CMS Announces Initiatives to Strengthen Nursing Home Safety and Transparency – On January 18, 2023, CMS issued a Quality, Safety & Oversight Group memorandum announcing its initiative to improve nursing home safety and transparency. Specifically, CMS will conduct audits to determine whether nursing homes are appropriately diagnosing and coding patients for schizophrenia, and based on the audit findings, CMS will adjust the quality measure star ratings if inaccurate coding is discovered. Additionally, CMS will post all citations that a nursing home receives on the Nursing Home Care Compare website to provide consumers with transparency.
Adjusting Quality Measure Ratings Based on Audit of Schizophrenia Coding in Nursing Homes
In a pilot audit of nursing homes conducted earlier this year, CMS found several issues related to inaccurate coding and diagnosis of residents with schizophrenia, including a lack of comprehensive psychiatric evaluations and misdiagnosis based on conditions or behaviors related to dementia, rather than schizophrenia. Accordingly, CMS will launch off-site audits of nursing homes to identify problematic coding and diagnosis, with the goal to reduce the use of unnecessary antipsychotic drugs, which CMS indicates are often prescribed to residents who are erroneously diagnosed with schizophrenia.
CMS notes that antipsychotic drugs can be dangerous, especially among the nursing home population, because of their severe side effects, including death. The use of antipsychotic drugs among long-stay nursing home residents is one Quality Measure (QM) used in the Five-Star rating system on the Nursing Home Care Compare website. However, CMS is concerned that this measure does not include residents with a diagnosis of schizophrenia, which can mask the nursing home’s true rate of antipsychotic drug use.
Accordingly, if an audit identifies that a nursing home has inaccurately coded residents with a diagnosis of schizophrenia, the nursing home’s QM ratings will be adjusted as follows:
- The overall QM and long stay QM ratings will be downgraded to one star for six months (this drops the facility’s overall star rating by one star).
- The short stay QM rating will be suppressed for six months.
- The long stay antipsychotic QM will be suppressed for 12 months.
Nursing homes selected for an audit will receive a letter from CMS explaining the purpose and process of the audit, and they will have an opportunity to discuss the audit results with CMS at the conclusion of the audit. Additionally, nursing homes will have the opportunity to forgo the audit by admitting they have error and committing to correct the issue.
Posting Citations on the Nursing Home Care Compare Website
CMS will also increase transparency of nursing home information by posting on the Nursing Home Care Compare website all citations that a nursing home receives. Currently, citations are not posted until nursing homes complete the dispute process under the Informal Dispute Resolution (IDR) and Independent Informal Dispute Resolution (IIDR), which takes approximately 60 days. In the interest of increasing transparency and nursing home accountability, CMS will be posting all citations regardless of their dispute status under the IDR/IIDR. While the citations will be displayed, they will not affect the Five-Star rating until the disputes are complete.
The CMS memorandum is available here.