MDS Alert

Published on Tue May 03, 2016 PDF

Plus: What to do if you get a SNF QRP noncompliance notification.

Before even the start of mandatory reporting of electronic staffing data in the Payroll-Based Journal (PBJ) system, which begins on July 1, there are already changes to the Policy Manual that you need to know about.

On March 16, the Centers for Medicare & Medicaid Services (CMS) released the updated PBJ Policy Manual V2 to reflect changes to the submission guidelines, which are redlined in the text. And on March 18, CMS issued a Survey & Certification (S&C) memo reminding long-term care (LTC) facilities that the voluntary submission period will end on June 30, and the mandatory submission period will begin the next day. The memo also restates instructions on how to register and where to find instructions for submitting data to the PBJ system.

Don’t panic: The changes to the PBJ Manual are not extensive, according to Washington, D.C.-based Leading Age. The changes mainly involve clarifications on:

1. How PBJ requirements don’t apply to swing-beds;
2. How to submit for staff who split their primary duties; and
3. Who you should report under Administration Services.

The first clarification notes that only LTC facilities that are subject to meeting the Requirements for Participation in 42 CFR Part 483, Subpart B are subject to the PBJ reporting requirements. This requirement doesn’t apply to swing-beds.

The second change clarifies that in certain cases, facilities can change the designated job title and report, for example, four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). You may need to do this if you have staff that completely shift their primary roles in a given day — such as if a nurse spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse.

Finally, CMS updated the “Description of Services” for Administrative Services (Labor Category Code 1), Administrator (Job Title Code 1) to read: “Administrative staff responsible for facility management as required under 483.75(d) such as the administrator and the assistant administrator.”

CMS also renamed the Labor Category Code 2 labor description as “Physician Services.”

Links: You can access the updated PBJ Policy Manual in the “Downloads” section at the bottom of the webpage at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. Also, the S&C: 16-13-NH memo is available at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-13.pdf.

In Other News …

SNFs: How To Submit A Reconsideration Request For QRP Noncompliance

If you don’t comply with the new Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) requirements, you could suffer a 2-percentage-point reduction in your annual payment update (APU). But you do have a potential remedy to save your facility from a pay cut.

On March 24, the Centers for Medicare & Medicaid Services (CMS) announced the SNF QRP Reconsideration and Appeals Procedures for the fiscal year (FY) 2018 Payment Determination. CMS finalized the FY 2016 SNF QRP requirements in the Prospective Payment System (PPS) Final Rule (42 FR Part 483).

Background: To comply with the SNF QRP requirements, you must collect MDS data on the following quality measures (from Oct. 1, 2016 through Dec. 31, 2016) and submit that data by May 15, 2017:

• Percent of Patients or Residents with Pressure Ulcers that are New or Worsened (NQF #0678);
• Percent of Residents Experiencing One or More Falls with Major Injury, Long Stay (NQF #0674); and
• Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631).

If CMS finds you in noncompliance with the SNF QRP requirements, you’ll receive a notification letter along with instructions for requesting a reconsideration of the compliance decision. You can file for reconsideration if you believe the noncompliance finding is wrong or if you have evidence of extraordinary circumstances that prevented timely submission of data.

What to do: You must submit the request for reconsideration to CMS within a 30-day deadline, and the only way you can submit the request is via email — to the SNF Exception and Extension mailbox at SNFQRPReconsiderations@cms.hhs.gov.

You must make the subject of the email “SNF QRP Exception or Extension Request,” and your email must include the following information:

• SNF CMS Certification Number (CCN);
• SNF name;
• CEO or CEO-designated personnel contact information including name, telephone number, email address, and mailing address (the address must be a physical address, not a post office box);
• SNF’s reason for requesting an exception or extension;
• Evidence of the impact of extraordinary circumstances, including but not limited to photographs, newspaper and other media articles; and
• A date when you believe you’ll be able to again submit SNF QRP data and a justification for the proposed date.

If you’re requesting reconsideration, you should submit other documentation including:

• Proof of submission;
• Email communications;
• Data submission reports from the Quality Improvement Evaluation System (QIES);
• Data submission reports from the National Healthcare Safety Network (NHSN);
• Proof of approved exception or extension for the reporting timeframe; and
• Copy of the CCN activation letter.

Mistake: Don’t include protected health information (PHI) or other HIPAA violations in the documentation that you’re submitting to CMS for review. For future updates, visit the “SNF Quality Reporting Reconsideration and Exception & Extension” webpage at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-QR-Reconsideration-and-ExceptionExtension.html.