Digest 2023 - Dignity Alliance

In April 2022, the Centers for Medicare & Medicaid Services (CMS) announced it was beginning the process of implementing a minimum staffing standard for nursing facilities. This standard would require nursing homes to have enough staff to provide each resident with a minimum amount of direct care each day. Since the announcement, CMS has undertaken a study to determine the standard and intends to publish proposed rules in early 2023. When implemented, this standard will be the most significant increase in protections for nursing homes in decades.

Staffing nursing homes adequately has multiple benefits to residents. Numerous studies have found that there is a correlation between higher staffing levels and improved care quality. A 2001 CMS study found that nursing home residents require 4.1 hours per resident day (hprd) of direct nursing care to avoid being at an increased risk of harm. The study found that every day residents need, at a minimum, .75 hours of care performed by a Registered Nurse, .55 hours of care performed by a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN), and the remaining 2.8 hours of care to be performed by a Certified Nursing Assistant (CNA). Any new federal staffing standard should separately mandate staffing hours for each nursing staff category, i.e., RN, LPN/LVN, CNA. A 2020 paper recommended a guide for determining adequate staffing that resulted in a proposal for six different minimum staffing standards based on PDPM resident acuity levels.

Consumer Voice strongly supports the creation of a staffing standard that creates different minimum staffing baselines based on the acuity of nursing home residents. It is essential that this standard provide minimum staffing levels based on resident acuity and be broken down into nursing staff to resident ratios. A minimum staffing standard will save countless lives and result in better health outcomes for nursing home residents across the country.

Spotlight – Inappropriate Use of Antipsychotics

Biden-Harris Administration Takes Additional Steps to Strengthen Nursing Home Safety and Transparency

Centers for Medicare & Medicaid Services, January 18, 2023

CMS to increase oversight of inappropriate antipsychotics use

As part of the continuing efforts under President Biden’s initiative to improve nursing home transparency, safety and quality, and accountability, today the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new actions to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families.

“President Biden issued a call to action to improve the quality of America’s nursing homes, and HHS is taking action so that seniors, people with disabilities, and others living in nursing homes receive the highest quality care,” said HHS Secretary Xavier Becerra. “No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic. The steps we are taking today will help prevent these errors and give families peace of mind.”

CMS to Reinforce Safeguards against Unnecessary Medications and Treatments

Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medications. Antipsychotic medications are especially dangerous among the nursing home population due to their potential devastating side effects, including death. This action advances the Biden-Harris Administration’s goal of reinforcing safeguards against unnecessary medications and treatments that was outlined in President Biden’s State of the Union Action Plan for Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes.

“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. “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.”

This action furthers the Administration’s objective to improve the accuracy of the quality information that is publicly reported and the nursing home Five-Star Rating System. The use of antipsychotic medications among nursing home residents is an indicator of nursing home quality and used in a nursing home’s Five-Star rating, however it excludes residents with schizophrenia. If an audit identifies that a facility has a pattern of inaccurately coding residents as having schizophrenia, the facility’s Five-Star Quality Measure Rating on the Care Compare site will be negatively impacted. For audits that reveal inaccurate coding, 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.

CMS to Post Citations Under Dispute on Care Compare

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

While 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 a facility. This new information will begin appearing on Care Compare on January 25, 2023. While the citations will be publicly displayed, they will not be included in the Five-Star Quality Rating calculation until the dispute is complete.

Today’s actions by CMS are the latest among several actions the agency has taken over the years to strengthen public reporting and the Five-Star Quality Rating System. These actions include:

Adding the results of focused infection control surveys to the Care Compare website and Five-Star Quality Rating System,
Increasing the Quality Measure rating thresholds to incentivize improved quality, and
Adding measures of staff turnover to inform consumers of the stability of a nursing home’s staff (which is linked to the quality of care a nursing home provides).

Read 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 .

Feds to investigate nursing home abuse of antipsychotics

AP News, January 18, 2023

The federal government says it will begin a targeted crackdown on nursing homes’ abuse of antipsychotic drugs and misdiagnoses of schizophrenia in patients.

The Centers for Medicare and Medicaid Services is launching investigations this month into select nursing homes, aimed at verifying whether patients have been properly diagnosed with the psychiatric disorder.

Evidence has mounted over decades that some facilities wrongly diagnose residents with schizophrenia or administer antipsychotic drugs to sedate them, despite dangerous side effects that could include death, according to the agency.

“No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic,” Health and Human Services Secretary Xavier Becerra said in a statement Wednesday. “The steps we are taking today will help prevent these errors and give families peace of mind.”

Some facilities may be dodging increased scrutiny around gratuitous use of antipsychotic medications by coding residents as having schizophrenia, even when they do not show signs of the extremely rare disorder, a government report last year found. Less than 1% of the population is believed to have schizophrenia, which is marked by delusions, hallucinations and disordered thinking.

In 2012, the federal government began tracking when nursing homes use antipsychotics on residents — doing so can impact the facility’s quality rating in a public database — but only for those who have not been diagnosed with schizophrenia.

Antipsychotics for those nursing home residents has dropped to under 20% in recent years, according to federal data.

A November report from the HHS Office of the Inspector General, however, revealed that the number of residents reported as having schizophrenia without a corresponding diagnosis skyrocketed between 2015 and 2019, with 99 nursing homes in the country reporting that 20% or more of their residents have the disorder.

“The number of unsupported schizophrenia diagnoses increased and in 2019 was concentrated in relatively few nursing homes,” the report concluded.

CMS will start targeted audits to ask nursing homes for documentation of the diagnoses in the coming days, focusing on nursing homes with existing residents who have been recorded as having schizophrenia.

The rating scores for nursing homes that have a pattern of inaccurately coding residents as having schizophrenia will be negatively impacted, CMS said in a statement released Wednesday, stopping short of threatening to levy fines against facilities.

The agency does not have plans to immediately intervene in the patients’ care directly or notify relatives of residents who have been wrongly coded or given antipsychotics, according to senior HHS officials who insisted on anonymity to brief The Associated Press on the matter on Tuesday. CMS will monitor the facilities to make sure the issues are corrected, officials said.

Issue #121 – January 9, 2023

Download the Word Digest: Dignity Digest 121.docx
Download the PDF Digest: Dignity Digest 121.pdf

Spotlight – The Call for Nursing Home Reform: Will It Have Any Effect?

Forbes, January 5, 2023

Nursing homes have probably been the absolute last choice of where to go for any impaired elder in need of some care. The average age of a nursing home resident is 86. Many folks are there because they have no other option. About 60% of the 1.4 million residents receive Medicaid as their only payment source for living there.
All kinds of professionals and stakeholders are in agreement that the nursing home industry is broken. This is not new news. As a 19-year-old nursing student, decades ago, I worked in nursing homes and I saw what was going wrong firsthand. From what is observable now, things have only gotten worse in the decades since. Most glaringly, failure of nursing homes to adequately address the pandemic led to approximately 133,000 deaths from Covid. We can only speculate that if these facilities had adequate protective equipment (masks, gloves, and gowns) that some of these deaths were avoidable. We can also speculate that if their administrators and staff had adequate education about infection prevention, that Covid-related outcomes would have been much better. Have we learned anything from this?
Beautiful plans are in place to make nursing homes less hospital-like and more friendly. Great minds have devised reform policies for everything from staff-resident ratios to construction of facilities that feel more like homes than outdated, cold, unfriendly structures they usually are. And what will become of those lofty goals?
My guess: not much. It will all depend a great deal on Congress authorizing funding for such reforms. From here, it does not appear that taking care of our frail and dependent elders is a broad legislative mandate. The residents in these homes are not the target voters of those who attain legislative power. Nor are their families, many the spouses and adult children of their frail elders, some of whom are impaired to some extent themselves. We simply don’t see nursing home residents’ families marching in the streets demanding that their elected representatives in Congress do something about the broken system.
In 2022, President Biden announced in his State of the Union address that his administration planned to set higher standards for nursing homes. The plan included setting minimum staffing standards in them. What’s wrong with that idea? Barely any of these homes are adequately staffed and they have trouble attracting workers. If they pay workers more, that will cut into the profits of the private equity firms that own many of them. By 2018, private equity firms had invested $100 billion in for-profit nursing homes. And of course, one must find workers willing to do the hard and often messy work. We have a nationwide labor shortage and this sector is no exception.
Another prong of the plan: find ways to reduce shared rooms in nursing homes. These are the only kind of rooms Medicare (for short term stays only) and Medicaid (long term stays) pay for. Do you think that the motivation of our Federal legislators is to spend more money on Medicare benefits or expand Medicaid benefits? I say, fat chance. Many seem bent on reducing government spending, not increasing it.
All the lofty goals of reforming nursing homes are well thought out, and worth the time of those involved to create a vastly better vision for what nursing homes should be. And, unfortunately, it does not look like the dysfunctional legislative body we have now is going to bring any of those worthy plans to fruition. They are far more likely, sad to say, to just let things be as they’ve been for the past 70 years.
Anyone who has a loved one who must go to or live in a nursing home would probably agree that it is unsatisfactory to have them there. If you want change, you need to bring this to the repeated attention of your elected representatives and to ask directly for the much-needed changes.
Your allies include: LeadingAge a national coalition of age-focused nonprofit organizations, and service providers, and Moving Forward Coalition, a group of nursing home providers and others, working to create action plans to improve nursing home care. Additional state-based organizations have vigorously advocated for legislative change for years. It all boils down to the question of how to get the Federal funding to make these essential changes a reality.

Issue #120 – January 3, 2023

Download the Word Digest: Dignity Digest 120.docx
Download the PDF Digest: Dignity Digest 120.pdf

Spotlight: Judy Woodruff on how her son with disabilities changed her view of health care

Washington Post (free access), December 29, 2022

The ‘PBS NewsHour’ anchor is stepping down but still plans to report from around the country, with some stories about people with disabilities. . .

One subject close to her heartthat she wants to highlight? People with disabilities.

Her oldest son, Jeffrey Hunt, was born with what she calls a “very mild” case of spina bifida. When he was a teenager, what was a supposed to be a routine operation left him in a wheelchair and in need of full-time care. It was life-altering for Jeffrey and the entire family. . .

“I thought I was sensitive and compassionate before Jeff was injured,” Woodruff says. “But I found that there’s just a whole other level of what he was experiencing that affected me profoundly.” As a parent and caregiver, “you suddenly belong to this community that you never knew you were going to be part of, and none of us probably wanted to be there.” . .

“It makes you appreciative of how difficult and expensive a serious health issue is,” Al [Hunt, Judy Woodruff’s husband] says. “It used to infuriate me when politicians would talk about how good the current health-care-delivery system was. They never went through the hell of not being about to afford the best care.”

He and Woodruff credit politicians such as Bob Dole, John McCain, Tom Harkin, and Ted Kennedy, who fought for the Americans with Disabilities Act and other legislation that protects people with disabilities from discrimination and mandates public accommodations. Obamacare, he says, has also helped millions of families. . .

Their experience has also provided a better understanding of how health care and disabilities are reported in the media. “I’ve gotten to know journalists over the years who cover people with disabilities — and recognize, frankly, how little it’s covered,” Woodruff says. “There certainly are plenty of groups out there beating the drum for cancer and heart disease and covid. They’re all worthy. They’re all important.”

Covering disabilities is complicated by the fact that they occur for so many reasons: genetic conditions, illness, accidents, war injuries. “Because there are so many different organizations and people advocating, it’s been hard to come together and make one case,” she says. “It pits one good cause against another good cause.”

Over the next two years, Woodruff says, she plans to do more segments on disability in America, with a special interest in the lack of resources for adults living with disabilities. It is an issue that cuts across politics, demographics, and party lines; she hopes she can bring her personal experience to the stories and help restore some of the country’s broken trust in the media.

“We have to walk that fine line between having a heart and caring and being human, but also understanding that we have a job to do,” she says. “So, I guess I’m asking the public to understand that. Most of us are trying to do the right thing. We’re trying to get the story right.”