CMS Highlights Key Areas of Skilled Nursing Enforcement, Improvement

Improving surveys, clarifying nursing facilities’ reporting requirements, and providing more detail on citations are some of the current top priorities for the Centers for Medicare & Medicaid Services (CMS).

Karen Tritz, director of the Division of Nursing Homes in CMS’ Quality and Safety Oversight Group, walked through several policies and their status in a presentation at LeadingAge’s annual conference and expo in Philadelphia on Tuesday.

First up: The new process of surveying long-term care facilities, which is approaching its first year. The top deficiencies turned up so far include issues related to infection prevention, food procurement, and storage, as well as the comprehensive care plan — which essentially serves as the blueprint on which an entire facility’s operational strategy is based.


“The care plan really does focus on: What is the outcome to the resident and what does the care plan have to say about that? What should and should not have occurred, and what was implemented?” Tritz said. “What we’ve heard is the care plan is really a paper thing, and how can you ensure that every ‘i’ is dotted and ‘t’ is crossed? And surveyors are looking for a missed dotted ‘i.’ But then we’ve also heard that the care plan is central to everything. It becomes the foundation document for how the care is provided.”

CMS is focusing on the efficiency and effectiveness of the new survey process as compared with the traditional process, but due to differences in the data points, a direct contrast isn’t possible. Still, CMS can see the average number of deficiencies, which is slightly higher in the new survey process than in the traditional process — and though the number of investigations per surveyor is almost double what it was, there’s no indication that it has affected the total number of deficiencies, at least on the national level.

“The net doubling did not end up doubling the average number of deficiencies per survey,” Tritz said. “We are looking at that; for example, what are the citations that actually result while going through this investigative part of the process? And that also really varies.”


Phase III, facility reporting also in the works

The third phase of the Requirements of Participation will still take effect on November 28, 2019, and CMS is working on guidance for that effort — particularly focusing on areas such as trauma-informed care, Tritz said. The “patients over paperwork” initiative, launched by administrator Seema Verma in an attempt to cut certain regulatory hurdles for providers, is also ongoing.

The agency’s public regulations agenda additionally notes that there will be a long-term care burden reduction rule released, Tritz added. Though she did not want to give the date, “I can tell you it’s in process,” she said.

Tritz noted that the health inspection rating on Nursing Home Compare will soon be unfrozen, after being temporarily halted to ensure better data comparison. CMS has received several questions about this, she said, and details will be forthcoming.

In other policy issues, CMS is also working on revisions to the “immediate jeopardy” classification in an effort to make the reasoning behind such a citation clearer. Providers tagged with that label have, in CMS’s view, directly endangered a resident’s life through noncompliance with regulations, and the tag represents a serious threat to both the facility’s operations and its residents.

“For those of you who’ve been doing this for a while, you know one of the concerns with immediate jeopardy is there is not clear, consistent application always,” Tritz said. “Immediate jeopardies are less than 1% of all citations in this country, and so these represent the most serious deficiencies out there. If they represent less than 1% of all deficiencies cited, they should be pretty clear.”

Staff reporting of incidents is an area where state-level implementation of CMS rules could be improved, Tritz said. Facilities have reported to CMS that they aren’t sure what to report, and state guidelines vary — or, in some cases, aren’t readily available. In particular, there’s a need to clarify the triage level of different incidents; currently they’re based on the level of resident harm, she said.

“Right now, our triage decisions are based solely on the resident status, on resident harm,” she said. “One of the things that, if you look at this process, we don’t consider in our policy is: What are the actions the facility has taken to do a proper investigation, to protect the resident, to take appropriate action? And we think that could become part of the decision-making in terms of states’ responsibilities.”

Written by Maggie Flynn

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