Updates to Nursing Home Care Compare Staffing and Quality Measures

Posted in INDUSTRY NEWS, Long-Term Care

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

Wednesday, September 20, 2023, CMS posted QSO-23-21-NH … Updates to Nursing Home Care Compare Staffing and Quality Measures.

As noted above in the Summary:

  • The actions described in this memorandum are separate from the proposed rule. CMS will review and address any comments related to the proposed rule through the rulemaking process. To review and submit comments to the proposed rule, please visit the Federal Register.
  • CMS will also be removing the CMS-672 form (Resident Census and Conditions of Residents) since the Section G MDS data used to populate this form is being discontinued.

Effective September 29, 2023, facilities are no longer required to complete these fields (F79 – F145) and surveyors are no longer be required to enter this information (fields F79 – 93) in the survey system. The census information (fields F75-F78), the ombudsman information (fields F146 and F147), and the medication error rate (field F148) should still be completed. On October 22, the census, medication error rate, and ombudsman information fields will be relocated to the form CMS-671, and the CMS-672 form will be removed. This change will help streamline the survey process for surveyors and facilities. We are aware that researchers and other stakeholders may use CMS-672 data, so we will be exploring other ways to make MDS-based data publicly available to all stakeholders through a separate mechanism.

  • Furthermore, to help incentivize providers to submit accurate staffing data, CMS will revise the staffing rating methodology so providers that fail to submit staffing data or submit erroneous data will receive the lowest score possible for corresponding staffing turnover measures.

Also, The MDS changes also have implications for 4 of 15 QMs used in the Nursing Home Five Star Rating System. QMs impacted by the MDS G-GG transition:

  • Percentage of Residents Who Made Improvements in Function (short stay)
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (long-stay) 
  • Percent of Residents Whose Ability to Move Independently Worsened (long stay) 
  • Percent of High-Risk Residents with Pressure Ulcers (long stay) Starting in April 2024, CMS will freeze (hold constant) these four measures on Nursing Home Care Compare.

In October 2024, CMS will replace the short-stay functionality QM with the new cross-setting functionality QM, which is used in the SNF Quality Reporting Program (QRP). The remaining three measures will continue to be frozen until January 2025 while the data for the equivalent measures are collected.

Please review and share this 3-page Memorandum with your team and colleagues.