Facility Characteristics - Post Acute Care

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1 Comparison Group Used: All PIP Facilities: Apr - Jun, Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Facility Characteristics - Post Acute Care Resident Characteristic Gender Age Number of Residents Male 48 Female 93 <5 years old 5-54 years old years old years old years old years old 8 Payment Source (all that apply) Medicaid per diem 8 Medicare per diem 38 Medicare ancillary part A 4 Medicare ancillary part B Self or family pays for full per diem 8 Medicaid resident liability or Medicare co-payment 8 Private insurance per diem (including co-payment) All other per diem Diagnostic Characteristics Psychiatric diagnosis 4 Mental retardation Hospice Type of Assessment Admission 4 Annual Significant change in status 3 Significant correction of prior full assessment Quarterly Significant correction of prior quarterly All Other 33 Stability of Conditions Conditions/disease make resident unstable 44 Acute episode or chronic flareup End-stage disease, 6 or fewer months to live Discharge Potential No potential 3 Within 3 days days 6 Uncertain 5 Facility %* Comparison Group %* Notes: * Numbers may not total to % because of missing data. Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page of

2 Comparison Group Used: All PIP Facilities: Apr - Jun, Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 QI /QM Report Changes Why are my reports different? Recently CMS made a series of changes in the Quality of Care reports used by surveyors in the quality monitoring process. In general, the changes were minimal and have little impact on a facility's QI average. However, some QI definitions changed and a new way of adjusting for risk factors was introduced for 3 QIs. Also, the numbering and descriptions of the QIs were revamped. For more details about the changes, please look in the epip Quality Center. In an effort to keep consistent, CHSRA has changed your epip reports to reflect these changes in the survey process. What has changed? The epip QI/QM reports are slightly different from previously available epip reports. We have renumbered indicators on these reports and modified the QIs so that they match what is now available to state surveyors. These updated reports are also similar to the new reports available to facilities via the CASPER reporting process that was added to the state MDS systems. However, these new QI/QM epip reports while including all the new definitions, risk factor adjustments and new QI/QMs also provide you with further information on high/low and overall percentile rankings for many of the QI/QMs that is not available via the CASPER reporting system. How do I find out more information? If you have any questions please refer to the epip Quality Center for more detailed information. You can also call the CHSRA epip helpdesk at

3 Comparison Group Used: All PIP Facilities: Apr - Jun, Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Domain - QI / QM Facility QI / QM Profile - Post Acute Care Based on the 5 and 4 day assessments (Numbers in parantheses are adjusted using the new CMS risk adjustment process) # in Num # in Denom Facility Percent Comparison Group Percent Percentile Rank Post-Acute Care 3. Short-stay residents with delirium High risk w risk 3. Short-stay residents who had moderate to severe pain 3.3 Short-stay residents with pressure ulcers High risk w risk (.3) 5.3 (4.7) () 5 8. (8.3) 4.3 (4.4) 83 (83) 4.8 (.3) 5.4 (4.4) () (3.4) 9.4 (9.5) 7 (8) (3.7).9 (9.4) 77 (8) (3.) 3.9 (7.) () Report ID: 66 User ID: ADMIN Report Set: Run Date:3/3/6 : Page of

4 Comparison Group Used: All PIP Facilities: Apr - Jun, Report Period Ending: Jun, MDS Data Submitted As Of: 3//6 Domain - QI / QM Post-Acute Care Facility QI / QM History - Post Acute Care Jun'99 Facility Percent Sep'99 Facility Percent Dec'99 Facility Percent Mar' Facility Percent Jun' Facility Percent Jun' Comparison Percent 3.. Short-stay residents with delirium High risk w risk Short-stay residents who had moderate to severe pain Short-stay residents with pressure ulcers High risk w risk Report ID: 66 User ID:ADMIN Report Set: Run Date:3/3/6 : pm Page of

5 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care REGRESSION ADJUSTED QI / QM #3. Short-stay residents with delirium Facility and comparison group numbers for the graph on this page have been adjusted using the same Regression Adjustment Process used for reports from CMS The graph on this page shows the overall facility average after adjusting for the risk factors specified by the Centers for Medicare and Medicaid Services (CMS). The comparison group average and percentile ranks are also adjusted for risk. Unadjusted QI / QM graphs for this indicator appear on adjacent pages Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page of 6

6 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care QI /QM #3. Short-stay residents with delirium QI /QM #3. Short-stay residents with delirium High risk Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page of 6

7 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care QI /QM #3. Short-stay residents with delirium w risk QI /QM #3. Short-stay residents who had moderate to severe pain Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 3 of 6

8 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care REGRESSION ADJUSTED QI / QM #3.3 Short-stay residents with pressure ulcers Facility and comparison group numbers for the graph on this page have been adjusted using the same Regression Adjustment Process used for reports from CMS The graph on this page shows the overall facility average after adjusting for the risk factors specified by the Centers for Medicare and Medicaid Services (CMS). The comparison group average and percentile ranks are also adjusted for risk. Unadjusted QI / QM graphs for this indicator appear on adjacent pages Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 4 of 6

9 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care QI /QM #3.3 Short-stay residents with pressure ulcers QI /QM #3.3 Short-stay residents with pressure ulcers High risk Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 5 of 6

10 Comparison Group Used: All PIP Facilities Report Period: 7/999 to 6/ MDS Data Submitted As Of: 3//6 Facility QI / QM Graphs over Months - Post Acute Care QI /QM #3.3 Short-stay residents with pressure ulcers w risk Legend Facility Average Comparison Group Average 75th Percentile 5th Percentile Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 6 of 6

11 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Resident ID Current Residents Most Recent Assessment Date AA8a AA8b Resident QI / QM Summary - Post Acute Care Delirium Hi (Ordered by discharge status and resident ID) Post Acute Care Pain Pressure Ulcers 996 // / 7/ 7 ü 538 6// 3 7 ü 543 6/8/ / 7/ /7/ // /5/ /3/ 7 ü 989 4/9/ 7 ü /3/ /8/ /5/ 7 ü // 7 ü 336 3/5/ 7 ü /3/ // 7 ü 343 3/6/ // 7 ü / 9/ 7 ü 346 3/ 3/ / 6/ / 6/ 7 ü / 3/ 7 ü 347 3/ 6/ /9/ /9/ 7 ü // // /3/ /6/ / / 7 ü 348 / 7/ // / / /9/ 7 ü 3489 /7/ /8/ 7 ü // / 4/ /6/ 7 ü Hi Total Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 Page of 4

12 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Resident ID Current Residents Most Recent Assessment Date AA8a AA8b Resident QI / QM Summary - Post Acute Care Delirium Hi (Ordered by discharge status and resident ID) Post Acute Care Pain Pressure Ulcers // /4/ 7 ü 348 // /9/ // 7 ü 343 /4/ 7 ü 343 // /6/ 7 ü 3444 /7/ /4/ / / 7 ü ü / / 7 ü 346 3/ / 7 ü ü ü / 3/ 7 ü // 7 ü /9/ 7 ü // 7 ü 359 3/3/ // 7 ü // // /3/ 7 ü ü /8/ 7 ü 353 3/3/ // /3/ 7 ü 353 3/7/ 7 ü /7/ 7 ü /7/ 7 ü /3/ 7 ü ü /7/ /6/ 7 ü 353 3// /4/ /5/ /7/ 7 ü /5/ 7 ü /3/ /6/ 7 ü /6/ 7 ü ü /3/ 7 ü Hi Total Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 Page of 4

13 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Resident ID Current Residents Most Recent Assessment Date AA8a AA8b Resident QI / QM Summary - Post Acute Care Delirium Hi (Ordered by discharge status and resident ID) Post Acute Care Pain Pressure Ulcers /3/ 7 ü ü / / 7 ü /3/ 7 ü /4/ 7 ü ü 356 6// / / 7 ü /9/ 7 ü // /9/ /8/ 7 ü ü /9/ 7 ü ü // 7 Hi Total Discharged Residents 5675 // 7 ü ü 379 3/ 4/ // /9/ / 5/ /6/ 7 ü 349 3/ 4/ / 5/ 7 ü / 4/ 7 ü / 5/ / 4/ 7 ü / 3/ 7 ü 346 3/ 4/ 7 ü 346 // // / 4/ /6/ // /9/ 7 ü ü // / / / 3/ 7 ü ü 349 // /3/ /3/ 7 ü 3438 / / 7 ü 344 /4/ 7 ü ü 3443 /6/ 7 Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 Page 3 of 4

14 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Resident ID Discharged Residents Most Recent Assessment Date AA8a AA8b Resident QI / QM Summary - Post Acute Care Delirium Hi (Ordered by discharge status and resident ID) Post Acute Care Pain Pressure Ulcers 345 / / 7 ü // // 7 ü /7/ 7 ü // 7 ü /7/ /7/ 7 ü ü 359 3/ 9/ 7 ü /6/ // / 9/ 7 ü /7/ // 7 ü /5/ 7 ü /8/ 7 ü / 4/ 7 ü /4/ /8/ /9/ 7 Hi Total Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 Page 4 of 4

15 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Individual QI / QM Series - Post Acute Care: Short-stay residents with delirium (Only includes residents flagging on or more QI/QMs ordered by resident ID) Most Recent Assessment Resident ID Date AA8a AA8b Delirium Current Residents Post Acute Care Pain Pressure Ulcers Hi Hi 346 3/ / 7 ü ü ü 3 Total Discharged Residents 346 / 3/ 7 ü ü 3436 /3/ 7 ü 344 /4/ 7 ü ü Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page of 4

16 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Individual QI / QM Series - Post Acute Care: Short-stay residents who had moderate to severe pain (Only includes residents flagging on or more QI/QMs ordered by resident ID) Most Recent Assessment Resident ID Date AA8a AA8b Delirium Current Residents Post Acute Care Pain Pressure Ulcers Hi Hi 49 6/ 7/ 7 ü 435 3/3/ 7 ü 989 4/9/ 7 ü /5/ 7 ü // 7 ü // 7 ü / 9/ 7 ü / 6/ 7 ü / 3/ 7 ü /9/ 7 ü 348 3/9/ 7 ü /8/ 7 ü 348 // 7 ü 343 /4/ 7 ü / / 7 ü ü / / 7 ü 346 3/ / 7 ü ü ü / 3/ 7 ü /9/ 7 ü // 7 ü /3/ 7 ü ü 353 3/7/ 7 ü /7/ 7 ü /3/ 7 ü ü 353 3/6/ 7 ü /7/ 7 ü /5/ 7 ü /6/ 7 ü ü /3/ 7 ü ü / / 7 ü /3/ 7 ü /4/ 7 ü ü / / 7 ü /8/ 7 ü ü /9/ 7 ü ü Total Discharged Residents 5675 // 7 ü ü 346 3/ 5/ 7 ü / 4/ 7 ü / 4/ 7 ü Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page of 4

17 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Individual QI / QM Series - Post Acute Care: Short-stay residents who had moderate to severe pain (Only includes residents flagging on or more QI/QMs ordered by resident ID) Most Recent Assessment Resident ID Date AA8a AA8b Delirium Discharged Residents Post Acute Care Pain Pressure Ulcers Hi Hi / 3/ 7 ü 346 3/ 4/ 7 ü 3489 /9/ 7 ü ü 346 / 3/ 7 ü ü 3438 / / 7 ü 344 /4/ 7 ü ü 345 / / 7 ü 358 3// 7 ü /7/ 7 ü 359 3/7/ 7 ü ü 359 3/ 9/ 7 ü / 9/ 7 ü // 7 ü /5/ 7 ü / 4/ 7 ü Total Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 3 of 4

18 Report Period: / / to 6/3/ MDS Data Submitted As Of: 3//6 Individual QI / QM Series - Post Acute Care: Short-stay residents with pressure ulcers (Only includes residents flagging on or more QI/QMs ordered by resident ID) Most Recent Assessment Resident ID Date AA8a AA8b Delirium Current Residents Post Acute Care Pain Pressure Ulcers Hi Hi 538 6// 3 7 ü 336 3/5/ 7 ü // 7 ü 348 / / 7 ü /6/ 7 ü /4/ 7 ü 3433 /6/ 7 ü / / 7 ü ü 346 3/ / 7 ü ü ü // 7 ü // 7 ü /3/ 7 ü ü /8/ 7 ü /3/ 7 ü /7/ 7 ü /3/ 7 ü ü /6/ 7 ü /6/ 7 ü ü /3/ 7 ü /3/ 7 ü ü /4/ 7 ü ü /9/ 7 ü /8/ 7 ü ü /9/ 7 ü ü Total Discharged Residents 5675 // 7 ü ü /6/ 7 ü 3489 /9/ 7 ü ü // 7 ü 359 3/7/ 7 ü ü /8/ 7 ü Report ID: 66 User ID: ADMIN Report Set: Run Date: 3/3/6 : Page 4 of 4

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