Percentage of residents with a valid target and a valid prior assessment whose need for more help with daily activities has increased
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
Residents with worsening (increasing MDS item score) in Late-Loss ADL self-performance at target relative to prior assessment.
1.Bed mobility – [Level at target assessment (G1a(A)[t]] – [ Level at previous assessment (G1a(A)[t-1]] > 0, or
2.Transfer - [Level at target assessment (G1b(A)[t]] – [ Level at previous assessment (G1b(A)[t-1]] > 0, or
3.Eating - [Level at target assessment (G1h(A)[t]] – [ Level at previous assessment (G1h(A)[t-1]] > 0, or
4.Toileting - [Level at target assessment (G1i(A)[t]] – [ Level at previous assessment (G1i(A)[t-1]] > 0,
OR at least one of the following is true:
1.Bed mobility – [Level at target assessment (G1a(A)[t]] – [ Level at previous assessment (G1a(A)[t-1]] > 1, or
2.Transfer - [Level at target assessment (G1b(A)[t]] – [ Level at previous assessment (G1b(A)[t-1]] > 1, or
3.Eating - [Level at target assessment (G1h(A)[t]] – [ Level at previous assessment (G1h(A)[t-1]] > 1, or
4.Toileting - [Level at target assessment (G1i(A)[t]] – [ Level at previous assessment (G1i(A)[t-1]] > 1.
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1.15 Denominator
All residents with a valid target and a valid prior assessment
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Exclusions
Exclusions: Residents meeting any of the following conditions:
1.None of the four Late-Loss ADLs (G1a(A), G1b(A), G1h(A), and G1i(A)) can show decline because each of the four have a value of 4 (total dependence) or a value 8 (activity did not occur) on the prior assessment [t-1].
2.The QM did not trigger (resident not included in the numerator) AND there is missing data on any one of the four Late-Loss ADLs (G1a(A)), G1b(A), G1h(A), or G1i(A)) on the tarot assessment [t] or prior assessment [t-1].
3.The resident is comatose (B1 = 1) or comatose status is unknown (B1 = missing) on the target assessment
4.The resident has end-stage disease (J5c = checked) or end-stage disease status is unknown (J5c – missing) on the target assessment.
5.The resident is receiving hospice care (P1ao = checked) or hospice status is unknown (P1ao = missing) on the target assessment of the most recent full assessment..
6.The resident is in a facility with a Chronic Care admission assessments with AA8a =01 in the facility over the previous 12 months).
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Nursing Homes- 2004Initial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid Services
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