Quality Measures
Strategy
Supportive Documentation
MISC
Name that RUG!
100

Ability to Walk Independently Worsened Triggers are determined by this one GG Item

What is............GG0170I -- Mobility--

Walk 10 Feet

100

I should be monitoring for this daily for residents with DM.

What is

Diabetes with both of the following: 

Insulin injections (N0350A) for all 7 days

Insulin order changes on 2 or more days (N0350B)

100

True/False

Hypodermoclysis can qualify for 

Parenteral or IV Feedings While a Resident and While NOT a Resident if Documentation that includes any and all nutrition and hydration received by the nursing home resident during the observation period either at the nursing home, at the hospital as an outpatient or an inpatient, provided the documentation supports the need for nutrition or hydration.

True

100
What are the 2 outlier nursing function scores that can result in a rug no higher than clinically complex?

15-16

100

Nursing Function Score 11

Isolation for active COVID Infection/single room droplet isolation with all care and services provided in room

ES1


200

When the frozen QM's are unfrozen for the January 2025 5 Star Report, What 4 Quarters of Data are to be pulled to calculate the measure?

What are:

Q4 2023

Q1 2024

Q3 2024

Q4 2024

200

A resident with Parkinson's disease whose usual performance fluctuates, and most recent assessment resulted in functional score of 12............what am i monitoring and why?

Monitor for functional score of 11 or less to bump to Special Care Low Category.

200

True/False

Lacerations that require suturing or butterfly closure can be coded as a surgical wound.

False

200

PHQ2-9 Score required to capture depression end-split

10 or higher

200

COPD AND SHORTNESS OF BREATH WHILE LYING FLAT

PHQ2-9 SCORE 12

NURSING FUNCTION SCORE 16

CA2
300

Long Stay ADL's Worsened QM is now determined by what 4 GG Items?

What is:

1.  Eating

2.  Sit to Stand

3.  Sit to Lying

4.  Toileting Transfers

300

You find in morning clinical meeting; a resident has a fever.  What are you looking for to pair with the fever, to bump up to Special Care High?

- Fever and one of the following:  

Pneumonia, Vomiting, Weight loss, or Feeding tube 51% or more of total calories OR (2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the last 7 days.


-  I2000 PneumoniaJ1550B VomitingK0300 Weight lossK0510B1 or K0510B2 Feeding tube1


300

This is required to support a depression end split 

Validation of completion of interview items D0150 A - I at Z0400 dated on or before the ARD and within the observation period.

300

True/False

We may complete a staff Assessment of Resident Mood (PHQ2-9-OV) if resident refuses interview.

False-- The Staff Assessment of Resident Mood may only be completed if D0100 is coded as "No-- Resident is rarely or never understood"

300

Nursing function score 14

BIMS 6

Two Qualifying Restorative Programs with both at least 6 days a week

BA2

400

Which new Measure is replacing Short Stay improvement in function?

What is:  The SNF QRP Measure of Discharge Function Score

400

You currently have a resident at CA1 with COPD and SOB while flat.  You learn in clinical meeting that this resident has been requiring more assistance with transfers than usual.  What will you investigate and why?


Investigate the resident's usual performance to assess for functional score change of 14 or less to bump up to speical care high.

400

Supportive Documentation to capture isolation for active ATB resistant UTI in contact isolation are:

N/A We cannot capture isolation for a urinary tract infection, encapsulated PNE, or a wound infection

400

Name the 3 CMI categories who are eligible for depression end splits..............

Special Care High

Special Care Low

Clinically Complex

400

Dx Parkinson's disease is active

Nursing Function Score 12

PHQ2-9 = 0

PBC1

500

Name at least 2 co-variates for the new Long Stay Pressure Ulcer Measure

What is:

Diabetes, PVD, PAD, Low BMI, Infection, Malnutrition or at risk for, Hospice, Bowel Incontinence, Impaired lying to sitting is partial/mod/substantial/max or not attempted.

500
You learn that a resident you currently have LBC1 for respiratory failure with oxygen use has new order for Nebulizer treatments x 10 days. What am i checking and why?

1.  Ask DON or designee if respiratory training documentation up to date for all nurses to administer treatments.

2.  Assure MAR is setup correctly with minutes included.

3.Share with team goal to obtain documentation for 15 min/day for 7 days.

500

What is the following requirement for?

Documentation of the date(s) staff member(s) interviewed across all shifts, dates of staff observations, and the frequency reported for each applicable item D0500 A-J.  If family member(s) or significant other(s) were interviewed, the date the interview was conducted, dates of family member(s) or significant other(s) obs

Staff Assessment of Resident Mood (PHQ-9-OV)

500

Number of RUG Groups within the Nursing Component

What are 25?

26 if default rug included


500

Returned from hospital yesterday 

Nursing Function Score = 5

PHQ2-9 = 10

Received IV fluids for documented hydration purposes while in the hospital (2 days ago)

HDE2