Verma Touts Low SNF Provider Terminations, Wants to Give Operators Chance to ‘Turn Things Around’

The head of the Centers for Medicare & Medicaid Services (CMS) touted the agency’s changes around enforcement of quality and safety standards in a blog post published on Tuesday, as part of a series on its five-part strategy to improve care in nursing homes across the country.

The strategy’s components include: strengthening oversight, enhancing enforcement, increasing transparency, improving quality, and putting patients over paperwork, according to the agency.

As part of the CMS’s work to improve enforcement, it has taken a new look at its methods, administrator Seema Verma wrote. While the agency has the option to terminate providers from Medicare and Medicaid participation, that’s “an action of last resort,” she said in the post.


“In fact, we involuntarily terminate fewer than 10 providers each year — that’s less than one percent — because we rely on other, more targeted, enforcement tools and we want to give facilities opportunities to turn things around,” Verma wrote. “As a part of the Enhancing Enforcement pillar of our five-part strategy, we have done a comprehensive review of these enforcement mechanisms, and we’re now making significant, creative enhancements to these important efforts.”

The second entry in the series came about six months after the first, which was published in August 2019 and focused on strengthening oversight by creating more consistency among State Survey Agencies (SSAs). Verma continued that theme in the February 2020 update, emphasizing that improvements begin with oversight of SSAs.

The agency rolled out stricter standards for SSAs in October 2019, and the goal is for CMS to establish “clearer timelines” for the SSAs so they are aware of the expectations for investigating abuse and neglect allegations, Verma wrote.


CMS wants to use its enforcement tools to improve quality of care and life for residents, she added, adding that the agency has long-standing concerns about the inappropriate use of antipsychotic medications in the nursing home setting. As a result, the agency announced additional enforcement for facilities with high antipsychotic medication rates — or “late adopters,” Verma noted — last year.

“These tools include discretionary Denials of Payment for New Admissions, meaning late adopters may lose the ability to seek Medicare reimbursement in some instances,” she wrote. “They also include a per-day CMP [civil monetary penalty]. Each facility was notified of its status as a late adopter through the reports CMS provides to facilities each month.”

CMS is identifying corporate nursing home chains that have high numbers of these late adopters, and that has led to results: Antipsychotic medication use in late adopters has decreased 34 percent since the beginning of the Trump administration, according to Verma.

In addition, registered nurse (RN) staffing has come under the microscope, with CMS implementing an overhaul of its skilled nursing staffing standards that led to several SNFs receiving downgrades because they fell short on the required RN hours. Verma touted the payroll-based journal (PBJ) as “a more precise staffing reporting tool,” adding that CMS in 2018 directed SSAs to use this data for targeted inspections during off-hours at facilities that have had low nurse staffing levels during those times — the evenings, weekends and holidays.

CMS is also working on making civil monetary penalties even and uniform across states, Verma added, while improving its own internal structure dealing with nursing home enforcement.

She also noted the agency’s work with Congress on this issue, reiterating the fiscal 2021 budget request for $442 million for Survey and Certification work for nursing homes — a $45 million increase from the previous year.

“The increased funding would enable CMS to continue to meet the statutory survey requirements while dealing with the increase in volume and severity of complaints, and rising survey costs,” Verma wrote.

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