May this Thanksgiving be filled with love, friendship and hope. I am grateful to each of you for your continued support of Extended Care Products and this monthly publication. Chip Kessler has been an inspiration since we embarked on this collaborative journey to provide quality education, risk management and other relevant resources to the health care community. Thank you for the opportunity, Chip!

On Oct. 24, 2018, in accordance with Section 1899B(g)(1) of the Social Security Act, which requires CMS to provide for the public reporting of SNF provider performance on the quality measures, CMS announced the inaugural release of the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality data on Nursing Home (NH) Compare.

Specifically, the following five SNF QRP measures are now being displayed on the NH Compare site:

Assessment-based measures:

  • Percent of Residents or Patients with Pressure Ulcers that are New or Worsened

  • Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury

Claims-based measures:

  • Medicare Spending Per Beneficiary

  • Discharge to Community

CMS has decided not to publish a 6th quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time. Per CMS, “Additional time would allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. This additional testing will ensure that the future, publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality. While we conduct this additional testing, CMS will not post reportable data for this measure, including each SNF’s performance, as well as the national rate.”

On Nov. 1, 2018, SNF Provider Preview Reports were updated and are now available. Providers have until Nov. 30, 2018 to review their performance data on quality measures based on Quarter 2 - 2017 to Quarter 1 - 2018 data, prior to the January 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate.

The SNF QRP is a critical component to the Patient-Driven Payment Model (PDPM) taking effect on Oct. 1, 2019. I addressed the keys to the PDPM in the August 2018 edition of this publication. In order to enable assessment of the functional outcome measures, CMS added new Section GG items to the MDS on Oct. 1, 2018. Below are observations and researched recommendations on what the new measures mean to you.

Initially, the only financial penalty associated with these new measures will be a 2 percent withhold of Med A payments based on failure to report at an 80 percent threshold of Med A stays. Beginning in FY 2020 (Oct. 1, 2019), facilities will be measured on their actual performance, with outcome incentives and penalties applied based on facility performance against established benchmarks for performance.  The data collected between 10/1/18 and 12/31/18 will be used to inform payment bonus/penalty starting 10/1/19 (FY20). The data collection period will then move to a calendar year, and the data from 1/1/19 to 12/31/19 will be used to inform payment starting 10/1/20 (FY21) and so on.

What the new measures mean to you.

Increase in measures focusing on Section GG of the MDS version effective  10/1/18 reflects additional questions in Section GG. There are added questions regarding ability to self care prior to admission to the SNF, as well as an additional question regarding the resident’s cognition and the effect on self care prior to admission to the SNF. QRP measures are also beginning to compare function recorded on the 5 day PPS assessment to the SNF Part A PPS discharge assessment. Did your resident improve or decline in function over the course of the stay? Did the resident reach the goals set with them during the stay?

All MDS measures are based on the five-day PPS assessment and the SNF Part A PPS discharge assessment and impact traditional Medicare A only. The measures are calculated based on the data from MDS assessments submitted to the QIES-ASAP system. If items are dashed, the calculation is not accurate. If errors are present on the items completed, the data is not accurate. If assessments are completed late or submitted late the data is not accurate. These considerations present risk issues for facilities for litigation and how the data is used by Plaintiff’s attorneys.

QRP and the MDS Section GG.

The five-day PPS assessment requires Section GG Admission Performance and Discharge Goal (at least 1) be completed. Discharge goals are not required if the stay is incomplete, meaning less than three days or unplanned discharge or death. The end of the Medicare PPS stay discharge assessment requires the discharge performance to be completed. For the MDS Coordinator, the codes used in Section GG are different than those used in Section G. Also, determining usual function is not typical for how items on the MDS are coded.

Consider how to prepare for the new measures and changes.

All but three of the measures are based on MDS data, so discuss with your MDS coordinator/RNAC how is this data gathered.

What sources are utilized?

Is there communication and collaboration with the therapy department?

How and where is this information documented?

If there is a change in self care/mobility, what steps are taken especially if there is a decline to attempt improvement?  And, who is aware there is a change during the stay and not just on discharge?

Are your MDS assessments accurate and completed per regulation?

Are your MDS assessments submitted per regulation?

If not, is there a plan in place to correct those issues?

Are the review and correct reports accessed routinely? And if needed, are corrections being done within the time frame specified?

If there are issues noted with the QRP MDS-based measures, is this a part of your QAPI?

The new measures, increased reporting and increased risks of public information used in litigation, the SNF QRP measures present many questions and concerns. It is difficult to comprehend how consumers can understand what a specific measure means and the impact on a resident. The information can be helpful, yet tells only a fraction of a community’s story and quality of care. Likewise, for the communities, the quality measures focus only on a portion of what a community can offer a resident and families.

Above all else, know your data and be prepared to explain the information to prospective residents and their families.


The annual, complimentary long-term care conference I host along with Horne Rota and Kaufman Borgeest & Ryan is in its 7th year and not to be missed! Please save the dates April 3-4, 2019 for The National Long-Term Care Defense Summit (love our new conference name!) in Memphis! Education, networking, blues and BBQ! Please contact me for more information and stay tuned for details.

master-0022 (2).jpg

About Rebecca Adelman:

Rebecca Adelman is an entrepreneur, influencer, thought leader and founder of Adelman Law Firm, established in 2001. For nearly 30 years, Rebecca has concentrated her practice in insurance defense and business litigation. The firm’s practice extends through the Tri-States of Arkansas, Mississippi and Tennessee. Rebecca’s insurance defense practice includes representation of insurance companies and long‐term care providers and their insurers, both regionally and nationally. She also provides consulting services and educational programming to healthcare professionals and business associates. She has active practices in the areas of general liability, professional liability, premises, and employment law. She is a listed mediator serving all areas of business and healthcare litigation. Contact Rebecca at and visit and

Rebecca Adelman