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 TypeElectronic Clinical Quality Measure (eCQM)Level Of AnalysisCare SettingNumerator
The numerator is the number of long-stay residents with a selected target assessment who are frequently or always incontinent of bowel or bladder.
DenominatorThe denominator is all long-stay residents in the nursing facility with a target assessment (OBRA, PPS or discharge) except those with exclusions.
ExclusionsA 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.Testing Data Sources
- Measure StructureClinical Condition Topic AreaTarget PopulationNational Quality Strategy PrioritiesEffective Communication and Care Coordination
- Risk Adjustment
- Current or planned use(s)
- Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Person and Family-Centered Care Endorsement Maintenance ProjectInitial EndorsementEndorsement StatusLast UpdatedRemoval Date
- Steward Organization Email