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

Financial Exploitation of Elderly Must Be Addressed

Published in Pawtucket Times, February 7, 2015

 Professor Philip Marshall, Coordinator of the Historic Preservation Program at Roger Williams University in Bristol, entered Room 562 in the Dirkson Senate Building not to testify on historic preservation policy, as he often did, but to share a family tragedy.  Marshall’s testimony detailed how his grandmother, New York philanthropist Brooke Astor, was financially exploited in her later years by his father.

Brooke Astor, a philanthropist, socialite and writer, was presented the Presidential Medal of Freedom by President Bill Clinton in 1998, for her generous giving of millions of dollars to social and cultural cause.  Marshall, one of four witnesses who came before the U.S. Senate Special Committee on Aging this past Wednesday, would say, that his 105 year old grandmother, who died on August 13, 2007, was considered to be “New York’s First Lady,” and a “humanist aristocrat with a generous heart.”

Marshall, a resident of South Dartmouth, Massachusetts, told the panel his mother would never have wanted to be known as “one of America’s most famous cases of elder abuse.”

“Nor did she, while in the throes of dementia, choose to be victimized to be deprived, manipulated and robbed – all as a calculated ‘scheme to defraud,’ as later characterized by the Manhattan District Attorney,” said Dr. Marshall.

Astor’s financial exploitation “may be her greatest, most lasting legacy,” says  Marshall.

In his testimony, Marshall told the attending Senators that after a three-month battle for guardianship to protect his grandmother’s assets, a settlement was reached five days before the court date.  A criminal investigation launched by the Manhattan District Attorney after a potential forgery was referred to his Elder Abuse Unit, would later lead to the indictment in 2007 of his father and a lawyer, says Marshall.

Two years later, after a six-month criminal trial the jury would find Marshall’s father guilty on 13 of 14 counts against him.  All, but one, were held up on appeal.

“While my grandmother’s stolen assets were reclaimed, many elders never reclaim their money – or their lives,” observes Marshall.  “Here, for financial transactions, enhanced detection, mandatory reporting, and greater reporting of suspicious activity will help,” he says.

A Growing Epidemic

 In her opening statement, Senator Susan M. Collins, (R-Maine) who chaired, the Senate Aging Panel’s hearing, “Broken Trust: Combating Financial Exploitation Targeting Vulnerable Seniors,” warns that a growing epidemic of financial exploitation is happening – one that she estimates to cost seniors an estimated $2.9 billion in 2010, according to the Government Accounting Office.

Financial exploitation is a growing problem in Rhode Island, too, notes Senator Sheldon Whitehouse (D-RI), a member of the Senate Aging Panel. “Sadly, this number likely underestimates the cost to victims because older adults often do not report abuse, particularly when it involves a family member.”

Senator Whitehouse noted that this week’s Special Committee on Aging hearing examined the challenges to identifying and prosecuting fraud schemes and highlighted strategies to prevent the financial exploitation of seniors. “There are steps we can take to address this problem, and I strongly support the Older Americans Act, which recently advanced out of the HELP Committee and addresses financial exploitation and other forms of elder abuse,” he added.

“Over the past several years the Rhode Island State Police has experienced a steady increase in the number of complaints of elderly exploitation and larceny from individuals over sixty-five-years, says Colonel Steven O’Donnell, who oversees the Rhode Island State Police.  During the past six years his Agency has investigated 40 complaints amounting to a total loss to victims of over $1,000,000.00.

According to O’Donnell, in 2010, State Police investigated four complaints related to elderly exploitation and/or larceny.  Four years later, 14 complaints were investigated. “These increases may be attributed to the increased computer literacy of willing perpetrators and the increased accessibility to bank accounts online, which provides perpetrators the opportunity to conduct their criminal activity behind closed doors,” he says.

Combating Financial Exploitation

To ratchet up the protection of older Rhode Islanders against financial exploitation, Rhode Island Attorney General Peter Kilmartin and the Rhode Island General Assembly passed a bill last year that extends the statute of limitations for elder exploitation from three years to ten years. Kilmartin says the new law, sponsored by retired Representative Elaine A. Coderre (D-District 60, Pawtucket) and Senator Paul V. Jabour (D- District 5, Providence), gives law enforcement officials the necessary time to build a proper case for charging and subsequent prosecution, bringing it in line with other financial crimes.

“The law about financial exploitation is on the books—let’s enforce it,” says, Kathleen Heren, State Long Term Care Ombudsman, at the Warwick-based Alliance for Better Long Term Care. “What a sad world we are in where a senior or a disabled person loses everything they have scrimped and saved for to a greedy individual who, in the majority of cases, is a family member,” she adds.  Over the years she has also seen financial exploitation involving clergy, lawyers, bank tellers, brokers, and “people who you would never suspect would steal from a frail elder.”

“Many people who hear “elder abuse and neglect” [or financial exploitation] think about older people living in nursing homes or about elderly relatives who live all alone and never have visitors. But elder abuse and financial exploitation are not just problems of older people we never see. It is right in our midst, and as Attorney General, I am committed to doing all I can to protect all of the citizens of our state,” says Kilmartin.

“Many elders rely on others for assistance, but oftentimes think they can easily trust these helpers to handle their financial affairs, only to be robbed of their hard earned money,” says Kilmartin, noting that in some cases the perpetrator leaves the victim penniless.

Kilmartin notes that financial exploitation of elders is one of the most challenging crimes to investigate, charge and prosecute.  By the time law enforcement becomes aware of the abuse and investigates the matter, the statute of limitations has often expired.  “The statute of limitations needs to be more reasonable so these complicated cases can be prosecuted appropriately,” states Rhode Island’s Attorney General. “Seniors, especially those who must rely on others for care, were unnecessarily made more vulnerable by the previous short statute of limitations,” he says.

According to Kilmartin, The Office of Attorney General has a specialized unit of prosecutors and investigators that handle elder abuse cases.  Several years ago, the Elder Abuse Unit was created because of the large percentage of Rhode Islanders who were age 60 and over. The special needs of the older victims and the fact that elder abuse, neglect and exploitation crosses all racial, socio-economic, gender and geographic lines made the need for a special unit apparent.  Coupled with this fact that this age group is the State’s fastest growing demographic, crimes against older persons often times go unreported, presenting high temptation and low risk for prosecution.

In Rhode Island, there is a mandatory duty of all citizens to report a suspicion of elder abuse and/or elder financial exploitation. To report elder physical abuse and/or elder financial abuse, contact your local police, Rhode Island State Police or the Rhode Island Division of Elderly Affairs at (401) 462-3000 or dea.ri.gov.

Herb Weiss, LRI ’12 is a Pawtucket writer covering aging, health care and medical issues.  He can be reached at hweissri@aol.com or at 401 742-4372.