April 15, 2019By: Seema Verma, Administrator, Centers for Medicare & Medicaid Services
Ensuring Safety and Quality in America’s Nursing Homes
CMS is charged with developing and enforcing quality and safety standards across the nation’s health care system, a responsibility we consider a sacred trust. While we support and promote the private sector’s critical role in our health care system, CMS’ duty to monitor the safety of the nation’s hospitals, nursing homes, and other providers, is a unique governmental task which lies at the core of government’s role in health care. This duty is especially important when it comes to the care provided for some of the most vulnerable in our society, Americans residing in nursing homes.
Every nursing home resident deserves to retain their basic human dignity and to be treated with respect at all times. Abuse and neglect are never acceptable. CMS’ approach to oversight of nursing homes is constantly evolving. Just as we’re unleashing innovative strategies and technologies in other areas of CMS, we’re continuously looking for ways to improve our approach to nursing home safety and quality. We must never be complacent – we should always push ahead to continuously improve our efforts.
CMS is not waiting, and not settling for the status quo: I have directed my team at CMS to undertake a comprehensive review of our regulations, guidelines, internal structure, and processes related to safety and quality in nursing homes. America deserves nursing homes that ensure residents are treated with dignity and kept safe from abuse and neglect; that are rewarded for value and quality; whose patient outcomes are transparent to consumers; all without unnecessary paperwork that keeps providers from focusing on patients. We have demonstrated our commitment to this path by developing a five-part plan to ensure the care provided in America’s nursing homes is of the highest possible quality. While we pursue these efforts, we welcome interest and input from all stakeholders, Congress, and our other federal partners. But we have already started executing our plan, and we’ve got our eyes on the future.
Strengthen Oversight
CMS works in partnership with State Survey Agencies (SSAs) to oversee nursing homes, since these agencies are generally also responsible for state licensure. The SSAs visit and survey every Medicare and Medicaid participating nursing home in the nation at least annually to ensure they are meeting CMS’ health and safety requirements as well as state licensure requirements. To be effective, SSAs must be fair and consistent in applying CMS rules.
In recent years, we have found wide variation across SSAs. Some states frequently identify serious issues in nursing homes, while others don’t identify concerns with the same seriousness or severity – including application of penalties. Residents deserve consistent nursing home quality, regardless of location, so CMS is revising our oversight of SSA performance. We’re examining the way surveyors identify issues such as abuse, facility staffing levels, and dementia care, and we are clarifying expectations regarding when abuse must be reported to the State and law enforcement. This means setting clear timelines for SSAs to review allegations of abuse and neglect. We will also be updating Nursing Home Compare to make it easier for consumers to identify specific instances of non-compliance related to abuse or inappropriate antipsychotic medication use.
We’re also rethinking the guidance we provide to SSAs. When surveyors determine that a nursing home is providing care poor enough to seriously harm residents or is likely to cause serious harm– a situation called “Immediate Jeopardy”– that finding should be based on consistent application of standards nationwide. Patients must be protected from dangerously poor quality, no matter where they live. We recently revised and streamlined the guidelines for determining Immediate Jeopardy used by surveyors. Going forward, SSAs will be armed with clearer procedures so, as they conduct their review of each nursing home, dangerous issues will be discovered and promptly reported to CMS so residents are kept safe through appropriate enforcement actions intended to bring about rapid and sustainable compliance. Information about these kinds of findings and associated enforcement actions are available on Nursing Home Compare.
Finally, we’re working on new ways to identify abuse and stop it in its tracks. We’re looking at our organizational structure to enhance collaboration across our regional staff, who work on the front lines with providers particularly when serious quality issues like abuse are identified. We’re exploring the possible use of Medicare claims data and associated adverse outcomes or indicators, including the use of artificial intelligence and text mining, to inform our nursing home survey and oversight process, especially for individuals transferred from a nursing home to a hospital. Additionally, to help prevent abuse, we think it is critical to more effectively identify workers with a history of abuse. While reviewing the feasibility of these steps, we are strengthening our oversight to ensure that survey findings reflect the quality of facilities, regardless of their location. We will continuously strive to ensure all entities that survey nursing homes are doing so appropriately and consistently.
Enhance Enforcement
CMS enforces the compliance of basic health and safety standards for nursing homes to ensure patient safety and quality care. Here, too, we’re working to improve. We’re strengthening our enforcement policies to hold nursing homes accountable for the care they provide. As part of this effort, we’re developing new ways to root out bad actors and repeat offenders.
CMS has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care. CMS collects staffing data from nursing facilities through the PBJ system based on payroll and other verifiable and auditable data, as required by law. Since November 2018, CMS has shared this data with SSAs so they know which nursing homes may have potential staffing problems and can target their reviews. SSAs are conducting a portion of their unannounced after-hours and weekend inspections to focus on staffing problems during those times. SSAs will take appropriate enforcement actions against those facilities that fail to provide the required nurse staffing.
We’re also improving quality of life for nursing home residents. Too often, residents with dementia-related psychosis have been deemed to be unruly or difficult, and have been given antipsychotic sedative drugs in contravention of FDA guidelines. CMS has worked through our National Partnership to Improve Dementia Care in Nursing Homes to curb the inappropriate use of these drugs in nursing homes. On March 1st, we announced enhanced oversight and enforcement of nursing homes that have not improved their antipsychotic medication utilization rates for long-stay nursing home residents since 2011, or “late adopters.” We’ve begun imposing stricter sanctions like denying payment for new admissions and per-day Civil Money Penalties on late adopters that have a history of noncompliance with our rules related to chemical restraints, dementia care, and psychotropic drugs, and have been determined in a current survey to be out of substantial compliance with those requirements. CMS and SSAs will be closely monitoring these facilities to ensure that they achieve and continue to maintain substantial compliance in these areas.
We’re also committed to working with Congress to strengthen nursing home enforcement. In President Trump’s Fiscal Year 2020 budget, we’ve asked Congress to provide us the authority to adjust the frequency of mandatory nursing home surveys so we can focus more of our time and resources on nursing homes that are poor performers while continuing efforts to respond to complaints. The FY 2020 Budget also requests $442 million for Survey and Certification, a $45 million increase from the previous year. The increased funding would enable CMS to continue to meet the statutory survey requirements while dealing with the increase in volume and severity of complaints, and rising survey costs.
Increase Transparency
CMS is empowering consumers, their families, and their caregivers by giving them the resources they need to make informed decisions, and key to our effort is our Nursing Home Compare website. Nursing Home Compare offers a wide variety of data related to nursing home quality. We’re constantly working to make sure the information on Nursing Home Compare is as accurate and informative as possible. In April 2018, for example, we incorporated data on nursing home staffing based from a new payroll-based journal (PBJ) system into Nursing Home Compare and the Nursing Home Five-Star Quality Rating System. The new PBJ data allows CMS to more accurately track staffing levels in nursing homes. Adding this data to Nursing Home Compare provided an entirely new and key source of quality information to nursing home residents, their families, and caregivers. We are continuing to explore other ways to improve Nursing Home Compare, including highlighting specific quality issues like abuse or the inappropriate use of antipsychotic medication.
In addition to the transparency resources found on Nursing Home Compare, we’ve developed further ways to publish more important quality information. We’ve increased public awareness of nursing homes failing to meet our minimum health and safety standards. Now, instead of publishing notices in local newspapers, we’re publicizing instances in which CMS terminates our agreements with nursing homes due to poor quality on our website. Additionally, the public should know how we inspect nursing homes, so we’ve made our Long Term Care surveyor training available online.
Finally, when a survey finds a nursing home deficient in any way, the public has a right to know. Surveys of nursing homes generate official health and safety deficiency reports, which convey important quality of care findings. Because these reports can be difficult for the public to understand, we’re working on ways to make them more accessible. We want them to be clear so the public has full knowledge of the scope and severity of any problems identified during our nursing home inspections.
We’re doing everything we can to give the public more and better information so they can make the choice that’s best for them. We’re committed to transparency, and we will never stop working to give patients and residents the clearest and most accurate information possible.
Improve Quality
While CMS is holding nursing homes accountable through oversight and enforcement measures, we’re also actively keeping patients safe by helping nursing homes improve. We’re doing that by developing quality measures that score providers based on patient outcomes, not adherence to processes. We’re also investing in programs that focus on key areas of nursing home care to help achieve higher quality.
CMS fines nursing homes that don’t comply with our requirements, and we recently launched an initiative to invest these Civil Money Penalty (CMP) dollars in efforts to reduce adverse events, improve staffing quality and improve quality of care for residents with dementia. We’ve also begun to incorporate value into how we pay for skilled nursing care. In our Skilled Nursing Facility (SNF) Value-Based Purchasing Program, a portion of a SNF’s payments is based on performance. We’re also focusing a significant portion of our clinical quality improvement work on nursing homes. We developed precise, quantifiable goals to measure our success in decreasing infections and adverse drug events, both of which are significant sources of patient harm in nursing homes. We are focusing on measures that focus on improving patient outcomes while minimizing burden and through CMS’ Meaningful Measures Initiative prioritizing those measures through all areas of our work to improve quality. We’re also investing in programs that take best practices from high-performers and share them with lower quality facilities.
We’ve already reaped rewards from our quality improvement work. Between 2011 and the third quarter of 2018, for example, our work with the National Partnership to Improve Dementia Care in Nursing Homes helped decrease the national prevalence of antipsychotic medication use among long-stay nursing home residents by 38.9 percent to a national prevalence of 14.6 percent. This simple step has helped improve quality of life for nursing home residents nationwide.
We’re not done. We’re unleashing our expertise in quality measurement to address serious quality issues like healthcare-associated infections, and we’re looking at how we can better spend CMP dollars on the most critical quality issues.
Put Patients Over Paperwork
Ensuring access to quality nursing home care is our priority, and it’s a delicate balance. As we have seen time and again, more regulation is not necessarily better regulation, nor does it always translate into better care or outcomes. When administrative burden increases with little or no benefit, patients suffer because mountains of unnecessary paperwork keep providers from patients. Additionally, high administrative costs can make it difficult for facilities to operate. In rural America, a shuttered nursing home can present serious access to care problems. We are developing our regulatory strategy in a way that puts patient quality and safety first while removing unnecessary burdens on providers that create staffing challenges and increase cost without increasing quality. We want to make sure providers spend time caring for residents instead of completing unnecessary paperwork.
Every time we implement a new rule or requirement, we think about minimizing burden while keeping patients safe. In 2016, CMS issued a final rule that revised the federal health and safety requirements for nursing homes for the first time in over 25 years. These changes reflect substantial advances that have been made over the past several years in resident care and quality assessment practices. As we continue to implement this rule, we are keenly focused on minimizing administrative burden for providers.
Additionally, we helped nursing homes meet an important new requirement related to infection control. We worked with CDC to develop online training about infection prevention and control, and offered it to nursing homes at no cost. Going forward, we will continue to think about how we can streamline processes and eliminate obsolete, unnecessary, or duplicative provisions and we are interested in hearing from all stakeholders on ways to improve our programs.
Finally, if you have knowledge of abuse or neglect in a nursing home, please alert a supervisor, social worker, administrator, or doctor. You can also follow the facility’s required grievance procedures. If you need outside help, you can use our website to find the contact information for your state’s SSA and Long-Term Care Ombudsman.
We at CMS are personally committed to making sure Americans have access to the highest-quality nursing home care. This work should never stop. This is not business as usual – we are pushing beyond the status quo. We are focused on ensuring America’s nursing homes are keeping residents safe by rewarding quality and value, making outcomes transparent, and reducing unnecessary paperwork that detracts from patient care, and we will not hesitate to use every tool at our disposal to complete our mission.
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