CMS MDS 3.0 User Manual
MDS 3.0 Quality Measures
USER’S MANUAL
(v14.0)
Effective October 1, 2020
QUALITY MEASURES (QM) USER’S MANUAL
CONTENTS
MDS 3.0 Quality Measures USER’S MANUAL (v14.0) ....................................................... i
QUALITY MEASURES (QM) USER’S MANUAL CONTENTS ................................. i
NOTABLE CHANGES TO THE MDS QUALITY MEASURES (QM)
USER’S MANUAL V14 .........................................................................................1
Chapter 1 QM Sample and Record Selection Methodology ......................................................3
Section 1: Definitions .......................................................................................................3
Section 2: Selecting the QM Samples ...............................................................................5
Section 3: Short Stay Record Definitions .........................................................................7
Section 4: Long Stay Record Definitions .........................................................................9
Section 5: Transition from the Pressure Ulcer to Skin Integrity Quality
Measures ................................................................................................................12
Section 6: Transition to the Patient Driven Payment Model ..........................................12
Chapter 2 MDS 3.0 Quality Measures Logical Specifications ................................................15
Section 1: Short Stay (SS) Quality Measures .................................................................16
Table 2-1 Changes in Skin Integrity Post-Acute Care: Pressure
Ulcer/Injury ................................................................................................16
Table 2-2 Percent of Residents Who Were Assessed and Appropriately
Given the Seasonal Influenza Vaccine (SS) ..............................................17
Table 2-3 Percent of Residents Who Received the Seasonal Influenza
Vaccine (SS) ..............................................................................................18
Table 2-4 Percent of Residents Who Were Offered and Declined the
Seasonal Influenza Vaccine (SS) ...............................................................19
Table 2-5 Percent of Residents Who Did Not Receive, Due to Medical
Contraindication, the Seasonal Influenza Vaccine (SS) ............................20
Table 2-6 Percent of Residents Assessed and Appropriately Given the
Pneumococcal Vaccine (SS)21
Table 2-7 Percent of Residents Who Received the Pneumococcal
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 i
.....................................................................
Vaccine (SS
)
22
..
Table 2-8 Percent of Residents Who Were Offered and Declined the
Pneumococcal Vaccine (SS)23
.....................................................................
Table 2-9 Percent of Residents Who Did Not Receive, Due to Medical
Contraindication, the Pneumococcal Vaccine (SS)
24...................................
Table 2-10 Percent of Residents Who Newly Received an Antipsychotic
Medication (SS) .........................................................................................25
Table 2-11 Percent of Residents Who Made Improvements in Function
(SS) ............................................................................................................27
Section 2: Long Stay (LS) Quality Measures .................................................................30
Table 2-12 Percent of Residents Experiencing One or More Falls with
Major Injury (LS) .......................................................................................30
Table 2-13 Percent of High-Risk Residents With Pressure Ulcers (LS) ...............31
Table 2-14 Percent of Residents Assessed and AppropriatelyGiven the
Seasonal Influenza Vaccine (LS) ...............................................................33
Table 2-15 Percent of Residents Who Received the Seasonal Influenza
Vaccine (LS) ..............................................................................................34
Table 2-16 Percent of Residents Who Were Offered and Declined the
Seasonal Influenza Vaccine (LS) ...............................................................35
Table 2-17 Percent of Residents Who Did Not Receive, Due to Medical
Contraindication, the Seasonal Influenza Vaccine (LS) ............................36
Table 2-18 Percent of Residents Assessed and Appropriately Given the
Pneumococcal Vaccine (LS) ......................................................................37
Table 2-19 Percent of Residents Who Received the Pneumococcal
Vaccine (LS) ..............................................................................................38
Table 2-20 Percent of Residents Who Were Offered and Declined the
Pneumococcal Vaccine (LS) ......................................................................39
Table 2-21 Percent of Residents Who Did Not Receive, Due to Medical
Contraindication, the Pneumococcal Vaccine (LS)40
...................................
Table 2-22 Percent of Residents with a Urinary Tract Infection (LS) ...................41
Table 2-23 Percent of Low Risk Residents Who Lose Control of Their
Bowel or Bladder (LS) ...............................................................................42
Table 2-24 Percent of Residents Who Have/Had a Catheter Inserted and
Left in Their Bladder (LS) .........................................................................44
Table 2-25 Percent of Residents Who Were Physically Restrained (LS) ..............46
Table 2-26 Percent of Residents Whose Need for Help with Activities of
Daily Living Has Increased (LS) ...............................................................47
Table 2-27 Percent of Residents Who Lose Too Much Weight (LS) ....................49
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 ii
Table 2-28 Percent of Residents Who Have Depressive Symptoms (LS) .............50
Table 2-29 Percent of Residents Who Received an Antipsychotic
Medication (LS) .........................................................................................52
Table 2-30 Prevalence of Falls (LS) 53 ...........
...........
Tabel 2-31 Prevalence of Antianxiety/Hypnotic Use (LS)
Table 2-32 Prevalence of Behavior Symptoms Affecting Others (LS)56
...............................................
...................................
.....
54
............
Table 2-33 Percent of Residents Whose Ability to Move Independently
Worsene
d (LS) ...........................................................................................57
Table 2-34 Percent of Residents Who Used Antianxiety or Hypnotic
Medication (LS) .........................................................................................60
Chapter 3 Technical Details .....................................................................................................61
Quality Measures (QM) Technical Details .....................................................................62
Section 1 Introduction .....................................................................................................63
Section 2 Steps Used in National QM Calculation .........................................................65
Section 3 Calculation of the Expected QM Score ..........................................................69
Section 4 Calculation of the Adjusted QM Score ...........................................................72
Chapter 4 Parameters Used for Each Quarter ..........................................................................73
Table 4-1. Logistic Regression Coefficients .........................................................74
Table 4-2. National Observed QM Means ............................................................75
Chapter 5 Episode and Stay Determination Logic ...................................................................76
Table 5-1: Possible Entry Dates When Entry Record is Missing ..........................79
Chapter 6 Specifications for the Facility Characteristics Report .............................................83
Table 6-1: Facility Characteristics Report Measure Definitions ...........................85
APPENDIX A Quality Measure Identification Number by CMS Reporting Module..............1
Table A-1: Quality Measures (QMs) by CMS Reporting Module – Short
Stay ..............................................................................................................5
Table A-2: Quality Measures (QMs) by CMS Reporting Module – Long
Stay ..............................................................................................................7
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 iii
NOTABLE CHANGES TO THE MDS QUALITY MEASURES (QM)
USER’S MANUAL V14
Transition from the Pressure Ulcer to Skin Integrity Measure
Beginning with the FY 2020 SNF QRP effective October 1, 2020, , Percent of Residents or
Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (CMS ID: S002.02) will
be removed from the SNF QRP measure set and replaced with a modified version of that
measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: S038.02),
to include the addition of new or worsened unstageable pressure ulcers. This SNF QRP measure
will also be reported as a part of the NHQI effective 10/01/2020. For additional details on this
transition, please see Chapter 1 Section 5 of this manual.
Surveyor Quality Measures
The appendix on surveyor quality measures contained in previous versions of this user’s manual
has been removed from MDS QM User’s Manual V14, and the measures have been relocated to
Section 2 (Long Stay) of Chapter 2. Quality measure reports are available to State Surveyors and
facility staff through CMS’s CASPER reporting system. Quality measures available to facilities
through CASPER are also available to State Surveyors. Information regarding which measures
are available in CASPER is located in the Quality Measure by CMS Reporting Module, located
in Appendix A of this manual.
Measures Withdrawn from NQF Submission
The appendix on measures withdrawn from NQF submission contained in previous versions of
this user’s manual has been removed from MDS QM User’s Manual V14, and the measures have
been relocated to Section 1 (Short Stay) and Section 2 (Long Stay) of Chapter 2 respectively.
The following list contains measures that were previously approved or given time limited
endorsement by the National Quality Forum (NQF) but have been withdrawn from NQF
submission. The specifications for the Short Stay measures withdrawn from NQF submission can
be found in Chapter 2 Section 1 of this manual, and the specifications for the long stay measures
withdrawn from NQF submission can be found in Chapter 2 Section 2 of this manual.
• Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
(Short Stay) (CMS: N007.02) (NQF #0682 withdrawn)
• Percent of Residents Who Received the Pneumococcal Vaccine
(Short Stay) (CMS: N008.02) (NQF #0682A withdrawn)
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine
(Short Stay) (CMS: N009.02) (NQF #0682B withdrawn)
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the
Pneumococcal Vaccine (Short Stay) (CMS: N010.02) (NQF #0682C withdrawn)
• Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
(Long Stay) (CMS: N020.02) (NQF #0683 withdrawn)
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 1
• Percent of Residents Who Received the Pneumococcal Vaccine
(Long Stay) (CMS: N021.02) (NQF #0683A withdrawn)
• Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine
(Long Stay) (CMS: N022.02) (NQF #0683B withdrawn)
• Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the
Pneumococcal Vaccine (Long Stay) (CMS: N023.02) (NQF #0683C withdrawn)
• Percent of Residents Who Have Depressive Symptoms
(Long Stay) (CMS: N030.02) (NQF #0690 withdrawn)
• Percent of Low Risk Residents Who Lose Control of Their Bowel or Bladder
(Long Stay) (CMS: N025.02) (NQF #0685 withdrawn)
Renaming of Appendices
The Appendices contained in previous versions of this user’s manual have been renamed as
chapters. The only Appendix (A) in the MDS QM User’s Manual V14 contains the Quality
Measure Identification Number by CMS Reporting Module V1.8. The following list contains the
new chapter names in this user’s manual paired with the associated appendix name from
previous versions of this user’s manual:
• “Chapter 3: Technical Details,” previously “Appendix A: Technical Details”
• “Chapter 4: Parameters Used for Each Quarter,” previously “Appendix B: Parameters
Used for Each Quarter”
• “Chapter 5: Episode and Stay Determination Logic,” previously “Appendix C: Episode
and Stay Determination Logic”
• “Chapter 6: Specifications for the Facility Characteristics Report,” previously “Appendix
F: Specifications for the Facility Characteristics Report”
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 2
Chapter 1
QM Sample and Record Selection Methodology
The purpose of this chapter is to describe the methodology that is used to select the short and
long stay samples as well as the key records that are used to compute the QMs for each of those
samples. The first section below will present definitions that are used to describe the selection
methodology. The second section describes the selection of the two samples. The third and
fourth sections describe the selection of the key records within each of the two samples.
The logic presented below depends upon the concepts of stays and episodes. Detailed
specifications for the identification of stays and episodes are presented in Appendix C of this
document.
Section 1: Definitions
Target period. The span of time that defines the QM reporting period (e.g., a calendar quarter).
Influenza Season. Influenza season is July 1 of the current year to June 30 of the following year
(e.g., July 1, 2019 through June 30, 2020 for the 2019 – 2020 influenza season).1
Stay. The period of time between a resident’s entry into a facility and either (a) a discharge, or
(b) the end of the target period, whichever comes first. A stay, thus defined, may include
interrupted stays lasting 3 calendar days or less. The start of a stay is either:
• An admission entry (A0310F = [01] and A1700 = [1]), or
• A reentry (A0310F = [01] and A1700 = [2]).
The end of a stay is the earliest of the following:
• Any discharge assessment (A0310F = [10, 11]), or
• A death in facility tracking record (A0310F = [12]), or
• The end of the target period.
Interrupted Stay. During a stay the resident had an interruption in their stay and resumed the
same stay within three consecutive calendar days. Interrupted stays apply only to Medicarecovered stays and pertain to both short- and long-stay resident episodes.
1
This definition is applicable to each of the long- and short-stay influenza vaccination measures. The short-stay
measures are identified as the following: NQF #0680 (CMS ID: N003.03); NQF #0680A (CMS ID: N004.03);
NQF #0680B (CMS ID: N005.03); NQF #0680C (CMS ID: N006.03). The long-stay measures are identified as
the following: NQF #0681 (CMS ID: N016.03); NQF #0681A (CMS ID: N017.03); NQF #0681B (CMS ID:
N018.03); NQF #0681C (CMS ID: N019.03).
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 3
Episode. A period of time spanning one or more stays. An episode begins with an admission
(defined below) and ends with either (a) a discharge, or (b) the end of the target period,
whichever comes first. An episode starts with:
• An admission entry (A0310F = [01] and A1700 = [1]).
The end of an episode is the earliest of the following:
• A discharge assessment with return not anticipated (A0310F = [10]), or
• A discharge assessment with return anticipated (A0310F = [11]) but the resident did not
return within 30 days of discharge, or
• A death in facility tracking record (A0310F = [12]), or
• The end of the target period.
Admission. An admission entry record (A0310F = [01] and A1700 = [1]) is required when any
one of the following occurs:
• Resident has never been admitted to this facility before; or
• Resident has been in this facility previously and was discharged return not anticipated; or
• Resident has been in this facility previously and was discharged return anticipated and
did not return within 30 days of discharge.
Reentry. A reentry record (A0310F = [01] and A1700 = [2]) is required when all of the
following occurred prior to this entry; the resident was:
• Discharged return anticipated, and
• Returned to facility within 30 days of discharge.
Cumulative days in facility (CDIF). The total number of days within an episode during which
the resident was in the facility. It is the sum of the number of days within each stay included in
an episode. If an episode consists of more than one stay separated by periods of time outside the
facility (e.g., hospitalizations), and/or one or more stays with interruptions lasting 3 calendar
days or less, only those days within the facility would count towards CDIF. Any days outside of
the facility (e.g., hospital, home, etc.) would not count towards the CDIF total. The following
rules are used when computing CDIF:
• When counting the number of days until the end of the episode, counting stops with (a)
the last record in the target period if that record is a discharge assessment (A0310F = [10,
11]), (b) the last record in the target period if that record is a death in facility (A0310F =
[12]), or (c) the end of the target period is reached, whichever is earlier.
• When counting the duration of each stay within an episode, include the day of entry
(A1600) but not the day of discharge (A2000) unless the entry and discharge occurred on
the same day in which case the number of days in the stay is equal to 1.
o For example: if a resident is admitted on Monday and discharged the following
day (Tuesday), the duration of that episode would be 1 day.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 4
• While death in facility records (A0310F = [12]) end CDIF counting, these records are not
used as target records because they contain only tracking information and do not include
clinical information necessary for QM calculation.
• Special rules for influenza vaccination measures. Influenza vaccination measures are
calculated only once per 12-month influenza season, which begins July 1 of a given year
and ends on June 30 of the subsequent year. For these measures, the target period begins
on October 1 and ends on March 31. This means that the 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.
o Note, the target period (i.e., October 1 – March 31) is different than the selection
period, which begins October 1 and ends June 30 of the following year. The
selection period for the influenza vaccination measures is discussed more in
Sections 3 and 4 below.
Short stay. An episode with CDIF less than or equal to 100 days as of the end of the target
period. Short stays may include one or more interruptions, indicated by Interrupted Stay
(A0310G1 = [1]).
Long stay. An episode with CDIF greater than or equal to 101 days as of the end of the target
period. Long stays may include one or more interruptions, indicated by Interrupted Stay
(A0310G1 = [1]).
Target date. The event date for an MDS record, defined as follows:
• For an entry record (A0310F = [01]), the target date is equal to the entry date (A1600).
• For a discharge record (A0310F = [10, 11]) or death-in-facility record (A0310F = [12]),
the target date is equal to the discharge date (A2000).
• For all other records, the target date is equal to the Assessment Reference Date (ARD,
A2300).
Section 2: Selecting the QM Samples
Two resident samples are selected for computing the QMs: a short-stay sample and a long-stay
sample. These samples are selected using the following steps:
1. Select all residents whose latest episode either ends during the target period or is ongoing
at the end of the target period. This latest episode is selected for QM calculation.
2. For each episode that is selected, compute the cumulative days in the facility (CDIF).
3. If the CDIF is less than or equal to 100 days, the resident is included in the short-stay
sample.
4. If the CDIF is greater than or equal to 101 days, the resident is included in the long-stay
sample.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 5
Note that all residents who are selected in Step 1 above will be placed in either the short- or
long-stay sample and that the two samples are mutually exclusive. If a resident has multiple
episodes within the target period, only the latest episode is used.
Within each sample, certain key records are identified which are used for calculating individual
measures. These records are defined in the following sections.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 6
Section 3: Short Stay Record Definitions
ASSESSMENT
SELECTED PROPERTY
Target
assessment
Initial
assessment
Selection period Most recent 6 months (the short stay target period).
Qualifying RFAs2
Selection logic
Rationale
Selection period
Qualifying RFAs
Selection logic
Rationale
A0310A = [01, 02, 03, 04, 05, 06] or
A0310B
A0310F = [10, 11]
Latest assessment that meets the following criteria: (a) it is
cont
qualifying RFA, and (c) its target date is no more than 120 days
before the end of the episode.
Records with a qualifying RFA contain all of the items needed to
defi
date within the target period, but it must occur within 120 days
before the end of the resident’s selected episode (either the target
date of a discharge assessment or death in facility record that is the
last record in the target period or the end of the target period if the
episode is ongoing). 120 days allows 93 days between quarterly
assessments plus an additional 27 days to allow for late
assessments. The target assessment represents the resident’s
status at the end of the episode.
First assessment following the admission entry record at the
beginni
A0310A = [01] or
A0310B
A0310F = [10, 11]
Earliest assessment that meets the following criteria: (a) it is
cont
qualifying RFA, (c) it has the earliest target date that is greater than
or equal to the admission entry date starting the episode, and (d) its
target date is no more than 130 days prior to the target date of the
target record. The initial assessment cannot be the same as the
target assessment. If the same assessment qualifies as both the
initial and target assessments, it is used as the target assessment
and the initial assessment is considered to be missing.
Records with a qualifying RFA contain all of the items needed to
defi
within the target period. The initial assessment represents the
resident’s status as soon as possible after the admission that marks
the beginning of the episode. If the initial assessment is more than
130 days prior to the target assessment, it is not used and the initial
record is considered to be missing. This prevents the use of an
initial assessment for a short stay in which a large portion of the
resident’s episode was spent outside the facility. 130 days allows
for as many as 30 days of a 100-day stay to occur outside of the
facility.
= [01] or
ained within the resident’s selected episode, (b) it has a
ne the QMs. The target assessment need not have a target
ng of the resident’s selected episode.
= [01] or
ained within the resident’s selected episode, (b) it has a
ne the QMs. The initial assessment need not have a target date
(continued)
SELECTION SPECIFICATIONS
3
2
RFA: Reason For Assessment.
3
A short stay episode can span more than 100 calendar days because days outside of the facility are not counted in
defining a 100-day or less short stay episode.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 7
Short Stay Record Definitions (continued)
ASSESSMENT
SELECTED PROPERTY SELECTION SPECIFICATIONS
Look-back Scan Selection period Scan all qualifying RFAs within the current episode.
Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] or
Influenza
vaccination
assessment
A0310B = [01]
A0310F = [10, 11]
Selection logic
Include the target assessment and qualifying earlier
assessments in the scan. Include an earlier assessment in the
scan if it meets all of the following conditions: (a) it is contained
within the resident’s episode, (b) it has a qualifying RFA, and
(c) its target date is on or before the target date for the target
assessment. The target assessment and qualifying earlier
assessments are scanned to determine whether certain events
or conditions occurred during the look-back period. These
events and conditions are specified in the definitions of
measures that utilize the look-back scan.
Rationale Some measures utilize MDS items that record events or
conditions that occurred since the prior assessment was
performed. The purpose of the look-back scan is to determine
whether such events or conditions occurred during the lookback period. All qualifying RFAs with target dates within the
episode are examined to determine whether the event or
condition of interest occurred at any time during the episode.
4
Selection period
All assessments with target dates on or after October 1 of the
most recently completed influenza season (i.e., the target date
must be on or between October 1 of the current year and June
30 of the following year).
Qualifying RFAs
A0310A = [01, 02, 03, 04, 05, 06] or
A0310B = [01]
A0310F = [10, 11]
Selection logic Select the record with the latest target date that meets all of
the following conditions:
a) It has a qualifying RFA, and
b) Target date is on or after October 1 of the most recently
c
fall on or between October 1 and June 30), and
c) A1600 (entry date) is on or before March 31 of the most
recently completed influenza season.
Rationale The selection logic defined above is intended to identify the
latest assessment that reports the influenza vaccine status for
a resident who was in the facility for at least one day from
October 1 through March 31.
or
or
ompleted influenza season (i.e., the target date must
4
The selection period uses a June 30th end date to ensure residents who are vaccinated between October 1 and
March 31, but do not have an assessment completed until after March 31, are captured in the measure sample.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 8
Section 4: Long Stay Record Definitions
ASSESSMENT
SELECTED PROPERTY
Target assessment Selection period Most recent 3 months (the long stay target period).
Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] or
A0310B = [01] or
A0310F = [10, 11]
Selection logic Latest assessment that meets the following criteria: (a) it is
contained within the resident’s selected episode, (b) it has a
qualifying RFA, and (c) its target date is no more than 120
before the end of the episode.
Rationale Records with a qualifying RFA contain all of the items needed
to define the QMs. The target assessment need not have a
target date within the target period, but it must occur within 120
days of the end of the resident’s episode (either the last
discharge in the target period or the end of the target period if
the episode is ongoing). 120 days allows 93 days between
quarterly assessments plus an additional 27 days to allow for
late assessments. The target assessment represents the
resident’s status at the end of the episode.
Prior assessment Selection period Latest assessment that is 46 to 165 days before the target
assessment.
Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] or
A0310B = [01] or
A0310F = [10, 11]
Selection logic Latest assessment that meets the following criteria: (a) it is
contained within the resident’s episode, (b) it has a qualifying
RFA, and (c) its target date is contained in the window that is
46 days to 165 days preceding the target date of the target
assessment. If no qualifying assessment exists, the prior
assessment is considered missing.
Rationale Records with a qualifying RFA contain all of the items needed
to define the QMs. The prior assessment need not have a
target date within the target period, but it must occur within the
defined window.
SELECTION SPECIFICATIONS
The window covers 120 days, which allows 93 days between
erly assessments plus an additional 27 days to allow for
quart
late assessments. Requiring a 45-day gap between the prior
assessment and the target assessment insures that the gap
between the prior and target assessment will not be small
(gaps of 45 days or less are excluded).
(continued)
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 9
Long Stay Record Definitions (continued)
ASSESSMENT
SELECTED PROPERTY SELECTION SPECIFICATIONS
Look-back Scan Selection period Scan all qualifying RFAs within the current episode that have
target dates no more than 275 days prior to the target
assessment.
Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] or
A0310B = [01]
A0310F = [10, 11]
Selection logic Include the target assessment and all qualifying earlier
assessments in the scan. Include an earlier assessment in the
scan, if it meets all of the following conditions: (a) it is
contained within the resident’s episode, (b) it has a qualifying
RFA, (c) its target date is on or before the target date for the
target assessment, and (d) its target date is no more than 275
days prior to the target date of the target assessment. The
target assessment and qualifying earlier assessments are
scanned to determine whether certain events or conditions
occurred during the look-back period. These events and
conditions are specified in the definitions of measures that
utilize the look-back scan.
Rationale Some measures utilize MDS items that record events or
conditions that occurred since the prior assessment was
performed. The purpose of the look-back scan is to determine
whether such events or conditions occurred during the lookback period. These measures trigger if the event or condition
of interest occurred any time during a one year period. A 275day time period is used to include up to three quarterly OBRA
assessments. The earliest of these assessments would have a
look-back period of up to 93 days, which would cover a total of
about one year. All qualifying RFAs with target dates in this
time period are examined to determine whether the event or
condition of interest occurred at any time during the time
interval.
or
(continued)
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 10
Long Stay Record Definitions (continued)
ASSESSMENT
SELECTED PROPERTY SELECTION SPECIFICATIONS
Influenza vaccination
assessment
Selection
5
period
Qualifying RFAs A0310A = [01, 02, 03, 04, 05, 06] or
Selection logic Select the record with the latest target date that meets all of
Rationale The selection logic defined above is intended to identify the
All assessments with target dates on or after October 1 of the
most recently completed influenza season (i.e., the target date
must be on or between October 1 of the current year and June
30 of the following year).
A0310B = [01]
A0310F = [10, 11]
the following conditions:
a) It has a qualifying RFA, and
b) Target date is on or after October 1 of the most recently
c
fall on or between October 1 and June 30), and
c) A1600 (entry date) is on or before March 31 of the most
r
latest assessment that reports the influenza vaccine status for
a resident who was in the facility for at least one day from
October 1 through March 31.
or
ompleted influenza season (i.e., the target date must
ecently completed influenza season.
5
The selection period uses a June 30th end date to ensure residents who are vaccinated between October 1 and
March 31, but do not have an assessment completed until after March 31, are captured in the measure sample.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 11
Section 5: Transition from the Pressure Ulcer to Skin Integrity Quality Measures
In order to reduce provider burden and duplication of measures, as well as to align measures
across the NHQI and the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP), the
NHQI version of the quality measure, Percent of Residents or Patients with Pressure Ulcers That
Are New or Worsened (Short Stay) (CMS ID: N002.04), was replaced with the SNF QRP
version of the measure (CMS ID: S002.02) effective January 1, 2020. Beginning with the FY
2020 SNF QRP effective October 1, 2020, CMS ID: S002.02 will be removed from the SNF
QRP measure set and replaced with a modified version of that measure, Changes in Skin
Integrity Post-Acute Care: Pressure Ulcer/Injury (CMS ID: S038.02), to include the addition of
new or worsened unstageable pressure ulcers. This SNF QRP measure will also be reported as a
part of the NHQI effective 10/01/2020. The specifications for CMS ID: S038.02 can be found in
the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting
User’s Manual V3.0 on the SNF QRP website6 under the downloads section at the bottom of the
page.
Section 6: Transition to the Patient Driven Payment Model
The Medicare PPS Patient Driven Payment Model (PDPM)7 became effective October 1, 20198.
This payment change, including changes to the Medicare PPS assessment schedule and the
introduction of interrupted stays, may have moderate to small impacts on measures that include
Medicare Part A SNF stays that occur during a short-stay or long-stay episode. One example of a
small measure impact is seen in the Percent of Residents Who Newly Received an Antipsychotic
Medication (Short Stay) (NQF: None) (CMS ID: N011.02). The residents who are included in
this measure may have Medicare Part A SNF stays that are used to calculate this measure; these
stays may be ongoing while the PDPM policies become effective (i.e., Medicare Part A SNF
stays with an admission prior to the effective date of October 1, 2019, and discharges on or after
October 1, 2019). The remaining discussion refers to Medicare Part A SNF stays that are
embedded within an episode.
For Medicare Part A SNF stays with an admission prior to the implementation date of October 1,
2019, and discharges on or after October 1, 2019, the Medicare Part A SNF stay will use the
definitions and follow the measure specifications outlined in the MDS 3.0 QM User’s Manual
Version 12.1 through September 30, 2019. Beginning October 1, 2019, the Medicare Part A SNF
stay will use the definitions and follow the measure specifications outlined in the MDS 3.0 QM
6
Please refer to the Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s
Manual V3.0 on the SNF QRP website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
struments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-
In
Reporting-Program-Measures-and-Technical-Information.html
7
The Patient Driven Payment Model was finalized under the FY 2019 SNF PPS final rule (83 FR 39183 through
39265). Please refer to the FY 2019 SNF PPS final rule: https://www.govinfo.gov/content/pkg/FR-2018-08-
08/pdf/2018-16570.pdf
8
Quality measure scores calculated using the new PDPM specifications were publicly reported as of April 2020.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 12
User’s Manual Version 13.0. The information from all available qualifying RFAs throughout the
episode may be used in the measure calculation. Two examples below illustrate this instruction:
• Resident entered the facility on August 1, 2019 and began a Medicare Part A SNF
stay on September 1, 2019 and was discharged from the Medicare Part A SNF stay on
October 30, 2019
– The PPS 5-Day and PPS 14-Day Assessments are completed prior to the October
1, 2019 PDPM implementation date
– The PPS Discharge Assessment is completed after the October 1, 2019 PDPM
implementation date
o If the PPS 5-Day and PPS 14-Day Assessments are initial, prior, or target
assessments for a quality measure, then measure calculations would be based
on QM specifications in the MDS 3.0 QM User’s Manual Version 12.1 for the
PPS 5-Day and PPS 14-Day Assessments completed prior to October 1, 2019.
If the PPS Discharge Assessment is an initial, a prior, or a target assessment
for a quality measure, then measure calculations would be based on QM
specifications in the MDS 3.0 QM User’s Manual Version 13.0 for the PPS
Discharge Assessment which is completed after October 1, 2019 in this
example. In this instance, if appropriate, measure calculations may utilize
information from the PPS 5-Day, PPS 14-Day, and PPS Discharge
Assessments because all assessments are valid Qualifying RFAs at the time
the assessment was completed. OBRA assessments (stand-alone or combined
with PPS assessments) may also be completed during the Medicare Part A
SNF stay and used in measure calculations9.
• Rationale: The resident began the Medicare Part A SNF stay before
October 1, 2019. The measure specifications follow the instructions in the
MDS 3.0 QM User’s Manual Version 12.1 for all assessments completed
on or before September 30, 2019, which include PPS 14-Day
Assessments.
• Resident entered the facility on September 1, 2019 and began a Medicare Part A SNF
stay on October 1, 2019 and was discharged from the Medicare Part A SNF stay on
October 30, 2019
– PPS 5-Day and PPS Discharge Assessments are completed on or after the October
1, 2019 PDPM implementation date
o If the PPS 5-Day Assessment and/or PPS Discharge Assessment are initial,
prior, or target assessments for a quality measure, then measure calculations
would be based on QM specifications in the MDS 3.0 QM User’s Manual
Version 13.0. In this instance, if appropriate, measure calculations may utilize
information from the PPS 5-Day and PPS Discharge Assessments because
9
Please refer to Chapter 1, Sections 3 and 4 to identify Qualifying RFAs for short and long stay measure
calculations.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 13
those are the only PPS assessments that are valid Qualifying RFAs. OBRA
assessments (stand-alone or combined with PPS assessments) may also be
completed during the Medicare Part A SNF stay and used in measure
calculations10.
• Rationale: The resident began the Medicare Part A SNF stay on or after
October 1, 2019. The measure specifications follow the instructions in the
MDS 3.0 QM User’s manual Version 13.0, which, with respect to PPS
assessments, only require a PPS 5-Day and PPS Discharge Assessment
for quality measure calculations; all other interim PPS assessments used
in quality measure calculations no longer exist under the PDPM. Note,
Interim Payment Assessments (IPAs) are also part of the PPS item sets. If
applicable, IPAs may also be completed during the Medicare Part A SNF
stay; however, data from IPAs are used for PPS payment purposes only
and are not used in measure calculations.
10
Please refer to Chapter 1, Sections 3 and 4 to identify Qualifying RFAs for short and long stay measure
calculations.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 14
Chapter 2
MDS 3.0 Quality Measures Logical Specifications
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 15
Section 1: Short Stay (SS) Quality Measures
Table 2-1
Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury11
(CMS ID: S038.02) (NQF: None)
This quality measure is calculated using the SNF Quality Reporting Program measure Changes in Skin Integrity Post-Acute Care:
Pressure Ulcer/Injury (CMS ID: S038.02). To review the measure logic specifications for CMS ID: S038.02, please refer to the SNF
Quality Reporting Program Measure Calculations and Reporting User’s Manual V3.0 on the SNF QRP website12 under the downloads
section at the bottom of the page. The measure logical specifications can be found in Chapter 7, Table 7-5.
11
This measure is used in the Five-Star Quality Rating System.
12
Please refer to the SNF Quality Reporting Program Measure Calculations and Reporting User’s Manual V3.0 on the SNF QRP website:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-
gram/SNF-Quality-Reporting-Program-Measures-and-Technical-Information.html
Pro
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 16
Table 2-2
Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (SS)
(CMS ID: N003.03) (NQF #0680)
Measure Description
The measure reports the percent of short-stay residents who are assessed and/or given, appropriately, the influenza vaccination during the most recent
influenza season.
Measure Specifications
Numerator
Residents meeting any of the following criteria on the selected influenza vaccination assessment:
1. Resident received the influenza vaccine during the most recent influenza season, either in the facility (O0250A = [1]) or outside the facility (O0250C
[2]); or
=
2. Resident was offered and declined the influenza vaccine (O0250C = [4]); or
3. Resident was ineligible due to medical contraindication(s) (O0250C = [3]) (e.g., anaphylactic hypersensitivity to eggs or other components of the
v
accine, history of Guillian-Barré Syndrome within 6 weeks after a previous influenza vaccination, bone marrow transplant within the past 6
months).
Denominator
All short-stay residents with a selected influenza vaccination assessment. This includes all residents who have an entry date (A1600) on or before March 31 of
the most recently completed influenza season and have an assessment with a target date on or after October 1 of the most recently completed influenza season
(i.e., the target date must fall on or between October 1 and June 30), except those with exclusions.
Exclusions
Resident’s age on target date of selected target assessment is 179 days or less.
Notes
This measure is only calculated once per 12-month influenza season which begins on July 1 of a given year and ends on June 30 of the subsequent year, and
r
eports data for residents who were in the facility for at least one day during the target period of October 1 through March 31.
Not applicable.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 17
Covariates
Table 2-3
Percent of Residents Who Received the Seasonal Influenza Vaccine (SS)
(CMS ID: N004.03) (NQF #0680A)
Measure Description
The measure reports the percent of short-stay residents who received the influenza vaccination during the most recent influenza season.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected influenza vaccination assessment:
1. Resident received the influenza vaccine during the most recent influenza season, either in the facility (O0250A = [1]) or outside the facility (O0250C
[2]).
=
Denominator
All short-stay residents with a selected influenza vaccination assessment. This includes all residents who have an entry date (A1600) on or before March 31 of
he most recently completed influenza season and have an assessment with a target date on or after October 1 of the most recently completed influenza season
t
(i.e., the target date must fall on or between October 1 and June 30), except those with exclusions.
Exclusions
Resident’s age on target date of selected target assessment is 179 days or less.
Notes
This measure is only calculated once per 12-month influenza season which begins on July 1 of a given year and ends on June 30 of the subsequent year and
reports data for residents who were in the facility for at least one day during the target period of October 1 through March 31.
Not applicable.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 18
Covariates
Table 2-4
Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine (SS)
(CMS ID: N005.03) (NQF #0680B)
Measure Description
The measure reports the percent of short-stay residents who are offered and declined the influenza vaccination during the most recent influenza season.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected influenza vaccination assessment:
1. Resident was offered and declined the influenza vaccine during the most recent influenza season (O0250C = [4]).
Denominator
All short-stay residents with a selected influenza vaccination assessment. This includes all residents who have an entry date (A1600) on or before March 31 of
he most recently completed influenza season and have an assessment with a target date on or after October 1 of the most recently completed influenza season
t
(i.e., the target date must fall on or between October 1 and June 30), except those with exclusions.
Exclusions
1. Resident’s age on target date of selected influenza vaccination assessment is 179 days or less.
Notes
This measure is only calculated once per 12-month influenza season which begins on July 1 of a given year and ends on June 30 of the subsequent year and
reports data for residents who were in the facility for at least one day during the target period of October 1 through March 31.
Not applicable
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 19
Covariates
Table 2-5
Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine (SS)
(CMS ID: N006.03) (NQF #0680C)
Measure Description
The measure reports the percent of short-stay residents who did not receive, due to medical contraindication, the influenza vaccination during the most recent
influenza season.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected influenza vaccination assessment:
1. Resident was ineligible for the influenza vaccine during the most recent influenza season due to medical contraindication(s) (O0250C = [3]) (e.g.,
aphylactic hypersensitivity to eggs or other components of the vaccine, history of Guillian-Barré Syndrome within 6 weeks after a previous
an
influenza vaccination, bone marrow transplant within the past 6 months).
Denominator
All short-stay residents with a selected influenza vaccination assessment. This includes all residents who have an entry date (A1600) on or before March 31 of
he most recently completed influenza season and have an assessment with a target date on or after October 1 of the most recently completed influenza season
t
(i.e., the target date must fall on or between October 1 and June 30), except those with exclusions.
Exclusions
1. Resident’s age on target date of selected influenza vaccination assessment is 179 days or less.
Notes
This measure is only calculated once per 12-month influenza season which begins on July 1 of a given year and ends on June 30 of the subsequent year and
r
eports data for residents who were in the facility for at least one day during the target period of October 1 through March 31
Not applicable
Covariates
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 20
Table 2-6
Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine (SS)
(CMS ID: N007.02) (NQF #0682 – Withdrawn)
Measure Description
This measure reports the percent of short-stay residents whose pneumococcal vaccine status is up to date during the 12-month reporting period.
Measure Specifications
Numerator
Residents meeting any of the following criteria on the selected target assessment:
1. Pneumococcal vaccine status is up to date (O0300A = [1]); or
2. Were offered and declined the vaccine (O0300B = [2]); or
3. Were ineligible due to medical contraindication(s) (O0300B = [1]) (e.g., anaphylactic hypersensitivity to components of the vaccine; bone marrow
ansplant within the past 12 months; or receiving a course of chemotherapy within the past two weeks).
tr
Denominator
All short-stay residents with a selected target assessment.
Exclusions
Resident’s age on target date of selected target assessment is less than 5 years (i.e., resident has not yet reached fifth birthday on target date).
Not applicable
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 21
Covariates
Table 2-7
Percent of Residents Who Received the Pneumococcal Vaccine (SS)
(CMS ID: N008.02) (NQF #0682A – Withdrawn)
Measure Description
This measure reports the percent of short-stay residents who received the pneumococcal vaccine during the 12-month reporting period.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected target assessment:
1. Pneumococcal vaccine status is up to date (O0300A = [1]).
Denominator
All short-stay residents with a selected target assessment.
Exclusions
Resident’s age on target date of selected target assessment is less than 5 years (i.e., resident has not yet reached fifth birthday on target date).
Covariates
Not applicable
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 22
Table 2-8
Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine (SS)
(CMS ID: N009.02) (NQF #0682B – Withdrawn)
Measure Description
This measure reports the percent of short-stay residents who were offered and declined the pneumococcal vaccine during the 12-month reporting period.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected target assessment:
1. Were offered and declined the vaccine (O0300B = [2]).
Denominator
All short-stay residents with a selected target assessment.
Exclusions
Resident’s age on target date of selected target assessment is less than 5 years (i.e., resident has not yet reached fifth birthday on target date).
Covariates
Not applicable.
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 23
Table 2-9
Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine (SS)
(CMS ID: N010.02) (NQF #0682C – Withdrawn)
Measure Description
This measure reports the percent of short-stay residents who did not receive, due to medical contraindication, the pneumococcal vaccine during the 12-month
reporting period.
Measure Specifications
Numerator
Residents meeting the following criteria on the selected target assessment:
1. Were ineligible due to medical contraindication(s) (O0300B = [1]) (e.g., anaphylactic hypersensitivity to components of the vaccine; bone marrow
ransplant within the past 12 months; or receiving a course of chemotherapy within the past two weeks).
t
Denominator
All short-stay residents with a selected target assessment.
Exclusions
Resident’s age on target date of selected target assessment is less than 5 years (i.e., resident has not yet reached fifth birthday on target date).
Not applicable.
Covariates
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 24
Table 2-10
Percent of Residents Who Newly Received an Antipsychotic Medication (SS)13
(CMS ID: N011.02) (NQF: None)
Measure Description
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.
Measure Specifications
Numerator
Short-stay residents for whom one or more assessments in a look-back scan (not including the initial assessment) indicates that antipsychotic medication was
ved:
recei
1. N0410A = [1, 2, 3, 4, 5, 6, 7].
Note that residents are excluded from this measure if their initial assessment indicates antipsychotic medication use or if antipsychotic medication use is
known on the initial assessment (see exclusion #3, below).
un
Denominator
A
ll short-stay residents who do not have exclusions and who meet all of the following conditions:
1. The resident has a target assessment, and
2. The resident has an initial assessment, and
3. The target assessment is not the same as the initial assessment.
Exclusions
he following is true for all assessments in the look-back scan (excluding the initial assessment):
1. T
1.1. For assessments with target dates on or after 04/01/2012: (N0410A = [-]).
2. Any of the following related conditions are present on any assessment in a look-back scan:
2.1. Schizophrenia (I6000 = [1]).
2.2. Tourette’s syndrome (I5350 = [1]).
2.3. Huntington’s disease (I5250 = [1]).
13
This measure is used in the Five-Star Quality Rating System
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 25
Measure Specifications Continued
3. The resident’s initial assessment indicates antipsychotic medication use or antipsychotic medication use is unknown:
3.1. For initial assessments with target dates on or after 04/01/2012: (N0410A = [1, 2, 3, 4, 5, 6, 7, -]).
Covariates
Not applicable
MDS 3.0 Quality Measures User’s Manual V14 – Effective October 1, 2020 26
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