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

Bill would (re)create a RI Department of Healthy Aging

Published in Pawtucket Times on March 21, 2022

There are new efforts on Smith Hill to transform the state’s Office of Healthy Aging (OHA) into a department making it far more visible and effective as an advocate for the state’s growing senior population.  H. 7616, introduced by Rep. Lauren H. Carson (D-District 75, Newport), would expand the office in the Department of Human Services (DHS) into a full-fledged state department, expand its director’s authority, and appoint local senior centers as hubs for service delivery, with authority to bill Medicaid for transportation services.

The RI Department of Elderly Affairs (DEA) was created by law in 1977 and remained a department until 2011, when the legislature changed it to a division within the Department of Human Services (DHS). In 2019, the department was re-named the Office of Healthy Aging (OHA), shifting narratives and perceptions associated with growing older. At press time, the Office of Healthy Aging remains a division under the Department of Human Services. 

“Rhode Island should invest much more than we do in services that enable people to age in place and safely remain in their communities. Those services are far more cost-efficient overall, and encourage an active, more fulfilling lifestyle for people as they age”, says Carson in a statement announcing the introduction of the bill on March 2, 2022. “Considering that a quarter of our population consists of seniors, and that ratio is growing as the Baby Boomers join them, now is the time,” she adds.

At press time, the bill has been sent to the House Finance Committee, and its cost has not yet been determined and there is no companion measure introduced yet in the Senate.

“Working cooperatively with the senior centers operating around the state, we could make it much easier for people to access the support they need as they age, and really make the quality of life much better for the entire older population of our state,” says Carson expressing the importance of the state’s senior centers.

H. 7616 would authorize the new Department of Healthy Aging to protect and enable seniors to stay healthy and independent by providing meals, health programs, transportation, benefits counseling and more. Under the bill, the department would provide professional development to agencies and programs that provide services to seniors in the state and become a clearing house to help those agencies and businesses assist senior centers, which would serve as hubs for the delivery of services from the state.

In particular, H 7616 directs the new department to manage and develop a multi-tiered transportation system that works with the Department of Human Services, the Department of Transportation, senior centers and with all existing modes of public transportation to develop transportation plans that suit the elderly population of each municipality. The director would be enabled to authorize senior centers to bill Medicaid for transportation they provide.

The legislation also seeks to have the new department develop and submit to the General Assembly a funding formula to meet the requirements the new law sets forth, including input from seniors and the caregivers and allocating funding to each municipality based on its senior population, with restrictions that the funding be used only for senior programs.

Carson explains that this bill is intended to start important dialogue among state lawmakers, state officials and aging organizations about appropriately providing for Rhode Island’s aging population.

 “Whether or not we pass this bill this year, we have to address the needs of our growing older population. Leaving those needs unmet has a much greater price tag than decent locally administered basic programs would. Our whole state would be better served by investments that keep seniors safe with support in their community,” Carson said.

OHA and Aging Advocates Give Their Two Cents

Nicole Arias, a spokeswoman for OHA, says “we look forward to any future discussions and collaborations with community members, partners, and legislators.” When asked if the Rhode Island Advisory Commission on Aging, charged with advising the governor on aging policies and problems impacting older Rhode Islanders, Chair James Nyberg stated the commission also plans to review and discuss the bill at an upcoming meeting. 

“Our office looks forward to participating in dialogue that empowers and supports our aging residents and championing essential quality of life items such as healthy housing and reliable transportation. While our office is still unpacking H 7616, we appreciate Rep. Carson and the bill’s cosponsors for advocating on behalf of our senior residents,” says Lt. Gov. Sabina Matos, who over sees the state’s Long-Term Care Coordinating Council (LTCCC). The group works to preserve senior’s quality of life in all settings and coordinates state policy concerning all sectors of long-term care for seniors.

Bernard J. Beaudreau, Executive Director of the Senior Agenda Coalition of Rhode Island, says his group strongly supports any and all efforts that increase the state’s programs and services to address the growing needs of our aging population, especially those with low and moderate incomes.  The state-wide coalition calls for the reinstatement of OHA to a full department, but not without the commensurate expansion of funding and services that are needed for this important state government function.   

“When the Department of Elderly Affairs was reorganized to be a division of the Department of Human Services, we were concerned that it signified a diminishing of the importance of senior needs in the state budget.  While from a management perspective, the division within the larger Department of Human Services could streamline the delivery of services, there would still be the need to increase staffing and programs to meet the growing needs,” says Beaudreau. This did not happen in the ensuing years.

“Restoring the OHA to a department status will strengthen its position at the budget table and elevate the importance of programs supporting older residents of our state. We hope that will make a difference,” says Beaudreau.

“The legislation proposed by Rep. Carson elevates the conversation about the importance of age-friendly policies that enable Rhode Islanders to choose how we live as we age,” said AARP Rhode Island State Director Catherine Taylor. “AARP Rhode Island looks forward to being part of this conversation and continuing to advocate fiercely at both the state and local levels for enhanced home and community-based supportive services, accessible and affordable housing and transportation options, and full inclusion of people of all ages and abilities in community life,” she said. 

According to Maureen Maigret, policy consultant and chair of the Aging in Community Sub-committee of Rhode Island’s Long-Term Care Coordinating Council, H 7616 is a very significant bill that will help to stimulate a long due discussion as to how the state should fund senior programs and services in light of the state’s growing age 65 and older population. This age group is projected to represent at least one in five of  the state’s residents by 2040.

Maigret recalls that the state’s Department of Elderly Affairs was created by law in 1977 and remained a cabinet level department until 2011 when the Rhode Island General Assembly changed it to a division within the Department of Human Services as part of the enacted budget bill.  Eight years later, lawmakers would change the agency’s name from the division of elderly affairss the OHA. The enacted law placed OHA in the Department of Human Services for administrative purposes and called for the OHA Director to be appointed by and to report to the Governor with advice and consent of the Senate.

When Maigret left her position of Director of Elderly Affairs (serving from 1991 to 1994), its budget for FY1995 was $13.9 million (state funds) and it had at least 60 full-time employees. The state’s  FY2022  budget for OHA stands at $12 million (state funds) with 31 authorized employees, she said.

Maigret warns that the existing OHA is under-resourced both in state funding and human resources. She calculates that Rode Island spends about fifty dollars per older person (age 65 and older) when taking into account state funding for senior services and its population age 65 and over.

“We could do so much more to support our older adults by addressing service gaps especially for those not poor enough to meet our strict Medicaid income eligibility rules which require older adults to have income less than $13,600 and assets less than $4,000 single and $6,000 for a couple,” Maigret says. Funding for local senior centers and programs in Rhode Island municipalities should be calculated by at least $10 per person aged 65. 

Maigret urges state lawmakers to support local transit assistance efforts, to increase funding for caregiver support programs, and to expand information services to provide assistance to seniors to assist them to find subsidized home maintenance and chore service programs.  Better funding should be allocated to support volunteer programs that provide companionship and other services to reduce social isolation,“ she says.

“I suggest reverting the OHA to a full department as called for in H 7616 only if there is a concomitant increase funding and resources, says Maigret, noting that one source of funding could be available from  the Perry/Sullivan law (that the Governor’s budget proposes to defer for FY2023.),  These state funds could be used to allow OHA to truly provide the needed supports and services to older adults to live full and healthy lives as intended in the department’s creation,” she says.

“Older adults suffered greatly during the COVID pandemic – 90% of the deaths were individuals 60 and over, claims Vin Marzullo, a well-known aging advocate who served as a federal civil rights and and national service administrator. “We must provide greater attention and care for this vulnerable population,” he says. 

“Since the proposed legislation to elevate the OHA to department status was initiated by the Rhode Island House, I would hope that former House legislator, Marie Cimini, would welcome and embrace this legislation to become a premiere agency for the Governor, quips the West Warwick resident. He notes that Cimini was recently nominated by Gov. Dan McKee for the position of Director of the state’s Office of Healthy Aging.  This nomination requires Senate confirmation.

The other cosponsors of the H 7616 include Rep. Deborah Ruggiero (D-Dist. 74, Jamestown, Middletown), Rep. James N. McLaughlin (D-Dist. 57, Cumberland, Central Falls), Rep. Terri Cortvriend (D-Dist. 72, Portsmouth, Middletown), Rep. June S. Speakman (D-Dist. 68, Warren, Bristol), Rep. Edith H. Ajello (D-Dist. 1, Providence) and Rep. Brandon Potter (D-Dist. 16, Cranston).

Hopefully the upper chamber will see the wisdom in considering a companion measure to  H. 7616.  Let the debate begin. 

For more details about OHA, go to https://oha.ri.gov/