The following modifications to current ORYX performance measurement requirements for accredited long term care organizations and those seeking accreditation become effective immediately. These modifications will remain in effect until such time as a consensus set of performance measures for Medicare/Medicaid-certified skilled nursing facilities/nursing facilities are established and implemented by the Centers for Medicare and Medicaid Services (CMS) and/or relevant core measures for long term care are established and implemented by the Joint Commission.
While these temporary modifications no longer require participation with a listed performance measurement system if the LTC organization is a SNF or NF, the Joint Commission encourages long term care organizations that seek accreditation under the Comprehensive Long Term Care Accreditation Program to consider taking advantage of the option of continuing to participate with a listed measurement system and submitting ORYX performance measure data to the Joint Commission. For long term care organizations that do not collect and submit Minimum Data Set (MDS) data to their state agency, continued participation in a listed performance measurement system will provide comparative data that may not otherwise be readily available. Continued participation in a listed performance measurement system also will help facilitate ongoing compliance with performance measurement and improvement requirements as detailed in the Joint Commission's long term care standards. Those long term care organizations that seek accreditation under the Skilled Nursing Facility/Nursing Facility Certification Based Accreditation Program will not have the option to participate with a listed performance measurement system.
Long Term Care Organizations Accredited or Seeking Accreditation Under the Joint Commission's Comprehensive Long Term Care Accreditation Program
Medicare/Medicaid-certified skilled nursing facilities/nursing facilities Required to collect and submit MDS data to a state agency per CMS regulations
Until such time as a consensus set of performance measures for Medicare/Medicaid-certified skilled nursing facilities/nursing facilities is established and implemented by CMS:
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OPTION 1:
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Share monthly Facility Quality Indicator (QI) Profiles, Quality Measure (QM) reports, CMS Form 2567 reports and "Plans of Correction" and/or publicly reported Quality Measure reports, as appropriate, with Joint Commission surveyors at the time of survey.
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Discuss how the data were used in identifying priorities for performance improvement activities.
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No data are required to be submitted to the Joint Commission.
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This option will permit Medicare/Medicaid Certified Skilled Nursing Facilities/Nursing Facilities to use the same data to satisfy both federal performance data reporting requirements and ORYX requirements.
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OPTION 2:
Upon CMS implementation of a consensus set of measures for Medicare/Medicaid-certified skilled nursing facilities/nursing facilities
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Self-report aggregate data derived from the consensus set of measures directly to the Joint Commission through a Joint Commission Internet-based application.
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This option will permit Medicare/Medicaid certified skilled nursing facilities/nursing facilities to use the same data to satisfy both state and federal performance data reporting requirements and Joint Commission ORYX requirements.
Long term care organizations Not Required to collect and submit MDS data to a state agency per CMS regulations
Until such time as a relevant set of standardized performance measures is established and implemented by the Joint Commission:
- Continue to participate with a listed performance measurement system.
- Submit aggregate monthly data to the Joint Commission on six performance measures.
Upon Joint Commission implementation of core measures for long term care organizations Not Required to collect and submit MDS data per CMS regulations
- Participate with a listed performance measurement system that has elected to embed the core measures.
- Submit aggregate measure data to the Joint Commission through the measurement system.
Long Term Care Organizations Accredited or Seeking Accreditation Under the Joint Commission's Skilled Nursing Facility/Nursing Facility Certification-Based Long Term Care Accreditation Program
Medicare/Medicaid-certified skilled nursing facilities/nursing facilities Required to collect and submit MDS data to a state agency per CMS regulations
Until such time as a consensus set of performance measures for Medicare/Medicaid-certified skilled nursing facilities/nursing facilities is established and implemented by CMS:
- OPTION 1:
- Share monthly Facility Quality Indicator (QI) Profiles, Quality Measure (QM) reports, or CMS Form 2567 reports and "Plans of Correction" and/or publicly reported Quality Measure reports, as appropriate, with Joint Commission surveyors at the time of survey.
- Discuss how the data were used in identifying priorities for performance improvement activities.
- No data are required to be submitted to the Joint Commission.
- This option will permit Medicare/Medicaid-certified skilled nursing facilities/nursing facilities to use the same data to satisfy both federal performance data reporting requirements and ORYX requirements.
Upon CMS implementation of a consensus set of measures for Medicare/Medicaid-certified skilled nursing facilities/nursing facilities
- Share relevant reports based on the consensus set of measures with Joint Commission surveyors at the time of survey.
- Discuss how the data were used in identifying priorities for performance improvement activities.
- No data are required to be submitted to the Joint Commission.
- This option will permit Medicare/Medicaid-certified skilled nursing facilities/nursing facilities to use the same data to satisfy both federal performance data reporting requirements and ORYX requirements.