MDS 3.0 Quality Measures User's Manual - v12.0, Effective ... · Title: MDS 3.0 Quality Measures...

MDS 3.0 Quality Measures

USER’S MANUAL

(v12.0)

Effective January 1, 2019

Prepared for:The Centers for Medicare & Medicaid Services under Contract No. HHSM500- 2013-13015I (HHSM-500-T0001). (RTI Project Number 0214077.001.001)

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RTI International January 2019 (v12.0) i

QUALITY MEASURES (QM) USER’S MANUAL

CONTENTS

Chapter 1 QM Sample and Record Selection Methodology......................................................1

Section 1: Definitions .......................................................................................................1

Section 2: Selecting the QM Samples...............................................................................3

Section 3: Short Stay Record Definitions .........................................................................4

Section 4: Long Stay Record Definitions .........................................................................6

Section 5: Transition of the Pressure Ulcer Quality Measures .........................................9

Chapter 2 MDS 3.0 Quality Measures Logical Specifications ................................................11

Section 1: Short Stay Quality Measures .........................................................................13

Table 2-1 MDS 3.0 Measure: Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay) (NQF #0676) (CMS ID: N001.01) ....................................................................................................13

Table 2-2 MDS 3.0 Measure: Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) (CMS ID: N002.03).......................................................................14

Table 2-3 MDS 3.0 Measure: Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) (CMS ID: N003.02) ...................................................15

Table 2-4 MDS 3.0 Measure: Percent of Residents Who Received the Seasonal Influenza Vaccine (Short Stay) (NQF #0680A) (CMS ID: N004.02) ....................................................................................................16

Table 2-5 MDS 3.0 Measure: Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine (Short Stay) (NQF #0680B) (CMS ID: N005.02) ....................................................................17

Table 2-6 MDS 3.0 Measure: Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine (Short Stay) (NQF #0680C) (CMS ID: N006.02) .....................................18

Table 2-7 MDS 3.0 Measure: Percent of Residents Who Newly Received an Antipsychotic Medication (Short Stay) (NQF: None) (CMS ID: N011.01) ....................................................................................................19

Table 2-8 MDS 3.0 Measure: Percent of Residents Who Made Improvements in Function (Short Stay) (NQF: None) (CMS ID: N037.02) ....................................................................................................21

RTI International January 2019 (v12.0) ii

Section 2: Long Stay Quality Measures..........................................................................24

Table 2-9 MDS 3.0 Measure: Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF: 0674) (CMS ID: N013.01) ....................................................................................................24

Table 2-10 MDS 3.0 Measure: Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay) (NQF: 0677) (CMS ID: N014.02) ....................................................................................................25

Table 2-11 MDS 3.0 Measure: Percent of High-Risk Residents With Pressure Ulcers (Long Stay) (NQF: 0679) (CMS ID: N015.02) ...............27

Table 2-12 MDS 3.0 Measure: Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay) (NQF #0681) (CMS ID: N016.02) ............................................................29

Table 2-13 MDS 3.0 Measure: Percent of Residents Who Received the Seasonal Influenza Vaccine (Long Stay) (NQF #0681A) (CMS ID: N017.02) ....................................................................................................30

Table 2-14 MDS 3.0 Measure: Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine (Long Stay) (NQF #0681B) (CMS ID: N018.02) ....................................................................31

Table 2-15 MDS 3.0 Measure: Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine (Long Stay) (NQF #0681C) (CMS ID: N019.02) .......................32

Table 2-16 MDS 3.0 Measure: Percent of Residents with a Urinary Tract Infection (Long Stay) (NQF: 0684) (CMS ID: N024.01)..........................33

Table 2-17 MDS 3.0 Measure: Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay) (NQF #0686) (CMS ID: N026.02).......................................................................34

Table 2-18 MDS 3.0 Measure: Percent of Residents Who Were Physically Restrained (Long Stay) (NQF #0687) (CMS ID: N027.01) ......................35

Table 2-19 MDS 3.0 Measure: Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay) (NQF #0688) (CMS ID: N028.01).......................................................................36

Table 2-20 MDS 3.0 Measure: Percent of Residents Who Lose Too Much Weight (Long Stay) (NQF #0689) (CMS ID: N029.01)............................38

Table 2-21 MDS 3.0 Measure: Percent of Residents Who Received an Antipsychotic Medication (Long-Stay) (NQF: None) (CMS ID: N031.02) ....................................................................................................39

Table 2-22 MDS 3.0 Measure: Percent of Residents Who Used Antianxiety or Hypnotic Medication (Long Stay) (NQF: None) (CMS ID: N036.01) ...................................................................................40

Table 2-23 MDS 3.0 Measure: Percent of Residents Whose Ability to Move Independently Worsened (Long Stay) (NQF: None) (CMS ID: N035.02) ..............................................................................................41

RTI International January 2019 (v12.0) iii

Appendix A: Technical Details............................................................................................. A-1

Appendix B: Parameters Used for Each Quarter ...................................................................B-1

Appendix C: Episode and Stay Determination Logic............................................................C-1

Appendix D: Measures Withdrawn from NQF Submission................................................. D-1

Appendix E: Surveyor Quality Measures ..............................................................................E-1

Appendix F: Specifications for the Facility Characteristics Report ......................................F-1

RTI International January 2019 (v12.0) iv


RTI International January 2019 (v12.0) 1

Chapter 1

QM Sample and Record Selection Methodology

The purpose of this chapter is to describe the methodology that is used to select the short and long stay samples as well as the key records that are used to compute the QMs for each of those samples. The first section below will present definitions that are used to describe the selection methodology. The second section describes the selection of the two samples. The third and fourth sections describe the selection of the key records within each of the two samples.

The logic presented below depends upon the concepts of stays and episodes. Detailed specifications for the identification of stays and episodes are presented in Appendix C of this document.

Section 1: Definitions

Target period. The span of time that defines the QM reporting period (e.g., a calendar quarter).

Influenza Season: Influenza season is July 1 of the current year to June 30 of the following year(e.g., July 1, 2018 through June 30, 2019 for the 2018 – 2019 influenza season).1

Stay. The period of time between a resident’s entry into a facility and either (a) a discharge, or (b) the end of the target period, whichever comes first. A stay is also defined as a set of contiguous days in a facility. The start of a stay is either:

• An admission entry (A0310F = [01] and A1700 = [1]), or

• A reentry (A0310F = [01] and A1700 = [2]).

The end of a stay is the earliest of the following:

• Any discharge assessment (A0310F = [10, 11]), or

• A death in facility tracking record (A0310F = [12]), or

• The end of the target period.

Episode. A period of time spanning one or more stays. An episode begins with an admission (defined below) and ends with either (a) a discharge, or (b) the end of the target period, whichever comes first. An episode starts with:

• An admission entry (A0310F = [01] and A1700 = [1]).

1 This definition is applicable to each of the long- and short-stay influenza vaccination measures. The short-stay measures are identified as the following: NQF #0680 (CMS ID: N003.02); NQF #0680A (CMS ID: N004.02); NQF #0680B (CMS ID: N005.02); NQF #0680C (CMS ID: N006.02. The long-stay measures are identified as the following: NQF #0681 (CMS ID: N016.02); NQF #0681A (CMS ID: N017.02); NQF #0681B (CMS ID: N018.02); NQF #0681C (CMS ID: N019.02).


The end of an episode is the earliest of the following:

• A discharge assessment with return not anticipated (A0310F = [10]), or

• A discharge assessment with return anticipated (A0310F = [11]) but the resident did not return within 30 days of discharge, or

• A death in facility tracking record (A0310F = [12]), or

• The end of the target period.

Admission. An admission entry record (A0310F = [01] and A1700 = [1]) is required when any one of the following occurs:

• Resident has never been admitted to this facility before; or

• Resident has been in this facility previously and was discharged return not anticipated; or

• Resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge.

Reentry. A reentry record (A0310F = [01] and A1700 = [2]) is required when all of the following occurred prior to this entry; the resident was:

• Discharged return anticipated, and

• Returned to facility within 30 days of discharge.

Cumulative days in facility (CDIF). The total number of days within an episode during which the resident was in the facility. It is the sum of the number of days within each stay included in an episode. If an episode consists of more than one stay separated by periods of time outside the facility (e.g., hospitalizations), only those days within the facility would count towards CDIF. Any days outside of the facility (e.g., hospital, home, etc.) would not count towards the CDIF total. The following rules are used when computing CDIF:

• When counting the number of days until the end of the episode, counting stops with (a) the last record in the target period if that record is a discharge assessment (A0310F = [10, 11]), (b) the last record in the target period if that record is a death in facility (A0310F = [12]), or (c) the end of the target period is reached, whichever is earlier.

• When counting the duration of each stay within an episode, include the day of entry (A1600) but not the day of discharge (A2000) unless the entry and discharge occurred on the same day in which case the number of days in the stay is equal to 1.

• While death in facility records (A0310F = [12]) end CDIF counting, these records are not used as target records because they contain only tracking information and do not include clinical information necessary for QM calculation.

• Special rules for influenza vaccination measures. Influenza vaccination measures are calculated only once per 12-month influenza season, which begins July 1 of a given year and ends on June 30 of the subsequent year. For these measures, the target period begins on October 1 and ends on March 31. This means that the end-of-episode date will be March 31 for an episode that is ongoing at the end of the influenza season and that March


31 should be used as the end date when computing CDIF and for classifying stays as long or short for the influenza vaccination measures.

– Note, the target period (i.e., October 1 – March 31) is different than the selection period, which begins October 1 and ends June 30 of the following year. The selection period for the influenza vaccination measures is discussed more in Sections 3 and 4below.

Short stay. An episode with CDIF less than or equal to 100 days as of the end of the target period.

Long stay. An episode with CDIF greater than or equal to 101 days as of the end of the target period.

Target date. The event date for an MDS record, defined as follows:

• For an entry record (A0310F = [01]), the target date is equal to the entry date (A1600).

• For a discharge record (A0310F = [10, 11]) or death-in-facility record (A0310F = [12]), the target date is equal to the discharge date (A2000).

• For all other records, the target date is equal to the assessment reference date (A2300).

Section 2: Selecting the QM Samples

Two resident samples are selected for computing the QMs: a short-stay sample and a long-stay sample. These samples are selected using the following steps:

1. Select all residents whose latest episode either ends during the target period or is ongoing at the end of the target period. This latest episode is selected for QM calculation.

2. For each episode that is selected, compute the cumulative days in the facility (CDIF).

3. If the CDIF is less than or equal to 100 days, the resident is included in the short-stay sample.

4. If the CDIF is greater than or equal to 101 days, the resident is included in the long-stay sample.

Note that all residents who are selected in Step 1 above will be placed in either the short- or long-stay sample and that the two samples are mutually exclusive. If a resident has multiple episodes within the target period, only the latest episode is used.

Within each sample, certain key records are identified which are used for calculating individual measures. These records are defined in the following sections.


Section 3: Short Stay Record Definitions

ASSESSMENT SELECTED PROPERTY SELECTION SPECIFICATIONS

Targetassessment

Selection period Most recent 6 months (the short stay target period).

Qualifying RFAs1 A0310A = [01, 02, 03, 04, 05, 06] orA0310B = [01, 02, 03, 04, 05, 06] orA0310F = [10, 11]

Selection logic Latest assessment that meets the following criteria: (a) it is contained within the resident’s selected episode, (b) it has a qualifying RFA, and (c) its target date is no more than 120 days2

before the end of the episode.

Rationale Records with a qualifying RFA contain all of the items needed to define the QMs. The target assessment need not have a target date within the target period, but it must occur within 120 days before the end of the resident’s selected episode (either the target date of a discharge assessment or death in facility record that is the last record in the target period or the end of the target period if the episode is ongoing). 120 days allows 93 days between quarterly assessments plus an additional 27 days to allow for late assessments. The target assessment represents the resident’s status at the end of the episode.

Initial assessment

Selection period First assessment following the admission entry record at the beginning of the resident’s selected episode.

Qualifying RFAs A0310A = [01] orA0310B = [01, 06] orA0310F = [10, 11]

Selection logic Earliest assessment that meets the following criteria: (a) it is contained within the resident’s selected episode, (b) it has a qualifying RFA, (c) it has the earliest target date that is greater than or equal to the admission entry date starting the episode, and (d) its target date is no more than 130 days prior to the target date of the target record. The initial assessment cannot be the same as the target assessment. If the same assessment qualifies as both the initial and target assessments, it is used as the target assessment and the initial assessment is considered to be missing.

Rationale Records with a qualifying RFA contain all of the items needed to define the QMs. The initial assessment need not have a target date within the target period. The initial assessment represents the resident’s status as soon as possible after the admission that marks the beginning of the episode. If the initial assessment is more than 130 days prior to the target assessment, it is not used and the initial record is considered to be missing. This prevents the use of an initial assessment for a short stay in which a large portion of the resident’s episode was spent outside the facility. 130 days allows for as many as 30 days of a 100-day stay to occur outside of the facility.

1 RFA: reason for assessment. (continued)2 A short stay episode can span more than 100 calendar days because days outside of the facility are not counted in

defining a 100-day or less short stay episode.


Short Stay Record Definitions (continued)


Look-back Scan Selection period Scan all assessments within the current episode.

Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] orA0310B = [01, 02, 03, 04, 05, 06] orA0310F = [10, 11]

Selection logic Include the target assessment and qualifying earlier assessments in the scan. Include an earlier assessment in the scan if it meets all of the following conditions: (a) it is contained within the resident’s episode, (b) it has a qualifying RFA, and (c) its target date is on or before the target date for the target assessment. The target assessment and qualifying earlier assessments are scanned to determine whether certain events or conditions occurred during the look-back period. These events and conditions are specified in the definitions of measures that utilize the look-back scan.

Rationale Some measures utilize MDS items that record events or conditions that occurred since the prior assessment was performed. The purpose of the look-back scan is to determine whether such events or conditions occurred during the look-back period. All assessments with target dates within the episode are examined to determine whether the event or condition of interest occurred at any time during the episode.

Influenza vaccination assessment

Selection period3 All assessments with target dates on or after October 1 of the most recently completed influenza season (i.e., the target date must be on or between October 1 of the current year and June 30 of the following year).


Selection logic Select the record with the latest target date that meets all of the following conditions:

a) It has a qualifying RFA, andb) Target date is on or after October 1st of the most

recently completed influenza season (i.e., the target date must fall on or between October 1 and June 30),and

c) A1600 (entry date) is on or before March 31st of the most recently completed influenza season

Rationale The selection logic defined above is intended to identify the latest assessment that reports the influenza vaccine status for a resident who was in the facility for at least one day from October 1 through March 31.

3 The selection period uses a June 30th end date to ensure residents who are vaccinated between October 1 and March 31, but do not have an assessment completed until after March 31, are captured in the measure sample.


Section 4: Long Stay Record Definitions


Target assessment Selection period Most recent 3 months (the long stay target period).


Selection logic Latest assessment that meets the following criteria: (a) it is contained within the resident’s selected episode, (b) it has a qualifying RFA, and (c) its target date is no more than 120 before the end of the episode.

Rationale Records with a qualifying RFA contain all of the items needed to define the QMs. The target assessment need not have a target date within the target period, but it must occur within 120 days of the end of the resident’s episode (either the last discharge in the target period or the end of the target period if the episode is ongoing). 120 days allows 93 days between quarterly assessments plus an additional 27 days to allow for late assessments. The target assessment represents the resident’s status at the end of the episode.

Prior assessment Selection period Latest assessment that is 46 to 165 days before the target assessment.


Selection logic Latest assessment that meets the following criteria: (a) it is contained within the resident’s episode, (b) it has a qualifying RFA, and (c) its target date is contained in the window that is 46 days to 165 days preceding the target date of the target assessment. If no qualifying assessment exists, the prior assessment is considered missing.

Rationale Records with a qualifying RFA contain all of the items needed to define the QMs. The prior assessment need not have a target date within the target period, but it must occur within the defined window.

The window covers 120 days, which allows 93 days between quarterly assessments plus an additional 27 days to allow for late assessments. Requiring a 45-day gap between the prior assessment and the target assessment insures that the gap between the prior and target assessment will not be small (gaps of 45 days or less are excluded).

(continued)


Long Stay Record Definitions (continued)


Look-back Scan Selection period Scan all assessments within the current episode that have target dates no more than 275 days prior to the target assessment.


Selection logic Include the target assessment and all qualifying earlier assessments in the scan. Include an earlier assessment in the scan if it meets all of the following conditions: (a) it is contained within the resident’s episode, (b) it has a qualifying RFA, (c) its target date is on or before the target date for the target assessment, and (d) its target date is no more than 275 days prior to the target date of the target assessment. The target assessment and qualifying earlier assessments are scanned to determine whether certain events or conditions occurred during the look-back period. These events and conditions are specified in the definitions of measures that utilize the look-back scan.

Rationale Some measures utilize MDS items that record events or conditions that occurred since the prior assessment was performed. The purpose of the look-back scan is to determine whether such events or conditions occurred during the look-back period. These measures trigger if the event or condition of interest occurred any time during a one year period. A 275-day time period is used to include up to three quarterly OBRA assessments. The earliest of these assessments would have a look-back period of up to 93 days which would cover a total of about one year. All assessments with target dates in this timeperiod are examined to determine whether the event or condition of interest occurred at any time during the time interval.

(continued)


Long Stay Record Definitions (continued)


Influenza vaccination assessment

Selection period4

All assessments with target dates on or after October 1 of the most recently completed influenza season (i.e., the target date must be on or between October 1 of the current year and June 30 of the following year).


Selection logic Select the record with the latest target date that meets all of the following conditions:

a) It has a qualifying RFA, andb) Target date is on or after October 1st of the most

recently completed influenza season (i.e., the target date must fall on or between October 1 and June 30),and

c) A1600 (entry date) is on or before March 31st of the most recently completed influenza season

Rationale The selection logic defined above is intended to identify the latest assessment that reports the influenza vaccine status for a resident who was in the facility for at least one day from October 1 through March 31.

4 The selection period uses a June 30th end date to ensure residents who are vaccinated between October 1 and March 31, but do not have an assessment completed until after March 31, are captured in the measure sample.


Section 5: Transition of the Pressure Ulcer Quality Measures

In order to reduce provider burden and duplication of measures, as well as to align measures across the NHQI and the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP), the NHQI version of the quality measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), is being replaced with the SNF QRP version of the measure. The SNF QRP specifications for NQF #0678 can be found in the latest version of the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual on the SNF QRP website2 under the downloads section at the bottom of the page.Furthermore. beginning with the FY 2020 SNF QRP, the measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), will be removed from the SNF QRP measure set and replaced with a modified version of that measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury Star, to include the addition of new or worsened unstageable pressure ulcers. This SNF QRP measure will also be reported as a part of the NHQI. Specifications for the measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, may also be found in the latest version of the Skilled Nursing FacilityQuality Reporting Program Measure Calculations and Reporting User’s Manual on the SNF QRP website.

2 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html


Chapter 2

MDS 3.0 Quality Measures Logical Specifications

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f th

e S

kill

ed N

ursi

ng F

acil

ity

Qua

lity

R

epor

ting

Pro

gram

Mea

sure

Cal

cula

tion

s an

d R

epor

ting

Use

r’s

Man

ual o

n th

e S

NF

QR

P w

ebsi

te3

unde

r th

e do

wnl

oads

sec

tion

at t

he

bott

om o

f th

e pa

ge. T

he m

easu

re lo

gica

l spe

cifi

cati

ons

can

be f

ound

in C

hap

ter

7, T

able

7-1

.

3ht

tps:

//w

ww

.cm

s.go

v/M

edic

are/

Qua

lity

-Ini

tiat

ives

-Pat

ient

-Ass

essm

ent-

Inst

rum

ents

/Nur

sing

Hom

eQua

lityI

nits

/Ski

lled

-Nur

sing

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ility

-Qua

lity

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ortin

g-P

rogr

am/S

NF

-Qua

lity-

Rep

orti

ng-P

rogr

am-M

easu

res-

and-

Tec

hnic

al-I

nfor

mat

ion.

htm

l

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)1

5

Tab

le 2

-3M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o W

ere

Ass

esse

d a

nd

Ap

pro

pri

atel

y G

iven

the

Sea

son

al I

nfl

uen

za V

acci

ne

(Sh

ort

Sta

y)(N

QF

#06

80)

(CM

S I

D:

N00

3.02

)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f sh

ort-

stay

res

iden

ts w

ho a

reas

sess

ed a

nd/o

rgi

ven,

app

ropr

iate

ly, t

he in

flue

nza

vacc

inat

ion

duri

ng th

e m

ost r

ecen

t in

flue

nza

seas

on.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng a

ny o

f th

e fo

llow

ing

crit

eria

on

the

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t:

1.R

esid

ent r

ecei

ved

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son,

eith

er in

the

faci

lity

(O02

50A

= [

1])

orou

tsid

e th

e fa

cili

ty (

O02

50C

=

[2]

); o

r

2.R

esid

ent w

as o

ffer

ed a

nd d

eclin

ed th

e in

flue

nza

vacc

ine

(O02

50C

= [

4]);

or

3.R

esid

ent w

as in

elig

ible

due

to m

edic

al c

ontr

aind

icat

ion(

s) (

O02

50C

= [

3])

(e.g

., an

aphy

lact

ic h

yper

sens

itiv

ity

to e

ggs

or o

ther

com

pone

nts

of th

e va

ccin

e, h

isto

ry o

f G

uill

ain-

Bar

re S

yndr

ome

wit

hin

6 w

eeks

aft

er a

pre

viou

s in

flue

nza

vacc

inat

ion,

bon

e m

arro

w tr

ansp

lant

wit

hin

the

past

6

mon

ths)

.

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent.

Thi

s in

clud

es a

ll re

side

nts

who

hav

e an

ent

ry d

ate

(A16

00)

on o

r be

fore

Mar

ch 3

1 of

th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on a

nd h

ave

an a

sses

smen

twit

h a

targ

et d

ate

on o

r af

ter

Oct

ober

1 o

f th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on

(i.e

., th

e ta

rget

dat

e m

ust f

all o

n or

bet

wee

n O

ctob

er 1

and

June

30)

, exc

ept t

hose

with

exc

lusi

ons.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s 17

9 da

ys o

r le

ss.

Not

esT

his

mea

sure

is o

nly

calc

ulat

ed o

nce

per

12-m

onth

infl

uenz

a se

ason

whi

ch b

egin

s on

Jul

y 1

of a

giv

en y

ear

and

ends

on

June

30

of th

e su

bseq

uent

yea

r, a

nd

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)1

6

Tab

le 2

-4M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o R

ecei

ved

the

Sea

son

al I

nfl

uen

za V

acci

ne

(Sh

ort

Sta

y)(N

QF

#06

80A

) (C

MS

ID

: N

004.

02)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f sh

ort-

stay

res

iden

ts w

ho r

ecei

ved

the

infl

uenz

a va

ccin

atio

n du

ring

the

mos

t rec

ent i

nflu

enza

sea

son.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent r

ecei

ved

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son,

eith

er in

the

faci

lity

(O02

50A

= [

1])

orou

tsid

e th

e fa

cili

ty (

O02

50C

=

[2]

).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent.

Thi

s in

clud

es a

ll re

side

nts

who

hav

e an

ent

ry d

ate

(A16

00)

on o

r be

fore

Mar

ch 3

1 of

th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on a

nd h

ave

an a

sses

smen

t wit

h a

targ

et d

ate

on o

r af

ter

Oct

ober

1 o

f th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on

(i.e

., th

e ta

rget

dat

e m

ust f

all o

n or

bet

wee

n O

ctob

er 1

and

Jun

e 30

), e

xcep

t tho

se w

ith e

xclu

sion

s.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s 17

9 da

ys o

r le

ss.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)1

7

Tab

le 2

-5M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o W

ere

Off

ered

an

d D

ecli

ned

the

Sea

son

al I

nfl

uen

za V

acci

ne

(Sh

ort

Sta

y)(N

QF

#06

80B

) (C

MS

ID

: N

005.

02)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f sh

ort-

stay

res

iden

ts w

ho a

re o

ffer

ed a

nd d

ecli

ned

the

infl

uenz

a va

ccin

atio

n du

ring

the

mos

t rec

ent i

nflu

enza

sea

son.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent w

as o

ffer

ed a

nd d

eclin

ed th

e in

flue

nza

vacc

ine

duri

ng th

e m

ost r

ecen

t inf

luen

za s

easo

n (O

0250

C =

[4]

).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent.

Thi

s in

clud

es a

ll re

side

nts

who

hav

e an

ent

ry d

ate

(A16

00)

on o

r be

fore

Mar

ch 3

1 of

th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on a

nd h

ave

an a

sses

smen

t wit

h a

targ

et d

ate

on o

r af

ter

Oct

ober

1 o

f th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on

(i.e

., th

e ta

rget

dat

e m

ust f

all o

n or

bet

wee

n O

ctob

er 1

and

Jun

e 30

), e

xcep

t tho

se w

ith e

xclu

sion

s.

Exc

lusi

ons

1.R

esid

ent’

s ag

e on

targ

et d

ate

of s

elec

ted

infl

uenz

a va

ccin

atio

n as

sess

men

t is

179

days

or

less

.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)1

8

Tab

le 2

-6M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o D

id N

ot R

ecei

ve, D

ue

to M

edic

al C

ontr

ain

dic

atio

n,

the

Sea

son

al I

nfl

uen

za V

acci

ne

(Sh

ort

Sta

y)(N

QF

#06

80C

) (C

MS

ID

: N

006.

02)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f sh

ort-

stay

res

iden

ts w

ho d

id n

ot r

ecei

ve, d

ue to

med

ical

con

trai

ndic

atio

n, th

e in

flue

nza

vacc

inat

ion

duri

ng th

e m

ost r

ecen

t in

flue

nza

seas

on.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent w

as in

elig

ible

for

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son

due

to m

edic

al c

ontr

aind

icat

ion(

s) (

O02

50C

= [

3])

(e.g

., an

aphy

lact

ic h

yper

sens

itiv

ity

to e

ggs

or o

ther

com

pone

nts

of th

e va

ccin

e, h

isto

ry o

f G

uill

ian-

Bar

ré S

yndr

ome

wit

hin

6 w

eeks

aft

er a

pre

viou

s in

flue

nza

vacc

inat

ion,

bon

e m

arro

w tr

ansp

lant

wit

hin

the

past

6 m

onth

s).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent.

Thi

s in

clud

es a

ll re

side

nts

who

hav

e an

ent

ry d

ate

(A16

00)

on o

r be

fore

Mar

ch 3

1 of

th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on a

nd h

ave

an a

sses

smen

t wit

h a

targ

et d

ate

on o

r af

ter

Oct

ober

1 o

f th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on

(i.e

., th

e ta

rget

dat

e m

ust f

all o

n or

bet

wee

n O

ctob

er 1

and

Jun

e 30

), e

xcep

t tho

se w

ith e

xclu

sion

s.

Exc

lusi

ons

1.R

esid

ent’

s ag

e on

targ

et d

ate

of s

elec

ted

infl

uenz

a va

ccin

atio

n as

sess

men

t is

179

days

or

less

.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31

Cov

aria

tes

Not

app

licab

le

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)1

9

Tab

le 2

-7M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o N

ewly

Rec

eive

d a

n A

nti

psy

chot

ic M

edic

atio

n (

Sh

ort

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N01

1.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

shor

t-st

ay r

esid

ents

who

are

rec

eivi

ng a

n an

tipsy

chot

ic m

edic

atio

n du

ring

the

targ

et p

erio

d bu

t not

on

thei

r in

itia

l as

sess

men

t.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Shor

t-st

ay r

esid

ents

for

who

m o

ne o

r m

ore

asse

ssm

ents

in a

look

-bac

k sc

an (

not i

nclu

ding

the

init

ial a

sses

smen

t) in

dica

tes

that

ant

ipsy

chot

ic m

edic

atio

n w

as

rece

ived

:

1.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or b

efor

e 03

/31/

2012

: (N

0400

A =

[1]

).

2.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or a

fter

04/

01/2

012:

(N

0410

A =

[1,

2, 3

, 4, 5

, 6, 7

]).

Not

e th

at r

esid

ents

are

exc

lude

d fr

om th

is m

easu

re if

thei

r in

itia

l ass

essm

ent i

ndic

ates

ant

ipsy

chot

ic m

edic

atio

n us

e or

if a

ntip

sych

otic

med

icat

ion

use

is

unkn

own

on th

e in

itia

l ass

essm

ent (

see

excl

usio

n #3

, bel

ow).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ho d

o no

t hav

e ex

clus

ions

and

who

mee

t all

of

the

follo

win

g co

ndit

ions

:

1.T

he r

esid

ent h

as a

targ

et a

sses

smen

t, an

d

2.T

he r

esid

ent h

as a

n in

itia

l ass

essm

ent,

and

3.T

he ta

rget

ass

essm

ent i

s no

t the

sam

e as

the

initi

al a

sses

smen

t.

Exc

lusi

ons

1.T

he f

ollo

win

g is

true

for

all

asse

ssm

ents

in th

e lo

ok-b

ack

scan

(ex

clud

ing

the

init

ial a

sses

smen

t):

1.1.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

bef

ore

03/3

1/20

12: (

N04

00A

= [

-]).

1.2.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

aft

er 0

4/01

/201

2: (

N04

10A

= [

-]).

2.A

ny

of th

e fo

llow

ing

rela

ted

cond

itio

ns a

re p

rese

nt o

n an

yas

sess

men

t in

a lo

ok-b

ack

scan

:

2.1.

Schi

zoph

reni

a (I

6000

= [

1]).

2.2.

Tou

rette

’s s

yndr

ome

(I53

50 =

[1]

).

2.3.

Hun

ting

ton’

s di

seas

e (I

5250

= [

1]).

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

0

Tab

le 2

-7 (

con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o N

ewly

Rec

eive

d a

n A

nti

psy

chot

ic M

edic

atio

n (

Sh

ort

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N01

1.01

)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

3.T

he r

esid

ent’

s in

itia

l ass

essm

ent i

ndic

ates

ant

ipsy

chot

ic m

edic

atio

n us

e or

ant

ipsy

chot

ic m

edic

atio

n us

e is

unk

now

n:

3.1.

For

initi

al a

sses

smen

ts w

ith

targ

et d

ates

on

or b

efor

e 03

/31/

2012

: (N

0400

A =

[1,

-])

.

3.2.

For

initi

al a

sses

smen

ts w

ith

targ

et d

ates

on

or a

fter

04/

01/2

012:

(N

0410

A =

[1,

2, 3

, 4, 5

, 6, 7

, -])

.

Cov

aria

tes

Not

app

licab

le

1T

his

mea

sure

is u

sed

in th

e F

ive-

Star

Qua

lity

Rat

ing

Sys

tem

.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

1

Tab

le 2

-8M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o M

ade

Imp

rove

men

ts in

Fu

nct

ion

(S

hor

t S

tay)

1

(NQ

F:

Non

e) (

CM

S I

D:

N03

7.02

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

shor

t-st

ay r

esid

ents

who

wer

e di

scha

rged

fro

m th

e nu

rsin

g ho

me

that

gai

ned

mor

e in

depe

nden

ce in

tran

sfer

, lo

com

otio

n, a

nd w

alki

ng d

urin

g th

eir

epis

odes

of

care

.

Mea

sure

Spe

cifi

cati

ons

NO

TE

:

1.A

“va

lid p

rece

ding

5-d

ay P

PS

asse

ssm

ent o

r O

BR

A A

dmis

sion

ass

essm

ent”

ref

ers

to th

e da

te o

f th

e ea

rlie

st a

sses

smen

t if

a re

side

nt h

as b

oth

a5-

day

PP

S a

sses

smen

t (A

0310

B =

[01

]) a

nd a

n O

BR

A A

dmis

sion

ass

essm

ent (

A03

10A

= [

01])

.

2.A

“va

lid d

isch

arge

ass

essm

ent”

ref

ers

to a

dis

char

ge a

sses

smen

t wit

h a

date

clo

sest

to th

e va

lid p

rece

ding

5-d

ay P

PS

asse

ssm

ent o

r O

BR

A A

dmis

sion

as

sess

men

t whe

re a

ret

urn

is n

ot a

ntic

ipat

ed (

A03

10F

= [

10])

.

3.T

he 5

-day

PP

S as

sess

men

tor

OB

RA

Adm

issi

on a

sses

smen

t sho

uld

be u

sed

to c

alcu

late

the

terc

ile c

utof

fs. I

f re

side

nt h

as b

oth

a 5-

day

PP

S as

sess

men

t and

an

OB

RA

Adm

issi

on a

sses

smen

t, ca

lcul

ate

cova

riat

e us

ing

the

asse

ssm

ent w

ith

the

earl

ier

date

. Ter

cile

s ar

e re

calc

ulat

ed in

eac

h qu

arte

r.

Num

erat

or

Shor

t-st

ay r

esid

ents

who

:

1.H

ave

a va

lid d

isch

arge

ass

essm

ent (

A03

10F

= [

10])

and

a va

lid p

rece

ding

5-d

ay P

PS

asse

ssm

ent o

r O

BR

A A

dmis

sion

ass

essm

ent;

and

2.H

ave

a ch

ange

in p

erfo

rman

ce s

core

that

is n

egat

ive

([va

lid d

isch

arge

ass

essm

ent]

-[v

alid

pre

cedi

ng 5

-day

PP

S a

sses

smen

tor

OB

RA

Adm

issi

on

asse

ssm

ent]

< [

0]).

Per

form

ance

is c

alcu

late

d as

the

sum

of

G01

10B

1 (t

rans

fer:

sel

f-pe

rfor

man

ce),

G01

10E

1 (l

ocom

otio

n on

uni

t: s

elf-

perf

orm

ance

), a

nd G

0110

D1

(wal

k in

co

rrid

or: s

elf-

perf

orm

ance

), w

ith 7

’s (

acti

vity

occ

urre

d on

ly o

nce

or tw

ice)

and

8's

(ac

tivi

ty d

id n

ot o

ccur

) re

code

d to

4's

(to

tal d

epen

denc

e).

Den

omin

ator

Shor

t-st

ay r

esid

ents

who

mee

t all

of

the

follo

win

g co

ndit

ions

, exc

ept t

hose

wit

h ex

clus

ions

:

1.H

ave

a va

lid d

isch

arge

ass

essm

ent (

A03

10F

= [

10])

, and

2.H

ave

a va

lid p

rece

ding

5-d

ay P

PS

ass

essm

ent (

A03

10B

= [

01])

or

OB

RA

Adm

issi

on a

sses

smen

t (A

0310

A =

[01

]).

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

2

Tab

le 2

-8(c

onti

nu

ed)

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Mad

e Im

pro

vem

ents

in F

un

ctio

n (

Sh

ort

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N03

7.02

)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

Exc

lusi

ons

1.R

esid

ents

sat

isfy

ing

any

of th

e fo

llow

ing

cond

itio

ns:

1.1.

Com

atos

e (B

0100

= [

1])

on th

e 5-

day

PP

S a

sses

smen

t or

OB

RA

Adm

issi

on a

sses

smen

t, w

hich

ever

was

use

d in

the

QM

.

1.2.

Lif

e ex

pect

ancy

of

less

than

6 m

onth

s (J

1400

= [

1])

on th

e 5-

day

PP

S as

sess

men

t or

OB

RA

Adm

issi

on a

sses

smen

t, w

hich

ever

was

use

d in

the

QM

.

1.3.

Hos

pice

(O

0100

K2

= [

1])

on th

e 5-

day

PP

S as

sess

men

t or

OB

RA

Adm

issi

on a

sses

smen

t, w

hich

ever

was

use

d in

the

QM

.

1.4.

Res

iden

ts w

ith

G01

10B

1, G

0110

D1,

or

G01

10E

1 m

issi

ng o

n an

y of

the

asse

ssm

ents

use

d to

cal

cula

te th

e Q

M (

i.e.,

valid

dis

char

ge a

sses

smen

t, an

d 5-

day

PP

S a

sses

smen

t or

OB

RA

Adm

issi

on a

sses

smen

t, w

hich

ever

was

use

d in

the

QM

).

1.5.

Res

iden

ts w

ith

no im

pair

men

t (su

m o

f G

0110

B1,

G01

10D

1 an

d G

0110

E1

= [

0])

on th

e 5-

day

PP

S as

sess

men

t or

OB

RA

Adm

issi

on a

sses

smen

t, w

hich

ever

was

use

d in

the

QM

.

1.6.

Res

iden

ts w

ith

an u

npla

nned

dis

char

ge o

n an

y as

sess

men

t dur

ing

the

care

epi

sode

(A

0310

G =

[2]

)

Cov

aria

tes

All

cov

aria

tes

used

thro

ugho

ut th

is m

easu

re a

re c

alcu

late

d us

ing

the

vali

d pr

eced

ing

5-da

y P

PS

asse

ssm

ent o

r O

BR

A A

dmis

sion

ass

essm

ent d

escr

ibed

in th

e N

OT

E a

t the

top

of th

e m

easu

re s

peci

fica

tions

.

1.A

ge o

n th

e 5-

day

PP

S as

sess

men

t (A

0310

B =

[01

]) o

rO

BR

A A

dmis

sion

ass

essm

ent (

A03

10A

= [

01])

asca

lcul

ated

by

subt

ract

ing

date

of

birt

h (A

0900

) fr

om th

e da

te o

f as

sess

men

t (A

2300

)

If(M

ON

TH

(A23

00)

> M

ON

TH

(A09

00))

or

(MO

NT

H(A

2300

) =

MO

NT

H(A

0900

) an

d

DA

Y(A

2300

) >

= D

AY

(A09

00))

then

Age

= Y

EA

R(A

2300

)-Y

EA

R(A

0900

) el

seA

ge =

YE

AR

(A23

00)-

YE

AR

(A09

00)-

1

1.1

and

1.2

Cov

aria

te A

ge C

ateg

ory

54 to

84

= 1

if A

ge >

54 a

nd

1.3

Cov

aria

te A

ge C

ateg

ory

>84

= 1

if A

ge >

84 a

nd

2.G

ende

r

2.1

Cov

aria

te =

1 if

(A

0800

= [

2])

(Fem

ale)

2.2

Cov

aria

te =

0 if

(A

0800

= [

1])

(Mal

e)

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

3

Tab

le 2

-8(c

onti

nu

ed)

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Mad

e Im

pro

vem

ents

in F

un

ctio

n (

Sh

ort

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N03

7.02

)

Cov

aria

tes

(con

tinu

ed)

3.Se

vere

cog

niti

ve im

pair

men

t

3.1

Cov

aria

te =

1 if

(C

1000

= [

3] a

ndC

0700

= [

1])

orB

IMS

sum

mar

y sc

ore

(C05

00)

<[7

]

3.2

Cov

aria

te =

0 if

eit

her

of th

e fo

llow

ing

crit

eria

are

met

:

3.2.

1(C

1000

= [

0, 1

, 2]

orC

0700

= [

0])

and

(C05

00 =

[>

7, ^

, -, 9

9])

3.2.

2(C

0500

> [

7])

and

(C10

00 =

[0,

1, 2

, ^, -

]or

C07

00 =

[0,

^, -

])

3.3

If C

ovar

iate

has

not

bee

n se

t to

1 or

0 b

ased

on

logi

c in

3.1

and

3.2

, the

n C

ovar

iate

= [

0].

4.L

ong

Form

AD

L (

LF

AD

L)

Sca

le (

G01

10A

1 +

G01

10B

1 +

G01

10E

1 +

G01

10G

1 +

G01

10H

1 +

G01

10I1

+ G

0110

JI).

If

any

(G01

10A

1, G

0110

B1,

G

0110

E1,

G01

10G

1, G

0110

H1,

G01

10I1

, G01

10J1

) =

[7,

8],

reco

de th

e ite

m to

equ

al [

4].

4.1

Cov

aria

te =

0 if

LF

AD

L =

(m

iddl

e te

rcile

2or

hig

hest

terc

ile)

or

if a

ny (

G01

10A

1, G

0110

B1,

G01

10E

1, G

0110

G1,

G01

10H

1, G

0110

I1,

G01

10J1

) =

[-]

Cov

aria

te =

1 if

LF

AD

L =

low

est t

erci

le

4.2

Cov

aria

te =

0 if

(lo

wes

t ter

cile

or

high

est t

erci

le)

Cov

aria

te =

1 if

LF

AD

L =

mid

dle

terc

ile (

refe

renc

e)

4.3

Cov

aria

te =

0 if

(lo

wes

t ter

cile

or

mid

dle

terc

ile)

Cov

aria

te =

1 if

LF

AD

L =

hig

hest

terc

ile

5.H

eart

fai

lure

5.1

Cov

aria

te =

1 if

(I0

600

= [

1])

Cov

aria

te =

0 if

(I0

600

= [

0, -

])

6.C

VA

, TIA

, or

Stro

ke

6.1

Cov

aria

te =

1 if

(I4

500

= [

1])

Cov

aria

te =

0 if

(I4

500

= [

0, -

])

7.H

ip F

ract

ure

7.1

Cov

aria

te =

1 if

(I3

900

= [

1])

Cov

aria

te =

0 if

(I3

900

= [

0, -

])

8.O

ther

Fra

ctur

e

8.1

Cov

aria

te =

1 if

(I4

000

= [

1])

Cov

aria

te =

0 if

(I4

000

= [

0, -

])

1T

his

mea

sure

is u

sed

in th

e F

ive-

Star

Qua

lity

Rat

ing

Sys

tem

.2

Lon

g F

orm

AD

L S

cale

terc

iles

are

rec

alcu

late

d in

eac

h qu

arte

r us

ing

the

5-da

y P

PS

or O

BR

A A

dmis

sion

ass

essm

ent.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

4

Se

cti

on

2:

Lo

ng

Sta

y Q

ua

lity

Me

as

ure

s

Tab

le 2

-9M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Exp

erie

nci

ng

On

e or

Mor

e F

alls

wit

h M

ajor

In

jury

(L

ong

Sta

y)1

(NQ

F:

0674

) (C

MS

ID

: N

013.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

hav

e ex

peri

ence

d on

e or

mor

e fa

lls w

ith

maj

or in

jury

rep

orte

d in

the

targ

et p

erio

d or

look

-bac

k pe

riod

.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h on

e or

mor

e lo

ok-b

ack

scan

ass

essm

ents

that

indi

cate

one

or

mor

e fa

lls th

at r

esul

ted

in m

ajor

inju

ry (

J190

0C =

[1,

2])

.

Den

omin

ator

All

long

-sta

y nu

rsin

g ho

me

resi

dent

s w

ith

one

or m

ore

look

-bac

k sc

an a

sses

smen

ts e

xcep

t tho

se w

ith

excl

usio

ns.

Exc

lusi

ons

Res

iden

t is

excl

uded

if o

ne o

f th

e fo

llow

ing

is tr

ue f

or a

lllo

ok-b

ack

scan

ass

essm

ents

:

1.T

he o

ccur

renc

e of

fal

ls w

as n

ot a

sses

sed

(J18

00 =

[-]

), o

r

2.T

he a

sses

smen

t ind

icat

es th

at a

fal

l occ

urre

d (J

1800

= [

1])

and

the

num

ber

of f

alls

wit

h m

ajor

inju

ry w

as n

ot a

sses

sed

(J19

00C

= [

-]).

Cov

aria

tes

Not

app

licab

le.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

rQ

uali

tyR

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

5

Tab

le 2

-10

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Self

-Rep

ort

Mod

erat

e to

Sev

ere

Pai

n (

Lon

g S

tay)

1

(NQ

F:

0677

) (C

MS

ID

: N

014.

02)

Mea

sure

Des

crip

tion

Thi

s m

easu

re c

aptu

res

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho r

epor

t eit

her

(1)

alm

ost c

onst

ant o

r fr

eque

nt m

oder

ate

to s

ever

e pa

in in

the

last

5 d

ays

or (

2) a

ny

very

sev

ere/

horr

ible

in th

e la

st 5

day

s.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re th

e ta

rget

ass

essm

ent m

eets

eit

her

or b

oth

of th

e fo

llow

ing

two

cond

itio

ns:

1.C

ondi

tion

#1:

res

iden

t rep

ort a

lmos

t con

stan

t or

freq

uent

mod

erat

e to

sev

ere

pain

in th

e la

st 5

day

s. B

oth

of th

e fo

llow

ing

cond

itio

ns m

ust b

e m

et:

1.1.

Alm

ost c

onst

ant o

r fr

eque

nt p

ain

(J04

00 =

[1,

2])

, and

1.2.

At l

east

one

epi

sode

of

mod

erat

e to

sev

ere

pain

: (J0

600A

= [

05, 0

6, 0

7, 0

8, 0

9] o

rJ6

00B

= [

2, 3

]).

2.C

ondi

tion

#2:

res

iden

t rep

orts

ver

y se

vere

/hor

ribl

e pa

in o

f an

y fr

eque

ncy

(J06

00A

= [

10]

orJ0

600B

= [

4]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

he ta

rget

ass

essm

ent i

s an

adm

issi

on a

sses

smen

t, a

5-da

y P

PS

asse

ssm

ent,

ora

Med

icar

e R

eadm

issi

on/r

etur

n as

sess

men

t (A

0310

A =

[01

] or

A03

10B

= [

01, 0

6]).

2.T

he r

esid

ent i

s no

t inc

lude

d in

the

num

erat

or (

the

resi

dent

did

not

mee

t the

pai

n sy

mpt

om c

ondi

tions

for

the

num

erat

or)

and

any

of th

e fo

llow

ing

cond

itio

ns a

re tr

ue:

2.1.

The

pai

n as

sess

men

t int

ervi

ew w

as n

ot c

ompl

eted

(J0

200

= [

0, -

, ^])

.

2.2.

The

pai

n pr

esen

ce it

em w

as n

ot c

ompl

eted

(J0

300

= [

9, -

, ^])

.

2.3.

For

resi

dent

s w

ith

pain

or

hurt

ing

at a

ny ti

me

in th

e la

st 5

day

s (J

0300

= [

1]),

any

of th

e fo

llow

ing

are

true

:

2.3.

1.T

he p

ain

freq

uenc

y ite

m w

as n

ot c

ompl

eted

(J0

400

= [

9, -

, ^])

.

2.3.

2.N

eith

er o

f th

e pa

in in

tens

ity

item

s w

as c

ompl

eted

(J0

600A

= [

99, -

, ^]

and

J060

0B =

[9,

-.

^]).

2.3.

3.T

he n

umer

ic p

ain

inte

nsit

y ite

m in

dica

tes

no p

ain

(J06

00A

= [

00])

.

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

6

Tab

le 2

-10

(con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

o Se

lf-R

epor

t M

oder

ate

to S

ever

e P

ain

(L

ong

Sta

y)1

(NQ

F:

0677

) (C

MS

ID

: N

014.

02)

Cov

aria

tes

Inde

pend

ence

or

mod

ifie

d in

depe

nden

ce in

dai

ly d

ecis

ion

mak

ing

on th

e pr

ior

asse

ssm

ent

Cov

aria

te =

1 if

(C

1000

= [

0, 1

] or

Cov

aria

te =

0 if

any

of th

e fo

llow

ing

is tr

ue:

1.(C

1000

= [

2, 3

]) o

r

2.an

d or

3.(C

0500

= [

99, -

, ^]

and

C10

00 =

[-,

^])

.

All

cov

aria

tes

are

mis

sing

if n

o pr

ior

asse

ssm

ent i

s av

aila

ble.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

7

Tab

le 2

-11

MD

S 3

.0 M

easu

re:

Per

cen

t of

Hig

h-R

isk

Res

iden

ts W

ith

Pre

ssu

re U

lcer

s (L

ong

Sta

y)1

(NQ

F:

0679

) (C

MS

ID

: N

015.

02)

Mea

sure

Des

crip

tion

Thi

s m

easu

re c

aptu

res

the

perc

enta

ge o

f lo

ng-s

tay,

hig

h-ri

sk r

esid

ents

wit

h St

age

II-I

V o

r un

stag

eabl

e pr

essu

re u

lcer

s

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t tha

t m

eets

bot

hof

the

follo

win

g co

nditi

ons:

1.C

ondi

tion

#1:

The

re is

a h

igh

risk

for

pre

ssur

e ul

cers

, whe

re “

high

-ris

k” is

def

ined

in th

e de

nom

inat

or d

efin

itio

n be

low

.

2.C

ondi

tion

#2:

Sta

ge I

I-IV

or

unst

agea

ble

pres

sure

ulc

ers

are

pres

ent,

as in

dica

ted

by a

nyof

the

follo

win

g si

x co

nditi

ons:

2.1.

(M03

00B

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e])

or

2.2.

(M03

00C

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e])

or

2.3.

(M03

00D

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e])

or

2.4.

(M03

00E

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e])

or

2.5.

(M03

00F

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e])

or

2.6.

(M03

00G

1 =

[1,

2, 3

, 4, 5

, 6, 7

, 8, 9

, or

mor

e]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t who

mee

t the

def

init

ion

of h

igh

risk

, exc

ept t

hose

wit

h ex

clus

ions

. Res

iden

ts a

re d

efin

ed a

s hi

gh-r

isk

if th

ey m

eet o

ne o

r m

ore

of th

e fo

llow

ing

thre

e cr

iteri

a on

the

targ

et a

sses

smen

t:

1.Im

pair

ed b

ed m

obili

ty o

r tr

ansf

er in

dica

ted,

by

eith

er o

r bo

thof

the

follo

win

g:

1.1.

Bed

mob

ility

, sel

f-pe

rfor

man

ce (

G01

10A

1 =

[3,

4, 7

, 8])

.

1.2.

Tra

nsfe

r, s

elf-

perf

orm

ance

(G

0110

B1

= [

3, 4

, 7, 8

]).

2.C

omat

ose

(B01

00 =

[1]

).

3.M

alnu

triti

on o

r at

ris

k of

mal

nutr

ition

(I5

600

= [

1])

(che

cked

).

. Exc

lusi

ons

1.T

arge

t ass

essm

ent i

s an

OB

RA

Adm

issi

on a

sses

smen

t (A

0310

A =

[01

]) o

ra

5-da

y P

PS

ora

Med

icar

e R

eadm

issi

on/r

etur

n as

sess

men

t (A

0310

B =

[0

1, 0

6]).

2.If

the

resi

dent

is n

ot in

clud

ed in

the

num

erat

or (

the

resi

dent

did

not

mee

t the

pre

ssur

e ul

cer

cond

itio

ns f

or th

e nu

mer

ator

) an

d an

yof

the

follo

win

g co

ndit

ions

are

true

:

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

8

Tab

le 2

-11

(con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of H

igh

-Ris

k R

esid

ents

Wit

h P

ress

ure

Ulc

ers

(Lon

g S

tay)

1

(NQ

F:

0679

) (C

MS

ID

: N

015.

02)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

2.1.

(M03

00B

1 =

[-]

).

2.2.

(M03

00C

1 =

[-]

).

2.3.

(M03

00D

1 =

[-]

).

2.4.

M03

00E

1 =

[-]

.

2.5.

M03

00F

1 =

[-].

2.6.

M03

00G

1 =

[-]

.

Cov

aria

tes

Not

app

licab

le.

1 Thi

s m

easu

re is

use

d in

the

Fiv

e-St

ar Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)2

9

Tab

le 2

-12

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts A

sses

sed

an

d A

ppro

pri

atel

yG

iven

th

e S

easo

nal

In

flu

enza

Vac

cin

e (L

ong

Sta

y)(N

QF

#06

81)

(CM

S I

D:

N01

6.02

)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho a

re a

sses

sed

and/

orgi

ven,

app

ropr

iate

ly, t

he in

flue

nza

vacc

inat

ion

duri

ng th

e m

ost r

ecen

t inf

luen

za

seas

on.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng a

nyof

the

follo

win

g cr

iteri

a on

the

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t:

1.R

esid

ent r

ecei

ved

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son,

eith

er in

the

faci

lity

(O02

50A

= [

1])

orou

tsid

e th

e fa

cilit

y(O

0250

C =

[2]

);or

2.R

esid

ent w

as o

ffer

ed a

nd d

eclin

ed th

e in

flue

nza

vacc

ine

(O02

50C

= [

4]);

or

3.R

esid

ent w

as in

elig

ible

due

to m

edic

al c

ontr

aind

icat

ion(

s) (

O02

50C

= [

3])

(e.g

., an

aphy

lact

ic h

yper

sens

itiv

ity

to e

ggs

or o

ther

com

pone

nts

of th

e va

ccin

e, h

isto

ry o

f G

uill

ain-

Bar

re S

yndr

ome

wit

hin

6 w

eeks

aft

er a

pre

viou

s in

flue

nza

vacc

inat

ion,

bon

e m

arro

w tr

ansp

lant

wit

hin

the

past

6

mon

ths)

.

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t.T

his

incl

udes

all

resi

dent

s w

ho h

ave

an e

ntry

dat

e (A

1600

) on

or

befo

re M

arch

31

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

and

hav

e an

ass

essm

ent w

ith

a ta

rget

dat

e on

or

afte

r O

ctob

er 1

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

(i

.e.,

the

targ

et d

ate

mus

t fal

l on

or b

etw

een

Oct

ober

1 a

nd J

une

30),

exc

ept t

hose

with

exc

lusi

ons.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d in

flue

nza

vacc

inat

ion

asse

ssm

ent i

s 17

9 da

ys o

r le

ss.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

0

Tab

le 2

-13

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Rec

eive

d t

he

Sea

son

al I

nfl

uen

za V

acci

ne

(Lon

g S

tay)

(NQ

F #

0681

A)

(CM

S I

D:

N01

7.02

)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho r

ecei

ved

the

infl

uenz

a va

ccin

atio

n du

ring

the

mos

t rec

ent i

nflu

enza

sea

son.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent r

ecei

ved

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son,

eith

er in

the

faci

lity

(O02

50A

= [

1])

orou

tsid

e th

e fa

cili

ty (

O02

50C

=

[2]

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t.T

his

incl

udes

all

resi

dent

s w

ho h

ave

an e

ntry

dat

e (A

1600

) on

or

befo

re M

arch

31

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

and

hav

e an

ass

essm

ent w

ith

a ta

rget

dat

e on

or

afte

r O

ctob

er 1

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

(i

.e.,

the

targ

et d

ate

mus

t fal

l on

or b

etw

een

Oct

ober

1 a

nd J

une

30),

exc

ept t

hose

with

exc

lusi

ons.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d in

flue

nza

vacc

inat

ion

asse

ssm

ent i

s 17

9 da

ys o

r le

ss.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

1

Tab

le 2

-14

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Wer

e O

ffer

ed a

nd

Dec

lin

edth

e S

easo

nal

In

flu

enza

Vac

cin

e (L

ong

Sta

y)(N

QF

#06

81B

) (C

MS

ID

: N

018.

02)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho a

re o

ffer

ed a

nd d

ecli

ned

the

infl

uenz

a va

ccin

atio

n du

ring

the

mos

t rec

ent i

nflu

enza

sea

son.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent w

as o

ffer

ed a

nd d

eclin

ed th

e in

flue

nza

vacc

ine

duri

ng th

e m

ost r

ecen

t inf

luen

za s

easo

n (O

0250

C =

[4]

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t.T

his

incl

udes

all

resi

dent

s w

ho h

ave

an e

ntry

dat

e (A

1600

) on

or

befo

re M

arch

31

ofth

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on a

nd h

ave

an a

sses

smen

t wit

h a

targ

et d

ate

on o

r af

ter

Oct

ober

1 o

f th

e m

ost r

ecen

tly

com

plet

ed in

flue

nza

seas

on

(i.e

., th

e ta

rget

dat

e m

ust f

all o

n or

bet

wee

n O

ctob

er 1

and

Jun

e 30

), e

xcep

t tho

se w

ith e

xclu

sion

s.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d in

flue

nza

vacc

inat

ion

asse

ssm

ent i

s 17

9 da

ys o

r le

ss.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

2

Tab

le 2

-15

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Did

Not

Rec

eive

, Du

e to

Med

ical

Con

trai

nd

icat

ion

,th

e S

easo

nal

In

flu

enza

Vac

cin

e (L

ong

Sta

y)(N

QF

#06

81C

) (C

MS

ID

: N

019.

02)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho d

id n

ot r

ecei

ve, d

ue to

med

ical

con

trai

ndic

atio

n, th

e in

flue

nza

vacc

inat

ion

duri

ng th

e m

ost r

ecen

t in

flue

nza

seas

on.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed in

flue

nza

vacc

inat

ion

asse

ssm

ent:

1.R

esid

ent w

as in

elig

ible

for

the

infl

uenz

a va

ccin

e du

ring

the

mos

t rec

ent i

nflu

enza

sea

son

due

to m

edic

al c

ontr

aind

icat

ion(

s) (

O02

50C

= [

3])

(e.g

., an

aphy

lact

ic h

yper

sens

itiv

ity

to e

ggs

or o

ther

com

pone

nts

of th

e va

ccin

e, h

isto

ry o

f G

uill

ain-

Bar

ré S

yndr

ome

wit

hin

6 w

eeks

aft

er a

pre

viou

s in

flue

nza

vacc

inat

ion,

bon

e m

arro

w tr

ansp

lant

wit

hin

the

past

6 m

onth

s).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

infl

uenz

a va

ccin

atio

n as

sess

men

t.T

his

incl

udes

all

resi

dent

s w

ho h

ave

an e

ntry

dat

e (A

1600

) on

or

befo

re M

arch

31

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

and

hav

e an

ass

essm

ent w

ith

a ta

rget

dat

e on

or

afte

r O

ctob

er 1

of

the

mos

t rec

entl

y co

mpl

eted

infl

uenz

a se

ason

(i

.e.,

the

targ

et d

ate

mus

t fal

l on

or b

etw

een

Oct

ober

1 a

nd J

une

30),

exc

ept t

hose

with

exc

lusi

ons.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d in

flue

nza

vacc

inat

ion

asse

ssm

ent i

s 17

9 da

ys o

r le

ss.

Not

es

Thi

s m

easu

re is

onl

y ca

lcul

ated

onc

e pe

r 12

-mon

th in

flue

nza

seas

on w

hich

beg

ins

on J

uly

1 of

a g

iven

yea

r an

d en

ds o

n Ju

ne 3

0 of

the

subs

eque

nt y

ear

and

repo

rts

data

for

res

iden

ts w

ho w

ere

in th

e fa

cilit

y fo

r at

leas

t one

day

dur

ing

the

targ

et p

erio

d of

Oct

ober

1 th

roug

h M

arch

31.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

3

Tab

le 2

-16

3 MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts w

ith

a U

rin

ary

Tra

ct I

nfe

ctio

n (

Lon

g S

tay)

1

(NQ

F:

0684

) (C

MS

ID

: N

024.

01)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

enta

ge o

f lo

ng s

tay

resi

dent

s w

ho h

ave

a ur

inar

y tr

act i

nfec

tion

.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t tha

t ind

icat

es u

rina

ry tr

act i

nfec

tion

wit

hin

the

last

30

days

(I2

300

= [

1]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

arge

t ass

essm

ent i

s an

adm

issi

on a

sses

smen

t (A

0310

A =

[01

]) o

ra

5-da

y P

PS

ora

Med

icar

e R

eadm

issi

on/r

etur

n as

sess

men

t (A

0310

B =

[01

,06]

).

2.U

rina

ry tr

act i

nfec

tion

valu

e is

mis

sing

(I2

300

= [

-]).

Cov

aria

tes

Not

app

licab

le.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

4

Tab

le 2

-17

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Hav

e/H

ad a

Cat

het

er I

nse

rted

an

d L

eft

in T

hei

r B

lad

der

(Lon

g S

tay)

1

(NQ

F #

0686

) (C

MS

ID

: N

026.

02)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

resi

dent

s w

ho h

ave

had

an in

dwel

ling

cat

hete

r in

the

last

7 d

ays.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t tha

t ind

icat

es th

e us

e of

indw

elli

ng c

athe

ters

(H

0100

A =

[1]

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

arge

t ass

essm

ent i

s an

adm

issi

on a

sses

smen

t (A

0310

A =

[01

]) o

ra

5-da

y P

PS

ora

Med

icar

e R

eadm

issi

on/r

etur

n as

sess

men

t (A

0310

B =

[01

,06]

).

2.T

arge

t ass

essm

ent i

ndic

ates

that

indw

elli

ng c

athe

ter

stat

us is

mis

sing

(H

0100

A =

[-]

).

3.T

arge

t ass

essm

ent i

ndic

ates

neu

roge

nic

blad

der

(I15

50 =

[1]

) or

neu

roge

nic

blad

der

stat

us is

mis

sing

(I1

550

= [

-]).

4.T

arge

t ass

essm

ent i

ndic

ates

obs

truc

tive

uro

path

y (I

1650

= [

1])

orob

stru

ctiv

e ur

opat

hy s

tatu

s is

mis

sing

(I1

650

= [

-]).

Cov

aria

tes

1.Fr

eque

nt b

owel

inco

ntin

ence

on

prio

r as

sess

men

t (H

0400

= [

2, 3

]).

1.1.

Cov

aria

te =

[1]

if (

H04

00 =

[2,

3])

.

1.2.

Cov

aria

te =

[0]

if (

H04

00 =

[0,

1, 9

, -])

.

2.P

ress

ure

ulce

rs a

t sta

ges

II, I

II, o

r IV

on

prio

r as

sess

men

t:

2.1.

Cov

aria

te =

[1]

if a

nyof

the

follo

win

g ar

e tr

ue:

2.1.

1.(M

0300

B1

= [

1, 2

, 3, 4

, 5, 6

, 7, 8

, 9])

, or

2.1.

2.(M

0300

C1

= [

1, 2

, 3, 4

, 5, 6

, 7, 8

, 9])

, or

2.1.

3.(M

0300

D1

= [

1, 2

, 3, 4

, 5, 6

, 7, 8

, 9])

.

2.2.

Cov

aria

te =

[0]

if th

e fo

llow

ing

is tr

ue:

2.2.

1.(M

0300

B1

= [

0, -

, ^])

and

2.2.

2.(M

0300

C1

= [

0, -

, ^])

and

2.2.

3.(M

0300

D1

= [

0, -

, ^])

.

3.A

ll co

vari

ates

are

mis

sing

if n

o pr

ior

asse

ssm

ent i

s av

aila

ble.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

5

Tab

le 2

-18

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Wer

e P

hys

ical

ly R

estr

ain

ed (

Lon

g S

tay)

1

(NQ

F #

0687

) (C

MS

ID

: N

027.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y nu

rsin

g fa

cili

ty r

esid

ents

who

are

phy

sica

lly

rest

rain

ed o

n a

dail

y ba

sis.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t tha

t ind

icat

es d

aily

phy

sica

l res

trai

nts,

whe

re:

1.T

runk

res

trai

nt u

sed

in b

ed (

P010

0B =

[2]

), o

r

2.L

imb

rest

rain

t use

d in

bed

(P0

100C

= [

2]),

or

3.T

runk

res

trai

nt u

sed

in c

hair

or

out o

f be

d (P

0100

E =

[2]

), o

r

4.L

imb

rest

rain

t use

d in

cha

ir o

r ou

t of

bed

(P01

00F

= [

2]),

or

5.C

hair

pre

vent

s ri

sing

use

d in

cha

ir o

r ou

t of

bed

(P01

00G

) =

[2]

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

Res

iden

t is

not i

n nu

mer

ator

and

any

of

the

foll

owin

g is

true

:

1.(P

0100

B =

[-]

), o

r

2.(P

0100

C =

[-]

), o

r

3.(P

0100

E =

[-]

), o

r

4.(P

0100

F=

[-]

), o

r

5.(P

0100

G =

[-]

).

Cov

aria

tes

Not

app

licab

le.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

6

Tab

le 2

-19

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

hos

e N

eed

for

Hel

pw

ith

Act

ivit

ies

of D

aily

Liv

ing

Has

In

crea

sed

(L

ong

Sta

y)1

(NQ

F #

0688

) (C

MS

ID

: N

028.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

se n

eed

for

help

with

late

-los

s A

ctiv

itie

s of

Dai

ly L

ivin

g (A

DL

s) h

as in

crea

sed

whe

n co

mpa

red

to

the

prio

r as

sess

men

t.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h se

lect

ed ta

rget

and

pri

or a

sses

smen

t ass

essm

ents

that

indi

cate

the

need

for

hel

p w

ith

late

-los

s A

ctiv

ities

of

Dai

ly L

ivin

g (A

DL

s) h

as

incr

ease

d w

hen

the

sele

cted

ass

essm

ents

are

com

pare

d. T

he f

our

late

-los

s A

DL

item

s ar

e se

lf-p

erfo

rman

ce b

ed m

obil

ity

(G01

10A

1), s

elf-

perf

orm

ance

tran

sfer

(G

0110

B1)

, sel

f-pe

rfor

man

ce e

atin

g (G

0110

H1)

, and

sel

f-pe

rfor

man

ce to

ileti

ng (

G01

10I1

).

An

incr

ease

is d

efin

ed a

s an

incr

ease

in tw

o or

mor

e co

ding

poi

nts

in o

ne la

te-l

oss

AD

L it

em o

ron

e po

int i

ncre

ase

in c

odin

g po

ints

in tw

o or

mor

e la

te-l

oss

AD

L it

ems.

Not

e th

at f

or e

ach

of th

ese

four

AD

L it

ems,

if th

e va

lue

is e

qual

to [

7, 8

] on

eit

her

the

targ

et o

r pr

ior

asse

ssm

ent,

then

rec

ode

the

item

to e

qual

[4]

to

all

ow a

ppro

pria

te c

ompa

riso

n.

Res

iden

ts m

eet t

he d

efin

itio

n of

incr

ease

d ne

ed o

f he

lp w

ith

late

-los

s A

DL

s if

eith

erof

the

follo

win

g ar

e tr

ue

1.A

t lea

st tw

oof

the

follo

win

g ar

e tr

ue (

note

that

in th

e no

tati

on b

elow

, [t]

ref

ers

to th

e ta

rget

ass

essm

ent,

and

[t-1

] re

fers

to th

e pr

ior

asse

ssm

ent)

:

1.1

Bed

mob

ility

: ([L

evel

at t

arge

t ass

essm

ent (

G01

10A

1[t]

)] -

[Lev

el a

t pri

or a

sses

smen

t (G

0110

A1[

t-1]

)])

>[0

], o

r

1.2

Tra

nsfe

r: (

[Lev

el a

t tar

get a

sses

smen

t (G

0110

B1[

t])]

-[L

evel

at p

rior

ass

essm

ent (

G01

10B

1[t-

1])]

) >

[0],

or

1.3

Eat

ing:

([L

evel

at t

arge

t ass

essm

ent (

G01

10H

1[t]

)] -

[Lev

el a

t pri

or a

sses

smen

t (G

0110

H1[

t-1]

)])

>[0

], o

r

1.4

Toi

letin

g: (

[Lev

el a

t tar

get a

sses

smen

t (G

0110

I1[t

])]

-[L

evel

at p

rior

ass

essm

ent (

G01

10I1

[t-1

])])

>[0

].

2.A

t lea

st o

ne

of th

e fo

llow

ing

is tr

ue:

2.1

Bed

mob

ility

: ([L

evel

at t

arge

t ass

essm

ent (

G01

10A

1[t]

)] -

[Lev

el a

t pri

or a

sses

smen

t (G

0110

A1[

t-1]

)])

>[1

], o

r

2.2

Tra

nsfe

r: (

[Lev

el a

t tar

get a

sses

smen

t (G

0110

B1[

t])]

-[L

evel

at p

rior

ass

essm

ent (

G01

10B

1[t-

1])]

) >

[1],

or

2.3

Eat

ing:

([L

evel

at t

arge

t ass

essm

ent (

G01

10H

1[t]

)] -

[Lev

el a

t pri

or a

sses

smen

t (G

0110

H1[

t-1]

)])

>[1

], o

r

2.4

Toi

letin

g: (

[Lev

el a

t tar

get a

sses

smen

t (G

0110

I1[t

])]

-[L

evel

at p

rior

ass

essm

ent (

G01

10I1

[t-1

])])

>[1

].

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

nd p

rior

ass

essm

ent,

exce

pt th

ose

wit

h ex

clus

ions

.

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

7

Tab

le 2

-19

(con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

ose

Nee

d f

or H

elp

wit

h A

ctiv

itie

s of

Dai

ly L

ivin

g H

as I

ncr

ease

d (

Lon

gS

tay)

1

(NQ

F #

0688

) (C

MS

ID

: N

028.

01)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

Exc

lusi

ons

1.A

ll fo

ur o

f th

e la

te-l

oss

AD

L it

ems

indi

cate

tota

l dep

ende

nce

on th

e pr

ior

asse

ssm

ent,

as in

dica

ted

by:

1.1.

Bed

Mob

ility

(G

0110

A1)

= [

4, 7

, 8]

and

1.2.

Tra

nsfe

rrin

g (G

0110

B1)

= [

4, 7

, 8]

and

1.3.

Eat

ing

(G01

10H

1) =

[4,

7, 8

] an

d

1.4.

Toi

letin

g (G

0110

I1)

= [

4, 7

, 8].

2.T

hree

of

the

late

-los

s A

DL

s in

dica

te to

tal d

epen

denc

e on

the

prio

r as

sess

men

t, as

in #

1 A

ND

the

four

th la

te-l

oss

AD

L in

dica

tes

exte

nsiv

e as

sist

ance

(v

alue

3)

on th

e pr

ior

asse

ssm

ent.

3.If

res

iden

t is

com

atos

e (B

0100

= [

1, -

]) o

n th

e ta

rget

ass

essm

ent.

4.P

rogn

osis

of

life

exp

ecta

ncy

is le

ss th

an 6

mon

ths

(J14

00 =

[1,

-])

on

the

targ

et a

sses

smen

t.

5.H

ospi

ce c

are

(O01

00K

2 =

[1,

-])

on

the

targ

et a

sses

smen

t.

6.T

he r

esid

ent i

s no

t in

the

num

erat

or a

nd

6.1.

Bed

Mob

ility

(G

0110

A1

= [

-])

on th

e pr

ior

or ta

rget

ass

essm

ent,

or

6.2.

Tra

nsfe

rrin

g (G

0110

B1

= [

-])

on th

e pr

ior

or ta

rget

ass

essm

ent,

or

6.3.

Eat

ing

(G01

10H

1)=

[-]

) on

the

prio

r or

targ

et a

sses

smen

t, or

6.4.

Toi

letin

g (G

0110

I1 =

[-]

) on

the

prio

r or

targ

et a

sses

smen

t. Cov

aria

tes

Not

app

licab

le.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

8

Tab

le 2

-20

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Los

e T

oo M

uch

Wei

ght

(Lon

g S

tay)

(NQ

F #

0689

) (C

MS

ID

: N

029.

01)

Mea

sure

Des

crip

tion

The

mea

sure

cap

ture

s th

e pe

rcen

tage

of

long

-sta

y re

side

nts

who

had

a w

eigh

t los

s of

5%

or

mor

e in

the

last

mon

th o

r 10

% o

r m

ore

in th

e la

st 6

mon

ths

who

w

ere

not o

n a

phys

icia

n pr

escr

ibed

wei

ght-

loss

reg

imen

not

ed in

an

MD

S a

sses

smen

t dur

ing

the

sele

cted

qua

rter

.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay n

ursi

ng h

ome

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent w

hich

indi

cate

s a

wei

ght l

oss

of 5

% o

r m

ore

in th

e la

st m

onth

or

10%

or

mor

e in

the

last

6

mon

ths

who

wer

e no

t on

a ph

ysic

ian

pres

crib

ed w

eigh

t-lo

ss r

egim

en (

K03

00 =

[2]

).

Den

omin

ator

Lon

g-st

ay n

ursi

ng h

ome

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent e

xcep

t tho

se w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

arge

t ass

essm

ent i

s an

OB

RA

Adm

issi

on a

sses

smen

t (A

0310

A=

[01

]) o

ra

5-da

y P

PS

asse

ssm

ent (

A03

10B

= [

01])

, or

aM

edic

are

Rea

dmis

sion

/ret

urn

asse

ssm

ent (

A03

10B

= [

06])

.

2.P

rogn

osis

of

life

exp

ecta

ncy

is le

ss th

an 6

mon

ths

(J14

00 =

[1]

) or

the

Pro

gnos

is it

em is

mis

sing

(J1

400

= [

-])

on th

eta

rget

ass

essm

ent.

3.R

ecei

ving

Hos

pice

car

e (O

0100

K2

= [

1])

or th

e H

ospi

ce c

are

item

is m

issi

ng (

O01

00K

2 =

[-]

) on

the

targ

et a

sses

smen

t.

4.W

eigh

t los

s ite

m is

mis

sing

(K

0300

= [

-])

on th

e ta

rget

ass

essm

ent. Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)3

9

Tab

le 2

-21

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Rec

eive

d a

n A

nti

psy

chot

ic M

edic

atio

n (

Lon

g-S

tay)

1

(NQ

F:

Non

e) (

CM

S I

D:

N03

1.02

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

long

-sta

y re

side

nts

who

are

rec

eivi

ng a

ntip

sych

otic

dru

gs in

the

targ

et p

erio

d.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re th

e fo

llow

ing

cond

itio

n is

true

: an

tips

ycho

tic m

edic

atio

ns r

ecei

ved.

Thi

s co

nditi

on is

def

ined

as

foll

ows:

1.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or b

efor

e 03

/31/

2012

: (N

0400

A =

[1]

).

2.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or a

fter

04/

01/2

012:

(N

0410

A =

[1,

2, 3

, 4, 5

, 6, 7

]).

Den

omin

ator

Lon

g-st

ay n

ursi

ng h

ome

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent e

xcep

t tho

se w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

he r

esid

ent d

id n

ot q

ualif

y fo

r th

e nu

mer

ator

and

any

of th

e fo

llow

ing

is tr

ue:

1.1.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

bef

ore

03/3

1/20

12: (

N04

00A

= [

-]).

1.2.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

aft

er 0

4/01

/201

2: (

N04

10A

= [

-]).

2.A

ny

of th

e fo

llow

ing

rela

ted

cond

itio

ns a

re p

rese

nt o

n th

e ta

rget

ass

essm

ent (

unle

ss o

ther

wis

e in

dica

ted)

:2.

1.Sc

hizo

phre

nia

(I60

00 =

[1]

).2.

2.T

oure

tte’s

syn

drom

e (I

5350

= [

1]).

2.3.

Tou

rette

’s s

yndr

ome

(I53

50 =

[1]

) on

the

prio

r as

sess

men

t if

this

item

is n

ot a

ctiv

e on

the

targ

et a

sses

smen

t and

if a

pri

or a

sses

smen

t is

avai

labl

e.2.

4.H

unti

ngto

n’s

dise

ase

(I52

50 =

[1]

).

Cov

aria

tes

Not

app

licab

le.

1T

his

mea

sure

is u

sed

in th

e F

ive-

Sta

r Q

uali

ty R

atin

g S

yste

m.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)4

0

Tab

le 2

-22

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Use

d A

nti

anxi

ety

or H

ypn

otic

Med

icat

ion

(Lon

g S

tay)

(NQ

F:

Non

e) (

CM

S I

D:

N03

6.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pr

eval

ence

of

anti

anxi

ety

or h

ypno

tic

med

icat

ion

use

(lon

g st

ay)

duri

ng th

e ta

rget

per

iod.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re a

ny o

f th

e fo

llow

ing

cond

itio

ns a

re tr

ue:

1.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or b

efor

e 03

/31/

2012

:

1.1

Ant

ianx

iety

med

icat

ions

rec

eive

d (N

0400

B =

[1]

), o

r

1.2

Hyp

notic

med

icat

ions

rec

eive

d (N

0400

D =

[1]

).

2.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or a

fter

04/

01/2

012:

2.1

Ant

ianx

iety

med

icat

ions

rec

eive

d (N

0410

B =

[1,

2, 3

, 4, 5

, 6, 7

]), o

r

2.2

Hyp

notic

med

icat

ions

rec

eive

d (N

0410

D =

[1,

2, 3

, 4, 5

, 6, 7

]).

Den

omin

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

he r

esid

ent d

id n

ot q

ualif

y fo

r th

e nu

mer

ator

and

any

of th

e fo

llow

ing

is tr

ue:

1.1.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

bef

ore

03/3

1/20

12: (

N04

00B

= [

-]or

N04

00D

= [

-]).

1.2.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

aft

er 0

4/01

/201

2: (

N04

10B

= [

-]or

N04

10D

= [

-]).

2.A

ny o

f th

e fo

llow

ing

rela

ted

cond

ition

s ar

e pr

esen

t on

the

targ

et a

sses

smen

t (un

less

oth

erw

ise

indi

cate

d):

2.1.

Lif

e ex

pect

ancy

of

less

than

6 m

onth

s (J

1400

= [

1]).

2.2.

Hos

pice

car

e w

hile

a r

esid

ent (

O01

00K

2 =

[1]

).

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)4

1

Tab

le 2

-23

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

hos

e A

bil

ity

to M

ove

Ind

epen

den

tly

Wor

sen

ed (

Lon

g S

tay)

1

(NQ

F:

Non

e) (

CM

S I

D:

N03

5.02

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

exp

erie

nced

a d

ecli

ne in

inde

pend

ence

of

loco

mot

ion

duri

ng th

e ta

rget

per

iod.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t and

at l

east

one

qua

lify

ing

prio

r as

sess

men

t who

hav

e a

decl

ine

in lo

com

otio

n w

hen

com

pari

ng th

eir

targ

et a

sses

smen

t wit

h th

e pr

ior

asse

ssm

ent.

Dec

line

iden

tifi

ed b

y:

1.R

ecod

ing

all v

alue

s (G

0110

E1

= [

7, 8

]) to

(G

0110

E1

= [

4]).

2.A

n in

crea

se o

f on

e or

mor

e po

ints

on

the

“loc

omot

ion

on u

nit:

self

-per

form

ance

” it

em b

etw

een

the

targ

et a

sses

smen

t and

pri

or a

sses

smen

t (G

0110

E1

on ta

rget

ass

essm

ent –

Den

omin

ator

Lon

g-st

ay r

esid

ents

who

hav

e a

qual

ifyi

ng M

DS

3.0

targ

et a

sses

smen

t and

at l

east

one

qua

lify

ing

prio

r as

sess

men

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

Res

iden

ts s

atis

fyin

g an

y of

the

follo

win

g co

ndit

ions

:1.

Com

atos

e or

mis

sing

dat

a on

com

atos

e (B

0100

= [

1, -

]) a

t the

pri

or a

sses

smen

t.

2.P

rogn

osis

of

less

than

6 m

onth

s at

the

prio

r as

sess

men

t as

indi

cate

d by

:

2.1.

Pro

gnos

is o

f le

ss th

an s

ix m

onth

s of

life

(J1

400

= [

1]),

or

2.2.

Hos

pice

use

(O

0100

K2

= [

1]),

or

2.3.

Nei

ther

indi

cato

r fo

r be

ing

end-

of-l

ife

and

and

a m

issi

ng v

alue

on

eith

er in

dica

tor

(J14

00 =

[-

]or

O01

00K

2 =

[-])

.

3.R

esid

ent t

otal

ly d

epen

dent

dur

ing

loco

mot

ion

on p

rior

ass

essm

ent (

G01

10E

1 =

[4, 7

, or

8]).

4.M

issi

ng d

ata

on lo

com

otio

n on

targ

et o

rpr

ior

asse

ssm

ent (

G01

10E

1 =

[-]

).

5.P

rior

ass

essm

ent i

s a

disc

harg

e w

ith

or w

itho

ut r

etur

n an

ticip

ated

(A

0310

F =

[10

, 11]

).

6.N

o pr

ior

asse

ssm

ent i

s av

aila

ble

to a

sses

s pr

ior

func

tion

.

6.1.

Tar

get a

sses

smen

t is

an O

BR

A A

dmis

sion

ass

essm

ent (

A03

10A

= [

01])

, a 5

-day

PP

S (

A03

10B

= [

01])

, or

aM

edic

are

Rea

dmis

sion

/ret

urn

asse

ssm

ent(

A03

10B

= [

06])

orth

e fi

rst a

sses

smen

t aft

er a

n ad

mis

sion

(A

0310

E =

[1]

).

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)4

2

Tab

le 2

-23

(con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

ose

Ab

ilit

y to

Mov

e In

dep

end

entl

y W

orse

ned

(L

ong

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N03

5.02

)

Cov

aria

tes

Cov

aria

tes

used

to r

isk-

adju

st th

is m

easu

re in

clud

e:

1.E

atin

g (s

elf-

perf

orm

ance

) fr

om p

rior

ass

essm

ent

1.1

Nee

ds H

elp

Cov

aria

te =

1 if

(G

0110

H1

= [2

, 3])

and

Cov

aria

te =

0 if

(G

0110

H1

= [

-, 0

, 1, 4

, 7, 8

]).

1.2

Dep

ende

nce

Cov

aria

te =

1 if

(G

0110

H1

= [4

,7,8

)] a

ndC

ovar

iate

= 0

if (

G01

10H

1 =

[-,

0,1

,2,3

]).

2.T

oile

ting

(sel

f-pe

rfor

man

ce)

from

pri

or a

sses

smen

t

2.1

Nee

ds H

elp

Cov

aria

te =

1 if

(G

0110

I1 =

[2,

3])

and

Cov

aria

te =

0 if

(G

0110

I1 =

[-,

0, 1

, 4, 7

, 8])

.

2.2

Dep

ende

nce

Cov

aria

te =

1 if

(G

0110

I1 =

[4,

7,8]

) an

dC

ovar

iate

= 0

if (

G01

10I1

= [

-, 0

,1,2

,3])

.

3.T

rans

fer

(sel

f-pe

rfor

man

ce)

from

pri

or a

sses

smen

t

3.1

Nee

ds H

elp

Cov

aria

te =

1 if

(G

0110

B1

= [

2,3]

) an

dC

ovar

iate

= 0

if (

G01

10B

1 =

[-,

0, 1

, 4, 7

, 8])

.

3.2

Dep

ende

nce

Cov

aria

te =

1 if

(G

0110

B1

= [

4,7,

8])

and

Cov

aria

te =

0 if

(G

0110

B1

= [

-, 0

,1,2

,3])

.

4.W

alki

ng in

Cor

rido

r (s

elf-

perf

orm

ance

) fr

om p

rior

ass

essm

ent

4.1

Inde

pend

ence

Cov

aria

te =

1 if

(G

0110

D1

= [

0,1]

) an

dC

ovar

iate

= 0

if (

G01

10D

1 =

[-,

2, 3

, 4, 7

, 8])

.

4.2

Nee

ds S

ome

Hel

p C

ovar

iate

= 1

if (

G01

10D

1 =

[2]

) an

dC

ovar

iate

= 0

if (

G01

10D

1 =

[-,

0, 1

, 3, 4

, 7, 8

]).

4.3

Nee

ds M

ore

Hel

p C

ovar

iate

= 1

if (

G01

10D

1 =

[3]

)an

dC

ovar

iate

= 0

if (

G01

10D

1 =

[-,

0, 1

, 2, 4

, 7, 8

]).

5.Se

vere

cog

niti

ve im

pair

men

t fro

m p

rior

ass

essm

ent

5.1

Cov

aria

te =

1 if

(C

1000

= [

3] a

ndC

0700

= [

1])

or

Cov

aria

te =

0 if

eit

her

of th

e fo

llow

ing

crit

eria

are

met

:

(C10

00 =

[0,

1, 2

] or

C07

00 =

[0]

) an

d(C

0500

= [

>7,

^, -

, 99]

).

(C05

00 >

[7]

) an

d(C

1000

= [

0, 1

, 2, ^

, -]

orC

0700

= [

0, ^

, -])

.

If C

ovar

iate

has

not

bee

n se

t to

1 or

0 b

ased

on

logi

c in

5.1

and

5.2

, the

n C

ovar

iate

= [

0].

6.L

inea

r A

ge

If(M

ON

TH

(A23

00)

> M

ON

TH

(A09

00))

or(

MO

NT

H(A

2300

) =

MO

NT

H(A

0900

) an

d

DA

Y(A

2300

) >

= D

AY

(A09

00))

then

Lin

ear

Age

= Y

EA

R(A

2300

)-Y

EA

R(A

0900

) el

se L

inea

r A

ge =

YE

AR

(A23

00)-

YE

AR

(A09

00)-

1

7.G

ende

r

7.1

Cov

aria

te =

1 if

(A

0800

=[2

]) (

Fem

ale)

.

Cov

aria

te =

0 if

(A

0800

=[1

]) (

Mal

e).

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ja

nu

ary

20

19

(v1

2.0

)4

3

Tab

le 2

-23

(con

tin

ued

)M

DS

3.0

Mea

sure

: P

erce

nt

of R

esid

ents

Wh

ose

Ab

ilit

y to

Mov

e In

dep

end

entl

y W

orse

ned

(L

ong

Sta

y)1

(NQ

F:

Non

e) (

CM

S I

D:

N03

5.02

)

Cov

aria

tes

(con

tinu

ed)

8.V

isio

n

8.1

Cov

aria

te =

1 if

B10

00 c

hang

e sc

ore

>0

wit

h ch

ange

sco

re c

alcu

late

d fr

om B

1000

on

the

prio

r as

sess

men

t to

B10

00 o

n th

e la

test

ass

essm

ent w

ith

non-

mis

sing

aft

er th

e pr

ior

asse

ssm

ent.

Cov

aria

te =

0 if

eit

her

of th

e fo

llow

ing

crit

eria

are

met

:

ior

asse

ssm

ent t

o B

1000

on

the

late

st a

sses

smen

t wit

h no

n-m

issi

ng B

1000

aft

er p

rior

ass

essm

ent.

B10

00 is

not

mis

sing

on

the

prio

r as

sess

men

t, B

1000

is m

issi

ng o

n th

e ta

rget

ass

essm

ent,

and

no in

term

edia

te a

sses

smen

t has

ano

n-m

issi

ng

valu

e fo

r B

1000

.

If C

ovar

iate

has

not

bee

n se

t to

1 or

0 b

ased

on

logi

c in

8.1

and

8.2

, the

n C

ovar

iate

= [

0].

9.O

xyge

n us

e

9.1

Cov

aria

te =

1 w

here

(O

0100

C2=

[0])

on

prio

r an

d (O

0100

C2

= [

1])

on th

e la

test

ass

essm

ent w

ith

non-

mis

sing

O01

00C

2af

ter

prio

r as

sess

men

t.

Cov

aria

te =

0 if

(O

0100

C2

= [

0 o

r 1]

) on

the

prio

r as

sess

men

t and

eit

her

of th

e fo

llow

ing

crit

eria

are

met

:

(O01

00C

2 =

[0]

) on

the

late

st a

sses

smen

t wit

h no

n-m

issi

ng O

0100

C2

afte

r pr

ior

asse

ssm

ent.

O01

00C

2 is

not

mis

sing

on

the

prio

r as

sess

men

t, O

0100

C2

is m

issi

ng o

n th

e ta

rget

ass

essm

ent,

and

no in

term

edia

te a

sses

smen

t has

a n

on-

mis

sing

val

ue f

or O

0100

C2.

If C

ovar

iate

has

not

bee

n se

t to

1 or

0 b

ased

on

logi

c in

9.1

and

9.2

, the

n C

ovar

iate

= [

0].

10.

All

cova

riat

es a

re m

issi

ng if

no

prio

r as

sess

men

t is

avai

labl

e.

1T

his

mea

sure

isus

ed in

the

Fiv

e-S

tar

Qua

lity

Rat

ing

Sys

tem

.


USER’S MANUAL

APPENDIX A

Technical Details

(v12.0) Effective January 1, 2019

Prepared for:The Centers for Medicare & Medicaid Services under Contract No. HHSM500- 2013-13015I (HHSM-500-T0001). (RTI Project Number 0214077.001.000.002)

RTI International Appendix A January 2019 (v12.0) A-i

Quality Measures (QM) Technical Details

List of Contents:

Section 1 Introduction................................................................................ A-1

Section 2 Steps Used in National QM Calculation.................................... A-3

Section 3 Calculation of the Expected QM Score ..................................... A-7

Section 4 Calculation of the Adjusted QM Score...................................... A-9

RTI International Appendix A January 2019 (v12.0) A-ii


RTI International Appendix A January 2019 (v12.0) A-1

Section 1Introduction

This appendix presents technical details regarding the calculation of the nursing home quality measures (QMs), including the methodology used for risk adjustment.

Overview of QM Calculations

The QMs are created from counts of nursing facility long stay residents or short stay residents who have certain conditions or problems (e.g., falls resulting in major injury). For example, facility-level scores for the long stay falls QM are computed by: 1) counting residents in the facility who had a fall resulting in major injury and 2) computing the percent of residents in the facility who had valid MDS data and who experienced such a fall. The detailed logic for defining the resident-level outcomes for each QM is presented in the QM Sample and Record Selection Methodology section and in the Quality Measure Logic Specifications section of this manual. This logic is listed under the "Numerator" entry for each QM.

A Note on Risk Adjustment

Risk adjustment refines raw QM scores to better reflect the prevalence of problems that facilities should be able to address. Two complementary approaches to risk adjustment are applied to the QMs.

One approach involves exclusion of residents whose outcomes are not under nursing facility control (e.g., outcome is evidenced on admission to the facility) or the outcome may be unavoidable (e.g., the resident has end-stage disease or is comatose). All of the QMs, except the vaccination QMs, are shaped by one or more exclusions. For each QM, the prevalence of the outcome across all residents in a nursing facility, after exclusions, is the facility-level observed QM score.

A second approach involves adjusting QM scores directly, using logistic regression. This method of adjustment employs resident-level covariates that are found to increase the risks of an outcome. Detailed specifications for resident-level covariates are presented in the Quality Measure Logical Specifications section of this manual. This approach involves the following steps:

• First, resident-level covariates were used in a logistic regression model to calculate a resident-level expected QM score (the probability that the resident will evidence the outcome, given the presence or absence of characteristics measured by the covariates). Section 3 of this Appendix presents the details for calculating expected scores for residents.

• Then, an average of all resident-level expected QM scores for the nursing facility was calculated to create a facility-level expected QM score.

• The final facility-level adjusted QM score was based on a calculation which combines the facility-level expected score and the facility-level observed score. The details for


calculating facility-level adjusted scores are presented in Section 4 of this Appendix. The parameters used for each release of the QMs are presented in Appendix B.

Only five of the QMs are adjusted using resident level covariates for public reporting:

• N002.03: Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay)

• N037.02: Percent of Residents Who Improved Performance on Transfer, Locomotion, and Walking in the Corridor (Short Stay)

• N014.02: Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

• N026.02: Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (Long Stay)

• N035.02: Percent of Residents Who Declined in Independence in Locomotion (Long Stay)

The remaining QMs are not adjusted using resident-level covariates. For these measures, facility-level observed QM scores are reported.


Section 2Steps Used in National QM Calculation

Introduction

This section outlines the processing steps used to calculate QMs. The description below uses Q1 2018 as the target period. The dates associated with these steps would be updated, as appropriate, for subsequent quarterly releases of the QMs. It is important to note two items that recurred throughout the process:

Every step in file construction and QM calculation proceeded in parallel for two samples of residents and facilities: a “Long stay” (LS) sample and a “Short stay” (SS) sample.

• Two “target periods” were defined:

– a “Current Period” which was one quarter, Q1 2018, for LS residents and two quarters, Q4 2017 and Q1 2018, for SS patients. Data from the current periods were used as the target period for final QM reporting;

– a “Current Year”, Q2 2017 through Q1 2018, data which were used to estimate logistic regressions for risk adjustment.

Processing Steps:

1. MDS Selection. All MDS records for U.S. nursing facilities in Q2 2017 through Q1 2018were selected.

2. Episode Creation. Using the definitions contained elsewhere in this document, episodes were created from the available data. Each episode was classified as either long or short stay depending upon the number of cumulative days in the facility. Only the latest episode was retained for each resident.

3. Sampling for LS QMs. Nursing facilities and residents were sampled to provide data for LSQM and covariate calculations.

a. “Current Period” LS resident sample: residents were included in this sample if they had a long stay episode that ended within the last quarter of the target period (i.e., Q12018).

b. “Current Year” LS resident sample: residents were included in this sample if they had a long stay episode in the target period Q2 2017 through Q1 2018).

c. “Influenza Season” LS resident sample: includes residents with an influenza vaccination target assessment for the most recently completed influenza season,which begins on July 1 of a given year and ends on June 30 of the subsequent year.Only sampled once a year for the annual calculation of the influenza vaccination QMs, which occurs after the most recent influenza season has been completed (i.e., after the end of June).


4. Sampling for SS QMs. Nursing facilities and residents were sampled to provide data for SS QM and covariate calculations.

a. “Current Period” SS resident sample: residents were included in this sample if they had a short stay episode that ended within the last two quarters of the target period (i.e., Q4 2017 and Q1 2018).

a. “Current Year” SS resident sample: residents were included in this sample if they hada short stay episode in the target period Q2 2017 through Q1 2018).

b. “Influenza Season” SS resident sample: includes residents with an influenza vaccination target assessment for the most recently completed influenza season,which begins on July 1 of a given year and ends on June 30 of the subsequent year.Only sampled once a year for the annual calculation of the influenza vaccination QMs, which occurs after the most recent influenza season has been completed (i.e., after the end of June).

5. Resident-level QM Calculation Files. At this point, resident-level QM calculation files were created, separately for each LS resident sample and each SS resident sample, using the specified target, prior, initial, and influenza vaccination assessments for each resident recordas appropriate.

6. Resident-level QM and Covariate Calculation Files. Next, resident-level QM scores were calculated (and covariate values were calculated for the risk-adjusted QMs), separately for each LS resident and SS resident.

a. Resident-level QM calculation (all QMs):

i. Resident exclusions: For each QM, excluded residents were assigned a missing value for that QM. Residents with missing covariate values were also assigned a missing value for that QM.

ii. QM values: does the resident “trigger” the QM?

1. If “Yes”, then store a value of 1 for that QM in the resident-level QM calculation record appropriate to that resident for a sample.

2. If “No”, then store a value of 0 for that QM in the resident-level QM calculation record appropriate to that resident for a sample.

b. Resident-level covariate calculation (risk-adjusted QMs):

i. Resident exclusions: For each QM, excluded residents were assigned a missing value for that QM. Residents with missing covariate values were also assigned a missing value for that QM.

ii. Covariate: does the resident “trigger” the covariate?

1. If “Yes”, then store a value of 1 for that covariate in the resident-level QM calculation record appropriate to that resident for a sample.

2. If “No”, then store a value of 0 for that covariate in the resident-level QM calculation record appropriate to that resident for a sample.


7. Logistic Regressions. With the resident-level files complete, and all relevant exclusions applied, logistic regressions for the risk-adjusted QMs were estimated using the Current Year LS and SS samples (Q2 2017 through Q1 2018).

a. Input: LS or SS resident-level file.

b. Dependent variable: was the QM triggered? (yes = 1, no = 0).

c. Predictors: resident-level covariates.

d. Calculation of logistic regressions: (See Section 3 in this Appendix).

e. Output values: logistic regression constant term and resident-level covariate coefficients for each of the risk-adjusted QMs. The resulting values are given in Table B.1 of Appendix B.

The logistic regression results calculated for Q1 2018 will remain in effect for QM calculation in subsequent quarters. Recalculation may occur sometime in the future if deemed appropriate.

8. Resident-level Expected QM Scores. For the QMs that were risk adjusted, resident-level expected QM scores were calculated for each resident for the Current Period LS and SS samples. (See Section 3 in this Appendix for calculation formulas).

a. Input: logistic regression constant term and resident-level covariate coefficients from the previous step for each adjusted QM.

b. Output values: resident-level expected QM scores for each resident, for each of the risk-adjusted QMs.

9. National Mean QMs. National mean observed QMs were needed for calculating the facility-level adjusted QM scores below. The overall national mean observed QM scores for the Current Period LS and SS samples were calculated, for each risk adjusted QM:

a. Numerator: for each QM, count the total number or residents that triggered the QM and sum for the nation.

b. Denominator: for each QM, count the total number of residents retained after exclusions and sum for the nation. Note that the sample will include only those residents with non-missing data for the component covariates.

c. Overall national mean observed QM score: divide the numerator by the denominator.

10. Facility-level Observed QM Scores. For all QMs, the facility-level observed QM scores were calculated for the Current Period LS and SS samples -- for the QMs that were not risk adjusted, these are the measures that will be publicly reported.

a. Numerator: for each QM, count the total number of residents who triggered the QM in each facility and sum for the nursing facility.

b. Denominator: for each QM, count the total number of residents retained after exclusions for each facility and sum for the nursing facility. Note that the sample will include only those residents with non-missing data for the component covariates.


c. Facility-level observed QM scores: divide the numerator by the denominator for each QM and nursing facility.

11. Facility-level Expected QM Scores. For the risk-adjusted QMs, the facility-level expected QM scores are calculated for the Current Period LS and SS samples. This is done by averaging the resident-level expected QM scores for each QM within each nursing facility. Note that the sample will include only those residents with non-missing data for the component covariates.

12. Facility-level Adjusted QM Scores. Finally, for the risk-adjusted QMs, the facility-level adjusted QM scores were calculated for the Current Period LS and SS samples.

a. Input -- for each of the risk-adjusted QMs

i. Facility-level observed QM scores

ii. Facility-level expected QM scores

iii. National mean observed QM scores

b. Calculation: (See Section 4 of this Appendix for calculation formulas)

c. Output: Facility-level adjusted QM scores for the five risk-adjusted QMs

13. Final Facility-level Output File. The final facility-level output files for the Current Period LS and SS QMs contained the following:

a. For all QMs:

i. Facility numerator counts

ii. Facility denominator counts

iii. Facility-level observed QM scores (publicly reported for the unadjusted QMs)

b. For the risk-adjusted QMs: Facility-level adjusted QM scores (publicly reported scores)


Section 3Calculation of the Expected QM Score

For the QMs adjusted with resident-level covariates, the resident-level expected QM score was calculated as an intermediate step to obtaining an adjusted QM score for the facility. This section describes the technical details referred to in Section 2 of this Technical Appendix.

Calculating Resident-level Expected QM Scores

The resident-level expected score for a QM is an estimate of the risk that a resident will trigger the QM. This estimate is based on consideration of the resident-level covariates associated with the QM.

For each of the risk-adjusted QMs, a resident-level logistic regression was estimated. Data came from the short stay and long stay samples described in the prior section of this appendix. The resident-level observed QM score was the dependent variable. The predictor variables were one or more resident-level covariates associated with the QM. Calculation of the QM and covariate scores is described in Section 2 (Step 5) of this Appendix.

Each logistic regression had the following form:

where is the logistic regression constant, is the logistic regression coefficient for the first covariate, is the resident-level score for the first covariate, is the logistic regression coefficient for the second covariate (where applicable), and is the resident-level score for the second covariate (where applicable), and so on.

Each resident’s expected QM score could then be calculated with the following formula:

where e is the base of natural logarithms and x is a linear combination of the constant and the logistic regression coefficients times the covariate scores (from Formula [1], above). A covariate score will be 1 if the covariate is triggered for that resident, and 0 if not.

As an example, consider the actual calculation used for the expected score for the LS "Percent of residents who have moderate to severe pain" QM (N014.02). The covariate for that QM is an indicator of independence in daily decision-making on the prior assessment. The equation used for this QM (with the parameters from Table B.1 for Q1 2018) is:

where B0 is the logistic regression constant, B1 is the logistic regression coefficient for IndpDec, and IndpDec is the resident-level covariate indicating independence in daily decision-making.

[1] QM triggered (yes = 1, no = 0) = B0 + B1*COVA + B2*COVB + …+ BN *COVN

B0 B1COVA B2

COVB

[2] Resident-level expected QM score = 1/ [1+e-X]


The N014.02 score for a resident who triggers the independence in decision making covariate (covariate score = 1) is expected to be:

For a resident who does not trigger the independence in decision making covariate (covariate score = 0), the N014.02 score is expected to be:

Thus, a resident who is independent in decision making (i.e. covariate = 1) is over twice as likely to report severe pain (15.72 percent, compared to 5.63 percent for a resident who is not independent in decision making).

The parameters used for calculating the resident-level expected QM scores are presented in Table B.1 of Appendix B.

Calculating Facility-level Expected QM Scores

Once an expected QM score has been calculated for all residents at risk, the facility-level expected QM score is simply the average of all resident-level scores for each of the risk-adjusted QMs.


Section 4Calculation of the Adjusted QM Score

The risk-adjusted QM score is a facility-level QM score adjusted for the specific risk for that QM in the nursing facility. The risk-adjusted QM score can be thought of as an estimate of what the nursing facility's QM rate would be if the facility had residents with average risk.

The facility-level adjusted score is calculated using the following scores:

• The facility-level observed QM score,

• The facility-level average expected QM score, and

• The national average observed QM score.

The actual calculation of the adjusted score uses the following equation:

where

Adj is the facility-level adjusted QM score, and

Obs is the facility-level observed QM rate,

Exp is the facility-level expected QM rate, Nat is the national observed QM rate, and Ln indicates a natural logarithm.

e is the base of natural logarithms

Note that the adjusted QM rate (Adj) is calculated differently in two special cases:

1. When Obs equals 0.00, then Adj is set to 0.00 (without using the equation).2. When Obs equals 1.00, then Adj is set to 1.00 (without using the equation).

The adjusted QM score equation will produce adjusted scores in the range of 0 to 1. These adjusted scores can then be converted to percentages for ease of interpretation.

These adjusted score calculations are applied to QMs that use expected scores based on resident-level covariates (See Section 3 of this Appendix). The national average observed QM rates, required for these calculations, are presented in Appendix B.


USER’S MANUAL

APPENDIX B

Parameters Used for Each Quarter



RTI International Appendix B January 2019 (v12.0) B-1

Introduction

This appendix presents the model parameters that were estimated for the risk adjusted QMs for the following time period:

• The period ending March 31, 2018, referred to as Q1 2018.

The purpose of this document is to present the logistic regression coefficients used in the risk adjustment calculations that were applied to the risk-adjusted QMs. For details regarding the use of these parameters, please refer to Appendix A.

Logistic Regression Coefficients

Five QMs are risk adjusted. The logistic regression coefficients used are presented in Table B.1. Where risk adjustment involves the use of more than one resident-level covariate, coefficients are listed in the order presented in the LS and SS matrices that are presented in the MDS 3.0 Quality Measures Logical Specifications section of this manual. The calculations in Table B.1 are based on calculations for the Current Year sample ending with Q1 2018.

Table B.1. Logistic Regression CoefficientsQM Constant (Intercept) Resident-Level Covariates

N002.03 For the Constant and Resident-Level Covariates, please refer to the latest version of the Risk Adjustment Appendix File for SNF Measure Calculations and Reporting User’s Manual, found at the following URL:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html

N037.02 0.7823972 1.

2. Covariate 1.2 (Age Category 54 to 84) (reference category)

0.0

3. Covariate 1.3 (Age Category>84)

4. Covariate 2.1 (Female) 0.0272314

5. Covariate 3.1 (Cognitive Impairment)

6. Covariate 4.1 (ADL Lowest Tercile) 0.161358

7. Covariate 4.2 (ADL Middle Tercile) (reference category)

0.0

8. Covariate 4.3 (ADL Highest Tercile)

9. Covariate 5.1 (Heart Failure)

10. Covariate 6.1 (CVA/TIA/Stroke)

11. Covariate 7.1 (Hip Fracture) 0.2954314

12. Covariate 8.1 (Other Fracture) 0.233453

N014.02 3.33806 1. Covariate 1 (Independence in Daily Decision-making)

1.238107

(continued)

RTI International Appendix B January 2019 (v12.0) B-2

Table B.1. Logistic Regression Coefficients (continued)QM Constant (Intercept) Resident-Level Covariates

N026.02 4.281009 1. Covariate 1.1 (Bowel Incontinence) 0.4587008

2. Covariate 2.1 (Pressure Ulcer) 2.26932

N035.02 2.469571 1. Covariate 1.1 (Help with Eating) 0.0095926

2. Covariate 1.2 (Dependence Eating)

0.5191111

3. Covariate 2.1 (Help with Toileting) 0.2583423

4. Covariate 2.2 (Dependence Toileting)

0.4434241

5. Covariate 3.1 (Help with Transfer) 0.0760023

6. Covariate 3.2 (Dependence with Transfer)

0.4310152

7. Covariate 4.1 (Independence with Walking)

0.0428471

8. Covariate 4.2 (Some Help with Walking)

9. Covariate 4.3 (More Help with Walking)

10. Covariate 5 (Severe Cognitive Impairment)

0.1311536

11. Covariate 6 (Age) 0.008044

12. Covariate 7 (Female) 0.0277615

13. Covariate 8 (Impaired Vision) 0.3495715

14. Covariate 9 (Oxygen Use) 0.8450993

National Observed Means

The national observed QM means are updated for each quarterly release. Table B.2 presents these means for Q1 2018, as an example.

Table B.2. National Observed QM Means

QM Q1 2018

N002.03 NA4

N037.02 0.6458298

N014.02 0.0641216

N026.02 0.0227849

N035.02 0.1854863

4 Please refer to the latest version of the Risk Adjustment Appendix File for SNF Measure Calculations and Reporting User’s Manual found at the following URL: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html


USER’S MANUAL

APPENDIX C

Episode and Stay Determination Logic



RTI International Appendix C January 2019 (v12.0) C-1

MDS 3.0 Episode and Stay Determination Logic

Introduction

Several CMS applications are based upon the identification of stays and episodes using MDS 3.0 data. This document provides definitions and detailed logic that can be used by these applications.

This document begins with definitions of key terms and concepts. It then explains how stays and episodes are identified in a well-defined assessment data stream (i.e., when all assessment completion and submission rules are followed). It concludes with detailed logic that handles exceptional cases (e.g., missing entry or discharge records).

Definitions

An episode consists of one or more stays, and a stay is defined as a set of contiguous days in a facility. Because an episode is built from a set of one or more stays, the episode can be identified if the stays have been built properly. Therefore, this section will describe how to build stays.

Three properties of each stay must be determined:

• The starting date.

• The ending date.

• The stay type (admission or reentry).

The starting date is the date the resident entered the facility (either for the first time or after a previous discharge). The ending date is either (a) the discharge date, or (b) the end of the target period, whichever is earlier. The stay type is defined as follows:

Admission. An admission occurs when any one of the following conditions apply:

• The resident has never been admitted to this facility before; or

• The resident has been in this facility previously and was discharged return not anticipated; or

• The resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge.

Reentry. A reentry occurs when both of the following conditions apply:

• The resident has a discharge return anticipated, and

• The resident returned to the facility within 30 days of discharge.


Rules for a Well- Constructed Data Stream

In a well-constructed data stream (where all records are submitted and correctly coded), the following logic will correctly determine the starting date, ending date, and type for each stay.This logic assumes that the resident’s records have been sorted in reverse chronological order (see the end of this section for sorting details). Stays and episodes must be contained within a single facility, so the following logic applies to the records for a single facility.

1. If the first (latest) record that is on or before the end of the reporting period is a discharge (A0310F = [10, 11, 12]), then the stay end date is equal to the discharge date (A2000). Otherwise, the stay is ongoing and the stay end date is equal to the end of the reporting period.

2. If the stay end date of the resident’s latest stay chronologically precedes the beginning of the target period5, then the episode is not included in the sample. If the stay is ongoing or if the discharge occurs within the target period, then continue.

3. Scan backwards chronologically until an entry record (A0310F = [01]) is encountered. The stay start date is equal to the entry date (A1600) on the entry record.

4. Look at the chronologically preceding record. The stay type is defined as follows:

4.1. If a chronologically preceding record is found and if it is a discharge return anticipated (A0310F = [11]) and if the discharge date of the discharge record is within 30 days of the stay start date defined above, then the stay type is a reentry. Otherwise, the stay type is an admission. Admissions occur under any of the following conditions:

4.1.1. No chronologically preceding record is found.

4.1.2. A chronologically preceding record is found and it is a discharge return not anticipated (A0310F = 10).

4.1.3. A chronologically preceding record is found and it is a discharge return anticipated (A0310F = 11) and the discharge date is 31 days or more before the stay start date.

5. If the stay was classified as an admission stay, then scanning would stop because this would mark the beginning of the episode. If the stay was a reentry, then the scan logic would continue with the stay that ended with the record found in Step #4 (if any). Stays would continue to be scanned and classified until one of the following conditions occurred:

5.1. An admission stay was identified, or

5 The span of time that defines the application’s reporting period (e.g., a calendar quarter).


5.2. No more records were found for the same resident and facility, or

5.3. An application-specific rule was met. For example, for short stay Quality Measures (QMs), processing stops when the number of cumulative days in the facility (CDIF) exceeded 100 days (CDIF is the sum of the number of days within each of the stays that are contained in the episode).

Handling Missing Records

Exceptions to the rules will occur when entry and/or discharge records are missing from a resident’s data stream. When this occurs, starting and/or ending dates must be imputed and the stay type must be determined as accurately as possible. The following rules will describe how these situations are handling. This discussion will refer to three types of records:

• Entry record (where A0310F= [01]).

• Discharge record (where A0310F= [10, 11, 12]).

• A normal assessment (where A0310F= [99]).

Missing Entry Records

In the scan logic described above, if a normal assessment is immediately preceded chronologically by a discharge record or if there is no chronologically preceding record, then an entry record is missing. In this case the stay start date and type must be imputed. The imputation rules are as explained below. In these rules, the assessment that is preceded chronologically by a discharge or that has no preceding record is termed the “problem assessment”.

The table below is used to impute the entry date when there is a missing entry record.

Table C1: Possible Entry Dates When Entry Record is Missing

Type of Problem Assessment

Reasons for Assessment

Possible Entry Dates

Earliest Date Latest Date

5-day PPS A0310B = [01] A2300 - 7 days A2300

14-day PPS A0310B = [02] A2300 - 18 days A2300 - 10 days




Medicare Readmission/ return

A0310B = [06] A2300 - 7 days A2300

OBRA Admission A0310A = [01] A2300 - 13 days A2300

Other OBRA A0310A = [02,03,04,05,06] A2300 - 106 days A2300

OMRA A0310B = [07] A2300 - 7 days A2300

Discharge A0310F = [10,11,12] A1600 A1600


The table above lists various types of problem assessments and shows the earliest and latest possible entry dates that are associated with each one. The following steps explain how to use this table to impute an entry date and stay type when a problem assessment is chronologically preceded by a discharge assessment or where no record precedes the problem assessment.

1. Use the table above to classify the problem assessment. Classify the assessment using the reason for assessment items indicated in the table. If the problem assessment qualifies for more than one of the rows in the table, use the first (top-most) row for which it qualifies.

2. Determine the earliest and latest entry date associated with the selected row.

3. Determine the entry date (A1600) that is reported on the problem assessment.

4. Determine a tentative entry date, as follows:

4.1. If the entry date (A1600) on the problem assessment falls between the earliest and latest entry date in the table, set the tentative entry date equal to this value of A1600.

4.2. Otherwise, set the tentative entry date equal to the date that is listed in the “earliest date” column of the table.

5. Determine a final imputed entry date, as follows:

5.1. If the problem assessment is chronologically preceded by a discharge record, addone day to the discharge date (A2000) on the discharge record and compare the resulting date with the tentative entry date (A1600 from the assessment). Set the final imputed entry date equal to the later of these two dates.

5.2. If there is no record that chronologically precedes the problem assessment, then set the final imputed entry date equal to the tentative entry date.

6. Determine the stay type, as follows:

6.1. If the problem assessment is chronologically preceded by a discharge record, determine the stay type using the normal logic described above.

6.2. If there is no record that chronologically precedes the problem assessment, then set the stay type as an admission stay.

MISSING DISCHARGE RECORDS

In the scan logic described above, if an entry record is immediately preceded chronologically by a normal assessment, then a discharge record is missing. In this case, the end date of the chronologically preceding stay and the stay type of the current stay must be imputed. The imputation rules are as follows. In these rules, the assessment that chronologically precedes the entry record is termed the “ending index assessment”. The “current stay” is the stay that begins with the entry record. The “chronologically preceding stay” is the stay that contains the ending index assessment.


1. The end date of the chronologically preceding stay is set equal to the assessment reference date that is recorded on the ending index assessment.

2. Set the stay type of the current stay as follows:2.1. Determine the value of A1700 that is recorded on the entry record of the current stay.2.2. If A1700 is equal to [1] (admission), then set the stay type for the current stay to

“admission”.2.3. If A1700 is equal to [2] (reentry), then set the stay type for the current stay to

“reentry”.

Multiple Entry Records

If there are two or more entry records which are adjacent to one another in the resident’s data stream, keep the latest entry record and ignore the earlier adjacent entry record(s).

Multiple Discharge Records

If there are two or more discharge records which are adjacent to one another in the resident’s data stream, keep the latest discharge record and ignore the earlier adjacent discharge record(s).

Sorting Rules

As noted above, stays are identified from the records for a given resident and facility that are sorted in reverse chronological order. Sorting criteria must be applied to handle the case where there is more than one record on a given target date. The exact sorting criteria are as follows:

a. State ID +

b. Facility internal ID +

c. Resident internal ID +

d. Target date (descending) +

e. Record type (descending) +

f. Assessment internal ID (descending)

Note that record type (record_type) is defined as follows:

1. If A0310F = 01 (the record is an entry record), then record_type = [1].

2. Else if A0310F = 99 (the record is not an entry or discharge), then:a. If the item subset code6 is equal to NC (comprehensive assessment), then record_type

= [7].

b. Else if the item subset code is equal to NQ (quarterly assessment), then record_type =[6].

c. Else if the item subset code is equal to NP (PPS assessment), then record_type = [5].

6 The item subset code is contained in the field ITM_SBST_CD.


d. Else if the item subset code is equal to NO (“other” OMRA assessment), then record type = [4].

e. Else if the item subset code is equal to NS (start-of-therapy OMRA assessment), then record_type = [3].

f. Else record_type = [2] (this condition should not occur).

3. Else if A0310F = [10] (discharge, return not anticipated), then record_type = [8].

4. Else if A0310F = [11] (discharge, return anticipated), then record_type = [9].

5. Else if A0310F = [12] (death in facility), then record_type = [10].

Also note that the assessment internal ID is used as the final tie-breaker on the assumption that records that should be later in the sort sequence will be submitted and processed later than the other records. The record processing timestamp would be a slightly better field to use for this purpose. However, it is available only to users who have direct access to the ASAP database. The assessment internal ID was therefore adopted as a reasonable substitute for the timestamp so that all users would have access to the same sorting fields.


USER’S MANUAL

APPENDIX D

Measures Withdrawn from NQF Submission



RTI International Appendix D January 2019 (v12.0) D-1

Measures Withdrawn from NQF Submission

The following measures were previously approved or given time limited endorsement by the National Quality Forum (NQF) but have been withdrawn from NQF submission.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-2

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts A

sses

sed

an

d A

ppro

pri

atel

yG

iven

th

e P

neu

moc

occa

l Vac

cin

e (S

hor

t S

tay)

(NQ

F #

0682

) (C

MS

: N

007.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

shor

t-st

ay r

esid

ents

who

se p

neum

ococ

cal v

acci

ne s

tatu

s is

up

to d

ate

duri

ng th

e 12

-mon

th r

epor

ting

per

iod.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng a

ny o

f th

e fo

llow

ing

crit

eria

on

the

sele

cted

targ

et a

sses

smen

t:

1.P

neum

ococ

cal v

acci

ne s

tatu

s is

up

to d

ate

(O03

00A

=[1

]); o

r

2.W

ere

offe

red

and

decl

ined

the

vacc

ine

(O03

00B

=[2

]); o

r

3.W

ere

inel

igib

le d

ue to

med

ical

con

trai

ndic

atio

n(s)

(O

0300

B=

[1])

(e.

g., a

naph

ylac

tic h

yper

sens

itiv

ity

to c

ompo

nent

s of

the

vacc

ine;

bon

e m

arro

w

tran

spla

nt w

ithi

n th

e pa

st 1

2 m

onth

s; o

rre

ceiv

ing

a co

urse

of

chem

othe

rapy

wit

hin

the

past

two

wee

ks).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s le

ss th

an 5

yea

rs (

i.e.,

resi

dent

has

not

yet

rea

ched

5th

birt

hday

on

targ

et d

ate)

.

Cov

aria

tes

Not

app

licab

le

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-3

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Rec

eive

d t

he

Pn

eum

ococ

cal V

acci

ne

(Sh

ort

Sta

y)

(NQ

F #

0682

A)

(CM

S:

N00

8.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

shor

t-st

ay r

esid

ents

who

rec

eive

d th

e pn

eum

ococ

cal v

acci

ne d

urin

g th

e 12

-mon

th r

epor

ting

peri

od.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.P

neum

ococ

cal v

acci

ne s

tatu

s is

up

to d

ate

(O03

00A

=[1

]).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s le

ss th

an 5

yea

rs (

i.e.,

resi

dent

has

not

yet

rea

ched

5th

birt

hday

on

targ

et d

ate)

.

Cov

aria

tes

Not

app

licab

le

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-4

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Wer

e O

ffer

ed a

nd

Dec

lin

ed t

he

Pn

eum

ococ

cal V

acci

ne

(Sh

ort

Sta

y)

(NQ

F #

0682

B)

(CM

S:

N00

9.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

shor

t-st

ay r

esid

ents

who

wer

e of

fere

d an

d de

clin

ed th

e pn

eum

ococ

cal v

acci

ne d

urin

g th

e 12

-mon

th r

epor

ting

peri

od.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.W

ere

offe

red

and

decl

ined

the

vacc

ine

(O03

00B

=[2

]).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s le

ss th

an 5

yea

rs (

i.e.,

resi

dent

has

not

yet

rea

ched

5thbi

rthd

ay o

n ta

rget

dat

e).

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-5

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Did

Not

Rec

eive

, Du

e to

Med

ical

Con

trai

nd

icat

ion

,th

e P

neu

moc

occa

l Vac

cin

e (S

hor

t S

tay)

(NQ

F #

0682

C)

(CM

S:

N01

0.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

shor

t-st

ay r

esid

ents

who

did

not

rec

eive

, due

to m

edic

al c

ontr

aind

icat

ion,

the

pneu

moc

occa

l vac

cine

dur

ing

the

12-m

onth

re

port

ing

peri

od.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.W

ere

inel

igib

le d

ue to

med

ical

con

trai

ndic

atio

n(s)

(O

0300

B=

[1])

(e.

g., a

naph

ylac

tic h

yper

sens

itiv

ity

to c

ompo

nent

s of

the

vacc

ine;

bon

e m

arro

w

tran

spla

nt w

ithi

n th

e pa

st 1

2 m

onth

s;or

rece

ivin

g a

cour

se o

f ch

emot

hera

py w

ithi

n th

e pa

st tw

o w

eeks

).

Den

omin

ator

All

sho

rt-s

tay

resi

dent

s w

ith

a se

lect

ed ta

rget

ass

essm

ent.

Exc

lusi

ons

Res

iden

t’s

age

on ta

rget

dat

e of

sel

ecte

d ta

rget

ass

essm

ent i

s le

ss th

an 5

yea

rs (

i.e.,

resi

dent

has

not

yet

rea

ched

5th

birt

hday

on

targ

et d

ate)

.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-6

MD

S 3

.0 M

easu

re:

Th

e P

erce

nta

ge o

f R

esid

ents

on

a S

ched

ule

d P

ain

Med

icat

ion

Reg

imen

on

Ad

mis

sion

Wh

o S

elf-

Rep

ort

a D

ecre

ase

in P

ain

In

ten

sity

or

Fre

qu

ency

(S

hor

t S

tay)

(NQ

F #

0675

) (C

MS

: N

012.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re c

aptu

res

the

perc

enta

ge o

f sh

ort-

stay

res

iden

ts w

ho c

an s

elf-

repo

rt p

ain,

are

on

a sc

hedu

led

pain

med

icat

ion

regi

men

at t

heir

initi

al a

sses

smen

t, an

d w

ho r

epor

t low

ered

leve

ls o

f pa

in o

n th

eir

targ

et a

sses

smen

t.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Shor

t-st

ay r

esid

ents

wit

h bo

th a

n in

itia

l ass

essm

ent a

nd a

sub

sequ

ent t

arge

t ass

essm

ent,

and

who

can

sel

f-re

port

on

pain

(J0

200

= [1

]) o

n bo

th th

e in

itial

ass

essm

ent a

nd th

e ta

rget

ass

essm

ent.

and

who

are

on

a sc

hedu

led

pain

med

icat

ion

regi

men

on

thei

r in

itia

l ass

essm

ent (

J010

0A=

[1])

,

and

who

rep

ort r

educ

ed p

ain

on th

eir

targ

et a

sses

smen

t whe

n co

mpa

red

wit

h th

eir

init

ial a

sses

smen

t as

indi

cate

d by

any

of th

e fo

llow

ing:

1.R

esol

utio

n of

pai

n w

ith

J030

0 =

[1]

(pa

in p

rese

nt)

on th

e in

itia

l ass

essm

ent a

ndJ0

300

=[0

] (n

o pa

in)

on th

e ta

rget

ass

essm

ent.

2.D

ecre

ase

in p

ain

freq

uenc

y in

dica

ted

by J

0400

= [

1, 2

, 3, 4

] on

bot

h th

e in

itial

and

targ

et a

sses

smen

ts a

nd J

0400

on

the

targ

et a

sses

smen

t > J

0400

on

the

init

ial a

sses

smen

t. A

sco

re o

f [1

] on

J04

00 in

dica

tes

the

mos

t fre

quen

t pai

n an

d a

scor

e of

[4]

indi

cate

s th

e le

ast f

requ

ent.

3.R

educ

ed in

tens

ity

of p

ain

indi

cate

d by

J06

00A

= [

00, 0

1, 0

2, 0

3, 0

4, 0

5, 0

6, 0

7, 0

8, 0

9, 1

0] o

n bo

th th

e in

itia

l and

targ

et a

sses

smen

ts a

nd J

0600

A o

n th

e ta

rget

ass

essm

ent <

J06

00A

on

the

init

ial a

sses

smen

t. A

sco

re o

f [1

0] o

n J0

600A

indi

cate

s th

e m

ost i

nten

se p

ain

and

a sc

ore

of [

00]

indi

cate

s no

pa

in.

4.R

educ

ed in

tens

ity

of p

ain

indi

cate

d by

J06

00B

= [

1, 2

, 3, 4

] on

bot

hth

e in

itia

l and

targ

et a

sses

smen

ts a

nd J

0600

B o

n th

e ta

rget

ass

essm

ent <

J06

00B

on

the

initi

al a

sses

smen

t. A

sco

re o

f [4

] on

J06

00B

indi

cate

s th

e m

ost i

nten

se p

ain

and

a sc

ore

of [

1] in

dica

tes

the

leas

t int

ense

pai

n.

Den

omin

ator

Shor

t-st

ay r

esid

ents

wit

h bo

th a

n in

itia

l ass

essm

ent a

nd a

sub

sequ

ent t

arge

t ass

essm

ent,

and

Who

can

sel

f-re

port

on

pain

(J0

200

= [1

]) o

n bo

th th

e in

itia

l ass

essm

ent a

nd th

e ta

rget

ass

essm

ent.

and

Who

are

on

a sc

hedu

led

pain

med

icat

ion

regi

men

(J0

100A

=[1

]) o

n th

e in

itia

l ass

essm

ent,

exce

pt th

ose

who

mee

t the

exc

lusi

on c

rite

ria.

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-7

MD

S 3

.0 M

easu

re:

Th

e P

erce

nta

ge o

f R

esid

ents

on

a S

ched

ule

d P

ain

Med

icat

ion

Reg

imen

on

Ad

mis

sion

Wh

o S

elf-

Rep

ort

a D

ecre

ase

in P

ain

In

ten

sity

or

Fre

qu

ency

(S

hor

t S

tay)

(con

tin

ued

)

(NQ

F #

0675

-w

ith

dra

wn

) (C

MS

: N

012.

01)

Mea

sure

Spe

cifi

cati

on (

cont

inue

d)

Exc

lusi

ons

Res

iden

ts a

re e

xclu

ded

in a

nyof

the

follo

win

g ca

ses:

1.T

he r

esid

ent i

s no

t inc

lude

d in

the

num

erat

or A

ND

the

valu

e fo

r J0

300

or J

0400

is [

9] o

r da

sh [

-] in

dica

ting

not

ass

esse

d on

eith

er th

e in

itia

l or

targ

et

asse

ssm

ent.

2.T

he r

esid

ent i

s no

t inc

lude

d in

the

num

erat

or a

nda

valid

com

pari

son

coul

d no

t be

mad

e be

twee

n th

e in

itia

l and

targ

et a

sses

smen

t on

eith

er J

0600

A o

r J0

600B

. In

ord

er f

or a

val

id c

ompa

riso

n to

be

mad

e, a

t lea

st o

neof

the

follo

win

g m

ust b

e tr

ue:

2.1.

Item

J06

00A

mus

t hav

e a

valu

e of

[00

] th

roug

h [1

0] o

n bo

th th

e in

itia

l and

targ

et a

sses

smen

ts.

2.2.

Item

J06

00B

mus

t hav

e a

valu

e of

[1]

thro

ugh

[4]

on b

oth

the

init

ial a

nd ta

rget

ass

essm

ents

.

3.T

here

was

no

oppo

rtun

ity

for

the

pain

leve

ls to

impr

ove

beca

use

pain

leve

ls w

ere

at th

eir

low

est l

evel

pos

sibl

e on

the

init

ial a

sses

smen

t. T

his

will

oc

cur

if o

ne o

f th

e fo

llow

ing

is tr

ue f

or th

ein

itia

l ass

essm

ent:

3.1.

J030

0 =

[0]

(th

e re

side

nt r

epor

ts n

o pa

in).

3.2.

Bot

hth

e fo

llow

ing

cond

itio

ns a

re tr

ue:

3.2.

1.J0

400

= [

4] (

pain

occ

urs

rare

ly)

and

3.2.

2.J0

600A

= [

00, -

, ^]

(no

pain

rep

orte

d) o

rJ0

600B

= [

1, 9

, ^]

(no

pain

rep

orte

d).

Cov

aria

tes

Not

app

lica

ble.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-8

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts A

sses

sed

an

d A

pp

rop

riat

ely

Giv

en t

he

Pn

eum

ococ

cal V

acci

ne

(Lon

g S

tay)

(NQ

F #

0683

) (C

MS

: N

020.

01)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

se p

neum

ococ

cal v

acci

ne s

tatu

s is

up

to d

ate.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng a

ny o

f th

e fo

llow

ing

crit

eria

on

the

sele

cted

targ

et a

sses

smen

t:

1.H

ave

an u

p to

dat

e pn

eum

ococ

cal v

acci

ne s

tatu

s (O

0300

A=

[1])

; or

2.W

ere

offe

red

and

decl

ined

the

vacc

ine

(O03

00B

=[2

]); o

r

3.W

ere

inel

igib

le d

ue to

med

ical

con

trai

ndic

atio

n(s)

(e.

g., a

naph

ylac

tic

hype

rsen

siti

vity

to c

ompo

nent

s of

the

vacc

ine;

bon

e m

arro

w tr

ansp

lant

wit

hin

the

past

12

mon

ths;

or

rece

ivin

g a

cour

se o

f ch

emot

hera

py w

ithi

n th

e pa

st tw

o w

eeks

) (O

0300

B=

[1])

.

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-9

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Rec

eive

d t

he

Pn

eum

ococ

cal V

acci

ne

(Lon

g S

tay)

(NQ

F #

0683

A)

(CM

S:

N02

1.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

rec

eive

d th

e pn

eum

ococ

cal v

acci

ne d

urin

g th

e 12

-mon

th r

epor

ting

per

iod.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.P

neum

ococ

cal v

acci

ne s

tatu

s is

up

to d

ate

(O03

00A

=[1

]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-10

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Wer

e O

ffer

ed a

nd

Dec

lin

ed t

he

Pn

eum

ococ

cal V

acci

ne

(Lon

g S

tay)

(NQ

F #

0683

B)

(CM

S:

N02

2.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

wer

e of

fere

d an

d de

clin

ed th

e pn

eum

ococ

cal v

acci

ne d

urin

g th

e 12

-mon

th r

epor

ting

peri

od.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.W

ere

offe

red

and

decl

ined

the

vacc

ine

(O03

00B

=[2

]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-11

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Did

Not

Rec

eive

, Du

e to

Med

ical

Con

trai

nd

icat

ion

, th

e P

neu

moc

occa

l Vac

cin

e (L

ong

Sta

y)

(NQ

F #

0683

C)

(CM

S:

N02

3.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

t of

long

-sta

y re

side

nts

who

did

not

rec

eive

, due

to m

edic

al c

ontr

aind

icat

ion,

the

pneu

moc

occa

l vac

cine

dur

ing

the

12-m

onth

re

port

ing

peri

od.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Res

iden

ts m

eeti

ng th

e fo

llow

ing

crite

ria

on th

e se

lect

ed ta

rget

ass

essm

ent:

1.W

ere

inel

igib

le d

ue to

med

ical

con

trai

ndic

atio

n(s)

(O

0300

B=

[1])

(e.

g., a

naph

ylac

tic h

yper

sens

itiv

ity

to c

ompo

nent

s of

the

vacc

ine;

bon

e m

arro

w

tran

spla

nt w

ithi

n th

e pa

st 1

2 m

onth

s;or

rece

ivin

g a

cour

se o

f ch

emot

hera

py w

ithi

n th

e pa

st tw

o w

eeks

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-12

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Hav

e D

epre

ssiv

e S

ymp

tom

s (L

ong

Sta

y)

(NQ

F #

0690

) (C

MS

: N

030.

01)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

enta

ge o

f lo

ng-s

tay

resi

dent

s w

ho h

ave

had

sym

ptom

s of

dep

ress

ion

duri

ng th

e 2-

wee

k pe

riod

pre

cedi

ng th

e M

DS

3.0

targ

et

asse

ssm

ent d

ate.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re th

e ta

rget

ass

essm

ent m

eets

eit

her

of

the

follo

win

g tw

o co

ndit

ions

:

CO

ND

ITIO

N A

(The

res

iden

t moo

d in

terv

iew

mus

t mee

t Par

t 1 a

ndP

art 2

bel

ow)

PA

RT

1: L

ittl

e in

tere

st o

r pl

easu

re in

doi

ng th

ings

half

or

mor

e of

the

days

ove

r th

e la

st tw

o w

eeks

(D

0200

A2

=[2

, 3])

.

or

Feel

ing

dow

n, d

epre

ssed

, or

hope

less

hal

f or

mor

e of

the

days

ove

r th

e la

st tw

o w

eeks

(D

0200

B2

=[2

, 3])

.

PA

RT

2:

The

res

iden

t int

ervi

ew to

tal s

ever

ity

scor

e in

dica

tes

the

CO

ND

ITIO

N B

: (T

he s

taff

ass

essm

ent o

f re

side

nt m

ood

mus

t mee

t Par

t 1 a

ndP

art 2

bel

ow)

PA

RT

1: L

ittl

e in

tere

st o

r pl

easu

re in

doi

ng th

ings

hal

f or

mor

e of

the

days

ove

r th

e la

st tw

o w

eeks

(D

0500

A2

=[2

, 3])

.

or

Feel

ing

or a

ppea

ring

dow

n, d

epre

ssed

, or

hope

less

hal

f or

mor

e of

the

days

ove

r th

e la

st tw

o w

eeks

(D

0500

B2

=[2

, 3])

.

PA

RT

2:

[10]

and

D06

00[3

0]).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-13

MD

S 3

.0 M

easu

re:

Per

cen

t of

Res

iden

ts W

ho

Hav

e D

epre

ssiv

e S

ymp

tom

s (L

ong

Sta

y)(c

onti

nu

ed)

(NQ

F #

0690

) (C

MS

: N

030.

01)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

Exc

lusi

ons

1.R

esid

ent i

s co

mat

ose

or c

omat

ose

stat

us is

mis

sing

(B

0100

= [

1, -

]).

2.R

esid

ent i

s no

t inc

lude

d in

the

num

erat

or (

the

resi

dent

did

not

mee

t the

dep

ress

ion

sym

ptom

con

diti

ons

for

the

num

erat

or)

AN

Dbo

th o

f th

e fo

llow

ing

are

true

:

2.1.

D02

00A

2 =

[^,

-]

orD

0200

B2

=[^

,-]

orD

0300

= [

99,

^, -

].

2.2.

D05

00A

2 =

[^,

-]

orD

0500

B2

= [

^, -

]or

D06

00 =

[^,

-].

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-14

MD

S 3

.0 M

easu

re:

Per

cen

t of

Low

Ris

k R

esid

ents

Wh

o L

ose

Con

trol

of

Th

eir

Bow

el o

r B

ladd

er (

Lon

g S

tay)

(NQ

F #

0685

) (C

MS

: N

025.

01)

Mea

sure

Des

crip

tion

The

mea

sure

rep

orts

the

perc

ent o

f lo

ng-s

tay

resi

dent

s w

ho f

requ

entl

y lo

se c

ontr

ol o

f th

eir

bow

el o

r bl

adde

r.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t tha

t ind

icat

es f

requ

entl

y or

alw

ays

inco

ntin

ence

of

the

blad

der

(H03

00=

[2, 3

]) o

rbo

wel

(H

0400

=[2

, 3]

).

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

arge

t ass

essm

ent i

s an

adm

issi

on a

sses

smen

t (A

0310

A =

[01

]) o

ra

5-da

yP

PS

orM

edic

are

Rea

dmis

sion

/ret

urn

asse

ssm

ent (

A03

10B

= [

01,0

6]).

2.R

esid

ent i

s no

t in

num

erat

or a

nd H

0300

= [

-]or

H04

00 =

[-]

.

3.R

esid

ents

who

hav

e an

yof

the

follo

win

g hi

gh-r

isk

cond

itio

ns:

3.1.

Seve

re c

ogni

tive

impa

irm

ent o

n th

e ta

rget

ass

essm

ent a

s in

dica

ted

by (

C10

00=

[3]

and

C07

00=

[1])

or

(C05

00[7

]).

3.2.

Tot

ally

dep

ende

nt in

bed

mob

ilit

y se

lf-p

erfo

rman

ce (

G01

10A

1 =

[4,

7, 8

]).

3.3.

Tot

ally

dep

ende

nt in

tran

sfer

sel

f-pe

rfor

man

ce (

G01

10B

1 =

[4,

7, 8

]).

3.4.

Tot

ally

dep

ende

nt in

loco

mot

ion

on u

nit s

elf-

perf

orm

ance

(G

0110

E1

= [

4, 7

, 8])

.

4.R

esid

ent d

oes

not q

uali

fy a

s hi

gh r

isk

(see

#3

abov

e) a

nd b

oth

of th

e fo

llow

ing

two

cond

itio

ns a

re tr

ue f

or th

e ta

rget

ass

essm

ent:

4.1.

C05

00 =

[99

, ^, -

], a

nd

4.2.

C07

00 =

[^,

-]

orC

1000

= [

^, -

].

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ap

pe

nd

ix D

Ja

nu

ary

20

19

(v1

2.0

)D

-15

MD

S 3

.0 M

easu

re:

Per

cen

t of

Low

Ris

k R

esid

ents

Wh

o L

ose

Con

trol

of

Th

eir

Bow

el o

r B

ladd

er (

Lon

g S

tay)

(con

tin

ued

)

(NQ

F #

0685

) (C

MS

: N

025.

01)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

5.R

esid

ent d

oes

not q

uali

fy a

s hi

gh r

isk

(see

#3

abov

e) a

nd a

ny o

f th

e fo

llow

ing

thre

e co

ndit

ions

are

true

:

5.1.

G01

10A

1 =

[-]

.

5.2.

G01

10B

1 =

[-]

.

5.3.

G01

10E

1 =

[-]

.

6.R

esid

ent i

s co

mat

ose

(B01

00=

[1])

orco

mat

ose

stat

us is

mis

sing

(B

0100

=[-

]) o

n th

e ta

rget

ass

essm

ent.

7.R

esid

ent h

as a

n in

dwel

ling

cat

hete

r (H

0100

A =

[1]

) or

indw

elli

ng c

athe

ter

stat

us is

mis

sing

(H

0100

A =

[-]

) on

the

targ

et a

sses

smen

t.

8.R

esid

ent h

as a

n os

tom

y (H

0100

C =

[1]

) or

osto

my

stat

us is

mis

sing

(H

0100

C =

[-]

) on

the

targ

et a

sses

smen

t.

Cov

aria

tes

Not

app

licab

le.

RTI International Appendix D January 2019 (v12.0) D-16



USER’S MANUAL

APPENDIX E

Surveyor Quality Measures



RTI International Appendix E January 2019 (v12.0) E-1

Surveyor Quality Measures

Quality measure reports are available to State surveyors and facility staff through CMS’s CASPER reporting system. These reports contain a subset of the measures that are documented in the main body of this user’s guide plus several additional measures that are available only on the CASPER reports.

The table below lists the measures that are contained on the CASPER QM reports and indicates whether each measure is documented above (in the main body of this user guide) or within this appendix. The first column of the table shows the label for the measure that is used on the CASPER reports. The next column shows whether the measure uses the short- or long-stay sample. The third column indicates the unique CMS identification number. The fourth column shows the NQF ID for the measure, if available. The final column indicates whether the measure is defined in the main body of this manual (“above”) or whether it is defined in this appendix (Appendix E). The specifications for the measures that are unique to the CASPER reportsappear after the table.

Table E1: Measures Listed on CASPER QM Reports

Measure LabelShort/Long

Stay CMS IDNQF

IDSpecs

Definition

SR Mod/Severe Pain (S) Short N001.01 0676 Above

SR Mod/Severe Pain (L) Long N014.02 0677 Above

Hi-risk Pres Ulcer (L) Long N015.02 0679 Above

New/worse Pres Ulcer (S) Short N002.03 0678 Above

Phys restraints (L) Long N027.01 0687 Above

Falls (L) Long N032.01 Appendix E

Falls w/Maj Injury (L) Long N013.01 0674 Above

Antipsych Med (S) Short N011.01 Above

Antipsych Med (L) Long N031.02 Above

Antianxiety/Hypnotic (L) Long N033.01 Appendix E

BehavSx affect Others (L) Long N034.01 Appendix E

Depress Sx (L) Long N030.01 0690 Above

UTI (L) Long N024.01 0684 Above

Cath Insert/Left Bladder (L) Long N026.02 0686 Above

Lo-Risk Lose B/B Con (L) Long N025.01 0685 Above

Excess Wt Loss (L) Long N029.01 0689 Above

Incr ADL Help (L) Long N028.01 0688 Above

RT

I In

tern

ati

on

al

Ap

pe

nd

ix E

Ja

nu

ary

20

19

(v1

2.0

)E

-2

MD

S 3

.0 Q

M M

easu

re:

Pre

vale

nce

of

Fal

ls (

Lon

g S

tay)

(NQ

F#:

Non

e) (

CM

S:

N03

2.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

long

-sta

y re

side

nts

who

hav

e ha

d a

fall

duri

ng th

eir

epis

ode

of c

are.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h on

e or

mor

e lo

ok-b

ack

asse

ssm

ents

that

indi

cate

the

occu

rren

ce o

f a

fall

(J18

00 =

[1]

).

Den

omin

ator

All

long

-sta

y nu

rsin

g ho

me

resi

dent

s w

ith

one

or m

ore

look

-bac

k sc

an a

sses

smen

ts e

xcep

t tho

se w

ith

excl

usio

ns.

Exc

lusi

ons

Res

iden

t is

excl

uded

if th

e fo

llow

ing

is tr

ue f

or a

ll o

f th

e lo

ok-b

ack

scan

ass

essm

ents

:

1.T

he o

ccur

renc

e of

fal

ls w

as n

ot a

sses

sed

(J18

00 =

[-]

).

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix E

Ja

nu

ary

20

19

(v1

2)

E-3

MD

S 3

.0 M

easu

re:

Pre

vale

nce

of

An

tian

xiet

y/H

ypn

otic

Use

(L

ong

Sta

y)

(NQ

F#:

Non

e) (

CM

S:

N03

3.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

long

-sta

y re

side

nts

who

are

rec

eivi

ng a

ntia

nxie

ty m

edic

atio

ns o

r hy

pnot

ics

but d

o no

t hav

e ev

iden

ce o

f ps

ycho

tic

or

rela

ted

cond

ition

s in

the

targ

et p

erio

d.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re a

nyof

the

follo

win

g co

ndit

ions

are

true

:

1.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or b

efor

e 03

/31/

2012

:

1.1.

Ant

ianx

iety

med

icat

ions

rec

eive

d (N

0400

B =

[1]

), o

r

1.2.

Hyp

noti

c m

edic

atio

ns r

ecei

ved

(N04

00D

= [

1]).

2.Fo

r as

sess

men

ts w

ith

targ

et d

ates

on

or a

fter

04/

01/2

012:

2.1.

Ant

ianx

iety

med

icat

ions

rec

eive

d (N

0410

B=

[1,

2, 3

, 4, 5

, 6, 7

]), o

r

2.2.

Hyp

noti

c m

edic

atio

ns r

ecei

ved

(N04

10D

= [

1, 2

, 3, 4

, 5, 6

, 7])

.

Den

omin

ator

All

long

-sta

y re

side

nts

wit

h a

sele

cted

targ

et a

sses

smen

t, ex

cept

thos

e w

ith

excl

usio

ns.

Exc

lusi

ons

1.T

he r

esid

ent d

id n

ot q

ualif

y fo

r th

e nu

mer

ator

and

any

of th

e fo

llow

ing

is tr

ue:

1.1.

For

asse

ssm

ents

wit

h ta

rget

dat

es o

n or

bef

ore

03/3

1/20

12: N

0400

B =

[-]

orN

0400

D =

[-]

.

1.2.

For

asse

ssm

ents

wit

h ta

rget

dat

e on

or

afte

r 04

/01/

2012

: N04

10B

= [

-]or

N04

10D

= [

-].

2.A

ny

of th

e fo

llow

ing

rela

ted

cond

ition

s ar

e pr

esen

t on

the

targ

et a

sses

smen

t (un

less

oth

erw

ise

indi

cate

d):

2.1.

Schi

zoph

reni

a (I

6000

= [

1]).

2.2.

Psy

chot

ic d

isor

der

(I59

50 =

[1]

).

2.3.

Man

ic d

epre

ssio

n (b

ipol

ar d

isea

se)

(I59

00 =

[1]

).

2.4.

Tou

rette

’s s

yndr

ome

(I53

50 =

[1]

).

2.5.

Tou

rette

’s s

yndr

ome

(I53

50 =

[1]

) on

the

prio

r as

sess

men

t if

this

item

is n

ot a

ctiv

e on

the

targ

et a

sses

smen

t and

if a

pri

or a

sses

smen

t is

avai

labl

e.

2.6.

Hun

ting

ton’

s di

seas

e(I

5250

= [

1]).

(con

tinu

ed)

RT

I In

tern

ati

on

al

Ap

pe

nd

ix E

Ja

nu

ary

20

19

(v1

2)

E-4

MD

S 3

.0 M

easu

re:

Pre

vale

nce

of

An

tian

xiet

y/H

ypn

otic

Use

(L

ong

Sta

y)(c

onti

nu

ed)

(NQ

F#:

Non

e) (

CM

S:

N03

3.01

)

Mea

sure

Spe

cifi

cati

ons

(con

tinu

ed)

2.7.

Hal

luci

nati

ons

(E01

00A

= [

1]).

2.8.

Del

usio

ns (

E01

00B

= [

1]).

2.9.

Anx

iety

dis

orde

r (I

5700

= [

1]).

2.10

.P

ost-

trau

mat

ic s

tres

s di

sord

er (

I610

0 =

[1]

).

2.11

.P

ost-

trau

mat

ic s

tres

s di

sord

er (

I610

0 =

[1]

) on

the

prio

r as

sess

men

t if

this

item

is n

ot a

ctiv

e on

the

targ

et a

sses

smen

t and

if a

pri

or a

sses

smen

t is

ava

ilab

le.

Cov

aria

tes

Not

app

licab

le.

RT

I In

tern

ati

on

al

Ap

pe

nd

ix E

Ja

nu

ary

20

19

(v1

2)

E-5

MD

S 3

.0 M

easu

re:

Pre

vale

nce

of

Beh

avio

r S

ymp

tom

s A

ffec

tin

g O

ther

s (L

ong

Sta

y)

(NQ

F#:

Non

e) (

CM

S:

N03

4.01

)

Mea

sure

Des

crip

tion

Thi

s m

easu

re r

epor

ts th

e pe

rcen

tage

of

long

-sta

y re

side

nts

who

hav

e be

havi

or s

ympt

oms

that

aff

ect o

ther

s du

ring

the

targ

et p

erio

d.

Mea

sure

Spe

cifi

cati

ons

Nu

mer

ator

Lon

g-st

ay r

esid

ents

wit

h a

sele

cted

targ

et a

sses

smen

t whe

re a

nyof

the

follo

win

g co

ndit

ions

are

true

:

1.T

he p

rese

nce

of p

hysi

cal b

ehav

iora

l sym

ptom

s di

rect

ed to

war

ds o

ther

s (E

0200

A =

[1,

2, 3

]), o

r

2.T

he p

rese

nce

of v

erba

l beh

avio

ral s

ympt

oms

dire

cted

tow

ards

oth

ers

(E02

00B

= [

1, 2

, 3])

, or

3.T

he p

rese

nce

of o

ther

beh

avio

ral s

ympt

oms

not d

irec

ted

tow

ards

oth

ers

(E02

00C

= [

1, 2

, 3])

,or

4.R

ejec

tion

of c

are

(E08

00 =

[1,

2, 3

]), o

r

5.W

ande

ring

(E

0900

= [

1, 2

, 3])

.

Den

omin

ator

All

res

iden

ts w

ith

a se

lect

ed ta

rget

ass

essm

ent,

exce

pt th

ose

wit

h ex

clus

ions

.

Exc

lusi

ons

Res

iden

t is

not i

n nu

mer

ator

and

any

of th

e fo

llow

ing

is tr

ue:

1.T

he ta

rget

ass

essm

ent i

s a

disc

harg

e (A

0310

F =

[10

11].

2.E

0200

A is

equ

al to

[-,

^].

3.E

0200

B is

equ

al to

[-,

^].

4.E

0200

C is

equ

al to

[-,

^].

5.E

0800

is e

qual

to [

-, ^

].

6.E

0900

is e

qual

to [

-, ^

].

Cov

aria

tes

Not

app

licab

le.

RTI International Appendix E January 2019 (v12.0) E-6



USER’S MANUAL

APPENDIX F

Specifications for the Facility Characteristics Report



RTI International Appendix F January 2019 (v12.0) F-1

Specifications for Facility Characteristics Report

Record Selection

The Facility Characteristic Report is populated using data from records selected using the standard QM episode and record selection logic as given in the QM User’s Manual. The Facility Characteristics measures can be processed with the QM measures. Each Facility Characteristic measure is computed using all residents (both short-stay and long-stay residents).

Most of the Facility Characteristic measures are populated using data from a look-back scan of the assessment records selected for each resident. For each resident, the look-back scan begins with the target assessment selected for QM processing. The resident’s records are scanned in reverse chronological order (by ARD) and all data items required for the Facility Characteristics report are populated from data that are available from each assessment. As assessments are scanned, each required item is initially populated with the item value from the target assessment.If the value from the target assessment is a valid (non-missing) value, then the scan for that item stops. If the value for the target assessment is not a valid value (a missing value), then the scan continues with the earlier assessments in reverse chronological order. Once a valid value is found for an item, that value is used for the report (i.e., the value is not changed if additional values are present in earlier records).

A “valid value” is any value that is one of the “normal” responses to an item. Missing non-valid values are:

1. A dash (“-”) indicating that the item was not assessed.2. A caret (“^”) indicating that the item was skipped.3. A null (.) indicating that the item is inactive.

Note that the diagnosis code items (I8000A through I8000J) are not used in the measure specifications below and are therefore not included in the look-back scan.

For each resident, the look-back scan continues until any of the following conditions is satisfied:

• All required items have been populated with valid values, as defined above, or

• All selected records for a resident have been scanned.

Note that scanning stops for a resident as soon as either of these conditions is satisfied.

Measure Specifications

The definitions in the following table are applied to a look-back scan of the records selected for a resident as described in the prior section on Record Selection. Counts of the number of residents within each facility that meet the numerator criteria for each measure below are used as the numerator to produce facility percentages for the report.

The denominator used to produce the facility percentages in the report will vary for differentmeasures, depending on missing data. If missing data precludes determination of the status for a


measure as indicated in the “Exclusions” section, then the resident is excluded from both the numerator and denominator in the facility percentage.

Table F1: Facility Characteristics Report Measure DefinitionsMeasure Description and Definition

Gender

Male Description: Resident is included if Item A0800 (Gender) is equal to 1(Male). Records with dashes (not assessed) in A0800 are excluded from the male/female counts.

Numerator: A0800 = 1 (Male).

Exclusions: A0800 missing

Female Description: Resident is included if Item A0800 (Gender) is equal to 2(Female). Records with dashes (not assessed) in A0800 are excluded from the male/female counts.

Numerator: A0800 = 2 (Female).


Age

Calculation of Age, based on Items A0900 (Birth Date) and A2300 (Assessment Reference Date ARD):IF (MONTH(A2300) > MONTH(A0900)) OR

(MONTH(A2300) = MONTH(A0900) ANDDAY(A2300) >= DAY(A0900)) THEN

Age = YEAR(A2300)-YEAR(A0900) ELSEAge = YEAR(A2300)-YEAR(A0900)-1

<25 years old Description: Age less than 25 years old.

Numerator:Record triggers if age < 25.

25-54 years old Description: Age of 25 through 54 years old.

Numerator:Record triggers if age >= 25 and <= 54.



65-74 years old Description: Age of 65 to 74 years old.




(continued)


Table F1: Facility Characteristics Report Measure Definitions (continued)

Measure Description and Definition

85+ years old Description: Age of 85 years of age or older.

Numerator:Record triggers if age >= 85.

Diagnostic Characteristics

PsychiatricDiagnosis

Description: Resident is included as having a psychiatric diagnosis if any of the following is true:

• Any psychiatric mood disorders are checked (=1) in items I5700 through I6100, or

• Item I5350 (Tourette’s Syndrome) is checked (=1), or• Item I5250 (Huntington’s Disease) is checked (=1).

Numerator:

• Any of the following items are checked (-1): I5250, I5350, I5700 through I6100.

Exclusions: No value I5250, I5350, I5700 through I6100 = 1 and anyvalue I5250, I5350, I5700 through I6100 is missing

Intellectual Disability (ID) (Mental retardation as defined at 483.45(a)) or Developmental Disability (DD)

Description: Resident is counted as having ID/DD if any of the following items are checked:

• A1550A (Down syndrome).• A1550B (Autism).• A1550C (Epilepsy).• A1550D (Other organic condition related to ID/DD).• A1550E (ID/DD with no organic condition).

Numerator:

A1550A, B, C, D, or E is checked (=1).

Exclusions: No value A1550A, B, C, D, or E = 1 and any value A1550A, B, C, D, or E missing

Hospice Description: Resident is included if Item O0100K2 (Hospice care) is checked.

Numerator: O0100K2 is checked (=1).

Exclusions: O0100K2 missing(continued)




Prognosis

Life expectancy of less than 6 months

Description: Resident is included if item J1400 (Prognosis) is coded 1(Yes).

Numerator: J1400 = 1 (Yes).

Exclusions: J1400 missing

Discharge Plan

Discharge planning IS NOT already occurring for the resident to return to the community.

Description: Resident is included if Item Q0400A (Discharge Plan) is coded 0 (No).

Numerator: Q0400A = 0 (No).

Exclusions: Q0400A missing

Discharge planning IS already occurring for the resident to return to the community.

Description: Resident is included if Item Q0400A (Discharge Plan) is coded 1 (Yes).

Numerator: Q0400A = 1 (Yes).

Exclusions: Q0400A missing

Referral

Referral not needed. Description: Resident is included if Item Q0600 (Referral) is coded 0 (No - Referral not needed).

Numerator: Q0600 = 0 (No - Referral not needed).

Exclusions: Q0600 missing

Referral is or may be needed, but has not been made.

Description: Resident is included if Item Q0600 (Referral) is coded 1(Yes – Referral is or may be needed).

Numerator: Q0600 = 1 (No - Referral is or may be needed).

Exclusions: Q0600 missing

Referral has been made. Description: Resident is included if Item Q0600 (Referral) is coded 2(Yes - Referral made).

Numerator: Q0600 = 2 (Yes - Referral made).

Exclusions: Q0600 missing(continued)




Type of Entry

Admission Description: Resident is included if Item A1700 (Type of Entry) is coded 1, (Admission).

Numerator: A1700 = 1 (Admission).


Reentry Description: Resident is included if Item A1700 (Type of Entry) is coded 2, (Reentry).

Numerator: A1700 = 2 (Reentry).


Entered Facility From

Community (private home/apartment board/care, assisted living, group home)

Description: Resident is included if Item A1800 (Entered From) is coded01 (Community).

Numerator: A1800 = 01 (Community).


Another nursing home or swing bed

Description: Resident is included if Item A1800 (Entered From) is coded 02 (Another nursing home or swing bed).

Numerator: A1800 = 02 (Another nursing home or swing bed).


Acute hospital Description: Resident is included if Item A1800 (Entered From) is coded 03 (Acute hospital).

Numerator: A1800 = 03 (Acute hospital).


Psychiatric hospital Description: Resident is included if Item A1800 (Entered From) is coded 04 (Psychiatric hospital).

Numerator: A1800 = 04 (Psychiatric hospital).


Inpatient rehabilitation facility

Description: Resident is included if Item A1800 (Entered From) is coded 05 (Inpatient rehabilitation facility).

Numerator: A1800 = 05 (Inpatient rehabilitation facility).

Exclusions: A1800 missing(continued)




ID/DD facility Description: Resident is included if Item A1800 (Entered From) is coded 06 (ID/DD facility).

Numerator: A1800 = 06 (ID/DD facility).


Hospice Description: Resident is included if Item A1800 (Entered From) is coded 07 (Hospice).

Numerator: A1800 = 07 (Hospice).


Long Term Care Hospital (LTCH)

Description: Resident is included if Item A1800 (Entered From) is coded 09 (Long Term Care Hospital (LTCH)).

Numerator: A1800 = 09 (Long Term Care Hospital (LTCH)).


Other Description: Resident is included if Item A1800 (Entered From) is coded 99 (Other).

Numerator: A1800 = 99 (Other).


MDS 3.0 Quality Measures User's Manual - v12.0, Effective ... · Title: MDS 3.0 Quality Measures...

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Transcript of MDS 3.0 Quality Measures User's Manual - v12.0, Effective ... · Title: MDS 3.0 Quality Measures...