Endorsement Removed

This measure is based on data from MDS 3.0 assessments of long-stay nursing facility residents. The measure reports the percentage of all long-stay residents 5 years and older who were assessed and appropriately given the Pneumococcal Vaccination as reported on the target MDS assessment (OBRA, PPS or discharge) during the 12-month reporting period. This proposed measure is harmonized with NQF’s quality measure on Pneumococcal Immunizations.(1) The MDS 3.0 definitions have been changed to conform to the NQF standard.

This measure reports the percentage of long-stay residents, 180 days of age and older, who were in a nursing facility for at least one day during the most recently completed influenza vaccination season (IVS), and who were assessed and appropriately given the seasonal influenza vaccine . The IVS is defined as beginning on October 1 and ends on March 31 of the following year.

The measure reports the percentage of short stay nursing home residents or IRF or LTCH patients who were assessed and appropriately given the pneumococcal vaccine during the 12-month reporting period.

This quality measure reports the percent of patients or short-stay residents with Stage 2-4 pressure ulcer(s) that are new or worsened since admission. The measure is based on data from the Minimum Data Set (MDS) 3.0 assessments of

This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument.

This measure reports the percentage of long-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. This measure is risk-adjusted for resident cognitive status. Long-stay nursing facility residents are identified as those who have had 101 or more cumulative days of nursing facility care.

This measure reports the percentage of short-stay residents in a nursing facility, who reported almost constant or frequent pain, and at least one episode of moderate to severe pain, or any very severe/horrible pain in the 5 days prior to the target assessment. This measure is based on data from the Minimum Data Set (MDS 3.0) OBRA, PPS, and/or discharge assessments during the selected quarter. Short-stay nursing facility residents are identified as those who have had 100 or fewer cumulative days of nursing facility care.

This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use.

The percentage of births with birthweight <2,500 grams

Percentage of patients undergoing cervical spine radiographs in trauma who do not have neck pain, distracting pain, neurological deficits, reduced level of conciousness or intoxication.