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Poor Care for Residents, Limited Enforcement Consequences for Facilities || Center for Medicare Advocacy

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Nursing amenities which might be recognized as amongst these offering the poorest high quality care to their residents face restricted, if any, enforcement actions.  This Report appears at these nursing amenities.

Background

In cooperation with states, the Facilities for Medicare & Medicaid Providers (CMS), identifies nursing amenities which have a historical past of great noncompliance.  These amenities – that are referred to as Particular Focus Amenities (SFFs)[1]  – are among the many worst performing amenities within the nation.  Nursing amenities recognized as SFFs have a further commonplace survey annually and are anticipated, inside 18-24 months, to “graduate” from the SFF program, to be terminated, or to stay (if they’ve made substantial enchancment or are anticipated to be bought).  Every month, CMS identifies new SFFs and identifies which present SFFs haven’t improved, have improved, or have been terminated.

The Nursing House Reform Regulation governs the requirements of care (referred to as Necessities of Participation) that Medicare and Medicaid amenities should meet so as to be eligible for reimbursement underneath the federal cost packages; the survey course of used to find out compliance with federal requirements of care; and cures or penalties that could be imposed for noncompliance.[2]  

CMS categorizes deficiencies which are cited because of unannounced surveys based on their scope (what number of residents are affected) and severity (how critical the noncompliance is).  Nationwide, in 2014, solely zero.9% of deficiencies have been cited as quick jeopardy (the very best class of noncompliance) and a couple of.2%, as hurt (the second highest degree of noncompliance).[3]  Most deficiencies are recognized as inflicting residents no-harm.[4]  The remaining deficiencies are recognized as inflicting residents no-harm or as substantial compliance.[5]   CMS imposes penalties primarily for jeopardy- and harm-level deficiencies.  Among the many cures that CMS might impose are civil cash penalties (CMPs), both per day or per occasion CMPs. 

Per day CMPs for jeopardy-level deficiencies vary from $6394 to $20,965; per occasion CMPs for jeopardy-level deficiencies vary from $2097 to $20,965.[6]  The distinction between the 2 forms of CMPs is that per day CMPs improve with the variety of days a facility is cited as being out of compliance with federal requirements of care, whereas per occasion CMPs mirror a flat high-quality unrelated to the period of noncompliance.

CMS’s web site Nursing Residence Examine reviews scores for every nursing facility that participates in Medicare or Medicaid, or each, on three domains: well being survey (based mostly on unannounced annual and grievance surveys which are carried out by state survey businesses); nurse staffing knowledge (based mostly, since Might 2018, on payroll-based info[7]); and high quality measures (based mostly totally on self-reported and unaudited resident evaluation info offered by amenities).  CMS assigns star scores to every of the three domains and an general rating, which begins with the well being survey score and revises the general score downward or upward to mirror, respectively, one-star and five-star scores on the staffing and high quality measure domains.  Scores in every area and within the general score vary from one to 5 stars, with one star reflecting the bottom efficiency and 5 stars, the very best efficiency.

Nursing House Examine reviews two of the federal penalties –  CMPs[8] and denials of cost for new admissions (DPNAs).[9]  When amenities attraction CMPs, the CMPs usually are not reported on Nursing House Examine until and till they’re upheld and last. 

The federal Nursing Residence Reform Regulation requires nursing amenities to have RNs on website eight hours per day, seven days per week.[10]  Nursing House Examine consists of an icon to determine amenities that report seven or extra days within the quarter with no registered nurse on website, fail to report auditable knowledge, or fail to report nurse staffing knowledge.[11]  CMS stories that 6% of amenities nationwide had insufficient RN protection within the fourth quarter of calendar yr 2017, as so outlined. 

The Knowledge Under

The June 21, 2018 listing of newly-identified SFFs (that’s, nursing amenities which were included on the listing of SFFs for one to 3 months) consists of 13 nursing amenities in 9 states; the July 19, 2018 report added 5 amenities in 5 states.[12]  The Middle checked out Nursing House Examine to determine what number of jeopardy-level and harm-level deficiencies the 18 SFFs had within the present and prior survey cycles, whether or not any CMPs or DPNAs have been imposed within the prior three years, whether or not the SFFs lacked mandated RN protection or had different issues in staffing knowledge, and their high quality measure scores. 

The chart under studies the variety of jeopardy and hurt deficiencies within the present survey cycle and instantly prior yr.  Two years’ knowledge are reported as a result of the survey star score is predicated on two years of survey outcomes, as frozen for a yr in November 2017.[13]  The chart individually identifies jeopardy and hurt deficiencies cited in 2018.  As famous above, Nursing House Examine stories solely ultimate CMPs; CMPs which might be on attraction will not be included.  This apply might end result within the under-reporting of further CMPs that CMS has imposed towards these SFFs.  The chart additionally reviews CMPs and DPNAs that have been imposed within the prior three years.

Nursing House Examine stories the next details about these 18 amenities. 

Particular Focus Amenities, Newly-Added, as of June 21, 2018 and July 19, 2018

Identify of facility

State

Survey score

(stars)

Employees score (stars)

High quality measure score

(stars)

General score (stars)

Variety of jeopardy and hurt deficiencies (most up-to-date and prior years)

Enforcement actions (Three years)

Added June 21, 2018

 

 

 

 

 

 

 

Chulio Hills Well being & Rehab

GA

1

2

1

1

15 jeopardy

2 CMPs totaling $23,627;
no DPNA

Helia Healthcare of Champaign

IL

1

1

four

1

1 hurt
(2018: Three jeopardy)

2 CMPs totaling $20,777;
no DPNA

Richmond Pines Healthcare and Rehab Ctr

NC

1

1

1

1

9 jeopardy

four CMPs totaling $123,708;
1 DPNA

The Heights of Summerlin

NV

1

four

Three

2

None

No CMPs;
no DPNA

Isabelle Ridgway Submit Acute Care Campus

OH

1

1

four

1

2 hurt

2 CMPs totaling $20,125;
no DPNA

Pristine Senior Dwelling & Publish Acute Care of Portsmouth

OH

1

Three

four

1

1 jeopardy;
1 hurt

1 CMP of $120,619;
no DPNA

Falling Spring Nursing & Rehab Ctr

PA

1

2

four

1

1 jeopardy;
1 hurt

No CMPs;
no DPNA

Gardens at West Shore

PA

1

2

2

1

1 jeopardy;
1 hurt
(2018: 2 hurt)

2 CMPs totaling $116,896; 
Three DPNAs

Benbrook Nursing & Rehab Ctr

TX

1

Three

1

1

12 jeopardy;
1 hurt

No CMPs;

1 DPNA

Encourage New Boston

TX

1

1

1

1

10 jeopardy;
Three hurt

6 CMPs totaling $233,427;
Three DPNAs

Bay at Maple Ridge Well being & Rehab

WI

1

2

Three

1

Three jeopardy

1 CMP of $12,675
2 DPNAs

Trinity Well being Care of Logan

WV

1

Three

2

1

2 jeopardy

1 CMP of $142,433;
no DPNA

 

 

 

Cheyenne Well being Care Middle

WY

1

four

four

2

5 hurt

2 CMPs totaling $110,708;
2 DPNAs

Added July 19, 2018

 

 

 

 

 

 

 

Worcester Well being Middle

MA

1

Three

four

1

6 jeopardy;
1 hurt

$58,787;
No DPNA

Dover Middle for Well being & Rehabilitation

NH

1

2

four

1

None

None

New Grove Manor

NJ

1

four

four

2

Three jeopardy

None

Emerald South Nursing and Rehabilitation Middle

NY

1

1

5

2

1 hurt

None

Pines Rehab & Well being Ctr

VT

1

four

2

2

four hurt

1 CMP of $eight,453;
No DPNA

Complete

 

 

 

 

 

66 jeopardy;
23 hurt

$992,235
11 DPNAs (6 amenities)

The 18 newly-identified SFFs may be described as follows:

Deficiencies

  • 12 SFFs have been cited with jeopardy-level deficiencies
  • four SFFs have been cited solely with harm-level deficiencies
  • 2 SFFs have been cited with neither jeopardy-level nor harm-level deficiencies

Penalties

  • The 18 SFFs had CMPs totaling $992,325 and 12 DPNAs over a Three-year interval
    • 12 SFFs had CMPs imposed starting from 1 CMP ($8453) to six CMPs totaling $233,517 over a Three-year interval
      • 6 of the SFFs had CMPs over $100,000 ($123,708, $120,619, $116,896, $233,517, $142,433, $110,708)
      • 5 of the SFFs with CMPs additionally had DPNAs imposed; 7 didn’t
    • 1 SFF had DPNA however no CMP
    • 5 SFFs had neither CMPs nor DPNAs imposed

Nurse staffing

  • Three SFFs didn’t submit staffing knowledge, reported giant numbers of days with no RN protection, or submitted knowledge that would not be verified
    • 1 of those SFFs had each CMPs and DPNAs imposed
    • 2 of those SFFs had solely CMPs

High quality measure area

  • 6 SFFs had four stars on the standard measures area
  • 1 SFF had 5 stars on the standard measure area

Dialogue

What can we study these amenities from Nursing Residence Examine?

  1. The SFFs present exceptionally poor care, as mirrored by the excessive numbers of jeopardy and hurt deficiencies cited within the present and instantly prior years.  These 18 SFFs, collectively, have been cited with 66 jeopardy deficiencies and 23 hurt deficiencies over a two-year interval.
     
  2. Enforcement actions are comparatively minor.  Whereas 12 of the 18 SFFs had CMPs imposed within the three prior years, the typical CMP for the 12 amenities that had at the very least one CMP imposed was $27,562 per yr per facility.  If the full CMPs for the Three-year interval ($992,325) are attributed to all 18 SFFs, the typical CMP per yr for every SFF is $18,375. 

Furthermore, 5 of the 18 SFFs (28%) had neither CMPs nor DPNA imposed within the prior three years.

Enforcement actions are declining.In 2016, the Obama Administration issued steerage to impose per day CMPs because the default.[14]In 2018, the Trump Administration changed the Obama steerage with new steerage calling for per occasion CMPs because the default.[15]The outcome, already, is fewer per day CMPs and extra per occasion CMPs.[16]

In Fiscal Yr (FY) 2016, beneath the Obama Administration, there have been 1,728 per day CMPs (averaging $53,846) and 942 per occasion CMPs (averaging $Three,162).So far in FY 2018, 563 per day CMPs (averaging $71,635.77) and 1,262 per occasion CMPs (averaging $9,576.83) have been imposed.[17]CMS will impose decrease complete CMPs going ahead.

  1. Three SFFs reported excessive numbers of days with none registered nurse (RN) protection, did not report nurse staffing knowledge, or did not submit auditable nurse staffing knowledge.  Almost 17% of newly-identified SFFs fall into this class.

    Nurse staffing ranges are decrease than reported on Nursing House Examine.  The New York Occasions lately reported that the brand new employees reporting system paperwork that on no less than at some point within the final quarter of 2017, 25% of nursing amenities reported a minimum of at some point with out an RN on website.[18]  The Occasions finds that nurse staffing ranges have been overstated for a few years and that the brand new system, whereas higher than the prior self-reported system, doesn’t mirror amenities’ erratic and fluctuating staffing ranges.
     

  2. Six SFFs report resident evaluation info that leads to 4 stars within the high quality measure area (outlined as above common efficiency) and 1 SFF reviews  resident evaluation info that leads to 5 stars within the high quality measure area (outlined as a lot above common efficiency).  Since amenities which are among the many poorest high quality amenities within the nation don’t present top quality care, the self-reported high quality measure area is very deceptive, if not fraudulent.

    The New York Occasions reported in 2014 that nursing houses recreation the 5-Star Score System by reporting evaluation info that provides them excessive scores within the high quality measure area.[19]

    An evaluation of the primary 5 years of the 5 Star Score System, ready for CMS by Abt Associates, discovered that the share of amenities receiving 4 or 5 stars on the standard measure area elevated from 35.2% in 2009 to 50.5% in 2013, whereas the share of amenities receiving one star within the high quality measure area declined from 22.7% to 10.5% over the identical five-year interval.[20]

Conclusion

Amenities which are recognized as among the many most poorly performing amenities within the nation present extraordinarily poor care and should fail to have adequate numbers of RNs, however they face restricted, if any, fines.  Going ahead, nursing amenities are more likely to have even decrease fines. 

CMS must strengthen the SFF program to take simpler motion towards amenities that present poor care.  It additionally must revise Nursing Residence Examine to extra precisely mirror nurse staffing ranges in any respect nursing amenities nationwide and to discontinue utilizing the standard measure area in score amenities.

July 27, 2018
Toby S. Edelman
Senior Coverage Lawyer
Middle for Medicare Advocacy


[1] CMS, Particular Focus Facility (“SFF”) Initiative, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/SFFList.pdf. 
[2] 42 U.S.C. §§1395i-Three(a)-(h), 1396r(a)-(h), Medicare and Medicaid, respectively.
[3] CMS, Nursing Residence Knowledge Compendium 2015 Version, Desk 2.5.e, web page 85, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/nursinghomedatacompendium_508-2015.pdf. 
[4] The Middle for Medicare Advocacy and the Lengthy Time period Care Group Coalition collectively publish a month-to-month publication of so-called “no harm” deficiencies.  See http://www.medicareadvocacy.org/newsletter-elder-justice-what-no-harm-really-means-for-residents/. 
[5] The Middle for Medicare Advocacy and the Lengthy Time period Care Group Coalition collectively publish a month-to-month publication of so-called “no harm” deficiencies.  See http://www.medicareadvocacy.org/newsletter-elder-justice-what-no-harm-really-means-for-residents/. 
[6] 82 Fed. Reg. 9174, 9182 (Feb. Three, 2017), https://www.gpo.gov/fdsys/pkg/FR-2017-02-03/pdf/2017-02300.pdf. 
[7] CMS, “Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on Medicare.gov and the Five Star Quality Rating System,” QSO-18-17-NH (Apr. 6, 208), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf. 
[8] 42 U.S.C. §§1395i-Three(h)(2)(B)(ii), 1396r(h)2)(A)(ii), 1396r(h)(Three)(C)(ii); 42 C.F.R. §§488.430-.444,
[9] 42 U.S.C. §§1395i-Three(h)(2)(B)(i), 1396r(h)(2)(A)(i), 1396r(h)(Three)(C)(i); 42 C.F.R. §488.417.
[10] 42 U.S.C. §§1395i-Three(b)(four)(C)(i), 1396r(b)(four)(C)(i)(II), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(b)(1).
[11] CMS, “Transition to Payroll-Based Journal (PBJ) Staffing Measures on the Nursing Home Compare tool on Medicare.gov and the Five-Star Quality Rating System,” QSO-18-17–NH, web page 2 (Apr. 6, 2018), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.
[12] CMS, Particular Focus Facility (“SFF”) Initiative, Desk A, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/SFFList.pdf.
[13] [13] In November 2017, CMS froze the survey scores for a yr (till Nov. 27, 2018) and indicated that it might base the well being survey star score on two years of survey and grievance knowledge.  CMS, “Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare,” S&C 18-04-NH (Nov. 24, 2017), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-04.pdf. 
[14] CMS, “Mandatory Immediate Imposition of Federal Remedies and Assessment Factors Used to Determine the Seriousness of Deficiencies for Nursing Homes,” S&C: 16-31-NH (Jul. 22, 2016), revised 7.29.16, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-31.pdf.
[15] CMS, “Final Revised Policies Regarding the Immediate Imposition of Federal Remedies,” QSO 18-18-NH (Jun. 15, 2018), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-18-NH.pdf.
[16] https://qcor.cms.gov/enf_cmp.jsp?which=0&report=enf_cmp.jsp.
[17] https://qcor.cms.gov/enf_cmp.jsp?which=0&report=enf_cmp.jsp (website visited Jul. 28, 2018).
[18] Jordan Rau, “‘It’s Almost Like a Ghost Town.’  Most Nursing Homes Overstated Staffing for Years,” The New York Occasions (Jul. 9, 2018), https://www.nytimes.com/2018/07/07/health/nursing-homes-staffing-medicare.html.
[19] Katie Thomas, “Medicare Star Ratings Allow Nursing Homes to Game the System,” The New York Occasions (Aug. 14, 2014), https://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html. 
[20] Abt Associates, Inc., Nursing House Examine 5 Star High quality Score System: 5 Yr Report [Public Version] (Jun. 16, 2014), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/NHC-Year-Five-Report.pdf.