Final Rule: SNFRM, Quality Measures & SNF Staffing

On August 4, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a final rule, “Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection.” The proposed rule was issued earlier this year, and much of the feedback from stakeholders was taken into account when issuing this final rule. Here’s an overview of the changes:

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

Part of the SNF Value Based Purchasing Program (SNFVBP), which focuses on improving the quality of care being provided by nursing homes rather than the volume of care that is provided, includes this readmission measure. As the name implies, the SNFRM calculates the rate of all-cause/condition, unplanned hospital readmissions by residents of nursing homes within 30 days of prior inpatient admission to a hospital, CAH, or psychiatric hospital.

Quality Reporting Program

The IMPACT Act requires that a quality reporting program (QRP) be implemented. Beginning FY 2018, all SNFs will be required to submit standardized patient data to CMS. If this data is not submitted, then the facility will be subject to a reduction in their payments by 2 percentage points. In the early stages of this requirement, 80% of all submitted MDS assessments would need to contain 100% of the data required to calculate these QMs, with the intention being to require more assessments to be 100% complete in the future. The IMPACT Act also requires that facilities are provided with feedback on their performance and that the information is publicly reported.

Quality Measures

Three Quality Measures (QMs) will be used for the QRP at its outset. These three QMs satisfy the domains of:

  • Skin integrity and changes in skin integrity – The QM measures the percentage of short-stay residents with Stage 2-4 pressure ulcers that are new or worsened since admission. This measure has already been implemented in nursing facilities with stays of <100 days. The data used for this QM will be submitted through the QIES ASAP.
  • Incidence of major falls – The QM measures the percentage of long-stay residents who have one or more falls with major injury. The QM reports on a 3-month period and will also be submitted by nursing homes through the QIES ASAP. This measure is not used for short-stay residents.
  • Functional status, cognitive function and changes in function and cognitive function – The QM measures resident function upon admission and then upon discharge as well as an activity goal that has been created for each resident. A new MDS 3.0 section has been created for this measure, Section GG. This QM provides the biggest change for the QRP, and includes a 6-level scale in the new MDS section and the addition of CARE function items. “Gateway questions” have been added to reduce the time required to fill out this section, allowing staff to skip questions that are not relevant to the particular resident.


With the announcement of Nursing Home 3.0 and MDS-Focused surveys with a staffing review included came the pending requirement for using the Payroll Based Journal (PBJ) to submit staffing information in a uniform fashion as required by the IMPACT Act of 2014. All direct care staffing information will be required to be submitted to CMS and must distinguish between contract/agency staff and facility staff. Facilities that are part of a larger organization such as a CCRC or hospital and have staff that rotate throughout the units must clarify how much direct care time was spent on SNF resident care.

Check back on the CMSCG blog in the next few days for information on a complimentary Long Term Living webinar on staffing changes, hosted by CMS Compliance Group President Linda Elizaitis.  

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