CMS revises standards to strengthen oversight of nursing home inspections

As part of CMS’s efforts to improve nursing home resident safety and respond to concerns about inconsistent and untimely inspections, CMS has revised the State Performance Standards System (SPSS) process. The updates to the SPSS aim to enable CMS and State Agencies to address areas of concern more effectively and ultimately improve beneficiary safety and the quality of their care (CMS Letter to State Survey Agency Directors, Admin Info: 20-02-ALL, October 17, 2019).

Structural changes

Included in the changes to the SPSS guidance is a new non-scored tier of measures that includes frequency run-rates and State Performance Indicators. Frequency run-rates measure goals during the fiscal year will be published in the form of a quarterly data extract. These frequency run-rates will be useful to assess mid-year progress made towards meeting Frequency measures during the fiscal year. The State Performance Indicators will help identify underlying causes for inadequate performance in one or more of the scored performance measures.

Domain changes

Within the Frequency Domain, a new process for State Survey Agencies to request permission from CMS to exclude surveys from frequency measure calculations is included in the guidance. It was also updated to include an evaluation of the timely completion of initial certification surveys for the End Stage Renal Disease (ESRD) program. Sub-domains were established within the Quality Domain that focus on the standard survey and complaint survey processes, separately. The method of evaluating and the criteria associated with the documentation of deficiencies was revised to reduce subjectivity and burden. Finally, the Enforcement Domain was renamed “Coordination of Provider Noncompliance,” to more accurately reflect the role of State Survey Agencies.

Guidance

The guidance provides instructions to Regional Offices on how to evaluate State Survey Agency performance. Measures should be calculated according to the specific instructions for each measure in the guidance and the scores should be entered into the database within the CMS SharePoint site. The guidance provides a timeline for the evaluation period along with deadlines. For each measure that is scored as “not met,” the State Survey Agency should develop and implement a corrective action plan that will address identified problems. The guidance also provides direction as to how and when the Regional Office should follow-up on progress toward making corrections.

Kusserow on Compliance: GAO reports CMS gaps in nursing home oversight

CMS needs to address gaps in federal oversight of nursing home abuse investigations

The Government Accountability Office (GAO) reviewed CMS oversight of nursing home abuse in response to a request from the Congress. As part of its review, the GAO interviewed officials from survey agencies about how they investigate complaints and facility-reported incidents of resident abuse in nursing homes in five selected states.

The GAO noted, there are approximately 15,600 nursing homes providing care to about 1.4 million nursing home residents, a population of elderly and disabled individuals. CMS defines the standards nursing homes must meet to participate in the Medicare and Medicaid programs, including standards for resident care and safety. To monitor compliance with these standards, CMS enters into agreements with state survey agencies to conduct standard surveys or evaluations of the state’s nursing homes. Those surveys and evaluations investigate both complaints from the public and facility-reported incidents regarding resident care or safety, such as abuse. Investigations of nursing homes based on public complaints and facility-reported incidents offer a unique opportunity for the state survey agencies to identify potential abuse, as these can provide a timely alert of acute issues that otherwise might not be addressed until the standard survey.  Federal nursing home surveys and investigations of complaints and facility-reported incidents can be cited and tracked by CMS. Where deficiencies are found, CMS can impose federal sanctions to prompt the correction of deficiencies.

The review focused on Oregon, a state with 135 nursing homes caring for approximately 7,000 residents. The GAO found failure to follow federal requirements that the survey agency investigate all complaints and facility-reported incidents. Additionally, the GAO found CMS failed to address gaps in federal oversight in Oregon for at least 15 years. The GAO suggested to CMS that these problems may extend to other states and that CMS needs to take corrective action.

GAO recommendations to the administrator of CMS included: (1) evaluating state survey agency processes in all states to ensure all state survey agencies are meeting federal requirements that state survey agencies are responsible for; (2) investigating complaints and facility-reported incidents alleging abuse in nursing homes; and (3) that the results of those investigations are being shared with CMS.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Increased CMS Spotlight on Nursing Facilities

CMS and states visit nursing homes on a regular basis with “survey” or “inspection” teams to determine if the nursing homes are providing the quality of care that is required by Medicare and Medicaid, as well as to identify deficiencies in meeting CMS safety requirements. When deficiencies are identified, they must be corrected, and, if serious ones are not corrected, it may lead to termination from participation in Medicare and Medicaid.

Most facilities correct their problems within a reasonable period. However, some have significantly more problems that the norm with a pattern of serious problems persisting over three or more years. Although some facilities institute enough improvement that they are in substantial compliance on one survey, significant problems often resurface by the time of the next survey. Such facilities are referred to by CMS as a “yo-yo” or “in and out” compliance history. These facilities rarely address underlying systemic problems that are giving rise to repeated cycles of serious deficiencies. To address this problem CMS created the “Special Focus Facility” (SFF) initiative that is a listing of problematic nursing homes that have had a history of serious quality issues and are included in a special program to stimulate improvements in their quality of care.

Those on the SFF list are visited in person by survey teams twice as frequently as other nursing homes (about twice per year). The longer the problems persist, the more stringent the enforcement actions, including imposition of civil monetary penalties (“fines”) or termination from Medicare and Medicaid.  Within about 18 to 24 months after a facility is identified by CMS as an SFF nursing home, CMS expects: (1) improvement & graduation off the SFF; (2) termination from participation in Medicare/Medicaid programs; or (3) extension of time on SFF because of some progress or change of ownership. For more information check the CMS website that posts SFF Nursing Homes in five (5) categories:

  1. newly added to the SFF;
  2. failing to show significant improvement since being posted on the SFF;
  3. showing significant improvement by the most recent survey, and CMS is monitoring;
  4. graduating off the SFF because they not only improved, but they sustained significant improvement for about 12 months (through two standard surveys); and
  5. terminated by CMS from participation in Medicare and Medicaid within, or voluntarily chose not to continue such participation.

To assist in improving Nursing Home quality, CMS began rating all nursing homes using a Five-Star Quality Rating System that can be found at https://www.medicare.gov/NHCompare.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Meeting nursing home compliance program legal mandates

The November 28, 2019 deadline approaches for skilled nursing facilities and nursing homes to adopt and implement an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs. At that time, state survey agencies will begin assessing facility compliance with implementation of an effective compliance and ethics program. Yet, the OIG continues to find major problems with that health care sector. The OIG recently reported that posthospital extended care services or Medicare beneficiary coverage must be preceded by an inpatient stay in a hospital for not less than three consecutive calendar days. The OIG found that CMS improperly paid 65 of the 99 skilled nursing facility (SNF) claims sampled by the OIG.  Projecting from its sample, the OIG estimated that CMS improperly paid $84 million for SNF services over a two-year period.

Those nursing homes that followed the OIG guidance will have little problem in meeting the new mandate, but those who did not have only months to come into compliance. Organizations trying to catch up should consider having a compliance expert perform a gap analysis to identify elements needed for the compliance program and how be able to evidence program effectiveness. A gap analysis should provide a “road map” and step-by-step plan for bringing a facility into compliance with the mandates. Those that have already implemented a compliance program should consider having an effectiveness evaluation conducted by experts to verify that the program will meet mandated standards.

For more information about meeting the standards of these new mandates, Tom Herrmann may be reached at thermmann@strategicm.com or at (703) 535-1410.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.