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Type:
Hosp Inpt eCQMs - Hospital Inpatient eCQMs
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Resolution: Unresolved
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Priority:
Moderate
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Component/s: None
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None
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Michele Deppisch
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330-697-1365
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National Pressure Injury Advisory Panel
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CMS0826v3
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Possible Stage 2 reporting confusion and seven patient conditions as unavoidable exclusions
The CMS text states that The Joint Commission is in alignment with the CMS criteria for the HH-PI reporting. However, the newly released SRE List from TJC states that TJC is counting Stage 3, Stage 4, Unstageable, and Deep Tissue Pressure Injury. The Joint Commission does not count Stage 2. Additionally, TJC recognizes the following as an exclusion:
Refusal of preventative measures in instances such as end-of-life care
• Skin changes identified during end-of-life care (i.e., Kennedy terminal ulcer, Trembly-Bromley ulcer)
• Circumstances occurring prior to admission that are known causative factors for pressure injuries or deep
tissue pressure injuries (e.g., immobility after a fall, prolonged interfacility transport) and are documented in the
medical record
• Pressure injuries associated with clinical circumstances where preventive measures are limited or restricted,
which may include patients with the following:
» Hemodynamic instability with turning despite implementation of small, increasing incremental turns (e.g.,
patients requiring high doses of vasopressors, patients on extracorporeal membrane oxygenation treatment for
whom cannula dislodgement is a high risk)
» An unstable or unrepaired fracture (e.g., spinal, pelvic)
» An open chest
See pages 111-114 of attachment