Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
January 18, 2023 … As part of the continuing efforts under President Biden’s initiative to improve nursing home transparency, safety and quality, and accountability, today the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new actions to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families.
“President Biden issued a call to action to improve the quality of America’s nursing homes, and HHS is taking action so that seniors, people with disabilities, and others living in nursing homes receive the highest quality care,” said HHS Secretary Xavier Becerra. “No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic. The steps we are taking today will help prevent these errors and give families peace of mind.”
CMS to Reinforce Safeguards against Unnecessary Medications and Treatments
Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medications. Antipsychotic medications are especially dangerous among the nursing home population due to their potential devastating side effects, including death. This action advances the Biden-Harris Administration’s goal of reinforcing safeguards against unnecessary medications and treatments that was outlined in President Biden’s State of the Union Action Plan for Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes.
“We have made significant progress in decreasing the inappropriate use of antipsychotic medications in nursing homes, but more needs to be done,” said CMS Administrator Chiquita Brooks-LaSure. “People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications.”
This action furthers the Administration’s objective to improve the accuracy of the quality information that is publicly reported and the nursing home Five-Star Rating System. The use of antipsychotic medications among nursing home residents is an indicator of nursing home quality and used in a nursing home’s Five-Star rating, however it excludes residents with schizophrenia. If an audit identifies that a facility has a pattern of inaccurately coding residents as having schizophrenia, the facility’s Five-Star Quality Measure Rating on the Care Compare site will be negatively impacted. For audits that reveal inaccurate coding, CMS will downgrade the facility’s Quality Measure ratings to one star, which would drop their Overall Star Rating as well. CMS will monitor each facility’s data to determine whether they have addressed the identified issues. After that, CMS will decide whether any downgrades should be reversed.
CMS to Post Citations Under Dispute on Care Compare
Separately, CMS plans to take a new step to increase the transparency of nursing home information by publicly displaying survey citations that facilities are disputing. Currently, when a facility disputes a survey deficiency, that deficiency is not posted to Care Compare until the dispute process is complete. This process usually takes approximately 60 days; however, some cases can take longer.
While the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance such as Immediate Jeopardy (IJ) citations. This level of citation occurs when the health and safety of residents could be at risk for serious injury, serious harm, serious impairment or death. Displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating a facility. This new information will begin appearing on Care Compare on January 25, 2023. While the citations will be publicly displayed, they will not be included in the Five-Star Quality Rating calculation until the dispute is complete.
Today’s actions by CMS are the latest among several actions the agency has taken over the years to strengthen public reporting and the Five-Star Quality Rating System. These actions include:
- Adding the results of focused infection control surveys to the Care Compare website and Five-Star Quality Rating System,
- Increasing the Quality Measure rating thresholds to incentivize improved quality, and
- Adding measures of staff turnover to inform consumers of the stability of a nursing home’s staff (which is linked to the quality of care a nursing home provides).
The QSO memo (QSO-23-05-NH) — Updates to the Nursing Home Care Compare website and Five-Star Quality Rating System: Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute — is available here.
Here are some key excerpts from QSO-23-05-NH:
- To increase our focus on this issue, CMS will begin conducting offsite audits to assess the accuracy of Minimum Data Set (MDS) data. Specifically, we will examine the facility’s evidence for appropriately documenting, assessing, and coding a diagnosis of schizophrenia in the MDS for residents in a facility.
- This action supports CMS’s goal to reduce the use of unnecessary antipsychotics and improve the accuracy of the quality measure and the five-star rating system. It is also consistent with the White House’s Fact Sheet – February 22, 2022 listing efforts to improve safety and quality of care in the nation’s nursing homes. Specifically, the Fact Sheet states that, “CMS will launch a new effort to identify problematic diagnoses and refocus efforts to continue to bring down the inappropriate use of antipsychotic medications.”
- Facilities selected for an audit will receive a letter explaining the purpose of the audit, the process that will be utilized, and instructions for providing supporting documentation. During the audit process, facilities will have the opportunity to ask questions and seek any clarification needed. Additionally, at the conclusion of the audit, the facility will have the opportunity to discuss the audit results with CMS.
- Facilities that have coding inaccuracies identified through the schizophrenia MDS audit will have their QM ratings adjusted as follows:
- The Overall QM and long stay QM ratings will be downgraded to one star for six months (this drops the facility’s overall star rating by one star).
- The short stay QM rating will be suppressed for six months.
- The long stay antipsychotic QM will be suppressed for 12 months.
- Also, we plan to offer facilities the opportunity to forego the audit by admitting they have errors and committing to correct the issue. This will reduce the burden of conducting audits for CMS and nursing homes and allow CMS to audit more facilities. To incentivize this admission and to promote improvement, for facilities that admit miscoding after being notified by CMS that the facility will be audited, but prior to the start of the audit, CMS will consider a lesser action related to their star ratings than those listed above, such as suppression of the QM ratings (rather than downgrade).
- For all facilities where patterns of coding inaccuracies were identified, either through an audit or through a facility’s admission, CMS will monitor each audited facility’s data to identify if the information indicates they have addressed the identified issues, and if any downgrades or suppressions that are applied should be lifted at the timeframes indicated above. Also, a follow-up audit may be conducted to confirm the issue is corrected.
- CMS will post deficiency citations under IDR/IIDR in each section of Nursing Home Care Compare that currently displays citations and will indicate if a citation is under dispute. If, based on the results of the IDR/IIDR process, the citations are upheld, they will remain posted and will be included in the calculation of the facility’s star rating if applicable. If the citations are overturned (i.e., removed), they will be removed from the website. If the level of scope or severity of a citation is reduced, the citation will be displayed at the reduced level. We note that on average, the majority of citations (approximately 75%) do not change after completion of the IDR/IIDR process. [From the Press Release: This new information will begin appearing on Care Compare on January 25, 2023.]
- While the citations will be publicly displayed, we will not include them in the calculation of a facility’s star rating until the dispute is complete (and the survey is considered final). In order to be consistent in how citations are reported across different platforms, CMS will also include citations under IDR/IIDR on the QCOR website.
- CMS will update the Five Star Rating Technical Users’ Guide and Chapter 7 of the State Operations Manual to reflect these changes. (These documents have not been updated as of this blog posting.)