Solutions Syllabus: Quality Measures

Preferred Therapy Solutions is hosting a monthly educational series based on the RAI Manual for coding the MDS to ensure accuracy with Quality Measures (QMs).

Our Solutions Syllabus will provide extensive guidance on the importance of accurate coding of the MDS and the impact on Quality Measures. This educational series will include a comprehensive guide on QM’s and corresponding MDS sections that affect regulatory programs such as 5-Star and are publicly reported through Care Compare. Understanding the data and the significance of coding is vital for SNFs and LTC communities to thrive in the ever-changing healthcare industry.

Throughout the year, we will cover several QMs for an in-depth review. REGISTER NOW FOR THESE INFORMATIVE SESSIONS

Introduction to QMs: Quality Measures Made Easy

MDS Section G – QMs Related to Daily Activities and Mobility
This program has been approved for Continuing
Education for 0.50 total participant hours by
NAB/NCERS—Approval #20230425-0.50-A83211-DL

MDS Section J – QMs Related to Falls
NAB/NCERS—Approval #20230530-0.50-A83992-DL

MDS Section GG QM Self Care & Mobility
This program is pending NAB/NCERS—Approval


CMS Mandates Strict Testing of COVID-19 for Nursing Home Staff. Fines up to $8,000 for Non-compliance.

To our valued customers:   Yesterday, The Centers for Medicare & Medicaid Services (CMS) implemented new regulatory changes for Skilled Nursing Facilities (SNF); all SNF’s must regularly test their personnel for the COVID-19 virus and are required to offer testing to their residents. As part of this mandate, facilities that use point-of-care COVID-19 testing devices are required to report their diagnostic test results as part of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

CMS Administrator, Seema Verma stated: “Reporting of test results and other data are vitally important tools for controlling the spread of the virus and give providers on the front lines what they need to fight it.”  

Skilled Nursing Facilities that do not act in accordance with this new rule will be cited and fined for noncompliance and may face fines based on the severity of the violation. Penalties of $400 per day, or over $8,000 for an instance of noncompliance. To learn more about the new rule, please visit the CMS website at

Preferred Therapy Solutions continues to provide its partners with vital information that may impact rehabilitation management, reimbursement policies, and clinical programs, supported with compliance and regulatory requirements that are necessary for a thorough understanding on practices and procedures. If you have any questions, please contact  Maria Maggi, Vice President of Quality, Outcomes, and Compliance at:


CMS Publishes FY 2022 SNF Annual Payment Update (APU) Overview Table


Skilled Nursing Facility (SNF) Quality Reporting Program Measures

The Impact Act of 2014 required implementation of clinical assessment areas using standardized data elements in each of the instruments used across all post-acute settings. For a given data submission period, the Minimum Data Set (MDS) assessments submitted by a SNF must meet a minimum submission threshold of no less than 80 percent of the MDS assessments having 100 percent completion of the required SNF QRP data elements. Successful assessment completion is submission of actual resident data, as opposed to non-informative response options, i.e., “dash” (–).

Failure to meet the minimum submission threshold may result in a two (2) percentage point reduction in the SNF’s Annual Payment Update (APU).

For a listing of all SNF QRP Measures, please click Here

What You Need To Know

Skilled Nursing Facility (SNF) Quality Reporting Program Annual Payment Update (APU)

On Feb 7, 2020, the Centers for Medicare and Medicaid Services (CMS) published the FY 2022 skilled nursing facility (SNF) Annual Payment Update (APU) table.  This table indicates the data elements CMS will use for the FY 2022 SNF Quality Reporting Program (QRP) APU determinations.

Of importance to SNF’s, the amount of required data elements that will impact the APU will increase significantly starting in the Q4 2020 data collection time period. There will be over 250 required data elements starting in October 2020 compared to about 100 required elements currently required.

The FY 2022 SNF APU Table can be found Here

PTS will continue to monitor for updates and keep our valued partners informed. If you have any questions, please contact Maria Maggi, Vice President of Compliance at

*TIME SENSITIVE* CMS HOSTING NATIONAL PROVIDER CALL Learn CMS’ Review and Corrections Process for VBP before it’s too late!

Phase One Review and Corrections Call — March 20th

The SNF Value Based Program measure, Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) estimates the risk-standardized rate of all-cause, unplanned hospital readmissions of Medicare SNF beneficiaries within 30 days of discharge from their prior acute hospitalization. Incentive payments based on this measure began in Oct 2018 for FY 2019. It is based on how a facility scores when comparing their baseline period versus their performance period, and utilizes a performance and achievement score.

Phase One is an opportunity for SNFs to review and submit corrections to the quality and facility-level information that will be made publicly available. The deadline for correction submission is April 1, 2019.

What you need to know
On Wednesday, March 20, 2019, the Medicare Learning Network will host a National Provider Call entitled, “Skilled Nursing Facility (SNF) Value-Based Purchasing (VBP) Program: Phase One Review and Corrections call.” During this call, participants will learn about the SNF VBP Program Review and Corrections process and receive answers to frequently asked questions about Phase One of the process.

There will also be a question and answer session following the presentation; however, attendees may email questions in advance to with “SNF VBP Mar 20 NPC” in the subject line.

To register for this MLN event, follow the instructions provided in the following link:

Courtesy of NASL

If you have any questions, please contact:
Maria Maggi, Vice President of Compliance

*TIME SENSITIVE* SNF Provider Preview Reports Now Available


Prior to the release of SNF QRP data on Nursing Home Compare, SNFs have the opportunity to review their quality measure results during a 30-day preview period. Providers have until March 4, 2019, to review QRP data prior to the April 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. SNFs are encouraged to review the SNF Provider Preview Report, issued quarterly by CMS and accessed through the CASPER system. Instructions on how to access these reports are located here.

Corrections to the underlying data will not be permitted during this time, however, providers can request a CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

What you need to know

The data contained within the Preview Reports is based on quality data submitted by SNFs during the following quarterly time frames:

  • Quarter 3 – 2017 to Quarter 2 – 2018 data
    • Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
    • Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay)
    • Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • Quarter 4 – 2016 to Quarter 3 – 2017 data 
    • Medicare Spending Per Beneficiary – Post-Acute Care (PAC) Skilled Nursing Facility Measure
    • Discharge to Community- Post Acute Care (PAC) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)

As we stated in our last alert, CMS announced in October 2018 that it will not publish the 6th previously posted quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time. According to CMS, additional time will allow for more testing to determine if modifications to the measure and method of displaying it are needed. This additional testing will ensure that the future publicly reported measure is thoroughly evaluated so Nursing Home Compare users have an accurate picture of provider quality. While CMS conducts this additional testing, the agency will not post reportable data for this measure, including each SNF’s performance, as well as the national rate. To view the updated quality data, please visit the Nursing Home Compare website.

Courtesy of NASL

If you have any questions, please contact Maria Maggi, Vice President of Compliance