the transcript. - The New England QIN-QIO
Contents
1. The denominator is smaller one or 2 residents can send a percentage higher in the click you have an issue but when you look at actual numbers of people and maybe one or 2 residents I hope that answers your question if it doesn t I can clarify Who in the Department of Public health should we contact Questions on fixing the 671 Form I would start with your survey lead team lead for your survey who you had contact with We can t get in contact with them go up to whoever is in charge of the nursing home Wyse Ensure division it could be a manager you contact me via branch chief start with your survey or team lead first Those are all the questions and chat if anyone on the line would like to ask a question you can press pound 6 to unmute your line and ask Michelle a question We talked about a lot of information in a short period of time feel free if you want to email me or give me a call to ask questions I m happy to answer any questions you may have if you think of them later How long after survey are you put back into compliance Does it take for the overall star rating to change from your survey results I m assuming this is how most of the departments of public health operate once they of your survey in the close it out back in compliance no outstanding IDR s and they closed it and can upload that information nursing home compare as soon as that is done the following month is when CMS will upload it that happens on the 22. contribute to my five star ratings Choose your answers true or false And then press submit We will move on to examples for calculating your score while we get the results calculated Our first example health inspection rating of 3 3 distinct scoring methodologies 3 stars health inspection one start staffing reading 3 for quality measures For the math or calculation we start with the 3 stars that is our foundation and the basis of our overall scores We subtract a star because of her performance in staffing the only have one star there For quality measures what you think we will too will we add or subtract for the 3 stars We want to anything we will add zero or subtract zero 3 stars is in the middle we do not add or lose a star Your overall rating is now a 2 Had about the next example Health inspection rating of 2 staffing 3 quality measures of 5 With our calculation we start with health inspection so we start with a 2 Now we add or subtract We are going to add anything 3 is in the middle we don t add or subtract anything How about quality measures We start out with 5 stars we add or subtract their Absolutely we will add another star you performed really well for quality measures So this facility and up with an overall rating of 3 Our next example Health inspection rating of one staffing rating of 5 quality measure reading of 5 as well Buyer calculation we start with one star and health inspection 5 stars f
3. contribute to your five star rating is just when the information is updated You can take a look at that When I say updated monthly it doesn t mean your information will change every month but your department of public health once your surveys are completed and they do the paperwork and it is uploaded into the CMS system they will uploaded into nursing home compare and your department of public health those that every month Your staffing information it is a snapshot during your 2 weeks of the survey remember the 671 form Remember you are paying close attention to that and make sure you completed to collect all the staffing you are providing That information is updated monthly on the 2nd Tuesday as well because the staffing information is captured during the survey and uploaded during your survey information as well Your quality measure information is an average of those three quarters and a rolling three quarters there is a six month lag and that is updated every quarter and on the 3rd Thursday of every month When you look at the rolling quarters of information picture you weight until the 3rd Thursday to see if your star rating will change This will help you with information and went your star rating will change I mentioned the health and fire safety and staff is updated monthly it may not mean your information is updated but it means you can see changes to your overall score It is a bell curve how the facilities are ranked accor
4. differently Data I think is one of the most powerful mechanisms for telling stories I take a huge pile of data and try to get it to tell stories Steven Levitt had said that it is a great way to capture what the that nursing homes should tell you as well We will open it up this is the end of my presentation we will open up to questions Someone said I must small facility how my calculated as I don t have the 20 or 30 residence for the denominator That is a fantastic question For those facilities who don t have enough to calculate your denominator you may see something on nursing home compare that says in a calm denominators are smaller something to say doesn t calculate a score If that is one of the quality measures that contribute to your five star rating here is another caveat to the whole five star system and I am sorry I am the bearer of bad news Luckily we are on a webinar and can throw tomatoes at me If you do not have enough information to calculate a dominator for short or long stay what CMS does in order to give you the star rating they will take the average of the state s performance in the quality measure and substitute your lack of data in that area because of the dominator and use that average Facilities may be struggling and that measure in the state average is that of an yours you make out in that area Unfortunately if you are smaller facility who may be performing better than the state average when CMS uses the st
5. include it Your RN more than 40 hours a week I m sure that your facility make sure you capture that Back to quality measures and looking at five star domain This information is reported by the nursing home based on their assessment of the residence using MDS data All the quality measure information is coming directly from you Quality measures included short stay in long stay are listed here important to point out catheters moderate severe pain under the long stays and under the short stays are risk adjusted it is done for you as well So your quality measure information is based on the 3 most recent quarters of data Not just one quarter but an average of those three quarters In order to have information that contributes to the star rating your short state measures you have to have a denominator a minimum of 20 people and for your long stay a minimum of 30 For smaller facilities you have to look at that whether you have enough to contribute for that denominator score Your points are assigned based on facility performance Scores are assigned under quality measures and the scenario you want higher scores Populations for each of the quality measures Cost so take a look at that The caveat the quality measure information is an average of those three quarters But there is a six month lag in the data Right now we are in quarter 4 2015 70 have to count back to quarters six month lag That brings us to quarter one of this year
6. my facilities five star rating is an average of all the categories reading If you could contribute to a true or false We will go back to that as well After you choose your answer if you could hit submit to the bottom of the chat box that will help with the polling information On the five star quality rating system featured on nursing home compare it has multiple star ratings Health inspection staffing quality measures and then you also have an overall rating If you are thinking about your overall rating being an average of the first 3 you would be wrong Your overall rating is not an average of those components We will go into the math behind the overall rating it is a little counterintuitive to what most of us think So most of you answered that the five star overall rating is not an average and you are correct The nursing home compare a quick shot of what it looks like You have 4 different star rating And they mean what you think they what 3 is average one star is much below average and 5 stars is much above average The way they are distributed based on a bell curve Name of the mindset that all the nursing homes in your state are doing excellent work and considered five star building they should all be 5 stars Unfortunately as a way to make the stars evenly distributed among the states there is a bell curve applied The top 10 facilities scoring in each state are considered five star The bottom 20 of facilities p
7. worked for the Alzheimer s Association Connecticut chapter for many years as a volunteer Support facilitator and director of client and family services she holds a Masters in social work administration and business administration from the University of Connecticut and she holds a bachelor s degree in social work from Providence College Please welcome Michelle Thank you so much good afternoon and thank you for joining us today We a lot of information to go through I want to make the presentation as interactive as possible if you have questions feel free to put them in the chat will take them throughout the program if it applies and save some for the end as well Today we ll talk about the various data sources available for you to monitor your quality and performance We ll compare and contrast which ones you should pay attention to in which ones to validate against each other We will understand what contributes to your five star rating and for you to know which resources to use to understand the data The New England QIO QIO covers all 6 states in New England this is a website please go on tour websites for information and resources and to access the library of the educational programs we provide you If you don t know your state nursing home contact here is the information their names and contact any of our team members they are fantastic and there to help and support you in your quality improvement efforts Data monitoring for
8. ASPER report and you will only have 3 of those measures in your reports Your composite score doesn t record on any of your short stay measures your five star rating only 3 of those measures should be to your five star rating You see so much more we come to the long stay measures publicly reported on nursing home compare what is available on your CASPER reports on your composite score or SAR report you ll get from the QIN QIO Let s say you have your leadership administrator orders owners cut corporation or whatever it is saying why are you only a 3 star whatever it is you want to come to this crosswalk and say what contributes to my five star rating If you start looking at incontinence for low risk or vaccination or anything like that which by all means don t stop we want to make sure you look at all the quality measures but to put a quality improvement project or initiative surrounding one of those it will not change your five star rating If you want to drill down to what contributes to your five star makes a difference in your rating score look at the quality measures Same for your CASPER reports maybe on nursing home compare the reports are with false but you want to know what is going on with false your organization you can go to your CASPER report and that s for the information is available So this is a crosswalk between short stay in long state to find out what information is housed where Looking at your data images CASP
9. ER for those of you who aren t familiar with the CASPER reports there s a bike to Friday reports available to you through your MDS computer You can pull down the information on a monthly basis for an entire year you can look at your report and assigned what report to look at What I would recommend if you re worried about your five star rating go into CASPER your MDS computer into CASPER and pull down the reporting period for the exact same three quarters the nursing home compare is reporting your information on We know there is a six month lag which is unfortunate and frustrating That is what the public is looking at it could be said there was an issue in with taking care of it and resolved that in our scores are better but unfortunately it will take a while for it to show up That is one your messaging to your residence staffing and family could you want them to know that they are tuned into what information is available on nursing home compare and how it contributes to the information and projects with the organization The CASPER reports are real time you can pull us down for how you perform in September if you want to look at that You can validate what is on nursing home compare internal committees that may be happening in with your MDS and care plans fast you can get resident level data you look at your CASPER purports to say while Mrs Jones is chugging it on the antipsychotic vacation but I don t recall her having a psychotic d
10. Event Name Understanding CMS 5 Star Rating System How the Quality Measures contribute to your rating Event Date October 22 2015 Event Time 2 00 3 00pm ET Please stand by for realtime captions Hello everyone this is Morgan from the New England QIO and we will get started in about three minutes Hello everyone this is Morgan from the New England QIO thank you for joining us for today s webinar on understanding CMS five star rating system how the quality measures contribute to your rating Before we get started I will review a few housekeeping items this call is recorded for training purposes I will provide you details on accessing it at the end of the webinar The phone lines are unmute but we are hearing some feedback so if you could mute your line we would appreciate it We ll take questions at the end and I will provide you instructions on how to unmute at that time For now our speaker Michelle Pandolfi has 17 years experience in the long term care profession is in the license nursing home administrator in Connecticut She is the director and has managed national nursing home quality improvement projects care transition projects She helped create the Connecticut culture change coalition in 2006 and maintains an active leadership role She is spoke nationally about patient safety person centered care in nursing homes Previous work includes managing Alzheimer s dementia units in nursing homes in Connecticut and Rhode Island She has
11. So the information in a nursing home compare takes those quarters from quarter one and the last two quarters of last year as well The calculations of the Q Adams you can get 20 to 100 points based on facility performance in this case the higher points better if you observe percent residence triggering for any quality measure you can get 100 points that means they are triggering The points are assigned a stunt national percentile and the same for every facility All the 11 quality measures are given equal weight But your ADL quality measure is based on your state performance versus national performance That is the only variation it is still an average of how your state performs but it does account for geographical differences Your points across all quality measures for your scores relate your quality measures If you wanted to figure out quality measure score to the manual for details because each quality measure has its own formula too much to go into and too much math I don t want to do automatic it would rather CMS do it for me You can see where you fall based on your quality measure star rating and your points here As I mentioned there were changes earlier this year antipsychotic medication use was added for short stay in long stay CMS change the methodology and calculations on how to earn points for 2 stars are greater for facilities and you must meet the RN or total staffing by for more stars to achieve a four star overall r
12. ate average it could pull down your whole star rating That happened to a facility I worked with them they couldn t figure out what it happened and to we went through the different domains and looked at everything It is in the five star manual took us a while to figure it out and because the state average was lower than the usual facility performance to pull down the star rating from 5 to 4 Great question thank you We had 2 more questions come in how can we fix staffing number that was submitted on the 6 everyone form if there was an error Contact your Department of Public health depending on when you determine there was an error on the form depending on where they are in their upload process the CMS system they may be able to stop the upload and fix the form based on what you provide them Honestly I would contact the Department of Public health and find out where they are and if they can work with you It is happened in the past and is worth a call Does the overall number of beds certified have an effect on the scores I will assume that when you say overall number of beds certified means Medicare and Medicaid certified because those are the only beds that will contribute to your scores If you are a large facility compared to a fall tour small facility it can contribute in the fact that anyone less than 100 beds cut even one or 2 residents can make your percentages seem higher than other facilities that were over 100 beds for instance
13. ating The calculations were changed a little and based off the new methodologies being used You may have seen based on these updates the five star system your own quality measures or other staffing scores change The stuff that The new calculations The goods to do everything differently put your store operating may have been adjusted How you calculate your overall star rating 3 simple steps Start with your health inspection rating that is why when you look at the five star program we took each individual domain separately and start with health inspection The event as the foundation of your overall star rating that is what we re trying to get to Your overall rating Start with health inspection You will figure out your health inspection rating and we talked about that calculation and we looked at the 3 years and wait them Then look at your staffing reading at a star if you actually received a 4 or 5 star rating understaffing The caveat is and it is greater than your health inspection rating If you started out with a 3 for your health inspection you at the star Subtract a star from staffing if you received a one star staffing reading Then you will look at your quality measure reading look at your house inspection add or subtract for the staffing and look at your quality measure reading You are at a star if you received 5 stars for your quality measure and you will subtract a star if you received a one star in your qual
14. ding to their overall rating of five star down to one star Depending on how your neighbors perform or someone else in your state may perform it could affect your rating if you are on the cusp between say a 3 and a4 or 4 and 5 or 2 ina3 What drives your five star rating MDS 3 0 information All this information make sure you take a look at it Pull down the five star technical users guide it will give you information you need to know about calculations more of the information I explained in this presentation if you like math and want to do it by all means you can calculate all your scores on your own Our polling question the question we asked looking at nursing home compare publicly reported and we looked at does it publicly report quality measures that don t contribute to your five star rating Absolutely true is the correct answer nursing home compare has measures that are publicly recorded in your five star rating only has 11 that contribute So way to go We talked about so many different data sources nursing home compare five star rating different domains and five star your CASPER reports all of that what goes where and how to get the information Here s the crosswalk can look at Of your short stay measures nursing home compare all of them moderate to severe pain nor worse You vaccinations and a psychotic meds Your CASPER reports you will hold down and they are available anytime from your MDS computer pulled on your C
15. e updated Your complaint surveys all your complaint surveys are contributing to star ratings but these are weighted like your regular annual survey Your most recent you have to last 12 months is 15 of your score the one before that is 33 and the one before that is 16 If you had a complaint survey conducted within 15 days of your animal survey before or after they will not count the deficiencies twice They will group them the same deficiencies and counted as one but they will take whatever scope and severity is the highest and use it and apply it I can t see if you have a complaint that was 30 days before after that they will do the same thing it is really just 15 days Most of you are familiar with this survey deficiency score It looks like the weights for the different types of deficiencies related to scope and severity Notice the points assigned this is how you will know how many points are assigned to you based on how many deficiencies you have in each survey window or survey period you have It contributes to your overall score Those point you see in the parentheses are based off the points assigned if your department of public health needs to come out multiple times to look at revisits Right here you see the table for repeat visits The first time they come out there is no additional points assigned If they come out a 2nd 3rd or 4th you will have more points assigned to your health inspection and that is when they sta
16. ere feel free to click on it when you have time to look at it It is your go to document to understand how do I get this information about my long stay or short stay quality measure If I want to look at falls what does that mean if you look in the user manual you can see what your numerator and denominator are you can also see any exclusions If you questions like something doesn t make sense you can figure it out to the user s manual Years ago when we had restraints as commonplace in nursing home facilities a lot of facilities would say to me we know we have an issue with this our present a high but that is because we use side rails Okay so we can look at that one when you look at the user s manual you would know side rails though captured on the NBS did not contribute to the percentage of physical restraint numbers Some people could walk around with false information or misunderstanding of what contributes to the percentage This user manual will tell you what does and what doesn t What you need to know about nursing home compare You need to know not all the quality measures contribute to your five star rating I mentioned 5 stars is different than nursing home compare it is a component on nursing home compare website The nursing home compare website include more than 5 star Not all your quality measures are available on your CASPER report that is good information to know What is publicly reported may not be the same you get on
17. erforming in every state are considered one star Equally distributed amongst 2 to 4 stars The five star health inspection domain for different domains and we ll talk about the first one health inspections Your health inspection star rating is comprised of 3 of your annual inspections your last 3 surveys are what contribute to your star rating It is weighted so your most recent survey is 50 the survey last year is considered 33 in 3 years ago is 16 Of your star rating If you had complaints or health inspections and or revisits in the last 3 years those are included as well The rating considers the number and the scope and severity of deficiencies Your life safety surveys and federal comparative surveys are not included in your star ratings for health inspection but keep in mind any focused surveys are included If you are one of the facilities that may be chosen to have a focused survey MDS or dementia or whatever that will be included in it is included one because it is a survey and also because the way your department of public health in your state needs to enter it into the CMS system goes under the complaint survey So it will contribute to your star rating Your health inspection ratings are based on relative performance in your state You re compared against how your peers are doing The data is updated each month related to health inspections We will go over the time frames for how the health inspections and star ratings ar
18. iagnosis so let s look at that Your other data is your composite score driving improvement projects based on the support of the QIN QIO and benchmarks you against others performance And of course your five star program you can calculate your own score benchmark yourself use it to make sure people understand information you have is publicly available If you questions related to your five star rating make sure you use the preview helpline CMS makes available For 3 days every quarter when the information will change You will get noticed through your MDS computer and there is a helpline available for 3 short days you can call they can walk you through every calculation you have If you want to know how you are performing and you can t get it because your math doesn t add up to their math have them walk you through it We had one facility that one from a five star to a four star in staffing and couldn t figure out why they call the helpline and they walked them through the mass and what it came down to they were 100 of the point away It doesn t mean you ve done anything different you have to put huge quality improvement project behind it find out what the masses first When she do user data always Data will help make decisions and guide changes how you measure your improvement projects to educate your staff residence families you can budget according to it we need to invest more dollars or not should we put in more staffing or educate
19. ity measure reading So you need to look at each of these 3 pockets has 3 distinct scores to figure out what your overall rating is because it is not an average By doing all this starting with health inspection and adding or subtracting staffing and adding or subtracting quality measures you would come out with your quality rating It can be confusing so let s go over a couple of examples that will help us solidify this There are some caveats to this for your health inspection if you start with your health inspection as a one star you are unable to gain additional stars more than one He started your health inspection with one say you had a five star in staffing and quality measure based on the above calculations you would end up being a three star facility Caveat is if we start with your health inspection you can t gain more than one star the matter how you perform in the other 2 areas can only become a to start facility The other caveat is if you are a special focus facility then you cannot exceed more than 3 stars total Let s say you started with health inspection rating of 2 based on the above calculations if you had 5 stars for staffing and quality measure you gain 2 stars to become a four star cut you cannot do that if you are a focus building you Out at 3 Quick polling question and we will move on if we can open up the polling question that would be great Sure falls nursing home compare publicly reports quality measures that don t
20. nd Tuesday of every month It should happen shortly after that If you have questions about how long it takes you can contact your survey team lead if they can t answer the question have them direct you to the manager and the manager can let you know where they are in queue for the uploads In my state they try to work hard on getting that information updated and upload it as quickly as possible So your scores don t take a long time It should happen in a couple of months Again if you ve a question online you can press pound 6 to ask a question To the state or federal government determine star rating for survey Your star rating is based on how you score the score is the same depending on your score and severity Kovac to the grid we looked at feel free to go back to that Grid and take a look You see the points assigned that is how you find out your score your score will determine your star rating and that is included in the manual so you can look at that That is equal for everyone Thank you Michelle for that wonderful presentation If you have additional questions Michelle has included her information in the PowerPoint deck when you close out of the webinar you will be taken to the evaluation if you could fill it out we greatly appreciate it If you don t have time today or you are sharing your computer we will send out a follow up email tomorrow with a link to the evaluation as well as a link to where the PowerPoint recording in tran
21. or staffing what will we do there At a star we to go Staffing that performed well How about quality measures we of 5 would we add a star here We will not add a star because the caveat for this is your house and section started with the one star one star health inspection you cannot gain any more than one star the matter your performance in the other 2 domains This facility would be an overall to star facility Now we have an example for special focus facility Health inspection rating of 3 staffing rating of 5 and quality measure of 3 How will we end up for our overall rating Our calculation will start with 3 stars are based For staffing get 5 stars what we do here We will not add a star We add anything for quality measures We want anything because you wouldn t add or subtract for 3 This is an overall star rating of 3 you will ask why we didn t gain a star for staffing If you remember I said one of the caveats if you are special focus facility you are At 3 stars that you can t you are done at 3 stars cut you can t gain any more if you started with 3 My trip to make sure you are paying attention The date on the time frames and updates for looking at your five star information in nursing home compare Your health and fire safety inspections they look at 3 years worth of surveys include complaints and focused service All the information is updated monthly on the 2nd Tuesday I listed your fire inspections but it doesn t mean they
22. quality in your organization There are various resources available to you public and private public sources include nursing home compare and the five star program I said no separately because they are two distinct entities on nursing home compare and we ll talk about that little bit The private sources available include your SAR reports and composite score if you are part of the New England QIO collaborative you are getting those and if you aren t that is good reason to join us CASPER Other private sources include your report and internally collected data We will start out with a quick polling question how often do you review your Kaspar reports Monthly quarterly and Emily or what is a Kaspar report If we could open up the polling question will get everyone about 30 seconds or minutes answer and then once the answers are populated we will come back to the question Emily or Jennifer if you are on the line could you open our first polling question What we would like you to do is answer how often do you review your CASPER reports We re trying understand part of this presentation is to understand what your CASPER are in the value they bring to you Moving on to nursing home compare Most of you are aware of what it is and if you haven t been on it yet this is the direct site you can go to The link Nursing home compare searches nursing homes across the country it was meant to be a consumer driven websites that consumers no matter
23. rt to wait things To calculate your survey score before you can get your rating you need to figure your score there is a way you can do this on your own For the first step you will list the deficiency you receive on survey if you received any I each survey year You will look at your most recent and work back so you have 3 years total Your next step is to assign a score and go back to the survey focus severity create we looked at and add up the scores that way You will assign a score to each deficiency You want to sum up each year Based off each year will multiply your most recent survey 5 5 He will by 5 You will then multiply your score from 2 years ago by 33 And from 3 years ago by 16 This gives you the waiting we talked about And then you will add your new scores together and that gives you your survey score Now cut you don t want to forget about the complete investigation so look at your annual surveys and complaint investigations focused surveys you received as well You have your five star staffing to me Now the staffing data is interesting because a lot goes into it The staffing information captures the number of hours of care on average provided to your residence each day it includes your RNs directors of nursing RNs of administration duties full time and part time employees and agents your contract staff as well The information in staffing data and points of how the stars are assigned is based on the CMS staffing st
24. script for the webinar will be located The PowerPoint has been added to our website and I did put the link on chat If you want to go there you can download the presentation from today Thank you for attending Michelle one more thing to say I want to make sure I provide further information related to the last question about star ratings related to the survey Scoring methodology is the same matter how you cut your deficiency whether you are in Alaska or Alabama your relative performance is in each state Your scoring in the distribution cut the Bell curve of scoring will determine by each state We all say some state is easier than others whether it is true or not but because the humans are involved or that element of subjectivity and where states with trying QIN versus traditional if the methodology is in your state applies to each individual deficiency on its own It will determine your performance in your state Hopefully that clarifies and doesn t confuse anyone further Contact me if you have further questions Thank you everyone have a good afternoon Event Concluded
25. to staffing measures the information that feeds into the overall staffing they are given equal weight so when you group your RNs LPNs and see us together and look at your RNs those 2 that contribute to the star rating are given the equal weight These of that you are assigned a star rating based on a percentile based method you will see from table for out of the manual you will see where you may fall based on what your score ends up being Then you can get your overall rating based on how you performed in those 2 areas If we go back to the first table you ll get a star rating based on just your RN in a star rating based on all of your nursing staff together Based on how you did that the average is how you would fall into this overall staffing point in rating scale You will see here it is very difficult to get a five star rating in staffing because you need to have over 4 4 and for total staffing and for your RNs you need to be over 7 or 7 to get your five star Of course it comes always down to 3 Left to right I m sorry right to left Your staffing score as I said you must obtain a pretty high score to get your for five star rating There is a caveat when it comes to staffing and I don t mean it to confuse you in order to obtain a for five star rating in the staffing domain the overall staffing score you will get you must exceed the five star level for both our and in total staffing numbers We talked about that when I showed
26. udy done a few years ago Where the CMS get this information and how to calculate your staffing scores From the data source you fill out the 671 form on your annual survey On the annual survey you will get the form and fill it out so pay attention and make sure you have a few people look at it make sure it is accurate You want to capture all you are doing in your organization that you can have the best staffing score you can get Your staffing information based on 2 different data points Looking at your total nursing hours per resident day everyone in your nursing department But also looks at just your RN hours per resident day as well On the table you will see when I pull these tables I am pulling it from the five star manual so you have access to this information beyond this presentation I will show you how to get to that It looks at what the average hours per resident to be and this is based off the national average it does say April 2012 cut that is the last time CMS updated this They are saying the national average hours per resident day for total staffing is a little over 4 and a little under one for registered nurses Your staffing information is case mix adjusted accounting for differences the level of need for care of resident to have an based on your rugs 3 grouping This is the calculation you can use if you really wanted to do fun math and try to figure out what your staffing information would be as well Now also
27. where they are across the country had a common way to search for nursing homes You could look to see mom was in California and I need to know what is available to her even though I am in Connecticut My neighbor in New York is at the corner of New York and Massachusetts and wants to know what nursing home to go to This is your way of doing that CMS tried to make it as even inconsistent as possible across the country for people to do that Basic information available is demographic information about every nursing home health and fire safety inspection information staffing quality measures penalties nursing home may have received during annual survey in the five star ratings Results are up to our question It looks like the majority of people use it monthly which is great some people didn t answer so that is okay but we would like you to get involved we want to understand how you use the reports Of those using them monthly is great quarterly is great and really you want to think about using the more often By the end of today s presentation hopefully you ll change your mind That to nursing home compare it has both your short stay a long stay quality measures Short stay include pain pressure ulcers vaccinations and antipsychotic medication use Long stay includes more Falls UTIs pain ulcers incontinence Abuse weight loss depression etc Your quality measure user manual version 8 is the one most available in the link h
28. you the overall matrix To receive at least a 3 star rating on both our and in total staffing and receive a rating of 45 stars on one of those domains to get 4 stars To get 5 stars you have to be perfect or exceed that in both of those scoring methodologies for overall staffing and RN but to receive a 4 star in both areas have to have at least 3 star rating and you must have 4 or 5 in one of the domains It can get complicated Polling question true or false I shouldn t include my director of nursing RN hours on my 671 form If we could open up the question and provide your information true or false in click submit We will move on Wait for that to pop up So we look at nursing five star rating we look at inspection staffing and now let s move on to the quality measure to me Of the quality measures that are on this there are 11 quality measures out of the possible 18 When we look at nursing home compare we saw that there were so many of the long stay in the short stick When it comes to the five star rating it doesn t look at all those 18 but takes 11 of them 3 short stay and 8 long stay Why 11 CMS felt these core measures have the highest reliability Some of the new added in February this year long stay in short state antipsychotic medication measure as well The results are up You do want to include your director of nursing hours in your 671 form Absolutely Work with your surveyors to fill it out as well but you want to
29. your CASPER report And all of your quality measures contribute to your composite score We will go through these as we continue on in the presentation keep it in mind as we continue What drives your quality measure data I hope you all said MDS 3 0 because that is it What you are capturing on MDS is what drives your quality measure information what you will see under home compare a CASPER report and here the reports to collaborative The RAI manual here is a link is so important to others any what you are supposed to capture on your MDS If you don t have a QAPI you can download it for free off of this website so make sure you read it as much as MDS people are doing this day in and out it is impossible to memorize all the information included in the RAI manual I encourage you to go back and read it and read often especially if you re questioning your numbers and percentages and what they are saying And With your quality measure user manual and make sure you understand the numerator denominator and what tries it Another tidbit is to make sure anyone filling out your MDS 3 0 form has the RAI manual whether it is social service therapy or whoever it is make sure they have a they understand how to code the intent etc Now five star I mentioned it as a component in nursing home compare and that is where you can find the information We will start with a polling question before we get into this component of the training Sure or false
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