FH16 - Developed by Polaris Group Page 1 of 140

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2 FH16 - Developed by Polaris Group Page 1 of 140

3 FH16 - Developed by Polaris Group Page 2 of 140

4 FH16 - Developed by Polaris Group Page 3 of 140

5 MDS 3.0 Quality Measures 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 FH16 - Developed by Polaris Group Page 4 of 140

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8 CASPER QMs Review Reports: See draft sample: Facility characteristics Facility QM report Resident Level QM report Facility Characteristics FH16 - Developed by Polaris Group Page 7 of 140

9 Resident Level Summary Resident ID Type 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) FH16 - Developed by Polaris Group Page 8 of 140

10 Resident Level Summary for each QM assigned to that resident s MDS b same as blank Quality Measure Count - Adds up total number of QMs for that MDS FH16 - Developed by Polaris Group Page 9 of 140

11 Traditional Survey Pre-select Residents Surveyors will survey all QMs which are triggered at the 75 th 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 FH16 - Developed by Polaris Group Page 10 of 140

12 Which MDS are used to calculate QMs? Glossary of Terms MDS 3.0 Quality Measures Glossary 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 FH16 - Developed by Polaris Group Page 11 of 140

13 MDS 3.0 Quality Measures Glossary of Terms 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. FH16 - Developed by Polaris Group Page 12 of 140

14 Target Date MDS 3.0 Quality Measures Glossary of Terms 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. FH16 - Developed by Polaris Group Page 13 of 140

15 Assessment Types SHORT STAY Target Assessments: All OBRA Assessments All scheduled PPS MDS Discharge Assessments Initial Assessments: Admission 5-day MDS Discharge 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. FH16 - Developed by Polaris Group Page 14 of 140

16 Covariate Impact: Glossary of Terms 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 facilitylevel expected score and the facility-level observed score. FH16 - Developed by Polaris Group Page 15 of 140

17 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. FH16 - Developed by Polaris Group Page 16 of 140

18 Short Stay Quality Measures Percent of Short Stay Residents Who Self-Report Moderate to Severe Pain. FH16 - Developed by Polaris Group Page 17 of 140

19 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) FH16 - Developed by Polaris Group Page 18 of 140

20 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. FH16 - Developed by Polaris Group Page 19 of 140

21 Assessment and Care Planning Investigation Steps Pain Screens Pain Assessment Pain CAA Daily/every shift Pain Scale PRN versus routine Non-drug interventions Pharmacy review Weekly/Monthly Risk Reviews Percent of Short Stay Residents with Pressure Ulcers that are New or Worsened. FH16 - Developed by Polaris Group Page 20 of 140

22 Short Stay Worsened Pressure Ulcer Percent of Residents with Pressure Ulcers that are New or Worsened. CASPER, NHC, and Impacts 5 Star Percent of short stay residents with new or worsening Stage 2 4 Pressure Ulcers. Short Stay Worsened Pressure Ulcer 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, FH16 - Developed by Polaris Group Page 21 of 140

23 Short Stay Worsened Pressure Ulcer FH16 - Developed by Polaris Group Page 22 of 140

24 Short Stay Worsened Pressure Ulcer 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 Index Must have the Comprehensive Initial Assessment to calculate all covariates. Assessment and Care Planning Investigation Steps Risk Score Additional risk factors Admission care plan CAA Weekly body checks Aide and nurse Ongoing Care plan At time of new/repeat PU FH16 - Developed by Polaris Group Page 23 of 140

25 Short Stay Worsened Pressure Ulcer 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. Seasonal Influenza Vaccine FH16 - Developed by Polaris Group Page 24 of 140

26 Short Stay and Long Stay Flu NHC 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 Flu NHC 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. FH16 - Developed by Polaris Group Page 25 of 140

27 Short Stay/Long Stay Flu NHC 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. FH16 - Developed by Polaris Group Page 26 of 140

28 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. Short Stay and Long Stay Pneumococcal NHC only 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). FH16 - Developed by Polaris Group Page 27 of 140

29 Short Stay and Long Stay Pneumococcal NHC only Investigation: Immunization NHC only 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. FH16 - Developed by Polaris Group Page 28 of 140

30 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 FH16 - Developed by Polaris Group Page 29 of 140

31 Short Stay Antipsychotic Meds 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. FH16 - Developed by Polaris Group Page 30 of 140

32 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]) Tourette s Syndrome (I5350 = [1]) Huntington s Disease (I5250 = [1]). 2. The resident s initial assessment indicates antipsychotic medication use or antipsychotic medication use is unknown (blank/dashes) Short Stay Antipsychotic Meds 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. FH16 - Developed by Polaris Group Page 31 of 140

33 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) FH16 - Developed by Polaris Group Page 32 of 140

34 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 Short Stay - Improvement in Function NHC Only 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 FH16 - Developed by Polaris Group Page 33 of 140

35 Short Stay - Improvement in Function NHC Only 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 Short Stay - Improvement in Function NHC Only 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: FH16 - Developed by Polaris Group Page 34 of 140

36 Short Stay - Improvement in Function - NHC Only Covariates from 5-day/admission MDS Investigation: Short Stay - Improvement in Function - NHC Only 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. FH16 - Developed by Polaris Group Page 35 of 140

37 Long Stay Quality Measures Percent of Residents Experiencing One or More Falls with Major Injury. FH16 - Developed by Polaris Group Page 36 of 140

38 Long Stay - Fall with Major Injury Percent of Residents Experiencing One or More Falls with Major Injury. CASPER, NHC, and Impacts 5 Star 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 FH16 - Developed by Polaris Group Page 37 of 140

39 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 MDS J0800 Fall = 1 Yes No exclusions CASPER Only Long Stay - Falls FH16 - Developed by Polaris Group Page 38 of 140

40 Fall Risk tools Long Stay - Falls/ with Major Injury Investigation Steps 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 Long Stay - Falls/ with Major Injury 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. FH16 - Developed by Polaris Group Page 39 of 140

41 Long Stay - Falls/ with Major Injury Investigation Steps New interventions on care plan Post summary note on IDT note in care plan Percent of Long Stay Residents Who Self-Report Moderate to Severe Pain. FH16 - Developed by Polaris Group Page 40 of 140

42 Long Stay - Pain Percent of Residents Who Self-Report Moderate to Severe Pain. CASPER, NHC, and Impacts 5 Star 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) FH16 - Developed by Polaris Group Page 41 of 140

43 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 FH16 - Developed by Polaris Group Page 42 of 140

44 Long Stay - Pain Investigation Same as for short stay Pain FH16 - Developed by Polaris Group Page 43 of 140

45 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) FH16 - Developed by Polaris Group Page 44 of 140

46 Long Stay - Pressure Ulcers Numerator: Must meet both of the following conditions: #1 Meets High Risk #2 Any of the three: M0300B1 > 0 M0300C1 > 0 M0300D1> 0 FH16 - Developed by Polaris Group Page 45 of 140

47 Long Stay - Pressure Ulcers 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 FH16 - Developed by Polaris Group Page 46 of 140

48 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. FH16 - Developed by Polaris Group Page 47 of 140

49 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). FH16 - Developed by Polaris Group Page 48 of 140

50 Long Stay - Lose Control Bladder/Bowel Long Stay - Lose Control Bladder/Bowel 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 C (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). FH16 - Developed by Polaris Group Page 49 of 140

51 Long Stay - Lose Control Bladder/Bowel 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). Long Stay - Lose Control Bladder/Bowel 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. FH16 - Developed by Polaris Group Page 50 of 140

52 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. CASPER, NHC, and Impacts 5 Star Numerator: Indwelling Catheter (H0100A) FH16 - Developed by Polaris Group Page 51 of 140

53 Long Stay - Catheter Exclusions: Excludes Admission Assessment Excludes 5-day MDS Neurogenic Bladder (I1550) Obstructive Uropathy (I1650) Long Stay - Catheter Covariates: Frequent Bowel Inc. (H0400 = 2, 3) on prior assessment Pressure Ulcer Stage 2, 3, or 4 on prior assessment (M0300B1, C1, D1) FH16 - Developed by Polaris Group Page 52 of 140

54 Long Stay - Catheter 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. Long Stay - Catheter 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. FH16 - Developed by Polaris Group Page 53 of 140

55 Long Stay - Catheter Investigation o o o Physician documentation supports medical necessity. Ensure infection control practices are followed. Ensure dignity is maintained. Percent of Residents Who Were Physically Restrained FH16 - Developed by Polaris Group Page 54 of 140

56 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. CASPER, NHC, and Impacts 5 Star Long Stay - Restraints 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). FH16 - Developed by Polaris Group Page 55 of 140

57 Long Stay - Restraints Long Stay - Restraints Investigation o Assessment done o 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 restrictive Note: QM does not include restrictive side rails. FH16 - Developed by Polaris Group Page 56 of 140

58 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. CASPER, NHC, and Impacts 5 Star FH16 - Developed by Polaris Group Page 57 of 140

59 Long Stay - ADL Decline 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. FH16 - Developed by Polaris Group Page 58 of 140

60 Long Stay - ADL Decline 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 MDS 3. Comatose (B0100) on Target MDS 4. Life Expectancy is less than 6 months (J1400) on Target MDS 5. 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 FH16 - Developed by Polaris Group Page 59 of 140

61 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. Numerator Exclusions: None Long Stay - Independent Mobility Worsened 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: FH16 - Developed by Polaris Group Page 60 of 140

62 Long Stay - Independent Mobility Worsened Covariates from prior assessment Long Stay - ADL Decline or Function Worsened Investigation o Investigate all residents who trigger this QM o Evaluate coding of Locomotion items for new Refer to restorative or therapy o Update care plan to decline o Ensure all risk factors are documented o Ensure function is unavoidable FH16 - Developed by Polaris Group Page 61 of 140

63 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 FH16 - Developed by Polaris Group Page 62 of 140

64 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 Long Stay - Weight Loss Numerator: Weight loss that is not physician prescribed (K0300=2) Exclusion: Exclude Admission Assessment Exclude 5-day MDS FH16 - Developed by Polaris Group Page 63 of 140

65 Long Stay - Weight Loss Long Stay - Weight Loss Investigation o Weights complete and accurate o High risk residents identified o Monitor high risk residents with at least a monthly summary and weekly weights o 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 FH16 - Developed by Polaris Group Page 64 of 140

66 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 FH16 - Developed by Polaris Group Page 65 of 140

67 Long Stay - Depression 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 (D and D ). FH16 - Developed by Polaris Group Page 66 of 140

68 Numerator: Long Stay - Depression 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 (D and D ). FH16 - Developed by Polaris Group Page 67 of 140

69 Long Stay - Depression Exclusions: Comatose (B0100) Investigation Long Stay - Depression Diagnoses as indicated; if not due to depression then why symptoms? Care plan addresses mood issues with both drug and nondrug interventions. Ensure referral to mental health specialist as indicated. Consider Target behaviors for effectiveness of non-drug interventions. Appropriate medication management, if not on antidepressants, why not? See Psychoactive Drug Use Investigation. FH16 - Developed by Polaris Group Page 68 of 140

70 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 FH16 - Developed by Polaris Group Page 69 of 140

71 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. 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 monitoring in place Side effect monitoring in place Pharmacy drug reviews in compliance High Risk Residents with diagnosis of dementia. FH16 - Developed by Polaris Group Page 70 of 140

72 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 N0400B Antianxiety meds = 1, 2, 3, 4, 5, 6, or 7 N0400D Hypnotic meds = 1, 2, 3, 4, 5, 6, or 7 FH16 - Developed by Polaris Group Page 71 of 140

73 CASPER Only Long Stay Antianxiety/Hypnotic Use 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) CASPER Only Long Stay Antianxiety/Hypnotic Use 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. FH16 - Developed by Polaris Group Page 72 of 140

74 CASPER Only - Long Stay - Antianxiety/Hypnotics 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 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) FH16 - Developed by Polaris Group Page 73 of 140

75 Long Stay - Antianxiety or Hypnotic Medication - NHC Only Measurement Period: Updated quarterly Numerator: Number of long stay residents who receive an antianxiety or hypnotic medication in the target assessment Numerator Exclusions: None Long Stay - Antianxiety or Hypnotic Medication - NHC Only Denominator: All long stay residents with a target assessment Denominator Exclusion: FH16 - Developed by Polaris Group Page 74 of 140

76 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) CASPER Only Long Stay Behavior Symptoms Exclusions: Target Assessment is Discharge Assessment Any of the items are blank or dashed FH16 - Developed by Polaris Group Page 75 of 140

77 CASPER Only Long Stay Behavior Symptoms 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 FH16 - Developed by Polaris Group Page 76 of 140

78 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 rehospitalized 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. FH16 - Developed by Polaris Group Page 77 of 140

79 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. Numerator Exclusions: None FH16 - Developed by Polaris Group Page 78 of 140

80 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. FH16 - Developed by Polaris Group Page 79 of 140

81 Outpatient Emergency Room Visits Measurement Period: Rolling 12 months. Updated every six months. 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 Numerator Exclusions: None Outpatient Emergency Room Visits Denominator: All residents admitted to the nursing home within one day of discharge from an inpatient hospitalization. Denominator Exclusions: Medicare Advantage enrollees FH16 - Developed by Polaris Group Page 80 of 140

82 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 Re-hospitalization Within 30 Days Measurement Period: Rolling 12 months. Updated every six months. 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 FH16 - Developed by Polaris Group Page 81 of 140

83 Re-hospitalization Within 30 Days Denominator: All residents admitted to the nursing home within one day of discharge from an inpatient hospitalization. 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. FH16 - Developed by Polaris Group Page 82 of 140

84 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. MDS 3.0 Quality Measures Review Nursing Home Compare to identify high risk areas for next survey. Download your QM report Identify care areas which are triggered at the 75 th 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. FH16 - Developed by Polaris Group Page 83 of 140

85 Nursing Home Compare Five-Star Ratings of Nursing Homes Provider Rating Report Incorporating data reported through 06/30/2016 Overall Quality Ratings for Charlestown Community Inc (215223) Catonsville, Maryland Health Inspection Quality 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 on Wednesday, July 27, The Quality Measure (QM) Rating that will be posted is based on MDS 3.0 quality measures using data from the second, third and fourth quarters 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 five quality 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 Home Compare in July 2016, is shown on page 3 of this report. The new measures were not included in your facility's Quality Measure rating for June 2016 but are included in July Prior to the update of the Nursing Home Compare website in July, the Technical Users Guide will be revised to reflect the changes in 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 four quarters. 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 other five-star QMs, that is, they will receive 10 to 50 points for each measure. In January 2017, the weights of the new measures will increase to be 100% (receiving 20 to 100 points for each measure). FH16 - Developed by Polaris Group Page 84 of 140

86 STAFFING DATA SUBMISSION IS NOW MANDATORY! Beginning in July 2016, all Medicare- and Medicaid-participating nursing homes must submit staffing data 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 the registration sites below). For access to CMSNET, please visit this site: Step 1: Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don t already have one for other QIES applications ( (many users may already have this access for MDS submission). Step 2: Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access. ( Training: PBJ Training Modules for an introduction to the PBJ system and step by step registration instruction are available on QTSO e-university, select the PBJ option. ( More information about staffing data submission is available at: For additional assistance with or questions related to PBJ registration process, please contact the QTSO Help Desk at or via at help@qtso.com The Five-Star Helpline will operate Monday - Friday, for two weeks from July 25, August 5, 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 The Helpline will be available again for two weeks August 22-August 26, and August 29-September 2, During other times, direct inquiries to BetterCare@cms.hhs.gov, as Helpline staff will respond to inquiries when the telephone Helpline is not operational The Technical Users' Guide and other information on the Five-Star Quality Rating System can be found in the Downloads section on the CMS website. Go to Detailed descriptions and specifications for the MDS-based QMs can be found in the MDS 3.0 QM User s Manual located in the downloads section at: Detailed descriptions and specifications for the claims-based QMs are available in the downloads section on the CMS website at: Nursing home data are available for download at Important information on the Skilled Nursing Facility Value Based Purchasing Program and Confidential Feedback Quarterly Reports is available on the last page of this provider preview. FH16 - Developed by Polaris Group Page 85 of 140

87 MDS 3.0 Long-Stay Measures Lower percentages are better. Percentage of residents experiencing one or more falls with major injury Quality Measures that are Included in the QM Rating Provider State National 2015Q2 2015Q3 2015Q4 2016Q1 4Q avg Rating Points 1 4Q avg 4Q avg 3.5% 5.3% 5.5% 6.6% 5.2% % 3.3% Percentage of residents who self-report 2.6% 0.0% 0.0% 1.0% 0.9% % 8.2% moderate to severe pain 2 Percentage of high-risk residents with pressure ulcers Percentage of residents with a urinary tract infection 9.2% 1.9% 2.8% 3.8% 4.3% % 5.8% 3.5% 0.0% 0.9% 1.7% 1.5% % 4.8% Percentage of residents with a catheter 1.0% 0.9% 0.0% 0.0% 0.5% % 3.0% inserted and left in their bladder 2 Percentage of residents who were physically restrained Percentage of residents whose need for help with daily activities has increased Percentage of residents who received an antipsychotic medication 0.0% 0.0% 0.0% 0.0% 0.0% % 0.8% 17.6% 17.0% 13.1% 17.1% 16.2% % 15.4% 9.8% 8.9% 11.3% 7.6% 9.4% % 17.3% Percentage of residents whose ability 14.1% 18.8% 13.9% 32.9% 19.8% % 18.2% to move independently worsened 2,3 MDS 3.0 Short-Stay Measures Higher percentages are better. Percentage of residents who made 84.2% 75.2% 74.3% 76.2% 77.6% % 63.0% improvements in function 2,3 Lower percentages are better. Percentage of residents who self-report moderate to severe pain 8.5% 6.0% 6.0% 2.8% 5.5% % 16.7% Percentage of residents with pressure 1.3% 0.9% 0.6% 0.6% 0.9% % 1.2% ulcers that are new or worsened 2 Percentage of residents who newly received an antipsychotic medication 0.5% 0.5% 0.5% 1.1% 0.7% % 2.2% Time period for data used in reporting is 7/1/2014 through 6/30/2015 Provider State National Claims-Based Measures A higher percentage is better. Percentage of residents who were successfully discharged to the community 2,3 Observed Rate 4 Expected Rate 5 Risk- Adjusted Rate 6 Rating Points 1 Risk- Adjusted Rate Risk- Adjusted Rate 64.6% 58.9% 58.8% % 50.7% Lower percentages are better. Percentage of residents who were re-hospitalized after a nursing home admission 2,3 14.7% 18.2% 17.4% % 21.1% Percentage of residents who had an 4.8% 9.3% 5.7% % 11.5% outpatient emergency department visit 2,3 Total Quality Measure Points Total QM points with new quality measures weighted 50% for Provider FH16 - Developed by Polaris Group Page 86 of 140

88 MDS3.0 Quality Measures that are Not Included in the QM Rating Note: For the following long-stay MDS measures, higher percentages are better. Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Note: for the following long-stay MDS measures, lower percentages are better. Percentage of low-risk long-stay residents who lose control of their bowels or bladder Percentage of long-stay residents who lose too much weight Percentage of long-stay residents who have depressive symptoms Percentage of long-stay residents who received an antianxiety or hypnotic medication Note: For the following short-stay MDS measures, higher percentages are better. Percentage of short-stay residents assessed and appropriately given the seasonal influenza vaccine Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Provider State National 2015Q2 2015Q3 2015Q4 2016Q1 4Q avg 4Q avg 4Q avg 98.6% 98.6% 98.6% 96.2% 98.0% 95.0% 94.5% 96.5% 98.2% 90.6% 91.8% 94.1% 92.2% 93.4% 78.4% 90.5% 88.6% 80.0% 84.7% 58.0% 46.6% 8.3% 10.0% 11.2% 9.0% 9.6% 6.3% 7.1% 1.9% 1.8% 1.7% 2.6% 2.0% 4.8% 5.4% 10.6% 10.3% 8.0% 12.0% 10.2% 18.3% 23.6% 85.5% 85.5% 85.5% 66.9% 80.2% 82.4% 80.1% 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 quarterly basis. For individual quarters for the MDS-based QMs, d<20 means the denominator for the measure (the number of eligible resident assessments) is too small to report. When d<20 is listed for individual quarters, a four quarter average 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 which to base your rating and may occur even though your facility's data for this measure may be reported on Nursing Home Compare. 1 If the four quarter average for your facility is NA for a given QM, but rating points are provided for the QM, then there were insufficient data to compute a four-quarter average, and the points provided are based on the average points from other measures for which data are available according to the scoring rules described in detail in the Technical Users Guide at: 2 These measures are risk adjusted. 3 This is one of the new QMs, first reported on Nursing Home Compare in April The new QMs that are included in the QM rating can contribute half the number of points (10-50 points for each individual QM) compared to points for the other QMs included in the QM rating. 4 The observed rate is the actual rate observed for the facility without any risk-adjustment. 5 The expected rate is the rate that would be expected for the facility given the risk-adjustment profile of the facility. 6 Risk-adjusted rate is adjusted for the expected rate of the outcome and is calculated as (observed rate for facility / expected rate for facility) * national average of observed rate. Only the risk-adjusted rate will appear on Nursing Home Compare. 7 This measure includes some imputed data because there are fewer than 20 resident assessments or stays across the four quarters. This value is used in calculating the QM points and used in the QM rating calculation but will not be displayed on Nursing Home Compare. FH16 - Developed by Polaris Group Page 87 of 140

89 Physical Therapy Staffing for your nursing home is 8 minutes per resident per day. The national average 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 for surveys 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, 2013 March 10, 2014 April 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 percentage ownership is also listed. If the listing indicates 'Ownership Information Not Available', this is because CMS does not currently have ownership information for your nursing home. The legal business name for Charlestown Community Inc is CHARLESTOWN COMMUNITY, INC. OPERATIONAL/MANAGERIAL CONTROL ERICKSON LIVING MANAGEMENT LLC, since 04/30/2010 DIRECTOR BANKOSKI, VINSON, since 05/21/2009 BARNES, RICHARD, since 11/06/2008 BASHAM, JAMES, since 03/19/2015 BROWN, CHARLES, since 09/02/2009 BURNETT, JANICE, since 08/02/2012 COONEY, DAVID, since 03/30/2006 DENTON, CHARLES, since 09/12/2013 GAMBLE, CHARLES, since 02/05/2007 GANTERT, NEAL, since 04/30/2010 GROVE, RICHARD, since 03/30/2006 IVEY, LENWOOD, since 06/12/1997 MAUSER, JAMES, since 11/04/2015 MCAFEE, NAOMI, since 08/15/2010 MOORE, DANIEL, since 04/22/2013 MOORE, ROBIN, since 12/11/2015 OSTROFF, LAURA, since 02/02/2013 PARKER, CLARA, since 08/13/2012 PHIPPS, BONNIE, since 08/15/2010 POLLAK, JOANNE, since 03/30/1990 SMITH, SUSAN, since 05/14/2015 WEIGMAN, MARK, since 02/02/2013 OFFICER BANKOSKI, VINSON, since 04/30/2010 BASHAM, JAMES, since 03/19/2015 GAMBLE, CHARLES, since 03/30/1990 GANTERT, NEAL, since 09/06/2012 GROVE, RICHARD, since 03/30/2006 FH16 - Developed by Polaris Group Page 88 of 140

90 MOORE, ROBIN, since 12/11/2015 PARKER, CLARA, since 09/06/2012 SMITH, SUSAN, since 05/14/2015 MANAGING EMPLOYEE BANKOSKI, VINSON, since 04/30/2010 BASHAM, JAMES, since 03/19/2015 GANTERT, NEAL, since 04/30/2010 MATTHIESEN, TODD, since 06/15/2010 MOORE, ROBIN, since 12/11/2015 PARKER, CLARA, since 08/13/2012 WILSON, MICHAEL, since 06/11/2012 YOUNG, STEPHANIE, since 03/04/2014 If you believe this information is incorrect, go to or call the PECOS helpline at FH16 - Developed by Polaris Group Page 89 of 140

91 Information on the Skilled Nursing Facility Value Based Purchasing Program and Confidential Feedback Quarterly Reports Beginning October 2016 Section 215 of the Protecting Access to Medicare Act (PAMA) of 2014 (P.L ) added sections 1888(g) and (h) to the Social Security Act (the Act), and authorizes the Secretary of the U.S. Department of Health and Human Services to implement the Skilled Nursing Facility Value Based Purchasing (SNF VBP) Program beginning with claims paid in fiscal year (FY) Section 1888(g)(5) of the Act further requires that the Secretary begin providing quarterly confidential feedback reports to SNFs on their performance on the measure specified under the SNF VBP Program beginning on October 1, CMS will furnish quarterly confidential reports via CASPER beginning October 1, The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510) adopted for the SNF VBP Program is a different measure than that currently reported on Nursing Home Compare. Additional information regarding the SNF VBP Program and SNFRM can be found on the CMS website at: FH16 - Developed by Polaris Group Page 90 of 140

92 CASPER Report MDS 3.0 Facility Characteristics Report Page 1 of 1 Facility ID: CCN: Facility Name: CHARLESTOWN COMMUNITY INC City/State: CATONSVILLE, MD Data was calculated on: 07/04/2016 Report Period: 06/01/16-06/30/16 Comparison Group: 11/01/15-04/30/16 Run Date: 07/06/16 Report Version Number: 1.00 Facility Comparison Group Num Denom Observed Percent State Average National Average Gender Male % 38.0% 37.4% Female % 62.0% 62.6% Age <25 years old % 0.2% 0.4% years old % 6.9% 5.6% years old % 12.1% 10.8% years old % 19.7% 18.9% years old % 26.0% 27.5% 85+ years old % 35.2% 36.8% Diagnostic Characteristics Psychiatric diagnosis % 48.6% 56.0% Intellectual or Developmental Disability % 0.7% 1.4% Hospice % 3.5% 6.1% Prognosis Life expectancy of less than 6 months % 2.8% 4.7% Discharge Plan Not already occurring % 47.2% 61.0% Already occurring % 52.8% 39.0% Referral Not needed % 88.1% 89.4% Is or may be needed but not yet made % 3.1% 3.3% Has been made % 8.8% 7.2% Type of Entry Admission % 74.0% 70.2% Reentry % 26.0% 29.8% Entered Facility From Community % 6.9% 10.0% Another nursing home % 3.2% 6.3% Acute Hospital % 87.6% 79.8% Psychiatric Hospital % 1.0% 2.0% Inpatient Rehabilitation Facility % 0.4% 0.6% ID/DD facility % 0.0% 0.0% Hospice % 0.3% 0.3% Long Term Care Hospital % 0.1% 0.3% Other % 0.5% 0.6% This report may contain privacy protected data and should not be released to the public. FH16 - Developed by Polaris Group Page 91 of 140

93 CASPER Report MDS 3.0 Facility Level Quality Measure Report Page 1 of 1 Facility ID: CCN: Facility Name: CHARLESTOWN COMMUNITY INC City/State: CATONSVILLE, MD Data was calculated on: 07/04/2016 Report Period: 06/01/16-06/30/16 Comparison Group: 11/01/15-04/30/16 Run Date: 07/06/16 Report Version Number: 2.00 Note: Dashes represent a value that could not be computed Note: S = short stay, L = long stay Note: I = incomplete; data not available for all days selected Note: * is an indicator used to identify that the measure is flagged Measure Description CMS ID Data Num Denom Facility Observed Percent Facility Adjusted Percent Comparison Group State Average Comparison Group National Average Comparison Group National Percentile SR Mod/Severe Pain (S) N % 13.0% 13.6% 16.0% 47 SR Mod/Severe Pain (L) N % 1.0% 6.1% 7.6% 20 Hi-risk Pres Ulcer (L) N % 4.0% 7.9% 6.4% 35 New/worse Pres Ulcer (S) N % 0.0% 1.2% 1.2% 0 Phys restraints (L) N % 0.0% 0.5% 0.7% 0 Falls (L) N % 54.5% 43.1% 45.0% 74 Falls w/maj Injury (L) N % 3.3% 2.9% 3.4% 56 Antipsych Med (S) N % 0.0% 2.0% 2.3% 0 Antipsych Med (L) N % 8.4% 14.2% 16.7% 20 Antianxiety/Hypnotic (L) N % 5.7% 7.2% 8.8% 41 Behav Sx affect Others (L) N % 8.4% 18.6% 22.7% 18 Depress Sx (L) N % 3.5% 4.8% 5.6% 62 UTI (L) N % 0.9% 4.5% 4.6% 21 Cath Insert/Left Bladder (L) N % 1.9% 2.7% 3.2% 38 Lo-Risk Lose B/B Con (L) N % 77.6% 57.9% 46.8% 94 * Excess Wt Loss (L) N % 6.8% 7.2% 8.0% 44 Incr ADL Help (L) N % 6.1% 19.1% 15.9% 11 This report may contain privacy protected data and should not be released to the public. FH16 - Developed by Polaris Group Page 92 of 140

94 Page 1 of 18 CASPER Report MDS 3.0 Resident Level Quality Measure Report Report Period: 06/01/16-06/30/16 Run Date: 07/06/16 Report Version Number: 2.00 Facility ID: Facility Name: CHARLESTOWN COMMUNITY INC CCN: City/State: CATONSVILLE, MD Data was calculated on: 07/04/2016 Note: S = short stay, L = long stay; X = triggered, b = not triggered or excluded, C = complete; data available for all days selected, I = incomplete; data not available for all days selected Quality Measure Count Incr ADL Help (L) Excess Wt Loss (L) Lo-Risk Lose B/B Con (L) Cath Insert/Left Bladder (L) UTI (L) Depress Sx (L) Behav Sx Affect Others (L) Antianxiety/Hypnotic (L) Antipsych Med (L) Antipsych Med (S) Falls w/maj Injury (L) Falls (L) Phys restraints (L) New/worse Pres Ulcer (S) Hi-risk Pres Ulcer (L) SR Mod/Severe Pain (L) SR Mod/Severe Pain (S) Resident Name Resident ID A0310A/B/F FH16 - Developed by Polaris Group Page 93 of 140 Data C C C C C C C C C C C C C C C C C Active Residents AGNELLO, JEAN /99/99 b b b b b X b b b b b b b b b b b 1 AMATI, JACQUELINE /99/99 b b b b b b b b b b b b b b b b b 0 ANDERSON, AILEEN /01/99 X b b b b b b b b b b b b b b b b 1 ANDERSON, EILEEN /02/99 X b b b b b b b b b b b b b b b b 1 ARNOLD, BETTY /99/99 b b b b b X b b b b b b b b b b b 1 BAKER, VIRGINIA /99/99 b b b b b X b b b b b b b b b b b 1 BARDARIK, MARTHA /99/99 b b b b b X b b b b X b b b b b b 2 BARRANGER, GEORGE /99/99 b b b b b b b b b b b b b b b b b 0 BARROWS, ROBERT /03/99 b b b b b b b b b b b b b b b b b 0 BARTON, WILLIS /01/99 b b b b b b b b b b b b b b b b b 0 BATEMAN, JEAN /99/99 b b b b b b b b b b b b b b b b b 0 BEARD, ROLAND /99/99 b b b b b X b b b b X b b b X b b 3 BECKMANN, JEAN /01/99 X b b b b b b b b b b b b b b b b 1 BEERE, JEANNE /99/01 b b b b b b b b b b b b b b b b b 0 This report may contain privacy protected data and should not be released to the public.

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