DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
Ref: QSO-23-05-NH QSO-23-05-NH (PDF) - CMS
DATE: January 18, 2023
TO: State Survey Agency Directors
FROM: Director, Quality, Safety & Oversight Group (QSOG)
SUBJECT: 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
Memorandum Summary
•Adjusting Quality Measure Ratings: CMS will be conducting audits of schizophrenia coding in the Minimum Data Set data and, based upon the results, adjust the Nursing Home Care Compare quality measure star ratings for facilities whose audits reveal inaccurate coding.
•Posting Citations Under Dispute: To be more transparent, CMS will now display citations under informal dispute on the Nursing Home Care Compare website.
Background:
Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding
In 2008, CMS added the Five-Star Quality Rating System to the CMS Nursing Home Compare website. The rating system comprises three rating domains: health inspections, staffing, and quality measures (QMs). One of the QMs reported on Nursing Home Care Compare and included in the star rating calculation is the percentage of long-stay residents who are receiving antipsychotic drugs. This measure excludes residents with diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome. CMS is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use. Therefore, CMS will conduct offsite audits of schizophrenia coding and, based upon the results, adjust the quality measure star ratings for facilities whose audit reveals inaccurate coding.
Posting Citations Under Informal Dispute Resolution and Independent Informal Dispute Resolution (IDR/IIDR)
The Informal Dispute Resolution (IDR) process gives nursing homes an informal opportunity to dispute citations. Additionally, when CMS imposes a civil money penalty, providers have the opportunity to request an Independent IDR (IIDR). Currently, citations under IDR/IIDR are not posted publicly on the Nursing Home Care Compare and the Quality Certification and Oversight Reports (QCOR) website until the dispute is complete. This process usually takes approximately 60 days, however, there are some cases that take longer. For example, based on surveys that occurred within the past two years, there are over 300 citations under informal dispute that are 6 months or older and are still not posted on Nursing Home Care Compare.
There are over 200,000 citations posted on the Nursing Home Care Compare website. So, the number of citations under IDR/IIDR is relatively small, however, they can include severe instances of non-compliance. For example, in the past two years, there were 80 deficiencies across 67 surveys identified as Immediate Jeopardy (IJ) that went through the IDR/IIDR process. Deficiencies are identified as IJ if the noncompliance placed the health and safety of residents at risk for serious injury, serious harm, serious impairment or death. Waiting to post these citations leaves consumers without knowledge of serious citations. Therefore, to be more transparent, CMS will now display these citations on Nursing Home Care Compare with a note that they are under dispute by the nursing home.
Discussion:
Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding
When nursing home residents are given erroneous schizophrenia diagnoses, they are subject to poor care and unnecessary antipsychotic medications, both of which can be very dangerous. Additionally, this inaccurate coding misleads the public by misrepresenting the nursing homes’ rate of antipsychotic usage in the posted quality measure.
In 2016, CMS launched focused schizophrenia onsite surveys to specifically address the issue of erroneous coding of schizophrenia in nursing homes. These surveys identified facilities with patterns of erroneous coding of residents with a diagnosis of schizophrenia. To increase our focus on this issue, CMS will begin conducting offsite audits to assess the accuracy of Minimum Data Set (MDS) data. Specifically, we will examine the facility’s evidence for appropriately documenting, assessing, and coding a diagnosis of schizophrenia in the MDS for residents in a facility.
Earlier this year, CMS conducted pilot audits to test the effectiveness of the MDS audit process. During these pilot audits, we found several issues related to the inaccurate MDS coding of residents with a diagnosis of schizophrenia. For example, there was an absence of comprehensive psychiatric evaluations and behavior documentation. Also, many residents had only sporadic behaviors noted in their medical records, and these behaviors were related to dementia, rather than schizophrenia. Moving forward, CMS will conduct these audits and, based upon the results, adjust the quality measure star ratings for facilities whose audits reveal inaccurate MDS coding. This action supports CMS’s goal to reduce the use of unnecessary antipsychotics and improve the accuracy of the quality measure and the five-star rating system. It is also consistent with the White House’s Fact Sheet listing efforts to improve safety and quality of care in the nation’s nursing homes. Specifically, the Fact Sheet states that, “CMS will launch a new effort to identify problematic diagnoses and refocus efforts to continue to bring down the inappropriate use of antipsychotic medications.”
Facilities selected for an audit will receive a letter explaining the purpose of the audit, the process that will be utilized, and instructions for providing supporting documentation. During the audit process, facilities will have the opportunity to ask questions and seek any clarification needed. Additionally, at the conclusion of the audit, the facility will have the opportunity to discuss the audit results with CMS.
Facilities that have coding inaccuracies identified through the schizophrenia MDS audit will have their QM ratings 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.
Also, we plan to offer facilities the opportunity to forego the audit by admitting they have errors and committing to correct the issue. This will reduce the burden of conducting audits for CMS and nursing homes, and allow CMS to audit more facilities. To incentivize this admission and to promote improvement, for facilities that admit miscoding after being notified by CMS that the facility will be audited, but prior to the start of the audit, CMS will consider a lesser action related to their star ratings than those listed above, such as suppression of the QM ratings (rather than downgrade).
For all facilities where patterns of coding inaccuracies were identified, either through an audit or through a facility’s admission, CMS will monitor each audited facility’s data to identify if the information indicates they have addressed the identified issues, and if any downgrades or suppressions that are applied should be lifted at the timeframes indicated above. Also, a follow-up audit may be conducted to confirm the issue is corrected.
Nursing homes should work with their psychiatric providers and medical directors to ensure the appropriate professional standards and processes are being implemented related to diagnosing individuals with schizophrenia. Information is also available in Appendix PP of the State Operations Manual (F-tags 658, 740, and 758) and the Minimum Data Set 3.0 Resident Assessment Instrument Manual (page 2 of the Errata (v2) effective July 15, 2022). Additionally, for assistance in reducing the use of antipsychotic medications, we encourage nursing homes to contact their Quality Improvement Organization (QIO) for additional resources, assistance, and tools that are available. Facilities can locate their QIO by visiting Locate Your QIO | qioprogram.org.
Posting Citations Under Informal Dispute Resolution and Independent Informal Dispute Resolution (IDR/IIDR)
As part of CMS’s commitment to transparency, consumers should have as much information about nursing homes as possible to support their healthcare decisions. Allowing consumers to see all of the citations a facility receives regardless of whether they are under IDR/IIDR is consistent with our commitment to transparency and also enhances accountability and oversight of nursing homes.
Therefore, CMS will post deficiency citations under IDR/IIDR in each section of Nursing Home Care Compare that currently displays citations, and will indicate if a citation is under dispute. If, based on the results of the IDR/IIDR process, the citations are upheld, they will remain posted and will be included in the calculation of the facility’s star rating if applicable. If the citations are overturned (i.e., removed), they will be removed from the website. If the level of scope or severity of a citation is reduced, the citation will be displayed at the reduced level. We note that on average, the majority of citations (approximately 75%) do not change after completion of the IDR/IIDR process.
While the citations will be publicly displayed, we will not include them in the calculation of a facility’s star rating until the dispute is complete (and the survey is considered final). In order to be consistent in how citations are reported across different platforms, CMS will also include citations under IDR/IIDR on the QCOR website.
CMS will update the Five Star Rating Technical Users’ Guide and Chapter 7 of the State Operations Manual to reflect these changes
Contact:
For questions or concerns relating to this memorandum, please contact BetterCare@cms.hhs.gov
For questions about the schizophrenia MDS audits, please contact DNH_BehavioralHealth@cms.hhs.gov
Effective Date:
Immediately. Please communicate to all appropriate staff.
/s/
David R. Wright
Director, Quality, Safety & Oversight Group
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