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MDS 3.0 Quality Measures



Nursing Home Compare Quality Measures

• 24 Quality Measures on NHC • 16 of those 24 impact Five Star Rating CASPER Quality Measures – No CHANGE yet

• QM Reports are available from CASPER• QM Reports: Include 17 QMs

– 3 of the 17 are only on CASPER report



CASPER QMs

Review Reports: See draft sample: – Facility characteristics– Facility QM report– Resident Level QM report


Facility Characteristics




Resident Level Summary

Resident IDType of Assessment indicated by A0310A, B, F

- 04 (SCSA)/99/99 (not Medicare or discharge)- 01/01/99 (Initial combined with 5-day)- 99/99/11 (discharge assessment)




Resident Level Summary

for each QM assigned to that resident’s MDSb – same as “blank”

Quality Measure Count

- Adds up total number of QMs for that MDS




Traditional Survey Pre-select Residents

• Surveyors will survey all QMs which are triggered at the 75th percentile or greater.

• Will then survey other care areas with high ranking or combinations; PRE-SELECT SAMPLE – Pressure ulcer & weight loss– UTI & catheter and/or Low Risk Incontinence– Falls and restraints - Pain & ADL decline– Psychoactive medications - Depressed – ADL decline and restraints



Which MDS are used to calculate QMs?

Glossary of Terms


MDS 3.0 Quality MeasuresGlossary of Terms

• Target Period or look-back period

– Span of time which defines the QM reporting period. • Stays

– Period of time between Entry and either discharge or end of target period, which ever comes first.

• Episode– Period of time spanning one or more stays which ends

either in a discharge/death or end of target period whichever comes first.

• End of episode is the earliest – Discharge, Death, or end of target period



• Cumulative Days in the Facility (CDIF)– Total days within an episode – sum of number of days

within each stay included in the episode.• End of an “episode” is when the last MDS is a

Discharge Assessment within target period, or• Death, or• Target Period ends.

– Any days for temporary discharges e.g. hospitalization do not count toward (CDIF).• Discharge Return anticipated & returns within 30

days is treated as a reentry but within same episode.



MDS 3.0 Quality Measures Glossary of Terms

• Long Stay – Resident CDIF is over 100 days.• Short Stay – Resident CDIF is 100 days or less.

• All MDS/residents are sorted into either Long Stay or Short Stay.

• QM data is updated weekly, adding MDS submitted the prior week.




• Target Date

– The event date for MDS• Entry Date (A1600), or• Discharge or Death Date (A2000), or• Assessment Reference Date (ARD) (A2300)


MDS 3.0 Quality Measures Glossary of Terms

• Target Assessment – Latest assessment which meets criteria in the Target

Period. • Initial Assessment

– First assessment following entry record at the beginning of the selected episode.

• Prior Assessment – Latest assessment that is 46 to 165 days before the

target assessment.



Assessment Types

SHORT STAY

Target Assessments:• All OBRA Assessments• All scheduled PPS MDS• Discharge Assessments

Initial Assessments:Admission5-day MDSDischarge Assessments

LONG STAY

Target Assessments & Prior Assessments:

• All OBRA Assessments• All scheduled PPS MDS• Discharge Assessments


Glossary of Terms

• Numerator – The number of MDS in the report that qualify for the

QM.• Denominator

– The number of MDS in the report period that could qualify for the QM.

• Exclusions– Types of residents that are not included in either the

numerator or denominator due to a certain diagnosis or condition.



Glossary of Terms

• Covariate Impact: – Facility-level Observed QM score is calculated.– Resident-level covariates are used to calculate a

Resident-level Expected QM score (the probability that the resident will evidence the outcome, given the presence or absence of characteristics measured by the covariates).

– Then, an average of all resident-level expected QM scores for the nursing facility is calculated to create a Facility-level Expected QM score.


Glossary of Terms

Covariate Impact:• The final Facility-level Adjusted QM score was

based on a calculation which combines the facility-level expected score and the facility-level observed score.



Glossary of Terms

• Risk Adjustment– High risk are more at risk for outcomes.

• State Average– Average scores for each QM from all MDS submitted

within your state.• National Average

– The roll-up national average of all submitted MDS used to calculate QM.




Short Stay Quality Measures


Percent of Short Stay Residents Who

Self-ReportModerate to Severe Pain.



Short Stay - Pain

Percent of Residents Who Self-Report Moderate to Severe Pain.

CASPER, NHC, and Impacts 5 Star

– Short stay residents with at least one episode of moderate/severe pain or horrible/excruciating pain of any frequency.


Short Stay - Pain

• Numerator: most recent MDS – Meets either or both conditions

– Condition #1

• Almost constant or frequent pain (J04001, 2) and• At least one episode of moderate to severe pain

(J0600A=05-09 or B=2, 3) – Condition #2

• Severe/horrible pain of any frequency (J0600A=10 or B=4)



Short Stay - Pain


Short Stay - Pain

Exclusions:

Incomplete data or not interviewed.Ongoing QA:

– Ensure accurate coding.– Pharmacy consultant monthly review. – Ensure care plan addresses pain and includes

non-drug interventions.– Risk Team - Review residents with QM monthly

and/or on routine pain meds.



Assessment and Care Planning

• Pain Screens• Pain Assessment• Pain CAA• Daily/every shift Pain Scale• PRN versus routine• Non-drug interventions• Pharmacy review • Weekly/Monthly Risk Reviews

Investigation Steps


Percent of Short Stay Residents with Pressure Ulcers that are New

or Worsened.



Short Stay Worsened Pressure Ulcer

Percent of Residents with Pressure Ulcers that are New or Worsened.


– Percent of short stay residents with new or worsening Stage 2 – 4 Pressure Ulcers.



• Numerator: Most recent MDS.

– Target assessment indicates one or more new or worsened Stage 2 - 4 Pressure Ulcers.

1. Stage 2 (M0800A) > 0 and M0800A < = M0300B1, OR

2. Stage 3 (M0800B) > 0 and M0800B < = M0300C1, OR

3. Stage 4 (M0800C) > 0 and M0800C < = M0300D1,




• Exclusions:– No usable MDS related to coding.

• Covariates:– Bed mobility (G0110A -2, 3, 4, 7, 8)– Incontinence of bowel at least occasionally (H0400)– Diabetes or PVD– Low Body Mass IndexMust have the Comprehensive Initial Assessment

to calculate all covariates.


Assessment and Care Planning

• Risk Score – Additional risk factors

• Admission care plan• CAA • Weekly body checks

– Aide and nurse• Ongoing Care plan• At time of new/repeat PU

Investigation Steps




Risk Team reviews weekly• Accurate assessment and documentation of pressure

ulcers.• Review care plan for any residents with new or

worsened pressure ulcers to ensure all risk factors are documented and care planned.

• Weekly assessment of each PU.– Revise care plan and notify physician if PU is not

improving within 2 - 4 weeks.

Investigation Steps


Seasonal Influenza Vaccine



Short Stay and Long Stay FluNHC only

Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine.

– Percent of short stay residents who are given, appropriately, the influenza vaccination during the current or most recent influenza season.

This measure is only calculated once a year with a target period of October 1 of the prior year to June 30 of the current year and reports for the October 1 through March 31 influenza vaccination season.


Short Stay/Long Stay FluNHC only

Numerator: Total Score #0680

• Exclusion– O0250C=1 Not in facility during flu season.– Resident’s age on target date of selected target is

179 days or less.



Short Stay/Long Stay FluNHC only

Numerator: Total Score #0680 • #0680A - Resident received the influenza vaccine during

the current/most recent influenza season, either in the facility (O0250A=1) or outside the facility (O0250C=2); or

• #0680B - Resident was offered and declined the influenza vaccine (O0250C=4); or

• #0680C - Resident was ineligible due to contraindication(s) (O0250C=3) per definitions.




Short Stay and Long Stay Pneumococcal NHC only

Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine.

– Percent of short stay residents whose pneumococcal polysaccharide vaccine (PPV) status is up-to-date during the 12-month reporting period.



Numerator: 12-month Target Period

• #0682A - PPV status is up-to-date (O0300A=1); or • #0680B - Were offered and declined the vaccine

(O0300B=2); or • #0680C - Were ineligible due to medical

contraindication(s) (O0300B=1)Exclusions: Resident’s age on target date of selected

target assessment is less than 5 years (i.e. resident has not yet reached 5th birthday on target date).





Immunization NHC only

Investigation:

– Ongoing Infection Control consistently tracks status of immunizations.

– Keep permanent immunization records in the medical record.

– Ensure timely and effective education for residents and families.

– Why missed? Investigate unless shortage.



Percent of Short Stay Residents

Who Newly Receive an Antipsychotic Medication


Short Stay – Antipsychotic Meds

Numerator: • Short-stay residents for whom one or more

assessments in a look-back scan (not including the initial assessment) indicates that antipsychotic medication was received: Newly Received – N0410A=[1,2,3,4,5,6,7]

– CASPER, NHC and Impacts 5 Star rating





Denominator

All short-stay residents who do not have exclusions and who meet all of the following conditions:

• The resident has a target assessment, and • The resident has an initial assessment, and • The target assessment is not the same as the initial

assessment.



Short Stay - Antipsychotic Meds

Exclusions

1. Any of the following related conditions are present on any assessment in a look-back scan:

2.1. Schizophrenia (I6000 = [1]). 2.2. Tourette’s Syndrome (I5350 = [1]). 2.3. Huntington’s Disease (I5250 = [1]).

2. The resident’s initial assessment indicates antipsychotic medication use or antipsychotic medication use is unknown (blank/dashes)



• Investigation– Ensure accurate coding of diagnosis.

• Ensure medical record contains a diagnosis for use even if not one of the exclusions.

– Evidence of drug reduction or documentation by physician supporting decision to not reduce meds.

– Behavior monitor in place.– Side effect monitoring in place. – Pharmacy drug reviews in compliance.– High Risk – Residents with diagnosis of dementia.



Improvement in Function – Short Stay


Short Stay - Improvement in Function

Percent of short-stay residents who make improvements in function.

NHC, Impacts 5 Star at 50% weight until January 2017, then full weight like other QMs.

• Calculated by adding up ADL scores 0-4 (If Coded 7 or 8 it counts as “4”) for self performance. – Transfer G0110B1– Locomotion on Unit G0110E1– Walk in Corridor G0110D1– Measures from 5-day/Admission Assessment to Discharge

Assessment (No Return Anticipated)



Short Stay - Improvement in Function – NHC Only

• Measurement Period: Updated quarterly• Numerator: The number of short-stay residents

who have negative change (total score goes down because function improved) in score for Transfer, Locomotion on Unit and Walk in Corridor, from the 5-day or admission assessment when compared to the Planned Discharge Return Not Anticipated assessment.

• Numerator Exclusions: None



• 5-day MDS – Total Score of 8 – Transfer G0110B1 – CODED 3 - Extensive Assist– Locomotion on Unit G0110E1 – CODED 3 - Extensive

Assist – Walk in Corridor G0110D1 – CODED 2 - Limited Assist




• Discharge Assessment – Total Score of 6 – IMPROVED – Transfer G0110B1 – CODED 2 - Limited Assist– Locomotion on Unit G0110E1 – CODED 2 - Limited Assist – Walk in Corridor G0110D1 – CODED 2 - Limited Assist



• Denominator: All short stay residents who have a valid planned discharge (return not anticipated) assessment and a valid preceding 5-day or admission assessment (whichever is earliest in stay)

• Denominator Exclusions:



Short Stay - Improvement in Function - NHC Only

Covariates from 5-day/admission MDS


Short Stay - Improvement in Function - NHC Only

Investigation: • Review coding definitions for locomotion on unit and

walking in corridor. • QA coding for a sample of charts to ensure accuracy.• If QA is worse than national average, then review

more closely coding accuracy.• Investigate like other QMs once added to CASPER

report in the future.



Long Stay Quality Measures


Percent of Residents Experiencing One or More Falls with

Major Injury.



Long Stay -Fall with Major Injury

Percent of Residents Experiencing One or More Falls with Major Injury.


– Percent of long stay residents who have experienced one or more falls with major injury reported in the target period or look-back period.


Long Stay -Fall with Major Injury

• Numerator:

– Fall with major injury since admission or prior assessment (J1900C=1, 2)

– Most recent MDS.

• Exclusions:

– Blanks/dashes



CASPER Only –Long Stay - Falls

The Percentage of residents who have had a Fall

Numerator: Any falls since admission/entry/reentry/prior OBRA/Scheduled PPS MDSJ0800 Fall = 1 Yes

No exclusions


CASPER Only –Long Stay - Falls



Long Stay -Falls/ with Major Injury

• Fall Risk tools– When update?

• Fall CAA• Care plan addresses risk factors

– Be clear about what the problem is

• F/U post fall assessment • Immediate Plan• Incident Report Initiated

Investigation Steps



Ensure incident report completed.• Immediate investigation, re-assessment, and care

plan review/revised post-event. • Refer to therapy or restorative as indicated.• Review assessment for underlying cause and care

planning prior to fall to determine if fall or injury might have been avoidable.

• Risk Team review all falls at least weekly.

Investigation Steps




• New interventions on care plan• Post summary note on IDT note in care plan

Investigation Steps


Percent of Long Stay Residents Who

Self-ReportModerate to Severe Pain.



Long Stay - Pain

Percent of Residents Who Self-Report Moderate to Severe Pain.


• Percent of long stay residents who report either (1) almost constant or frequent moderate to severe pain in the last 5 days or (2) any very severe/horrible in the last 5 days.


Long Stay - Pain

• Numerator: most recent MDS – Meets either or both conditions

– Condition #1

• Almost constant or frequent pain (J04001,2) and• At least one episode of moderate to severe pain

(J0600A=05-09 or B=2,3) – Condition #2

• Severe/horrible pain of any frequency (J0600A=10 or B=4)



Long Stay - Pain

• Exclusions:– Excludes 5-day MDS– Excludes Admission Assessment – Incomplete data or not interviewed

• Covariates: Resident Level Adjustment if more

cognitively intact

– In prior assessment; C1000=0,1 (Independent Decision Making) or

– C0500>=13 and C0500<=15 (BIMS)


Long Stay - Pain




Long Stay - Pain

• Investigation

– Same as for short stay Pain



Percent of High Risk Residents

With

Stage 2-4 Pressure Ulcers


Long Stay - Pressure Ulcers

Percent of High Risk Residents With Pressure Ulcers

• The percentage of long stay, high-risk residents with Stage 2-4 pressure ulcers.

• CASPER, NHC, and Impacts 5 Star

• High Risk: Meets one or more of the following criteria:

– Impaired Bed Mobility or Transfer, or (G0110A1 or B1=3, 4, 7, 8 (either or both))

– Comatose (B0100=1), or– Malnutrition/or risk (I5600=1)




• Numerator: Must meet both of the following conditions:– #1 Meets High Risk

– #2 Any of the three:

• M0300B1 > 0• M0300C1 > 0• M0300D1> 0





• Exclusions: – Excludes Admission Assessments – Excludes 5-day MDS– Not high risk with missing data

• Investigation: – Risk assessments and care plan addresses all risks.– Update care plan to new pressure ulcers or worsening

pressure ulcers. – See QA for short stay


Percentage of Residents with Urinary Tract Infections



Long Stay - UTI

Percent of residents with Urinary Tract Infections.

– Percentage of long stay residents who have a urinary tract infection

– CASPER, NHC, and Impacts 5 Star

• Numerator:

– UTI within last 30 days (I2300) • Exclusions:

– Admission Assessment– 5-day MDS


Long Stay - UTI

• Investigation:

– Ensure accurate coding per RAI. – Track and trend through Infection Control

system.



Percentage of Low Risk

Residents Who

Lose Control of Their

Bowel or Bladder


Long Stay -Lose Control Bladder/Bowel

Percent of Low Risk Residents Who Lose Control of Their Bowel or Bladder.

– The percent of long stay residents who frequently lose control of their bowel or bladder.

– CASPER and NHC

• Numerator:

– Frequently or always incontinence of the bladder (H0300 =2, 3) or bowel (H0400 =2, 3).






• Exclusions: – Admission Assessment

– 5-day MDS

– Any of the high risk conditions• Severe cognitive impairment on the target assessment as

indicated by C1000 = 3 (Decision Making) and C0700 = 1(Short Term Memory ) OR C0500 7 (BIMS).

• Totally dependent in bed mobility (G0110A1 = 4, 7, 8).• Totally dependent in transfer (G0110B1 = 4, 7, 8).• Totally dependent in locomotion on unit self-performance

(G0110E1 = 4, 7, 8).




• Exclusions: – Not high risk but missing data C0500 and C0700.– Not high risk and any of the following three

conditions are true: Missing data G0110A1, B1, E1.

– Comatose (B0100)– Indwelling catheter (H0100A = 1 or data missing)– Ostomy (H0100C = 1 or missing data).



• Investigation – Ensure voiding patterns are performed

• If “check and change” ensure all risk factors are documented

– Develop toileting plan/referrals – Ensure toileting plan is implemented– Initial B/B risk assessments– CAA – If resident has an increase in incontinence, perform

voiding pattern and adjust toileting plan.



Percent of Residents Who Have/Had a Catheter Inserted

and Left in Their Bladder


Long Stay - Catheter

Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder.

– The percentage of residents who have had an indwelling catheter in the last 7 days.


• Numerator:

– Indwelling Catheter (H0100A)




• Exclusions:

– Excludes Admission Assessment– Excludes 5-day MDS– Neurogenic Bladder (I1550) – Obstructive Uropathy (I1650)



• Covariates:

– Frequent Bowel Inc. (H0400 = 2, 3) on prior assessment

– Pressure Ulcer Stage 2, 3, or 4 on prior assessment (M0300B1, C1, D1)




Justification:– Urinary retention that cannot be treated or corrected

medically or surgically, for which alternative therapy is not feasible and which is characterized by: • Documented post void residual (PVR) volumes in

a range over 200 milliliters (ml); • Inability to manage retention/incontinence with

intermittent catheterization; and• Persistent overflow incontinence, symptomatic

infections, and/or renal dysfunction.



Justification:– Contamination of Stage 3 or 4 pressure ulcer with

urine which has impeded healing, despite appropriate personal care for the incontinence; and

– Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain.




• Investigation o Physician documentation supports medical

necessity. o Ensure infection control practices are followed.o Ensure dignity is maintained.


Percent of Residents Who Were Physically Restrained



Long Stay - Restraints

Percent of Residents Who Were Physically Restrained.

– The percent of long stay nursing facility residents who are physically restrained on a daily basis.




• Numerator: Coded as Daily Use – trunk restraint used in bed (P0100B = 2), OR – limb restraint used in bed (P0100C = 2), OR – trunk restraint used in chair or out of bed (P0100E

= 2), OR – limb restraint used in chair or out of bed (P0100F =

2), OR – chair prevents rising used in chair or out of bed

(P0100G) = 2).






• Investigation o Assessment doneo Physician orders and consent in place

• Consider Assessment or address in CAA if not restrictive but device in place

o Care plan is current.o Physician orders are followed.o Continue to reduce and ensure least restrictiveNote: QM does not include restrictive side rails.



Percent of Long Stay Residents Whose Need for Help with

Activities of Daily Living has Increased


Long Stay - ADL Decline

Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased.

– The percent of long stay residents whose need for help with late loss Activities of Daily Living (ADLs) has increased when compared to the prior assessment.





• Numerator: Prior assessment is compared to target assessment.

– Decline in one coding point in two or more late loss ADLs – Bed Mobility, Transfers, Eating, Toileting.

Or

– Decline in two or more coding points in one late loss ADL.





• Exclusions: 1. All four late loss ADLs were coded 4, 7, or 8 on

prior MDS 2. Three late loss ADLs were coded 4, 7, or 8, and

the fourth ADL is a “3” on prior MDS3. Comatose (B0100) on Target MDS4. Life Expectancy is less than 6 months (J1400) on

Target MDS5. Hospice (O0100K2) on Target MDS


Long Stay - Independent Mobility Worsened

• Percent residents whose ability to move independently worsened.

• NHC and Impact 5 Star at 50% weight until January 2017, then full weight.

• Calculated by adding up ADL score 0-4 (If coded 7, 8 then counted as “4”) for self performance. – Locomotion on Unit G0110E1



Long Stay - Independent Mobility Worsened - NHC Only

• Measurement Period: Updated quarterly

• Numerator: Long Stay residents who have a decline in locomotion since the prior assessment. Decline is measured by an increase of one or more points between the target and prior assessments.




• Denominator: Long stay residents who have a qualifying MDS target assessment that is not an Admission or 5-day accompanied by at least one qualifying prior assessment.

• Denominator Exclusions:




• Covariates from prior assessment


Long Stay - ADL Decline or Function Worsened

• Investigation o Investigate all residents who trigger this QMo Evaluate coding of Locomotion items for new

Refer to restorative or therapyo Update care plan to declineo Ensure all risk factors are

documentedo Ensure function is unavoidable



Long Stay - ADL Decline or Function Worsened

Investigations:

• Review coding definitions of locomotion on unit.

• QA coding on these new non-RUG related MDS items in Section G.

• If declines coded in Transfer, Locomotion/walking consider referral to therapy/restorative.


Percent of Long Stay Residents Who Lose Too Much Weight



Long Stay - Weight Loss

Percent of Residents Who Lose Too Much Weight.– The percentage of long stay residents who had a

weight loss of 5% or more in the last month or 10% or more in the last two quarters who were not on a physician prescribed weight-loss regimen noted in an MDS assessment during the selected quarter.

– CASPER and NHC



• Numerator:

– Weight loss that is not physician prescribed (K0300=2)

• Exclusion:

– Exclude Admission Assessment – Exclude 5-day MDS






• Investigation o Weights complete and accurateo High risk residents identifiedo Monitor high risk residents with at least a monthly

summary and weekly weightso Any calorie a good calorie o Revise care plan for whether weight loss can or

cannot be minimized.o RD oversight Tube Feedings o Fluids offered



Percent of Residents Who Have Depressive Symptoms


Long Stay - Depression

Percent of Residents Who Have Depressive Symptoms.

– The percentage of long stay residents who have had symptoms of depression during the 2-week period preceding the MDS 3.0 target assessment date.

– CASPER and NHC




• Numerator: • CONDITION A (The resident mood interview must meet

Part 1 and Part 2 below) • PART 1: little interest or pleasure in doing things half or more

of the days over the last two weeks is equal or greater than two (D0200A2 = 2, 3) OR – Feeling down, depressed, or hopeless half or more of the

days over the last two weeks (D0200B2 = 2, 3) • PART 2: The resident interview total severity score indicates the

presence of depression (D0300 10 and D0300 27).





• Numerator:

• CONDITION B: (The staff assessment of resident mood must meet Part 1 and Part 2 below)

• PART 1: Little interest or pleasure in doing things half or more of the days over the last two weeks is equal or greater than two (D0500A2 = 2, 3) OR – Feeling or appearing down, depressed, or hopeless half or

more of the days over the last two weeks (D0500B2 = 2, 3) • PART 2: The staff assessment total severity score indicates the

presence of depression (D0600 10 and D0600 30).





• Exclusions: – Comatose (B0100)



• Investigation – Diagnoses as indicated; if not due to depression then why

symptoms? – Care plan addresses mood issues with both drug and non-

drug interventions.– Ensure referral to mental health specialist as indicated.– Consider Target behaviors for effectiveness of non-drug

interventions.– Appropriate medication management, if not on anti-

depressants, why not?– See Psychoactive Drug Use Investigation.



Long Stay–Antipsychotic Meds

Percent of Residents Who Are Receiving Antipsychotic Drugs


Long Stay–Antipsychotic Meds

The Percentage of residents who are receiving antipsychotic drug.

CASPER, NHC and Impacts 5 Star

Numerator:

N0410A Antipsychotic Meds = 1, 2, 3, 4, 5, 6, or 7



Long Stay – Antipsychotic Meds

Exclusions:• Any of the related conditions are present on target

assessment– Schizophrenia (I6000=1)– Tourette’s Syndrome (I5350=1) on target or prior

MDS– Huntington’s (I5250=1)Ongoing QA: Same as for short stay QM


Short/Long Stay – Antipsychotic Meds

• Investigation – Ensure accurate coding of diagnosis.



– Behavior monitoring in place– Side effect monitoring in place – Pharmacy drug reviews in compliance– High Risk – Residents with diagnosis of dementia.



CASPER Only –Long Stay – Antianxiety/Hypnotic Use

Percentage of residents who are receiving antianxiety or hypnotic but do not have evidence of a psychotic or related condition

Numerator: – Assessments on or after 04.01.12

• N0400B Antianxiety meds = 1, 2, 3, 4, 5, 6, or 7• N0400D Hypnotic meds = 1, 2, 3, 4, 5, 6, or 7





Exclusions:

• Any of the following related conditions are present on target assessment – Schizophrenia (I6000=1)– Psychotic disorder (I5950=1)– Manic Depression (bi-polar) (I5900=1)– Tourette’s Syndrome (I5350=1) on target or prior MDS– Huntington’s (I5250=1)



Exclusions:

• Any of the following related conditions are present on target assessment – Hallucinations (E0100A=1)– Delusions (E0100B=1)– Anxiety disorder (I5700=1)– Post Traumatic Stress Disorder (I6100=1) on target

assessment or prior assessment.



CASPER Only - Long Stay -Antianxiety/Hypnotics

• Investigation– Ensure accurate coding of diagnosis.



– Behavior monitor in place if applies – Side effect monitoring in place– Pharmacy drug reviews in compliance


Long Stay - Antianxiety or Hypnotic Medication - NHC Only

• Percentage of long-stay residents who receive antianxiety or hypnotic medications.

• Will not impact 5 Star Rating.

• Antianxiety med received N0410B (1,2,3,4,5,6,7)• Hypnotic med received N0410D (1,2,3,4,5,6,7)




• Measurement Period: Updated quarterly

• Numerator: Number of long stay residents who receive an antianxiety or hypnotic medication in the target assessment




• Denominator: All long stay residents with a target assessment

• Denominator Exclusion:



CASPER Only –Long Stay – Behavior Symptoms

Percentage of residents who have behavior symptoms that affect others.

Numerator: • Physical Behavior directed towards others (E0200A=1, 2, or 3) • Verbal behaviors directed toward others (E0200B=1, 2, or 3)• Other behaviors directed not toward others (E0200C=1, 2, or

3) • Rejection of Care (E0800= 1, 2, or 3)• Wandering (E0900 = 1, 2, or 3)



Exclusions:

• Target Assessment is Discharge Assessment• Any of the items are blank or dashed




Investigation

• Ensure care plan is current and reflects both drug and non-drug interventions to decrease episodes of behavior.

• What escalates behaviors? • Safety issues care planned • Target behaviors are monitored • Protection of others?


Claims Based Quality Measures

Short Stay



Short Stay, Claims Based QM’s

• Percentage of short stay residents who were successfully discharged to the community.

• Percentage of short stay residents who have had an outpatient emergency department visit.

• Percentage of short stay residents who were re-hospitalized after a nursing home admission.


Claims Based Measures

• Measures are calculated from the claim (UB-04).– Some variables will be from the MDS for Successful

Discharges• Measures use ONLY Traditional Medicare Claims.

– Medicare Advantage enrollees may be included in the future.

• All are short stay measures that only include those residents admitted to the nursing home within 1 day following an inpatient hospitalization.



Discharged to the Community

• Measure uses MDS Assessments to identify community discharges and claims to determine if the discharge was successful. – Was the resident successfully discharged within 100

days of admission to the nursing home.– Successful Discharge: Resident was NOT

hospitalized, readmitted to a nursing home and did not die in the 30 days after discharge.


Discharge to the Community

• Measurement Period: Rolling 12 months. Updated every six months.

• Numerator: The number of SNF stays where there was a successful discharge to the community within 100 days of admission.




Discharge to the Community

• Denominator: All residents admitted to the nursing home within one day of discharge from an inpatient hospitalization.

• Denominator Exclusions: – Medicare Advantage enrollees– Those who were in a nursing home prior to the

hospitalization– Those who enroll in hospice during the observation

period.


Outpatient Emergency Room Visits

• Measure uses the same 30-day timeframe as the re-hospitalization measure and considers all outpatient visits EXCEPT those that result in inpatient admission. • Those are captured by the re-hospitalization measure.

• Data is compiled from Part B Claims for outpatient ER visits.





• Numerator: The number of SNF stays where there was an outpatient ER visit within 30 days of admission, not resulting in an inpatient stay or observation stay





• Denominator Exclusions: Medicare Advantage enrollees



Re-hospitalization Within 30 Days

• Measure uses Part A Claims to identify inpatient readmissions and Part B Claims for observation stays.

• Measure includes re-hospitalizations that occur within 30 days of admission to the nursing home following an acute care inpatient hospitalization. – Includes those who were previously in a nursing home– Includes those who are new admits




• Numerator: The number of SNF stays where the resident was admitted to an acute care facility within 30 days of the SNF admission.

• Numerator Exclusions: Planned re-admissions





• Denominator Exclusions: Medicare Advantage enrollees


Strategies for Claims-Based QMs

• Perform an investigation of all hospital unplanned transfers – ER, inpatient, or observation bed.

• Identify root cause and opportunities for improvement.

• Analyze gap between Observed Rate, Expected Rate, that negatively impacts Risk Adjusted Rate– If a large gap, QA coding of Co-Morbidities on

MDS.



Strategies for Claims-Based QMs

• Review processes for discharging to community to ensure resident/family understands discharge plan and understanding of medications. – Track discharged residents for 30 days after discharge

to community.



• Review Nursing Home Compare to identify high risk areas for next survey.

• Download your QM report • Identify care areas which are triggered at the 75th

percentile or greater.– Review at least monthly by QA– Investigate any triggered QMs

• Review all coding items which impact QM to ensure accurate coding – focus on triggered QMs and new QMs.


Nursing Home Compare Five-Star Ratings of Nursing HomesProvider Rating Report

Incorporating data reported through 06/30/2016

Ratings for Charlestown Community Inc (215223)Catonsville, Maryland

Overall QualityHealth

InspectionQuality

Measures Staffing RN Staffing

The July 2016 Five-Star ratings provided above will be displayed for your nursing home on the Nursing Home Compare website onWednesday, July 27, 2016.

The Quality Measure (QM) Rating that will be posted is based on MDS 3.0 quality measures using data from the second, third and fourthquarters of 2015 and the first quarter of 2016, and claims-based quality measures using data from 7/1/2014 through 6/30/2015.

Quality Measure Ratings will change beginning July 27, 2016 with the addition of the following fivequality measures:

Percentage of short-stay residents who made improvements in function Percentage of long-stay residents whose ability to move independently worsened Percentage of short-stay residents who were re-hospitalized after a nursing home admission Percentage of short-stay residents who have had an outpatient emergency department visit Percentage of short-stay residents who were successfully discharged to the community

Information on the five new quality measures listed above is not yet available on the CASPER reports.

A preview of your facility’s data on these new measures, which will be displayed on Nursing HomeCompare in July 2016, is shown on page 3 of this report. The new measures were not included in yourfacility's Quality Measure rating for June 2016 but are included in July 2016. Prior to the update of theNursing Home Compare website in July, the Technical Users’ Guide will be revised to reflect the changesin the QM rating calculation. Please see page 2 of this report for the link to the Technical Users’ Guide.

Overview of July 2016 Changes to the Quality Measure (QM) Rating Methodology: The QM calculation will now utilize four quarters of data instead of three quarters. The four quarter average for the long-stay ADL QM will be compared to the national average (instead

of the state average) to provide consistency across QMs. Both the short and long-stay QMs will need 20 assessments across the four quarters to be included in

the QM calculation. The imputation strategy has changed (when applicable for low denominators) to utilize the data for the

individual facility and then to impute the remaining assessments to reach 20 assessments across the fourquarters. Please see the updated Technical Users’ Guide for more detailed information.

In July 2016, the five new QMs that were added to the QM rating are given half the weight of the otherfive-star QMs, that is, they will receive 10 to 50 points for each measure. In January 2017, the weights ofthe new measures will increase to be 100% (receiving 20 to 100 points for each measure).

Charlestown Community Inc (215223)Catonsville, Maryland


STAFFING DATA SUBMISSION IS NOW MANDATORY!

Beginning in July 2016, all Medicare- and Medicaid-participating nursing homes must submit staffingdata to CMS through a new electronic system called the Payroll-based Journal (PBJ).

Follow these steps to submit staffing here (NOTE: you must log in to the CMSNET to get access to theregistration sites below). For access to CMSNET, please visit this site: https://www.qtso.com/cmsnet.html

Step 1: Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don’talready have one for other QIES applications (https://www.qtso.com/cmsnet.html) (many users mayalready have this access for MDS submission).

Step 2: Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access.(https://mds.qiesnet.org/mds_home.html)

Training: PBJ Training Modules for an introduction to the PBJ system and step by step registrationinstruction are available on QTSO e-University, select the PBJ option.(https://www.qtso.com/webex/qiesclasses.php)

More information about staffing data submission is available at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

For additional assistance with or questions related to PBJ registration process, please contact the QTSOHelp Desk at 877-201-4721 or via email at [email protected].

----------------------------------------------------------------------------The Five-Star Helpline will operate Monday - Friday, for two weeks from July 25, 2016 - August 5, 2016.Hours of operation will be from 9 am - 5 pm ET, 8 am - 4 pm CT, 7 am - 3 pm MT, and 6 am - 2 pm PT.The Helpline number is 1-800-839-9290. The Helpline will be available again for two weeks August22-August 26, and August 29-September 2, 2016. During other times, direct inquiries [email protected], as Helpline staff will respond to e-mail inquiries when the telephone Helplineis not operational.

----------------------------------------------------------------------------The Technical Users' Guide and other information on the Five-Star Quality Rating System can be foundin the Downloads section on the CMS website. Go tohttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.html

Detailed descriptions and specifications for the MDS-based QMs can be found in the MDS 3.0 QM User’sManual located in the downloads section at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html

Detailed descriptions and specifications for the claims-based QMs are available in the downloads sectionon the CMS website at:http://www.cms.gov/Medicare/Provider-Enrollment-and-certification/CertificationandComplianc/FSQRS.html

Nursing home data are available for download at https://data.medicare.gov/data/nursing-home-compare

----------------------------------------------------------------------------Important information on the Skilled Nursing Facility Value Based Purchasing Program andConfidential Feedback Quarterly Reports is available on the last page of this provider preview.


Quality Measures that are Included in the QM RatingQuality Measures that are Included in the QM Rating

Provider 215223 State National

2015Q2 2015Q3 2015Q4 2016Q1 4Q avgRatingPoints1 4Q avg 4Q avg

MDS 3.0 Long-Stay MeasuresLower percentages are better.

Percentage of residents experiencingone or more falls with major injury

3.5% 5.3% 5.5% 6.6% 5.2% 20.00 2.9% 3.3%

Percentage of residents who self-reportmoderate to severe pain2

2.6% 0.0% 0.0% 1.0% 0.9% 100.00 6.4% 8.2%

Percentage of high-risk residents withpressure ulcers

9.2% 1.9% 2.8% 3.8% 4.3% 80.00 6.8% 5.8%

Percentage of residents with a urinarytract infection

3.5% 0.0% 0.9% 1.7% 1.5% 100.00 4.5% 4.8%

Percentage of residents with a catheterinserted and left in their bladder2

1.0% 0.9% 0.0% 0.0% 0.5% 100.00 2.5% 3.0%

Percentage of residents who werephysically restrained

0.0% 0.0% 0.0% 0.0% 0.0% 100.00 0.6% 0.8%

Percentage of residents whose need forhelp with daily activities has increased

17.6% 17.0% 13.1% 17.1% 16.2% 60.00 18.7% 15.4%

Percentage of residents who received anantipsychotic medication

9.8% 8.9% 11.3% 7.6% 9.4% 80.00 14.1% 17.3%

Percentage of residents whose abilityto move independently worsened2,3

14.1% 18.8% 13.9% 32.9% 19.8% 20.00 22.3% 18.2%

MDS 3.0 Short-Stay MeasuresHigher percentages are better.

Percentage of residents who madeimprovements in function2,3

84.2% 75.2% 74.3% 76.2% 77.6% 40.00 64.8% 63.0%

Lower percentages are better.

Percentage of residents who self-reportmoderate to severe pain

8.5% 6.0% 6.0% 2.8% 5.5% 100.00 14.2% 16.7%

Percentage of residents with pressureulcers that are new or worsened2

1.3% 0.9% 0.6% 0.6% 0.9% 50.00 1.3% 1.2%

Percentage of residents who newlyreceived an antipsychotic medication

0.5% 0.5% 0.5% 1.1% 0.7% 80.00 2.2% 2.2%

Time period for data used in reporting is7/1/2014 through 6/30/2015 Provider 215223 State National

Observed

Rate4Expected

Rate5

Risk-Adjusted

Rate6RatingPoints1

Risk-Adjusted

Rate

Risk-Adjusted

Rate

Claims-Based MeasuresA higher percentage is better.

Percentage of residents who weresuccessfully discharged to thecommunity2,3

64.6% 58.9% 58.8% 40.00 55.2% 50.7%

Lower percentages are better.

Percentage of residents who werere-hospitalized after a nursing homeadmission2,3

14.7% 18.2% 17.4% 40.00 21.0% 21.1%

Percentage of residents who had anoutpatient emergency department visit2,3

4.8% 9.3% 5.7% 40.00 9.8% 11.5%

Total Quality Measure Points

Total QM points with new quality measures weighted 50% for Provider 215223 1050.00


MDS3.0 Quality Measures that are Not Included in the QM RatingMDS3.0 Quality Measures that are Not Included in the QM Rating

Provider 215223 State National 2015Q2 2015Q3 2015Q4 2016Q1 4Q avg 4Q avg 4Q avgNote: For the following long-stay MDS measures,higher percentages are better.

Percentage of long-stay residents assessed andappropriately given the seasonal influenza vaccine

98.6% 98.6% 98.6% 96.2% 98.0% 95.0% 94.5%

Percentage of long-stay residents assessed andappropriately given the pneumococcal vaccine

96.5% 98.2% 90.6% 91.8% 94.1% 92.2% 93.4%

Note: for the following long-stay MDS measures,lower percentages are better.

Percentage of low-risk long-stay residents wholose control of their bowels or bladder

78.4% 90.5% 88.6% 80.0% 84.7% 58.0% 46.6%

Percentage of long-stay residents who lose toomuch weight

8.3% 10.0% 11.2% 9.0% 9.6% 6.3% 7.1%

Percentage of long-stay residents who havedepressive symptoms

1.9% 1.8% 1.7% 2.6% 2.0% 4.8% 5.4%

Percentage of long-stay residents who receivedan antianxiety or hypnotic medication

10.6% 10.3% 8.0% 12.0% 10.2% 18.3% 23.6%

Note: For the following short-stay MDS measures,higher percentages are better.

Percentage of short-stay residents assessed andappropriately given the seasonal influenza vaccine

85.5% 85.5% 85.5% 66.9% 80.2% 82.4% 80.1%

Percentage of short-stay residents assessed andappropriately given the pneumococcal vaccine

96.0% 70.2% 55.2% 60.7% 70.4% 81.1% 81.4%

The claims-based QMs will update every six months, while the MDS based QMs continue to update on a quarterlybasis.

For individual quarters for the MDS-based QMs, d<20 means the denominator for the measure (the number ofeligible resident assessments) is too small to report. When d<20 is listed for individual quarters, a four quarteraverage may be displayed if there are at least 20 eligible resident assessments summed across the four quarters.

Quality measures are reported as NA if: for measures not included in the QM rating, no data are available, or the total number of eligible resident

assessments summed across the four quarters is less than 20; for measures included in the QM rating, data on this measure for your facility are not used in the calculation of

your QM rating. This will happen if your facility does not have enough short-stay or long-stay measures upon whichto base your rating and may occur even though your facility's data for this measure may be reported on NursingHome Compare.1If the four quarter average for your facility is NA for a given QM, but rating points are provided for the QM, then there wereinsufficient data to compute a four-quarter average, and the points provided are based on the average points from other measuresfor which data are available according to the scoring rules described in detail in the Technical Users’ Guide at:http://www.cms.gov/Medicare/Provider-Enrollment-and-certification/CertificationandComplianc/FSQRS.html

2These measures are risk adjusted.

3This is one of the new QMs, first reported on Nursing Home Compare in April 2016. The new QMs that are included in the QMrating can contribute half the number of points (10-50 points for each individual QM) compared to 20-100 points for the other QMsincluded in the QM rating.

4The observed rate is the actual rate observed for the facility without any risk-adjustment.

5The expected rate is the rate that would be expected for the facility given the risk-adjustment profile of the facility.

6Risk-adjusted rate is adjusted for the expected rate of the outcome and is calculated as (observed rate for facility / expected ratefor facility) * national average of observed rate. Only the risk-adjusted rate will appear on Nursing Home Compare.

7This measure includes some imputed data because there are fewer than 20 resident assessments or stays across the fourquarters. This value is used in calculating the QM points and used in the QM rating calculation but will not be displayed on NursingHome Compare.


Physical Therapy Staffing for your nursing home is 8 minutes per resident per day. The nationalaverage for physical therapy staffing is 6 minutes per resident per day.

*****************************************************************************************************************Nursing Home Statement(s) of Deficiencies (CMS 2567) for your nursing home will be posted forsurveys that took place on the following date(s). This includes both standard surveys and complaints.Dates of surveys without deficiencies are not listed.

February 15, 2013March 10, 2014April 23, 2015

*****************************************************************************************************************Ownership Information. The list below shows all individuals or organizations with a 5 percent or more(direct or indirect) ownership interest in your nursing home that are listed on Nursing Home Compare. This information was supplied on Form CMS-855A. We include individuals listed as owners, directors,officers, partners, or those with managerial control. For direct and indirect owners only, the percentageownership is also listed. If the listing indicates 'Ownership Information Not Available', this is becauseCMS does not currently have ownership information for your nursing home.

The legal business name for Charlestown Community Inc is CHARLESTOWN COMMUNITY, INC.

OPERATIONAL/MANAGERIAL CONTROLERICKSON LIVING MANAGEMENT LLC, since 04/30/2010

DIRECTORBANKOSKI, VINSON, since 05/21/2009BARNES, RICHARD, since 11/06/2008BASHAM, JAMES, since 03/19/2015BROWN, CHARLES, since 09/02/2009BURNETT, JANICE, since 08/02/2012COONEY, DAVID, since 03/30/2006DENTON, CHARLES, since 09/12/2013GAMBLE, CHARLES, since 02/05/2007GANTERT, NEAL, since 04/30/2010GROVE, RICHARD, since 03/30/2006IVEY, LENWOOD, since 06/12/1997MAUSER, JAMES, since 11/04/2015MCAFEE, NAOMI, since 08/15/2010MOORE, DANIEL, since 04/22/2013MOORE, ROBIN, since 12/11/2015OSTROFF, LAURA, since 02/02/2013PARKER, CLARA, since 08/13/2012PHIPPS, BONNIE, since 08/15/2010POLLAK, JOANNE, since 03/30/1990SMITH, SUSAN, since 05/14/2015WEIGMAN, MARK, since 02/02/2013

OFFICERBANKOSKI, VINSON, since 04/30/2010BASHAM, JAMES, since 03/19/2015GAMBLE, CHARLES, since 03/30/1990GANTERT, NEAL, since 09/06/2012GROVE, RICHARD, since 03/30/2006

for Charlestown Community Inc is CHARLESTOWN COMMUNITY, INC.The legal business name

OPERATIONAL/MANAGERIAL CONTROLERICKSON LIVING MANAGEMENT LLC, since 04/30/2010

DIRECTORBANKOSKI, VINSON, since 05/21/2009BARNES, RICHARD, since 11/06/2008BASHAM, JAMES, since 03/19/2015BROWN, CHARLES, since 09/02/2009BURNETT, JANICE, since 08/02/2012COONEY, DAVID, since 03/30/2006DENTON, CHARLES, since 09/12/2013GAMBLE, CHARLES, since 02/05/2007GANTERT, NEAL, since 04/30/2010GROVE, RICHARD, since 03/30/2006IVEY, LENWOOD, since 06/12/1997MAUSER, JAMES, since 11/04/2015MCAFEE, NAOMI, since 08/15/2010MOORE, DANIEL, since 04/22/2013MOORE, ROBIN, since 12/11/2015OSTROFF, LAURA, since 02/02/2013PARKER, CLARA, since 08/13/2012PHIPPS, BONNIE, since 08/15/2010POLLAK, JOANNE, since 03/30/1990SMITH, SUSAN, since 05/14/2015WEIGMAN, MARK, since 02/02/2013

OFFICERB VINSON, since 04/30/2010BANKOSKI, BASHAM, JAMES, since 03/19/2015GAMBLE, CHARLES, since 03/30/1990GANTERT, NEAL, since 09/06/2012GROVE, RICHARD, since 03/30/2006


MOORE, ROBIN, since 12/11/2015PARKER, CLARA, since 09/06/2012SMITH, SUSAN, since 05/14/2015

MANAGING EMPLOYEEBANKOSKI, VINSON, since 04/30/2010BASHAM, JAMES, since 03/19/2015GANTERT, NEAL, since 04/30/2010MATTHIESEN, TODD, since 06/15/2010MOORE, ROBIN, since 12/11/2015PARKER, CLARA, since 08/13/2012WILSON, MICHAEL, since 06/11/2012YOUNG, STEPHANIE, since 03/04/2014

If you believe this information is incorrect, go to https://pecos.cms.hhs.gov or call the PECOS helpline at1-866-484-8049.

MOORE, ROBIN, since 12/11/2015PARKER, CLARA, since 09/06/2012SMITH, SUSAN, since 05/14/2015

MANAGING EMPLOYEEBANKOSKI, VINSON, since 04/30/2010BASHAM, JAMES, since 03/19/2015GANTERT, NEAL, since 04/30/2010MATTHIESEN, TODD, since 06/15/2010MOORE, ROBIN, since 12/11/2015PARKER, CLARA, since 08/13/2012WILSON, MICHAEL, since 06/11/2012YOUNG, STEPHANIE, since 03/04/2014


Information on the Skilled Nursing Facility Value Based Purchasing Program and ConfidentialFeedback Quarterly Reports Beginning October 2016

Section 215 of the Protecting Access to Medicare Act (PAMA) of 2014 (P.L. 113-93) added sections1888(g) and (h) to the Social Security Act (the Act), and authorizes the Secretary of the U.S. Departmentof Health and Human Services to implement the Skilled Nursing Facility Value Based Purchasing (SNFVBP) Program beginning with claims paid in fiscal year (FY) 2019. Section 1888(g)(5) of the Act furtherrequires that the Secretary begin providing quarterly confidential feedback reports to SNFs on theirperformance on the measure specified under the SNF VBP Program beginning on October 1, 2016.

CMS will furnish quarterly confidential reports via CASPER beginning October 1, 2016. The SkilledNursing Facility 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510) adopted for the SNFVBP Program is a different measure than that currently reported on Nursing Home Compare. Additionalinformation regarding the SNF VBP Program and SNFRM can be found on the CMS website at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html


CASPER ReportMDS 3.0 Facility Characteristics Report

Page 1 of 1

Facility ID: 03063CCN: 215223Facility Name: CHARLESTOWN COMMUNITY INCCity/State: CATONSVILLE, MDData was calculated on: 07/04/2016

Report Period: 06/01/16 - 06/30/16Comparison Group: 11/01/15- 04/30/16Run Date: 07/06/16Report Version Number: 1.00

Facility Comparison Group

Num DenomObservedPercent

StateAverage

NationalAverage

Gender

Male 57 232 24.6% 38.0% 37.4%Female 175 232 75.4% 62.0% 62.6%

Age

<25 years old 0 232 0.0% 0.2% 0.4%25-54 years old 0 232 0.0% 6.9% 5.6%55-64 years old 0 232 0.0% 12.1% 10.8%65-74 years old 15 232 6.5% 19.7% 18.9%75-84 years old 48 232 20.7% 26.0% 27.5%85+ years old 169 232 72.8% 35.2% 36.8%

Diagnostic Characteristics

Psychiatric diagnosis 83 232 35.8% 48.6% 56.0%Intellectual or Developmental Disability 0 161 0.0% 0.7% 1.4%Hospice 9 232 3.9% 3.5% 6.1%

Prognosis

Life expectancy of less than 6 months 9 232 3.9% 2.8% 4.7%

Discharge Plan

Not already occurring 105 231 45.5% 47.2% 61.0%Already occurring 126 231 54.5% 52.8% 39.0%

Referral

Not needed 216 217 99.5% 88.1% 89.4%Is or may be needed but not yet made 0 217 0.0% 3.1% 3.3%Has been made 1 217 0.5% 8.8% 7.2%

Type of Entry

Admission 191 232 82.3% 74.0% 70.2%Reentry 41 232 17.7% 26.0% 29.8%

Entered Facility From

Community 43 232 18.5% 6.9% 10.0%Another nursing home 2 232 0.9% 3.2% 6.3%Acute Hospital 187 232 80.6% 87.6% 79.8%Psychiatric Hospital 0 232 0.0% 1.0% 2.0%Inpatient Rehabilitation Facility 0 232 0.0% 0.4% 0.6%ID/DD facility 0 232 0.0% 0.0% 0.0%Hospice 0 232 0.0% 0.3% 0.3%Long Term Care Hospital 0 232 0.0% 0.1% 0.3%Other 0 232 0.0% 0.5% 0.6%

This report may contain privacy protected data and should not be released to the public.

21522303063

CHARLESTOWN COMMUNITY INCCATONSVILLE, MD


CASPER ReportMDS 3.0 Facility Level Quality Measure Report

Page 1 of 1

Facility ID: 03063CCN: 215223Facility Name: CHARLESTOWN COMMUNITY INCCity/State: CATONSVILLE, MDData was calculated on: 07/04/2016

Report Period: 06/01/16 - 06/30/16Comparison Group: 11/01/15- 04/30/16Run Date: 07/06/16Report Version Number: 2.00

Note: Dashes represent a value that could not be computedNote: S = short stay, L = long stayNote: I = incomplete; data not available for all days selectedNote: * is an indicator used to identify that the measure is flagged

Measure DescriptionCMS

ID Data Num Denom

FacilityObservedPercent

FacilityAdjustedPercent

ComparisonGroupState

Average

ComparisonGroup

NationalAverage

ComparisonGroup

NationalPercentile

SR Mod/Severe Pain (S) N001.01 14 108 13.0% 13.0% 13.6% 16.0% 47

SR Mod/Severe Pain (L) N014.02 1 97 1.0% 1.0% 6.1% 7.6% 20

Hi-risk Pres Ulcer (L) N015.01 4 99 4.0% 4.0% 7.9% 6.4% 35

New/worse Pres Ulcer (S) N002.02 0 110 0.0% 0.0% 1.2% 1.2% 0

Phys restraints (L) N027.01 0 121 0.0% 0.0% 0.5% 0.7% 0

Falls (L) N032.01 66 121 54.5% 54.5% 43.1% 45.0% 74

Falls w/Maj Injury (L) N013.01 4 121 3.3% 3.3% 2.9% 3.4% 56

Antipsych Med (S) N011.01 0 62 0.0% 0.0% 2.0% 2.3% 0

Antipsych Med (L) N031.02 10 119 8.4% 8.4% 14.2% 16.7% 20

Antianxiety/Hypnotic (L) N033.01 5 88 5.7% 5.7% 7.2% 8.8% 41

Behav Sx affect Others (L) N034.01 10 119 8.4% 8.4% 18.6% 22.7% 18

Depress Sx (L) N030.01 4 115 3.5% 3.5% 4.8% 5.6% 62

UTI (L) N024.01 1 111 0.9% 0.9% 4.5% 4.6% 21

Cath Insert/Left Bladder (L) N026.02 3 111 2.7% 1.9% 2.7% 3.2% 38

Lo-Risk Lose B/B Con (L) N025.01 38 49 77.6% 77.6% 57.9% 46.8% 94 *Excess Wt Loss (L) N029.01 7 103 6.8% 6.8% 7.2% 8.0% 44

Incr ADL Help (L) N028.01 6 98 6.1% 6.1% 19.1% 15.9% 11

This report may contain privacy protected data and should not be released to the public.

: 03063: 215223

CHARLESTOWN COMMUNITY INCCATONSVILLE, MD


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