The Centers for Medicare & Medicaid Services (CMS) released memo QSO-23-05-NH on January 18 announcing 2 new changes for nursing homes coming this month. These changes, aimed at improving quality of care and transparency, target inappropriate coding of schizophrenia to support antipsychotic usage and public reporting of nursing home citations that are actively being disputed by the nursing home. These changes are effective immediately and anticipated to be reflected in the January 25 update to Nursing Home Care Compare.

Inaccurate Coding of Schizophrenia for Antipsychotic Usage

CMS will begin conducting off-site audits of the Minimum Data Set (MDS) to identify potentially inaccurate coding of schizophrenia diagnoses. CMS reports that schizophrenia diagnoses may be inappropriately assigned to nursing home residents in order to justify the use of antipsychotic medications without impacting the nursing home’s quality measures. Nursing homes selected for audit will be notified by CMS and provided information on the process for the audit and how to provide supporting documentation for review. Nursing homes that are found through audit to have coding inaccuracies will see adjustments on Nursing Home Care Compare:

• Quality Measure domain ratings and long-stay ratings will be downgraded to one star for 6 months. This automatically reduces the nursing home’s overall star rating by one star.
• The short stay antipsychotic quality measure rating will be suppressed for 6 months.
• The long-stay antipsychotic quality measure rating will be suppressed for 12 months.

Nursing homes selected for audit will alternatively be given the opportunity, prior to beginning the audit, to admit to errors and commit to correction. Should a nursing home choose to go this route, CMS will impose lesser adjustments to Quality Measure ratings.

CMS will continue to monitor data for all nursing homes in which coding inaccuracies were identified and follow up audits may be conducted to confirm correction of issues.

Posting of Citations Under Dispute

CMS will begin including on Nursing Home Care Compare survey citations that are currently under informal dispute resolution (IDR) and independent informal dispute resolution (IIDR). Currently, these citations are withheld from Nursing Home Care Compare during the IDR/IIDR process and only posted publicly when the IDR/IIDR process has been completed. CMS states that this process usually concludes in 60 days, though some may take longer and while the number of citations that undergo the IDR/IIDR process is relatively small, it includes potentially serious instances of noncompliance that have been cited at immediate jeopardy (IJ) level.

CMS indicates that posting these citations on Nursing Home Care Compare is consistent with a commitment to transparency. Citations under IDR/IIDR will be posted in the health inspection and fire safety and emergency preparedness inspection sections with notation that the specific citation is under IDR/IIDR. These citations will continue not to be calculated in the nursing home’s Five Star rating until the dispute is resolved and the survey is considered complete. At that time, survey findings will also be adjusted accordingly. For example, citations that are overturned through the IDR/IIDR process will be removed from Nursing Home Care Compare. Citations that are downgraded in scope / severity through IDR/IIDR will be adjusted accordingly on Nursing Home Care Compare.

What This Means for Nursing Homes

Theoretically, these changes mean increased transparency for nursing homes, residents, families, and the general public, though opportunities for confusion or unintended negative consequences exist. LeadingAge recommends communicating these changes with residents, families, and staff. Residents and families should be educated on what these changes mean from a public reporting perspective, as well as any process changes.

For example, related to the posting of citations under IDR/IIDR, explain to residents and families the nursing home’s right to dispute citations and how this process occurs. Explain the change in CMS policy for now posting these disputed citations publicly, and how disputed citations will be identified. Ensure residents and families know where in the nursing home to locate findings from the most recent survey and to whom in the nursing home they can direct questions on survey findings. Staff should know where survey findings are located and know to whom in the nursing home questions should be referred.

Related to schizophrenia audits, consider discussing these changes with residents/families who have been assigned schizophrenia diagnoses. Notify them that CMS is conducting off-site audits and may be requesting medical records documentation to support diagnoses. Ensure staff are aware of these changes, particularly physicians and other clinical staff involved in assessment, diagnosis, and documentation of mental and behavioral health. Consider examining assessment, diagnosis, and care planning processes and identifying any opportunities for education. LeadingAge offers members resources on these processes on the Nursing Home RoPs Tools and Resources page under “Assessments and Care Planning”, “Behavioral Health”, and “Pharmacy and Medication.” These tools require a LeadingAge login to access.