This measure updates CMS’ MDS 2.0 QM on bowel and bladder control. It is based on data from Minimum Data Set (MDS) 3.0 assessments of low risk long-stay nursing facility residents (those whose cumulative days in the facility is greater than 100 days). This measure reports the percent of long-stay residents with a selected target assessment who are frequently or always bladder or bowel incontinent as indicated on the target MDS assessment (OBRA, PPS or discharge) during the selected quarter (3-month period).
Measure Specs
General Information
Numerator
The numerator is the number of long-stay residents with a selected target assessment who are frequently or always incontinent of bowel or bladder.
Denominator
The denominator is all long-stay residents in the nursing facility with a target assessment (OBRA, PPS or discharge) except those with exclusions.
Exclusions
A resident is excluded from the denominator if the selected MDS 3.0 assessment was conducted within 14 days of admission (A0310A = 01) or if there is missing data in the response fields for the relevant questions in the MDS. Other exclusions include residents with severe cognitive impairment, total dependence in mobility, comatose, or with an indwelling catheter.
Nursing facilities are excluded from public reporting if their samples include fewer than 30 residents.
Public Comments