CMS-10387 Final SNF QRP New and Modified Items

Final SNF QRP New and Modified Items – Effective Date: October 1, 2020
ADMISSION (Start of SNF Stay)
Section A

Identification Information

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, another Hispanic, Latino, or Spanish origin
X. Resident unable to respond
A1010. Race
What is your race?
Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I. Vietnamese
J. Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Resident unable to respond

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that
I need
C. No
X. Resident unable to respond
A1805. Entered From
Enter Code

01. Home/Community (e.g., private home/apt., board/care, assisted living, group
home, transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing bed)
04. Short-term general hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient rehabilitation facility (IRF, free standing facility or unit)
07. Inpatient psychiatric facility (psychiatric hospital or unit)
08. Intermediate care facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section B

Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Enter Code

Section D

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
8. Resident unable to respond

Mood

D0150. Resident Mood Interview (PHQ-2 to 9)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2 blank)
2. 7-11 days (half or more of the
days)
3. 12-14 days (nearly every day)
Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let
yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed.
Or the opposite—being so fidgety or restless that you have been
moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in
some way
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

D0160. Total Severity Score
Enter Score Add scores for all frequency responses in column 2, Symptom Frequency. Total score must be
between 02 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)
D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

Section J

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
8. Resident unable to respond

Health Conditions

J0510. Pain Effect on Sleep
Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
1. Rarely or not at all
Enter Code
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer
J0520. Pain Interference with Therapy Activities
Ask resident: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
Enter Code
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer
J0530. Pain Interference with Day-to-Day Activities
Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
Enter Code
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply on admission.

1.
On Admission
Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any medications by
pharmacological classification, not how it is used, in
the following classes
2. Indication noted
If column 1 is checked, check if there is an indication
noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
a.
On Admission
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
a.
On Admission
Check all that apply
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

PLANNED DISCHARGE (End of SNF Stay)
A0310G =1

Section A

Identification Information

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things
that I need
C. No
X. Resident unable to respond
A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12
01. Home/Community (e.g., private home/apt., board/care, assisted living, group
Enter Code
home, transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing bed)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient rehabilitation facility (IRF, free standing facility or unit)
07. Inpatient psychiatric facility (psychiatric hospital or unit)
08. Intermediate care facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
13. Deceased
99. Not Listed

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the resident’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Check all that apply
Route of Transmission
A. Electronic Health Record
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)
A2123. Provision of Current Reconciled Medication List to Resident at Discharge
At the time of discharge, did your facility provide the resident’s current reconciled medication list to the
resident, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the resident, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the resident, family and/or
caregiver
A2124. Route of Current Reconciled Medication List Transmission to Resident
Indicate the route(s) of transmission of the current reconciled medication list to the
resident/family/caregiver.
Route of Transmission

Check all that apply

A. Electronic Health Record (e.g., electronic access to patient portal)
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section B

Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
0. Never
Enter Code
1. Rarely
2. Sometimes
3. Often
4. Always
8. Resident unable to respond

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents
Enter Code

0. No (resident is rarely/never understood)  Skip to XXXX
1. Yes  Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
Enter Code
0. None
1. One
2. Two
3. Three
After the resident’s first attempt, repeat the words using cues (“sock, something to wear; blue, a
color; bed, a piece of furniture”). You may repeat the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Ask resident: “Please tell me what year it is right now.”
A. Able to report correct year
0. Missed by > 5 years or no answer
Enter Code
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask resident: “What month are we in right now?”
B. Able to report correct month
Enter Code
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Ask resident: “What day of the week is today?”
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
Ask resident: “Let's go back to an earlier question. What were those three words that I asked you to
repeat?” If unable to remember a word, give cue (something to wear; a color; a piece of furniture)
for that word.
Enter Code A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No - could not recall
Enter Code
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No - could not recall
Enter Code
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required
C0500. BIMS Summary Score
Enter Code

Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the resident was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status or Staff Assessment and reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code
Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes
Enter Code in Boxes
B. Inattention – Did the resident have difficulty focusing attention, for
Coding:
example being easily distractible or having difficulty keeping track of
0. Behavior not present
what was being said?
1. Behavior continuously
C. Disorganized thinking – Was the resident’s thinking disorganized or
present, does not
incoherent (rambling or irrelevant conversation, unclear or illogical
fluctuate
flow of ideas, or unpredictable switching from subject to subject)?
2. Behavior present,
fluctuates (comes and
D. Altered level of consciousness – Did the resident have altered level of
goes, changes in
consciousness as indicated by any of the following criteria?
severity)
• vigilant – startled easily to any sound or touch
• lethargic – repeatedly dozed off when being asked questions, but
responded to voice or touch
• stuporous – very difficult to arouse and keep aroused for the
interview
• comatose – could not be aroused
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

C1310. Signs and Symptoms of Delirium (from CAM©)
Confusion Assessment Method ©1988, 2003, Hospital Elder Life Program. All rights reserved.
Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

Section D

Mood

D0150. Resident Mood Interview (PHQ-2 to 9)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2 blank)
2. 7-11 days (half or more of the
days)
3. 12-14 days (nearly every day)
Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let
yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed. Or
the opposite – being so fidgety or restless that you have been moving
around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in
some way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in column 2, Symptom Frequency. Total score must
be between 02 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
0. Never
Enter Code
1. Rarely
2. Sometimes
3. Often
4. Always
8. Resident unable to respond

Section J

Health Conditions

J0510. Pain Effect on Sleep
Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
1. Rarely or not at all
Enter Code
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer
J0520. Pain Interference with Therapy Activities
Ask resident: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
Enter Code
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer
J0530. Pain Interference with Day-to-Day Activities
Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
Enter Code
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
3. While a Resident
Check all of the nutritional approaches that were received while a
resident of this facility and within the last 7 days
5. At Discharge
Check all of the nutritional approaches that were being received at
discharge

3.
While a
Resident

5.
At Discharge

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet – require change in texture of food
or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications by
pharmacological classification, not how it is used, in the
following classes
2. Indication noted
If column 1 is checked, check if there is an indication
noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

UNPLANNED DISCHARGE (End of SNF Stay)
A0310G =2
Section A

Identification Information

A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
Enter Code
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing bed)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient rehabilitation facility (IRF, free standing facility or unit)
07. Inpatient psychiatric facility (psychiatric hospital or unit)
08. Intermediate care facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
13. Deceased
99. Not Listed
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the resident’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Check all that apply
Route of Transmission
A. Electronic Health Record
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

A2123. Provision of Current Reconciled Medication List to Resident at Discharge
At the time of discharge, did your facility provide the resident’s current reconciled medication list to the
resident, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the resident, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the resident, family and/or
caregiver
A2124. Route of Current Reconciled Medication List Transmission to Resident
Indicate the route(s) of transmission of the current reconciled medication list to the
resident/family/caregiver.
Check all that apply
Route of Transmission
A. Electronic Health Record (e.g., electronic access to
patient portal)
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

Section C

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after evaluating cognitive status and reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code
Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes
Enter Code in Boxes
Coding:
B. Inattention – Did the resident have difficulty focusing attention, for
0. Behavior not present
example being easily distractible or having difficulty keeping track of
1. Behavior continuously
what was being said?
present, does not
C. Disorganized thinking – Was the resident’s thinking disorganized or
fluctuate
incoherent (rambling or irrelevant conversation, unclear or illogical
Behavior present, fluctuates
flow of ideas, or unpredictable switching from subject to subject)?

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

C1310. Signs and Symptoms of Delirium (from CAM©)
(comes and goes, changes in
D. Altered level of consciousness – Did the resident have altered level of
severity)
consciousness as indicated by any of the following criteria?
• vigilant – startled easily to any sound or touch
• lethargic – repeatedly dozed off when being asked questions, but
responded to voice or touch
• stuporous – very difficult to arouse and keep aroused for the
interview
• comatose – could not be aroused
Confusion Assessment Method ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from:
Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
3. While a Resident
Check all of the nutritional approaches that were received while a
resident of this facility and within the last 7 days
5. At Discharge
Check all of the nutritional approaches that were being received at
discharge

3.
While a
Resident

5.
At Discharge

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal [PEG])
C. Mechanically altered diet – require change in texture of food or
liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any medications by
pharmacological classification, not how it is used, in the
following classes
2. Indication noted
If column 1 is checked, check if there is an indication
noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Final Rule, Effective Date: October 1, 2020