CASPER Quality Measure Report Review

Monthly inspection template for reviewing CASPER quality measure reports, documenting trends, drilling down to resident-level findings, and handing off measures above threshold to QAPI for follow-up.

Review Identification

• Review month and year documented
  Record the month and year covered by this CASPER review.
• Facility or unit identified
  Identify the facility, campus, or unit included in the review.
• Reviewer name and role documented
  Identify the person completing the review and their role.
• CASPER report version or source noted
  Document the report source, export date, or report version used for the review.
• Review completed within monthly schedule
  Confirm the review was completed according to the monthly run schedule.

Measure Threshold Screening

• Measures above threshold identified
  Confirm whether any CASPER quality measures were above the facility threshold.
• Number of measures above threshold
  Count the number of measures exceeding threshold.
• Measures requiring QAPI handoff listed
  Select each measure that requires QAPI follow-up.
• Threshold source documented
  Document the internal threshold, benchmark, or comparison source used to determine whether a measure was above threshold.

Trend Analysis

• Trend direction assessed
  Select the overall trend direction for the measure(s) reviewed.
• Trend period reviewed
  Document the comparison period used for trend review, such as 3-month or 6-month trend.
• Persistent pattern identified
  Indicate whether the measure shows a persistent pattern rather than a one-time spike.
• Trend summary narrative
  Summarize the observed trend, including any seasonal, census-related, or process-related factors.

Resident-Level Drill-Down

• Resident-level drill-down completed
  Confirm that the review included resident-level analysis for the affected measure(s).
• Number of residents reviewed
  Count the residents included in the drill-down review.
• Primary contributing factors identified
  Select the factors most associated with the elevated measure.
• Resident-level examples documented
  Summarize resident-level findings without entering unnecessary personally identifiable information.
• Immediate risk issues escalated
  Indicate whether any immediate resident safety or clinical risk issues were escalated.

QAPI Handoff and Follow-Up

• QAPI handoff completed
  Confirm the measure review was formally handed off to QAPI when thresholds were exceeded.
• QAPI owner assigned
  Identify the QAPI owner or department responsible for follow-up.
• Corrective action plan documented
  Document the planned intervention, monitoring method, or process change.
• Follow-up due date documented
  Record when the next review or follow-up is due.
• Escalation to leadership or committee completed if needed
  Indicate whether escalation beyond QAPI was required based on severity or persistence.

Reviewer Attestation

• Reviewer signature
  Signature confirming the review is complete and accurate.