CMS Concentrates Regulatory Focus: Staffing, Dementia Care, Infectious Disease, and Adverse Drug Events

Taxes were not the only bad news to come out of Washington on April 15, 2019. The Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma released through her blog a description of CMS’ refocused regulatory efforts for skilled nursing facilities (SNFs). Her blog begins with a description of the CMS duty to monitor safety especially in the care for some of the most vulnerable in our society, ie, Americans residing in nursing homes (NHs).¹ She further states that “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.” To effect these beliefs, CMS is charged with developing and enforcing quality and safety standards across the nation’s health care system—a responsibility she considers a sacred trust and one that is constantly evolving. 

CMS seeks to ensure that SNFs treat residents with dignity and prevent abuse and neglect, rewarding them for value and quality through the SNF Value-Based Purchasing Program. CMS also says they want outcomes to be transparent to consumers—all these things without unnecessary paperwork that keeps providers from focusing on patients.¹

While SNF providers certainly embrace these objectives, the strategies CMS is using to achieve these goals appears to continue to be overly regulated and punitive. SNFs certainly acknowledge that there is always room for improvement but would appreciate a partnership with CMS focused first and foremost on Quality.  

CMS hopes to reach their goals and demonstrate their commitment to improving care through the following actions, which they call their new 5-part plan: 

1. Strengthen oversight
2. Enhance enforcement
3. Increase transparency
4. Improve quality
5. Patient over paperwork

At first glance, even the ordering of CMS’ 5-part plan seems misguided. The focus should ideally start with Quality, followed by Transparency and Reduced Paperwork, ending with Oversight and Enforcement. Instead, as has as always been the case with CMS, they initially and primarily focus on Oversight and Enforcement while paying lip service to paperwork reduction as SNFs continue to be subject to growing regulations that have never been subject to a reduction.

With these dynamics in mind, demonstrated by the order of items and past experience with/actions of CMS, it is important for SNF leaders to understand how CMS’ oversight and enforcement will be effected in practice so leaders may be prepared and can respond accordingly. 

CMS Enforcement and Areas of Focus

CMS oversight and enforcement activities are supervised by the State Survey Agencies (SSAs) who are responsible for state licensure. The SSAs visit and survey every Medicare and Medicaid participating NH in the nation at least annually to ensure they are meeting CMS’ health and safety requirements as well as state licensure requirements. 

CMS and others have found this process to be widely variable. Some states frequently identify serious issues in NHs, while others do not identify concerns with the same seriousness or severity, including application of penalties. As a result, CMS is revising oversight of SSA performance. SSAs surveyors determining that an NH is providing care poor enough to seriously harm residents or that is likely to cause serious harm—a situation called “immediate jeopardy”—should base their judgement on consistent application of standards nationwide. CMS recently revised and streamlined the surveryor guidelines for determining immediate jeopardy. Going forward, SSAs will be armed with clearer procedures, so that, as they conduct their review of each NH, dangerous issues will be discovered and promptly reported to CMS. Thus, residents will be kept safe through appropriate enforcement actions intended to bring about rapid and sustainable compliance. Further information about surveyor findings at specific NHs and associated enforcement actions can be searched for using the Nursing Home Compare online tool.²

Specifically, to standardize the surveyor evaluation process, CMS is focusing on issues of facility staffing levels, dementia care in terms of inappropriate antipsychotic medication use, and decreasing infections and adverse drug events. These 3 areas of focus will not only be evaluated during the onsite survey process but through data review. CMS is 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 NH survey and oversight processes, especially for individuals transferred from an NH to a hospital. As a result of this focus, SNFs should concentrate their efforts here as well.

Staffing

CMS has long identified staffing as one of the vital components of an NH’s ability to provide quality care. CMS collects staffing data from nursing facilities through the Payroll-Based Journal system, which contains payroll and other verifiable and auditable data, as required by law.³ Since November 2018, CMS has shared this data with SSAs so they know which NHs may have potential staffing problems and can target their reviews.⁴ 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 and report this data directly to the Nursing Home Compare.

Dementia Care

CMS believes that residents with dementia-related psychosis tend to be deemed unruly and difficult, resulting in staff giving them unnecessary antipsychotic sedative drugs outside the recommendations of national guidelines and best practices. CMS has worked through the National Partnership to Improve Dementia Care in Nursing Homes to curb the inappropriate use of these drugs in NHs. Between 2011 and the third quarter of 2018, this effort helped decrease the national prevalence of antipsychotic medication use among long-stay NH residents by 38.9% to a national prevalence of 14.6%.⁵ In March 2019, CMS announced that there would be enhanced oversight of NHs that have not improved their antipsychotic medication utilization rates for long-stay residents since 2011, or “late adopters,” to achieve continued improvement in this area. Thus, a continued drive to reduce inappropriate antipsychotic use is critical for all SNFs to adopt.

Infection Control and Adverse Drug Events

With infection control as a priority, CMS developed an online training about infection prevention and control with the Centers for Disease Control and Prevention (CDC). The Core Elements of Antibiotic Stewardship for Nursing Homes translates the CDC Core Elements of Hospital Antibiotic Stewardship⁶ into practical strategies to initiate or expand antibiotic stewardship activities in NHs, and CMS is offering this to NHs for free. NHs are “encouraged to work in a step-wise fashion, implementing one or two activities to start and gradually adding new strategies from each element over time. Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting.”⁷ Given CMS’ focus, these are available resources that SNFs should take advantage of as well.

Also of importance are adverse drug events, which are common in NH residents and often preventable.⁸ A study of residents of 2 large academic long-term care facilities indicated that the overall rate of adverse drug events was nearly 10 per 100 resident-months, of which 40% were considered preventable.⁹ Errors associated with preventable drug-related injuries occurred most often at the ordering and monitoring stages of pharmacotherapy. Residents taking medications in several drug categories—including antipsychotic agents, anticoagulants, diuretics, and antiepileptic medications—were found to be at particular risk for preventable adverse drug events. Potential strategies for improving medication safety in the NH setting include “enhanced inter-provider communication, improved approaches to medication reconciliation, and computerized provider order entry systems with sophisticated clinical decision support systems that incorporate relevant clinical information.”¹⁰ These efforts should be hard-wired into all SNF practices to reduce these adverse events.

The results of these efforts will be even more heavily promoted through the Nursing Home Compare site, which is being increasingly utilized by hospital discharge planners working with families and patients to identify “top” facilities. According to a 2018 report from the Medicare Payment Advisory Commission,¹¹ an independent agency that advises Congress on Medicare, nearly 84% of Medicare beneficiaries who go to an SNF after a hospital stay could have selected a higher-rated provider within a 15-mile radius.

Tools such as repisodic.com, which look and function like yelp.com, are being utilized to assist in ranking these SNFs, mainly based on these measures, making Nursing Home Compare data even more important to ensure appropriate referrals to one’s facility. 

Conclusion

Comprehensive understanding of where CMS is increasing focus and how their focus will likely translate into practice is critical for SNFs’ success. CMS has signaled that their latest areas of focus involve facility staffing levels, dementia care in terms of inappropriate antipsychotic medication use, and the decrease of infections and adverse drug events. Increased attention to these areas support CMS’ and state surveyors’ priorities of oversight and enforcement but, more importantly, should also help improve the care quality for SNF residents—the goal for which all stakeholders should be aiming. 

References

1. Verma S. Ensuring Safety and Quality in America’s Nursing Homes [blog]. April 15, 2019. https://www.cms.gov/blog/ensuring-safety-and-quality-americas-nursing-homes. Accessed April 23, 2019.

2. Centers for Medicare & Medicaid Services. Core elements of hospital antibiotic stewardship programs. cdc.gov website. https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html. Updated May 7, 2015. Accessed April 23, 2019.

3. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109(2):87-94.

4. Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. 2005;118(3):251-258.

5. Gurwitz J. Medication safety in nursing homes: what’s wrong and how to fix it. AHRQ Patient Safety Network. psnet.ahrq.gov website. https://psnet.ahrq.gov/perspectives/perspective/126/medication-safety-in-nursing-homes-whats-wrong-and-how-to-fix-it. Published August 2012. Accessed April 23, 2019.

6. Medicare Payment Advisory Commission. Encouraging Medicare beneficiaries to use higher quality post-acute care providers. https://www.medpac.gov/docs/default-source/reports/jun18_ch5_medpacreport_sec.pdf?sfvrsn=0. Published June 2018. Accessed April 23, 2019.

7. Centers for Medicare & Medicaid Services. Nursing Home Compare. medicare.gov website. https://www.medicare.gov/NursingHomeCompare/search.html. Accessed April 23, 2019.

8. Centers for Medicare & Medicaid Services. Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on Medicare.gov and the Five Star Quality Rating System [memorandum summary]. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf. Published April 6, 2018. Accessed April 23, 2019.

9. Gregory AG. CMS to take active role in ensuring adequate RN staffing in nursing facilities. JD Supra website. https://www.jdsupra.com/legalnews/cms-to-take-active-role-in-ensuring-46726/. Published December 13, 2018. Accessed April 23, 2019.

10. The National Nursing Home Quality Improvement Campaign. National partnership to improve dementia care in nursing homes: antipsychotic medication use data report. https://www.nhqualitycampaign.org/files/Antipsychotic_Medication_Use_Report.pdf. Published January 2019.
Accessed April 23, 2019.

11. Centers for Disease Control and Prevention. The core elements of antibiotic stewardship for nursing homes. cdc.gov website. https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html. Updated January 4, 2019. Accessed April 23, 2019.