Form CMS-10390 Hospice Data Submission Form

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Hospice Quality Reporting Program
Hospice Data Submission Form
Facility Provider Identification
Hospice Provider's Business Name

Hospice Provider's Mailing Address
Hospice Provider's Physical Address (if
different from mailing address)
Hospice Provider's Business Telephone
Number
(10 digits)
CMS Certification Number (CCN):
(6 digits)
Hospice Contact for questions:
Name
Phone

E-mail address

Data Collection Period October 1, 2012 through December 31, 2012
Part 1. Structural Measure
Q1. Does your hospice have a Quality Assessment and Performance Improvement (QAPI) program that includes

three or more quality indicators related to patient care?

A. Yes, our Hospice does have a QAPI program that includes three or more quality indicators related
to patient care.
B. No, our Hospice does not have a QAPI program that includes at least three quality indicators
related to patient care.

Q2. If your hospice's QAPI program includes at least one patient care related quality indicator, include each indicator

using the form provided below.

Check each box where you have one or more indicators in the Topic category
Domain

Sub-domain

Topic

Patient Safety
Infections

Infections-incidence/prevalence
Infections-treatment
Infections-other

Falls

Falls-incidence/prevalence
Falls-risk screening/assessment
Falls-interventions
Falls prevention education
Falls-patient/family ratings
Falls-other

Medication Safety

Medication Error-incidence
Medication Adverse Events-incidence
Medication reconciliation and/or comprehensive med review
Medication patient/family education
Medication-patient/family ratings
Medication-other

Pressure

Pressure ulcers/wounds-incidence/prevalence
Pressure ulcers-screening/risk assessment
Pressure ulcers prevention/intervention
Pressure ulcers/wounds-other

Oxygen Safety

Oxygen Safety-risk assessment
Oxygen Safety-patient/family safety education
Oxygen Safety-other

Patient Safety or incidents generally

Tracking incidents-broadly

Patient/family ratings of care
re: patient safety

Patient/family ratings of patient safety

Safety assessment/family education/interventions

Patient/family ratings of instruction/ education about patient safety

Domain

Sub-domain

Topic

Physical symptom management
Pain

Screening
Assessment
Interventions/treatment
Symptom control/comfort
Management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Dyspnea

Screening
Assessment
Interventions/treatment
Symptom control/comfort
Management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Nausea

Screening
Assessment
Interventions/treatment
Symptom control/comfort
Management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Bowel Management

Screening
Assessment
Interventions/treatment
Symptom control/comfort
Management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Physical Symptoms-other

Physical Symptoms --Other

Domain
Care coordination and transitions

Topic
Screening
Assessment
Interventions/treatment
Symptom control/comfort
Management/control/comfort in last 1-2 weeks of life
Patient/family education

Domain
Patient/family preferences

Topic
Advance Directives/surrogate designation
Documenting patient/family preferences and goals of care
Meeting patient/family preferences and goals of care

Domain
Communication and Education

Topic
Communication with patient/family re: hospice care broadly
Family ratings of communication
Family education/communication about the dying process
Family/caregiver confidence
Family education about managing symptoms
Family education about equipment use
Family education about safety
Family education about Advance Directives/surrogate designation

Domain
Patient/Family Experience/Ratings of Care
and/or services

Topic
Overall ratings/willingness to recommend
Patient personal care needs met
Respectful treatment
Improved comfort/wellbeing/QOL
Evening/weekend on-call service
Volunteer services
Family ratings of disciplines providing care

Domain

Topic

Spiritual

Screening/assessment/management of spiritual needs/issues
Patient/family experience/ratings of spiritual care
Spiritual care-other

Domain

Topic

Structure and Process of care

Visit frequently
Volunteer services
Other structures and processes of care

Sub-domain

Domain

Topic

Psychosocial
Depression

Depression screening
Depression ASSESSMENT
Depression interventions/treatment
Symptom control/comfort
Depression management/control/comfort in last 1-2 weeks of life
Patient/family education
Patient/family experience/ratings of care

Anxiety

Anxiety screening
Anxiety assessment
Anxiety interventions/treatment
Symptom control/comfort
Anxiety management/control/comfort in last 1-2 weeks of life
Patient/family education
Anxiety patient/family experience/ratings of care

Social

Assessment and management of social support

Psychosocial

Assessment and management of psychosocial distress

Psychosocial

Other psychosocial

Domain
Grief, Bereavement and Emotional Support

Topic
Grief and Bereavement assessment and care
Emotional care for patient/family before and/or at time of death
Emotional care for family after the death
Culturally sensitive caregiving

Q3. Please indicate the data source(s) for your QAPI indicators. Check all that apply:

Electronic medical record
Paper medical record
Family survey/questionnaire
Patient survey/questionnaire
Incident report/log

“I certify that I have been duly authorized to submit this data, and I certify that the data submitted is true,
accurate, and complete. I understand that the knowing, reckless, or willful omission, misrepresentation, or
falsification of any information contained in this submission or any communication supplying information to
Medicare may be punished by criminal, civil, or administrative penalties, including fines and imprisonment.”

ACCEPT

DECLINE

Part 2. NQF 0209 Pain Measure
Measure Title: Comfortable Dying: Pain Brought to a Comfortable Level Within 48 hours of Initial Assessment
Brief Description of measure: number of patients who report being uncomfortable because of pain at the initial
assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48
hours.
Enter the following numbers in the spaces provided:
1. Enter the number of admissions during the data collection period (October 1, 2012
through December 31, 2012)
2. Pain Measure Denominator: Enter the number of patients who answered YES to the
question “are you uncomfortable because of pain” at the initial assessment (after
admission to hospice services) during the data collection period (October 1, 2012
through December 31, 2012)
3. Enter the number of patients who answered NO to the question “are you
uncomfortable because of pain” at the initial assessment (after admission to hospice
services) during the data collection period (October 1, 2012 through December 31,
2012)
4. Enter the number of patients excluded)

5. Pain Measure Numerator: Enter the number of patients who answered YES to the
question “ was your pain brought to a comfortable level within 48 hours of the start
of hospice care?” during the data collection period (October 1, 2012 through
December 31, 2012)

6. Enter the number of patients who answered NO to the question “ was your pain
brought to a comfortable level within 48 hours of the start of hospice care?” during
the data collection period (October 1, 2012 through December 31, 2012)
7. Enter the number of patients unable to self report at follow up.

“I certify that I have been duly authorized to submit this data, and I certify that the data submitted is true,
accurate, and complete. I understand that the knowing, reckless, or willful omission, misrepresentation, or
falsification of any information contained in this submission or any communication supplying information to
Medicare may be punished by criminal, civil, or administrative penalties, including fines and imprisonment.”

ACCEPT

DECLINE