Financial and Operating Review for
The Nathaniel Witherell
Final Report
Appendices
Appendix A: BPCI Advanced Participants Located near The Nathaniel Witherell
Appendix B: Primary Referral Sources
Appendix C: Provider Profiles
Appendix D: New Executive Director/DON Training and Orientation Checklists
Appendix E: Insurance Verification Form
Appendix F: Resident Trust Fund Authorization Form
Appendix G: Bad Debt Worksheet Form
Appendix H: Office of Inspector General (OIG) Vendor Verification Form
Appendix I: IDEAL Discharge Process Checklist (Example)
Appendix J: Paid Time Off (PTO) Policy (Example)
Appendix K: CMS 5-Star User Guide
Appendix L: Minimum Data Set (MDS) Forms
Appendix M: Glossary of Terms
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX A: BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI)
ADVANCED PARTICIPANTS LOCATED NEAR THE NATHANIEL
WITHERELL
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell
Source: Centers for Medicare & Medicaid Services
Organization DBA Name
Participa
nt Type
City Clinical Episode
BAY AREA INPATIENT GROUP PGP DARIEN ACUTE MYOCARDIAL INFARCTION
BAY AREA INPATIENT GROUP PGP DARIEN BACK & NECK EXCEPT SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC ARRHYTHMIA
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC DEFIBRILLATOR
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC VALVE
BAY AREA INPATIENT GROUP PGP DARIEN CELLULITIS
BAY AREA INPATIENT GROUP PGP DARIEN CERVICAL SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CHRONIC OBSTRUCTIVE PULMONARY DISEASE, BRONCHITIS, ASTHMA
BAY AREA INPATIENT GROUP PGP DARIEN COMBINED ANTERIOR POSTERIOR SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CONGESTIVE HEART FAILURE
BAY AREA INPATIENT GROUP PGP DARIEN CORONARY ARTERY BYPASS GRAFT
BAY AREA INPATIENT GROUP PGP DARIEN DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS
BAY AREA INPATIENT GROUP PGP DARIEN DOUBLE JOINT REPLACEMENT OF THE LOWER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN FRACTURES OF THE FEMUR AND HIP OR PELVIS
BAY AREA INPATIENT GROUP PGP DARIEN GASTROINTESTINAL HEMORRHAGE
BAY AREA INPATIENT GROUP PGP DARIEN GASTROINTESTINAL OBSTRUCTION
BAY AREA INPATIENT GROUP PGP DARIEN HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT
BAY AREA INPATIENT GROUP PGP DARIEN LOWER EXTREMITY AND HUMERUS PROCEDURE EXCEPT HIP, FOOT, FEMUR
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR BOWEL PROCEDURE
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE UPPER EXTREMITY
BAY AREA INPATIENT GROUP PGP DARIEN PACEMAKER
BAY AREA INPATIENT GROUP PGP DARIEN PERCUTANEOUS CORONARY INTERVENTION
BAY AREA INPATIENT GROUP PGP DARIEN RENAL FAILURE
BAY AREA INPATIENT GROUP PGP DARIEN SEPSIS
BAY AREA INPATIENT GROUP PGP DARIEN SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
BAY AREA INPATIENT GROUP PGP DARIEN SPINAL FUSION (NON-CERVICAL)
BAY AREA INPATIENT GROUP PGP DARIEN STROKE
BAY AREA INPATIENT GROUP PGP DARIEN URINARY TRACT INFECTION
BAY AREA INPATIENT GROUP PGP DARIEN BACK & NECK EXCEPT SPINAL FUSION
BAY AREA INPATIENT GROUP PGP DARIEN CARDIAC DEFIBRILLATOR
BAY AREA INPATIENT GROUP PGP DARIEN PERCUTANEOUS CORONARY INTERVENTION
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN ACUTE MYOCARDIAL INFARCTION
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CARDIAC ARRHYTHMIA
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CELLULITIS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN CONGESTIVE HEART FAILURE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN GASTROINTESTINAL HEMORRHAGE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN PACEMAKER
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN RENAL FAILURE
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN SEPSIS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP PGP DARIEN URINARY TRACT INFECTION
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
BAY AREA INPATIENT GROUP INPATIENT 280, 281, 282
BAY AREA INPATIENT GROUP INPATIENT 518, 519, 520
BAY AREA INPATIENT GROUP INPATIENT 308, 309, 310
BAY AREA INPATIENT GROUP INPATIENT 222, 223, 224, 225, 226, 227
BAY AREA INPATIENT GROUP INPATIENT 216, 217, 218, 219, 220, 221, 266, 267
BAY AREA INPATIENT GROUP INPATIENT 602, 603
BAY AREA INPATIENT GROUP INPATIENT 471, 472, 473
BAY AREA INPATIENT GROUP INPATIENT 190, 191, 192, 202, 203
BAY AREA INPATIENT GROUP INPATIENT 453, 454, 455
BAY AREA INPATIENT GROUP INPATIENT 291, 292, 293
BAY AREA INPATIENT GROUP INPATIENT 231, 232, 233, 234, 235, 236
BAY AREA INPATIENT GROUP INPATIENT 441, 442, 443
BAY AREA INPATIENT GROUP INPATIENT 461, 462
BAY AREA INPATIENT GROUP INPATIENT 533, 534, 535, 536
BAY AREA INPATIENT GROUP INPATIENT 377, 378, 379
BAY AREA INPATIENT GROUP INPATIENT 388, 389, 390
BAY AREA INPATIENT GROUP INPATIENT 480, 481, 482
BAY AREA INPATIENT GROUP INPATIENT 492, 493, 494
BAY AREA INPATIENT GROUP INPATIENT 329, 330, 331
BAY AREA INPATIENT GROUP INPATIENT 469, 470
BAY AREA INPATIENT GROUP INPATIENT 483
BAY AREA INPATIENT GROUP INPATIENT 242, 243, 244
BAY AREA INPATIENT GROUP INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
BAY AREA INPATIENT GROUP INPATIENT 682, 683, 684
BAY AREA INPATIENT GROUP INPATIENT 870, 871, 872
BAY AREA INPATIENT GROUP INPATIENT 177, 178, 179, 193, 194, 195
BAY AREA INPATIENT GROUP INPATIENT 459, 460
BAY AREA INPATIENT GROUP INPATIENT 61, 62, 63, 64, 65, 66
BAY AREA INPATIENT GROUP INPATIENT 689, 690
BAY AREA INPATIENT GROUP OUTPATIENT
BAY AREA INPATIENT GROUP OUTPATIENT
BAY AREA INPATIENT GROUP OUTPATIENT
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 280, 281, 282
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 308, 309, 310
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 602, 603
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 291, 292, 293
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 377, 378, 379
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 469, 470
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 242, 243, 244
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 682, 683, 684
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 870, 871, 872
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 177, 178, 179, 193, 194, 195
CEP AMERICA - ILLINOIS HOSPITALISTS, LLP INPATIENT 689, 690
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Participa
nt Type
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
SAME INPATIENT 280, 281, 282
SAME INPATIENT 518, 519, 520
SAME INPATIENT 308, 309, 310
SAME INPATIENT 602, 603
SAME INPATIENT 471, 472, 473
SAME INPATIENT 190, 191, 192, 202, 203
SAME INPATIENT 291, 292, 293
SAME INPATIENT 533, 534, 535, 536
SAME INPATIENT 377, 378, 379
SAME INPATIENT 388, 389, 390
SAME INPATIENT 480, 481, 482
SAME INPATIENT 492, 493, 494
SAME INPATIENT 329, 330, 331
SAME INPATIENT 469, 470
SAME INPATIENT 483
SAME INPATIENT 242, 243, 244
SAME INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
SAME INPATIENT 682, 683, 684
SAME INPATIENT 870, 871, 872
SAME INPATIENT 177, 178, 179, 193, 194, 195
SAME INPATIENT 459, 460
SAME INPATIENT 61, 62, 63, 64, 65, 66
SAME INPATIENT 689, 690
SAME OUTPATIENT
SAME OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 280, 281, 282
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 518, 519, 520
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 308, 309, 310
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 222, 223, 224, 225, 226, 227
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 216, 217, 218, 219, 220, 221, 266, 267
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 602, 603
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 471, 472, 473
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 190, 191, 192, 202, 203
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 453, 454, 455
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 291, 292, 293
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 231, 232, 233, 234, 235, 236
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 441, 442, 443
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 461, 462
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 533, 534, 535, 536
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 377, 378, 379
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 388, 389, 390
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 480, 481, 482
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 492, 493, 494
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 329, 330, 331
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 469, 470
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 483
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 242, 243, 244
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 246, 247, 248, 249, 250, 251, 273, 274
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 682, 683, 684
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 870, 871, 872
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 177, 178, 179, 193, 194, 195
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 459, 460
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 61, 62, 63, 64, 65, 66
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC INPATIENT 689, 690
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
HOUSTON INPATIENT PHYSICIAN ASSOCIATES PLLC OUTPATIENT
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name
Participa
nt Type
City Clinical Episode
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC PGP GREENWICH MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC PGP GREENWICH MAJOR JOINT REPLACEMENT OF THE UPPER EXTREMITY
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD CARDIAC ARRHYTHMIA
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD GASTROINTESTINAL HEMORRHAGE
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD GASTROINTESTINAL OBSTRUCTION
STAMFORD HEALTH MEDICAL GROUP PGP STAMFORD RENAL FAILURE
STAMFORD HOSPITAL ACH STAMFORD ACUTE MYOCARDIAL INFARCTION
STAMFORD HOSPITAL ACH STAMFORD CARDIAC ARRHYTHMIA
STAMFORD HOSPITAL ACH STAMFORD CHRONIC OBSTRUCTIVE PULMONARY DISEASE, BRONCHITIS, ASTHMA
STAMFORD HOSPITAL ACH STAMFORD CONGESTIVE HEART FAILURE
STAMFORD HOSPITAL ACH STAMFORD CORONARY ARTERY BYPASS GRAFT
STAMFORD HOSPITAL ACH STAMFORD GASTROINTESTINAL HEMORRHAGE
STAMFORD HOSPITAL ACH STAMFORD GASTROINTESTINAL OBSTRUCTION
STAMFORD HOSPITAL ACH STAMFORD RENAL FAILURE
STAMFORD HOSPITAL ACH STAMFORD SIMPLE PNEUMONIA AND RESPIRATORY INFECTIONS
STAMFORD HOSPITAL ACH STAMFORD STROKE
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1A: Bundled Payment for Care Initiative (BPCI) Advanced
Located near The Nathaniel Witherell (continued)
Source: Centers for Medicare & Medicaid Services
Organization DBA Name Inpatient / Outpatient MS-DRG
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC INPATIENT 469, 470
ORTHOPAEDIC AND NEUROSURGERY SPECIALISTS, PC INPATIENT 483
STAMFORD HEALTH MEDICAL GROUP INPATIENT 308, 309, 310
STAMFORD HEALTH MEDICAL GROUP INPATIENT 377, 378, 379
STAMFORD HEALTH MEDICAL GROUP INPATIENT 388, 389, 390
STAMFORD HEALTH MEDICAL GROUP INPATIENT 682, 683, 684
STAMFORD HOSPITAL INPATIENT 280, 281, 282
STAMFORD HOSPITAL INPATIENT 308, 309, 310
STAMFORD HOSPITAL INPATIENT 190, 191, 192, 202, 203
STAMFORD HOSPITAL INPATIENT 291, 292, 293
STAMFORD HOSPITAL INPATIENT 231, 232, 233, 234, 235, 236
STAMFORD HOSPITAL INPATIENT 377, 378, 379
STAMFORD HOSPITAL INPATIENT 388, 389, 390
STAMFORD HOSPITAL INPATIENT 682, 683, 684
STAMFORD HOSPITAL INPATIENT 177, 178, 179, 193, 194, 195
STAMFORD HOSPITAL INPATIENT 61, 62, 63, 64, 65, 66
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX B: PRIMARY REFERRAL SOURCES
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1B: Acute Neurologic
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF
Length of
Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as
2nd PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL
ASSOCIATION
32
21.5
17.5%
55.6%
STAMFORD HOSPITAL
29
22.5
19.0%
60.3%
TOTAL/AVERAGE
61
22.0
18.2%
57.9%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 2B: Elective Joint Replacement
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
231
12.6
3.0%
31.2%
STAMFORD HOSPITAL
44
14.9
4.5%
70.5%
TOTAL/AVERAGE
275
13.0
3.3%
37.5%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 3B: Major Joint Replacement/Spinal Surgery
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
71
19.6
6.4%
56.0%
STAMFORD HOSPITAL
18
23.0
22.9%
60.0%
TOTAL/AVERAGE
89
20.3
9.7%
56.8%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 4B: Medical Management
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
418
22.6
18.7%
59.0%
STAMFORD HOSPITAL
387
22.4
16.3%
61.6%
TOTAL/AVERAGE
805
22.5
17.5%
60.2%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 5B: Non-Orthopedic Surgery
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
67
20.6
18.7%
56.0%
STAMFORD HOSPITAL
112
23.0
18.8%
60.1%
TOTAL/AVERAGE
179
22.1
18.8%
58.5%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Table 6B: Other Orthopedic
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
143
28.1
8.4%
63.6%
STAMFORD HOSPITAL
97
30.9
13.0%
62.7%
TOTAL/AVERAGE
240
29.2
10.2%
63.3%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 7B: Total Discharges
Primary Referral Sources
Hospital
Annualized
Discharges
First PAC
SNF Length
of Stay
Readmission
Rate (30
Days from
SNF
Admission)
HHA as 2nd
PAC
Setting
Within 14
Days of
SNF
Discharge
GREENWICH HOSPITAL ASSOCIATION
962
20.6
12.4%
52.4%
STAMFORD HOSPITAL
687
23.2
15.8%
62.0%
TOTAL/AVERAGE
1,649
21.7
13.8%
56.4%
Source: HDG analysis of CMS LDS Medicare Claims Data, compiled by Dobson Davanzo
Note: Opportunities (highlighted in yellow) identified as a minimum of 25 discharges with an average length of stay higher
than market average.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX C: HOSPITAL PROFILES
Financial and Operating Review for
The Nathaniel Witherell
Final Report
Table 1C: Hospital Profiles
Source: Definitive Healthcare
Greenwich Hospital Stamford Hospital
Location Greenwich, Connecticut Stamford, Connecticut
Hospital Type Short-Term Acute Care Hospital Short-Term Acute Care Hospital
Staffed Beds 184 279
Medicare-certified Beds 206 305
Total Discharges 10,701 13,888
Total Average Length of Stay 4.8 Days 4.3 Days
CMI 1.63 1.65
Affiliated Physicians (Primary) 405 652
Affiliated Physicians (Secondary) 371 249
ACO Affiliations Cigna - Northeast Medical Group ACO (Commercial) None
Readmission Reduction Adjustment Penalty Score -0.79% -0.20%
Readmission Reduction Revenue Adjustment ($356,673) ($99,738)
Value-Based Purchasing $45,158 ($230,900)
Hospital Acquired Conditions Reduction $0 $0
Medicare Spending per Patient $21,287 $21,950
Medicare Spend vs. National Median 1.04 1.04
Hospital Spend: Connecticut Average 1.00 1.00
Medicare Case-Mix Adjusted Cost Per Discharges $10,834 $13,096
State Average $10,513 $10,513
Medicare Overall Case Mix Index 1.6339 1.6498
Average Daily Census 123.2 146.8
% Medicare 41.0% 35.6%
% Medicaid 3.2% 20.8%
% Other 55.8% 43.6%
Network Yale New Haven Health System None
Hospital 9 0
Physician Group 7 0
Ambulatory Surgery Center 20 0
Imaging Center 24 0
Home Health Agency 1 0
Hospice 2 0
Skilled Nursing Facility 1 0
Ugent Care Clinic 9 0
Payor Mix
System Components
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX D: ORIENTATION AND TRAINING CHECKLISTS FOR NEW
EXECUTIVE DIRECTORS AND DIRECTORS OF NURSING
December 13, 2018
Page 1
Director of Nursing Training Completion Checklist
DON Name:
Hire Date:
Nurse Consultant Name:
HDG NURSING PROCESSES/SYSTEMS
Core Competency
Date
Completed
Initial
Trainer
Initial
DON
Anticoagulant Therapy
Diabetic Management
Pain Management
Dialysis
Change of Condition
Enteral Feeding
Tracheostomy Care
Hydration
Accidents/Incidents
Bowel & Bladder
Behavior Management
Nutrition at Risk
Medical Records
Skin/ Wound Care
Infection Control
QAPI/ Root Cause Analysis
Survey Readiness/Regulatory Compliance
Code Status System
Pharmacy Services
Investigations/Complaints/Grievances
Core Competency
Date
Completed
Initial
Trainer
Initial
DON
MDS
Medline University/Inservice/Education
Care Planning/ Quarterly Assessments
Admissions
December 13, 2018
Page 2
Discharges
Labor/ Staffing/ Performance Evals
802/672
INTERACT
Abaqis
PCC (Point Click Care)/ POC (Point of Care, if applicable)
Clinical Oversight- Daily, Weekly, Monthly, Quarterly
Quality Measures/ Casper Report
5 Star
Community Orientation
Date
Completed
Initial
Trainer
Initial
DON
Important Facility Information
Your Nursing Team
Staffing
Training Opportunities
Continuous Quality Improvement
Facility Manuals
Customer Satisfaction
Getting to Know your Role in your Community
Clinical Rounds
Infection Control
Communication Systems
Recruitment and Retention
Supplies and Ordering
Service Providers
RAI
Administrative Services
Business Office Services
Housekeeping Services
Laundry Services
Maintenance Services
Medical Director Services
December 13, 2018
Page 3
Medical Records Services
Nutritional Services
Activities and Recreation Services
Rehabilitation Services
Social Services
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Caring Above and Beyond / HDG Corporate
Review of HDG Values, Mission, Vision RDO/CEO
Review of Scope of Authority RDO
Explain role of company consultants (Clinical, MDS, HR, Billing, Safety, Marketing) RDO
Functional Policies, Procedures and Expectations. Each regional consultant meets with administrator and
discusses how they can be of help.
RDO
Discuss items used to measure success in each functional area. What are the measureable standards and
metrics for marketing, clinical, human resources, rehabilitation, etc.
RDO
Review of Caring Above and Beyond Values in Action VP of Quality Improvement
Review and explain Code of Conduct, Compliance Policies, OIG requirements Corporate Compliance Director
HIPAA Policies Corporate Compliance Director
Review of Scorecard process RDO
Emergency Contacts
Discuss emergency contacts and when to call (Regional Director of Operations, Nurse Consultant, HR
Consultant Business Office Consultant)
RDO
Trigger Event Process/VA/Investigative Events
Provides overview of reporting Process, Expectations, Who to call during State Survey/Complaint
Survey/OSHA Survey
RDO
Labor Management
Communicate Labor Expectations RDO
How to use Labor Reports: Includes explanation, demonstration on computer, coaching and feedback RDO
How to conduct a daily staffing meeting. Includes explanation, demonstration observation and feedback RDO
Daily Staffing RDO
Daily Profitability Report RDO
Labor Management
Employment Laws and procedure for reducing employee hours or pay, if needed HR Consultant /RDO
Smartlinx Overview Payroll Consultant
Block Scheduling Overview Payroll Consultant
Purchasing
WEEK ONE
EXECUTIVE DIRECTOR ONBOARDING CHECKLIST
-1
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
AP Director of AP/Insurance
Vendors, New Vendors W-9 forms Director of AP/Insurance
Purchasing Contracts/community Contracts and Agreements Director of AP/Insurance
People Policies
Provide an explanation of key manager polices in the Handbook/HR P&P Manual and answer questions. HR Consultant
Provide an explanation of key employee policies in the Employee Handbook and answer questions. HR Consultant
Small Group Policy Overview HR Consultant
Performance Review/Stay Interview Process HR Consultant
HDG Orientation/Mentorship Program 30/60/90 Check-ins HR Consultant
Explain HR Audit/Assessment. HR Consultant
Review employee survey and action plans HR Consultant
Review the Employee Handbook HR Consultant
Discuss Union Contracts/Labor Relations HR Consultant
Weekend Manager on Duty program RDO
Explain HDG Quality Compliance HotLine for employees and families VP Quality Improvement
Review last 90 days of Quality HotLine calls from employees and how to prepare a written response. VP Quality Improvement
Review Caring Above and Beyond and Family, Employee, and Resident QC committee's, QC committee
reporting calendar
VP Quality Improvement
Disciplinary Process and Termination
Provide an explanation of policies and procedures regarding the disciplinary process. HR Consultant
Provide an explanation of termination policies and procedures. HR Consultant
Compensation Process and Levels of Authorization
Explain the yearly compensation philosophy HR Consultant
Explain compensation process including levels of authorization, completion of form, hire bonus, shift bonus
and pay raises.
HR Consultant
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Financial Reports, Financial Documents, By-Weekly Labor Reports, and Budget
Provides overview of system and sets financial expectations RDO
How to understand and use Financial Reports, Financial Documents, Bi-weekly Labor Reports, Budget, and
Spend-Down Sheets to successfully run the business
RDO
Review Scorecard process RDO
Monthly Management Report and Monthly Variance Report RDO
FIRST MONTH
-2
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Processing travel expense - GL Account Coding RDO
Monthly Accrual Process RDO
Review ED Bonus Criteria RDO
Business Office Processes
Accounts Receivable process/reports, bad debt, collections, central billing office Business Office Consultant
Cash Receipting process (General depository, Lockbox) Business Office Consultant
Resident Trust Fund Business Office Consultant
PCC - Admin tab Business Office Consultant
Aging/Financial meeting, Triple Check, & payer verifications Business Office Consultant
Collection Agency Business Office Consultant
Administrator process & PCC - cash adjustments, ancillaries, census reconciliation Business Office Consultant
Private Statements Business Office Consultant
Pharmacy Statements Business Office Consultant
Ancillaries Bundled Pricing Business Office Consultant
Internal Audit Business Office Consultant
Consolidated Billing Business Office Consultant
Access and Use of Electronic Resources
Explanation and demonstration of how to use email, voicemail, telephone system, passwords and other
electronic resources.
RDO or as assigned
Explanation and demonstration of how information is organized and shared from HDG RDO
Email Encryption Corporate Compliance Director
PointClickCare and reports Business Office Consultant
Medicare Entitlement
Compliance: Pre-bill audit/ Triple check: Business Office Consultant
Beneficiary Notice and Electronic signatures Business Office Consultant
Regulatory
Standard Operations Policies RDO
Explain and communicate Survey History, Plan of Correction, Survey Readiness process, and PREP Survey
Nurse/Clinical Consultant
Explain and demonstrate Survey Readiness Nurse/Clinical Consultant
Review of community assessment Nurse/Clinical Consultant
Clinical Systems
Abuse Prevention Policy, DHS Reporting Nurse/Clinical Consultant
Additional Clinical Resources, e.g., door security, bed systems, memory unit, community layout, etc Nurse/Clinical Consultant
Review of clinical meetings (behavior, nutrition at risk, skin) Nurse/Clinical Consultant
-3
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
Review of Elopment Guidelines Nurse/Clinical Consultant
Weekly Medicare Meeting RUGS Meeting
Provide overview of Weekly Medicare meeting, the purpose and the process.
Director of Clinical Reimbursement
and Therapy
How to conduct the Medicare meeting. Includes observation of Medicare Meeting, explanation of how to run
the meeting, practice running the meeting with observer and feedback.
Director of Clinical Reimbursement
and Therapy
Review the triple check process and how it affects billing.
Director of Clinical Reimbursement
and Therapy
Assessment Reference Date Planner (Daily Meeting)
Daily Standup RDO
ED Routines RDO
Safety
Explain culture of safety excellence; safety committees, lifts, Injury-Reducing Safety Report Program, Disaster
Drills, Safe Patient Handling Policy and Equipment and Root Cause Analysis
Director of Safety and Risk
Management
Customer Service
Explain the company customer service CAAB VP Quality Improvement
Explain customer satisfaction measurement process (MyInnerview Survey), and the Quality Hot Line program VP Quality Improvement
Customer Satisfaction Survey Committees (Employee, Residents, Family) VP Quality Improvement
Sales and Marketing
Explain the importance of the Medicare and Managed Care business line, strategy and philosophy. Explain the
strategy of the admitting of high acuity patients.
Director of Market Development &
Admissions
Explain the general key account integration strategy
Director of Market Development &
Admissions
Explain the sales and marketing business tools including the Annual Sales Plan (ASP), Marketing Action Plan,
Admission Director Month End Report, and marketing collaterals.
Director of Market Development &
Admissions
Explain the sales team concept. Explain the roles of key sales positions including the Admissions Director and
Business Development Director
Director of Market Development &
Admissions
Explain the 24/7, Holiday, and Fast Admissions Process
Director of Market Development &
Admissions
Explain the Referral Development Team
Director of Market Development &
Admissions
Review the Clinical Capabilities of the building and Admission process with required policy and procedures
Director of Market Development &
Admissions
Quality Council and Performance Improvement
-4
EXAMPLE
KNOWLEDGE/SKILL TRAINER DATE COMPLETED
How to manage QAPI VP Quality Improvement
Sources of inputs VP Quality Improvement
Root cause analysis and how to develop an action plan VP Quality Improvement
Incident Reporting System VP Quality Improvement
Pharmacy Operations
Review and explain Rx Trend Reports, Omniview, and Pharmacy Operations Initiatives RDO
Review and explain basic pharmacy services procedures RDO
Review and explain how to escalate pharmacy issues. RDO
Omniview - Medication orders RDO
Medical Directors
Contracting for Medical Director/ Physicians RDO
Compensation Guidelines for Medical Directors and Physicians RDO
Rehabilitation
Responsibilities of the Director of Rehabilitation
Director of Clinical Reimbursement
& Therapy
Patient Scheduling
Director of Clinical Reimbursement
& Therapy
Non-billable service
Director of Clinical Reimbursement
& Therapy
Staffing Model
Director of Clinical Reimbursement
& Therapy
Rehabilitation Organization Chart
Director of Clinical Reimbursement
& Therapy
Life Safety
Review Life Safety expectations
Director of Safety & Risk
Management
Review Emergency Preparedness, Active Shooter/Workplace Violence policies, door security
Director of Safety & Risk
Management
Monthly Corporate Mandatory Reports
Monthly Management Report RDO
-5
EXAMPLE
1 | P a g e
Executive Director Routines
Instructions:
The purpose of this form is to outline the key leadership routines and cyclical processes of the Executive Director.
Documenting routines that occur on an annual, semi-annual, quarterly, monthly, weekly and bi-weekly basis help to
identify priorities within an organization and to streamline processes leading to improved efficiency and operational
outcomes across the care community. The document should include those activities that the Executive Director would
either provide primary leadership, secondary support or oversight. (i.e. What happens at the care community) The intent
of this document is to provide a general structure of framework for documentation. There could be other requirements based on the
specific needs of the community.
Annual Routines
Operational Area
Target
Completion
Date:
Back Up
HDG Resource
Quality
Operation plan development and
review: Quality Section
November
RDO
RDO
Conduct Resident Survey
Sept/Oct
RDO
VP Quality Improvement
Conduct Family Survey
Sept/Oct
RDO
VP Quality Improvement
Survey Preparedness
Determined by
survey cycle
DON
Clinical Consultant
Life Safety Audit
December
Plant Ops
Director of Safety & Risk
Management
Review Emergency Preparedness
Plan
January
Plant Ops/HR
Director of Safety & Risk
Management
OIG/Code of Conduct/Compliance
Policy Review by Employees
April
HR
Corporate Compliance
Officer
Review community and staff
licenses are up to date
July/August
HR/RDO
HR Consultant/RDO
Building License Review, CLIA
Waiver
July/August
RDO
RDO
Maintenance Annual
Inspection/Plan
January
Plant Ops
Director of Safety & Risk
Management
Activities Review Annual
Calendar/Community Involvement
January
Activity Director
RDO / Director of Market
Development
Community specific policy review /
approval on changes
December
RDO
RDO
QAPI review
October
DON
VP Quality Improvement
People
Operation plan development and
review: People Section
November
RDO
HR Consultant
Employee Survey
Sept/Oct
RDO
VP Quality Improvement
Employee Survey Communication,
Analysis and Identifications of
Action Plan
January
RDO
VP Quality Improvement
Employee Performance Reviews
Anniversary
Date or Annual
Date Set
HR
HR Consultant
EXAMPLE
2 | P a g e
HDG HR/Payroll Audit
November
HR
HR Consultant
Payroll Consultant
Compensation Planning
October
HR
Director of Total Rewards
Benefit Open Enrollment
October (for
Jan 1 renewals)
HR
Director of Total Rewards
Employee Handbook / P&P Review
December
HR
HR Consultant
Affirmative Action Plan Update, if
required
April
HR
HR Consultant
5500 401(k) or 403(b) Completion /
5500 Health & Welfare / 401(k)
Audit
July
HR
Director of Total Rewards
Review CBA / Contract
Negotiations, if required
As set by
contract
HR
VP Human Resources
Posting OSHA Log
By February 1
HR
Director of Safety & Risk
Management
Risk Management Audit / Claim
Review
October
HR
Director of Safety & Risk
Management
Operational Plan Review with
Employees & with Staff / Mission,
Vision, Values Review
January
RDO
RDO
Annual Required Trainings through
MedCom
December
HR
HR Consultant
W-2 Completion & Handout
January
HR
Payroll Consultant
Financial Performance
Operation plan development and
review: Financial Performance
Section
November
RDO
RDO
Budget planning
October
RDO
RDO
Capital Expenditure planning
October
RDO
RDO
Contract Review (payers and
vendors) and Renewal
July/August
RDO
RDO
EXAMPLE
3 | P a g e
Semi-Annual Routines
Operational Area
Target Completion
Date
Back Up
HDG Resource
Quality
Phase 1/Phase 2 Abaqis Check-in
on all appropriate phased tasks
January & July
DON
Clinical Consultant
Prep Survey
As set by HDG
DON
VP Quality
Improvement
Quarterly Routines
Operational Area
Target Completion
Date
Back Up
HDG Resource
Quality
Quality/Regulatory compliance
operations plan review
January, April, July,
October
RDO
RDO
Review meal menus, quality, update
action plan
January, April, July,
October
Culinary Director
Dietitian
Clinical Consultant
Community maintenance and curb
appeal plan - review
By end of month
Plan Operations
Director
VP of Safety and Risk
Management
Review PBJ CMS Status
January, April, July
October
HR
Payroll Consultant
People
People operations plan review
January, April, July,
October
RDO
RDO
Small Group Meetings
January, April, July,
October
DON
HR Consultant
Provides or Coordinate Leadership
Training (example: Talent Management,
Policy Procedures as needed)
February, May,
August, November
HR
HR Consultant
Financial Performance
Approve marketing and sales plan
January, April, July,
October
RDO
Director of Market
Development
Financial operations plan review
January, April, July,
October
RDO
RDO
Vendor usage/spend review/meet
with vendors to discuss opportunities
January, April, July,
October
DON
RDO
EXAMPLE
4 | P a g e
Monthly Routines
Operational Area
Target Completion
Date:
Back-Up
HDG Resource
Quality
Quality/Regulatory compliance
operations plan review
By end of month
RDO
RDO
Review Casper Report / Take to
QAPI
By end of month
RDO
RDO
Prepare monthly operations report
Before 20
th
of month
RDO
RDO
Attend Scorecard Call
Last two weeks of
month
RDO
RDO
Ensures PBJ Timely Report
2
nd
week of month
HR
Payroll Consultant
Resident QI Action Plan - ensure
teams on track and making progress
By end of month
Team Facilitator
VP of Quality
Improvement
Family QI Action Plan - ensure
teams on track and making progress
By end of month
Team Facilitator
VP of Quality
Improvement
5 Star Rating data to ensure
accuracy, update action plans
By end of month
DON
Director of Corporate
Compliance
Behavioral/Psychotropic meeting
By end of month
DON
Clinical Consultant
Attend Nutrition at Risk Meeting
By end of month
DON
Clinical Consultant
Meet with Medical Director and
Nurse Practitioner
By end of month
RDO
RDO
People
Meet with Leadership Team (outside
of stand-up)
By end of month
RDO
RDO
Review Turnover Data & Exit
Interview Trends
By end of month
HR
HR Consultant
Sign off on Monthly Benefit
Reconciliation
By end of month
HR
Director of Total Rewards
Leadership Webinar participation
3
rd
Wednesday of
Month
HR
HR Consultant
Safety Committee Action Plan -
ensure teams on track and safety
activities completed
By end of month
HR
Director Safety and Risk
Management
Employee QI Action Plan - ensure
teams on track and making progress
By end of month
HR
HR Consultant
Financial Performance
Review financial statements, update
action plan
15
th
of month
RDO
RDO
Accounts Receivable call with HDG
As scheduled
Bus Office/Billing
RevGroup
Admissions/Marketing data
analysis, update marketing plan
By end of month
Admissions
Director
Admissions Consultant
Attend triple check meeting to
assure that all UB’s have been
checked vs PCC and therapy bills
By end of month
RDO
RevGroup
Case mix call / report review
By end of month
MDS Coordinator
RevGroup
EXAMPLE
5 | P a g e
Bi-Weekly Routines
Operational Area
Target Completion
Date:
Back-Up
HDG Resource
People
Sign off on payroll/401(k)
submission
Payroll week
HR
Payroll Consultant
Review business analytics in
Smartlinx
Payroll week
HR
Payroll Consultant
Financial Performance
Prepare and submit financial
projection
1
st
and 3
rd
week of
each month
RDO
RDO
Review marketing plan with
marketing team
1
st
and 3
rd
week of
each month
RDO
Director of Market
Development
Weekly Routines
Operational Area
Target
Completion Date:
Back-Up
HDG Resource
Quality
Medicare meeting
Weekly
RDO
RevGroup
1:1 Operations update with RDO
Weekly
N/A
RDO
Walk around with plant
operations director, update
action plan
Weekly
N/A
RDO
Curb appeal walk around
Weekly
Admissions/Marketing
Director
RDO
Wound program meeting review
and documentation check
Weekly
DON
Nurse Consultant
People
Oversee & Attends New
Employee Orientation
At each orientation
HR
HR Consultant
Reviews Staffing/Recruiting
Needs with HR and managers
Weekly
HR
HR Consultant or
Centralized Recruiter
HDG HR Call with HR
Consultant to discuss projects,
issues
As scheduled
HR
HR Consultant
Meet with each manager, address
issues, review operational plan
progress, update action plans,
employee issues, labor
management, punch detail
completions
Weekly
RDO
RDO
Financial Performance
Spend down review/adjust
expenses if expenses not trending
to meet budget
Weekly
RDO
RDO
EXAMPLE
6 | P a g e
Daily Routines
Operational Area
Target Completion
Time:
Back-Up
HDG Resource
Quality
Oversees Daily Values in Action
DON
RDO/VP of Quality
Improvement
Facilitates Daily Stand Up Meeting
(using HDG stand-up routines)
DON
RDO
Daily Rounding twice per day at
least (using HDG rounding routine)
DON
RDO
Dining room meal monitoring
Culinary Director
VP of Quality
Improvement
Concern/grievance report review
DON
Clinical Consultant
Meet new admissions
Admissions
Director
Director of Market
Development
People
Oversees Employee
Relations/Investigations/Safety
Incidents
HR
RDO / HR Consultant
Address customer service issues with
families, residents and employees
DON/HR
RDO / HR Consultant
Follows up to resolution on payroll,
PTO, other compensation issues
HR
Payroll Consultant
Supports performance management
processes of community
HR
HR Consultant
Facilitates daily recognition
initiatives
HR
HR Consultant
Advises, consults, supports
Leadership
HR
RDO
Oversee completion of safety
activities
HR
Director of Safety & Risk
Management
Financial Performance
Daily Profitability Report Submission
RDO / HR
RDO
Directs Management to Review Daily
punch detail report (Reviews
compliance for
Attendance/Overtime/Meal Punches)
HR
HR Consultant
Review and approve labor variations
HR
HR Consultant
Review labor management/staffing
to census
DON
RDO
Reviews Projected
admissions/discharges
DON
Clinical Consultant
EXAMPLE
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX E: INSURANCE VERIFICATION FORM
June 2018
HDG 2018 Page 1
New Resident Insurance Information
Name of Resident: Date of Birth:
Date of Admit:
Medicare #: Medicaid #:
Insurance #:
Primary Insurance Secondary Insurance
Name of Insurance Company:
Claims Address:
Phone #: Fax #:
Prior Auth Phone #: Prior Auth Contact:
Policy ID #: Group ID #:
Insurance Effective Date: Auth. Number:
In Network Yes No Out of Network Yes No
3-day hospital stay needed? Yes No Deductible met? Yes No
Max out of pocket met? Yes No Out of pocket Max $
100 % paid for days? Co-insurance of after day ?
Co Pay for Days to Co Pay for Days to
Co Pay for Days to Co Pay for Days to
Type of Service
Covered
Prior
Authorization
Needed
Description of Coverage
Skilled Room and Board
Medicare RUGs
Negotiated Rate
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Physical Therapy
Yes No
Yes No
Occupational Therapy
Yes No
Yes No
Speech Therapy
Yes No
Yes No
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX F: RESIDENT TRUST FUND AUTHORIZATION FORM
June 2018
HDG 2018 Page 1
Resident Trust Fund Authorization
Resident
By my signature below, I authorize the Care Community to hold my personal funds in
the Resident Trust Account. I understand my money will be held in an interest bearing
Bank account. Receipts will be kept for all expenditures, and the account will be
managed in accordance with all State and Federal codes. Quarterly statements will be
sent to the authorized person. I will have access to my account during the normal
business hours as posted at the office.
I
Do
Do Not
I authorize to have my income direct deposited into the Resident Trust Account as well
as my resident liability withdrawn for my room and board.
I
Do
Do Not
Authorize the Care Community to withdraw monies as needed for personal needs,
medical needs, and/or activity needs that I may have incurred, such as beautician,
barber, health insurance, clothing, etc., as such bills are presented to the care
community.
I authorize the following individuals to have access to the funds in my Resident Trust
Account in order to make purchases or payments on my behalf:
Authorized Person Relationship
Authorized Person Relationship
Resident Signature or Legally Authorized Representative
Witness Date
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX G: BAD DEBT WORKSHEET FORM
Billing and Collections Manual
June 2018
HDG 2018 Page 1
BAD DEBT WORKSHEET
Care Community Name:
Resident Name Resident Number
Payor Amount Service Dates
Explanation of uncollectible charges and collection efforts:
Steps taken to prevent this type of bad debit from recurring:
Prepared By: Date:
Business Office Consultant: Date:
Administrator: Date:
VP Finance: Date:
Admissions Coordinator (if applicable): Date:
Bad Debt Posted By: Date:
Posting Date: Adjustment Batch No:
Please Note: Please attach the following documentation: Current A/R Aging, Transaction
History Report, Collection Log; Collection Notes, Collections Letters & Copies of Statements,
and any other relevant documentation regarding collection attempts for this amount.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX H: OFFICE OF INSPECTOR GENERAL (OIG) VENDOR
VERIFICATION FORM
50.6.8 OIG/GSA Exclusion
(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07-20-12)
(Chapter 9 - Rev. 15, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07-20-12)
The Act §1862(e)(1)(B), 42 C.F.R. §§ 422.503(b)(4)(vi)(F), 422.752(a)(8), 423.504(b)(4)(vi)(F),
423.752(a)(6), 1001.1901
This section provides guidance regarding sponsors’ implementation of FWA safeguards to identify
excluded providers and entities. Medicare payment may not be made for items or services furnished
or prescribed by an excluded provider or entity. Sponsors shall not use federal funds to pay for
services, equipment or drugs prescribed or provided by a provider, supplier, employee or FDR
excluded by the DHHS OIG or GSA.
Sponsors must review the DHHS OIG List of Excluded Individuals and Entities (LEIE list) and the
GSA Excluded Parties Lists System (EPLS) prior to the hiring or contracting of any new employee,
temporary employee, volunteer, consultant, governing body member, or FDR, and monthly
thereafter, to ensure that none of these persons or entities are excluded or become excluded from
participation in federal programs. Monthly screening is essential to prevent inappropriate payment to
providers, pharmacies, and other entities that have been added to exclusions lists since the last time
the list was checked. After entities are initially screened against the entire LEIE and EPLS at the time
of hire or contracting, sponsors need only review the LEIE supplement file provided each month,
which lists the entities added to the list that month, and review the EPLS updates provided during the
specified monthly time frame.
OIGs LEIE includes all health care providers and suppliers that are excluded from participation in
federal health care programs, including those health care providers and suppliers that might also be
on the EPLS. In addition to health care providers (that are also included on the OIG LEIE), the EPLS
includes non-health care contractors.
Links to instructions for accessing this information are available in Appendix A: Resources.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX I: IDEAL DISCHARGE PROCESS (EXAMPLE)
Guide to Patient and Family Engagement :: 1
IDEAL Discharge Planning Overview, Process, and Checklist
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.
1,2
Research shows that
three-quarters of these could have been prevented
or ameliorated.
1
Common post-discharge complications
include adverse drug events, hospital-acquired infections,
and procedural complications.
1
Many of these
complications can be attributed to discharge planning
problems, such as:
Changes or discrepancies in medications before and
after discharge
3,4
Inadequa
te preparation for patient and family related
to medications, danger signs, or lifestyle changes
3,4,5
Disconne
ct between clinician information-giving and
patient understanding
3
Discontin
uity between inpatient and outpatient
providers
3
Involvin
g the patient and family in discharge planning can
improve patient outcomes, reduce unplanned
readmissions, and increase patient satisfaction.
6,7
More and more, hospitals are focusing on transitions in
care as a way to improve hospital quality and safety. As
one indicator of this, the Centers for Medicare and
Medicaid Services implemented new guidelines in 2012
that reduce payment to hospitals exceeding their
expected readmission rates.
To improve quality and reduce preventable readmissions,
[insert hospital name] will use the Agency for Healthcare
Research and Quality’s Care Transitions from Hospital to
Home: IDEAL Discharge Planning tools to engage
patients and families in preparing for discharge to home.
Key elements of IDEAL
Discharge Planning
Include the patient and family as full partners in the
discharge planning process.
Discuss with the patient and family five key areas to
prevent problems at home:
1. Describe what life at home will be like
2. Review medications
3. Highlight warning signs and problems
4. Explain test results
5. Make followup appointments
Educate the patient and family in plain language about
the patient’s condition, the discharge process, and
next steps throughout the hospital stay.
Assess how well doctors and nurses explain the
diagnosis, condition, and next steps in the patient’s
care to the patient and family and use teach back.
Listen to and honor the patient’s and family’s goals,
preferences, observations, and concerns.
This process will include at least one meeting to discuss
concerns
and questions with the patient, family of their
choice, and [identify staff].
What does this mean for clinicians?
We expect all clinicians to:
Incorporate the IDEAL discharge elements in
their work
Make themselves available to the [identify staff]
who will work closely with the patient and family
Take part in trainings on the process
Guide to Patient and Family Engagement :: 2
How do you implement
IDEAL Discharge Planning?
Each part of IDEAL Discharge Planning has
multiple components:
I
nclude the patient and family as full partners in the
discharge planning process.
Always include the patient and family in team
meetings about discharge. Remember that
discharge is not a one-time event but a process
that takes place throughout the hospital stay.
Identify which family or friends will provide care
at home and include them in conversations.
Discuss with the patient and family five key areas to
prevent problems at home.
1. Describe what life at home will be like. Include
the home environment, support needed, what the
patient can or cannot eat, and activities to do or
avoid.
2. Review medications. Use a reconciled medication
list to discuss the purpose of each medicine, how
much to take, how to take it, and potential side
effects.
3. Highlight warning signs and problems. Identify
warning signs or potential problems. Write down the
name and contact information of someone to call if
there is a problem.
4. Explain test results. Explain test results to the
patient and family. If test results are not available at
discharge, let the patient and family know when
they should get the results and identify who they
should call if they have not gotten results by that
date.
5. Make followup appointments. Offer to make
followup appointments for the patient. Make sure
that the patient and family know what followup is
needed.
Educate the patient and family in plain language
about the patient’s condition, the discharge process,
and next steps at every opportunity throughout the
hospital stay.
Getting all the information on the day of discharge can be
overwhelming. Discharge planning should be an ongoing
process throughout the stay, not a one-time event. You
can:
Elicit patient and family goals at admission and
note progress toward those goals each day
Involve the patient and family in bedside shift
report or bedside rounds
Share a written list of medicines every morning
Go over medicines at each administration: What
it is for, how much to take, how to take it, and
side effects
Encourage the patient and family to take part in
care practices to support their competence and
confidence in caregiving at home
Assess how well doctors and nurses explain the
diagnosis, condition, and next steps in the patient’s
care to the patient and family and use teach back.
Provide information to the patient and family in
small chunks and repeat key pieces of
information throughout the hospital stay
Ask the patient and family to repeat what you
said back to you in their own words to be sure
that you explained things well
Listen to and honor the patient and family’s goals,
preferences, observations, and concerns.
Invite the patient and family to use the white
board in their room to write questions or
concerns
Ask open-ended questions to elicit questions
and concerns.
Use Be Prepared to Go Home Checklist and
Booklet (Tools 2a and 2b) to make sure the
patient and family feel prepared to go home
Schedule at least one meeting specific to
discharge planning with the patient and family
caregivers
Guide to Patient and Family Engagement :: 3
IDEAL Discharge Planning Process
The elements of the IDEAL Discharge Planning process are incorporated into our current discharge. The information
below describes key elements of the IDEAL discharge from admission to discharge to home. Note that this process
includes at least one meeting between the patient, family, and discharge planner to help the patient and family feel
prepared to go home.
Initial nursing assessment
Daily
Identify the caregiver who will be at home
along with potential back-ups. These are the
individuals who need to understand instructions
for care at home. Do not assume that family in
the hospital will be caregivers at home.
Let the patient and family know that they can
use the white board in the room to write
questions or concerns.
Elicit the patient and family’s goals for when
and how they leave the hospital, as
appropriate. With input from their doctor, work
with the patient and family to set realistic goals
for their hospital stay.
Inform the patient and family about steps in
progress toward discharge. For common
procedures, create a patient handout, white
board, or poster that identifies the road map to
get home. This road map may include things like
“I can feed myself” or “I can walk 20 steps.”
Educate the patient and family about the
patient’s condition at every opportunity, such
as nurse bedside shift report, rounds, vital status
check, nurse calls, and other opportunities that
present themselves. Use teach back.
Who: All clinical staff
Explain medicines to the patient and family
(for example, print out a list every morning)
and at any time medicine is administered.
Explain what each medicine is for, describe
potential side effects, and make sure the patient
knows about any changes in the medicines they
are taking. Use teach back.
Who: All clinical staff
Discuss the patient, family, and clinician goals
and progress toward discharge. Once goals are
set at admission, revisit these goals to make
sure the patient and family understand how they
are progressing toward discharge.
Who: All clinical staff
Involve the patient and family in care practices
to improve confidence in caretaking after
discharge. Examples of care practices could
include changing the wound dressing, helping
the patient with feeding or going to the
bathroom, or assisting with rehabilitation
exercises.
Who: All clinical staff
Guide to Patient and Family Engagement :: 4
Prior to discharge planning meeting
When: 1 to 2 days before discharge planning meeting. For short stays, this meeting may occur at admission.
Give the patient and family Tools 2a and 2b: Be
Prepared to Go Home Checklist and Booklet.
Who: Hospital to identify staff person to distribute,
for example a nurse, patient advocate, or discharge
planner.
Schedule discharge planning meeting with the
patient, family, and hospital staff.
Who: Hospital to identify staff person to distribute,
for example a nurse, patient advocate, or discharge
planner.
Discharge planning meeting Day of discharge
When:
1 to 2 days before discharge, earlier for more
extended stays in the hospital
Use the Tools 2a and 2b: Be Prepared to Go
Home Checklist and Booklet as a starting
point to discuss questions, needs, and
concerns going home.
If the patient or family did not read or fill out
the checklist, review it verbally. Make sure to
ask if they have questions or concerns other
than those listed. You can start the dialogue
by asking, What will being back home look
like for you?”
Repeat the patient’s concerns in your own
words to make sure you understand.
Use teach back to check if the patient
understands the information given.
If another clinician is needed to address
concerns (e.g., pharmacist, doctor, or
nurse), arrange for this conversation.
Who: Hospital to identify staff to be involved in
meeting, for example the nurse, doctor, patient
advocate, discharge planner, or a combination.
Patient identifies if family or friends need to be
involved.
Offer to make followup appointments. Ask if
the patient has a preferred day or time and if
the patient can get to the appointment.
Who: Hospital to identify staff person to do, such
as a patient advocate or discharge planner.
Review a reconciled medication list with the
patient and family. Go over the list of current
medicines. Use teach back (ask them to repeat
what the medicine is, when to take it, and
how to take it). Make sure that patients have an
easy-to-read, printed medication list to take
home.
Who: Hospital to identify staff person to review
the medication list with patient and family.
Because this involves medications, we assume it
would be a clinician nurse, doctor, or
pharmacist.
Give the patient and family the patient’s
followup appointment times and include the
provider name, time, and location of
appointments in writing.
Who: Staff who scheduled appointment.
Give the patient and family the name,
position, and phone number of the person to
contact if there is a problem after discharge.
Make sure the contact person is aware of the
patient’s condition and situation (e.g., if the
primary care physician is the contact person,
make sure the primary care physician has a copy
of the discharge summary on the day of
discharge).
Who: Hospital to identify staff person to write
contact information, for example a nurse, patient
advocate, or discharge planner.
Guide to Patient and Family Engagement :: 5
IDEAL Discharge Planning Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:
Initial Nursing Assessment
Prior to Discharge
Planning Meeting
During Discharge
Planning Meeting
Day of Discharge
Identified the caregiver
at home and backups
Told patient and family
about white board
Elicited patient and
family goals for hospital
stay
Informed patient and
family about steps to
discharge
Distributed checklist and
booklet to patient and
family with explanation
Scheduled discharge
planning meeting
Scheduled for
/ / at
[time]
Discussed patient
questions
Discussed family
questions
Reviewed discharge
instructions as needed
Used Teach Back
Offered to schedule
followup appointments
with providers.
Preferred dates / times
for:
PCP:
Other:
Medication
Reconciled medication list
Reviewed medication list with patient
and family and used teach back
Appointments and contact information
Scheduled followup appointments:
1) With
on
/ / at [time]
2) With
on
/ / at [time]
Arranged any home care needed
Wrote down and gave appointments to the
patient and family
Wrote down and gave contact information
for followup person after discharge
Guide to Patient and Family Engagement :: 6
IDEAL Discharge Planning Daily Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:
Day 1 Day 2 Day 3 Day 4
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Educated patient and family
about condition and used
teach back
Discussed progress toward
patient, family, and clinician
goals
Explained medications to
patient and family
Morning
Noon
Evening
Bedtime
Other
Involved patient and family in
care practices, such as:
Notes
Guide to Patient and Family Engagement :: 7
References
1. Forster AJ, Murff HJ, Peterson JF, et al. The
incidence and severity of adverse events affecting
patients after discharge from the hospital. Ann
Intern Med 2003;138(3):1617.
2. Jencks SF, Williams MV, Coleman EA.
Rehospitalizations among patients in the Medicare
fee-for-service program. N Engl J Med
2009;360(14):141828.
3. Kripalani S, Jackson AT, Schnipper JL, et al.
Promoting effective transitions of care at hospital
discharge: a review of key issues for hospitalists.
J Hosp Med 2007;2(5):314–23.
4. Anthony MK, Hudson-Barr D. A patient-centered
model of care for hospital discharge. Clin Nurs Res
2004;13(2):11736.
5. Popejoy LL, Moylan K, Galambos C. A review of
discharge planning research of older adults 1990
2008. West J Nurs Res 2009;31(7):92347.
6. Bauer M, Fitzgerald L, Haesler E, et al. Hospital
discharge planning for frail older people and their
family. Are we delivering best practice? A review of
the evidence. J Clin Nurs 2009;18(18):253946.
7. Shepperd S, McClaran J, Phillips CO, et al.
Discharge planning from hospital to home.
Cochrane Database Syst Rev.
2010;20;(1):CD000313.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX J: PAID TIME OFF (PTO) POLICY (EXAMPLE)
Client Name
Paid Time Off & Paid Disability Leave
Paid Time-Off (PTO) Plan
Paid Time-Off (PTO) combines the traditional vacation, holiday and sick leave programs into
one paid time off plan. Full-time and part-time employees regularly scheduled for 40 hours per
two-week pay period are eligible for PTO benefits.
PTO accumulates from the first day of employment and is considered earned upon completion of
90 days of employment. Therefore, hourly-paid employees may use earned PTO starting on their
91
st
day of employment. Salaried employees may use accumulated PTO upon hire.
Holidays
Employees scheduled off an observed holiday will take the day off and use their PTO. PTO will
be automatically assigned for those employees taking the holiday off when it would otherwise be
normally scheduled. Employees working a holiday shall be paid at their normal rate and have
the ability to take additional PTO for holiday pay.
Employees not eligible for PTO benefits who work a holiday will be paid at time and a half (1.5)
times their base wage rate.
Observed Holidays include:
o New Year’s Day
o Memorial Day
o July 4 (Independence Day)
o Labor Day
o Thanksgiving Day
o Christmas Day
Granting time off:
Time off shall be granted to employees on a first come, first serve basis at the discretion
of management. Approvals for time off requests will be based on workloads and staffing
levels to ensure resident care needs are met. Changes to approved time off may be
granted at the discretion of the department director and Executive Director.
Any hours worked less than “regularly scheduled hours” require the use of PTO to make
the employee’s status/check “whole”. Exceptions may be made when the employer
temporarily reduces hours due to low census.
Unplanned time off (i.e. sick calls, weather absences, etc.) and planned time off requires
the use of PTO provided the employee is eligible and has an available balance of PTO
benefit.
Time off beyond the available PTO balance, will be considered and approved at the
discretion of the department director and Human Resources and in accordance with
community leave policies.
Paid Time-Off (PTO) Accrual
Regularly Scheduled Part-Time and Full-Time
Length
of
Service
PTO Accrual
Factor
Full Time
Annual Accrual
Maximum
Maximum
Annual
Balance
0 to < 3 years
.0654
17 days*
136 hours
3 to < 5 years
.0769
20 days*
160 hours
5 to < 10 years
.0962
25 days*
200 hours
10+ years
.1154
30 days*
200 hours
*These levels reflect the amount of hours accumulated by a full time employee that works 40 hours per week.
Years of continuous service are used to determine when an employee moves from one
accrual rate to the next.
PTO accrues each per pay period based upon the hours actually compensated, limited to
80 hours each pay period.
Non-exempt employees may use PTO in four (4) hour increments for planned time off
(i.e. vacation). PTO for unplanned absences (illness) will be taken in .25 hour
increments. Exempt employees must use PTO in four (4) hour increments.
Payment of PTO is limited to the available balance. Negative balances will not be
allowed. PTO balances are recorded on employee paychecks.
PTO may accrue to a maximum balance of 200 hours. Once the maximum is achieved,
no further accrual will occur until the balance falls below the accrual limit. Employees
will not be paid for hours in excess of the PTO balance.
Earned and unused PTO is paid out at termination provided a proper two (2) week
resignation notice is given to the employer for non-management employees and four (4)
week resignation notice for RN’s and management employees and the probationary
period has been completed. Involuntary termination will exclude an employee from
receiving any PTO payout.
Paid Disability Leave (PDL)
Paid Disability Leave (PDL) functions as a short term disability plan providing income for time
lost due to an illness/disability for oneself. Employees are required to notify Human Resources
and their director of absences or anticipated absences extending beyond three consecutive days.
PDL may be used after the employee has missed five (5) consecutive days of work. The first
three days of an illness/disability must be paid from the employee’s PTO account prior to
accessing PDL. PDL is accrued based upon compensated hours.
Waiting period:
An employee becomes eligible for PDL after an absence of more than five (5)
consecutive work days due to the illness/disability of oneself.
An employee is required to provide a “return-to- work” certification from a medical
provider when his/her illness/disability extends three (3) work days or longer.
Accrual limits:
Unused PDL accumulates to a maximum of 200 hours. Once the maximum accrual is
reached, no further accrual will occur. Employees are not compensated for hours in
excess of their PDL balance.
Should an employee exhaust their PDL account, he/she must use PTO for the remainder
of the absence or until PTO is also exhausted.
Earned and unused PDL are not paid out upon either voluntary or involuntary termination
of employment.
Paid Disability Leave Accrual
Full Time PDL
Accrual Per Year
Accrual
Rate
Maximum PDL
Accrual Hours
40 Hours (5 days)
.0308
200 hours
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX K: CMS 5-STAR USER GUIDE
Design for Nursing Home Compare
Five-Star Quality Rating System:
Technical Users’ Guide
July 2018
July 2018 Revisions
Beginning with the July 2018 update of the Nursing Home Compare website and the Five-Star Quality
Rating System, there are additional reasons why a nursing home may receive a one-star rating for
Staffing and RN Staffing. Additionally, the method of estimating the RUG-IV case-mix index, which is
used in the calculation of adjusted nurse staffing and adjusted RN staffing for assigning the star
ratings has changed slightly. These changes are described in the Staffing Domain section of this
document.
Additional text was added to the Health Inspection Domain section to explain how the health
inspection rating is being calculated for nursing homes with two or more health inspections occurring
on or after November 28, 2017.
May 2018 Revisions
Additional text was added to the staffing section to provide more detail about the resident census
calculation.
April 2018 Revisions
Beginning with the April 2018 update of the Nursing Home Compare website and the Five-Star
Quality Rating System, the Centers for Medicare and Medicaid Services (CMS) is replacing the
existing staffing measures (derived from the CMS-671 form and case-mix based on RUG-III) with
staffing reported through the payroll-based journal (PBJ) system, resident census derived from MDS
assessments, and case-mix based on RUG-IV.
These changes as they affect the Five-Star Quality Rating System are described in detail in the Staffing
Domain section of this document.
February 2018 Revisions
On November 28, 2017 the CMS instituted a new health inspection process along with an entirely new
set of “tags”. Beginning in February 2018, for a period of 12 months, CMS will not use deficiencies
cited on surveys conducted on or after November 28, 2017 in calculating the health inspection rating
for the Nursing Home Compare Five-Star Quality Rating System, to allow sufficient survey results to
accumulate from the new-process surveys. During that time, the health inspection rating will be based
on results from the two most recent standard surveys prior to November 28, 2017, as well as
deficiencies arising from complaint investigations during the two-year period prior to November 28,
2017.
Standard surveys and complaint surveys that occurred on or after November 28, 2017 (under the new
survey process) will be displayed on the Nursing Home Compare website, but will not be utilized to
calculate the health inspection rating during the twelve-month period beginning in February 2018.
These changes are described in more detail in the Health Inspection Domain section of this document.
1
Introduction
In December 2008, The Centers for Medicare & Medicaid Services (CMS) enhanced its Nursing Home
Compare public reporting site to include a set of quality ratings for each nursing home that participates in
Medicare or Medicaid. The ratings take the form of several “star” ratings for each nursing home. The
primary goal of this rating system is to provide residents and their families with an easy way to
understand assessment of nursing home quality, making meaningful distinctions between high and low
performing nursing homes.
This document provides a comprehensive description of the design for the Nursing Home Compare Five-
Star Quality Rating System. This design was developed by CMS with assistance from Abt Associates,
invaluable advice from leading researchers in the long-term care field who comprise the Technical Expert
Panel (TEP) for this project, and numerous ideas contributed by consumer and provider groups. All of
these organizations and groups have continued to contribute their input as the rating system has been
refined and updated to incorporate newly available data. We believe the Five-Star Quality Rating System
continues to offer valuable and comprehensible information to consumers based on the best data currently
available. The rating system features an Overall Quality Rating of one to five stars based on facility
performance for three types of measures, each of which has its own five-star rating:
Health Inspections - Measures based on outcomes from State health inspections: Facility
ratings for the health inspection domain are based on the number, scope, and severity of
deficiencies identified during the two most recent annual inspection surveys occurring prior to
November 28, 2017, as well as substantiated findings from complaint investigations occurring in
the 24 months prior to November 28, 2017. All deficiency findings are weighted by scope and
severity. This measure also takes into account the number of revisits required to ensure that
deficiencies identified during the health inspection survey have been corrected.
Staffing - Measures based on nursing home staffing levels: Facility ratings on the staffing
domain are based on two measures: 1) Registered nurse (RN) hours per resident day; and 2) total
staffing (RN+ licensed practical nurse (LPN) + nurse aide hours) hours per resident per day.
Other types of nursing home staff, such as clerical or housekeeping staff, are not included in the
staffing rating calculation. The staffing measures are derived from data submitted each quarter
through the Payroll-Based Journal System (PBJ), along with daily resident census derived from
Minimum Data Set, Version 3.0 (MDS 3.0) assessments, and are case-mix adjusted based on the
distribution of MDS 3.0 assessments by Resource Utilization Groups, version IV (RUG-IV
group).
QMs - Measures based on MDS and claims-based quality measures (QMs): Facility ratings for
the quality measures are based on performance on 16 of the 24 QMs that are currently posted on
the Nursing Home Compare website, and that are based on MDS 3.0 assessments as well as
hospital and emergency department claims. These include nine long-stay measures and seven
short-stay measures.
In recognition of the multi-dimensional nature of nursing home quality, Nursing Home Compare displays
information on facility ratings for each of these domains alongside the overall performance rating. In
addition to the overall staffing rating mentioned above, a five-star rating for RN staffing is also displayed
separately on the Nursing Home Compare website, when users seek more information on the staffing
component.
2
An example of the rating information included on Nursing Home Compare is shown in the figure below.
Users of the website can drill down on each domain to obtain additional details on facility performance.
A compa
nion document to this Technical Users’ Guide (Nursing Home CompareFive Star Quality
Rating System: Technical Users’ Guide State-Level Cut Point Tables) provides the data for the state-
level cut points for the star ratings included in the health inspection. The data table in the companion
document will be updated monthly. Cut points for the QM and staffing ratings have been fixed and do not
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vary monthly. Data tables giving the cut points for the staffing ratings are included in Tables 4 and 5 in
this Technical Users’ Guide. Table 7 provides the cut points for the QM ratings, and the cut points for the
individual QMs are in Appendix Table A-3.
Methodology for Constructing the Ratings
Health Inspection Domain
Nursing homes that participate in the Medicare and/or Medicaid programs have an onsite recertification
(standard) (“comprehensive”) inspection annually on average, with very rarely more than fifteen months
elapsing between inspections for any one particular nursing home. Inspections are unannounced and are
conducted by a team of health care professionals who spend several days in the nursing home to assess
whether the nursing home is in compliance with federal requirements. These inspections provide a
comprehensive assessment of the nursing home, reviewing facility practice and policies in such areas as
resident rights, quality of life, medication management, skin care, resident assessment, nursing home
administration, environment, and kitchen/food services. The methodology for constructing the health
inspection rating is based on the two most recent recertification surveys prior to November 28, 2017,
complaint deficiencies during the two-year period prior to November 28, 2017, and any repeat revisits
needed to verify that required corrections have brought the facility back into compliance. The Five-Star
Quality Rating System uses more than 200,000 records for the health inspection domain alone.
Scoring Rules
Beginning in February 2018, CMS calculates a health inspection score based on points assigned to
deficiencies identified in each active provider’s two most recent recertification health inspections prior to
November 28, 2017, as well as on deficiency findings from the most recent two years of complaint
inspections prior to November 28, 2017.
Health Inspection Results: Points are assigned to individual health deficiencies according to their
scope and severity more serious, widespread deficiencies receive more points, with additional
points assigned for substandard quality of care (see Table 1). If the status of the deficiency is
“past non-compliance” and the severity is “immediate jeopardy” (i.e., J-, K- or L-level), then
points associated with a G- level deficiency are assigned. Deficiencies from Life Safety surveys
are not included in calculations for the Five-Star rating. Deficiencies from Federal Comparative
Surveys are not reported on Nursing Home Compare or included in Five Star calculations, though
the results of State Survey Agency determinations made during a Federal Oversight Survey are
included.
Repeat Revisits - Number of repeat revisits required to confirm that correction of deficiencies
have restored compliance: No points are assigned for the first revisit; points are assigned only for
the second, third, and fourth revisits and are proportional to the health inspection score for the
survey cycle (Table 2). If a provider fails to correct deficiencies by the time of the first revisit,
then these additional revisit points are assigned up to 85 percent of the health inspection score for
the fourth revisit. CMS’ experience is that providers who fail to demonstrate restored compliance
with safety and quality of care requirements during the first revisit have lower quality of care than
other nursing homes. More revisits are associated with more serious quality problems.
4
Table 1
Health Inspection Score: Weights for Different Types of Deficiencies
Severity
Scope
Isolated
Pattern
Widespread
Immediate jeopardy to resident health or safety
J
50 points*
(75 points)
K
100 points*
(125 points)
L
150 points*
(175 points)
Actual harm that is not immediate jeopardy
G
20 points
H
35 points
(40 points)
I
45 points
(50 points)
No actual harm with potential for more than minimal
harm that is not immediate jeopardy
D
4 points
E
8 points
F
16 points
(20 points)
No actual harm with potential for minimal harm
A
0 point
B
0 points
C
0 points
Note: Figures in parentheses indicate points for deficiencies that are for substandard quality of care.
Shaded cells denote deficiency scope/severity levels that constitute substandard quality of care if the requirement
which is not met is one that falls under the following federal regulations: 42 CFR 483.13 resident behavior and
nursing home practices, 42 CFR 483.15 quality of life, 42 CFR 483.25 quality of care.
* If the status of the deficiency is “past non-compliance” and the severity is Immediate Jeopardy, then points
associated with a ‘G-level” deficiency (i.e., 20 points) are assigned.
Source: Centers for Medicare & Medicaid Services
Table 2
Weights for Repeat Revisits
Revisit Number
Noncompliance Points
First
0
Second
50 percent of health inspection score
Third 70 percent of health inspection score
Fourth
85 percent of health inspection score
Note: The health inspection score includes points from deficiencies cited on the standard health inspection and
complaint inspections during a given survey cycle.
C
MS calculates a total health inspection score for each facility. The total score is calculated as the
facility’s weighted deficiency score (including any repeat revisit points). Note that a lower survey score
corresponds to fewer deficiencies and revisits, and thus better performance on the health inspection
domain. In calculating the total weighted score, more recent surveys are weighted more heavily than
earlier surveys with the most recent period (rating cycle 1) being assigned a weighting factor of 60
percent and the previous period (rating cycle 2) having a weighting factor of 40 percent. The individual
weighted scores for each cycle are then summed to create the total weighted survey score for each facility.
Complaint inspections are assigned to a time period based on the 12-month period in which the complaint
survey occurred. Complaint inspections that occurred between November 28, 2016 and November 27,
2017 receive a weighting factor of 60 percent; those occurring between November 28, 2015 and
November 27, 2016 have a weighting factor of 40 percent. There are some deficiencies that appear on
both standard and complaint inspections. To avoid potential double-counting, deficiencies that appear on
complaint inspections that are conducted within 15 days of a recertification inspection (either prior to or
5
after the recertification inspection) are counted only once. If the scope or severity differs between the two
inspections, the highest scope-severity combination is used. Points from complaint deficiencies from a
given period are added to the health inspection score before calculating revisit points, if applicable.
Facilities with only one standard health inspection prior to November 28, 2017 are considered to have
insufficient data to determine a health inspection rating and are reported as “Too New to Rate” for the
health inspection domain. For these facilities, no overall quality rating is assigned, and no ratings are
reported for the staffing or QM domains, even if data for these domains are available.
Facilities with two or more health inspections on or after November 28, 2017
Results (dates, counts and lists of citations) from the three most recent health inspections are displayed on
Nursing Home Compare, regardless of whether these surveys took place before or after November 28,
2017. For example:
For facilities with one survey conducted on or after November 28, 2017, the posted results from
the three most recent health inspections would include:
o One survey conducted after November 28, 2017; and
o two surveys conducted prior to November 28, 2018
For nursing homes that have had two surveys on or after November 28, 2017, the rating will still be based
on the last two surveys conducted prior to November 28, 2017. However, since the results from the three
most recent surveys are posted, the results from the oldest survey will not be displayed on the main
website. For example:
For facilities with two surveys conducted on or after November 28, 2017, the posted results from
the three most recent health inspections would include:
o Two surveys conducted after November 28, 2017; and
o one survey conducted prior to November 28, 2018.
In other words, the oldest survey will still be used to calculate a facility’s rating, but the results from that
survey will not be displayed on the main website. Interested users can find these earlier survey results in
the health inspection files that are available at https://data.medicare.gov/data/nursing-home-compare
.
Rating Methodology
Health inspections are based on federal regulations, which surveyors implement using national
interpretive guidance and a federally-specified survey process. Federal staff train State inspectors and
oversee State performance. The federal oversight includes quality checks based on a 5% sample of the
health inspections performed by States, in which Federal inspectors either accompany State inspectors or
replicate the inspection within 60 days of the State and then compare results. These control systems are
designed to improve consistency in the survey process. Nonetheless there remains variation among states
in both inspection process and outcomes. Such variation derives from many factors, including:
Survey Management: Variation among states in the skill sets of inspectors, supervision of
inspectors, and the inspection processes;
State Licensure: State licensing laws set forth different expectations for nursing homes and affect
the interaction between State enforcement and Federal enforcement (for example, a few states
conduct many complaint investigations based on State licensure, and issue citations based on
State licensure rather than on the Federal regulations);
6
Medicaid Policy: Medicaid pays for the largest proportion of long term care in nursing homes.
Nursing home eligibility rules, payment, and other policies in the State-administered Medicaid
program may be associated with differences in survey outcome.
For the above reasons, CMS bases Five-Star quality ratings in the health inspection domain on the relative
performance of facilities within a state. This approach helps control for variation among states. CMS
determines facility ratings using these criteria:
The top 10 percent (with the lowest health inspection weighted scores) in each state receive a
health inspection rating of five stars.
The middle 70 percent of facilities receive a rating of two, three, or four stars, with an equal
number (approximately 23.33 percent) in each rating category.
The bottom 20 percent receive a one-star rating.
Rating thresholds are re-calibrated each month so that the distribution of star ratings within states remains
relatively constant over time. However, the rating for a given facility is held constant until there is a
change in the weighted health inspection score for that facility, regardless of changes in the statewide
distribution. While changes to health inspection scores (and thus rating changes) during the time period
when surveys conducted under the new process will be rare, there are a few reasons why facilities may
have a change. Items that could change the health inspection score include the following:
If a survey occurred prior to November 28, 2017 that has not yet entered the national database,
then it will result in a change to a provider’s health inspection score in the month following its
entry into the national database;
A second, third, or fourth revisit occurs that is associated with a survey occurring prior to
November 28, 2017;
Resolution of Informal Dispute Resolutions (IDR) or Independent Informal Dispute Resolutions
(IIDR) resulting in changes to the scope and/or severity of deficiencies for a survey that occurred
prior to November 28, 2017.
In the very rare case that a state or territory has fewer than five facilities upon which to generate the cut
points, the national distribution of health inspection scores is used. Cut points for the health inspection
ratings can be found in the Cut Point Table in the companion document to this Technical Users’ Guide:
Five Star Quality Rating System State-Level Cut Point Tables available in the ‘downloads’ section at:
https://www.cms.gov/medicare/provider-enrollment-and-
certification/certificationandcomplianc/fsqrs.html.
7
Staffing Domain
There is considerable evidence of a relationship between nursing home staffing levels and resident
outcomes. The CMS Staffing Study
1
, among other research, found a clear association between nurse
staffing ratios and nursing home quality of care.
The rating for staffing is based on two quarterly case-mix adjusted measures:
Total nursing hours per resident day (RN + LPN + nurse aide hours)
RN hours per resident day
The source for reported staffing hours is the Payroll-based Journal (PBJ) system
2
. These data are
submitted quarterly and are due 45 days after the end of each reporting period. Only data submitted and
accepted by the deadline are used by CMS for staffing calculations and the Five-Star Rating System. The
resident census is based on a daily resident census measure that is calculated by CMS using MDS
assessments.
The specific PBJ job codes that are used in the RN, LPN, and nurse aide hours calculations are:
RN hours: Includes RN director of nursing (job code 5), registered nurses with administrative
duties (job code 6), and registered nurses (job code 7).
LPN hours: Includes licensed practical/licensed vocational nurses with administrative duties (job
code 8) and licensed practical/vocational nurses (job code 9)
Nurse aide hours: Includes certified nurse aides (job code 10), aides in training (job code 11), and
medication aides/technicians (job code 12)
Note that the PBJ staffing data include both facility employees (full-time and part-time) and individuals
under an organization (agency) contract or an individual contract. The PBJ staffing data do not include
“private duty” nursing staff reimbursed by a resident or his/her family. Also not included are hospice staff
and feeding assistants.
The daily resident census, used in the denominator of the reported nurse staffing ratios, is derived from
MDS resident assessments and is calculated as follows:
1) Identify the reporting period (quarter) for which the census will be calculated (e.g., CY 2017 Q4:
October 1 – December 31, 2017).
2) Extract MDS assessment data for all residents of a facility beginning one year prior to the
reporting period to identify all residents that may reside in the facility (i.e., any resident with an
MDS assessment may still reside in the facility). For example, for the CY 2017 Q4 reporting
period, extract MDS data from October 1, 2016 through December 31, 2017.
3) Identify discharged residents using the following criteria:
1
Kramer AM, Fish R. “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home
Care.” Chapter 2 in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final
Report. Abt Associates, Inc., Winter 2001.
2
More detailed information about the PBJ system is available at: https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html
8
a) If a resident has an MDS Discharge assessment, use the discharge date reported on that
assessment and assume that the resident no longer resides in the facility as of the date of
discharge on the last assessment. If there is a subsequent admission assessment, then assume
that the resident re-entered the nursing home on the entry date indicated on the admission
assessment.
b) For any resident with an interval of 150 days or more with NO assessments, assume the
resident no longer resides in the facility as of the 150th day from the last assessment. (This
assumption is based on the requirement for facilities to complete MDS assessments on all
residents at least quarterly). If no assessment is present, assume the resident was discharged,
but the facility did not transmit a Discharge assessment.
For any particular date, residents whose assessments do not meet the criteria in #3 above prior to that date
are assumed to reside in the facility. The count of these residents is the census for that particular day.
NOTE ON RESIDENT MATCHING: MDS assessments for a given resident are linked using the
Resident Internal ID. The Resident Internal ID is a unique number, assigned by the Quality Improvement
Evaluation System (QIES) Assessment Submission and Processing (ASAP) system, which identifies a
resident. The combination of State and Resident Internal ID uniquely identifies a resident in the national
repository. The process by which the Resident Internal ID is created is described by the MDS 3.0
Provider User’s Guide - Appendix B
(https://qtso.cms.gov/download/guides/MDS/mds_30/Prvdr_Users_AppB.pdf
). The following MDS items
are used to define the Resident Internal ID:
State ID
Facility Internal ID (QIES ASAP system number)
Social Security Number (SSN)
Last Name
First Name
Date of Birth
Gender
Therefore, in order to achieve an accurate census, it is imperative that, in addition to having complete
assessment data for each resident including discharge assessment data, residents are assigned correct
Resident Internal IDs. To facilitate this, providers must ensure that MDS items, in particular the items
indicated above, are entered correctly on each assessment. Providers must also carefully monitor the Final
Validation Report, generated upon MDS submission, for any errors. Providers should work with their
State RAI Coordinator or State Automation Coordinator to correct any errors that arise during assessment
submission. In addition to using their Final Validation Report to validate the file structure and data
content of each successful MDS submission, providers can monitor their MDS data using additional
Certification and Survey Provider Enhanced Reports (CASPER) Reports. There are CASPER Reports for
Admissions, Discharges, Duplicate Residents, Errors, and daily Rosters, among others. Full descriptions
of these reports are available in Section 6 of the CASPER Reporting MDS Provider User’s Guide
available at the following link: https://qtso.cms.gov/download/guides/casper/cspr_sec6_mds_prvdr.pdf
.
Information about Final Validation Reports and error messages in the reports is available in Sections 4
and 5 of the MDS 3.0 Provider User's Guide available at the following link:
https://qtso.cms.gov/mdstrain.html.
9
The nurse staffing hours reported through PBJ and the daily MDS census are both aggregated (summed)
across the quarterly reporting period. The quarterly reported nurse staffing hours per resident per day
(HRD) are then calculated by dividing the aggregate reported hours by the aggregate resident census.
Only days that have at least some (>0) nurse staffing (for any job category 5-12) and at least one resident
are included in the calculations.
CMS uses a set of exclusion criteria to identify facilities with highly improbable PBJ staffing data and
neither staffing data nor a staffing rating are reported for these facilities (displaying “Data Not Available”
on the Nursing Home Compare website). These exclusion criteria are as follows:
The nursing home has 5 or more days with at least one resident but no nurse (RN, LPN or nurse
aide) staffing hours reported. Because nurse aides in training cannot operate independently as
nurses, nurse aides in training (job code 11) are not included.
Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with both nurses and
residents is excessively low (<1.5 HRD)
Total nurse staffing (job codes 5-12), aggregated over all days in the quarter with both nurses and
residents is excessively high (>12 HRD)
Nurse aide staffing (job codes 10-12) aggregated over all days in the quarter with both nurses and
residents is excessively high (>5.25 HRD)
Case-Mix Adjustment
CMS adjusts the reported staffing ratios for case-mix, using the Resource Utilization Group (RUG-IV)
case-mix system. The CMS Staff Time Resource Intensity Verification (STRIVE) Study measured the
number of RN, LPN, and nurse aide minutes associated with each RUG-IV group (using the 66 group
version of RUG-IV). CMS calculates case-mix adjusted hours per resident day for each facility for each
staff type using this formula:
T
he “r
eported” hours are those reported by the facility through PBJ as described above. “National
average” hours for a given staff type represent the national mean of expected hours across all facilities
active on the last day of the quarter and that submitted valid nurse staffing data for the quarter (shown in
Table 3). The National Average Hours values shown in Table 3 will be updated each quarter (in January,
April, July and October).
The “expected” values for each nursing home are based on the daily distribution of residents by RUG-IV
group in the same quarter as that covered by the PBJ reported staffing and estimates of daily expected
RN, LPN, and nurse aide hours from the CMS STRIVE Study (see Table A1). Specifically, expected
nurse staffing hours per resident day for a given nursing home are calculated as follows:
1) The MDS is used to assign a RUG-IV group to each resident for each day in the quarter. The
method is similar to that used for calculating the daily MDS census and is described below.
2) This information is aggregated to generate a count of residents in each of the 66 RUG-IV groups
in the nursing home for each day in the quarter. RUG-IV groups that are not represented on a
given day are assigned a count of 0. Residents for whom there is insufficient MDS information to
assign a RUG-IV category are not included.
10
3) Based on the number of residents in each RUG-IV group, expected total nursing and RN hours
are calculated by multiplying by nursing time estimates for each RUG-IV group from the
STRIVE study (Table A1).
4) Aggregate expected nursing and RN hours for the quarter are calculated by summing across all
days and RUG-IV groups. These are the numerators in the calculations of expected total nursing
and RN hours per resident day. The denominator for these calculations is the count of the total
number of resident-days in the quarter for which there is a valid RUG-IV group.
5) Expected total nursing and RN hours per resident day for each nursing home are calculated by
dividing aggregate expected hours (total nursing or RN) by the number of resident-days.
To determine the number of residents in each RUG-IV grouping for each day of the quarter for each
facility, the same algorithm is used as that used to generate the daily MDS census (with slight adjustment
to count RUG-IV groupings specifically, instead of just counting residents):
1) Identify the reporting period (quarter) for which the RUG groupings will be collected (e.g., CY
2017 Q4: October 1 – December 31, 2017).
2) Extract MDS assessment data (including RUG-IV 66 Hierarchical group) for all residents of a
facility beginning one year prior to the reporting period to identify all residents that may reside in
the facility (i.e., any resident with an MDS assessment may still reside in the facility). For
example, for the CY 2017 Q4 reporting period, extract MDS data from October 1, 2016 through
December 31, 2017.
3) Identify discharged residents using the following criteria:
a) If a resident has an MDS Discharge assessment, use the discharge date reported on that
assessment and assume that the resident no longer resides in the facility as of the date of
discharge on the last assessment. If there is a subsequent admission assessment, then assume
that the resident re-entered the nursing home on the entry date indicated on the admission
assessment.
b) For any resident with an interval of 150 days or more with NO assessments, assume the
resident no longer resides in the facility as of the 150th day from the last assessment. (This
assumption is based on the requirement for facilities to complete MDS assessments on all
residents at least quarterly). If no assessment is present, assume the resident was discharged,
but the facility did not transmit a Discharge assessment.
For any particular date, residents whose assessments do not meet the criteria in #3 above prior to that date
are assumed to reside in the facility. The RUG IV 66 Hierarchical groupings assigned to those residents
on their most recent assessments as of that date are counted as the RUG groupings for that facility on that
date.
Table 3
National Average Hours per Resident Day Used To Calculate Adjusted Staffing (as of July 2018)
1
Type of staff
National average expected hours per resident
per day
Total nursing staff (Aides + LPNs + RNs) 3.2146
Registered nurses 0.3763
1
These values will be updated each quarter and will be available in the State Averages table at
(https://data.medicare.gov/data/nursing-home-compare
)
11
The calculations of “expected”, “reported”, and “national average” hours are performed separately for
RNs and for all staff delivering nursing care (RNs, LPNs, and nurse aides). Adjusted hours are also
calculated for both groups using the formula discussed earlier in this section.
A downloadable file that contains the “expected”, “reported” and “case-mix adjusted" hours used in the
staffing calculations is available at:
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/FSQRS.html. The file, referred to as the “Expected and Adjusted
Staff Time Values Data Set,” contains data for both RNs and total staff for each individual nursing home.
Scoring Rules
The two staffing measures (RN and total nursing staff) are given equal weight. For each of RN staffing and
total staffing, a 1 to 5 rating is assigned based on a percentile-based method (Table 4). For each facility, the
overall staffing rating is assigned based on the combination of the two staffing ratings (Table 5).
The percentile cut points (data boundaries between star categories) were determined using the data
available as of March 2018. This was the first update of the cut points since December 2011 and was
necessary because of changes in the expected staffing due to the transition to RUG-IV. The cut points
were set so that the changes in expected staffing due to RUG-IV would not impact the overall distribution
of the five-star ratings; that is, they were selected so that the proportion of nursing homes in each rating
category would initially (i.e., for April 2018) be the same as it was in March 2018. CMS will evaluate
whether further rebasing is needed on a quarterly basis.
Table 4
National Star Cut Points for Staffing Measures, Based on Case-Mix Adjusted Hours per Resident
Day (updated April 2018)
Staff type 1 star 2 stars 3 stars 4 stars 5 stars
RN
< 0.246 0.246 - 0.382 0.383 0.586 0.587 0.883 >0.884
Total
< 3.176 3.176 3.551 3.552 - 4.009 4.010 4.237 >4.238
Note: Adjusted staffing values are rounded to three decimal places before the cut points are applied.
Rating Methodology
Facility ratings for overall staffing are based on the combination of RN and total nurse (RNs, LPNs, and
nurse aides) staffing ratings as shown in Table 5. To receive an overall staffing rating of five stars,
facilities must achieve a rating of five stars for both RN and total staffing. To receive a four-star staffing
rating, facilities must receive at least a three-star rating on one (either the RN or total nurse staffing) and a
rating of four or five stars on the other.
12
Table 5
Staffing Hours and Rating (updated April 2018)
RN rating and hours Total nurse staffing rating and hours (RN, LPN and nurse aide)
1 2 3 4 5
< 3.176 3.176 3.551
3.552 4.009 4.010 4.237 >4.238
1
< 0.246
★★ ★★ ★★★
2
0.246 - 0.382
★★ ★★★ ★★★ ★★★
3
0.383 0.586
★★
★★★
★★★ ★★★★
★★★★
4
0.587 0.883
★★ ★★★ ★★★★ ★★★★ ★★★★
5
>0.884
★★★ ★★★ ★★★★ ★★★★ ★★★★★
Note: Adjusted staffing values are rounded to three decimal places before the cut points are applied.
Scoring Exceptions
As of July 2018, there are the following exceptions to the scoring rules described above for assigning the
staffing rating and RN staffing rating.
Providers that fail to submit any staffing data by the required deadline will receive a one-star
rating for overall staffing and RN staffing for the quarter.
Providers that submit staffing data indicating that there were seven or more days in the quarter
with no RN staffing (job codes 5-7) but on which there were one or more residents in the facility
will receive a one-star rating for overall staffing and RN staffing for the quarter.
CMS conducts audits of nursing homes to verify the data submitted and to ensure accuracy.
Facilities that fail to respond to these audits and those for which the audit identifies significant
discrepancies between the hours reported and the hours verified will receive a one-star rating for
overall staffing and RN staffing for three months from the time at which the deadline to respond
to audit requests passes or discrepancies are identified.
Quality Measure Domain
A set of quality measures (QMs) has been developed from Minimum Data Set (MDS) and Medicare
claims data to describe the quality of care provided in nursing homes. These measures address a broad
range of function and health status indicators. The facility rating for the QM domain is based on its
performance on a subset of 13 (out of 24) of the MDS-based QMs and three MDS- and Medicare claims-
based measures currently posted on Nursing Home Compare. The measures were selected based on their
validity and reliability, the extent to which facility practice may affect the measure, statistical
performance, and importance.
Measures for Long-Stay residents (residents in the facility for greater than 100 days) that are derived from
MDS assessments:
Percentage of residents whose need for help with activities of daily living has increased
Percentage of residents whose ability to move independently worsened
13
Percentage of high risk residents with pressure ulcers (sores)
Percentage of residents who have/had a catheter inserted and left in their bladder
Percentage of residents who were physically restrained
Percentage of residents with a urinary tract infection
Percentage of residents who self-report moderate to severe pain
Percentage of residents experiencing one or more falls with major injury
Percentage of residents who received an antipsychotic medication
Measures for Short-Stay residents that are derived from MDS assessments:
Percentage of residents whose physical function improves from admission to discharge
Percentage of residents with pressure ulcers (sores) that are new or worsened
Percentage of residents who self-report moderate to severe pain
Percentage of residents who newly received an antipsychotic medication
Measures for Short-Stay residents that are derived from claims data and MDS assessments:
Percentage of residents who were re-hospitalized after a nursing home admission
Percentage of residents who have had an outpatient emergency department visit
Percentage of residents who were successfully discharged to the community
Table 6 contains more detailed information on these measures.
Technical specifications for the complete set of MDS-based QMs are available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V10.pdf
Technical specifications for the claims-based measures are available at:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-
04-05-16-.pdf.
Values for five of the MDS-based QMs (mobility decline, catheter, long-stay pain, short-stay functional
improvement, and short-stay pressure ulcers) are risk adjusted, using resident-level covariates that adjust
for resident factors associated with differences in the performance on the QM. For example, the catheter
risk-adjustment model takes into account whether or not residents had bowel incontinence or pressure
sores on the prior assessment. Additionally, all three of the claims-based measures are also risk adjusted
using both items from Medicare Part A claims that preceded the start of the nursing home stay and
information from the first MDS assessment associated with the nursing home stay.
The risk-adjustment methodology is described in more detail in the technical specification documents
referenced above. The covariates and the coefficients used in the risk-adjustment models are reported in
Table A-2 in the Appendix.
14
CMS calculates ratings for the QM domain using the four most recent quarters for which data are
available. This time period specification was selected to increase the number of assessments available for
calculating the QM rating. This increases the stability of estimates and reduces the amount of missing
data. The adjusted four-quarter QM values for each of the MDS-based QMs used in the five-star
algorithm are computed as follows:
Where QM
Q1
, QM
Q2
, QM
Q3
, and QM
Q4
correspond to the adjusted QM values for the four most recent
quarters and D
Q1
, D
Q2
, and D
Q3
D
Q4
are the denominators (number of eligible residents for the particular
QM) for the same four quarters.
Values for the three claims-based measures are calculated in a similar manner, except that the data used to
calculate the measures use a full year of data rather than being broken out separately by quarter.
Table 6 Quality Measures Used in the Five-Star Quality Measure Rating Calculation
Measure Comments
MDS Long-Stay Measures
Percentage of residents
whose ability to move
independently worsened
This measure is a change measure that reports the percent of long-stay residents
who have demonstrated a decline in independence of locomotion when comparing
the target assessment to a prior assessment. Residents who lose mobility may also
lose the ability to perform other activities of daily living, like eating, dressing, or
getting to the bathroom.
Percentage of residents
whose need for help with
activities of daily living has
increased
1
This measure reports the percentage of long-stay residents whose need for help
with late-loss Activities of Daily Living (ADLs) has increased when compared to the
prior assessment. This is a change measure that reflects worsening performance
on at least two late loss ADLs by one functional level or on one late loss ADL by
more than one functional level compared to the prior assessment. The late loss
ADLs are bed mobility, transfer, eating, and toileting. Maintenance of ADLs is
related to an environment in which the resident is up and out of bed and engaged
in activities. The CMS Staffing Study found that higher staffing levels were
associated with lower rates of increasing dependence in ADLs.
Percentage of high-risk
residents with pressure
ulcers
This measure captures the percentage of long-stay, high-risk residents with Stage
II-IV pressure ulcers. Residents at high risk for pressure ulcers are those who are
impaired in bed mobility or transfer, who are comatose, or who suffer from
malnutrition.
Percentage of residents who
have/had a catheter inserted
and left in their bladder
This measure reports the percentage of residents who have had an indwelling
catheter in the last seven days. Indwelling catheter use may result in complications,
like urinary tract or blood infections, physical injury, skin problems, bladder stones,
or blood in the urine.
Percentage of residents who
were physically restrained
This measure reports the percentage of long-stay residents who are physically
restrained on a daily basis. A resident who is restrained daily can become weak,
lose his or her ability to go to the bathroom without help, and develop pressure
ulcers or other medical complications.
Percentage of residents with
a urinary tract infection
This measure reports the percentage of long-stay residents who have had a urinary
tract infection within the past 30 days. Urinary tract infections can often be
prevented through hygiene and drinking enough fluid. Urinary tract infections are
relatively minor but can lead to more serious problems and cause complications
like delirium if not treated.
Percentage of residents who
self-report moderate to
severe pain
This measure captures the percentage of long-stay residents who report either (1)
almost constant or frequent moderate to severe pain in the last five days or (2) any
very severe/horrible pain in the last 5 days.
15
Table 6 Quality Measures Used in the Five-Star Quality Measure Rating Calculation
Measure Comments
Percentage of residents
experiencing one or more
falls with major injury
This measure reports the percentage of long-stay residents who have experienced
one or more falls with major injury reported in the target period or look-back period
(one full calendar year).
Percentage of residents who
received an antipsychotic
medication
This measure reports the percentage of long-stay residents who are receiving
antipsychotic drugs in the target period. Reducing the rate of antipsychotic
medication use has been the focus of several CMS initiatives.
MDS Short-Stay Measures
Percentage of residents
whose physical function
improves from admission to
discharge
This measure assesses the percentage of short-stay residents whose
independence in three mobility functions (i.e., transfer, locomotion, and walking)
increases over the course of the nursing home care episode.
Percentage of residents with
pressure ulcers that are new
or worsened
This measure captures the percentage of short-stay residents with new or
worsening Stage II-IV pressure ulcers.
Percentage of residents who
self-report moderate to
severe pain
This measure captures the percentage of short-stay residents, with at least one
episode of moderate/severe pain or horrible/excruciating pain of any frequency, in
the last 5 days.
Percentage of residents who
newly received an
antipsychotic medication
This measure reports the percentage of short-stay residents who are receiving an
antipsychotic medication during the target period but not on their initial
assessment.
Claims-Based Short-Stay Measures
Percentage of residents who
were re-hospitalized after a
nursing home admission
This measure reports the percentage of all new admissions or readmissions to a
nursing home from a hospital where the resident was re-admitted to a hospital for
an inpatient or observation stay within 30 days of entry or reentry.
Percentage of short-stay
residents who have had an
outpatient emergency
department (ED) visit
This measure reports the percentage of all new admissions or readmissions to a
nursing home from a hospital where the resident had an outpatient ED visit (i.e., an
ED visit not resulting in an inpatient hospital admission) within 30 days of entry or
reentry.
Percentage of short-stay
residents who were
successfully discharged to
the community
This measure reports the percentage of all new admissions to a nursing home from
a hospital where the resident was discharged to the community within 100 calendar
days of entry and for 30 subsequent days, did not die, was not admitted to a
hospital for an unplanned inpatient stay, and was not readmitted to a nursing
home.
1
Indicates ADL QM as referenced in scoring rules
Sources: Based on information from the AHRQ Measures Clearinghouse and the NHVBP Draft Design Report and
the MDS 3.0 Quality Measures User’s Manual.
Missing Data and Imputation
Consistent with the specifications used for Nursing Home Compare, MDS-based measures are reported if
the measure can be calculated for at least 20 residents’ assessments (summed across four quarters of data
to enhance measurement stability) for both the long- and short-stay QMs. The claims-based measures are
reported if the measure can be calculated for at least 20 nursing home stays over the course of the year.
For facilities with missing data or an inadequate denominator size for one or more QMs, meeting the
criteria described below, all available data from the facility are used. The remaining assessments (or
stays) are imputed to get the facility to the minimum required sample size of 20. For example, if a facility
had actual data for 12 resident assessments, the data for those 12 assessments would be used and the
remaining eight assessments would be imputed using the state average to get to the minimum sample size
to include the measure in the scoring for the QM rating. Missing values are imputed based on the
16
statewide average for the measure. The imputation strategy for the missing values depends on the pattern
of missing data.
For facilities that have an adequate denominator size for at least five of the nine long-stay QMs,
values are imputed for the long-stay measures with fewer than 20 assessments as described
above. Points are then assigned for all nine long-stay QMs according to the scoring rules
described below.
For facilities that have an adequate denominator size for at least four of the seven short-stay QMs
(including at least one of the three claims-based measures), values are imputed for the short-stay
measures with smaller denominators as described above. Points are then assigned for all seven
short-stay QMs according to the scoring rules described below.
For facilities with adequate denominator sizes on four or fewer long-stay QMs, the QM rating is
based on the short-stay measures only. Values for the missing long-stay QMs are not imputed,
and no long-stay measures are used in determining the QM rating.
Similarly, for facilities with adequate denominator sizes for three or fewer short-stay QMs or no
claims-based QMs, the QM rating is based on the long-stay measures only. Values for the
missing short-stay QMs are not imputed, and no short-stay measures are used in determining the
QM rating. One exception to this is for a small number of nursing homes that have adequate
denominators for all four of the MDS-based short-stay measures but none of the claims-based
measures. For these nursing homes, values are not imputed for the claims-based measures;
however, the points assigned for the MDS-based short-stay measures are used in generating the
QM rating according to the scoring rules described below.
Note that while values are imputed according to the rules described above for the purposes of assigning
points for the QM score, imputed data for QMs is not reported on the Nursing Home Compare website
nor included in the downloadable databases available at Data.Medicare.gov. QM values are publicly
reported only for providers meeting the minimum denominator requirements prior to any imputation.
Scoring Rules for the Individual QMs
For each measure, 20 to 100 points are assigned based on facility performance relative to the national
distribution of the QM. Points are assigned after any needed imputation of individual QM values, with the
points determined in the following way:
For long-stay ADL worsening, long-stay pressure ulcers, long-stay catheter, long-stay urinary
tract infections, long-stay pain, long-stay injurious falls, and short-stay pain: facilities are
grouped into quintiles based on the national distribution of the QM. The quintiles are assigned 20
points for the poorest performing quintile, 100 points for the best performing quintile, and 40, 60
or 80 points for the second, third and fourth quintiles respectively.
The long-stay physical restraint and short-stay pressure ulcer QMs are treated slightly
differently because they have low prevalence specifically, substantially more than 20 percent
(i.e. a quintile) of nursing homes have zero percent rates on these measures.
o For the long-stay physical restraint QM, facilities achieving the best possible score on
the QM (i.e. zero percent of residents triggering the QM) are assigned 100 points; this is
about 60 percent of facilities (or three quintiles). The remaining facilities are divided into
two evenly sized groups, (each with about 20 percent of nursing homes); the poorer
17
performing group is assigned 20 points, and the better performing group is assigned 60
points.
o The short-stay pressure ulcer QM is treated similarly: facilities achieving the best
possible score on the QM (i.e. zero percent of residents triggering the QM) are assigned
100 points; this is about one-third of nursing homes. The remaining facilities are divided
into three evenly sized groups, (each with about 23 percent of nursing homes) and
assigned 25, 50 or 75 points.
For measures that were added to the QM rating beginning in February 2015, the following
scoring rules use used:
o For the long-stay antipsychotic medication, long-stay mobility decline, short-stay
functional improvement, and the three claims-based measures, facilities are divided
into five groups based on the national distribution of the measure. The top-performing 10
percent of facilities receive 100 points; the poorest performing 20 percent of facilities
receive 20 points; the middle 70 percent of facilities are divided into three equally sized
groups (each including approximately 23.3 percent of nursing homes) and receive 40, 60
or 80 points.
o The short-stay antipsychotic medication QM is treated similarly; however, because
approximately 20 percent of facilities achieve the best possible score on this QM (i.e.
zero percent of residents triggering the QM), these facilities all receive 100 points; the
poorest performing 20 percent of facilities receive 20 points; the remaining facilities are
divided into three equally sized groups (each including approximately 20 percent of
nursing homes) and receive 40, 60 or 80 points.
Note that, for all of the measures, the groupings are based on the national distribution of the QMs, prior to
any imputation. For each of the MDS-derived QMs, the cut points are based on the QM distributions
averaged across the four quarters of 2015. For the claims-based QMs, the cut points are based on the
national distribution of the measures calculated for the period of Quarter 3 of 2014 through Quarter 2 of
2015.
Rating Methodology
After any needed imputation for individual QMs, the points are summed across all QMs based upon the
scoring rules above to create a total score for each facility. The total possible score ranges between 325
and 1,600.
Facilities that receive a QM rating are in one of the following categories:
They have points for all of the QMs.
They have points for only the nine long-stay QMs (long-stay facilities).
They have points for the nine long-stay QMs and the 4 MDS-based short-stay QMs
They have points for only the seven short-stay QMs (short-stay facilities)
They have points for only the four MDS-based short-stay QMs
No values are imputed for nursing homes with data on fewer than five long-stay QMs and fewer
than four short-stay QMs. No QM rating is generated for these nursing homes.
18
To ensure that all facilities are scored on the same scale, the total score is rescaled for long and short-stay
facilities:
If the facility has data for only the nine long-stay measures, the average of these point values is
assigned for each of the seven (missing) short-stay measures and the total score is recalculated.
If
the facility has data for the nine long-stay QMs and the four MDS-based short-stay QMs but
not the claims-based QMs, the average of the point values for the MDS-based short-stay QMs is
assigned for each of the three (missing) claims-based measures and the total score is recalculated.
If the facility has data for only the seven short-stay measures, the average of these point values is
assigned for each of the nine (missing) long-stay measures and the total score is recalculated.
I
f the facility has data for only the four MDS-based short stay QMs, but none of the long-stay
QMs or the claims-based QMs, the average of the point values for the MDS-based short-stay
QMs is assigned for each of the nine (missing) long-stay measures and each of the three (missing)
claims-based measures and the total score is recalculated.
O
nce the summary QM score is computed for each facility as described above, the five-star QM rating is
assigned, according to the point thresholds shown in Table 7. These thresholds were set so that the overall
proportion of nursing homes would be approximately 25 percent five-star, 20 percent for each of two-,
three-, and four-star and 15 percent one-star, which was the distribution in February 2015 (the previous
time that new measures were added and rebasing was required). The cut points associated with these star
ratings will be held constant for a period of at least one year (from January 2017), allowing the
distribution of the QM rating to change over time.
Table 7
Star Cut-points for Quality Measure Summary Score
QM Rating Point Range
325 789
★★
790 889
★★★
890 969
★★★★
970 1054
★★★★★
1055 1600
Overall Nursing Home Rating (Composite Measure)
Based on the star ratings for the health inspection domain, the staffing domain and the MDS quality
measure domain, CMS assigns the overall Five-Star rating in three steps:
Step 1: Start with the health inspection rating.
Step 2: Add one star to the Step 1 result if the staffing rating is four or five stars and greater than the
health inspection rating; subtract one star if the staffing rating is one star. The overall rating cannot be
more than five stars or less than one star.
19
Step 3: Add one star to the Step 2 result if the quality measure rating is five stars; subtract one star if
the quality measure rating is one star. The overall rating cannot be more than five stars or less than
one star.
Note: If the health inspection rating is one star, then the overall rating cannot be upgraded by more
than one star based on the staffing and quality measure ratings. If the nursing home is a Special Focus
Facility (SFF) that has not graduated, the maximum overall rating is three stars.
The rationale for upgrading facilities in Step 2 that receive a rating of four of five stars for staffing (rather
than limiting the upgrade to those with five stars) is that the criteria for the staffing rating is quite
stringent. However, requiring that the staffing rating be greater than the health inspection rating in order
for the score to be upgraded ensures that a facility with four stars on health inspections and four stars on
staffing (and more than one star on the quality measure rating) does not receive an overall rating of five
stars.
The rationale for limiting star rating upgrades is that two self-reported data domains should not
significantly outweigh the rating from actual onsite visits from trained surveyors who have found very
serious quality of care problems. Since the health inspection rating is heavily weighted toward the most
recent findings, a health inspection rating of one star reflects both a serious and recent finding.
The rationale for limiting the overall rating of a Special Focus Facility (SFF) is that the health inspection
rating is weighted toward more recent results and may not fully capture the long history of “yo-yo” or “in
and out” of compliance with federal safety and quality of care requirements that some nursing homes
exhibit. That type of history can be characteristic of the SFF nursing homes. The Nursing Home
Compare website should reflect the most recent data available so consumers can monitor facility
performance, however, the overall rating will be capped out of caution that the prior “yo-yo” pattern
could be repeated. Once a facility graduates from the SFF initiative by sustaining improved compliance
for about 12 months, the cap will be removed for the former SFF nursing home.
The method for determining the overall nursing home rating does not assign specific weights to the health
inspection, staffing, and QM domains. The health inspection rating is the most important dimension in
determining the overall rating, but, depending on the performance on the staffing and QM domains, the
overall rating for a facility may be increased or decreased by up to two stars.
If a facility has no health inspection rating, then no overall rating is assigned. If a facility has no health
inspection rating because it is too new to have two standard surveys, then no ratings for any domain are
displayed.
Change in Nursing Home Rating
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is
based on three individual domains, a change in any one of the domains can affect the overall rating.
Provided below are some potential reasons that a change in a domain could occur:
New Data for the Facility
Any new data for a facility could potentially change a star rating domain.
Events that could change the health inspection score include:
20
A new health inspection (that occurred prior to November 28, 2017),
New complaint deficiencies (that occurred prior to November 28, 2017),
A second, third, or fourth revisit (for a survey that occurred before November 28, 2017),
Resolution of Informal Dispute Resolutions (IDR) or Independent Informal Dispute Resolutions
(IIDR) resulting in changes to the scope and/or severity of deficiencies (for surveys prior to
November 28, 2017),
T
he data will be included as soon as they become part of the CMS database. The timing for this can vary
by state and depends on having the complete survey package for the State Survey Agency to upload to the
national database. Additional inspection data may be added to the database at any time because of
complaint investigations, outcomes of revisits, Informal Dispute Resolutions (IDR), or Independent
Informal Dispute Resolutions (IIDR). These data may not be added in the same cycle as the standard
inspection data.
PBJ staffing data are reported quarterly, so new staffing measures and ratings will be calculated and
posted quarterly. Changes in a facility’s staffing measure or rating may be due to differences in the
number of hours submitted for staff, changes in the daily census, or changes in risk adjustment from the
previous quarter.
Quality Measure data for the MDS-based QMs are updated on Nursing Home Compare on a quarterly
basis, and the nursing home QM rating is updated at the same time. The updates typically occur in
January, April, July, and October towards the end of these months. The claims-based QM data typically
update every six months (in April and October). Changes in the quality measures may change the star
rating.
Since the cut-points between star categories for the health inspection rating are based on percentile
distributions that are not fixed, those cut-points may vary slightly depending on the current facility
distribution in the database. However, while the cut-points for the health inspection ratings may change
from month to month, the rating for a given facility is held constant until there is a change in the weighted
health inspection score for that facility.
21
Appendix
Table A1
RUG-IV Based Case-Mix Adjusted Nurse and Aide Staffing Minute
1
Estimates
Major RUG
Group
RUG-IV
Code
STRIVE Study Average Times (Minutes)
1
RN LPN
Total
Licensed
Nurse Aide
Total Nurse
(RN+LPN+Aide)
Rehab Plus
Extensive
RUX
68.37
111.44
179.81
131.11
310.92
RUL
109.06
63.87
172.93
199.94
372.87
RVX
29.24
95.88
125.12
145.94
271.06
RVL
67.74
97.39
165.13
139.99
305.12
RHX
128.79
51.92
180.71
155.24
335.95
RHL
67.28
48.41
115.69
135.32
251.01
RMX
97.54
74.61
172.15
148.44
320.59
RML
133.82
84.01
217.83
153.24
371.07
RLX
133.82
84.01
217.83
153.24
371.07
Rehab
RUC
27.80
66.41
94.21
148.95
243.16
RUB
45.01
71.09
116.10
141.03
257.13
RUA
35.18
54.55
89.73
101.01
190.74
RVC
34.22
68.45
102.67
156.53
259.20
RVB
28.86
56.56
85.42
119.90
205.32
RVA
31.30
59.35
90.65
113.73
204.38
RHC
36.62
54.88
91.50
156.14
247.64
RHB
36.42
47.88
84.30
119.48
203.78
RHA
27.09
51.76
78.85
99.82
178.67
RMC
32.58
56.05
88.63
148.87
237.50
RMB
32.10
55.47
87.57
134.74
222.31
RMA
25.99
48.79
74.78
98.81
173.59
RLB
33.86
44.58
78.44
185.83
264.27
RLA
15.46
43.58
59.04
118.93
177.97
Extensive
Services
ES3
130.49
58.49
188.98
152.12
341.10
ES2
65.19
75.23
140.42
146.65
287.07
ES1
72.81
49.49
122.30
127.62
249.92
Special Care
High
HE2
21.25
67.93
89.18
190.47
279.65
HD2
41.89
70.63
112.52
153.76
266.28
HC2
35.13
53.63
88.76
154.72
243.48
HB2
60.64
67.91
128.55
133.86
262.41
HE1
19.20
67.73
86.93
149.47
236.40
HD1
16.89
54.54
71.43
141.80
213.23
HC1
22.43
54.17
76.60
135.33
211.93
HB1
21.65
50.50
72.15
106.77
178.92
22
Major RUG
Group
RUG-IV
Code
STRIVE Study Average Times (Minutes)
1
RN LPN
Total
Licensed
Nurse Aide
Total Nurse
(RN+LPN+Aide)
Special Care
Low
LE2
22.16
58.83
80.99
176.15
257.14
LD2
19.59
58.10
77.69
153.29
230.98
LC2
27.44
47.80
75.24
116.12
191.36
LB2
29.52
50.73
80.25
128.44
208.69
LE1
22.11
52.25
74.36
143.41
217.77
LD1
11.78
43.94
55.72
130.80
186.52
LC1
15.72
46.56
62.28
124.77
187.05
LB1
18.99
48.66
67.65
106.16
173.81
Clinically
Complex
CE2
21.05
44.13
65.18
162.70
227.88
CD2
20.01
45.17
65.18
175.51
240.69
CC2
19.77
36.95
56.72
132.92
189.64
CB2
23.50
36.46
59.96
114.97
174.93
CA2
20.69
44.63
65.32
80.92
146.24
CE1
21.26
33.75
55.01
159.10
214.11
CD1
15.31
41.90
57.21
151.40
208.61
CC1
16.00
35.10
51.10
126.91
178.01
CB1
16.17
34.99
51.16
118.45
169.61
CA1
22.39
40.22
62.61
72.76
135.37
Behavioral
Symptoms and
Cognitive
Performance
BB2
11.30
33.26
44.56
117.96
162.52
BA2
18.34
41.18
59.52
101.56
161.08
BB1
14.93
32.83
47.76
114.30
162.06
BA1
13.60
31.57
45.17
86.06
131.23
Reduced
Physical
Functioning
PE2
15.11
39.76
54.87
163.58
218.45
PD2
12.09
38.01
50.10
163.38
213.48
PC2
8.14
33.51
41.65
124.90
166.55
PB2
15.49
38.95
54.44
118.83
173.27
PA2
5.50
35.91
41.41
73.16
114.57
PE1
19.91
36.07
55.98
161.23
217.21
PD1
16.18
33.58
49.76
147.31
197.07
PC1
14.07
36.94
51.01
123.74
174.75
PB1
12.49
31.80
44.29
95.60
139.89
PA1
14.32
32.42
46.74
70.77
117.51
1
Note that time estimates in minutes are converted to hours (by dividing by 60) before being used in the calculations
for adjusted staffing.
23
Table A2
Coefficients for Risk-Adjustment Model
Quality Measure/Covariate
Constant
(Intercept)
Coefficient
Percentage of long-stay residents who had a catheter inserted and left in
their bladder
-3.645993
1. Indicator of frequent bowel incontinence on prior assessment 0.545108
2. Indicator of pressure sores at stages II, III, or IV on prior assessment 1.967017
Percentage of long-stay residents who self-report moderate to severe pain
-2.428281
1. Indicator of independence or modified independence in daily decision
making on the prior assessment 1.044019
Percentage of short-stay residents with pressure ulcers that are new or
worsened
-5.204646
1. Indicator of requiring limited or more assistance in bed mobility on the
initial assessment
1.013114
2. Indicator of bowel incontinence at least occasionally on initial
assessment
0.835473
3. Indicator of diabetes or peripheral vascular disease on the initial
assessment
0.412676
4. Indicator of low body mass index on the initial assessment
0.373643
Source: http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf
24
Table A3
Ranges for Point Values for Quality Measures, Using Four Quarter Average
Distributions
1
Quality measure
For QM values
Number of QM
points is…
between... and...
ADL Decline (long-stay) 0.00000000 0.10049021 100
0.10049022 0.13483145 80
0.13483146 0.16778523 60
0.16778524 0.20794393 40
0.20794394 1.00000000 20
Moderate to Severe Pain (long-stay) 0.00000000 0.02201134 100
0.02201135 0.04988420 80
0.04988421 0.08311380 60
0.08311381 0.13081113 40
0.13081114 1.00000000 20
High risk pressure Ulcers (long-stay) 0.00000000 0.02654868 100
0.02654869 0.04453437 80
0.04453438 0.06181819 60
0.06181820 0.08633095 40
0.08633096 1.00000000 20
Catheter (long-Stay) 0.00000000 0.01073927 100
0.01073928 0.02094371 80
0.02094372 0.03178361 60
0.03178362 0.04745521 40
0.04745522 1.00000000 20
Urinary Tract Infection (long-stay) 0.00000000 0.01851851 100
0.01851852 0.03423682 80
0.03423683 0.05128203 60
0.05128204 0.07598784 40
0.07598785 1.00000000 20
Physical Restraints (long-stay) 0.00000000 0.00000000 100
0.00000001 0.01424503 60
0.01424504 1.00000000 20
25
Quality measure
For QM values
Number of QM
points is…
between... and...
Injurious Falls (long-stay) 0.00000000 0.01315789 100
0.01315790 0.02403848 80
0.02403849 0.03511052 60
0.03511053 0.05035973 40
0.05035974 1.00000000 20
Antipsychotic Meds (long-stay) 0.00000000 0.06843265 100
0.06843266 0.12704916 80
0.12704917 0.17391305 60
0.17391306 0.23979592 40
0.23979593 1.00000000 20
Moderate to Severe Pain (short-stay) 0.00000000 0.07359305 100
0.07359306 0.13229570 80
0.13229571 0.18827161 60
0.18827162 0.26041665 40
0.26041666 1.00000000 20
New or Worsening Pressure Ulcers (short-stay) 0.00000000 0.00000000 100
0.00000001 0.00692691 75
0.00692692 0.01566247 50
0.01566248 1.00000000 25
Antipsychotic Meds (short-stay) 0.00000000 0.00000000 100
0.00000001 0.00999998 80
0.00999999 0.01912567 60
0.01912568 0.03486237 40
0.03486238 1.00000000 20
Mobility decline (long-stay)
0.00000000 0.08022493 100
0.08022494 0.14454544 80
0.14454545 0.19333225 60
0.19333226 0.24905966 40
0.24905967 1.00000000 20
26
Quality measure
For QM values
Number of QM
points is…
between... and...
Functional Improvement (short-stay)
0.81666872 1.00000000 100
0.70966590 0.81666871 80
0.62861965 0.70966589 60
0.52015014 0.62861964 40
0.00000000 0.52015013 20
Hospital readmission (short-stay)
0.00000000 0.13839278 100
0.13839279 0.18716279 80
0.18716280 0.21886203 60
0.21886204 0.25689121 40
0.25689122 1.00000000 20
ED Visits (short-stay)
0.00000000 0.05488714 100
0.05488715 0.08944665 80
0.08944666 0.11696705 60
0.11696706 0.15529003 40
0.15529004 1.00000000 20
Successful community discharge (short-stay)
0.66448731 1.00000000 100
0.59926791 0.66448730 80
0.54906047 0.59926790 60
0.47667646 0.54906046 40
0.00000000 0.47667645 20
1
For the claims-based measures (hospital readmission, ED visit, community discharge), points are based on data
from 2014Q3 2015Q2. For the MDS-based measures (all others), points are based on data from 2015Q1
2015Q4. A higher QM value corresponds to better performance for all measures except functional improvement and
successful community discharge where lower QM values correspond to better performance.
Financial and Operating Review for
The Nathaniel Witherell
Final Report
APPENDIX L: MINIMUM DATA SET (MDS) FORMS
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 1 of 50
Resident Identifier Date
MINIMUM DATA SET (MDS) - Version 3.0.
RESIDENT ASSESSMENT AND CARE SCREENING.
Nursing Home Comprehensive (NC) Item Set.
Section A. Identification Information.
A0050. Type of Record.
1. Add new record Continue to A0100, Facility Provider Numbers.
2. Modify existing record Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record Skip to X0150, Type of Provider.
Enter Code
A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
C. State Provider Number:
A0200. Type of Provider.
Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.
Enter Code
A0310. Type of Assessment.
A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
Enter Code
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. None of the above.
Enter Code
C. PPS Other Medicare Required Assessment - OMRA.
0. No.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
Enter Code
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No.
1. Yes.
Enter Code
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
Enter Code
A0310 continued on next page.
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 2 of 50
Resident Identifier Date
Identification Information.Section A.
A0310. Type of Assessment - Continued.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
Enter Code
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
Enter Code
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.
Enter Code
A0410. Unit Certification or Licensure Designation.
1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.
Enter Code
A0500. Legal Name of Resident.
A. First name: B. Middle initial:
C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers.
A. Social Security Number:
_ _
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.
A0800. Gender.
1. Male.
2. Female.
Enter Code
A0900. Birth Date.
Month
_
Day
_
Year
A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.
MDS 3.0 Nursing Home Comprehensive (NC) Version 1.16.0 Effective 10/01/2018 DRAFT Page 3 of 50
Resident Identifier Date
Identification Information.Section A.
A1100. Language.
A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No Skip to A1200, Marital Status.
1. Yes Specify in A1100B, Preferred language.
9. Unable to determine. Skip to A1200, Marital Status.
Enter Code
B. Preferred language:
A1200. Marital Status.
1. Never married.
2. Married.
3. Widowed.
4. Separated.
5. Divorced.
Enter Code
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
A1500. Preadmission Screening and Resident Review (PASRR).
Complete only if A0310A = 01, 03, 04, or 05
Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability
("mental retardation" in federal regulation) or a related condition?
0. <