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CMS Five-Star Quality Rating System: The Path to 5-Star QMs

Percent of residents whose need for help with activities of daily living has increased

One of the eight quality measures derived from MDS assessments used to calculate your Five-Star Quality Measure rating for Long-Stay residents (defined as residents who are in the nursing home for greater than 100 days) is the percent of residents whose need for help with activities of daily living has increased.

This measure reports the percent of long-stay residents whose need for help with late-loss Activities of Daily Living (ADLs) has increased when compared to the prior assessment. The late-loss ADLs (bed mobility, eating, transfers, and toilet use) are used for this measure because they are the ones that tend to decline last. As a result, functional decline in these areas provides significant information about the resident’s status.

An increase in need for help with ADLs is defined as an increase in two or more coding points, such as from Supervision (1) to Extensive (3); in one late-loss ADL item, or a one-point increase, such as from Limited (2) to Extensive (3), in two or more late-loss ADL items.

For this measure, ADL decline is identified by comparing Section G responses on the most recent MDS (target assessment) to the Section G responses on the previous MDS (prior assessment). For each of the four late-loss ADLs, the actual score from the prior MDS is subtracted from the actual score on the target MDS. When one of the four ADLs is coded 7 or 8 (activity occurred only once or twice or not at all by resident or staff), the code is converted to 4 (total dependence) for calculating this QM.

Increased need for help with ADLs is identified when:

  • The result is greater than 0 for two or more of the four late-loss ADLs, indicating at least a one-level decline in two areas; or
  • When the result is greater than 1 for any one of the four late-loss ADLs, indicating at least a two-level decline in one area.

Assessments are excluded from the calculation when the prior assessment indicates total dependence in all four of the ADLs or total dependence in three of them and extensive assistance for the fourth ADL. Assessments are also excluded if, on the target assessment, the resident was comatose, on hospice care, or had a prognosis of six months or less to live.

Focusing your 5 Star Improvement Efforts

Accuracy in section G is of the utmost importance. While the rise in electronic software systems has helped to increase efficiency and accuracy of coding section G by auto filling ADL charting, it is still necessary to validate information through other means. Talking to staff and observing the resident in different settings provides the MDS nurse an opportunity to obtain more specific information, as well as to validate what is (or is not) documented. For nursing facilities using paper documentation, further investigation is vital, since the documentation may include only one episode for the entire shift. Accurately capturing the highest level of dependency on an ongoing basis will help staff minimize the implications of coding variances, which could result in false declines in QM scores.

Consider what systems you have in place for reviewing ADL data for potential declines on a routine basis.

Best practices include:

  1. Alert reports that signal the team when there are declines in ADLs. The IDT should review residents who are triggering this alert and ensure immediate actions are implemented to prevent further decline.
  2. You should also have systems for reviewing ADL data with the quarterly MDS schedule to identify residents who may potentially trigger in this QM area, then ensuring appropriate actions have been implemented to address the change in status, rather than waiting for them to show up on your QM report.
  3. To ensure your team remains focused on improving this QM, consider establishing an interdisciplinary ADL focused committee that meets on a regular basis to review ADL data and practices. The ADL focused team should review residents with an identified decline in ADL function, focusing on identification of contributing factors for the decline and developing plans to improve function and/or prevent further declines by developing plans based on identified root causes for individual residents, as well as identified facility system issues that could impact outcomes.

Best practices for reducing ADL declines include:

  • Providing ADL training to all nurses and CNAs upon hire and at least annually
  • Document multiple times throughout the shift; point of service documentation
  • Establish a system for the MDS nurse to validate ADL coding and facilitate ongoing training
  • Select a nurse and CNA champion who serve as mentors for accurate ADL coding
  • Strong restorative nursing programs
  • Reduction of alarm use
  • Strong processes for identifying and reporting changes in condition

Featured Webinar: 5-Star Ready! 2019 5-Star Quality Rating System Changes

This 1.25-hour webinar recording focuses on exploring the April 2019 revisions to the three domains of the CMS 5 Star Quality Rating System: Health Inspections, Staffing, and Quality Measures. Webinar details here.

Featured Toolkit: Activities of Daily Living Competency Tool-Kit

This Tool-kit download is intended to supplement or enhance current SNF/NF educational programs for Restorative Nursing Programs to meet the intent of the new Requirements of Participation for competency based training. This Tool-kit includes PowerPoint slides, instructor guidance, ADL Coding Worksheet, ADL Observation form, Editable Excel workbook including an orientation & training checklist and 18 individual competency forms for evaluating a range of basic CNA skills. Toolkit details here.

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Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

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