Nursing Homes Face Multitude of Quality Measures

Legislation | August 28, 2017 | by Nicole Fallon

LeadingAge gave the following comments to Rep. Pat Tiberi, Chair of the U.S. House Ways and Means Committee, on the need to simplify, integrate and risk adjust measures of the quality of care in nursing homes.

The Nursing Home Reform Act, enacted 30 years ago as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA), set up an extensive and highly detailed system of nursing home regulation overseen by the Centers for Medicare and Medicaid Services (CMS). CMS posts the results of the regular inspections nursing homes undergo on the Nursing Home Compare website. In addition, Nursing Home Compare scores nursing homes on their performance on several quality measures based on clinical information nursing homes must report on their residents.

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which became law in 2014, requires post-acute care providers to report data on quality measures annually to CMS under a Quality Reporting Program. Although the law applies to four categories of post-acute care providers, only nursing homes are financially penalized for failure to report at least 80% of the required data by the deadlines specified. The quality measures on which nursing homes must report data under the IMPACT Act differ from those on which Nursing Home Compare assesses nursing home quality.

The Protecting Access to Medicare Act, also enacted in 2014, set up a system of Medicare value-based purchasing for skilled nursing homes. LeadingAge supports the concept on which this system is based, that payment systems should align with quality of services rather than volume. However, the value-based payment system assesses the “value” of nursing home care on a single hospital readmission measure also developed by CMS that is defined differently than the one these same providers are held accountable for under  the QRP and Nursing Home Compare requirements.  

Staffing levels can be an important indicator of the quality of care nursing homes are able to provide. Section 6106 of the Affordable Care Act requires nursing homes to electronically submit data on direct care staffing based on payroll. LeadingAge supported this requirement because independent research has shown that the not-for-profit nursing homes we represent tend to maintain higher than average staffing levels. However, the payroll-based journaling system that CMS has put into place for the quarterly reporting of staffing levels has been complicated and burdensome to implement.

The cumulative effect of all of this legislation and regulation is that the quality of care nursing homes provide is assessed according to a wide range of measures and data reporting systems, all developed and overseen by the same federal agency. Under these programs, SNFs are at risk of losing up to a cumulative 4% of their Medicare fee-for-service rates as they try to effectively improve quality on a growing, inconsistent list of measures. There is no unified, rational system of assessing the quality of care nursing homes provide. The burden of reporting different sets of data for different purposes takes human and financial resources that could better be devoted to services for nursing home residents. And it is difficult to see how the public is to understand the quality of care a nursing home provides when performance is measured and reported in so many different ways.

LeadingAge also is concerned that systems used to measure the quality of care nursing homes provide must be risk-adjusted to reflect the unique characteristics of nursing home residents and the challenges of caring for them. While increasing numbers of nursing homes are specializing in short-stay rehabilitation that assists patients in recuperating following a hospitalization, the majority of nursing home residents are long-stay, with the nursing home as the last place they will live. Outcomes of nursing home care for long-stay residents are more difficult to ascertain than for the services provided by other kinds of health care organizations because for long-stay residents, the goal is to maintain abilities and functioning for as long as possible rather than to effect a cure leading to discharge. Long-stay nursing home residents typically are advanced in age and have a number of physical and mental limitations that can compromise the effects of medical treatment and other care and services. Systems used to assess and report the quality of nursing home services must take these factors into account.

Related statute/regulation

Nursing Home Reform Act, part of Omnibus Budget Reconciliation Act of 1987, P.L. 100-203

Affordable Care Act, P.L. 111-148, Section 6106

Improving Medicare Post-Acute Care Transformation (IMPACT) Act, P.L. 113-185

Section 215 of the Protecting Access to Medicare Act (P.L. 113-93)

Proposed solutions:

  1. Quality measures must be risk adjusted to reflect nursing home resident characteristics and unique aspects of nursing home care.
  2. Congress should amend existing laws to permit CMS to use a single hospital readmission measure across VBP, QRP and Nursing Home compare, and where applicable, align other measures across these programs.  30 days from hospital discharge, potentially preventable.

    Current laws prohibit CMS from utilizing a single hospital readmission measure as the laws pertaining to each program prescribe their own definition.  Congress could amend these laws to state CMS should adopt a single hospital readmission measure to be used for the SNF VBP program (currently defined in PAMA), SNF QRP (currently defined through regulations promulgated as part of the IMPACT Act) and Nursing Home Compare.​​​​​​​

    The Skilled Nursing Facility Value-Based Purchasing (VBP) program sections 1888(h)(2)(A) and (B) of the Act only allow CMS to use two specified readmission measures for the VBP Program: first the readmission measure specified under section 1888(g)(1), and then in its place, the readmission measure specified under section 1888(g)(2) of the Act.

Even CMS has acknowledged in their recent rule making for FY2018 SNF PPS that the way in which these laws are written limit their ability to adopt a single readmission measure, “ We wish to clarify that the re-hospitalization measure reported on Nursing Home Compare is not a measure of potentially preventable readmissions, as required by PAMA. We agree that aligning measures across Programs, when feasible, may reduce provider confusion.” (CMS on p. 287 of FY2018 SNF PPS Final Rule)


Current Definitions for Hospital Readmission




CMS Nursing Home Compare Quality Measures


  • Current: 30-Day SNF All- Cause Readmission Measure (SNFFRM) – FY2019
  • Future:  30-Day SNF Potentially Preventable Readmissions Measure (SNFPPR)

Potentially preventable 30-day Post SNF Discharge Readmission Measures

Percent of short-stay residents re-admitted to a hospital for an unplanned inpatient stay or observation stay within 30 days of the start of the nursing home stay.

30-days from…

Hospital Discharge

SNF Discharge

Hospital Discharge

  1. Alternative solution: Eliminate the 2% failure to report penalty under the SNF QRP as it only applies to SNFs and as such does not reflect a fair playing field.  SNFs are otherwise required to conduct MDS assessments on all skilled residents upon admission and discharge.  Inadequate MDS assessments already impact a SNFs payment through improper classification of resident needs.

The primary purpose of the IMPACT Act was the development of mechanisms to assess patient characteristics, quality of services provided and resource use across the various settings of the post-acute care system.

IMPACT establishes varying timetables for the different categories of post-acute care providers to begin reporting on quality measures specified in the legislation. The indicators include functional status, cognitive function and changes in function; skin integrity; medication reconciliation; incidence of major falls; and accurate communication of a patient’s health information to caregivers when the patient transfers between hospital and post-acute care, including the patient’s home.

This quality reporting will be in addition to the survey and certification oversight system that currently applies to skilled nursing facilities. While the quality reporting requirements apply to all four categories of post-acute care providers, only skilled nursing facilities will be financially penalized (2% off their Medicare fee for service rates) for failure to make the reports.