Nursing Homes, Hospice Remain Challenges According to OIG

HHS Lists Rank This 5th in Importance of its 10 Challenges

Under the OIG microscope.. Thomas Northcut

A survey in the Journal of Research in Nursing shows that most nursing home staff do not fully understand the meaning and value of MDS 3.0.

A survey was used to measure clinical leadership's perceptions of staff understanding of the minimum data set (MDS) quality indicators (QIs) and ways to improve staff understanding of this system, as well as specific perceived training needs among Department of Veterans Affairs (VA) nursing home care unit (NHCU) clinical leadership.

An online survey using structured (quantitative) and open-ended (qualitative) items was conducted in 97 VA NHCUs nationwide. A total of 289 leadership staff including directors of nursing, medical directors, MDS coordinators participated.

That is why a newly issued list from HHS' Office of Inspector General shows that ensuring nursing home quality remains one of the top 10 challenges facing the Department of Health and Human Services.

As the median age of Americans continues to rise and as more Americans live with chronic medical conditions, the Department faces challenges in ensuring that beneficiaries who require nursing home, hospice, or home- and community-based services (HCBS) receive high quality care.

OIG continues to identify various problems with nursing home and hospice care. For example, in reports on nursing homes, OIG raised concerns about the frequency of preventable adverse events due to substandard care, the extent to which nursing homes comply with federal regulations for reporting abuse and neglect, and the lack of monitoring of nursing homes' resident hospitalization rates.

With respect to hospice care, OIG has raised concerns about insufficient monitoring of hospice service use, as well as inadequate oversight of hospice certification surveys and hospice-worker licensure requirements.

Progress in Addressing the Challenge

The Department continues to take steps to improve the quality of nursing home, hospice, and HCBS programs.

Through its Web site and in various outreach strategies, CMS is providing guidance to nursing homes on how to meet newly expanded quality assessment and performance improvement (QAPI) activities required under the Affordable Care Act.

Adding to this effort is a recent proposed rule that outlines actions CMS intends to take to remove obsolete or unnecessary provisions affecting nursing homes' ability to carry out these and other requirements. CMS also published rules strengthening nursing home requirements in areas such as emergency preparedness, dementia care, and infection control.

The Department has also taken steps to improve the quality of services beneficiaries receive in hospice settings and from HCBS programs. To improve hospice care, CMS proposed rules that would update the hospice quality reporting program and reform hospice payment methodologies.

For HCBS programs, CMS finalized rules covering minimum quality expectations for providers, new administrative flexibilities for states running HCBS programs, requirements for person-centered planning in these services, and enforcement actions CMS can take against HCBS programs out of compliance with requirements.

The Department also entered into a contract with the National Quality Forum to begin work on the development of a national quality measure set for HCBS.

OIG continues to pursue enforcement actions against nursing homes, hospices, and HCBS providers that render substandard care. CMS and OIG work closely with law enforcement partners at DOJ and through the federal Elder Justice Interagency Working Group to promote better care for older adults and to prosecute providers committing abuse or neglect. Additionally, state Medicaid Fraud Control Units (MFCUs), which receive oversight and funding from OIG, devote substantial resources to the investigation and prosecution of abuse and neglect in Medicaid-funded facilities, such as nursing homes and board-and-care homes.

What Needs To Be Done

The Department should continue to prioritize quality of nursing home, hospice, and HCBS. OIG has offered recommendations to assist the Department in this mission. For example, OIG recommended that the Department monitor how often nursing home residents are hospitalized and develop resources that can be used to help nursing home staff reduce the incidence of adverse events in nursing homes.

OIG has also recommended that the Department seek to link payments for services to meeting quality-of-care requirements and work with OIG to hold providers that have rendered substandard care accountable, thereby preventing additional harm to vulnerable beneficiaries.

Recently, Congress passed two laws that gave the Department new tools to improve the quality of care in nursing homes and other post-acute care providers. The Protecting Access to Medicare Act of 2014 (PAMA) establishes a value based payment program for nursing homes under which incentive payments will be made to high performing providers. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) includes new reporting requirements for nursing homes and other post-acute care providers, including standardized admission and discharge patient assessments.

IMPACT also includes requirements that hospice programs be surveyed at least once every 36 months and that oversight entities perform chart reviews, in some cases, of hospice episodes longer than 180 days.

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