I pulled the Q4 2023 Facility Level Quality Measure report for my facility in January and noticed several measures are displayed as “I” for incomplete including the following:

      • Percent of Residents Whose Ability to Walk Independently Worsened
      • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased
      • Percent of Residents with Pressure Ulcers
      • Percent of Residents with New ore Worsened Bowel or Bladder Incontinence

I understand that the measures related to the ADLs have been frozen due to the changes in the MDS 3.0 that were effective in October 2023 (including the removal of section G items,) but can you please explain why these measure calculations are shown as incomplete on my report?




Information related to this question can be found in the MDS QM User Manual V- 16.0 (effective 10/1/2023), which was updated on 12/18/2023 and can be downloaded at the following link Quality Measures | CMS.

As noted on page 11 of this manual the above measures have significant impact from the removal of section G. With the changes to the MDS, including the removal of many of the items used to calculate the above QMs, the measures have undergone significant changes. This includes a transition to using section GG tasks to address function, such as the ability to walk/move independently and need for help with ADLs increased. Since Section GG was not included on the OBRA item sets prior to October 1, 2023, if the target assessment has an ARD prior to 10/1/2023, the data necessary to calculate the updated measures. In addition, when the measure requires a comparison between the current (target assessment) and the prior assessment, both assessments must have target dates (ARDs) on or after 10/1/2023 to have the data necessary to calculate the measure. As a result, the measure specification excludes situations where either the prior or target assessment has an ARD prior to 10/1/2023.

Once sufficient assessment data has been collected to calculate the measure, they will no long show on the report as incomplete.


Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

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