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Endorsement Removed

Percent of Low Risk Residents Who Lose Control of Their Bowels or Bladder (Long-Stay)

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).

CBE ID
0685

Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (Long-Stay)

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.

CBE ID
0683

Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (long stay)

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.

CBE ID
0681

Percent of Residents Who Have Depressive Symptoms (Long-Stay)

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.

CBE ID
0690

Percent of Residents Who Self-Report Moderate to Severe Pain (Long Stay)

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.

CBE ID
0677

Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay)

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.

CBE ID
0676

Percent of Residents Who Were Physically Restrained (Long Stay)

The measure reports the percentage of all long-stay residents who were physically restrained daily during the 7 days prior to the target MDS 3.0 assessment (OBRA, PPS or discharge) during their episode of nursing home care ending in the target quarter (3-month period). Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

CBE ID
0687