Quality Measures

Now available! Our new Provider Data Catalog makes it easier for you to search and download our publicly reported data. We’ve also improved Medicare’s compare sites.

What's New

January 04, 2022

MDS 3.0 QM User’s Manual Version 15.0 Now Available

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual V15.0 and accompanying Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0 have been posted. The MDS 3.0 QM User’s Manual V15.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable Changes section that summarizes the major changes from MDS 3.0 QM User’s Manual V14.0. The MDS 3.0 QM User’s Manual V15.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V14.0 has been moved to the Quality Measures Archive webpage. The logistic regression coefficients used to risk adjust the Percent of Residents Who Made Improvements in Function (Short-Stay [SS]), Percent of Residents Whose Ability to Move Independently Worsened (Long-Stay [LS]), and Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (LS) measures have been updated using Q4 2019 data. These coefficients were previously contained in Chapter 4 of the MDS QM User’s Manual V14.0 but have been moved to the Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0.

One file related to the MDS 3.0 QM User’s Manual has been posted:

  1. MDS QM User’s Manual V15 Effective 01-01-2022 (ZIP) includes the MDS 3.0 QM User’s Manual V15.0, which contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. MDS QM User’s Manual V15 Effective 01-01-2022 (ZIP) also includes the Risk Adjustment Appendix File for MDS 3.0 Quality Measure User’s Manual V15.0, which contains the logistic regression coefficients used to risk adjust the Percent of Residents Who Made Improvements in Function (SS), Percent of Residents Whose Ability to Move Independently Worsened (LS), and Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder (LS) measures. MDS 3.0 QM User’s Manual V15 Effective 01-01-2022 (ZIP) is available under the Downloads section of this webpage.

The current nursing home quality measures are:

Short Stay Quality Measures

  • Percent of Short-Stay Residents Who Were Re-Hospitalized after a Nursing Home Admission
  • Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
  • Percent of Residents Who Newly Received an Antipsychotic Medication
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
  • Percent of Residents Who Made Improvements in Function
  • Percent of Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*

* These measures are not publicly reported but available for provider preview.

Long Stay Quality Measures

  • Number of Hospitalizations per 1,000 Long-Stay Resident Days
  • Number of Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
  • Percent of Residents Who Received an Antipsychotic Medication
  • Percent of Residents Experiencing One or More Falls with Major Injury
  • Percent of High-Risk Residents with Pressure Ulcers
  • Percent of Residents with a Urinary Tract Infection
  • Percent of Residents who Have or Had a Catheter Inserted and Left in Their Bladder
  • Percent of Residents Whose Ability to Move Independently Worsened
  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
  • Percent of Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
  • Percent of Residents Who Received the Seasonal Influenza Vaccine*
  • Percent of Residents Who Were Offered and Declined the Seasonal Influenza Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Seasonal Influenza Vaccine*
  • Percent of Residents Assessed and Appropriately Given the Pneumococcal Vaccine
  • Percent of Residents Who Received the Pneumococcal Vaccine*
  • Percent of Residents Who Were Offered and Declined the Pneumococcal Vaccine*
  • Percent of Residents Who Did Not Receive, Due to Medical Contraindication, the Pneumococcal Vaccine*
  • Percent of Residents Who Were Physically Restrained
  • Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
  • Percent of Residents Who Lose Too Much Weight
  • Percent of Residents Who Have Symptoms of Depression
  • Percent of Residents Who Used Antianxiety or Hypnotic Medication

* These measures are not publicly reported but available for provider preview.

Quality measure specifications are available in the Quality Measures (QM) Users’ Manual download file, which can be found under the Downloads section below. A sub-group of quality measures are incorporated into the Five-Star Quality Rating System and used to determine scoring for the quality measures domain on Nursing Home Compare.

Page Last Modified:
04/19/2022 01:32 PM