CMS Updated QM Manual

CMS Updates MDS 3.0 Quality Measure and Five-Star Manuals
The Centers for Medicare & Medicaid Services (CMS) recently released updates to the MDS 3.0 Quality Measures User’s Manual (v.16.0) and the Nursing Home Five-Star Quality Rating System: Technical User’s Guide (September 2023). Many of these updates were required due to the transition from section G to section GG with the MDS v1.18.11.

The following is a summary of changes due to the G to GG transition for MDS 3.0 Quality Measures and the Five-Star Quality Rating System:

Percentage of Residents Who Made Improvements in Function (Short-Stay) QM: This measure was replaced with the Discharge Function Score measure from the Skilled Nursing Facility Quality Reporting Program (SNF QRP), effective Oct. 1, 2023. Five-Star: This measure will be frozen with the April 2024 Care Compare refresh and will be replaced with the Discharge Function Score measure with the October 2024 refresh.

Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long-Stay) QM: This measure was respecified to use section GG data. Five-Star: This measure will be frozen with the April 2024 Care Compare refresh and will resume with the January 2025 refresh using section GG data.

Percent of Residents Whose Ability to Move Independently Worsened (Long-Stay) QM: Verbiage in this measure changed, including “move” to “walk.” The respecification of this measure to use section GG data significantly changes the measured outcomes. Five-Star: This measure will be frozen with the April 2024 Care Compare refresh and will resume with the January 2025 refresh using section GG data.
Percent of High-Risk Residents with Pressure Ulcers (Long-Stay) QM: This measure was replaced with a new measure, Percent of Residents with Pressure Ulcers, effective Oct. 1, 2023. Five-Star: This measure will be frozen with the April 2024 Care Compare refresh and will be replaced with the Percent of Residents with Pressure Ulcers, effective with the January 2025 refresh. Percent of Low-Risk Residents Who Lose Control of Their Bowel and Bladder (Long-Stay) QM: This measure was replaced with a new measure, Percent of Residents With New or Worsened Bowel or Bladder Incontinence, effective Oct. 1, 2023.

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