The measure will be stratified by resident population. Rates will be reported separately for the long-stay (chronic care) and short-stay (post-acute care) populations.
Denominator Statement for Chronic Care (Long-Stay) Residents All residents in the chronic care influenza vaccination sample with a valid MDS target record (any assessment or discharge tracking form) during the influenza vaccination reporting period (October 1 through June 30).
Chronic Care Influenza Vaccination Sample Definition The chronic care influenza vaccination sample includes residents meeting any of the following three conditions indicating a non-PPS stay during the season:
(1) resident has a non-PPS assessment during the influenza season (October 1 through March 31); or (2) resident has a discharge tracking form during the season and the prior MDS record was a non-PPS assessment within 100 days prior to discharge; or (3) resident had a stay with days during the season and was discharged prior to completion of an initial assessment. (Note that the discharge can be after the flu season end.)
Denominator Statement for Post-Acute Care (Short-Stay) Residents All residents in the post-acute care influenza vaccination sample with a valid MDS target record (any assessment or discharge) in the influenza vaccination reporting period (October 1 through June 30).
Post-Acute Care Influenza Vaccination Sample Definition The post-acute care influenza vaccination sample includes residents meeting either of the following conditions:
(1) resident has a PPS assessment during the influenza season; or (2) resident has a PPS assessment before the season with the next record being a discharge during the season
Denominator Statement for Post-Acute Care (Short-Stay) Residents All residents in the post-acute care influenza vaccination sample with a valid MDS target record (any assessment or discharge) in the influenza vaccination reporting period (October 1 through June 30). Post-Acute Care Influenza Vaccination Sample Definition The post-acute care influenza vaccination sample includes residents meeting either of the following conditions: (1) resident has a PPS assessment during the influenza season; or (2) resident has a PPS assessment before the season with the next record being a discharge during the season.
Exclusions
Exclusions
Resident-Level Exclusions Residents satisfying any of the following conditions on the selected target assessment or discharge are excluded from the denominator:
(1) The resident was not in the facility during the influenza season.
Note: Residents are not excluded if either or both of the influenza vaccine items (W2a and W2b) have dash (-) values indicating inability to determine.
Facility-Level Exclusions Facilities with small sample sizes are excluded from public reporting of the influenza vaccination measure.
Chronic Care Facility-Level Exclusions Facilities are excluded if either of the following is true:
(1) the chronic care influenza vaccination sample includes fewer than 30 residents; or (2) the facility has fewer than 30 non-PPS quarterly assessments (AA8a = 05) for the entire facility for the year ending with the last day of the last completed influenza season (March 31).
Post-Acute Care Facility-Level Exclusions Facilities are excluded if either of the following is true:
(1) the post-acute care influenza vaccination sample includes fewer than 20 residents; or (2) the facility is excluded if there are no 5-day PPS assessments (AA8b = 1) for the entire facility for the year ending with the last day of the influenza season (March 31)
Measure Record
Most Recent Endorsement Activity
Measure Retired and Endorsement Removed National Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations
Public Comments