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The OIG analysis showed that in that five-year period, 94% of the deficiencies cited on nursing home surveys were in the "less serious" categories, which the OIG defined as F or below on the scope and severity grid. Six percent of deficiencies cited were in the G category or above.

However, the OIG also noted that 31% of nursing homes had at least one repeat deficiency during the review period. Half of these nursing homes had repeat deficiencies that were categorized as "more serious", including deficiencies causing actual harm and immediate jeopardy. 

This Letter responds to recent media reports highlighting occurrences of nursing home staff taking unauthorized photographs or video recordings of residents, sometimes in compromised positions, and posting the photographs on social media networks, or sending them through multimedia messages. 

  • The Letter clarifies that “…taking photographs or recordings of a resident and/or his/her private space without the resident’s, or designated representative’s, written consent, is a violation of the resident’s right to privacy and confidentiality…”  Examples include staff taking unauthorized photographs of a resident’s room or furnishings; a resident eating in the dining room or participating in an activity in the common area.
    • For purposes of this memorandum, nursing home staff includes employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility.
  • Taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (e.g., cameras, smart phones, and other electronic devices) and/or keeping or distributing them through multimedia messages or on social media networks is a violation of a resident’s right to privacy and confidentiality §483.10(e) Privacy and Confidentiality (F164).
  • Surveyors are instructed to investigate at F223 and F226-Abuse if a photograph or recording, or the manner that it is used, is determined to demean or humiliate a resident(s), regardless of whether the resident provided consent and regardless of the resident’s cognitive status.
    • §483.13(b) Abuse: “The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.” The Guidance to Surveyors in Appendix PP at tag F223 in the State Operations Manual (SOM) states, “Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.”
  • Examples include “…photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, toileting, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part without the resident’s face whether it is the chest, limbs, or back, labeling resident’s pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position.”
  • Surveyors are to apply the ‘reasonable person’ approach [see below] in those situations where a resident “…is unable to express him/herself due to a medical condition and/or cognitive impairment….”  
    • Examples:
      • “Severity Level 4 (IJ):  The facility failed to protect two residents from mental and sexual abuse perpetuated by two staff members, who posted unauthorized videos and photographs on social media of the residents during bathing, toileting and grooming, including nude photos and photos of genitalia. Both residents were cognitively impaired and unable to express themselves. As a result, the two residents suffered public humiliation and dehumanization.
      • Severity Level 3 (harm):  The facility failed to protect a resident from mental abuse as a result of taking and sending an unauthorized video of a resident. A staff member had messaged to three of his/her co-workers a video of a cognitively impaired resident eating lunch in the facility’s dining room. In the video, the resident was feeding him/herself, using his/her fingers to eat the items on the plate, including mashed potatoes and pudding. The resident was pictured to have food items all over his/her face, clothing, and tray area. During an interview with the resident, the resident was incapable of perception and unable to express him/herself. During an interview with one of the staff members who had received the message, he/she initially thought that the video was funny. As a result, this unauthorized video had the effect of humiliation and embarrassment and did not promote an environment where the residents’ self-worth is being upheld.”   
  • Nursing homes are expected to review and/or revise their written abuse prevention policies and procedures to include and ensure that staff are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), to d include use of any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and recordings on social media.
  • Nursing homes are expected to include in abuse prevention training programs their policies and procedures prohibiting the use of equipment to take, keep, or distribute photographs or recordings that are demeaning or humiliating.
    • CMS notes:  “The provision of in-service education on abuse prohibition alone does not relieve the nursing home of its responsibility to assure the implementation of these policies and procedures. The nursing home must provide ongoing oversight and supervision of staff in order to assure that these policies are implemented as written.”
  • Nursing home management must assure that all staff are aware of reporting responsibilities, including how to identify possible abuse and how to report any allegations of abuse.
    • §483.13(c)(2) - Response to Alleged Violations (tag F225)- The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported within prescribed timeframes and thoroughly investigated…
    • “Section 1150B of the Social Security Act (the Act) requires certain individuals in federally funded long-term care facilities to report timely any reasonable suspicion of a crime committed against a resident of that facility….” 
  • Surveyors are expected to initiate the following actions 30 days from the release of this memorandum: 
    • “During the next standard survey, [traditional or Quality Indicator Survey (QIS)], the survey team must request and review nursing home policies and procedures related to prohibiting nursing home staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident(s).  
    • If the SA receives an allegation in the following circumstances, the SA must investigate onsite to determine whether the nursing home is in compliance with Federal requirements:
      • Unauthorized photographs or recordings of a resident(s) have been taken, kept, and/or distributed on social media or transmitted through multimedia messaging by staff; or
      • A photograph or video itself, or the manner that it is used, humiliates or demeans the resident(s), including, but not limited to, distributing on social media.
    • Depending on the seriousness of the allegation, the SA must conduct an onsite investigation within 2 to 10 days. In addition, the SA must evaluate whether the allegation may require referral to law enforcement. 
  • Surveyors are also instructed/reminded to consider the outcome, or likelihood of an outcome, as a result of the noncompliance in the context of the presence of or potential for psychosocial harm.
    • Examples include extreme embarrassment, ongoing humiliation, degradation as a human being, and fear or panic at the thought of the public or unknown persons accessing these types of photographs or recordings.
  • If the surveyor is unable to conduct interviews with the resident’s family, the surveyor must utilize the reasonable person approach, “…which considers how a reasonable person in the resident’s position would be impacted by postings of photographs and recordings, regardless of whether the resident consented, such as: non-offensive authorized photographs or recordings used in a demeaning or humiliating manner; or demeaning or humiliating photographs or videos of nudity, exposed bodily parts… or of posting examples of bodily functions such as toileting, provision of incontinence care exposing perineal areas, and/or fecal material on body parts or beddings/furnishings.” 

This Final Rule outlines fiscal year (FY) 2017 Medicare payment policies and rates for the Skilled Nursing Facility Prospective Payment System (SNF PPS), the SNF Quality Reporting Program (SNF QRP), and the SNF Value-Based Purchasing (SNF VBP) Program. 

Payment Rates Update for FY 2017

  • CMS projects that aggregate payments to SNFs will increase in FY 2017 by $920 million, or 2.4 %t, from payments in FY 2016. This estimated increase is attributable to a 2.7 % market basket increase reduced by 0.3 percentage points, in accordance with the multifactor productivity adjustment required by law. 

SNFVBP

  • The SNF VBP Program applies to freestanding SNFs, SNFs affiliated with acute care facilities, and all non-CAH swing-bed rural hospitals.
  • The final rule implements requirements for the SNFVBP including performance standards; scoring methodology, and a review and correction process for performance information to be made public.
  • The VBP measures will apply to payments for services furnished on or after 10/1/18; data collection will begin 10/1/16. 

All-Condition Risk-Adjusted Potentially Preventable Hospital Readmission Measure (SNFPPR)

  • The already final ‘SNF 30-Day All-Cause Readmission Measure (SNFRM) will be replaced “as soon as Practicable” by the All-Condition Risk-Adjusted Potentially Preventable Hospital Readmission Measure (SNFPPR) specified in this final rule. 
  • The SNF-PPR assesses the facility-level risk-standardized rate of unplanned, potentially preventable hospital readmissions for SNF patients within 30 days of discharge from a prior admission to a hospital paid under the Inpatient Prospective Payment System (IPPS); a critical access hospital; or a psychiatric hospital. 
  • The SNFPPR is claims-based, requiring no additional data collection or submission from SNFs.
  • The SNFPPR has 2 categories: (1) Within Stay; (2) Post SNF discharge to the end of the 30-day post hospital discharge. 
    • The within-stay list of PPR conditions includes 4 clinical rationale groupings: (1) Inadequate management of chronic conditions; (2) Inadequate management of infections; (3) Inadequate management of other unplanned events; (4) Inadequate injury prevention.
    • The post-SNF discharge clinical rationale has 3 groupings:  (1) Inadequate management of chronic conditions; (2) Inadequate management of infections; (3) Inadequate management of other unplanned events. 
  • The SNF-PPR is risk-adjusted for sociodemographic status (SES)/characteristics (diagnoses; hospital LOS; co-morbidities; # of prior hospitalizations over the past year.
  • Benchmarking includes an achievement threshold at the 25th percentile of national SNF performance. 
  • Scoring is on a 0 -100 point scale for achievement; a 0-90 point scale for improvement.
  • This measure is calculated using one full calendar year (CY) of data. 

Performance Standards; Baseline; Incentive Payments; Feedback Reports

  • Publication of Performance Standard Values:  CMS will announce performance standards by 11/1/16 for CY 2017 for FY 2019.
  • Proposed Baseline Period:  CMS is adopting CY year 2015 claims (1/1/15 – 12/31/15) as the baseline period for FY 2019.
  • SNF Performance Scores:  These scores will be used as the basis for ranking SNF performance and establishing the value-based incentive payment percentage.
  • SNF Value-Based Incentive Payments:  The payment percentage must be based on the SNF performance score and be appropriately distributed so highest-ranked SNFs receive the highest payments; lowest-ranked receive the lowest payments; and the payment rate for services furnished by SNFs in the lowest 40% is less than would otherwise apply.
    • The total amount of value-based incentive payments must be greater than or equal to 50%, but not greater than 70% of the total amount of the reductions to payments for the FY. 
  • 1/4ly Confidential Provider Feedback Reports:  Will be accessible via the QIES system CASPER Files.
  • Corrections on any 1/4ly report will be accepted with an annual deadline
    • 2 phases: 
      • Phase 1 allows SNFS to review /correct patient-level information used to calculate the measure rates;
      • Phase 2 – allows SNFs to review /correct performance scores and ranking.
      • CMS will order SNF performance scores from low to high and publish rankings on the Nursing Home Compare and QualityNet Web sites.
      • CMS will publish rankings for FY 2019 payment implications after 8/1/18.  

SNF Quality Reporting Program (QRP)

CMS finalized 1 new assessment-based quality measure and 3 resource use claims-based measures:  

  • Assessment:  1 QM to meet the Medication Reconciliation domain: 

Drug Regimen Review Conducted With Follow-Up for Identified Issues-Post Acute Care (PAC) SNF QRP (FY2020) 

  • Assesses whether providers were responsive to potential or actual significant medication issues by measuring the % of resident stays where medication is reviewed on admission and timely follow-up with a physician occurred each time clinically significant issues were identified.
  • Drug regimen review is defined as “…the review of all medications or drugs the resident is taking to identify any potential clinically significant medication issues.”
  • This measure uses both the processes of medication reconciliation and drug regimen review in the event an actual or potential medication issue occurred.
  • The calculation is based on the data collection of 3 standardized items to be included in the MDS; the 3 standardized items do not duplicate existing MDS items. 
  • The collection of data is obtained at admission and discharge.
  • The denominator is the number of resident stays with a discharge or expired assessment during the reporting period.
  • The numerator is the number of stays in the denominator where the medical record contains documentation of a drug regimen review conducted at: (1) admission; (2) discharge with a look-back through the resident stay, with all potential clinically significant medication issues identified during care and followed-up with a physician or designee by midnight of the next calendar day.
  • This measure is not risk adjusted.
  • Confidential feedback reports will be available to SNFs in 10/19.
  • Timelines: 
    • SNFs must complete the 3 added data items for submission through QIES beginning 10/1/18, affecting FY 2020 payment determinations.  
      • SNFs must submit data for residents admitted on and after 10/1/18, and discharged from Part A stays up to and including 12/31/18.  
    • CMS will collect a single ¼ of data FY 2020 to remain consistent with the [usual] October MDS release schedule. 
    • Following the close of the reporting quarter, 10/1/18 – 12/31/18, SNFs will have 4.5 months to submit/correct submit the quality data.    
  • Quality Measures Previously Finalized for Use in the SNF QRP: 
    • % of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay)
    • % of Residents Experiencing One or More Falls with Major Injury (Long Stay)
  • Beginning with the FY 2018 payment determination, SNFs must report all data necessary to calculate the QMs on at least 80% of the MDS assessments they submit.
  • Any SNF that does not meet the requirement that 80% of all MDS assessments submitted contain 100% of all data items necessary to calculate the QMs is subject to a 2 percentage point reduction to its FY 2018 market basket percentage.
    • “A SNF has reported all data necessary to calculate the QMs if the data actually can be used for purposes of calculating the QMs”.
  • Data collection period: 10/1/16 – 12/31/16. SNFs have 4.5 months from the end of the quarter (5/15/17) to complete submission/make corrections.
  • For FY 2019 payment determinations 2nd through 4th quarter 2017 will be collected.
  • Beginning with FY 2020 a full year of data will be collected.
  • Each 1/4ly deadline will continue to occur 4.5 months from the end of a given calendar ¼.  
  • Resource Use Measures:  CMS adopted 3 measures to meet the IMPACT Act mandated resource use and other measure domains:
    • Medicare Spending per Beneficiary—Post-Acute Care SNF QRP (FY 2018);
    • Discharge to Community—Post Acute Care SNF QRP (2018);
    • Potentially Preventable 30-Day Post-Discharge Readmission Measure - SNF QRP (2018).  

Medicare Spending Per Beneficiary (MSPB) (FY 2018)

  • Holds SNF providers accountable for the Medicare payments within an “episode of care” – “…the period during which a patient is directly under the SNF's care and a defined period after the end of the SNF care, “reflective of and influenced by services furnished by the SNF.”
  • Assesses Medicare Parts A and B spending within an episode.
  • Episodes may begin within 30 days of discharge from an inpatient hospital as part of the trajectory from an acute to a PAC setting. 
  • An episode begins at the ‘episode trigger’ - admission to a SNF.
  • The episode window includes a treatment period and an associated services period.
    • The treatment period - those services provided directly or reasonably managed by the SNF directly related to the beneficiary's care plan - begins at SNF admission and ends at discharge.  Readmissions to the same facility within 7 days do not trigger a new episode.  
    • The associated services period begins at the episode trigger and ends 30 days from the end of the treatment period.
    • Exclusion Criteria: Certain episodes will be excluded:
  • Any episode triggered by a SNF claim outside the 50 states, DC, Puerto Rico, and U.S. Territories.
  • Any episode where the claim(s) constituting the SNF provider's treatment have a standard allowed amount of zero or where the standard allowed amount cannot be calculated.
  • Any episode where a beneficiary is not enrolled in Medicare FFS for the entirety of a 90-day lookback period (prior to the episode trigger) plus episode window (including where the beneficiary dies), or is enrolled in Part C for any part of the lookback period plus episode window.
  • Any episode where a beneficiary has a primary payer other than Medicare.
  • Any episode where the claim(s) constituting the SNF provider's treatment include at least one related condition code indicating it is not a PPS bill.
  • Standardization and Risk Adjustment:  MSPB must be adjusted for factors including age, sex, race, severity of illness, and other factors the Secretary determines appropriate.
  • Reporting:  CMS will provide initial confidential feedback to providers, prior to public reporting. A minimum of 20 episodes is required for reporting.

 

Discharge to Community-Post Acute Care (PAC) SNF QRP (FY 2018)

  • Assesses successful discharge to the community including no unplanned rehospitalizations and no death within 31 days following discharge.
  • Uses “Patient Discharge Status Codes” on FFS claims.
  • Community is defined as home/self-care, including home and community-based settings such as group homes, foster care, independent living and other residential arrangements, with or without home health services, based on patient discharge codes on the Medicare FFS claim.
  • Excludes residents discharged to home or facility-based hospice care /with a hospice benefit in the 31 days post-discharge.
  • Will be calculated using 1 year of data; must include a minimum of 25 eligible stays in a given SNF for public reporting. 
  • Risk-adjusted for variables such as age and sex, principal diagnosis, comorbidities, ventilator status, ESRD status, and dialysis. 
  • To be reported as a ratio – with the denominator being the risk-adjusted estimate of the number of residents discharged to the community without an unplanned readmission.
  • CMS will provide confidential feedback to SNFs prior to public reporting. 
  • CMS will report this measure using claims data from discharges in CY 2016. 

Potentially Preventable 30-Day Post-Discharge Readmission Measure for SNF QRP (2018)

  • The QM assesses the facility-level risk-standardized rate of unplanned, potentially preventable hospital readmissions for Medicare FFS beneficiaries in the 30 days post-SNF discharge. The SNF admission must have occurred within 30 days of discharge from a prior proximal hospital stay. 
  • Assesses potentially preventable readmission rates, accounting for demographics; principal diagnosis in the prior hospital stay; comorbidities; and other factors.
  • It is calculated for each SNF based on the ratio of the predicted number of risk-adjusted, unplanned, potentially preventable hospital readmissions that occur within 30 days after SNF discharge, including estimated facility effect, to the estimated predicted number of risk-adjusted, unplanned inpatient hospital readmissions for the same residents at the average SNF.
  • A ratio above 1.0 indicates a higher than expected readmission rate; below 1.0 indicates a lower than expected rate. 
  • An eligible SNF stay is followed until: (1) The 30-day post-discharge period ends; or (2) the patient is readmitted to an acute care hospital. Planned readmissions are not counted in the measure rate.
  • Risk adjustment estimates the effects of patient characteristics, comorbidities, and select health care variables on the probability of readmission; demographic characteristics (age, sex, original reason for Medicare entitlement), principal diagnosis during the prior proximal hospital stay, body-system-specific surgical indicators, comorbidities, LOS during the patient's prior hospital stay, intensive care unit utilization, end-stage renal disease status, and number of acute care hospitalizations in the preceding 365 days.
  • The measure calculation uses 1 calendar year of FFS claims data; a minimum of 25 eligible stays is required for public reporting.
  • CMS will provide confidential feedback to SNFs prior to public reporting.  
  • Proposed Timeline/Data Submission Mechanisms for Claims-Based Measures for the FY 2018 Payment Determination and Subsequent Years

CMS will use 1 year of claims data beginning with CY 2016 for feedback reports for SNFs; CY 2017 claims data for public reporting.

This letter includes advanced guidance regarding revisions in State Operations Manual (SOM) Chapter 7-[Enforcement], Sections §7304 - 7304.3;  7306.1; 7308.3; 7400.5.1; 7400.6.2; 7313.2, pertaining to the Immediate Imposition of Federal Remedies (previously referred to as Opportunity to Correct or No Opportunity to Correct).



CMS advises: “CMS and the State Survey Agencies (SAs) have no statutory or regulatory obligation to provide noncompliant facilities an opportunity to correct their deficiencies prior to immediately imposing federal enforcement remedies (e.g., CMP, directed plan of correction, temporary management, etc.).”



CMS Regional Offices (ROs) will now be required to immediately impose a Civil Money Penalty (CMP) any time Immediate Jeopardy (IJ) is cited.



“Irrespective of a state recommendation to impose or not impose a remedy, the CMS RO must immediately impose, without permitting a facility an opportunity to correct deficiencies, one or more federal remedies based on the seriousness of the deficiencies or when actual harm or Substandard Quality of Care (SQC) is cited.” 

 

The following revised policies are effective for all surveys completed on or after September 1, 2016.  

 

  • Chapter 7 is revised to define new mandatory criteria for immediate imposition of federal remedies prior to affording a facility an opportunity to correct deficiencies.
    •  “The State Survey and/or Medicaid Agencies shall not permit changes to this policy and shall not offer a facility an opportunity to correct cited deficiencies before federal remedies are imposed if the situation meets the criteria in §7304.1.”:
      • Immediate Jeopardy (IJ) (scope and severity levels J, K, and L) is identified on the current survey; OR
      • Deficiencies of substandard quality of care (SQC) that are not IJ are identified on the current survey; OR
      • Any G level [actual harm] deficiency is identified on the current survey at §483.13, Resident Behavior and Facility Practices,; §483.15, Quality of Life; or §483.25, Quality of Care; OR
      • Deficiencies at G or above are determined on the current survey [with] deficiencies at G or above on the previous standard health or LSC survey OR deficiencies at G or above on any type of survey between the current survey and the last standard survey. These surveys must be separated by a period of compliance (i.e., from different noncompliance cycles).; OR
      • A facility is classified as a Special Focus Facility (SFF) AND has a deficiency citation at level “F” or higher on its current survey.
  • Section 7400.5.1 - Factors That Must Be Considered When Selecting Remedies, and the Assessment Factors Used to Determine the Seriousness of Deficiencies Matrix has been revised:

(a) Initial assessment. In order to select the appropriate remedy, if any, to apply to a facility with deficiencies, CMS and the State determine the seriousness of the deficiencies.

(b) Determining seriousness of deficiencies. CMS considers and the State must consider at least the following factors:

(1) Whether a facility's deficiencies constitute—

(i) No actual harm with a potential for minimal harm;

(ii) No actual harm with a potential for more than minimal harm, but not immediate jeopardy;

(iii) Actual harm that is not immediate jeopardy; or

(iv) Immediate jeopardy to resident health or safety.

(2) Whether the deficiencies—

(i) Are isolated;

(ii) Constitute a pattern; or

(iii) Are widespread.

(c) Other factors which may be considered in choosing a remedy within a remedy category. Following the initial assessment, CMS and the State may consider other factors, which may include, but are not limited to the following:

(1) The relationship of the one deficiency to other deficiencies resulting in noncompliance.

(2) The facility's prior history of noncompliance in general and specifically with reference to the cited deficiencies.

 

  • S/S citations at levels A, B and C now all indicate no remedies are required;
  • Termination and Temporary Management have been added as possible remedies under Category 2.

 

  • Effective Dates are Clarified:
    • Once a remedy is imposed, it is in effect as of the date in the notice letter (i.e., as soon as the minimum notice requirements are met). All remedies remain in effect and continue until the facility is in substantial compliance.  “… Substantial  compliance must be verified in accordance with §7317 of this Chapter….”
  • For Immediate Jeopardy Situations, removal of the IJ may, at CMS’s discretion, result in rescission of the 23­day termination imposed, but once minimum notice requirements are met, CMS shall not rescind any remedies imposed. 
    • Remedies will be immediately imposed and effectuated whether or not the immediate jeopardy was:
      • past noncompliance, or,
      • removed during the survey, or,
      • removed in a subsequent IJ-removal revisit before the 23rd day.

       

     

The advance copy of the Transmittal is attached. Revisions are red-lined/yellow-highlighted.



CMS notes it “…is in the process of updating the SOM to reflect this revised guidance. The final version of this document, when published in the on-line SOM may differ slightly from this interim advanced copy which is attached.”

This
memo announces CMS release of a second
report providing an overview of the National Partnership; summarizing
activities following the release of Survey & Certification policy
memorandum 14-19-NH [Interim Report on the CMS National Partnership to
Improve Dementia Care in Nursing Homes: Q4 2011 – Q1 2014 (11/14)];
and outlining next steps. 

The report also describes the results of the
Focused Dementia Care Surveys conducted in FY2015. The
report covers CY2014 Quarter 2 through CY2015 Quarter 3.   

Activities
Summary  

  • CMS
    continues to support State Coalitions efforts, e.g., facilitating bi-annual
    calls to share best practices and create peer-to-peer mentoring opportunities. 
  • CMS
    continues to partner with the Medicare Learning Network (MLN) Connects® to
    conduct quarterly national provider calls.  
  • In
    2014, a Federal grant utilizing CMP funds was awarded to The Eden Alternative,
    Inc. for their project entitled, “Creating a Culture of Person-Directed
    Dementia Care.” 
  • In
    2015, Advancing Excellence and CMS collaborated on an extensive renovation of
    the National Partnership resource repository housed on the Advancing Excellence
    website.   
  • In
    2012, ‘Hand-in-Hand’ was distributed for free to all certified nursing homes in
    the country.  
  • Between
    the end of 2011 and the end of 2013, the National Partnership achieved a
    reduction in national prevalence of antipsychotic medication use in long-stay
    nursing home residents by 15.1%, a decrease of 23.8% to 20.2% nationwide. 
  • CMS
    established a new national goal of reducing the use of antipsychotic
    medications in long-stay nursing home residents by 25% by the end of 2015, and
    30% by the end of 2016. 
  • Since
    the National Partnership inception, there has been a decrease of 27% in the
    prevalence of antipsychotic medication use in long-stay nursing home residents,
    to a national prevalence of 17.4% for FY 2015 Quarter 3. 
  • The
    long-stay prevalence measure on Nursing Home Compare (NHC) continues to track
    the progress of the CMS National Partnership. In 2/15, CMS began utilizing both
    the long-stay and short-stay quality measures for calculation in the Five-Star
    Quality Rating System. 
  • In
    2014, CMS piloted the Focused Dementia Care Survey; To expand the focused
    survey pilot, CMS conducted additional surveys in FY2015 and FY2016.    

Next
Steps

  • CMS
    will continue data analysis of State to State and regional variation in
    enforcement activity. Potential consequences of reducing antipsychotic medication
    use will be closely monitored.
  • CMS
    continues to conduct additional Focused Dementia Care Surveys across the
    country in 2016, targeting nursing homes with high rates of antipsychotic
    medication use.   

Overall
Themes – Focused Survey Data Analysis – FY2015

  • Deficient
    practices were easily identified and surveyors were able to follow the
    enforcement protocol.
  • Length
    of time needed to conduct the focused survey depends on the survey team’s
    familiarity with the process and surveyors’ background. Teams including a
    pharmacist felt better prepared to address unnecessary medication issues.
    Surveyors concluded the focused reviews can be completed in 3 days, with
    at least 3 surveyors if no serious issues are identified.
  • Some
    surveyors noted the interview worksheets still need revision for clarity.
  • Survey
    teams who conducted a brief review of MDS information (i.e., diagnosis,
    medication usage) prior to entering felt it simplified the sample
    selection process.
  • Surveyors
    identified the following as the most challenging aspects of the process:
    • Facility
      system problems (e.g., interviews with providers not readily available or
      time needed for facility to gather information);
    • Completing
      necessary observations;
    • Amount
      of time spent educating facility staff on the process or eliciting
      information about current dementia practices;
    • Lack
      of training for surveyors on evidence-based dementia practices and
      acceptable prescribing regimes.

This memo announces CMS posting of data on nursing home enforcement actions between 2006 and 2014. See the Posting attached to the Letter.       

    The information includes:

      • General information about nursing home enforcement such as an explanation of scope and severity and the types of remedies that may be imposed;
      • Frequently asked questions (FAQs) related to enforcement actions;
      • Enforcement reports detailing the distribution of federal enforcement remedies imposed from 2006 to 2014 by CMS Region (RO) and State (SA); type of action; year imposed. 
    • CMS notes the report comprises information regarding “…enforcement actions taken during the years that state governments were experiencing budget constraints as a consequence of the recession that began in December 2007...” and addresses survey and enforcement activities before and after the recession (12/07-12/09).
      • CMS cites potential sources for variation in survey results over this period, i.e., “The period before the recession was notable for an increase in survey activities, initiatives and deficiency citations, while the period after the recession began is notable for a decline in overall survey activities and enforcement actions…” 
    • The enforcement reports:
      • Enforcement Remedies In Effect for All Surveys by RO and by State
        • These tables include the number of enforcement remedies in effect for all health and life safety standard and complaint surveys, by RO and by State, respectively, during calendar years 2006 to 2014, as reported in the Certification and Survey Provider Enhanced Reports (CASPER).
        • These reports provide the administrative remedies that took effect, rather than those initially imposed, but never effected because the nursing home achieved substantial compliance prior to the effective date of the remedy.
      • Percent of Providers with Remedies by Region
        • These tables represent all health and life safety standard and complaint surveys during calendar years 2006 to 2014, and includes, by CMS RO, the % of nursing homes with remedies in effect, as reported in CASPER.
    • Civil Money Penalties (CMPs) by Region
      • These tables include, by CMS RO, the frequencies of per-day and per-instance CMPs in effect during calendar years 2006 t0 2014, as reported in CASPER and verified against the Civil Money Penalty Tracking System (CMPTS). 

    This memo advises that a DRAFT RAI Manual v1.14 has been posted to the CMS Nursing Home Quality Initiative web page. The Draft RAI manual is located in the downloads section of the web page so that users can preview significant changes before they become effective 10/1/16. 

    The many item set changes include the new Chapter 3, Section GG: Functional Abilities and Goals. Chapter 2 and Chapter 3, Section A provide information on the new Part A PPS Discharge assessment.

    The draft manual is a single PDF file with bookmarks that you can click on for each section of the manual. It includes the manual chapters, sections, appendices, and the change tables that crosswalk to v1.14.

    Appendices F and H or replacement pages, are not included and will be published with the final version 1.14 in 9/16.

    Provider training will be offered by CMS in the coming months. CMS will provide more information about training through other communications, including S&C memos, open door forums, and website postings.

    This memo announces the release of the CMS Survey and Certification Group FY 2016 to 2017 Nursing Home Action Plan.

    “The Plan outlines five inter-related and coordinated approaches – or principles of action – for nursing home quality, ultimately aligning with CMS’ main goals.”

    The Plan is organized into 5 actionable strategies:

      • Enhance Consumer Awareness and Assistance
      • Strengthen Survey Processes, Standards and Training
      • Improve Enforcement Activities
      • Promote Quality Improvement
      • Create Strategic Approaches through Partnerships

    The Action Plan is attached to this memo and located on the CMS website.

    Highlights: 

    5-Star Quality Rating System

    • Division of Nursing Homes (DNH) will continue to evaluate additional quality measures (QMs), particularly measures of hospitalization, discharge to community, and functional status improvement in both short- and long-stay residents.
    • 7/1/16 - Collection of 1/4ly payroll-based staffing data begins nationwide.

    Strengthen Survey Process, Standards and Training

    • Revisions to SOM Appendix PP based upon updated Interpretive Guidance and new S&C policy memos.
    • Updates to interpretive guidance pending publication of the final rule to revise the Requirements of Participation (RoPs); review existing interpretive guidance for clarity, effectiveness and updated standards of practice.
    • Build on Traditional and QIS survey processes to develop a single revised survey methodology; ongoing testing of revised survey methodology.
    • Sustain increase in validation surveys for Life Safety Code (LSC) through use of contractor.
    • Continue to assess the optimal frequency of LSC surveys within the context of other health and safety priorities.

    Complaint Investigation Process

    • Evaluation of SA’s complaint intake and triage procedures (including prioritization and processing).
    • Use of the ACTS (ASPEN Complaint Tracking System) database.
    • Survey investigations, substantiation/decision making, reporting of results (disclosure of information to complainants).
    • Regional Office oversight of the procedures and investigations conducted at the SA level.
    • Surveyor investigative skills (include creation of training components).   

    Infection Control  

    • DNH intra-agency agreement with the Centers for Disease Control and Prevention (CDC) to investigate HAIs during transitions of care. Includes funding to CMS from CDC to meet joint priorities related to assessing the continuum of infection prevention efforts between hospitals and nursing homes to prevent transmission of infections in both settings.
    • Infection control surveyor worksheet that for use in 10 pilot surveys to assist in strengthening the nursing home survey process and assess for new antibiotic stewardship requirement.
    • 40 hospital and LTC surveys (one hospital and one LTC facility in that hospital’s catchment area); use the survey findings to develop an action plan to improve infection control and prevention in each facility and during transitions of care, and offer technical assistance to each facility to implement the action plan (FY 2017).
    • Develop infection control webinars / other trainings for surveyors.
    • Initiate investigation into development of an infection control training for nursing home providers.
    • Revise policy guidance for F441 as needed. 
    • Explore the possibility of offering a 1 or 2-part webinar series to nursing home providers; development of cross-provider training regarding general infection control issues. 

    Improving Enforcement Activities

    • Track imposition of enforcement remedies through development of National, Regional and State-specific data reports that can be shared with CO, RO, States and the Public; 1/4ly calls with each RO to discuss enforcement trends, issues, concerns and enforcement improvement opportunities.
    • Additional web-based enforcement training for ROs and State Survey Agencies.
    • Revise Chapter 7 of the SOM to expand circumstances where remedies must be imposed; clarify guidance and ensure appropriate and consistent national application of enforcement policies.
    • Publish Nursing Home Enforcement Reports.
    • Improve efforts to monitor and track Special Focus Facilities.
    • Evaluate the use and application of the CMP Analytic Tool for efficiency and consistency.
    • Draft guidance for citing IJ where an IJ has occurred after the exit date of the last standard or LSC survey, but prior to the current survey yet noncompliance continues at a lower severity.   

    Federal Civil Money Penalty Fund

    • The Affordable Health Care, Elder Justice, and Social Security Acts authorize use of CMPs to further the mission of CMS by generating innovative thought and processes in the areas of reducing  adverse events, enhanced staffing, and improved dementia care in adult LTC. A multi-year CMP solicitation is currently being drafted; upon publication will specifically state CMP fund parameters and Office of Management and Budget (OMB) auditing requirements.
      • CMP Solicitation: 9/16; Publication of Solicitation: 10/16; Awarding of Funds: 12/16.

    Monitor Civil Monetary Penalty Amounts

    • Monitor CMP Analytic Tool use for consistency in application of enforcement remedies; meet with ROs to discuss results of analysis of national enforcement remedies.
    • SOM revisions that apply to the range of per instance CMPs (7/16). 

    SFFs

    • Develop several pilot programs to evaluate other interventions in various CMS ROs; may be additional policy adjustments to the SFF program.

    MDS 3.0 

    • National Expansion of MDS/Staffing Focused Survey.
    • Ongoing Revisions to the MDS 3.0 assessment tool for improved resident assessment; inclusion of standardized items related to the IMPACT Act (effective 10/16).
    • Revisions to the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, MDS 3.0 (Effective October each year).
    • State RAI Coordinator’s Training – Classroom training (Spring 2016).
    • MDS/RAI Provider Training (Summer 2016).  

    QAPI

    • Further addition / improvement of nursing home quality tools/resources;
    • Tools and resources for surveyors and consumers.
    • Develop training to help surveyors better identify when negative outcomes are symptoms of underlying systems failures. 

    National Partnership to Improve Dementia Care in Nursing Homes

    Develop quality measures and quality indicators, such as (a) use of claims data to generate frequency data on all nursing home residents; (b) development of MDS 3.0-based QMs on unjustified antipsychotic medication use

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