Q: I reviewed the Q4 2023 Facility Level Quality Measure report for my facility and noticed several measures are displayed as “I” for incomplete. Can you explain why?
A: Quality measures related to ADLs have been frozen due to changes to the MDS 3.0, specifically the removal of Section G. Information related to this question can be found in the MDS QM User Manual V-16.0.
These measures have been significantly impacted by Section G’s removal:
Residents whose ability to walk independently worsened
Residents whose need for help with activities of daily living increased
Residents with pressure ulcers
Residents with new or worsened bowel or bladder Incontinence
Because of these changes, we must transition to Section GG to inform QM logic. Since Section GG was not included on the OBRA item sets prior to Oct. 1, 2023, target assessments with an earlier assessment reference date prior do not have data needed to calculate measures.
In addition, when the measure requires a comparison between the current (target) assessment and the prior assessment, both assessments must have target dates on or after Oct. 1, 2023. As a result, specifications exclude situations where either the prior or target assessment has an ARD prior to Oct. 1, 2023.
For assessments conducted before the v1.18.11 implementation and target assessments performed on or after Oct. 1, 2023, the measure calculations will use the old measure specifications regarding items related to prior assessments. Measure calculations will use the new measure specifications regarding items related to the target assessment.
Once sufficient data has been collected, new measures will no longer show on your report as incomplete.
Eleisha Wilkes, RN, RAC-CTA, RAC-CT, DNS-CT, is a clinical consultant at Proactive Medical Review. Please send her your payment-related questions at [email protected].
