MDS Alert

Quality Measures:

Test Your Knowledge and Avoid Ratings Penalties

Don’t miss these updates or the ways they reflect upon your facility.

The Care Compare website, formerly known as Nursing Home Compare, has gone through a lot of changes since Dec. 1, 2020. Between the updates to the system itself and the inclusion, again, of various inspections including the focused infection control survey, your facility’s quality measures and rating may change.

While there are a handful of changes, including some that focus on the technical aspects, there are a few takeaways you need to know: health inspection rating changes, staffing rating changes, and quality measure rating changes. To make sure all the changes stick, try this quiz. Look for answers on page 7.

Background: With the declaration of the public health emergency (PHE), some elements of quality measures were temporarily paused, as the Centers for Medicare & Medicaid Services (CMS) put some surveys and inspections on the backburner to give nursing facilities the mental space to focus on COVID-19, minimize use of precious personal protective equipment (PPE), and focus surveys on infection control. Beginning Jan. 27, 2021, CMS is unpausing those elements affecting quality measures, as well as updating Care Compare.

   1. Ratings for the health inspections domain are based on which of the following?

        A. Number of deficiencies

        B. Scope of deficiencies

        C. Severity of deficiencies.

        D. All of the above

   2. True or false: Focused infection control surveys are included in the rating calculation, with citations from these surveys counting toward the total weighted health inspection score.

   3. The timeframe for the substantiated findings, complaint investigations, and focused infection control surveys that comprise the health inspections domain score is:

        A. 6 months

        B. 12 months

        C. 24 months

        D. 36 months

   4. True or false: All deficiency findings are weighted by scope and severity.

   5. Complete this sentence: The health inspections rating also take into account:

        A. The number of revisits required to ensure deficiencies identified during the survey have been corrected

        B. How many staff are on the floor compared to the number of residents

        C. Whether there’s a registered nurse working at any given shift

        D. How many citations a facility received during the past four years

   6. Complete the following sentence: Ratings for the staffing domain are based on the following measures:

              A. Registered nurse (RN) hours per resident per day

        B. Total nurse (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day

        C. Clerical or housekeeping staff hours per resident per day

              D. A and B but not C

   7. Which of the following describes a reason a facility’s staffing rating could be reduced to one star?

        A. Failing to report staffing data for October 2020 through December 2020

        B. Reporting two days in the quarter with no registered nurse

        C. Reporting four or more days in the quarter without a registered nurse

        D. A and C but not B

   8. True or false: The staffing measures are derived from data submitted each quarter through the Payroll-Based Journal (PBJ) System, along with information from Minimum Data Set (MDS) assessments; no separate rating for RN staffing needs to be reported.

   9. Ratings for quality measures are based on performance on:

        A. 10 quality measures

        B. 12 quality measures

        C. 15 quality measures

        D. 17 quality measures

   10. True or false: The aforementioned quality measures include both long-stay and short-stay measures.

 

Check your answers here.