SNF PEPPER Released by CMS: Helps With Internal Medicare Audits (8/13) – TMF Health Quality Institute

 Skilled Nursing Facilities to Receive PEPPER

CMS is making available free provider-specific comparative data reports for SNFs nationwide. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a report that summarizes a SNF’s Medicare claims data in areas that may be at risk for improper Medicare payments. It compares the SNF’s statistics with aggregate national statistics to identify whether it may be at risk for improper Medicare payments. SNFs can use the data to support internal auditing and monitoring activities.

PEPPER is distributed by TMF® Health Quality Institute under contract with CMS. The first release of the SNF PEPPER (version Q4FY12) was completed on August 30, 2013. SNFs administered through short-term acute-care hospitals received their SNF PEPPER electronically. The SNF PEPPER file was uploaded to the File Exchange inbox of hospital QualityNet Administrators and user accounts with the PEPPER recipient role. QualityNet Administrators received download instructions in a separate email.

Free-standing SNFs and SNFs administered through long-term acute-care hospitals and inpatient rehabilitation facilities will receive their PEPPER in hard copy format via USPS first-class mail, shipped on August 30, 2013. The envelope is addressed generically to the Chief Executive Officer/Administrator. SNFs should be on the look-out for this envelope and ensure it is appropriately routed internally.

For more information on the SNF PEPPER, including training and resources for SNFs, the SNF PEPPER User’s Guide, and to access information about My QualityNet accounts and frequently asked questions, please visit

Do you have questions or comments about PEPPER or need help obtaining your report? We have a Help Desk available on or you may provide your feedback through ourfeedback form.

The main PEPPER training and resources webpage for SNFs is

Sept. 11 Free AHRQ Webinar on Building Teamwork in Long-term Care: Register Now AHRQ

TeamSTEPPSR in Long-Term Care: Learn the financial and safety benefits to implementing TeamSTEPPSR in Nursing Homes and LTC Facilities

The Agency for Healthcare Research and Quality (AHRQ) is hosting a free one-hour webinar on September 11 from 1 – 2 p.m. ET highlighting how teamwork improves safety and quality in long term care (LTC) settings. AHRQ’s teamwork training program, TeamSTEPPS®, has been tested in real-world settings and is designed to address:

  • The science of teamwork in LTC settings;
  • The resident safety and financial benefits of TeamSTEPPS in LTC;
  • Practical and proven application of the TeamSTEPPS program in LTC facilities.

Presenters will include:

  • Sharon Kostboth-Harper, Project Manager, Tealwood Senior Living;
  • Erin Howe, DNP, Assistant Professor, University of Rochester School of Nursing;
  • Michelle Pandolfi, MSW, Director of Consulting Services, QUALIDIGM.

Presenters will discuss the following objectives:


1. Learn how the TeamSTEPPS Curriculum has been adapted for the Long-Term Care setting

2. Discuss the financial and patient safety benefits of TeamSTEPPS in Long-Term Care

3. Highlight the importance of implementing TeamSTEPPS in Long-Term Care Facilities and encourage the LTC community to use TeamSTEPPS tools and resources

4. Review steps taken to reach the planning process and development of an implementation plan

5. Share the implementation and outcomes of TeamSTEPPS in a LTC setting


Registration is now open.

To review the TeamSTEPPS Long-term Care Curriculum, go here.

Advancing Excellence Campaign Announces 9 New Quality Goals and Updated Tools

WASHINGTON, D.C. — The Advancing Excellence Campaign has announced its completion of nine new quality goals and toolkits and will feature them in a free, informational webinar on September 10 at 3pm ET. The Campaign’s objective is to engage and challenge nursing homes to provide valuable data as well as make quality improvements. It envisions every nursing home resident in America experiencing person-centered quality of life as a result of a stable and empowered workforce, dedicated to improving clinical and organizational outcomes, and engaging in open communication and transparency.

“We are very excited to announce our nine quality goals and free toolkits,” said Dr. David Gifford, MD, MPH, SVP, Quality & Regulatory Affairs, AHCA and Co-Chair, Advancing Excellence Campaign. “This effort demonstrates the Campaign’s ongoing commitment to make nursing homes better places to live, work, and visit.”

More than 60% of the nation’s nursing homes have joined the Campaign. They participate by committing to work on at least one process and one clinical goal. The Campaign aspires to establish national standards and best practices in line with the new CMS Quality Assurance Performance Improvement requirements.

The Advancing Excellence Campaign is supported by 52 Local Area Networks of Excellence (LANEs). These state-level coalitions promote the Campaign and engage nursing homes in performance improvement. The LANEs disseminate Campaign information and resources and organize statewide projects to improve nursing home performance related to Campaign goals.

The nine new quality goals are:

Process Goals:

  • Improving staff stability;
  • Increasing use of consistent assignment;
  • Increasing person-centered care planning and decision making;
  • Safely reducing hospitalizations;

Clinical Goals

  • Using medications appropriately;
  • Increasing resident mobility;
  • Preventing and managing infections safely;
  • Reducing the prevalence of pressure ulcers; and
  • Decreasing symptoms of pain.

“These nine new quality goals, along with their toolkits, were developed by many of the most esteemed experts in their fields,” commented Cheryl Phillips, MD, SVP, Advocacy, LeadingAge and Co-Chair, Advancing Excellence Campaign. “The unprecedented collaboration behind Advancing Excellence is what makes such impressive, meaningful impact possible.”

Free resources, including implementation tools correlating to each goal, are available at

The Campaign will host a free, informational webinar on September 10, 2013, at 3pm EST. Registration information can be found online.

Keynote speakers will include Advancing Excellence Board members:

Cheryl Phillips, MD, SVP, Advocacy, LeadingAge, Washington, DC
David Gifford, MD, MPH, SVP, Quality & Regulatory Affairs, AHCA, Washington, DC
Mary Jane Koren, MD, VP, Long-Term Care Quality Improvement, The Commonwealth Fund, New York, NY

About Advancing Excellence: The Advancing Excellence in America’s Nursing Homes Campaign is a coalition of long-term care providers, caregivers, medical and quality improvement experts, government agencies and consumers working to make Nursing Homes better places to live, work and visit.