CMS Moves to Strengthen Nursing Home Safety and Clarity of Consumer Info

Published in RINewsToday on January 23, 2023

To improve transparency of nursing home consumer information, the federal Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS), will now post Care Compare citations that are under dispute by nursing homes on its website.  CMS will also take steps to protect nursing home residents from being inappropriately diagnosed with schizophrenia which oftentimes leads to improper use of anti-psychotic medications to sedate and chemically restrain residents.

“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, announcing the new guidance this week. “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,” she says.

CMS’s actions advance President Biden’s goal of reinforcing safeguards against unnecessary medication use and treatments that was outlined in his State of the Union address to create an Action Plan for “Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes.”

Tackling the inappropriate drugging of Nursing Home residents

Beginning this month, CMS will conduct targeted, off-site audits of nursing homes to determine whether facilities are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of receiving poor care and being prescribed inappropriate anti-psychotic medications. Anti-psychotic medications are especially dangerous to these residents due to their potential devastating side effects, including death.

According to the Washington, DC-based National Consumer Voice for Quality Long-Term Care, in 2008, CMS first introduced a quality measure in its Care Compare rating system that calculates the percentage of long-stay residents (over 100 days) that were receiving anti-psychotic medications. This quality measure was initially introduced to address the practice of some nursing homes of illegally using anti-psychotic medications to sedate residents with dementia or other increased patient care needs, rather than providing appropriate hands-on care interventions.

The measure, excluding residents with certain diagnoses, including schizophrenia, Huntington’s disease, and Tourette’s syndrome, resulted in some nursing homes improperly diagnosing residents with schizophrenia, observed the Consumer Voice, a national organization representing consumers in issues related to long-term care, helping to ensure consumers are empowered to advocate for themselves.      

CMS’s new guidance acknowledges that there has been a steady rise in schizophrenia diagnoses since the quality measure was first introduced, charges the Consumer Voice, noting that it comes on the heels of a report issued by the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) which found that from 2015-2019 there was a 194% increase in the number of residents diagnosed with schizophrenia who did not have that diagnosis prior to admission to the nursing home.

“It is important to note that it is extremely rare for schizophrenia to suddenly occur in older people,” says the Consumer Voice, stating that the onset of schizophrenia generally occurs in someone’s late teens through their twenties.

CMS announced that it will begin to conduct audits of nursing homes with high rates of schizophrenia diagnoses and “examine the facility’s evidence for appropriately documenting, assessing, and coding a diagnosis of schizophrenia.” Facilities that have “inaccuracies” will have their Five-Star Quality Measure Rating adjusted. 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.

While Consumer Voice has expressed significant concern with the accuracy of CMS’s Quality Measure, it supports these actions. The Quality Measure rating often inflates a facility’s overall 5-Star rating on Care Compare. This action will help incentivize compliance and make sure the public is aware of these illegal practices in nursing homes, says the consumer advocacy group.

Increased transparency

Separately, CMS announced it plans to take a new step to increase the transparency of nursing home information provided to consumers 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. 

Although 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 and choosing a facility. This new information will begin appearing on Care Compare on January 25th. While citations will be publicly displayed, they will not be included in the Five-Star Quality Rating calculation until the dispute is complete. 

“We support anything that CMS can reasonably do to improve the health and safety of seniors in long-term care, especially those with cognitive impairment. When it comes to the nursing home industry’s concerns about new CMS rules, we think it’s best to err on the side of transparency. Seniors and their families need as much information as possible to make informed decisions about long-term care,” says a spokesperson for the Washington, DC-based National Committee to Preserve Social Security and Medicare, an advocacy group whose mission is to protect Social Security and Medicare.

Local reaction:  “You cannot un-ring a bell”

RI Health Care Association

“We fully support improving nursing home transparency, safety and quality, and accountability regarding our members’ service to the residents and patients entrusted to their care,” says John E. Gage, President and CEO of Rhode Island’s Health Care Association, representing 64 of the 80 nursing facilities in the state. “Eliminating any inappropriate use of psychotropic medications and ensuring the highest quality of care is a shared focus of both CMS and RIHCA,” notes Gage.

“We strongly disagree with CMS’ decision to post of deficiencies that are in the process of being disputed through established CMS policies, regardless of their scope and severity, says Gage. “Posting deficiencies that, in many instances, are incorrect, inaccurately cited or cited at an inappropriate level of scope and severity, during an approved appeals process is unfair and could damage a facility’s reputation unfairly,” he adds.

According to Gage, doing this is akin to convicting someone before their full trial, (prosecution and defense alike) before the verdict is announced. “You cannot “un-ring a bell,” he says.

“As mentioned by CMS, we are just talking about a relatively small number of deficiencies,” states Gage. Rather than potentially posting erroneous deficiencies, he calls on CMS to speed up the process of conducting Informal Dispute Resolutions (IDRs) or Independent Dispute Resolutions (IIDRs) to no more than forty-five (45) days to ensure that accurate information is posted timely. IDRs and IIDRs are two different options from CMS that nursing homes can choose to appeal of cited deficiencies.

“As to the changes to the public reporting and the Five-Star Quality Rating System, we are disappointed that the Biden Administration and CMS have apparently made this determination administratively, without any comment period to allow for an opportunity for nursing homes and the public to provide feedback,” says Gage.

LeadingAge RI

“I appreciate CMS’s goal of increasing oversight of unnecessary antipsychotic medication use, although it should be noted that there has been a National Partnership to reduce the unnecessary use of antipsychotic drugs for years, so the industry has been very engaged in these efforts already,” notes James Nyberg, Executive Director of LeadingAge RI, a not-for-profit membership organization comprised of not-for-profit providers of aging services. 

Nyberg expresses concern about CMS posting deficiencies that are under dispute publicly. “That is taking a guilty before proven innocent approach, which is unfair and detrimental to providers. There is an existing process to resolve disputes over deficiencies, and this seems to short-circuit it, especially when deficiencies can be/and are overturned during the process.  One more blow to a beleaguered industry,” he says.

Long-Term Care Ombudsman

“The inappropriate use of antipsychotic medications in nursing homes has been an on ongoing issue for many years,” observes Kathleen Heren, Rhode Island’s Long-Term Care Ombudsman. “It takes a skilled practitioner who gives a battery of tests to diagnose someone with schizophrenia. This shouldn’t be determined by a hospital intern who spends 20 minutes with an agitated resident in a hospital emergency room,” she says.

According to Heren, schizophrenia has an early onset [about 4% of schizophrenia arise before the age of 15, and about 1% before the age of 10].  A 78-year -old resident does not become schizophrenic all of a sudden because he or she is agitated. “I can say that I have not seen many deficiencies given to Rhode Island nursing homes for overusing anti-psychotic medications,” she says, because of the efforts of  Health Care Centrics, Rhode Island’s Quality Assurance organization, that has provided in-depth staff training on the use of these drugs. The surveyors from the Rhode Island Department of Health (RIDoH) are very quick to cite facilities for not following guidelines in the inappropriate use of these drugs.

Heren says that there have been cases where RIDOH has rescinded a deficiency based on the input received by the survey team during the Informal Dispute Resolution process. “There are some facilities that are continually receiving deficiencies and that families should be able to see why a deficiency was given and a facilities response as to why it was considered unfair,” she says.

CMS Actions promote quality of care

RI Department of Health

“At the Rhode Island Department of Health (RIDoH), one of our major focus areas is monitoring and ensuring that nursing homes and other healthcare facilities provide the highest quality of care and services in a clean and safe environment, says Joseph Wendelken, RIDoH’s Public Information Officer. 

“We will continue to do everything we can to protect patients and residents, which includes following any new CMS protocols and partnering with CMS on new initiatives,” Wendelken says. 

Senior Agenda Coalition of RI

Adds Maureen Maigret, Policy Advisor for the Senior Agenda Coalition of RI, “Rhode Island nursing homes have generally provided good quality of care over the years,” acknowledging that improvements can always be made. “Both of these changes are intended to promote better quality care,” she says. “If people are erroneously coded as having schizophrenia, they may be subject to poorer care and harmed by being prescribed inappropriate medication. Posting inspection citations under dispute on Nursing Home Compare with a notation they are under dispute is important in that resolution of the dispute could take 60 days or longer and in the meantime the public remains unaware of what could be significant deficiencies which could impact their decisions,” states Maigret says.

The QSO memo — 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 for review:

https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/policy-and-memos-states/updates-nursing-home-care-compare-website-and-five-star-quality-rating-system-adjusting-quality

Problem Solvers Caucus may be key to re-establishing Committee on Aging

Published in RINewsToday on Jan. 16, 2023

H.R. Res. 583, Reestablishing the Permanent House Select Committee on Aging (HSCoA), chances were growing slim in getting Congressional attention for passage in the final days of the 117th Congress. Extensive media coverage of the ongoing Ukraine War, the wrap up and issuance of the Jan. 6th hearing’s report and midterm election coverage kept Congressman David Cicilline’s (D-RI) resolution from getting political traction from being considered by the House Rules Committee for ultimate passage and floor action.

The HSCoA was a permanent select committee of the U.S. House of Representatives between 1974 and 1992. The committee was initially created with the intent not of crafting legislative proposals, but of conducting investigations and holding hearings to put the Congressional spotlight on aging issues. Its purpose was to push for legislation and other action, working with standing committees, through regular committee channels. If  H. Res. 583 was passed by the House Rules Committee, it would have brought back the HSCoA. No Senate action was required.

According to the Congressional Research Services, it is a very simple process to create an ad hoc (temporary) select committee by just approving a simple resolution that contains language establishing the committee—giving a purpose, defining membership, and detailing other issues that need to be address.  Salaries and expenses of standing committees, special and select, are authorized through the Legislative Branch Appropriations bill.

Taking a Looking Back

Last Congress, Cicilline’s H. Res 583 would reestablish a HSCoA without having legislative jurisdiction, this being no different than when the select committee previously existed. It would be authorized to conduct a continuing comprehensive study and review of aging issues, such as income maintenance, poverty, housing, health (including medical research), welfare, employment, education, recreation, and long-term care. These efforts influenced legislation taken up by standing committees.

H. Res. 583 would authorize the reestablished HSCoA Committee to study the use of all practicable means and methods of encouraging the development of public and private programs and policies which will assist seniors in taking a full part in national life and which will encourage the utilization of the knowledge, skills, special aptitudes, and abilities of seniors to contribute to a better quality of life for all Americans.

It would also allow the HSCoA to develop policies that would encourage the coordination of both governmental and private programs designed to deal with problems of aging and to review any recommendations made by the President or White House Conference on Aging in relation to programs or policies affecting seniors.

Cicilline’s H. Res. 583 drew the support and attention of the Max Richtman, President and CEO of the Washington, DC-based Leadership Council on Aging and a former Staff Director of the Senate Permanent Special Committee on Aging, along with President Nancy Altman of Social Security Works, and Chair of Strengthen Social Security Coalition.   

Robert Weiner, former chief of staff of the HSCoA, Tom Spulak, former staff director and General Counsel of the House Rules Committee and Vin Marzullo, a well-known aging advocate in Rhode Island, including this writer were strong advocates for passage of this resolution.

Although H. Res. 583 had strong backing from the aging network, the bill never was endorsed by House Speaker Nancy Pelosi nor considered by the Democratic controlled House Rules Committee As a result, the resolution never reached the House floor for a vote. As a result, the resolution died at the end of the 117th Congressional session.

The House must reestablish the HSCoA

It is now crucial for Cicilline to reach across the aisle for Republican cosponsors when he reintroduces H. Res. 583 during the new Congress. The need for reestablishing this investigative committee still exists today as when it was first introduced eight years ago.

“America’s seniors have spent a lifetime working hard and moving our country forward and they deserve the financially secure retirement that they worked and paid for. The pandemic disproportionately impacted seniors, and now those with fixed incomes are bearing the burden of inflation and the higher costs food, housing, and other essentials,” says Cicilline.

“I’m extremely proud that we were able to institute a $35 cap on insulin costs and bring down prescription and medical costs for seniors through the Inflation Reduction Act, but there is more work to be done. Reauthorizing the House Permanent Select Committee on Aging will give us the dedicated staff and resources necessary to study and address the issues that affect seniors to make sure they can live the rest of their lives with dignity and security,” adds Cicilline.

“It is vitally important that we ensure Rhode Island seniors have the financial security, access to high quality health care and quality of life they have earned. For this reason, I am proud to support the reestablishment of the HSCoA, and encourage my colleagues on both sides of the aisle make senior citizens’ issues a priority in the 118th Congress,” adds newly elected Congressman Seth Magaziner.

In the article, “Senior’s Need House of Reps to Bring Back Aging Committee,” I previously coauthored with Tom Spulak and Robert Weiner on this statewide news blog last July, provides the rational and reasoning for reestablishing the HSCoA.

Specifically…

“Every day, 12,000 Americans turn 60. By 2030, nearly 75 million people in the U.S.—or 20 percent of the country—will be age 65 or older. As America grows older, the need for support and services provided under programs like Social Security, SSI, Medicare, Medicaid and the Older Americans Act also increases,” and the need for re-establishing the HSCoA becomes even more important.”

“Historically, the HSCoA served as a unique venue that allowed open, bipartisan House debate from various ideological and philosophical perspectives to promote consensus that, in turn, helped facilitate the critical work of the standing committees. Addressing the needs of older Americans in a post-pandemic world will require this type of investigative, legislative oversight, work which can only be advanced and promoted by reestablishing the HSCoA.”

“As Americans are aging, we also face a variety of intergenerational concerns that merit the investigation by the HSCoA, such as growing demands on family caregivers and a burgeoning retirement security crisis.”

“Restoring the HSCoA would provide the House with an opportunity to more fully explore a range of aging issues and innovations that cross Standing Committee jurisdiction of importance to both Republicans and Democrats, while holding field hearings, convening remote hearings, engaging communities and promoting understanding and dialogue.”

“Today, the Senate Permanent Special Committee on Aging is working on everything from scams against seniors to increasing HCBS services, to calling out questionable billing practices by Medicare Advantage insurers. Seniors have been better off over the last 30 years with a Senate Aging Committee in existence — and the Senate investigative committee would benefit from a reestablished HSCoA, whose sole mission would be to look out for older American.”

“Over 30 years ago, working closely with authorizing committees with jurisdiction over aging programs and services, the HSCoA put an end to mandatory retirement.  Alzheimer’s became a household word because of its investigative hearings. Legislation was passed to improve the quality of care in the nation’s nursing homes, even creating the nation’s National Institute’s for Health.“

Centralist to play key role in passage 

“This is a unique moment in time where centrists from both sides in the House could influence legislative action thru genuine bipartisan collaboration”, said Vin Marzullo, who served 31 years as a career federal civil rights & social justice administrator at the National Service agency.   “I am urging our newly elected Congressman, Seth Magaziner, to join with the lead sponsor, Congressman David Cicilline, in the re-introduction of the House Resolution to re-establish HSCoA. 

Additionally, I would advise that bipartisan efforts begin by reaching out to Congressmen Brian Fitzpatrick (R-PA and Josh Gottheimer (D-NJ), co-chairs of the “Problems Solvers Caucus,” for their co-sponsorship/support”, added Marzullo.  “That could be a pathway for better legislating and governing and Congressman Magaziner stated during the campaign that he’d look for common ground with members on the other side of the aisle.  This is it — we need an adult conversation about the Aging of America and how we intend to aid and support our elders, caregivers, and long term care options.”

We’ll see if Cicilline and Magaziner tag-team for a fifth attempt to reestablish the HSCoA.  For the sake of improving the quality of life of America’s seniors, House Speaker Kevin McCarthy (R-Calif) must put politics aside and work with a Bi-Partisan Coalition and the Democratic Caucus, to achieve real results for our nation’s older adults. 

For details about the House Problem Solvers Caucus, go to  https://problemsolverscaucus.house.gov/.

Volunteering: Your Single New Years Resolution 

Published in RINewstoday on January 10, 2023

As the ball dropped in New York’s Time Square, many Americans have already penned New Year’s resolutions for 2023.  Making these resolutions as January approaches has become a very common tradition for millions.

According to the Statista 2022 Consumer Survey (413 adults ages 18 to 89 years old surveyed from Oct. 25 to Nov. 2, 2022) living a healthier life style by going to the gym, eating nutritious meals and even losing weight were the top three New Year’s resolutions for 2023.

While resolutions provide us with a road map as to how we can make improvements in our lives, many can’t overcome obstacles to keep them. An Inc. web article, written by Marcel Schwantes, noted only 9 percent will be successful in achieving their goals.

Just “Pick One” – Resolution

Second Harvest Heartland, one of the nation’s largest hunger relief organizations, calls on people to just put one resolution, “becoming a volunteer” on their list. “Picking a cause and getting out to volunteer turns out to be the one single, achievable, sustainable and widely beneficial resolution for New Year,” says the Minnesota-based company.

That’s a great suggestion.

According to Project Helping, research tells us that “volunteering helps improve mood, makes you feel healthier, increases your sense of purpose, and reduces your stress levels. Volunteering can also give us a deep sense of happiness both immediately and long-term,” the research studies say.

“Our volunteers give their time to help others, and rarely ever think about how it can impact their own lives in so many ways,” said Julie Greene, director of volunteer engagement at Second Harvest Heartland. “Of course, they feel a tremendous sense of satisfaction knowing their contributions are making a difference in people’s lives, but the benefits of their actions go way beyond that. 

Given the camaraderie people feel by coming together and the satisfaction of working on a common goal, I’m not surprised at all that research has proven the benefits of volunteering—we see it every day with the smiles on our volunteers’ faces,” says Greene.

“Volunteering is Medicine for the Soul”

Being a volunteer can also be a protective buffer from the curve balls that life may throw at us as we age. “Volunteering can be medicine for the soul. It allows you to connect with other people, explore and remedy emerging community issues, make a difference as a caregiver or mentor and change lives.

Volunteering is powerful and can define and redirect your life’s journey,” says Vincent Marzullo, who for 31 years served as RI’s National Service Director and still volunteers weekly at Hasbro Children’s Hospital.

Adds, James Connell, Executive Director, of Age-Friendly Rhode Island:  “There’s no better way to reduce tension, combat social isolation, and feel tremendous self-satisfaction than by connecting with others and giving back to the community and your neighbors by volunteering.”

Connell says Rhode Islanders as a population are aging, nearly one in three of us will become age 65 and over by the end of the decade. “Volunteers and volunteerism will be key factors in creating a great state in which to age. Older adults want to stay active, engaged, and remain in their homes; as a volunteer or by being the recipient of volunteers services we can achieve this and so much more,” he says.

“Aging Rhode Islanders need you,” says Connell.  “Volunteer to provide supports to stay at home, to connect and provide company to combat social isolation, and to positively impact their overall health and well-being trough connection and service,” he adds.

A sampling of Rhode Island volunteer opportunities

For volunteer opportunities, Connell calls on seniors to contact Retired Senior and Volunteer Program (RSVP), the nation’s largest volunteer network for those age 55 and over.  RSVP volunteers serve the community at non-profits, community programs, and service agencies. Volunteers mentor school children, prepare tax returns, knit caps for newborns, participate in volunteer transportation networks, and visit homebound Rhode Islanders, he says.

Why not  contact a Community Action Program (CAP) in your region to find out more about volunteer opportunities, suggests Connell, noting that they are located in East Bay (EBCAP), West Bay CAP, East Bay (EBCAP) and at Federal Hill House Providence.

Or you can contact the Diocese of Providence, or other faith communities, to learn more about volunteer opportunities. 

The Neighborhood Friendly Visitor Program, a community-based volunteer program, provides weekly visitors to isolated elderly and disabled adults in Rhode Island, seeks older volunteers, says Connell. “The program was developed in 1978 by Sister Rhea Lachapelle of the Sisters of Saint Ann to address the needs of a growing and diverse population of seniors living alone with little or no social support. Any senior age 60 and over, or disabled person who is homebound, residents of any nursing home or assisted living, or patients at hospitals, is eligible for this program. There are no income guidelines and there is no fee for this service,” adds. Connell.

Connell says that Friendly Visitor volunteers are available state-wide. Volunteers have supplied personnel references and passed a background check through the Office of the Attorney General. The program has on-going recruitment of volunteers who make a commitment to visit or call seniors for at least one hour each week. This program is funded in Partnership with the Rhode Island Office of Healthy Aging, he says.

The Senior Companion Program, sponsored by the Rhode Island Office of Healthy Aging (RIOHA) and the federally funded by the Corporation for National & Community Service, also seeks volunteers, says Connell. “Senior companions are over the age of 55 and provide companionship and reassurance with seniors and adults with special needs, he says, noting that these companions visit, and listen.

To request a Senior Companion or to apply to be a Senior Companion contact RIOHA at 401-462.0569.  

Connell also directs seniors to investigate volunteer opportunities at The Village Common of Rhode Island (TVC). The nonprofit, volunteer-driven membership organization supports seniors who wish to age in their home via a network of local villages – communities of mutual support – in Rhode Island.

“We currently have villages in Barrington, Edgewood, Providence and Westerly. Our volunteers assist members in a myriad of ways, from driving to medical appointments and running errands, to doing household chores and minor repairs, to providing technology support for TVs, phones and computers, to making friendly calls and visits,” says Connell, noting that TVC and its local villages host an array of social and educational events for our members and volunteers (live, and via zoom).

Finally, Connell also notes that local Senior Centers, Child and Family Rhode Island, located in Newport and Providence, Meals on Wheels, the Rhode Island Food Bank (or local food banks in every city and town, can be a great source for volunteering, too. 

For details about the benefits of becoming a volunteer, go to 

https://projecthelping.org/benefits-of-volunteering/.

To learn about volunteer opportunities, go to:

A listing of senior volunteer activities, Office of Healthy Aging, go to https://oha.ri.gov/get-involved/volunteer/

AARP Rhode Island, go to https://states.aarp.org/rhode-island/volunteering-aarp-rhode-island

Rhode Island Food Bank, go to https://rifoodbank.org/get-involved/volunteer-in-the-community/ or 

Local food bankshttps://dhs.ri.gov/sites/g/files/xkgbur426/files/Documents-Forms/FoodAssistanceProviderListFAL-October-16-2020.pdf

Children@FamilyRI, go to https://childandfamilyri.com/

Rhode Island Community Action Programs, go to  https://www.ricommunityaction.org/find-your-community-action-agency/

Rhode Island Senior and Volunteer Program, go to https://americorps.gov/serve/americorps-seniors

United Way of Rhode Island, go to https://volunteer.uwri.org/

RI Elder Info, Advocacy Agencies, go to https://rielderinfo.com/advocacy-assistance/

Diocese of Providence, go to https://dioceseofprovidence.org/elder-services