On January 18, 2023, the US Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced new actions, effective immediately, to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families. HHS Secretary Xavier Becerra said, “No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic. The steps we are taking today will help prevent these errors and give families peace of mind.”
Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medications. Antipsychotic medications are especially dangerous among the nursing home population due to their potential devastating side effects, including death.
The use of antipsychotic medications among nursing home residents is an indicator of nursing home quality and used in a nursing home’s Five-Star rating, however it excludes residents with schizophrenia. If an audit identifies that a facility has a pattern of inaccurately coding residents as having schizophrenia, the facility’s Five-Star Quality Measure Rating on the Care Compare site will be negatively impacted. For audits that reveal inaccurate coding, CMS will downgrade the facility’s Quality Measure (QM) ratings to one star, which would drop their Overall Star Rating as well. CMS will monitor each facility’s data to determine whether they have addressed the identified issues. After that, CMS will decide whether any downgrades should be reversed.
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.
CMS said they plan to offer facilities the opportunity to forego the audit by admitting they have errors and committing to correct the issue. 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).
Separately, CMS plans to take a new step to increase the transparency of nursing home information by publicly displaying survey citations that facilities are disputing. Currently, when a facility disputes a survey deficiency, that deficiency is not posted to Care Compare until the dispute process is complete.
While the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance such as Immediate Jeopardy (IJ) citations. This level of citation occurs when the health and safety of residents could be at risk for serious injury, serious harm, serious impairment, or death. CMS said that displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating a facility. This new information will begin appearing on Care Compare on January 25, 2023. While the citations will be publicly displayed, they will not be included in the Five-Star Quality Rating calculation until the dispute is complete.
You can read the guidance here.
Compliance Perspective
Issue
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. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug which is used in excessive dose (including duplicate drug therapy), for excessive duration, or without adequate monitoring, adequate indications for its use, or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Each resident’s entire drug/medication regimen should be managed and monitored to promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being. The diagnosis of schizophrenia should never be used unless a qualified medical practitioner has assessed and evaluated the resident for a proper diagnosis of schizophrenia.
Discussion Points
- Review your policies and procedures on psychotropic medication use and monitoring. Update as needed.
- Train all clinical staff on your psychotropic medication policies, including the risks and benefits of this classification of drug. Document that the trainings occurred and file the signed document in each employee’s education file.
- Audit to ensure psychotropic medications prescribed to residents list indication for use, are the correct dosage and duration, are adequately monitored by the attending physician or other designated practitioner, and that a licensed pharmacist has provided consultation. Also audit to see if there were any adverse consequences, and if so, that the dose had been reduced or discontinued. If decreasing or discontinuation of the psychotropic medication is not feasible, ensure that there is complete documentation of interventions that have been tried and were unsuccessful and a rationale for continuing use.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
