MDS Alert

Published on Wed Jun 29, 2016 PDF

Plus: CMS makes public new data on nursing home enforcement activities.

Instead of your preview reports remaining in your shared facility folder for 230 days, come Nov. 1 they will be stored there for only 90 days. And once the system deletes the reports, you can’t have them recreated.

Effective Nov. 1, 2016, the Quality Improvement and Evaluation System (QIES) will store your MDS 3.0 Facility-Level Quality Measure and Resident-Level Quality Measure Preview reports in the shared facility folder for only 90 days. These are automatically created preview reports.

This retention change won’t affect the MDS 3.0 Five-Star Preview reports, however. The QIES system will retain new reports saved into each nursing home’s shared facility folder after Nov. 1 for 90 days following the date the report was added to the folder, and existing reports created more than 90 days before Nov. 1 will be automatically deleted from the system.

If you have any reports saved in the shared facility folder that are scheduled for deletion on Nov. 1, you will need to print or save a copy of them as the system can’t recreate them once they’re deleted.

In other news …

Good News: Actual Harm/Immediate Jeopardy Deficiencies Are Declining

If you’re curious about trends in nursing home enforcement activities, you have some new data to consider.

On June 3, the Centers for Medicare & Medicaid Services (CMS) issued a Survey & Certification (S&C) memo announcing the public release of data on nursing home enforcement actions between 2006 and 2014. The memo (S&C: 16-27-NH) includes enforcement reports on the distribution of federal enforcement remedies imposed during these years by CMS Region and State, by type of enforcement action, and by year imposed.

For surveys, continued increases in oversight cause a steady rise in the average number of deficiencies cited per survey from 2003 through 2007. But CMS blames the steady decrease in the number of average survey deficiencies that occurred from 2008 through 2014 on the recession.

The percent of surveys yielding citations for pressure ulcers has steadily decreased over the years, while citations for unnecessary medications has skyrocketed. The percent of surveys with zero health deficiencies cited has steadily risen from just under 8 percent in 2008 to just over 10 percent in 2014.

The percent of surveys with Substandard Quality of Care deficiencies has declined only slightly, from just over 4 percent in 2008 to about 3 percent in 2014. But those with Actual Harm/Immediate Jeopardy deficiencies are another story — surveys with citations of these types of deficiencies have dropped dramatically, from a peak of 18 percent in 2006 to under 11 percent in 2013 and 2014.

The percent of active providers with any enforcement remedies has also declined, from 18.1 percent in 2006 to 14.2 percent in 2014. But the number of active providers that faced civil money penalties (CMPs) soared, from 28 in 2006 to 145 in 2014.

Link: To read the S&C memo and for more information on nursing home enforcement activities, visit www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationEnforcement/Nursing-Home-Enforcement.html.

Where Focused Dementia Care Surveys Will Persist Into FY 2016

Has your facility experienced a drop in its use of antipsychotic medications in residents with dementia? That’s great — but it doesn’t mean you’re off the hook.

On June 3, CMS released the Survey & Certification (S&C) memo “Update Report on the National Partnership to Improve Dementia Care in Nursing Homes.” CMS had set an initial goal of a 15-percent reduction in the prevalence of antipsychotic medication use. Between the end of 2011 through 2013, the National Partnership achieved (and slightly surpassed) this goal for long-stay nursing home residents, decreasing usage of antipsychotic medications from 23.8 percent to 20.2 percent nationwide.

According to the memo (S&C: 16-28-NH), CMS then set a new national goal of reducing antipsychotic medication in long-stay nursing home residents by 25 percent by the end of 2015 and 30 percent by the end of 2016. Since the beginning of the National Partnership, antipsychotic use in long-stay residents has decreased by 27 percent overall.

Look ahead: Also, CMS is conducting additional Focused Dementia Care Surveys in fiscal year (FY) 2016, following the pilot in 2014 and expanded surveys in FY 2015. The surveys will continue to “more thoroughly examine the process for prescribing antipsychotic medications and assess compliance with other federal requirements related to dementia care practices in nursing homes,” the memo states.

Watch out: In FY 2016, CMS will target additional Focused Dementia Care Surveys at nursing homes that continue to have higher rates of antipsychotic medication use. Certain regions continue to experience higher rates than others, including facilities in Texas and Louisiana.

New England and Mid-Atlantic states appear to be faring better, with many seeing reductions of more than 25 percent. Utah reduced its antipsychotic medication usage rate by nearly 42 percent and Vermont experienced a 36 percent drop in usage.

Resource: To read the S&C memo, go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-28.pdf.