By the time they arrive at your community, the survey team has already chosen the first phase resident sample. It isn’t magic—they have the same tools our communities have: a current CASPER report and the two federal forms: the 672 and the 802.
So why don’t we use them ourselves? Wouldn’t it be great to have your own “resident sample” that mirrors the surveyors'? You should also be using these tools as part of your QAPI and PIP process to improve QMs and health inspection reports!
We're often surprised how frequently management teams in our communities don't recognize the value the CASPER report has to their overall operations. There are even communities that don't know how to produce a CASPER report from their MDS system.
Using the CASPER Report at Your Community
So what do the surveyors do before showing up at your door?
The survey team reviews the Facility Characteristics Report to determine your community's demographics. This helps them identify whether your population is unusual and whether there are exceptions that they should be aware of. They also use the Roster/Sample Matrix (Form CMS-802) to highlight concerns identified for Phase 1 and to list preselected residents and the QM/QI conditions for which each was selected.
So where should you start?
- Begin with generating a six-month CASPER community-level Quality Measure report.
- Print off the CMS 802, resident roster, and condition. Identify the residents with the highest needs and highlight them.
- Review the Quality Measure report and highlight the flagged, or almost flagging categories.
- Go back to your resident roster and highlight the residents affected by the flagged areas on the Quality Measure report. These are your high-risk residents, the residents who are more likely to be included in the surveyors' phase I sample.
Remember, use the CASPER like a survey team. This report identifies system strengths and failures and is intended to be system-oriented—so bring it to your QAPI committee!
Consider running a CASPER report monthly, using a 6-month review time frame. Take this to your QAPI committee and use it to determine which systems need to be evaluated. The simple fact that an area is flagged on the CASPER report (i.e., higher than 75th percentile) doesn't necessarily mean there's a problem, but it means you should look at the area or system to determine if any action should be taken.
Similarly, choosing residents most likely to be included in the survey sample includes using CMS forms 672 and 802.
By understanding the scoring for Quality Measures, you can aim your goals at specific targets. You’ll earn 100 points for being in the top performers for restraints, short-stay wounds, and antipsychotic use. By knowing the benchmark, you can implement specific and measurable goals to improve your rating.
A Few Things to Keep in Mind
When you run the CASPER, don't forget these things:
- QM statistics are automatically recalculated weekly; this shows the last date the system calculation occurred.
- There are 24 Quality Measures but only 16 are used to calculate the 5-Star rating (this will probably change in the future).
- The reporting period is selected by the user when the report is requested. If the reporting period is too short the outcomes can be skewed—consider a 90-day period.
- State and national statistics are automatically calculated for various time periods and used to produce comparison statistics.
This is where QA Reader can help you! One of the most frequently cited F-tag and flag categories on the CASPER report is falls/falls with injuries. Consider how you're currently identifying those high risk residents. Are you truly able to identify root cause, frequency, time of day, location, etc.? How much time and effort goes into this process internally? With QA Reader, you can get this data in real time, all the time—with little to no hands-on nursing hours involved.
Next Steps
- Get more great content—subscribe to our blog
- Discover how QA Reader helps reduce incidents
- See QA Reader in action—request a live demo
