LeadingAge is urging the Centers for Medicare & Medicaid Services to delay the addition of a measure tracking healthcare-associated infections requiring hospitalization to the SNF Quality Reporting Program. 

CMS unveiled the proposal in early April. It would begin with the fiscal year 2023 SNF QRP late next year. It calls for tracking HAIs, with a reporting requirement and potential penalties linked to rates of sepsis, urinary tract infections and pneumonia. 

Medicare fee-for-service claims data would be used to estimate the rate of HAIs acquired in a SNF that lead to hospitalization. The goal, CMS said, is to determine which SNFs have notably higher rates of HAIs and provide information about a facility’s infection prevention and management program.

LeadingAge, in recently submitted public comments, recommended delaying the adoption of this measure until data can be collected outside of the public health emergency.

“We appreciate that CMS will not implement this as a QRP measure until such time as it receives [National Quality Forum] endorsement and that once the measure is to be implemented, CMS will calculate the measure using claims-based data so as not to add additional reporting burden on providers,” wrote Jodi Eyigor, LeadingAge’s director of nursing home quality and policy. “However, we are concerned that FY 2021 will include COVID-19 data and therefore will be incomparable to FY 2019 nonCOVID data.” 

The organization added that there also needs to be transparency and clarity around the data and how the measure is calculated. Eyigor argued that if providers are able to conduct their own calculations, then they can make changes to the infection control and quality improvement programs in real time. 

LeadingAge suggested that when calculating the measure, CMS “should be clear about the specific formula and data used to calculate the estimated number of SNF stays expected to have an HAI. 

“It is also important to provide SNFs with appropriate feedback reports. For this measure, we recommend a patient-level feedback data report to affect changes in performance. The proposed rule does not adopt such a report as part of this requirement to the program,” Eyigor wrote.  “Nonetheless, there should be a process in place for CMS to share the reported data with the nursing homes so that they may review and make corrections prior to publication of the data to Care Compare.”