Scope & Severity
Quality Measures
Imperial Standards
100

Name the letters and points in the severity category of [actual harm that is not immediate jeopardy]

What is G=20 points, H = 35 or (40) points, I = 45 (50) points

100

How many quality measures are included in your Five-Star calculation?

What is 15

100

How often should you review Quality Measures as a IDT team?

What is monthly

200

What scope of deficiencies can be considered substandard quality of care? 

Scope = F, H, I, J, K, or L (if identified in red on the CMS Federal Regulatory Groups for Long Term Care Facilities

200

Name at least 2 categories of measures included in your Five-Star report?

What is MDS LS, MDS SS, Claims-Based LS, and Claims-Based LS

200

Name pro-active ways to capture potential QM flags prior to coding MDS

Morning meeting

Daily orders reviews

PCC Diagnosis


300

How many survey cycles are included in your Five-Star calculation

What is 3

300

What is the length of time included in Short-Stay measures? 

What is < 100 days

300

Name one system Imperial uses to decrease abbreviated (complaint) surveys?

Care Concierge Rounds

400

How are survey cycles weighted?

What is cycle 1 = 1/2 of the total cycle points

What is cycle 2 = 1/3 of the total cycle points

What is cycle 3 = 1/6 of the total cycle points

400

What excludes a SS resident on an AP medication from triggering the SS AP Measure?

What is they were on the AP medication at the time of admission. 

400

What is survey management? 

Designated staff assigned to resident rooms and common areas. Routine rounding throughout the day on each day of survey.

500

How does CMS determine substandard quality of care?

Deficiencies cited at levels F, H, I, J, K, or L

Identified in red on CMS Federal Regulatory Groups for Long Term Care Facilities

500

How does Claims-Based rehospitalization effect VBP? 

What is the ability to earn the 2% MC payment reduction back