1. the Nursing Home Five Star How to be one with the force
Presented by Christy Johnson, ADC
Regional Training Director, Organizational Development
Good afternoon and welcome. I have had the honor of working within quality improvement since Back when stratus health and the U of M partnered with CMS to develop what is now know as Q-A-P-I.
So I was fortunate to be in one of the facilities that participated in the learning collaborative. I had a wonderful administrator and DON, at the time, that supported and lead efforts whole heartedly. Then they left. I became the primary QAPI implementer at our facility, which put me in this unique situation leading me in a direction I would have never thought I had an interest in. As it turned out, lucky me, I love this stuff and I’m totally nerdy about it. They tell me this is a good thing.

2. Objectives Participants will understand the five star rating
Participants will know where to find their facility information about the five star rating
Participants will understand how each section of the five star rating is scored
Participants will understand how they can improve their five star rating
Today we will be discussing the Federal 5 star rating. Please note that facilities have two five star ratings available to them. A state rating that you can find at nursing home compare and a federal rating that you find at Medicare.gov. This is the rating we will be focusing in on and the rating that is most used by consumers and hospitols we serve. My goal is for you to understand a little more about the rating, where you can find your facility information, for you to understand how your facilities scores are obtained and how you can impact those scores.
So at any point feel free to ask questions.
Here we go!

4. The STARS are assigned: 1. Much Below Average 2. Below Average
Starting in December of 2008, CMS improved its Nursing Home Compare reporting to include a set of quality ratings.
The ratings are giving in the form of “STARS” with the goal to provide easy to understand information to residents and families
The STARS are assigned:
1. Much Below Average
2. Below Average
3. Average
4. Above Average
5. Much Above Average
In December of 2008 at CMS improved is Nursing home compare reporting to include a set of quality ratings that would be easy for residents and families to use. They assigned star levels to quality, staff and survey results. This report did achieve the goal of being really easy for end users to use and read. However, for the facilities ... It is not so simple. And we have found our selves in situations scratching our heads going where did you get that information? Why don’t we have more stars? Unfortunately the consumers don’t know all the ins and out outs of the stars. I have worked with a facility that had one bad survey. They had 5 star rated quality measures and staffing but because of that one bad survey they remained a 2 star facility for 3 years. Sometimes the stars just don’t add up. What can we do about it? Maybe I’m getting ahead of my self? Let’s take a step back and start at the beginning.

5. Introduction The Five Star Rating is based on 3 areas
Health Inspections – Measures based on outcomes from State health inspections
Staffing – Measures based on nursing home staffing levels
Quality Measures (QM’s) – Measures based on Minimum Data Set (MDS) and claims-based quality measures
Here it is the 5 star rating is based on three areas. Health Inspections- or survey, Staffing, and quality measures.

6. Where can you find your facility Rating, scores and Measures?
Medicare.gov
re.gov/nursinghome compare/search.ht ml
Here is where you can find your facility information. Or any facility for that matter. This is consumer friendly and you can easily compare several nursing facilities at once.
The webpage medicare.gov nursing home compare is where many consumers go to find information. Consumers trust this information. That is why it is important to know what is out there.

7. Once you select a facility you will see a page like this
Once you select a facility you will see a page like this. The front page is basic demographics. Then survey/health inspection information, staffing and quality measures. There is also a penalty tab- if the home has any penalties they are included in the health inspection score.
Let’s start with the Health inspections survey

8. Health inspections Survey results Repeat visits
Pointes are assigned to each deficiency according to their scope and severity
Repeat visits
No points for first revisit only if additional visits are required
Health Inspections are based on survey results and multiple repeat visits. Each deficiency is assigned a point value based on their scope and severity. (the higher the scope and severity the higher the score) Surveyors needing to make multiple repeat visits will also increase your score.

9. Health inspections
How many here recognize this chart? Do you understand how deficiencies are given?
MIGHT NEED A BRIEF EXPLANATION OF DEFICENCIES.
In all my years working in LTC I’ve never seen an A, B, or C level deficiency given. Most surveyors that find something needing correction will start at a D level. You can see the points jump up quickly doubling from D-E and E-F. If you are in an IJ situation you can plan that your facility score will be at a 1-2 star for at least 3 years.

10. Health inspections
Three most recent surveys are weighted and included in score
Most recent survey = ½ of the score
Previous survey = 1/3 of the score
Second prior survey = 1/6 of the score
Includes any substantiated findings from the most recent 36 months of complaint investigations
So what is counted? Well the last three years worth of surveys. Each weighted a little different. Your current year or most recent survey is 1/2 of your score then prior year is 1/3 and second year prior is 1/6th of your score.
Any substantiated findings from OHFC investigations are also included in your score. The facility would have been given deficiencies based on findings and those are weighted and added to the total score the same way.

11. Health inspections-do the math
2014
1 Level F
2 Level E
2 Level D
2015
1 Level E
3 Level D
2016
1 Level D 16
Total 40 8
12 Total 20
Total 20
1/6 of 40
1/3 of 20
1/2 of 20
6.6 10
Let’s do the math. I’ve completely made this up for us to practice. Here are your facilities deficiencies for the last three health inspections. Using the chart we can assign the scores for each. Weighting them out gives your total score of 23.2
Any questions?
Total

12. Health inspections
Each facility’s score is compared only to other facilities in the state
Of all scores only the top 10% receive five stars
The middle 70% receive a rating of two, three, or four starts- approximately percent in each category
The bottom 20% automatically receive a one star rating
CLICK
Each facility’s score is compared only to other facilities in the state
So here is our beautiful MN
Of all scores only the top 10% receive five stars
The middle 70% receive a rating of two, three, or four starts- approximately percent in each category
The bottom 20% automatically receive a one star rating

13. Health inspections Your Score, Your State … Now what?
Cut Points by State updated monthly
Now you know your score, you know how the state is divided but now what. Well going to CMS looking up the 5 star rating cut points for the month you can see with our example facility they would receive … 4 stars. Now because these are always changing and our example facility is right at the cut point, what could happen is this month they receive a 4 star health inspection rating but next month, they might get bumped to a 3 star rating. These are always moving and recalibrating so you will see some fluctuation at times.

14. (sad beeps) Here’s the catch
A facility can only have one more star than it’s health inspection rating. So you can have 5 stars in quality measures and staffing but 1 star with a bad survey and the best you can be is a 2 star facility. With the three year weighted score this means a bad survey could keep your facility at 2 stars for three years.
So sad beep … if you are in that situation. As far as a know you can’t do anything but wait it out and have better surveys.
Questions about the health inspection and how it is scored, or rated?
(sad beeps)

15. Staffing How a facility gets scored
Registered nurse hours per resident per day
Total staffing hours per resident per day
Now let’s look at staffing.
Staffing levels count two things: Registered nursing hours per resident per day and total nursing staff per resident per day. Keep in mind.
RN hours: Includes registered nurses, RN director of nursing, and nurses with administrative duties. •
LPN hours: Includes licensed practical/licensed vocational nurses
Nurse aide hours: Includes certified nurse aides, aides in training, and medication aides/technicians
Adjustments are made according to case mix scores

16. Staffing how a facility’s score receives stars
So each measure RN hours and total hours are weighted equally. On the left axis is the total RN hours per resident per day and across the top total hours.
For a facility that staffs at RN hours per day and total nursing hours per day.
CLICK
They would be staffed at three star rating.
Any questions about the staffing rating?

17. Quality Measures Based on performance over 1 year
Facility ratings for nursing homes are based on 16 of the 24 quality measures that are currently posted.
Quality measures are based on information from the MDS 3.0 as well as hospital and emergency department claims.
Quality Measures are measurements taken form the MDS or minimum data set. They include 1 year of MDS’s in order to calculate the percentages. There are currently 24 quality measures posted on the Medicare.gov/nursing home compare website. Of those 16 are included in the star ratings.
Does everyone know what the MDS is?
May have to explain the assessment general ideas.
Basics of MDS
They are the result of the IDT assessments
They are done at least quarterly for every resident
All payments to the facility are based on the MDS information

18. Quality Measures Include 16 indicators/measures 9 long stay measures
7 short stay measures
Recently added in July 2016
Two additional long stay measures and four short stay measures
Of the 16 indicators -9 are long stay measures – which includes any resident that is in the facility for over 100 days.
7 are short stay measures meaning the resident discharged before day 100.
Recently in July 6 additional measures were added. These measures are mostly measured based on medicare claims. Which we will talk about more in a minute.
Let’s dig in to each of the measures a bit closer.
CLICK –BE READY FOR DANCING STORM TROOPERS

19. Transition slide
Believe it or not this to me is the fun part. I know I’m such a dork. But here is where we can really make a difference.

20. Quality Measures Description Details Exceptions
Suggestions for follow up
I’m going to go through each measure and share some key pieces of information. For each measure has a description, details of the QM, the exceptions and some thoughts about what to do if this is scoring high or triggering for residents.

21. Quality measure-Percentage of residents whose ability to move independently worsened-added July 2016 (Long Stay)
Measures the percent of residents who have declined in independence of locomotion.
The most recent MDS is compared to the last MDS where resident’s need for assistance with locomotion has increased.
Exclusions: Comatose End Stage Prognosis Hospice Resident was coded as total dependence on last assessment Short Stay Missing MDS information

22. Quality measure-Percentage of residents whose ability to move independently worsened(Long Stay)
Measures the percent of residents who have declined in independence of locomotion.
Follow up needed if triggered:
Review nursing rehab programs, care plan, offer OT/PT therapy. Conduct root cause analysis of why resident has decreased locomotion. Review weights and vitals?

23. Quality Measure-Percent of residents whose need for help with activities of daily living has increased (Long Stay)
This measure reports 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.
The most recent MDS is compared to the last MDS
Measures residents abilities that have declined in the areas of: eating, transferring, bed mobility, toileting, dressing, locomotion on unit, hygiene
READ AND DISCUSS SLIDE
Triggered when: or more areas have declined by 1 step 1 area has declined by 2 steps Or resident remains full dependency

24. Quality Measure-Percent of residents whose need for help with activities of daily living has increased (Long Stay)
This measure reports 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.
Exclusions: Comatose End Stage Prognosis Hospice Quadriplegia Short Stay Missing MDS Information
Follow up needed if triggered:
Review nursing rehab care plan, weight loss, or potential for therapy. Check for significant change.
End Stage Prognosis
A prognosis of less than 6 months

25. Quality Measure-Percent of high-risk residents with pressure ulcers (Long Stay)
This measure captures the percentage of long-stay, high-risk residents with Stage II-IV pressure ulcers.
Exclusions:
Not at a high risk for pressure ulcer Not dependent in bed mobility Not dependent in transfers Not comatose Not malnourished
Short Stay Missing MDS Information
Resident coded
1. Extensive assist or higher in bed mobility or transfers and
2. Coded with stage 2 or higher pressure ulcer

26. Quality Measure-Percent of high-risk residents with pressure ulcers (Long Stay)
This measure captures the percentage of long-stay, high-risk residents with Stage II-IV pressure ulcers.
Follow up needed if triggered:
Review skin assessment, cushion, care plan, supplements, and compliance of cares. Are further interventions needed? Review medications, wound cares, etc.
Review mobility? Do one of the exclusions apply? Was it coded correctly?

27. Quality Measure-Percent of residents who have/had a catheter inserted and left in their bladder (Long Stay)
This measure reports the percentage of residents who have had an indwelling catheter in the last 7 days.
Resident coded as having an indwelling catheter including suprapubic catheter and nephrostomy tube.
Exclusions:
End Stage Prognosis Hospice Care Neurogenic Bladder Obstructive Uropathy Short Stay

28. Quality Measure-Percent of residents who have/had a catheter inserted and left in their bladder (Long Stay)
This measure reports the percentage of residents who have had an indwelling catheter in the last 7 days.
Follow up needed if triggered:
If resident has a catheter: Has trial removal been done? Is the correct diagnosis given and coded? Is the resident appropriate for hospice or end stage prognosis?

29. Quality Measure-Percent of residents who were physically restrained (Long Stay)
This measure reports the percent of long-stay nursing facility residents who are physically restrained on a daily basis.
Daily use of trunk or limb restraints in or out of bed, or a chair that prevents rising is used daily.
Exclusions:
Missing MDS Information
Short Stay

30. Quality Measure-Percent of residents who were physically restrained (Long Stay)
This measure reports the percent of long-stay nursing facility residents who are physically restrained on a daily basis.
Follow up needed if triggered:
Only trunk, limb and chair restraints are used in this QI
If a resident is unable to stand on their own a geri chair is not a restraint.
Create a plan of care that manages the restraint device
Be sure the devise is being used as an improvement to the residents quality of life.

31. Quality Measure-Percent of residents with a urinary tract infection (Long Stay)
This measure reports the percent of long-stay nursing facility residents who have had a urinary tract infection within the past 30 days.
The UTI has a look-back of 30 days for active disease instead of 7 days.
Code only if all the following are met: Physician, NP, PA, or clinical nurse specialist or other authorized licensed staff has permitted by state law diagnosis of a UTI in the last 30 days Sign or symptom attributed to UTI, which may or may no include but not limited to: fever, urinary symptoms, pain, confusion or change in mental, status, change in character of urine Significant laboratory findings attending physician should determine level of significant findings and Current medication or treatment for a UTI in the last 30 days.

32. Quality Measure-Percent of residents with a urinary tract infection (Long Stay)
This measure reports the percent of long-stay nursing facility residents who have had a urinary tract infection within the past 30 days.
Exclusions:
End Stage Prognosis
Hospice
Short Stay
Follow up needed if triggered:
Root cause of most UTI’s is contamination from bacteria-typically from fecal matter. Look for excellent cleaning and toileting. Are the toileting times being audited? Identify residents at risk and implement necessary precautions (increased fluids, cranberry juice, etc.)

33. Quality Measure-Percent of residents who self-report moderate to severe pain (Long Stay)
This measure captures the 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 pain in the last 5 days.
Resident reports pain almost consistently or frequently at a level > 4
Pain > 8
Pain will trigger if they answer “Yes” to “Have you experienced pain over the past 5 days” AND
Pain occurs almost consistently or frequently AND pain is stated as greater than 4 on a 0-10 scale.

34. Quality Measure-Percent of residents who self-report moderate to severe pain (Long Stay)
This measure captures the 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 pain in the last 5 days.
Follow up needed if triggered:
Review pain medications, non-pharmacological interventions offered, resident education offered, timing of interviews,
Exclusions:
Missing MDS Information
Short Stay

35. Quality Measure-Percent of residents experiencing one or more falls with major injury (Long Stay)
This measure reports the percent of long-stay residents who have experienced one or more falls with major injury reported in the target period or look-back period (one full calendar year).
1 or more falls with a major injury since admission or prior assessment
Bone fractures, joint dislocations, closed head injury with altered consciousness, subdural hematoma
Exclusions:
Short Stay

36. Quality Measure-Percent of residents who received an antipsychotic medication (Long Stay)
This measure reports the percentage of long-stay residents who are receiving antipsychotic drugs in the target period.
Any number > 0 entered into section N0410A (antipsychotic)
Exclusions:
If the resident has a psychosis diagnosis coded in MDS Section I;
6000: Schizophrenia :Tourette’s : Huntington’s
Short Stay

37. Quality Measure-Percent of residents who received an antipsychotic medication (Long Stay)
This measure reports the percentage of long-stay residents who are receiving antipsychotic drugs in the target period.
Follow up needed if triggered:
Review care plan, behavior management, lowest possible effective dose, and trial dose reductions. Check medication classifications and proper diagnosis.

38. Quality measure-Percentage of residents whose Physical function improves from admission to discharge (short stay)
Measures the percent of short stay nursing home residents who made functional improvements on ADL’s during their complete episode of care.
Residents discharge assessment is compared to the admission assessment at increase in independence with transfer, self performance, locomotion on unit and walking in corridor.
If a resident is coded as independent on admission assessment they will be excluded from this measure.

39. Quality measure-Percentage of residents whose Physical function improves from admission to discharge (short stay)
Measures the percent of short stay nursing home resident who made functional improvements on ADL’s during their complete episode of care.
Exclusions:
Hospice Comatose End Stage Prognosis Was coded as independent on admission assessment Had unplanned discharge during care Missing MDS information
Follow up considerations- ensure accurate coding and documentation of cares. Share this measure with therapy teams and have them be aware of these facility goals.

40. Quality Measure-Percent of residents with pressure ulcers that are new or worsened (Short Stay)
This measure captures the percentage of short-stay residents with new or worsening Stage II-IV pressure ulcers.
Short stay resident who developed pressure sore or who had pressure sore get worse since admission
Pressure ulcers (stage 2, 3, 4) that were not present or were at a lesser stage on prior assessment.

41. Quality Measure-Percent of residents with pressure ulcers that are new or worsened (Short Stay)
This measure captures the percentage of short-stay residents with new or worsening Stage II-IV pressure ulcers.
Exclusions:
Missing MDS Information
Long Stay
Follow up needed if triggered:
Review skin assessments, cushion, care plan, supplements, and compliance of cares. Do you need any further interventions? Review medications, wound cares, etc.

42. Quality Measure-Percent of residents who self-report moderate to severe pain (Short Stay)
This measure captures the percent of short stay residents, with at least one episode of moderate/severe pain or horrible/excruciating pain of any frequency, in the last 5 days.
Resident reports pain almost consistently or frequently at a level > 4
Pain > 8
Pain will trigger if they answer “Yes” to “Have you experienced pain over the past 5 days” AND
Pain occurs almost consistently or frequently AND pain is stated as greater than 4 on a 0-10 scale.

43. Quality Measure-Percent of residents who self-report moderate to severe pain (Short Stay)
This measure captures the percent of short stay residents, with at least one episode of moderate/severe pain or horrible/excruciating pain of any frequency, in the last 5 days.
Exclusions:
Missing MDS Information
Long Stay
Follow up needed if triggered:
Review pain medications, non- pharmacological interventions offered, resident education offered, timing of interviews,

44. Quality Measure-Percent of residents who newly received an antipsychotic medication (Short Stay)
This measure reports the percentage of short-stay residents who are receiving an antipsychotic medication during the target period but not on their initial assessment.
Any number > 0 entered into section N0410A (antipsychotic)
AND in Prior assessment N0410 = 0
Exclusions:
If the resident has a psychosis diagnosis coded in MDS Section I;
6000: Schizophrenia :Tourette’s : Huntington’s
Long Stay

45. Quality Measure-Percent of residents who newly received an antipsychotic medication (Short Stay)
This measure reports the percentage of short-stay residents who are receiving an antipsychotic medication during the target period but not on their initial assessment.
Follow up needed if triggered:
Be sure your initial assessment captures any antipsychotic medications
Review care plan, behavior management, lowest possible effective dose, and trial dose reductions. Check medication classifications and proper diagnosis.

46. Quality measure-Percentage of residents who were re-hospitalized after a nursing home admission (short stay) claims based
Measures short-stay resident who entered or reentered the nursing home from a hospital and were re-admitted to a hospital for an unplanned inpatient stay or observation stay within 30 days of the start of the nursing home stay.
Resident was admitted to a hospital for an inpatient stay or outpatient observation stay within 30 days of entry/reentry to the nursing home.
This is regardless if they were discharged from the nursing home prior to the hospital readmission.
Determined by Medicare claims
RN’s should check POLST
On calls should ask can RN’s start IV’s, do diagnostics in house, is it something the RN can manage in the nursing home.
Are we D/Cing too early from hosp?

47. Quality measure-Percentage of residents who were re-hospitalized after a nursing home admission (short stay) claims based
Measures short-stay resident who entered or reentered the nursing home from a hospital and were re-admitted to a hospital for an unplanned inpatient stay or observation stay within 30 days of the start of the nursing home stay.
Exclusions: Hospice Comatose Missing MDS information
Follow up considerations-If a nursing home sends many residents back to the hospital, it may indicate that the nursing home is not properly assessing or taking care of its residents who are admitted to the nursing home from a hospital.
RN’s should check POLST
On calls should ask can RN’s start IV’s, do diagnostics in house, is it something the RN can manage in the nursing home.
Are we D/Cing too early from hosp?

48. Quality measure-Percentage of residents who Have had an outpatient emergency department visit (short stay) claims based
Measures short stay resident who entered or reentered the facility from a hospital, visited and emergency department within 30 days of the start of the stay, and this visit did not result in an inpatient or observation stay.
Resident was admitted to an emergency department for within 30 days of entry/reentry to the nursing home.
This is regardless if they were discharged from the nursing home prior to the hospital readmission.
Determined by Medicare Parts A and B claims

49. Quality measure-Percentage of residents who Have had an outpatient emergency department visit (short stay) claims based
Measures short stay resident who entered or reentered the facility from a hospital, visited and emergency department within 30 days of the start of the stay, and this visit did not result in an inpatient or observation stay.
Exclusions: Hospice Comatose Missing MDS information
Follow up considerations-If a nursing home often sends residents in for emergency visits, it may indicate that the nursing home is not properly assessing or taking care of its residents who are admitted to the home from the hospital. Better preventative care and access to physicians and NP’s could reduce ER visits.

50. Quality measure-Percentage of residents who were successfully discharged (short stay) claims based
Measures percent of short stay residents admitted to the nursing home from a hospital who were discharged to the community with 100 calendar days of the start of the episode, and who remained in the community for 30 consecutive days following discharge to the community.
Resident had discharge assessment indicating discharge to the community within 100 calendar days of the start of the episode AND
Was not admitted to a nursing home within 30 days of the community discharge-determined by Medicare claims AND
Did not have an unplanned inpatient hospital stay within 30 days of the community discharge
Premature discharge? Are we d/cing because of medicare? Medication management/education at d/c. Home care set ups? Follow up appointment once in community?

51. Quality measure-Percentage of residents who were successfully discharged (short stay) claims based
Measures percent of short stay residents admitted to the nursing home from a hospital who were discharged to the community with 100 calendar days of the start of the episode, and who remained in the community for 30 consecutive days following discharge to the community.
Exclusions: Hospice Comatose Missing MDS information
Follow up considerations-If a nursing home discharges few residents back to the community successfully, it may indicate that the nursing home is not properly assessing its residents who are admitted to the nursing home from a hospital or adequately preparing them for transition back to the community.
Premature discharge? Are we d/cing because of medicare? Medication management/education at d/c. Home care set ups? Follow up appointment once in community?

52. Quality Measures – how they are scored
Each measure is worth pts.
Measures are weighted with top percentages receiving the most points
All right are you still with me?
The quality measures are weighted with the 10% 70% 20% rule and given a score of points for each. It also notable that there are several risk factors that adjust the scores. A full list of each measure can be found in the users guide but that level of detail isn’t necessary. Just know that things like age, gender, demographics, comorbidities can all factor into the risk adjusted score.
Add the total for all your QM and you can find your star rating for QM’s

53. Great news we are nearing the finish line
Great news we are nearing the finish line. And because Yoda is my favorite (I had to get him in here somewehere) here is quick mental break-let’s face it after all that you earned it.

54. Overall nursing home rating
Step 1 Start with the health inspection rating
Step 2 If your staff rating is 4 or 5 add a star if it is 1 star then subtract a star
Step 3 If your quality rating is 5 stars add a star to step subtract a star if it is one star
If the nursing home health inspection rating is one star, then the overall rating cannot be upgraded by more than one star based on the staffing and quality measure ratings.
TALK THROUGH SLIDE

55. Case Study #1
Robert is a 79 year old male. Admitted to your facility two weeks ago. Robert weighs 350lbs and is too weak to toilet himself. He had a catheter placed in the hospital. He states he finds it easier to just use the catheter. He doesn’t want it removed and would like it to continue after therapy.

56. Case Study #2
Ethel has been your patient for years. She presented with early onset dementia in her late 50’s and she has since moved in to your facility. You have slowly watched her disease progression. You know that over the last 6 months she has had increased behaviors and she is starting to refuse cares. You review her chart before rounding to find that three weeks ago on a Saturday afternoon an on call Doctor proscribed Seroquel prn for dementia.

57. Case Study #3
Howard is a 85 year old man with a recent CVA. He is having a hard time adjusting to living at the facility and he expresses the desire to “go home”. Howard’s family really feels this is something he can overcome if he just try's hard enough in therapy. He is convinced that he should remain at full code but eats next to nothing at meals and has lost over 20% body weight in the last 2 months. His appetite is gone and he has declined any anti-depressant medications. You have discussed hospice with him but he and the family turned it down.

58. Case Study #4
Lilly is a vivacious 92 year old that has recently started dialysis, which she attends with the help of her daughter faithfully. During a treatment the dialysis nurse noticed some shortness of breath and after hearing some recognizable crackles recommended to her daughter that she be seen in the ER. After x-ray she is admitted to the hospital and diagnosed with pneumonia.

59. Thank you!!
Again thank you to the MMD for having me. I really appreciate all your time. If you found this helpful I’d love to hear about it.
CLICK

60. Resources Quality Measures User’s Manual CMS.gov
Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual- V10.pdf
Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User%E2%80%99s-Manual- V80.pdf
CMS.gov
certification/CertificationandComplianc/FSQRS.html
Certification/CertificationandComplianc/downloads/cutpointstable.pdf
ABT-Nursing Home compare Quality Measure Technical Specifications
Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT pdf

61. Questions??? Christy Johnson
Regional Training Director, Operational Development
Ecumen Home Office / 3530 Lexington Ave North Shoreview, MN 55126
W: (651) / C: (651) /
You can reach me via phone or . I also have cards if you would like one.
Any questions??