D.C. Mun. Regs. tit. 29, r. 29-6524
Beginning February 1, 2018, DHCF will implement the Nursing Facility Quality Improvement (NFQIP) Program.
Participation in the Nursing Facility Quality Improvement Reporting Track is mandatory for all nursing facilities in the District. Participation in the Nursing Facility Quality Improvement Incentive Track is optional. The two tracks are set forth below:
Quality reporting is mandatory for all District nursing facilities. Each nursing facility shall report to DHCF, annually, on the performance measures set forth below, which shall be calculated and reported as follows:
Nursing Facility Quality Improvement Reporting Performance Measures | ||||
Measure Number/Name | Measurement Domain | NQF # | Steward | Description |
1. Percent of high risk, long-stay residents with pressure ulcers | Quality of Care | 0679 | CMS | Numerator: The number of all long-stay residents with a selected target assessment that meets both of the following conditions: * Condition #1: There is a high risk for pressure ulcers, as "high-risk" is defined in the denominator definition below. * Condition #2: Stage II-IV or unstageable pressure ulcers are present, as indicated by any of the following six (6) conditions: * 2.1 (M0300B1 = [1, 2, 3, 4, 5, 6, 7, 8, 9]) or * 2.2 (M0300C1 = [1, 2, 3, 4, 5, 6, 7, 8, 9]) or * 2.3 (M0300D1 = [1, 2, 3, 4, 5, 6, 7, 8, 9]). Denominator: The number of all long-stay residents with a selected target assessment who meet the definition of high risk, except those with exclusions. Residents are defined as high-risk if they meet one (1) or more of the following three (3) criteria on the target assessment: * Impaired bed mobility or transfer indicated, by either or both of the following: * Bed mobility, self-performance (G0110A1 = [3, 4, 7, 8]) or * Transfer, self-performance (G0110B1 = [3, 4, 7, 8]) or * Comatose (B0100 = [1]) or * Malnutrition or at risk of malnutrition (15600 = [1]) (checked). Exclusions: * Target assessments that define a long-stay resident as high risk under this measure should be excluded from the denominator calculation if the target assessment is an admission assessment (A0310A = [01]) or a Prospective Payment System (PPS) 5-day or readmission/return assessment (A0310B = [01, 06]). * If the resident is not included in the calculation of the numerator (the resident did not meet the pressure ulcer conditions for the numerator) and any of the following conditions are true: * (M0300B1 = [-]). * (M0300C1 = [-]). * (M0300D1 = [-]). |
2. Percentage of long-stay residents who received an antipsychotic medication | Quality of Care | N/A | CMS | Numerator: The number of long-stay residents with a selected target assessment where the following condition is true: antipsychotic medications received. This condition is defined as follows: * For assessments with target dates on or before 03/31/2012: (N0400A = [1]). * For assessments with target dates on or after 04/01/2012: (N0410A = [1, 2, 3, 4, 5, 6, 7]). Denominator: The number of long-stay residents with a selected target assessment, except those with exclusions. Exclusions : Residents are excluded from the calculation of the numerator if any of the following is true: * For assessments with target dates on or before 03/31/2012: (N0400A = [-]). * For assessments with target dates on or after 04/01/2012: (N0410A = [-]). Residents are also excluded if any of the following related conditions are present on the target assessment (unless otherwise indicated): * Schizophrenia (16000 = [1]). * Tourette's syndrome (I5350 = [1]). * Tourette's syndrome is considered to be (I5350 = [1]) if this item is not active on a prior the target assessment or if a prior assessment is available; or. * Huntington's disease (I5250 = [1]). |
3. Percent of long-stay residents with a urinary tract infection | Quality of Care | 0684 | CMS | Numerator: The number of long-stay residents with a selected target assessment that indicates urinary tract infection within the last thirty (30) days (I2300 = [1]). Denominator: The number of all long-stay residents with a selected target assessment, except those with exclusions. Exclusions: Residents are excluded from the denominator calculation if: * Target assessment is an admission assessment of (A0310A = [01]) or a PPS 5-day or readmission/return assessment (A0310B = [01, 06]); or * Urinary tract infection value is missing (I2300 = [-]). |
4. Percent of low risk long-stay residents who lose control of their bowels or bladder | Quality of Care | N/A | CMS | Numerator: The number of long-stay residents with a selected target assessment that indicates frequently or always incontinence of the bladder (H0300 = [2, 3]) or bowel (H0400 = [2, 3]). Denominator: The number of all long-stay residents with a selected target assessment, except those with exclusions. Exclusions: Residents are excluded from the calculation of the denominator if: * Resident's target assessment is an admission assessment (A0310A = [01]) or a PPS five (5-) day or readmission/return assessment (A0310B = [01, 06]);. * Resident is not in numerator and H0300 = [-] OR H0400 = [-]. * Residents have any of the following high risk conditions: a. Severe cognitive impairment on the target assessment as indicated by (C1000 = [3] and C0700 = [1]) OR (C0500 = [7]); b. Totally dependent in bed mobility self-performance (G0110A1 = [4, 7, 8]).; c. Totally dependent in transfer self-performance (G0110B1 = [4, 7, 8])' or. d. Totally dependent in locomotion on unit self-performance (G0110E1 = [4, 7, 8]). * Resident does not qualify as high risk (see #3 above) and both of the following two (2) conditions are true for the target assessment: a. C0500 = [99, ^, -]; and b. C0700 = [^, -] or C1000 = [^, -]. * Resident does not qualify as high risk (see #3 above) and any of the following three (3) conditions are true: a. G0110A1 = [-]; b. G0110B1 = [-]; and c. G0110E1 = [-]. * Resident is comatose (B0100 = [1]) or comatose status is missing (B0100 = [-]) on the target assessment. * Resident has an indwelling catheter (H0100A = [1]) or indwelling catheter status is missing (H0100A = [-]) on the target assessment. * Resident has an ostomy (H0100C = [1]) or ostomy status is missing (H0100C = [-]) on the target assessment. |
5. Percent of long-stay residents experiencing one or more falls with major injury | Quality of Care | 0674 | CMS | Numerator: The number of long-stay residents with one or more look-back scan assessments that indicate one or more falls that resulted in major injury (J1900C = [1, 2]). Denominator: The number of all long-stay nursing home residents with a one or more look-back scan assessments except those with exclusions. Exclusions : Residents are excluded from the calculation of the denominator if one of the following is true for all of the look-back scan assessments: * The occurrence of falls was not assessed (J1800 = [-]), or * The assessment indicates that a fall occurred (J1800 = [1]) and the number of falls with major injury was not assessed (J1900C = [-]) |
6. Resident/ Family Satisfaction Survey | Quality of Life | N/A | DHCF or its representative | The survey will document resident/family satisfaction with the services provided by the nursing facility. The survey will be: * The AHRQ standardized nursing home CAHPS survey tool; and * Annually administered and tabulated by an external entity from the nursing facility and DHCF. A summary report of the survey and response rate will be made publicly available. |
7. End of Life Program | Quality of Life | N/A | DHCF | The facility must develop a program for all residents (including but not limited to those with a terminal diagnosis) that serves the staff, residents, and family members in preparation for the time when beneficiary is unable to communicate their wishes for themselves regardless of anticipated length of stay. Supporting documentation for the program provided by the nursing facility to DHCF must provide: * A detailed narrative of the facility's end of life program that identifies individual preferences, spiritual needs, wishes, expectations, specific grief counseling, a plan for honoring those that have died, and a process to inform the facility residents of such death; * Documentation of no less than four (4) and no greater than ten (10) residents' individual wishes and how the facility honored them; and * Proof of staff education on the facility's end of life planning program. |
8. Low-acuity Non-emergent ED visits | Utilization | N/A | DHCF | Percentage of inpatient admissions among nursing facility long stay residents for specific ambulatory care conditions that may have been prevented through appropriate outpatient care. |
9. All-cause 30-day Readmissions | Utilization | 1768 | NCQA | The number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within thirty (30) calendar days and the predicted probability of an acute readmission. Data are reported in the following categories: * Count of Index Hospital Stays (denominator); * Count of thirty (30)-Day Readmissions (numerator); and * Average adjusted Probability of Readmission. |
10. Potentially Preventable Hospital Admissions | Utilization | N/A | AHRQ | Percentage of inpatient admissions among nursing facility residents for specific ambulatory care conditions that may have been prevented through appropriate outpatient care. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, or heart failure without a cardiac procedure. |
11. Staff Continuing Education in MDS Training | Infrastructure | N/A | DHCF | Provide documentation that staff is trained to document MDS assessment in a uniform and consistent manner. |
12. Staff Turnover | Infrastructure | N/A | DHCF | The percentage of direct care staff^ who have been terminated^^ during the measurement period, calculated as follows: 100*(Number of nursing terminations at the nursing home during the period / (average number of nursing staff employees) - 100. ^Direct Care Staff - A ll full-time, part-time, permanent, short-term, seasonal, salaried and hourly RN, LPN, and CNA staff. Staff of temporary agencies and outside contractors are not included. ^^Terminated - Any person who is no longer employed by the nursing facility for any reason. |
13. RN hours per resident day | Infrastructure | N/A | DHCF | RN hours per resident day is calculated by adding RN hours plus fifty (50) percent of Direct of Nursing (DON) hours worked by nursing home employees plus eighty (80) percent of RN hours worked by contract agency staff, and dividing by total resident days for the reporting period. |
14. Quality Improvement Plan (This measure will be retired in FY2020 and will become a participation requirement for the NFQII program.) | Infrastructure | N/A | DHCF | Documentation on how the nursing facility will address transitions of care and optimize on performance measures. The measure will review the nursing facility's Quality Assurance and Performance Improvement program utilizing the ACA required guidelines. |
In addition to the reporting requirements set forth in § 6524.3, each nursing facility participating in NFQII shall report to DHCF, annually, on an additional set of requirements and performance measures set forth below:
Nursing Facility Quality Initiative Incentive Performance Measures | ||||
Measure Number/Name | Measurement Domain | NQF # | Steward | Description |
1. Certified EHR Adoption (NFQII only) | Infrastructure | N/A | DHCF | Demonstrate use of electronic health record (EHR) technology to support the creation and execution of a person-centered plan of care for each beneficiary that will facilitate transitions of care. |
2. Enrollment and Integration in the Chesapeake Regional Information System for our Patients (CRISP) to receive ENS (NFQII only) | Infrastructure | N/A | DHCF | Demonstrate use of enrollment in and use of Health Information Exchange tools as detailed below: * In year 1 nursing facilities provide proof of enrollment in the Chesapeake Regional Information System for our Patients (CRISP) or comparable system, to receive hospital and emergency department alerts for enrolled beneficiaries. * In year 2 nursing facilities provide narrative of how the facility has integrated the HIE connectivity into its workflow |
Results on all performance measures referenced in § 6524.3 shall be publicly posted on the DHCF website.
D.C. Mun. Regs. tit. 29, r. 29-6524