MDS Alert

Hint: Figuring out which days count as a stay is crucial.

The Centers for Medicare and Medicaid Services, in conjunction with RTI International, has released an updated MDS 3.0 Quality Measures User’s Manual, which expounds on the specifics of how exactly your facility’s quality is measured. Understanding CMS’s definitions of how to calculate a resident’s stay provides a foundation to navigating all of the measure specifications.

Fully understand these definitions from the QM User’s Manual so you don’t risk a drop in your facility’s rating.

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, 2018 through June 30, 2019 for the 2018 – 2019 influenza season).

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 is also defined as a set of contiguous days in a facility. 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.

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), only those days within the facility would count toward CDIF. Any days outside of the facility (e.g., hospital, home, etc.) would not count toward 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.
• 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. 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.

Short stay. An episode with CDIF less than or equal to 100 days as of the end of the target period.

Long stay. An episode with CDIF greater than or equal to 101 days as of the end of the target period.

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 (A2300).

Resource: You can find the complete manual along with the technical specifications and calculations and reporting on the CMS website: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/nhqiqualitymeasures.html.