CHAPTER 11 THE MINIMUM DATA SET, THE CASPER REPORT

CHAPTER 7QUALITY INDICATORS
PURPOSE:
THE MDS WAS CREATED TO PROVIDE A METHOD OF ASSESSING
PATIENT’S NEEDS IN A STANDARD FORMAT.
USES:
1. The M.D.S. tracks over 400 pieces of data on every patient in a nursing home.
2. The M.D.S. is done on every patient within 14 days of their admission, it is updated
quarterly and any time their
Condition changes
3. The answers in the M.D.S. may “trigger” further assessment when these answers
indicate that the resident is at increased risk of developing problems
4. This structured assessment of high risk areas is used to help the facility build a patient
care plan
5. Once the care plan is implemented the patient must be reviewed again to make sure
that the patient responding to the plan (outcome)
6. The data from the M.D.S. is transmitted to the government to allow data to be
collected for all residents in the facility. The facility can then be compared to other
facility’s in the region, the state and the country. This data is now used to identify
residents that will be reviewed during the survey process. (see the OSCAR report)
7. 108 of the M.D.S. data fields are used to assign the resident a rug’s score (resource
utilization group) which is used to determine the reimbursement rate from the
medicare program.
8. Data from the M.D.S. is also used to determine the Quality Indicators which are
published by Medicare to allow the public to compare nursing facilities
9. For more information on the MDS see “Medicare Benefit Policy Manual
Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (see http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf)
DEFINITIONS:
11.3
DIVIDED INTO AREAS OF PHYSICAL, FUNCTIONAL AND PSYCHOSOCIAL
STATUS
IDENTIFY RESIDENTS THAT ARE AT
RISK OF DEVELOPING PROBLEMS

(i.e. PATIENT OUTCOMES)
PATIENT IS ASSIGNED TO ONE OF 55 PAYMENT CATEGORIES BASED
ON 108 DATA FIELDS FROM THE PATIENT’S M.D.S.
(RUGS increased from 44 to 53 categories 1/1/2006)
(Reimbursements Range from $170/day to $650/day depending on the RUG score)
11.4
CMS OSCAR Data
Region Psychoactive Antipsychotic Anti- anxiety Antidepressant Hypnotic Total Total
Code State Meds Meds Meds Meds Meds Residents Facilities
United States 65.10% 25.20% 20.10% 48.10% 7.50% 1,402,485 15,720
1 CT 68.20% 0.3 0.2 50.10% 7.50% 26,114 239
MA 71.40% 28.30% 19.80% 55.60% 3.40% 43,282 429
ME 71.30% 24.50% 0.2 0.6 4.50% 6,458 109
NH 70.40% 28.20% 20.90% 54.50% 0.1 6,941 80
RI 0.7 23.40% 14.40% 56.60% 4.20% 8,059 86
VT 69.20% 26.80% 16.90% 53.40% 5.70% 2,987 40
2 NJ 56.90% 22.10% 17.20% 39.10% 0.1 45,782 359
NY 0.6 23.50% 0.1 39.10% 4.80% 109,910 640
PR 0.4 4.90% 6.80% 10.70% 23.30% 103 7
VI 21.40% 10.70% 7.10% 7.10% 3.60% 28 1
3 DC 43.10% 20.20% 9.90% 24.20% 4.20% 2,531 19
DE 61.10% 23.10% 21.80% 45.20% 6.20% 4,264 46
MD 57.40% 20.40% 14.50% 42.90% 5.90% 25,028 231
PA 66.60% 24.10% 21.20% 51.80% 5.70% 80,608 713
VA 63.70% 23.90% 22.30% 47.70% 8.30% 28,347 281
WV 0.7 23.90% 22.50% 50.50% 4.20% 9,639 128
4 AL 70.80% 27.60% 24.70% 0.5 7.70% 23,251 231
FL 66.60% 23.80% 26.40% 48.70% 13.30% 71,679 676(6) GA 69.40% 30.30% 21.80% 51.50% 8.60% 35,022 360
KY 71.10% 26.30% 27.80% 53.80% 0.1 23,361 287
MS 68.40% 28.80% 18.90% 50.50% 9.80% 16,330 202
NC 67.40% 22.80% 26.10% 51.50% 10.90% 37,570 424
SC 63.60% 22.60% 23.20% 46.30% 8.60% 17,210 178
TN 73.30% 29.90% 28.30% 57.20% 10.30% 32,109 320
5 IL 66.80% 32.80% 20.50% 44.30% 6.60% 75,752 794(4)
IN 65.90% 23.60% 0.2 50.50% 7.10% 39,099 503
MI 61.90% 17.20% 17.80% 47.70% 3.40% 40,237 429
MN 63.20% 21.40% 13.90% 0.5 0.0 30,025 385
OH 68.90% 26.60% 23.50% 52.50% 7.60% 80,034 962(3)
WI 64.80% 19.80% 19.30% 51.20% 3.50% 31,565 391
11.5
What is this?
255 59TH ST N SAINT PETERSBURG, FL 33710 (727) 345-2775
Mapping &
Directions
Corporation
Resident Councils Only
Ownership
View all Nursing Home Characteristics
Click on the links below to expand and view information about Health Inspections, Nursing Home Staffing, Quality Measures, and Fire Safety
Inspections.
1 out of 5 stars
Date of last standard health inspection: 11/06/2009
View Previous Inspection
Total number of Health Deficiencies for this nursing home:
16
8
8
ZIP Code: 33710
nursing home staffing and quality measures. More
stars are better.
Much Above Avg.
How to Read a Health / Fire Safety
Deficiency Chart
> Many)
1. Give professional services that meet a professional standard of quality.
11/06/2009 12/06/2009 2 = Minimal harm or potential for actual harm
Some
2. Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal- pharyngeal ulcers) and help restore eating skills, if possible.
11/20/2009 12/10/2009 4 = Immediate jeopardy to resident health or safety
Some
Inspections
Affected Definitions
1-888-419-3456
> Some - > Many)
3. 1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.
Few
> Some - > Many)
4. Provide care in a way that keeps or builds each resident's dignity and self respect.
Some
Affected (Few -
> Some - > Many)
5. Store, cook, and give out food in a safe and clean way.
Many
> Many)
6. 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.
Some
11/06/2009 12/06/2009 2 = Minimal harm or
Few
potential for actual harm
8. Make sure that residents are safe from serious medication errors.
Some
Some
Few
11. Make sure that a working call system is available in each resident's room or bathroom and bathing area.
Few
12. Provide at least one room to use as a dining room and for activities,
Few
that is a good size, with good lighting, airflow and furniture.
13. Make sure that the nursing home area is free of dangers that cause accidents.
Some
Few
15. Be administered in a way that leads to the highest possible level of well being for each resident.
Some
16. Make sure that nurse aides show they have the skills to be able to care for residents.
Some
4 out of 5 stars
its state agency. It contains the nursing home staffing hours for
a two-week period prior to the time of the state inspection.
CMS receives this data and converts it into the number of staff hours per resident per day.
National Average
Available
Total Number of Residents
94.1 111.2 161
Total Number of Licensed Nurse Staff Hours per Resident per Day
1 hour 24 minutes
1 hour 36 minutes
1 hour 44 minutes
5 minutes
2 hours 24 minutes
3 hours 2 hours
How to Read a Staffing Chart | About Staff Roles
1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.
Quality Measures
Information comes from data that the nursing homes regularly
report on all residents. It includes aspects of residents' health, physical functioning,
mental status and general well being.
2 out of 5 stars
Quality Measures National Average
important to you
NOTE: For the following measures, higer percentages are better.
Percent of long-stay residents given influenza vaccination during the flu season
91% 86% 95%
Percent of long-stay residents who were assessed and given pneumococcal vaccination
89% 86% 97%
NOTE: For the following measures, lower percentages are better.
Percent of long-stay residents whose need for help with daily activities has increased
14% 12% 15%
Percent of long-stay residents who have moderate to severe pain
3% 3% 1%
11% 12% 14%
2% 2% 2%
3% 4% 3%
Percent of long-stay residents who are more depressed or anxious
14% 10% 20%
Percent of low-risk long-stay residents who lose control of their bowels or bladder
50% 53% 48%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder
5% 5% 7%
Percent of long-stay residents who spend most of their time in bed or in a chair
11.13
Percent of long-stay residents whose ability to move about in and around their room got worse
11% 9% 12%
Percent of long-stay residents who had a urinary tract infection
9% 11% 13%
8% 8% 7%
Short-Stay Residents Read why Quality Measures are important to you
NOTE: For the following measures, higer percentages are better.
Percent of short-stay residents given influenza vaccination during the flu season
83% 78% 85%
Percent of short-stay residents who were assessed and given pneumococcal vaccination
83% 80% 91%
Percent of short-stay residents who have delirium
2% 1% 0%
Percent of short-stay residents who had moderate to severe pain
19% 19% 13%
13% 15% 21%
Fire Safety Inspections
Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not
included in the nursing home's Overall Rating.
Automatic Sprinkler Systems in all required areas
Fully Sprinklered
Dates of Complaint Investigations: 02/01/2009 - 04/30/2010
Total number of Fire Safety Deficiencies for this nursing home:
1
1
Average number of Fire Safety Deficiencies in the United States:
4
How to Read a Health / Fire Safety
Deficiency Chart
Few
Please use our Nursing Home Checklist for help with narrowing your nursing homes choices. The checklist provides questions and observations that are important to keep in mind as you visit nursing
homes and will help you make a good choice for you or your relative.

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CHAPTER 11 THE MINIMUM DATA SET, THE CASPER REPORT