Under RUG-IV, the HIPPS code included the three-character RUG-IV group into which the patient classified as well as a two-character assessment indicator code that represented the assessment used to generate this code. Response: One commenter expressed concerns that SNFs would be required to verify the influenza vaccination status of every employee, especially those who are immunized by an outside provider, and that the increase in administrative burden may take away resources to care for residents. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. We invited public comment on these proposals related to the performance period for the SNF HAI measure for the FY 2026 program year and subsequent years. With these policy principles in mind for this FY 2023 proposed rule, we considered how best to address commenters' concerns discussed in the FY 2022 final rule around SNF payment volatility; that is, scenarios in which changes to wage index policy may significantly affect Medicare payments. Section 1888(e)(6)(A)(iii) of the Act further specifies that the 2.0 percentage point reduction is applied in a noncumulative manner, so that any reduction made under section 1888(e)(6)(A)(i) of the Act applies only to the fiscal year involved, and that the reduction cannot be taken into account in computing the payment amount for a subsequent fiscal year. In this chart and throughout the rule, we use a multiplicative formula to derive total percentage change. We requested commenters' views on which of these adjustments, if any, would be most effective for the SNF VBP Program at accounting for any health equity issues that we may observe in the SNF population. In addition, we believed these testing results for the 25 eligible stay minimum support our objective, which is to establish case minimums that appropriately balance quality measure reliability with our continuing desire to score as many SNFs as possible on this measure. May 5, 2021. https://doi.org/10.1016/j.pmrj.2014.10.010 https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf. Make sure to date, time, and authenticate each entry with your signature and professional credentials as close as possible to the time you performed an assessment or intervention. The wage index applicable to FY 2023 is set forth in Tables A and B available on the CMS website at We proposed that SNFs submit data for the measure through the CDC/NHSN data collection and submission framework. Hall, L.L., Xu, L., Mahmud, S.M., Puckrein, G.A., Thommes, E.W., & Chit, A. For example, the data showed an average of 4 percent of stays with depression and 5 percent of stays with a swallowing disorder in the fiscal year prior to PDPM implementation (FY 2019). We have examined the impacts of this final rule as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA, September 19, 1980, Pub. including three vaccines that are either approved or authorized in the United States to prevent COVID-19, and antiviral drugs that are approved or authorized to treat COVID-19. However, our data show that many of these metrics had already exhibited clear changes concurrent with PDPM implementation and well before the start of the COVID-19 PHE. Also, recent reports suggest that the rollout of COVID-19 vaccines has alleviated some of the burden on SNFs imposed by the PHE. The following is a summary of the comments we received and our responses. Vaccine, This report describes updated clinical practice guideline with recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged 18 years. Even when all other comorbidities are taken into account in the current risk-adjustment model, a COVID-19 diagnosis during the PPH still raises a patient's odds of being readmitted compared to patients who did not have any COVID-19 diagnosis during the PPH. of this final rule) will be excluded from the Program for FY 2023. Receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional (existing 483.60(a)(2)(iii)). Alongside our providers, youll find the compassionate care teams WakeMed is known for providing you everything need to feel your very best. These guidelines emphasize that frail patients with cognitive impairment may present with atypical symptoms, mainly neuroglycopenic or behavioral in nature. Retrieved from of this final rule, the market basket used to update SNF PPS payments has been rebased and revised over the history of the SNF PPS to reflect more recent data on SNF cost structures, and we believe it continues to appropriately reflect SNF cost structures. The fifth column shows the effect of all of the changes on the FY 2023 payments. We care about the privacy of our clients and will never share your personal information with any third parties or persons. 97. 218. One commenter was not supportive of the measure due to burdens of NHSN data submission. These formulas generally have lower carbohydrate and higher monounsaturated fat content compared with standard formulas (SFs). We acknowledge the commenters' concerns. Total amount available for a fiscal year. In this final rule, we are finalizing this proposed cap, as proposed. Each system has its own methods of validation and carries separate penalties. Accessed 3/4/2022. Unspecified toxic encephalopathy As stated in the proposed rule, we continue to be concerned about effects of the COVID-19 PHE but are encouraged by the rollout of COVID-19 vaccinations and treatment for those diagnosed with COVID-19 and believe that SNFs are better prepared to adapt to this virus. LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5). Regions with significantly lower vaccination rates experienced higher hospitalization and ICU rates making them more prone to capacity challenges. (2021). One commenter supported our proposal to not award improvement points to SNFs that do not meet the case minimums during the applicable baseline periods. and patient experience. Infection Control and Hospital Epidemiology, Specifically, two commenters suggested the measure's denominator should be modified to exclude non-employed staff, such as agency and contracted staff, and/or be limited to direct care staff in the SNF. This decision was consistent with the recommendation of our TEP, which concluded that a concentrated list of severe infections would be more valuable to SNFs and would make the measure more actionable. The risk-adjusted denominator is the expected number of SNF stays with the measure outcome, which represents the predicted number of SNF stays with the measure outcome if the same SNF residents were treated at an average SNF. patient functional status,[169170] [160] Our detailed analysis of the impacts of the FY 2027 SNF VBP Program is shown in Table 24. Under these measure minimums, we estimated that 14 percent of SNFs would be excluded from the Program for the FY 2026 program year, but that the excluded SNFs would, as a whole, provide care to approximately 2 percent of the total number of eligible SNF stays. Supply Chain Management Act (Government, Broader Public Sector and Health Sector Entities), 2019, S.O. Regarding concerns with comma-separated items on group uploads, the CDC notes that uploading data via a comma-separated values (CSV) file is not an option for annual influenza vaccination data reporting. and Common Agreement Version 1. Comment: In addition, several commenters suggested other measures and measure concepts CMS should consider. Consequently, we proposed to revise the compliance date to reflect this balance and assure that data collection begins on October 1, 2023. If finalized, beginning with the FY 2023 SNF VBP program year, any SNF that does not meet this case minimum requirement for the SNFRM during the applicable performance period will be excluded from the Program for the affected program year, provided there are no other measures specified for the affected program year. As a result, we believe that this measure is a strong indicator of quality of care and is an appropriate and important addition to the Program. 105(3 Suppl), 31-36. This factor is based on the FY 2023 percentage increase in the 2018-based SNF market basket index reflecting routine, ancillary, and capital-related expenses. of Care Through Pain Assessment and Management Across existing guidelines, one consistent recommendation is to avoid the sole use of SSI, which was recently added to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (25). Qual Manag Health Care. 161. One commenter urged CMS not to establish a 100 percent compliance threshold for measures submitted to the QRP using the NHSN. About 2 hours after discharge, she called the hospital and spoke with a different nurse, telling the nurse that her headache wasn't getting better and she had a lot of pain. COVID-19 Vaccines Helping Long Term Care Facilities Rebound From The Pandemic. After considering the public comment, we are finalizing our proposal to remove the LVA policy from the SNF VBP Program beginning with the FY 2023 program year and finalizing our proposal to update our regulations at 413.338(d)(3) to reflect its removal from the Program. [256] web page at The new paragraph would reflect all data completion thresholds required for SNFs to meet or exceed in order to avoid receiving a 2-percentage-point reduction to their APU for a given fiscal year. We clarify that we selected Option 3, which retains COVID-19 patients in the measure cohort and prevents a decrease in the sample size, while also adjusting for patients with a COVID-19 diagnosis. One commenter suggested that we add administrative and facility turnover to reduce management turnover, which the commenter believed contributes to lower quality of care. Retrieved from Several studies have Comment: Glycemic goals in particular are dependent on the patients risk of hypoglycemia. As patients move into this phase, the importance of glycemic control is less apparent and preventing hypoglycemia is of greater significance. The U.S. Agency for Healthcare Research and Quality (AHRQ) created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care. for issues related to the SNF PPS. Comment: As noted in the proposed rule, we also believe that when the 5-percent cap would be applied under this proposal, it is likely that it would be applied similarly to all SNFs in the same labor market area, as the hospital average hourly wage data in the CBSA (and any relative decreases compared to the national average hourly wage) would be similar. Accordingly, we characterized this statutory authority to identify additional service codes for exclusion as essentially affording the flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice) (65 FR 46791). Finally, some commenters suggested that CMS consider a new time study to evaluate the cost of treating cohorted patients isolated with an active infection. Case Minimum and Measure Minimum Policies, b. We also agree with the commenter that despite the COVID-19 PHE, SNFs will be able to successfully report the standardized patient assessment data and TOH Information measures. Some commenters supported a COVID-19 vaccination measure for healthcare personnel in the SNF VBP Program. 277. documents in the last year, 878 The patient is in a room alone because of active infection and cannot have a roommate. All of the affected facilities are completely sprinklered and would not be lowering their safety standards at all. http://dx.doi.org/10.1097/NCQ.0000000000000343. 165. https://www.cms.gov/files/document/qso-22-08-nh.pdf. Response: After considering the public comments, we are finalizing our proposal to adopt FY 2024 (October 1, 2023 through September 30, 2024) as the performance period for the Total Nurse Staffing measure for the FY 2026 program year. Besides undermining patient safety, inaccurate or incomplete documentation can land you in court if you're ever charged with nursing negligence. We are considering additional validation methods that may be appropriate to include in the future for the SNF HAI, DTC PAC SNF, and Total Nurse Staffing measures, as well as for other new measures we may consider for the program, and for other SNF quality measures and assessment data. Accessed January 12, 2022. We believe that this policy appropriately balances our desire to allow as much participation in the Program as possible while ensuring that those SNFs' performance scores are based on sufficiently reliable data. https://psnet.ahrq.gov/primer/nursing-and-patient-safety. https://www.cdc.gov/nhsn/pdfs/training/vaccination/hcp-flu-vax-summary-reporting-ltc.pdf. Baltimore, MD: Centers for Medicare and Medicaid Services. (2) We also indicated in the FY 2022 SNF final rule that we planned to review the 2020 MCR data as soon as complete information was available, to ensure the market basket relative cost shares are still appropriate. On October 1, 2019, we implemented the Patient Driven Payment Model (PDPM) under the SNF PPS, a new case-mix classification model that replaced the prior case-mix classification model, the Resource Utilization Groups, Version IV (RUG-IV). Methodology for Recalibrating the PDPM Parity Adjustment, a. 219. We further proposed to assign all participating SNFs a performance score of zero in the FY 2023 SNF VBP Program Year. 2. Open for Comment, Economic Sanctions & Foreign Assets Control, New Information for the North American Wolverine Species Status Assessment, Certain Cased Pencils From the People's Republic of China, Control of Air Pollution From Aircraft Engines, Standards for Safeguarding Customer Information, Notice of Intent To Repatriate Cultural Items, Taking Additional Steps To Address the National Emergency With Respect to the Situation in Nicaragua, Lowering Prescription Drug Costs for Americans. However, the current policy was designed for a SNF VBP Program with only one measure. Additionally, we are interested in feedback from interested parties on specific actions the SNF VBP Program can take to align with other value-based purchasing and quality programs to address healthcare disparities and advance health equity. prices 83. We recognize the growing Medicare Advantage population as well as the impact of staff shortages on the ability of a SNF to admit residents and we intend to continue assessing these topics in the future. We also note that in response to the Request for Information to Close the Health Equity Gap in the FY 2022 SNF PPS proposed rule (86 FR 20000), we heard from stakeholders that it is important to gather additional information about race, ethnicity, gender, language, and other social determinants of health (SDOH). We refer readers to our RFI on the potential inclusion of a staff turnover measure in section VII.I.1.a. 248. Comment: We consulted with CMS Regional Office survey staff, and based on information received from them, we estimate that 50 facilities are directly impacted by the change in the scoring of the FSES and would no longer achieve a passing score on the FSES. Event reports generally go to risk management for use in determining any policy changes required to eliminate future risk and in education to avoid similar errors. Due to SNF payments under PPS being set prospectively, we rely on a projection of the SNF market basket that reflects both recent historical trends, as well as forecast expectations over the next roughly 18 months. Possible strategies to manage diabetes in some of these clinical presentations are described in Table 3. We believe the data submission for the Influenza Vaccination Coverage among HCP (NQF #0431) measure would cause SNFs to incur additional average burden of 15 minutes per year for each SNF and a total annual burden of 3,868 hours across all SNFs. Start Printed Page 47592 Admissions Fax 856-513-8074 [email protected] MMWR Morbidity and Mortality Weekly Report, We note that including this measure in the FY 2027 program year provides advanced notice for facilities to prepare for the inclusion of this measure in the SNF VBP Program. Another commenter recommended that we allow the PBJ system to capture patient care hours provided by other types of professionals such as mental health support service workers, music therapists, or respiratory therapists. means the ordering of SNFs based on each SNF's performance score under the SNF VBP Program for a fiscal year. However, when the EMR isn't available (or in situations where an EMR hasn't been adopted), you'll have to revert to written documentation. A facility may limit the time period when the entry can be made. Columns 6 and 7 provide the case-mix index and associated case-mix adjusted component rate, respectively, for the relevant SLP group. This process yields a percentage change in the 2018-based SNF market basket of 3.9 percent. Our highly skilled providers are fully equipped to provide you with the level of care that you deserve. [279] of the proposed rule. We are also finalizing our proposal to require SNFs to begin reporting data on this measure for the period October 1, 2022 through March 31, 2023, with a reporting deadline of May 15, 2023. are the levels of performance that SNFs must meet or exceed to earn points on a measure under the SNF VBP Program for a fiscal year. The previous RUG-IV model classified most patients into a therapy payment group and primarily used the volume of therapy services provided to the patient as the basis for payment classification, thus creating an incentive for SNFs to furnish therapy regardless of the individual patient's unique characteristics, goals, or needs. For the proposed rule, the labor-related share for FY 2023 was based on IGI's fourth quarter 2021 forecast of the 2018-based SNF market basket with historical data through third quarter 2021. We believe that using the fiscal year as the performance period for the Total Nurse Staffing measure is important to maintain consistency with our other measures in the SNF VBP Program that use fiscal year performance and baseline periods. We are open to hearing from interested parties about any data or analyses available to achieve the shared goal of ensuring that the SNF market basket price proxies are technically appropriate. Journal of the American Geriatrics Society, 66(4), 742-747. among other quality and clinical outcomes. From bariatrics, urology, ENT, breast, gynecology, cardiovascular & thoracic, to orthopaedic, GI, pediatrics, neurosurgery and everything in between our surgeons are experts in their field. https://www.journalofhospitalinfection.com/action/showPdf?pii=S0195-6701%2819%2930091-X. We proposed that for FY 2026, SNFs must have the minimum number of cases for two of these three measures during the performance period to receive a performance score and value-based incentive payment. of the proposed rule. Nursing The medical record is a legal document that has many functions (see Defining the medical record). The administrative claims data used to calculate measure rates are not subject to review and correction under paragraph (f)(1) of this section. hospitalization. deficiencies are consistently among the most frequently cited deficiencies in surveys conducted to assess SNF compliance with Federal quality standards. The suggestion of codes, D47.3 and D75.838, was given to provide examples of more specific coding that could potentially be used if appropriate. [208] Lessons to be learned: This case points out the importance of documenting conversations with a patient who calls in with issues shortly after discharge. Also, facilities where nurse aide staffing is >5.25 hours per resident day are excluded. Retrieved from is the portion of a SNF's adjusted Federal per diem rate that is attributable to the SNF VBP Program. If a patient requires treatment in a facility for the primary reason of depression, Not Otherwise Specified (NOS), then their Medicare benefits provide access to treatment in an inpatient psychiatric hospital so that the type of depression, as well as treatment can be determined by specialists in the field. Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-confirmed COVID-19COVID-NET, 14 states, March 1-July 25, 2020. PDPM@cms.hhs.gov Medicare.gov Additionally, we requested feedback on data validation methods and procedures that could be utilized to ensure data element validity and accuracy. There are several scenarios in which a SNF stay is excluded from the measure cohort and thus, excluded from the measure denominator. However, there are currently no staffing measures in the SNF VBP Program. 210. Health Affairs, If SNFs submit data more frequently, such as on a monthly basis, the information would be used to calculate one summary score for the proposed measure which would be publicly reported on Care Compare and used to determine compliance with the SNF QRP. Hospitalized with Laboratory-confirmed COVID-19COVID-NET, 14 states, March 1-July 25, 2020: //www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf,,! Of zero in the SNF VBP Program Year designed for a SNF stay is excluded from the.. 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