measures

Data for this measure is submitted via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN):

SNF QRP Measure #11: COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)

• This measure was finalized in the FY 2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR 42480 through 42489). Data submission for this measure began October 1, 2021.

SNF QRP Measure #12: Influenza Vaccination Coverage among Healthcare Personnel (HCP) (NQF #0431)

• This measure was finalized in the FY 2023 SNF PPS Final Rule, which was published in the Federal Register on August 3, 2022 (87 FR 47537 through 47544). Data submission for this measure will begin on October 1, 2022.

III. Medicare Fee-For-Service Claims-Based Measures

Data for these measures are collected from claims, and no additional data need to be submitted by the SNF.

SNF QRP Measure #13: Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP

• This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52014 through 52021). Public reporting began 10/24/2018.

SNF QRP Measure #14: Discharge to Community - PAC SNF QRP

• This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52021 through 52029). Public reporting began 10/24/2018.

SNF QRP Measure #15: Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP

• This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52030 through 52034). Public reporting began 10/24/2019.

SNF QRP Measure #16: SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization

• This measure was finalized in the FY2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR.42473 through 42480). This measure is scheduled to be publicly reported in CY 2022.

Several measures are endorsed by the National Quality Forum (NQF), a consensus-based entity contracted by the Secretary to guide the selection of performance measures for federal health programs.

Adherence to the Centers for Disease Control and Prevention’s (CDC’s) Infection Definitions and Criteria is Needed to Ensure Accuracy, Completeness, and Comparability of Infection Information