Using CASPER Reports for Quality Measure Monitoring with Recommended Run Schedule
This is part 2 or a 2 part blog on the effective use of CASPER reports.
As a continued review of CASPER Reports with Recommended Run Schedule, let’s take a look at Payroll Based Journal (PBJ), Final Validation, and Quality Reporting Period (QRP) reports and how ongoing analysis can reveal errors and promote effective facility processes.
Payroll Based Journal
Payroll Based Journal, better known as PBJ, became the system to report mandatory staffing information under the Affordable Care Act in July 2016. Under this Act, skilled nursing facilities must report the number of hours direct care staff is paid to work each day. This includes the Director of Nursing, Registered Nurses with and without administrative duties, Licensed Practical Nurses with and without administrative duties, Certified Nurse Aides, Medication Aides, and Nurse Aides in training. Both agency staff and contractors are included as well.
When this data is combined with census information, it can be used to determine the level of staff in each facility, which in turn can greatly impact the quality of care delivered. The staffing information is updated on a quarterly basis and all facilities have 45 days from the start of the new quarter to submit the data for the previous quarter. The PBJ submission deadlines are listed below, along with the month that the timely submitted data will be reflected in star ratings. Nursing Home Compare is typically updated on the 4th Wednesday of the month. Facilities who fail to submit complete PBJ data by the submission deadline will be assigned a 1-star rating for the quarter.
Below are the deadlines for each reporting period:
MDS 3.0 Submitter Final Validation Report
Another significant CASPER report providers should frequently review is the MDS 3.0 Submitter Final Validation Report. Within 24 hours of a successful MDS batch submission, the system will generate the final validation report. This report provides detailed information about the status of a submission batch, and indicates whether the records submitted in the batch were accepted or rejected. It will also detail any warnings or fatal errors.
Fatal errors are severe enough to prevent the entire submission batch or specific MDS assessments within the batch from being accepted into the QIES database. These errors will show a rejected assessment and need to be resubmitted after correction.
Warning errors are messages that alert the provider that there is an issue. These issues are either informational or they need to be corrected. These errors do not prevent the MDS assessment from being accepted into the database.
Common Fatal Errors include:
- Workflow Errors
- User Errors
- Software Errors
Common Warning Messages include:
- Sequencing or Timing Errors
- Data Errors
- Communication Errors
The report is generated automatically and is available for 60 days in the final validation reports (VR) folder in the CASPER reporting application. If a specific batch or date range is needed the provider can request that, as long as it is within the 60-day window. Those requests can be made by selecting the MDS 3.0 NH Final Validation report category on the CASPER Reports page. Reviewing this report should be part of the submission process and errors should be corrected immediately. For tips and troubleshooting error messages visit https://qtso.cms.gov/system/files/qtso/Users_Sec5_8.pdf.
Remember, reviewing the MDS 3.0 Submitter Final Validation Report should be part of your facility’s routine MDS submission process.
SNF Quality Reporting Program Review and Correct Report
Finally, the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Review and Correct Report is another invaluable tool in a facility’s ongoing data monitoring practices. In 2014 Congress passed the Improving Medicare Post-Acute Care Transformation Act, better known as the IMPACT Act. This Act requires the submission of standardized data to establish a quality reporting program by Skilled Nursing Facilities (SNFs) and other healthcare agencies. This data is available to the public, however, before the data is made public, SNF providers have the opportunity to review and correct it if necessary.
The intent of this report is for providers to have access to reports prior to the quarterly data submission deadline to ensure the accuracy of their data. This report can be retrieved via CASPER reporting in the QIES ASAP system and is available for 60 days. Your facility should review this data when it becomes available and determine if the information on the report is accurate for your facility. The reports are user-generated and can be requested at any time. Similar to other user-requested reports for CASPER, the completed reports are automatically saved to your inbox folder within the CASPER reporting application.
The Review and Correct Reports contain facility-level and resident-level measure information based on the last 4 quarters and are updated on a quarterly basis with data refreshed weekly as it becomes available. Quarterly reports contain quarterly rates and a cumulative rate. The quarterly quality measure data will be displayed using up to one quarter of data while the cumulative quality measure data will be displayed using all data in the target period. For new measures, data is accumulated until 4 quarters have been collected and then rolling quarters occur for successive years. For existing measures, data is displayed based on rolling quarters.
Based on the report calculation schedule, facilities should begin checking for new quarterly Review and Correct Reports on April 1st, July 1st, October 1st, and January 2nd. If it is determined a correction needs to be made, simply follow the MDS correction process and ensure the assessment has been submitted and accepted into the QIES database prior to the correction deadline.
- MDS 3.0 SUBMITTER FINAL VALIDATION REPORT 09/2019 v1., https://qtso.cms.gov/system/files/qtso/cspr_sec10_mds_prvdr.pdf Accessed 18 November 2019.
- MDS 3.0 Error Messages 09/2019 v1., https://qtso.cms.gov/system/files/qtso/Users_Sec5_8.pdf Accessed 18 November 2019.
- Minimum Data Set (MDS) 3.0 Provider User’s Guide on the QTSO MDS 3.0 web site at https://www.qtso.com/mds30.html. Accessed 18 November 2019.
- CASPER Reporting User’s Guide for MDS 3.0 Providers at https://www.qtso.com/mds30.html. Accessed 18 November 2019.
- Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 2.0 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Measure-Calculations-and-Reporting-Users-Manual-V20.pdf Accessed 19 November 2019.
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Blog by Jessica Cairns, RN, RAC-CT, CMAC, Clinical Consultant, Proactive Medical Review
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