Quality Measurement in Skilled Nursing Facilities Five Star Rating System

Judy Wilhide Brandt, RN, BA, RAC-MT, QCP, CPC, DNS-CT judy@judywilhide.com 909-800-9124 www.judywilhide.com Quality Measurement in Skilled Nursing Facilities Five Star Rating System January 2018 NC & VA Overview Quality Measures MDS Based Claims Based Five Star Five Star Survey SNF QRP SNF QRP SNF VBP JudyWilhide.com (c) 1

Five Star Rating System Survey Staffing Quality Measures Overall Rating Two years Annual 24 months Complaints Life Safety Code does not count Federal Oversight counts STEP 1 STEP 3 STEP 4 Federal Comparative does not count Add 1 star if 4 or 5 stars and above survey stars Subtract 1 star if 1 star Add 1 star if 5 stars Subtract 1 star if 1 star JudyWilhide.com (c) 2

Example: Overall Survey Staffing QM NH 1 5 4 3 5 NH 2 3 2 4 3 NH 3 3 3 3 4 NH 4 5 3 4 5 NH 5 3 5 1 1 5 Star Details: Ratings posted monthly Survey Stars Change: With any survey packet that is forwarded or a successful appeal Staffing Stars Change: Annually with CMS 671/CMS to begin using Payroll Based Journal (PBJ) in Spring 2018 Quality Measures Stars Change: MDS Based Quarterly: Jan, Apr, Jul, Oct Claims Based Biannually: Apr, Oct JudyWilhide.com (c) 3

J 50 Points (75 Points) K 100 Points (125 Points) L 150 Points (200 Points) Immediate Jeopardy to Health or Safety* Scope & Severity Grid G 20 Points H 30 Points (40 Points) I 45 Points (50 Points) Actual Harm D 4 Points E 8 Points F 16 Points (20 Points) No Actual Harm with Potential for Minimal Harm A 0 Points B 0 Points C 0 Points No Actual Hard with Potential for than Minimal Harm Few Some Many *If IJ * past non-compliance, G-level (20 points) assigned Old Substandard Quality of Care Cited at F, H, I, J, K, L New Any tag under: 483.13 resident behavior and nursing home practices, 483.15 quality of life, 483.25 quality of care. Certain tags under: 483.10 Resident Rights 483.40 Behavioral Health Services 483.45 Pharmacy Services 483.70 Administration (SW qualifications > 120 beds) All tags under: 483.12 Freedom from Abuse, Neglect, and Exploitation 483.24: Quality of Life 483.24: Quality of Care See Revised F-tag list JudyWilhide.com (c) 4

Understanding the Preview Report Preview of what will post at the end of the month. RN staffing FYI, included in staffing JudyWilhide.com (c) 5

Variable Information Sometimes Included in Preview Report Asheville: 28 days (of 92) no DON hours Quality Measures Included in the QM Rating JudyWilhide.com (c) 6

Last page: Surveys included in star rating that had any deficiencies Survey Star Changes February 2018 CMS will begin using the last two years of survey data instead of the last three years Two years standard survey Twenty-four months complaint survey Weight will be 60%/40% After this recalculation, survey stars will not be recalculated using surveys done under the new system, Long Term Survey Process (LTCSP) for the first year of implementation, beginning Nov 28, 2017. JudyWilhide.com (c) 7

Complaint Survey Weights Annual Survey Weights 13-24 mo 1-12 mo Prior Year Most Recent 1/3 1/2 1/3 1/2 1/6 1/6 25-36 mo Two Years Ago February 2018: Standard and Complaint Survey Weighing in Survey Stars Year Prior 40% Most Recent 60% *Surveys done for first year of new LTCSP will not be used for Survey Star Rating for that first year. JudyWilhide.com (c) 8

Bulk point add-on for revisits Revisits to Clear Revisit Number Noncompliance Points First 0 Second 50% of survey score added on Third 70% of survey score added on Fourth 85% of survey score added on Survey Star Details Cutpoints vary based on current distribution SNF rating held constant until you have survey event Same citation in annual & complaint counted once if within 15 days, worst one counts While SFF, overall max can be 3 stars If 1 star in survey, max overall can be 2 stars JudyWilhide.com (c) 9

Survey Star Distribution 10% 23.3% 23.3% 23.3% 20% SNF- 16.04 Annual Points: (16*.60) + (12*.40) = 14.44 Date Deficiency Points Weight 5/1/16 4 D 16 1/2 5/13/15 1D 1 E 12 1/3 Complaint Points: (0*.60) + (4*.40) = 1.6 Date Deficiency Points Weight Cycle 1 0 0 1/2 Cycle 2 1D 4 1/3 JudyWilhide.com (c) 10

Intra-State Considerations Example 20% 23.3 23.3 23.3 10% No of 2 Star 3 Star 4 Star 1 Star 5 Star State Facilities Upper Lower Upper Lower Upper Lower State 187 >64.667 <64.667 >32.667 <32.667 >19.333 <19.333 >5.333 <5.333 SNF: 16.04 Staffing JudyWilhide.com (c) 11

Staffing based on two case-mix adjusted measures, with equal weight. Total Nurse RN Census Block F78: Residents for whom a bed is maintained on the day the survey begins, including those temporarily away in a hospital or on leave. This should be representative of residents in the nursing facility or those who have a bed-hold. JudyWilhide.com (c) 12

Staffing from CMS-671 Last full 2 week pay period closest to survey Comprised of: RN Staffing (F39, F40, F41) Total Nurse Staffing (F39 F45) PBJ is expected to replace this method: Spring 2018 Total hours (each category) census on day 1 14 days = Hours per resident day (HRD) Summed across all categories to get Total Nurse HRD Expected Values: Based on distribution by RUG-III group determined using the most recent MDS assessment for current residents of the nursing home on the last day of the quarter closest to the date of the most recent standard survey RUG III-53 grouper Contains 15 Rehab Categories to include Rehab + Extensive JudyWilhide.com (c) 13

Example 3 RUGs from Table A1 Minutes RUC SE3 PA1 RN 100.75 143.56 28.2 Total Nurse 321.64 438.39 130.8 Simple example using 9 residents divided into 3 RUG III - 53 categories # res RN Total RUC 3 302.25 964.92 SE3 1 143.56 438.39 PA1 5 141 654 Total 9 586.81 2057.32 Expected 1.086 3.809 Convert minutes to hours and divide by # of residents Doing the math Hours adjusted = (Hours reported /Hours expected )*Hours National average Total Nurse Example 3 reported/ 6 expected = ½ x 4.0309 = 2.0154 adjusted hours National Average Hours per Resident Day Calculated April 2012 Total Nurse: 4.0309 RN: 0.7472 JudyWilhide.com (c) 14

Five Star Website Cut Points Actual Example SNF 1 RNs Total Nursing exp_rn exp_all adj_rn adj_total 0.814 3.543 0.91488 4.16834 0.66484 3.42617 Overall Survey Staffing QM 4 4 3 3 SNF 2 RNs Total Nursing exp_rn exp_all adj_rn adj_total 0.726 3.457 1.06904 4.19958 0.50735 3.31859 Overall Survey Staffing QM 3 3 3 4 SNF 1: RN: 4 stars Total Nurse: 2 star = 3 star overall SNF 2: RN: 3 stars Total Nurse: 2 star = 3 star overall JudyWilhide.com (c) 15

SNF Example Reported Hours Per Resident Per Day Aides LPNs RNs Total Licensed Total Nursing 1.75746 0.97412 0.72588 1.700 3.45746 Expected Hours Per Resident Per Day exp_aide exp_lpn exp_rn exp_nurse exp_all 2.439667249 0.69087414 1.069040204 1.759914344 4.199581593 Adjusted Hours Per Resident Per Day adj_aide adj_lpn adj_rn adj_nurse adj_total 1.767568755 1.170284938 0.507349989 1.52360256 3.318586675 JudyWilhide.com (c) 16

Example from Medicare.gov: Nursing Home Compare hrs_rn_don admin hrs_rn hrs_lpn_a dmin hrs_med hrs_na_t MDScens hrs_lpn hrs_cna Aide rn us PROVNAME CY_Qtr WorkDate Example NURSING AND REHABILITATION CENTER 2017Q2 20170401 0 14.92 0 43.5 134.5 0 0 56 Example NURSING AND REHABILITATION CENTER 2017Q2 20170402 0 8.5 0 45 149.5 0 0 56 Example NURSING AND REHABILITATION CENTER 2017Q2 20170403 8 14.25 0 63.5 155.75 0 0 56 Example NURSING AND REHABILITATION CENTER 2017Q2 20170404 8.25 21 0 46 166.5 0 0 57 Example NURSING AND REHABILITATION CENTER 2017Q2 20170405 10.5 15 0 64.25 160.5 0 0 58 Example NURSING AND REHABILITATION CENTER 2017Q2 20170406 0 8 0 63.5 165.75 0 0 58 Example NURSING AND REHABILITATION CENTER 2017Q2 20170407 0 8.75 0 52.5 155 0 0 59 Example NURSING AND REHABILITATION CENTER 2017Q2 20170408 0 11.66 0 42.17 147 0 0 58 Example NURSING AND REHABILITATION CENTER 2017Q2 20170409 0 18.17 0 36.83 149 0 0 58 Example NURSING AND REHABILITATION CENTER 2017Q2 20170410 0 14.67 0 70 163 0 0 59 Example NURSING AND REHABILITATION CENTER 2017Q2 20170411 8.25 8.5 0 64.83 151.5 0 0 58 Example NURSING AND REHABILITATION CENTER 2017Q2 20170412 8.25 8.5 0 67.75 163.25 0 0 58 JudyWilhide.com (c) 17

State Level Cut Point Tables Staffing Date for all SNFs: Example JudyWilhide.com (c) 18

Useful Casper Reports When Investigating Discrepancies Casper User s Guide: https://www.qtso.com/mdstrain.html 01 01 MDS 3.0 ROSTER: Lists residents for whom the latest accepted, federally required assessment is not a discharge/dif & target date is less than 36 months prior to report run date. MDS 3.0 MISSING ASSESSMENT: Residents for whom the target date of most recent OBRA assessment (not DC/DIF) is more than 138 days prior to the report run date, OR no OBRA record was submitted for a current episode that began more than 60 days prior to the run date. 02 03 MDS 3.0 ACTIVITY: Lists accepted assessments, tracking records, and inactivation requests that were submitted during a specified timeframe. MDS 3.0 ADMISSION/REENTRY: Residents who were admitted to or reentered a facility during a specified timeframe. 04 05 MDS 3.0 DISCHARGES: Residents discharged/dif during a specified timeframe. Five Star Quality Measures Measures selected due to validity and reliability, extent to which facility practice may affect the measure, statistical performance, and importance. -CMS JudyWilhide.com (c) 19

LS High-risk residents with pressure ulcers SS new/worse pressure ulcers LS self-report moderate to severe pain SS self-report moderate to severe pain LS antipsychotic use 5 Star Quality Measures SS newly received antipsychotic LS indwelling catheter LS UTI LS physically restrained LS fall with major injury 5 Star Quality Measures LS ADL decline LS residents whose ability to move worsened SS residents who made improvements in function SS residents emergency department visit SS residents re-hospitalization Claims Based Measures SS residents successfully community discharge JudyWilhide.com (c) 20

Five Star Preview Report MDS 3.0 Long-Stay Measures Lower percentages are better. Percentage of residents experiencing one or more falls with major injury Provider 1234567 State National 2015Q2 2015Q3 2015Q4 2016Q1 4Q avg Rating 1 Points 4Q avg 4Q avg 1.5% 3.2% 4.9% 7.9% 4.3% 40.00 Percentage of residents who self-report moderate to severe pain 2 12.7% 9.0% 15.2% 15.6% 13.1% 40.00 Percentage of high-risk residents with pressure ulcers Percentage of residents with a urinary tract infection 1.9% 0.0% 0.0% 1.8% 1.0% 0.0% 0.0% 5.0% 4.8% 2.4% 100.00 Percentage of residents with a catheter inserted and left in their bladder 2 0.0% 0.0% 1.9% 0.0% 0.5% 100.00 80.00 3.5% 3.3% 9.2% 8.2% 6.1% 5.8% 5.6% 4.8% 2.7% 3.0% 1 star 275-669 2 stars 670-759 3 stars 760-829 4 stars 830-904 5 stars 905-1350 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% 10.9% 3.8% 4.2% 10.2% 7.3% 16.4% 15.9% 18.0% 19.0% 17.3% 100.00 100.00 60.00 Percentage of residents whose ability to move independently worsened 2,3 17.9% 25.9% 10.5% 20.2% 18.7% 30.00 MDS 3.0 Short-Stay Measures Higher percentages are better. Percentage of residents who made improvements in function 2,3 78.8% 79.2% 78.1% 82.0% 79.5% 40.00 Lower percentages are better. Percentage of residents who self-report moderate to severe pain 16.3% 21.5% 16.2% 10.9% 16.1% 60.00 Percentage of residents with pressure ulcers that are new or worsened 2 0.7% 0.6% 0.0% 0.6% 0.5% 75.00 Percentage of residents who newly received an antipsychotic medication 0.0% 3.6% 3.1% 1.4% 2.1% 40.00 0.6% 0.8% 16.7% 15.4% 17.1% 17.3% 20.8% 18.2% 65.3% 63.0% 17.0% 16.7% 1.1% 1.2% 2.0% 2.2% 965 Time period for data used in reporting is 7/1/2014 through 6/30/2015 Claims-Based Measures A higher percentage is better. Observed Rate 4 Provider 495127 State National Expected Rate 5 Risk- Adjusted Rate 6 Rating Points 1 Percentage of residents who were successfully discharged to the community 2,3 77.1% 69.4% 64.0% 40.00 Lower percentages are better. Percentage of residents who were re-hospitalized after a nursing home admission 2,3 14.5% 16.8% 18.6% 40.00 Percentage of residents who had an outpatient emergency department visit 2,3 11.1% 9.4% 13.0% 20.00 Total Quality Measure Points Risk- Adjusted Rate Risk- Adjusted Rate 58.4% 54.2% 21.0% 21.1% 12.3% 11.5% Total QM points with new quality measures weighted 50% for Provider 495127 965.00 Provider 1234567 State National 2015Q2 2015Q3 2015Q4 2016Q1 4Q avg Rating Points 1 4Q avg 4Q avg MDS 3.0 Long-Stay Measures Lower percentages are better. Percentage of residents experiencing 1.1% 1.1% 2.1% 4.4% 2.2% 80.00 3.5% 3.3% one or more falls with major injury Percentage of residents who self-report 1.0% 3.3% 5.7% 5.9% 4.0% 80.00 9.2% 8.2% moderate to severe pain 2 Percentage of high-risk residents with pressure ulcers 6.4% 3.8% 6.1% 5.3% 5.4% 60.00 6.1% 5.8% Quality Measure Points Low High LS Falls w/major injury 100 0.00000000 0.01315789 80 0.01315790 0.02403848 60 0.02403849 0.03511052 40 0.03511053 0.05035973 20 0.05035974 1.00000000 Average from preview report Points assigned 0.022 80 JudyWilhide.com (c) 21

Low Prevalence Must have four quarter average of zero to get 100 points SS newly received pressure ulcers SS newly received antipsychotic LS physically restrained LS Restraints SS New/worsened pressure ulcer SS Newly prescribed antipsychotic 100 0.00000000 0.00000000 60 0.00067115 0.01424503 20 0.01424504 1.00000000 100 0.00000000 0.00000000 75 0.00021394 0.00692691 50 0.00692692 0.01566247 25 0.01566248 1.00000000 100 0.00000000 0.00000000 80 0.00000000 0.00999998 60 0.00999999 0.01912567 40 0.01912568 0.03486237 20 0.03486238 1.00000000 Target Records uses for both Long and Short Stay Measures OBRA Admission Quarterly Annual Significant change Significant Correction Scheduled PPS 5 Day 14 Day 30 Day 60 Day 90 Day OBRA Discharge Return anticipated Return not anticipated JudyWilhide.com (c) 22

Cumulative Days in the Facility CDIF: Does not count temporary absences >100 CDIF Long Stay <100 CDIF Short Stay Temporary absence: Time between DCRA & Reentry Admission Reentry CDIF = 1 Starts new episode CDIF Continues New stay in same episode judywilhide.com 46 JudyWilhide.com (c) 23

Episode Example Admission Reentry Reentry Stay 1 Stay 2 Stay 3 ADM MDS Target MDS DCRA DCRA End: DCRNA DCRA out > 30 days Death End of Target Period judywilhide.com 47 Short vs Long Stay Long Stay Admission Reentry Admission 1 32 33 78 1 103 ADM MDS SCSA/5 day MDS Admit MDS Qtry MDS D/C Return Anticipated (Out < 31 days) D/C Return Not-anticipated DCRA: >30 days Short Stay judywilhide.com 48 JudyWilhide.com (c) 24

MDS Based 13 4 Short Stay 9 Long Stay Not based on pay source Calculated once per resident, per quarter Add overall star If QM Rating is Five Stars Subtract overall star Claims Based 3 Short Stay Original Part A only Calculated per stay Could be more than once per resident If QM Rating is One Star Overview: 16 Five Star Quality Measures Short Stay MDS Based Measures: Include a rolling 6 month target period Jul Aug Sep Oct Nov Dec Oct Nov Dec Jan Feb Mar Jan Feb Mar Apr May Jun Apr May Jun Jul Aug Sep JudyWilhide.com (c) 25

Long Stay MDS Based Measures: Include a three month target period Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Resident Level Preview Report has names of all SS and LS residents in MDS based QM computation Q1 March 31 Record Selection MDS Based Measures SCSA Jan Feb Mar DIF Qtr An DCRA 5 Day Long Stay 14 D Oct Nov Dec DIF DCRNA 60 D DCRNA Jan Feb Mar DCRNA DCRA DCRNA DIF 5 D 30 D Qtr Short Stay JudyWilhide.com (c) 26

Understanding Individual QM data 300 Points from G0110 Column 1, Self Performance SS improvements in function Transfers Locomotion on Unit Walk in Corridor LS Help with ADLs Increased Bed Mobility Transfers Eating Toilet Use LS ability to move worsened Locomotion on Unit JudyWilhide.com (c) 27

Short-stay improvements in function Mid-loss ADL (MADL) Transfers Locomotion on Unit Walking in Corridor on unit Total G0110 Self Performance 5 Day or Admit Discharge Return Not Anticipated 3 2 3 3 8 1 10 6 Note: 7 or 8 added as 4 If total on DCRNA lower: Improved Short-stay improvements in function Entry Tracking: Admission Admit/5 day 5 day Admit DCRNA 1 100 One Stay Episode of Care Compares three midloss ADLs at two specific points in time: Initial MDS (5D or Admit) Discharge Return Not Anticipated JudyWilhide.com (c) 28

Short-stay improvements in function Entry Tracking: Admission Admit/5 day 5 day Admit DC Rtn Anticipated Entry Tracking: Reentry (within 30 days) DCRNA 1 57 57 100 Two-Stay Episode 5 day SCSA Quarterly Annual Short-stay improvements in function Entry Tracking: Admission Admit/5 day 5 day Admit Excluded DC Rtn Anticipated UNPLANNED Entry Tracking: Reentry (within 30 days) DCRNA 1 57 57 100 JudyWilhide.com (c) 29

On 5D or Admit (whichever used) Comatose Life expectancy of less than 6 months Hospice Sum of MADL is zero (totally independent) Exclusions (Not in numerator or denominator) On 5 day or Admit, or DCRNA Missing data in calculator fields Unplanned discharge at any time in episode of care Short-stay improvements in function Covariate: If enough residents have these characteristics on the 5 day/admit it will nudge your score up making you look better. (These folks are less likely to improve function) Female Age <54 or >84 Severe cognitive impairment Boxes checked in Section I: Heart Failure CVA/TIA/Stroke Hip Fracture Other Fracture Higher codes in self performance for 7 of 10 ADLs in G01101 (Long form ADLs): Bed mobility Transfers Locomotion on unit Dressing Eating Toileting Personal hygiene JudyWilhide.com (c) 30

Percentage of long-stay residents whose ability to move independently worsened Assessment Locomotion on Unit G0110 Self Performance Target 1 If score on target is higher than prior: worsened Prior 0 Note: 7 or 8 added as 4 Prior must be 45 to 165 days before target On Prior MDS Comatose Life expectancy of less than 6 months Hospice Totally dependent in locomotion on unit (4,7 or 8) Exclusions (Not in numerator or denominator) On Target or prior Missing data in calculator fields Prior assessment is a Discharge or no prior assessment exists JudyWilhide.com (c) 31

Percentage of long-stay residents whose ability to move independently worsened Covariate: If enough residents have these characteristics on the prior MDS it will nudge your score down making you look better. (These folks are more likely to worsen) Female Linear age (older more likely to worsen) Severe cognitive impairment Vision worsened from prior to latest Oxygen use on prior and latest Code 2 or 3 in: Eating Toileting Transfer Walking in Corridor Long Stay Help with ADLs Increased Two decline by one point Self Performance Bed Mobility Transfer Eating Toileting One declines by two points JudyWilhide.com (c) 32

Exclusions All four of the late-loss ADL items were total dependence (coded 4,7, or 8) on prior assessment 3 late-loss ADLs were total dependence on prior assessment AND the 4th was extensive assistance on prior assessment Comatose on target assessment Life expectancy less than 6 months on target assessment Hospice care on target assessment judywilhide.com 65 Long Stay target assessment selection period CDIF > 100 31 days Comparison is 46 165 days apart 1/2/15 Qtrly 4/1/15 Qtrly 5/4/15 SCSA Death Tracking Help with ADLs Increased Ability to Move Independently Worsened Calendar quarter judywilhide.com 66 JudyWilhide.com (c) 33

O0100K: Hospice while resident Exclusions J1400: Prognosis SS improvements in function LS Help with ADLs Increased LS ability to move worsened SS improvements in function LS Help with ADLs Increased LS ability to move worsened JudyWilhide.com (c) 34

Short Stay & Long Stay Moderate to Severe Pain INTERVIEW ONLY Almost Constantly or Frequently Almost Constant Frequently Occasionally Rarely 5-9 Moderate or Severe 10 Very Severe, horrible OR 5,6,7,8 or 9 Moderate or Severe JudyWilhide.com (c) 35

10 OR Very severe, horrible If enough were cognitively Intact on prior assessment More likely to report pain If enough were cognitively Impaired On prior assessment Less likely to report pain Long Stay Pain Covariate Nudges score down Nudges score up judywilhide.com 72 JudyWilhide.com (c) 36

Short Stay: New or Worsened Pressure Ulcers Look Back Scan Covariates M0800 ONLY if A0310E = 0 Any number > 0 for any MDS in lookback scan Short Stay Look Back Scan All assessments in the current episode Look-back Scan Admission Discharge Also Newly received antipsychotic New or Worsened Pressure Ulcer JudyWilhide.com (c) 37

New or Worsened Pressure Ulcers Covariates If Enough of these characteristics present on Initial Assessment Bed Mobility >=2 Bowel Incontinence >=occasionally Low BMI Diabetes Nudge score down Looks better Current JudyWilhide.com (c) 38

October 2018 draft Long stay high risk pressure ulcer Bed Mobility 3,4,7,8 Transfer 3,4,7,8 or High Risk if any one present or Comatose and Malnutrition I5600 St 2,3 or 4 PU in M0300 JudyWilhide.com (c) 39

Percent of Short-Stay Residents Who Newly Received an Antipsychotic Medication (look back scan) Initial Assessment Exclusions: Schizophrenia (I6000) Tourette s Syndrome (I5350) Huntington s Disease (I5250) Subsequent assessments = > 0 Short Stay Look Back Scan All assessments in the current episode Look-back Scan Admission Discharge Also Newly received antipsychotic New or Worsened Pressure Ulcer JudyWilhide.com (c) 40

Long Stay Antipsychotics Exclusions UTI Long Stay UTI Target Assessment JudyWilhide.com (c) 41

Item I2300 Urinary tract infection (UTI): The UTI has a lookback period of 30 days for active disease instead of 7 days. Code only if both of the following are met in the last 30 days: 1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND 2. A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days. Errata Document Dec 2017. Page I-9 (R) If UTI Dx was made prior to the resident s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork. When the resident is transferred, but not admitted, to a hospital (e.g., emergency room visit, observation stay) the facility must use evidence-based criteria to evaluate the resident and determine if the criteria for UTI are met AND verify that there is a physician-documented UTI diagnosis when completing I2300 Urinary Tract Infection (UTI). JudyWilhide.com (c) 42

Long Stay Catheter urinary retention? Ask why! Catheter on target assessment Neurogenic bladder excluded Obstructive uropathy excluded Enough on prior assessment Freq bowel incontinence St 2,3 or 4 PU Catheter Covariate Your text here Nudge score down judywilhide.com 86 JudyWilhide.com (c) 43

Long Stay Restraint Use Trunk restraint Limb restraint Chair prevents rising Used Daily Fall with Major Injury Q1: Jan 1 Mar 31 ARD 1/5/17 Target Assessment No Major Injury Fall When Major Injury happens, set ARD to get clock running Quarterly No Major injury Fall ARD 7/5/16 ARD 10/5/16 Quarterly No Major Injury Fall Annual Fall Major Injury ARD 6/4/16 275 Day lookback scan from ARD of target Assessment: June 5, 2016 Fall happened Mar 10, 2016 JudyWilhide.com (c) 44

Coding Falls Reentry Tracker DCRA ER/Hospital finds fracture due to fall SCSA/ 5 D Fall Call 911 To ER Major Injury goes on DCRA Major Injury does not go on initial assessment after return Claims Based 5 Star Measures judywilhide.com 90 JudyWilhide.com (c) 45

Claims-based measures Included Part A stay that begain within one day of hospital discharge (IRF/LTCH excluded) Risk Adjustments None are simple fractions. Actual numberator & denominator are risk adjusted based on characteristics present around the start of SNF stay Not enrolled in Medicare for risk period Missing data Hospice any time in risk period Comatose on 1 st MDS No 1 st MDS Excluded Stays Percentage of short-stay residents who were rehospitalized after a nursing home admission Part A Stays in which resident had: Unplanned hospital inpatient or outpatient observation stay Within 30 days of entering SNF Regardless of whether they were discharged from SNF prior to hospital readmission JudyWilhide.com JudyWilhide.com (c) 46

Planned Readmissions Principles Hospital Claim Diagnosis and Procedure Codes Always Planned Transplants, Maintenance Chemo, Pregnancy-related (anywhere on claim) Prespecified List of Codes for typically planned procedures Acute Illness or Injury will be Unplanned Even if accompanied by a planned procedure during hospital admission Claims items used in risk adjustment Unplanned readmission: Hospital claims Age and Sex hospital LOS prior to SNF admit Time in ICU prior to SNF admit Ever got Medicare due to disability ESRD Number of inpatient hospital stays in year preceding SNF stay Principal diagnosis (ICD code) Co-morbidities (ICD codes) JudyWilhide.com (c) 47

MDS items used in risk adjustment: unplanned readmission Eating Foot infection Radiation Seizure disorder Walk in room Diabetic foot ulcer Cough during meals Trach Ulcerative colitis Dialysis Fell in last month Fell in 2-6 months Walk in corridor Internal bleeding IV Med Wound infection Heart failure IV Fluid Wanders Dehydrated Vent UTI Dementia (all) Feeding tube Two person assist Daily pain Transfusions Chemo Rejected care Diabetes Cognitive status not intact Surgical wound Antibiotics Pneumonia Insulin Respiratory failure Acute change in mental status Rarely understood Total bowel incontinence Shortness of breath Entered from: Acute hospital Anemia Venous/ Arterial ulcers Viral hepatitis Cancer Septicemia Oxygen Ostomy care Prognosis CVA 1 st MDS since entry is Significant Change Percentage of short-stay residents who have had an outpatient emergency department visit Part A Stays in which resident had: Unplanned ED stay without acute admit or inpatient observation stay Within 30 days of entering SNF Regardless of whether they were discharged from SNF prior to hospital readmission JudyWilhide.com JudyWilhide.com (c) 48

Claims items used in risk adjustment ED Visit: Hospital claims Age and Sex hospital LOS prior to SNF admit Time in ICU prior to SNF admit Ever got Medicare due to disability ESRD Number of inpatient hospital stays in year preceding SNF stay Principal diagnosis (ICD code) Co-morbidities (ICD codes) MDS items used in risk adjustment: ED Visit Isolation Anticoagulant Radiation Seizure disorder Dialysis Fell in last month Walk in room Internal bleeding Trach Respiratory therapy Heart failure Fell in 2-6 months Walk in corridor Dehydrated Orthostatic hypotension COPD Rejected care IV Fluid Wanders Daily pain Vent UTI Insulin Feeding tube Two person assist Surgical wound Transfusions Pneumonia Viral hepatitis Respiratory failure Cognitive status not intact Speech Therapy Antibiotics Venous/ Arterial ulcers Ostomy care Cancer Acute change in mental status Shortness of breath Anemia Oxygen Rarely Understood Prognosis 1 st MDS since entry is Significant Change JudyWilhide.com (c) 49

Percentage of short-stay residents who were successfully discharged to the community Beneficiary stay that: Had an MDS discharge assessment indicating discharge to community within 100 calendar days of the start of the episode; AND within 30 days of this discharge the beneficiary: Was not admitted to a nursing home Did not have an unplanned inpatient hospital stay Did not die Claims items used in risk adjustment for Successful Discharge: Hospital claims Age and Sex hospital LOS prior to SNF admit Time in ICU prior to SNF admit Ever got Medicare due to disability ESRD Number of inpatient hospital stays in year preceding SNF stay Principal diagnosis (ICD code) Co-morbidities (ICD codes) JudyWilhide.com (c) 50

MDS items used in risk adjustment: Successful Discharge Psychotic Disorder Schizophrenia Married Interpreter needed Resident expectations (Q) Malnutrition HTN Hyperkalemia Hip/other fx CVA Anxiety disorder Manic Depression ADL Dependence Foot infection Radiation Seizure disorder Depression Weight loss Balance problem Diabetic foot ulcer Understands others Paraplegia Dialysis Fell in 2-6 months Hemiplegia Swallowing disorder (K0100) IV Med Wound infection Heart failure IV Fluid s/s delirium Suctioning Vent UTI Dementia (all) Feeding tube Medicare RUG Vision Impairment Transfusions Chemo MS Diabetes Cognitive Impairment Surgical wound Quadraplegia Pneumonia Huntington s Parkinson s Acute change in mental status Incontinence Anemia ID/DD or related condition Viral hepatitis Cancer Makes self understood Entered from:psych hospital Shortness of breath Septicemia Oxygen injections Antipsychotics Any behavior, wander, reject care, hallucination, delusion Mech Alt diet COPD Other MDS Based Quality Measures, not part of Five Star judywilhide.com 102 JudyWilhide.com (c) 51

Antianxiety or hypnotic medication: Two separate measures Casper Prevalence of Antianxiety/Hypnotic Use (Long Stay) N033.1 Exclusions: Schizophrenia (I6000 = [1]). Psychotic disorder (I5950 = [1]). Manic depression (bipolar disease) (I5900 = [1]). Tourette s syndrome (I5350 = [1]). Huntington s disease (I5250 = [1]). Hallucinations (E0100A = [1]). Delusions (E0100B = [1]). Anxiety disorder (I5700 = [1]). Post-traumatic stress disorder (I6100 = [1]). NH Compare & Casper Percent of Residents Who Used Antianxiety or Hypnotic Medication (Long Stay) N036.1 Exclusions: Life expectancy of less than 6 months (J1400 = [1]). Hospice care while a resident (O0100K2 = [1]). Long Stay Prevalence of Falls: All falls on any assessment in the LS lookback scan judywilhide.com 104 JudyWilhide.com (c) 52

Long Stay Behavior Symptoms Affecting Others : Anything more than zero in any of these boxes judywilhide.com 105 Long Stay Low Risk Bowel/Bladder Incontinence Bed Mobility 4,7,8 Severe cognitive impairment High Risk Transfer 4,7,8 Everyone deemed low risk coded frequently/always incontinent of bowel or bladder Locomotion on unit 4,7,8 Exclusions: Ostomy, catheter judywilhide.com 106 JudyWilhide.com (c) 53

Long Stay weight Loss Subtitle text here You can replace this text You can replace this text You can replace this text On Target Assessment Non-physician prescribed weight loss Subtitle text here judywilhide.com 107 Long Stay Depressive Symptoms Down, depressed, hopeless 7-14 days OR Little interest or pleasure 7-14 days Score >=10 And Uses Interview or Staff Assessment judywilhide.com 108 JudyWilhide.com (c) 54

The Vaccine Quality Measures: Short & Long Stay SNF State Nation Not on Casper Reports, Not Five Star 109 judywilhide.com Assessed and Appropriately Given the Pneumococcal Vaccine Up to date Offered/declined Medically Contraindicated JudyWilhide.com (c) 55

Special rules for influenza vaccination measures Flu vaccination measures are calculated once per year. In a normal year where the influenza season begins on October 1 and ends of March 31, the target period will coincide with these dates End-of-episode date will be March 31 for an episode that is ongoing at the end of the influenza season and that March 31 should be used as the end date when computing CDIF and for classifying stays as long or short for the influenza vaccination measures. 111 judywilhide.com Percentage of Appropriate Vaccines Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine (Long Stay) Numerator Or Code 2, Received outside of this facility Code 3, Not eligible medical contraindication Code 4, Offered and declined 112 judywilhide.com JudyWilhide.com (c) 56

Percentage of Appropriate Vaccines Denominator All long-stay residents with a selected influenza vaccination assessment, except those with exclusions. Exclusions Resident s age on target date of selected influenza vaccination assessment is 179 days or less. {pediatric NH} NO other exclusions! 113 judywilhide.com Percentage of Appropriate Vaccines Measure calculated once a year with target period October 1 of the prior year to June 30 of the current year and reports for the October 1 through March 31 influenza season. Scan all assessments with target dates on or after October 1 of the most recently completed influenza season. Select the record with the latest target date with: Qualifying reason for assessment OBRA, scheduled PPS or discharge Target date on/after October 1st of the most recently completed influenza season, and A1600 entry date is on or before March 31st of the most recently completed influenza season. 114 judywilhide.com JudyWilhide.com (c) 57

Target Period Oct 2015 Nov 2015 Dec 2015 DC Assmt ARD 10/25/16 Entry: 2/10/09 Jan 2016 Feb 2016 DC Assmt ARD 2/28/16 Entry: 7/10/09 Mar 2016 Apr 2016 May 2016 Jun 2016 115 Quarterly ARD 04/15/16 Entry: 9/2/12 PPS 60 Day ARD 5/1/16 Entry: 3/1/16 Flu QM No Exclusions Received in facility for this flu vaccination season Code 2, Received outside of this facility 72 Code 3, Not eligible medical contraindication Code 4, Offered and declined 130 Received in facility for this flu vaccination season Code 2, Received outside of this facility 116 judywilhide.com Code 3, Not eligible medical contraindication Code 4, Offered and declined Code 5, Not offered Code 6, Inability to obtain influenza vaccine due to a declared shortage Code 9, None of the above or unknown JudyWilhide.com (c) 58

Illustration of no exclusions 117 The Casper Reports QTSO.COM judywilhide.com 118 JudyWilhide.com (c) 59

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CASPER Report MOS 3.0 Facility Level Quality MeasureReport Data: I measure not active during entire selected report period. Covariates: Nudge observed percentage up or down to account for unique resident characteristics. judywilhide.com 125 CASPER Report MOS 3.0 Facility Level Quality MeasureReport Data: I measure not active during entire selected report period. These 3 first published on Casper 1/31/18. Data for new measures retroactively calculated to June 3, 2015. If a date range includes dates prior to June 3, 2015, an "I" (Incomplete) will display indicating data are not available judywilhide.com for all days selected. 126 JudyWilhide.com (c) 63

judywilhide.com 127 A0310A/B/F 99/02/99 99/99/10 99/03/99 02/99/99 99/99/11 99/01/10 04/99/99 99/99/10 judywilhide.com 128 JudyWilhide.com (c) 64

Individual QM Review 1. What triggered? 2. Why did it trigger, specifically? 3. Is the MDS Accurate? If not correct 4. Does the trigger represent a clinical area that must be addressed immediately? Is it unique to resident or systemic? Does the chart tell the story? judywilhide.com 129 Specific Quality Measures for Original Part A in a SNF JudyWilhide.com (c) 65

SNF Value Based Purchasing SNF Quality Reporting Program Purpose: To sort and reward highest performing SNFs on one PP claims based measure Purpose: To compare post acute settings to reshape the payment system Potentially Preventable Unplanned Rehospitalizations Measure(s) will change and evolve MDS-based measures Claims-based measures Will evolve over the next several years SNF payment incentives/penalties, through different programs, will largely be tied to our ability to prevent unnecessary rehospitalizations Re-hospitalizations Five Star SNF-QRP VBP None of these measures are exactly the same JudyWilhide.com JudyWilhide.com (c) 66

Successful Community Discharge Five Star SNF QRP JudyWilhide.com Protecting Access to Medicare Act (PAMA) of 2014: SNF Value Based Purchasing: Sort and reward SNFs who reduce Re-hospitalizations Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM NQF #2510) Performance Year CY 2017 Payment year FY2019 JudyWilhide.com JudyWilhide.com (c) 67

SNF VBP Funding: CMS will withhold 2% of SNF payment starting Oct 2018 Top performers can earn 50 70% of it back. Lowest performers can get back less or nothing. CMS will keep 30-50% 50-70% will be incentive payments to SNFs. JudyWilhide.com SNF VBP: One Measure only First year: Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM NQF #2510) To be replaced by: FY 17 Proposed Measure: SNF 30-Day Potentially Preventable Readmission Measure (SNFPPR) Changes/additions/deletions to VBP measures would come in future rule-making JudyWilhide.com JudyWilhide.com (c) 68

Two ways to earn points: Achievement Score Rate threshold 0 points Rate benchmark 100 points Rate between the two Achievement Threshold 25 th percentile of national SNF performance during CY 2015 1 to 99 points Benchmark Mean of top decile of national SNF performance (10 th percentile) during CY 2015 Achievement Performance: Happy Valley SNF s rate of all-cause readmissions (SNFRM) in CY 2017 compared to the national rate in CY 2015 Improvement Score Two ways to earn points: Rate threshold 0 points Rate benchmark 100 points Rate between the two 1 to 89 points Improvement Threshold Your SNF s performance during CY 2015 Benchmark Mean of top decile of national SNF performance (10 th percentile) during CY 2015 Improvement Performance: Happy Valley SNF s rate of all-cause readmissions (SNFRM) in CY 2017 compared to it s own rate in CY 2015 JudyWilhide.com (c) 69

Calculating Performance: Higher numbers will be better CMS thinks this is easier for public to understand If actual readmission rate is 20% i.e.: 20% of residents included in measure were rehospitalized Your rate would be 80% i.e.: 80% of residents included in measure were not rehospitalized CMS is required to pay the better of Achievement or Improvement JudyWilhide.com Questions/Discussion JudyWilhide.com (c) 70

Long Stay Measures Five Star Survey NH Compare Percent of Residents Experiencing One or More Falls With a Major Injury Percent of Residents Who Self-Report Moderate to Severe Pain Percent of Residents With Pressure Ulcers Percent of Residents With UTI Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder Percent of Low-Risk Residents Who Lose Control of Their Bowel or Bladder Percent of Residents Who Were Physically Restrained Percent of Residents Whose Need for Help With Daily Activities Has Increased Percent of Residents Who Lose Too Much Weight Percent of Residents Who Received an Antipsychotic Medication Percent of Residents Who Have Depressive Symptoms Percent of Residents Whose Ability to Move Independently Worsened Prevalence of Falls Percent of Residents Who Used an Antianxiety or Hypnotic Medication N036.1 Prevalence of Antianxiety/Hypnotic Use N033.1 Prevalence of Behavior Symptoms Affecting Others Percentage of Residents Assessed and Given Appropriately the Seasonal Influenza Vaccine Percentage of Residents Assessed and Given Appropriately the Pneumococcal Vaccine JudyWilhide.com

Short Stay MDS-Based Quality Measures Percent of Residents Who Self-Report Moderate to Severe Pain Five Star Survey NH Compare Percent of Residents With Pressure Ulcers That Are New or Worsened Percent of Residents Who Newly Received an Antipsychotic Medication Percent of Residents Who Made Improvements in Function (Called Residents Whose Physical Function Improves From Admission to Discharge in Five-Star User s Manual) Percentage of Residents Assessed and Given Appropriately the Seasonal Influenza Vaccine Percentage of Residents Assessed and Given Appropriately the Pneumococcal Vaccine Claims-Based Quality Measures Percent of Short-Stay Residents Who Were Successfully Discharged to the Community Five Star Percent of Short-Stay Residents Who Have Had an Outpatient ED Visit Percent of Short-Stay Residents Who Were Re-hospitalized After a Nursing Home Admission Skilled Nursing Facility 30-Day All-Cause Readmission Measure SNFRM Discharge to Community SNF-QRP Potentially Preventable 30-Day Post-Discharge Readmission SNF QRP VBP SNF-QRP Medicare Spending Per Beneficiary SNF QRP JudyWilhide.com