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Top Underused CASPER Management Reports That Can Help NACs

The Certification and Survey Provider Enhanced Reports (CASPER) Reporting application in the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system can give nurse assessment coordinators (NACs) and members of the management team vital insights into their facility’s accepted MDSs that are stored in the National Submissions Database and subsequently used in various payment and quality programs. While many NACs are at least familiar with the CASPER Reporting application’s available Quality Measure (QM) reports, such as the MDS 3.0 QM Reports that monitor the traditional CASPER QMs, they may not always be as knowledgeable about the MDS 3.0 Nursing Home Provider Reports, says Carol Hill, MSN, RN, RAC-MT, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL.

“NACs sometimes aren’t even aware that these management reports exist. Or if they know about the reports, they may not understand how or when to run them,” says Hill. “The Nursing Home Provider Reports tend to fall in the background and not rise to the level of ‘This is something important that you need to know,’ especially when a person is new to the NAC position and learning how to schedule and code MDSs.”

“These reports are requested reports, meaning that they don’t automatically drop into your QIES inbox the same way a Five-Star Provider Preview Report does,” says Christine Twombly, RN, RAC-MTA, RAC-MT, LHRM, CHC, an MDS consultant based in Trinity, FL.

“If you want these reports, you have to go into the CASPER Reporting application and request them,” says Twombly. “You need to know how to set the parameters for making those requests and how to interpret the reports. The CASPER Reporting User’s Guide for MDS Providers is the critical tool for using these reports efficiently.”

Note: To learn more about how QIES ASAP works, the role of the CASPER Reporting application and how it interacts with the MDS 3.0 Submission system, and resources for using available reports, see the AANAC tool, QIES ASAP System Walkthrough.

Here are some of the key management reports that can assist NACs:

MDS 3.0 Missing OBRA Assessment Report

The following excerpt from pages 6-27 – 6-28 in chapter 6, “MDS 3.0 Nursing Home Provider Reports,” of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Missing OBRA Assessment report lists the residents for whom the target date of the most recent OBRA assessment (other than a discharge or death record) is more than 138 days prior to the report run date. The report also includes residents for whom no OBRA record was submitted for a current episode that began more than 60 days prior to the report run date.

NOTE: Residents for whom the target date of all OBRA and PPS assessments is more than 730 days prior to the report run date are excluded from the report.

The MDS 3.0 Missing OBRA Assessment (Figure 6-20) details the following for each resident in the facility where, for the last assessment received, the value of A0310F is not 10, 11, or 12 (discharge or death assessment) and the target date is more than 138 days in the past. The report also includes residents for whom no OBRA record was submitted for a current episode that began more than 60 days in the past.

NOTE: If no OBRA assessments exist for a resident but one or more PPS assessments do exist, the PPS assessment with the latest target date is displayed on the report.

  • Resident Identifiers

o Resident Internal ID

o Resident Name (last name, first name)

o Social Security Number (SSN)

o Date of Birth

o Gender

  • Last Record Identifiers

o OBRA A0310A (Federal OBRA Reason for Assessment/Tracking)

o PPS A0310B (PPS Assessment)

o Target Date

The report is sorted in ascending order by Resident Name (Last, First).

NOTE: The information included in the report is only as current as the date of the last submission by the facility.

“The Missing Assessment Report is definitely an important report that is often underutilized,” says Twombly. “The goal is for this report to have no names on it at all.”

For any resident listed on the Missing Assessment Report, NACs must drill down and determine why so they can resolve the situation and get the resident removed from the report, says Hill. “One common reason is that a resident identifier in MDS section A (Identification Information) was different from one assessment to the next. For example, the date changed in A0900 (Birth Date), or a number changed in item A0600 (Social Security and Medicare Numbers).”

“Sending in an MDS that inadvertently changes a resident identifier essentially creates a new resident in the QIES ASAP system,” explains Twombly. “The Missing Assessment Report shows the last assessment that was accepted into the National Submissions Database for that resident. If the assessments aren’t matched to the same resident because a resident identifier changed, the resident will be listed on the report as missing an assessment. Therefore, it’s critical to verify birthdates, Social Security numbers, the spelling of the resident’s name, and other resident identifiers on each assessment before you submit it.”

If a resident is on the Missing Assessment Report because a resident identifier changed, a modification may be needed, adds Twombly. “You may have to correct or modify the assessment that has the incorrect information so that the two assessments will be matched, creating one resident with the correct assessments in the QIES ASAP system. In addition, if you need to modify an assessment when it is more than 24 months past the target date (i.e., the assessment reference date or ARD), you will need to reach out to your state RAI coordinator for assistance.”

Another common reason residents end up on the Missing Assessment Report is that the NAC didn’t complete either an OBRA Discharge assessment or a Death in Facility tracking record when required, says Hill. “For example, the report may show that a resident assessment is missing because that resident’s last assessment was four months ago, but the resident actually died three months ago, and no one completed the Death in Facility tracking record. While other reports specifically track discharges, the Missing Assessment Report can be a good first line of defense against missing Discharge assessments and Death in Facility tracking records.”

“NACs should look at this key report weekly,” suggests Hill. “For example, if you look at the Missing Assessment Report when you plan out your week each Monday, then you can add any issues that you find to your weekly to-do list so that you can go ahead and take care of them.”

However, NACs who are closely tracking their Final Validation Reports may only need to run the Missing Assessment Report on a monthly basis, points out Twombly. “If you transmit weekly and review the Final Validation Reports every time you transmit, those reports also will help you spot when a resident identifier changes so that you can address any problems as they occur. Then you can use the Missing Assessment Report as a monthly audit to catch anything you missed on the Final Validation Reports, but ideally, the Missing Assessment Report will be blank.”

It’s also useful to run the report when there are changes in MDS staff, adds Hill. “The new NAC can use it to quickly identify what they need to prioritize and whether they need additional assistance to correct long-standing problems.”

MDS 3.0 Discharges Report

The following excerpt from pages 6-19 – 6-20 in chapter 6 of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Discharges report lists the residents discharged (A0310F = 10, 11, or 12) from a facility during a specified timeframe. Editor’s note: A0310F = 10, 11, or 12 is defined as follows:10 (Discharge assessment-return not anticipated), 11 (Discharge assessment-return anticipated), or 12 (Death in Facility tracking record).

The MDS 3.0 Discharges report details the following for the residents discharged (A0310F = 10, 11, or 12) with a Discharge Date (A2000) within the specified timeframe.

  • Resident Internal ID
  • Social Security Number (SSN)
  • Resident Name (last name and first name)
  • Item Subset Code (ISC)
  • A0310F (Entry/discharge reporting)
  • A0310G (Type of discharge)
  • A0310H (SNF Part A PPS Discharge Assessment)
  • A2100 (Discharge Status)
  • Discharge Date (A2000)
  • Submission Date

The report is sorted in ascending order by Last Name, First Name, Resident Internal ID, A0310F value, and Discharge Date.

A total number of discharges is provided for each selected facility.

The Discharges Report shows all of the Discharge assessments and the Death in Facility tracking records submitted by the facility in the timeframe requested by the person who runs the report, says Hill. “Missed Discharge assessments and Death in Facility tracking records can inappropriately overinflate the facility’s MDS census. If you run this report monthly, you can use it as an audit tool by comparing it to a discharge list from your facility software to ensure you have done all of the necessary Discharge assessments and Death in Facility tracking records.”

In addition to running the Discharges Report monthly, it can be beneficial to pull the report whenever there is turnover in the MDS position, says Hill. “Instead of going through every resident in the MDS software to figure out whether a Discharge assessment was completed, the new NAC can run this report, run a discharge list from the software, and compare the two to identify missed discharges.”

MDS 3.0 Roster Report

The following excerpt from pages 6-33 – 6-34 in chapter 6 of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Roster report lists residents of a facility for whom the latest accepted, federally required assessment is not a discharge assessment (A0310F = 10, 11, or 12) and the target date is less than 24 months prior to the report run date.

NOTE: When Target Dates are the same, a discharge assessment is assumed to have happened after an Entry assessment and the resident is excluded from the report.

The MDS 3.0 Roster report details the following for each resident where the value of A0310F submitted in the last assessment is not 10, 11, or 12.

  • Resident Internal ID
  • Social Security Number (SSN)
  • Resident Name (last name, first name)
  • Date of Birth (DOB)
  • Gender/Race/Ethnicity

o A=American Indian or Alaska Native

o B=Asian

o C=Black or African American

o D=Hispanic or Latino

o E=Native Hawaiian or Other Pacific Islander

o F=White

  • Item Subset Code (ISC)
  • A0310A (Federal OBRA Reason for Assessment)
  • A0310B (PPS Assessment)
  • A0310C (PPS Other Medicare Required Assessment – OMRA)
  • A0310F (Entry/discharge reporting) 
  • A0310H (SNF Part A PPS Discharge Assessment)
  • Target Date
  • Submission Date
  • Admission Date
  • Admission Type (Admission or Reentry)

An asterisk (*) indicates an empty value was submitted.

The report is sorted in ascending order by Resident Name (Last, First).

NOTE: The information included in the report is only as current as the date of the last submission by the facility. Therefore, for example, if the facility has submitted no assessments in the last two weeks, the information on the report is two weeks old.

The total number of facility residents included in the report is provided.

“While the Discharges Report shows all of the Discharge assessments and Death in Facility tracking records completed during a given period, the Roster Report identifies all residents by name that the QIES ASAP system currently shows as being in your facility,” says Twombly.
“If there is a systemic problem with Discharge assessments, running the Roster Report every month often will show that you have a lot more residents than you have beds to put them in. For example, if a 120-bed facility has 160 residents listed on the Roster Report, that means that Discharge assessments haven’t been submitted.”

Using multiple tools to track discharges is important because the Staffing domain in the Five-Star Quality Rating System uses MDS census data to calculate a daily resident census, says Twombly. “That daily resident census is used in the denominator of the nurse staffing ratios (i.e., the total nursing hours per resident day and the RN hours per resident day) that are derived from Payroll-Based Journal (PBJ) data submissions. Consequently, missing discharges ultimately could affect your star rating in the Staffing domain.”

MDS 3.0 Error Detail by Facility Report

The following excerpt from pages 6-21 – 6-22 in chapter 6 of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Error Detail by Facility report details the errors encountered in successful submissions made by or on behalf of a facility during a specified timeframe.

The MDS 3.0 Error Detail by Facility report lists the following about the errors encountered by the facility during the specified timeframe:

  • Assessment ID
  • Item Subset Code (ISC)
  • Submission Date
  • Error Number
  • Error Description
  • Error Type
  • Field In Error
  • Value In Error

An asterisk (*) indicates an empty value was submitted.

The report is sorted in ascending order by Submission Date, Assessment ID, and Error Number.

“This report offers a cumulative way of looking at the types of errors the facility is receiving when submitting MDSs to the QIES ASAP system, making it easier to identify trends than when you look at individual Final Validation Reports,” says Hill.

“For example, if you commonly get warning message -1031 (Resident Information Mismatch: Submitted value(s) for the item(s) listed do not match the values in the QIES ASAP database. If the record was accepted, the resident information in the database was updated. Verify that the new information is correct.) when you run the report each month, then you need to drill down and find out why,” she explains. “If, for example, the resident’s Medicare number often changes from one assessment to the next, what is the facility’s process for obtaining the Medicare number? Can the process be changed to ensure the accurate number is entered the first time?”

Note: Error messages and their potential solutions are defined in section 5, “Error Messages,” of the MDS 3.0 Provider User’s Guide.

MDS 3.0 Assessments With Error Number XXXX Report

The following excerpt from pages 6-17 – 6-18 in chapter 6 of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Assessments with Error Number XXXX report lists the assessments submitted with a specified error for a facility during a specified period.

The MDS 3.0 Assessments with Error Number XXXX report details the following for the assessments submitted during the specified timeframe that encountered the specified error.

  • Submission Date
  • Field in Error
  • Value in Error

An asterisk (*) indicates an empty value was submitted.

The report is sorted in ascending order by State Code, Facility ID, Error Number, Submission Date, Resident/Patient Name, Assessment ID, Field in Error, and Value in Error.

“This report can be run as needed to help you do a deeper dive when you have identified that a specific error is trending in your facility,” says Hill. “In addition, it can help you look for specific errors that are useful to track, such as warnings for late assessments or warnings for the submission threshold for the Skilled Nursing Facility Quality Reporting Program (SNF QRP).”

Note: Currently, warning messages -1038, -1040, -3749a, -3749b, -3749c, -3749d, and -3749e indicate the late completion of assessments or care plans. Warning messages -3891, -3897, -3907, and -3908 could indicate problems with a facility’s ability to meet the SNF QRP submission threshold. For more information, see section 5 of the MDS 3.0 Provider User’s Guide.

MDS 3.0 Activity Report

The following excerpt from pages 6-12 – 6-14 in chapter 6 of the CASPER Reporting User’s Guide for MDS Providers explains what this report is:

The MDS 3.0 Activity report lists the accepted assessments, tracking records, and inactivation requests that were submitted by or on behalf of a facility during a specified timeframe.

The MDS 3.0 Activity report details the following data from assessments, tracking records, and inactivation requests that were submitted within the specified timeframe.

  • Resident Internal ID
  • Social Security Number (SSN)
  • Resident Name (last name and first name)
  • Medicare Number
  • Date of Birth (DOB)
  • Gender
  • A0310A (Federal OBRA Reason for Assessment)
  • A0310B (PPS Assessments)
  • A0310C (PPS Other Medicare Required Assessment – OMRA)
  • A0310D (Is this a Swing Bed clinical change assessment?)
  • A0310F (Entry/discharge reporting)
  • A0310G (Type of discharge)
  • A0310H (SNF Part A PPS Discharge Assessment)
  • Item Subset Code (ISC)
  • Target Date
  • Submission Date
  • Calculated Medicare (MCR) [PDPM] (based on the recalculated Z0100A value)
  • Calculated Medicaid (MCD) RUG (based on the recalculated Z0200A value)
  • A0050 (Type of Record)
  •  X0800 (Correction Number)
  •  X1100E (Attestation Date)

An asterisk (*) indicates an empty value was submitted.

The report is sorted in ascending order by Last Name, First Name, Resident ID, ISC, Submission Date, A0050, X0800, and Target Date.

“If you have residents who appear to be missing an assessment, you can run this report as needed to validate whether you in fact completed the missing assessment,” says Hill. “Sometimes, looking at which assessments were actually accepted into the National Submissions Database via this report can be easier than working through stacks of Final Validation Reports to try to find a particular assessment for a particular resident.”

Seeing trends is key

Resolving individual issues identified in a Nursing Home Provider Report is critical, but it’s also important to recognize trends that need to be taken through the Quality Assurance and Performance Improvement (QAPI) process, stresses Hill. “If you see a pattern, you should take it to your QA committee and develop an action plan so that you can identify and correct the root cause. Examples of trends could be specific error messages that continue to occur across multiple reports or a pattern of Discharge assessments not being completed.”


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