With reporting from Shelby Grebbin and Amy Stulick
The Centers for Medicare & Medicaid Services (CMS) has announced a plan to publicly display survey citations that nursing homes are disputing, as well as new policies related to antipsychotic use and related penalties.
Currently, disputed citations are not posted to Care Compare. This will change starting on Jan. 25, 2023, CMS announced Wednesday. The citations will not be included in a facility’s Five Star rating calculation while under dispute.
“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,” CMS noted in its announcement.
Also starting this month, CMS will begin conducting targeted, off-site audits focused on whether nursing homes are accurately assessing and coding individuals diagnosed with schizophrenia.
Erroneous schizophrenia diagnoses can lead to inappropriate use of antipsychotic medication.
Facilities that are found to have a pattern of inaccurate coding related to schizophrenia will see their Quality Measure ratings dropped to one star, affecting their overall Star Rating.
“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.”
The action on antipsychotic medications was not particularly surprising, given long-standing efforts related to this issue, but the penalty did come as more of a surprise, Joel VanEaton, executive vice president of post-acute care regulatory affairs and education at Broad River Rehab, told Skilled Nursing News.
The Biden administration framed these changes as part of its overall nursing home reform push, which kicked off about one year ago.
“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.”
Changes follow OIG report
In November 2022, a report released by the Department of Health & Human Services (HHS) Office of the Inspector General (OIG) found that the overall use of psychotropic drugs in nursing homes remained “high and unchanged” since 2011 — with 80% of nursing home residents between 2011 and 2019 prescribed a psychotropic drug, including antipsychotic drugs.
Perhaps most damningly, in 2019, nursing homes with lower ratios of registered nurse staff to residents were associated with higher use of psychotropic drugs, and nursing homes with higher percentages of residents with low-income subsidies were also associated with higher use of psychotropic drugs.
“Antipsychotic drugs are too often used on residents with dementia because a facility is unwilling to hire sufficient staff, with the appropriate competencies, to employ non-pharmacological approaches to dementia care,” Long Term Care Community Coalition said in a statement on the CMS announcement.
There was also a staggering 194% increase in the number of residents reported through the minimum data set (MDS) as having schizophrenia between 2015 and 2019, though OIG researchers noted they didn’t have corresponding diagnoses in Medicare claims and encounter data.
Still, finding that 6,400 residents were reported as having a schizophrenia diagnosis in 2015 and then 19,000 just four years later shook the long-term care industry, though some industry stakeholders said that monitoring psychotropic use through administrative data “may not tell the whole story.”
“In many cases, physicians not directly affiliated with the long-term care facility are diagnosing patients and prescribing these medications,” Dr. David Gifford, chief medical officer for the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said in a statement released in conjunction with the OIG report. “Many residents are already on these medications when they are admitted to the nursing home from the community or hospital, and physicians or family members are concerned about ceasing their use.”
Industry stakeholders weigh in
Broad River Rehab’s VanEaton is concerned that the potential penalty associated with the antipsychotic audits might be “a bit overbearing.”
“The short-stay quality measure rating will be suppressed for six months and the long-stay antipsychotic measure will be suppressed for 12 months; that’s a long time to have that quality measure be impacted … for something that can be remedied,” he said.
But he also pointed out that providers must be increasingly attuned to behavioral health issues, including and in addition to schizophrenia. Behavioral health is relevant to recent updates to the Medicare Conditions of Participation, such as the elements related to trauma-informed care, and is gaining prominence as acuity rises in nursing facilities.
VanEaton’s advice is for providers to “keep the resident at the center.”
“I think that will win the day, in terms of being able to comply with this new regulatory guidance,” he said.
LeadingAge, which represents over 5,000 nonprofit aging services providers, helped lead the creation of the National Partnership to Improve Dementia Care in Nursing Homes, a program overseen by CMS to develop tools and resources to help providers meet goals for eliminating the medications.
“We understand the challenges of implementing alternatives to drugs, particularly if programs that reduce the use of antipsychotics require more or specialized staff,” LeadingAge CEO Katie Smith Sloan said in a statement. “There is a workforce shortage in skilled nursing. However, this is a serious quality of care and quality of life issue for residents. Inappropriate use of potent drugs can compromise a person’s overall health. If stepped up enforcement is needed, we support that approach.”
Still, she said, CMS should address the issue of inappropriate antipsychotic use among providers of all types.
“Our members often tell us of having to admit residents who’ve been prescribed these meds while under the care of other providers,” she said. “Health care is a team sport; all providers in the system must be held to the same expectation.”
During an afternoon call with HHS Secretary Becerra, Janine Finck-Boyle, vice president of regulatory affairs for LeadingAge, spent some time bringing nursing home members up to speed on the CMS updates.
Finck-Boyle had some suggestions for members: make sure documentation is airtight.
“You want to work with your psychiatrists, with your medical directors, with your attending physicians, you want to do audits on your MDS, you want to review documentation,” said Finck-Boyle.”You really want to inform and educate your medical staff. Really make sure that you have the documentation … there might be some chance to work with your MDS Coordinator (and) MDS coder.”
In terms of making citations public on Care Compare, Finck-Boyle also acknowledged that the Biden administration in the end is trying to get closer to transparency between the industry and consumers.
AHCA/NCAL, the largest nursing home trade group in the nation, cautioned that dramatically downgrading entire ratings based on a single measure results in misleading information and causes more consumer confusion.
“AHCA/NCAL and our members have been active partners in a national effort to reduce the unnecessary use of antipsychotics in nursing homes, which in the past decade, has decreased by 40%,” Gifford said. “According to medical literature, there are still some situations where these medications may be necessary and beneficial to certain patients, including those with schizophrenia and hallucinations.”
He added that it is becoming “increasingly difficult” for consumers to use Care Compare to see and understand what is most important when searching for a nursing home.
“We must make certain that Care Compare remains a useful, clear tool for consumers and that enforcement is focused on the appropriate parties,” Gifford told SNN in an email.
VanEaton raised similar concerns, with regard to posting citations being disputed.
“While I think it’s important to have this kind of information out there, I think it only adds to the complexity, and makes that Five Star rating even more complex of an idea for people to digest,” he said.
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