In Dec 2020, CMS issued its 2020 measures under consideration (MUC) list that included two proposed new SNF QRP quality measures (QMs). The measures under consideration are:

      1. Skilled Nursing Facility Healthcare Associated Infections Requiring Hospitalization (outcome measure)
      2. SARS-CoV-2 Vaccination Coverage among Healthcare Personnel (process measure)

Skilled Nursing Facility Healthcare Associated Infections Requiring Hospitalization

The goal of this risk-adjusted measure is to identify SNFs that have notably higher rates of healthcare associated infections (HAIs) that are acquired during skilled nursing facility (SNF) care and result in hospitalization, when compared to peers. This measure will estimate the risk-adjusted rate for HAIs that are acquired during SNF care and result in hospitalizations. This measure focuses on severe infections and captures several infection types in the SNF setting (see Appendix A Table 1) The measure is risk adjusted to “level the playing field” and to allow comparison of measure performance based on residents with similar characteristics between SNFs. It will only consider hospitalizations that occur after day 4 of SNF admission and within 3 days after SNF discharge for HAIs that were not present on the most proximal hospitalization claim prior to the SNF admission. The Measure Applications Partnership (MAP) offered conditional support for rulemaking for this measure contingent on NQF endorsement for this measure.

SARS-CoV-2 Vaccination Coverage among Healthcare Personnel

This measure tracks SARS-CoV-2 vaccination coverage among healthcare personnel (HCP) in skilled nursing facilities, as well as other provider types. The numerator for this measure will include the cumulative number of HCP eligible to work in the facility for at least one day during the reporting period, who received a complete vaccination course against SARS-CoV-2 since the date vaccine was first available, or on a repeated interval revaccination on a regular basis as needed. The measure will exclude HCP with contraindications to the SARS-CoV-2 vaccination. MAP offered conditional support for rulemaking for this measure contingent on CMS bringing the measures back to MAP once the specifications are further refined.

Priorities for Facility Preparation

These measures highlight the importance of continued focus on Infection Control and Prevention practices post-pandemic. Proactive Medical Review & Consulting offers on-site and remote IP consultations by qualified Infection Preventionist Registered Nurses who can assist your team in implementing performance improvement plans to reduce infections and help you achieve regulatory and quality measure success. Our services include assistance with the areas most frequently required in Directed Plans of Corrections (DPOCs), such as:

      • Assisting facility’s in conducting root cause analysis (RCA)
      • Developing solutions and systemic changes that need to be taken to address the root cause of infection outbreaks and infection control citations
      • Reviewing the facility’s LTC infection control self-assessment to determine if it is an accurate reflection of the facility and making recommendations for updates to the assessment
      • Providing training, resources, and competencies related to Infection Control and Prevention practices

Proactive also provides:

      • Mock surveys and assistance with Plans of Correction
      • Assisting in on-going monitoring of solutions and changes until compliance in maintained
      • On-going consultation support

Contact us to see how we can help you reduce infections and to learn more about our services to assist you in maintaining on-going regulatory compliance.


Blog by Shelly Maffia, RN, RAC-CT, CMAC, Proactive Medical Review

Click here to learn more about Shelly and the rest of the Proactive team.