The State Performance Standards System—Making a Change AHFSA Annual Conference Portland, OR September 24, 2018

Disclaimer This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

Quality, Safety & Oversight Group Bonnie Reed, RN Technical Director, Division of Nursing Homes Dominick Esposito, Ph.D. Vice President, Insight Policy Research Christina Compher, MHS Project Manager, Epidemiologist

Agenda Background on the need for SPSS changes SPSS evaluation plan and milestones Preliminary data analysis Early RO/SA feedback Group participation/working session

Objectives of the SPSS An objective, effective, and efficient system to: Ensure the health and safety of all patients and residents Ensure effective and consistent application of federal oversight responsibilities (per 1864 Agreement) Identify improvements to policies or procedures (e.g., revised FOSS) Identify and remedy issues leading to inconsistency or unidentified noncompliance (placing residents at risk for harm): Where have we gone too far? What are we missing?

The Need for SPSS Changes Ensuring the SPSS as a tool is also relevant and accounts for the day-to-day work of ROs and SAs Reducing the risk of harm for residents requires that the SPSS is effective at gauging State performance at monitoring non-compliance Assessing State performance can and should be done more efficiently and objectively consistent

SPSS Evaluation Plan and Milestones Analysis of Existing Data Feedback from SPSS Stakeholders Recommendations to Improve the SPSS

SPSS Evaluation Plan and Milestones Review of SPSS data to establish patterns and identify outliers Analysis of the association between deficiency data and quality measures Analysis of complaints data Data analysis for both long-term care and other providers (i.e. dialysis facilities, hospitals, hospice, home health, ICF/IID)

SPSS Evaluation Plan and Milestones Feedback from SPSS Stakeholders Questionnaires on the SPSS for Regional Offices and State Agencies An AHFSA State Workgroup Conversations with Regional Office and State Agency Staff

SPSS Evaluation Plan and Milestones Late October ‘18. Evaluation Report Early November ‘18. Preliminary Recommendations December ‘18-March ‘19. Testing Phase Early April ‘19. Final Recommendations

Preliminary Data Analysis Long-term care quality measures matched to F-tags to examine association of quality to deficiencies cited 19 total quality measures (long- and short-stay) 23 total F-tags Compared average deficiencies per LTC facilities that scored on upper and lower ends of each quality measure Several commonalities across states to consider

Preliminary Data Analysis Common concern areas Residents who lose control of bowels/bladder Residents with a urinary tract infection Residents with one or more falls Other areas of concern Residents with pressure ulcers Residents who received an antipsychotic medication Staffing Hospitalizations

Preliminary Data Analysis Number of States from 2014-2017 where Facilities with Lower Quality Scores had Fewer Deficiencies than Facilities with Higher Quality Scores Quality Measure Three or Four Years Two to Four Years Bowels/Bladder 20 33 Urinary Tract Infection 13 26 Falls 10

Preliminary Data Analysis Long-stay residents who lose control of bowels or bladder High (low) quality score defined as 35 percent or fewer (60 percent or more) residents with bowels/bladder control issues.

Preliminary Data Analysis Long-stay residents experiencing one or more falls with major injury High (low) quality score defined as 1 percent or fewer (5 percent or more) residents with one or more falls with major injury.

Preliminary Data Analysis Average Number of Deficiencies per 100 Surveys in 2017; Nursing Homes Quality Measure Facilities with Higher Scores Facilities with Lower Scores Rehospitalization Rate Total Deficiencies 408.3 227.7 Substandard Quality of Care 5.0 13.5 IJ Deficiencies 161.0 218.2 ED Visits 268.7 493.9 23.4 162.7 195.6 Success. Discharge to Commty 353.0 240.9 11.4 4.2 170.7 290.6 High/Low quality cutoffs defined as: 21% (rehospitalizations); 11% (ED visits); 50% (Successful discharge)

Preliminary Data Analysis Many LTC Facilities with High Rates of Pressure Ulcers Are Not Cited for Them in 2017 In 23 states in 2017, 75-90% of LTC facilities that had 10 percent or more long-stay residents with a pressure ulcer also did not have any pressure ulcer citations. A high rate of pressure ulcers was defined as 10 percent or more long-stay residents. To identify citations for pressure ulcers we used F-tag 314 (Pressure sores (Ulcers)*).

Preliminary Data Analysis Percentage of Long Stay Residents who Received an Antipsychotic Medication Percentage of States where lower quality facilities had fewer average deficiencies cited than higher quality facilities High (low) quality defined as 10 percent or fewer (20 percent or more) residents who received an antipsychotic medication. Analysis of F-tags 329 (Unnecessary Drugs*) and 428 (Drug Regimen Review*).

Preliminary Data Analysis Average Number of Deficiencies per 100 Surveys in 2017; Dialysis Facilities Quality Measure Facilities with Higher Scores Facilities with Lower Scores Catheter Infection Rate 55.4 60.7 Number of ED Visits 34.0 33.5 Number of Hospital Admissions 29.4 14.5 Dialysis patient deaths 12.5 14.0 Standardized readmission ratio 31.9 30.2

Early RO/SA Feedback Data-driven measures in SPSS more favorable than subjective measures Some measures are too labor intensive and an inefficient use of resources Multiple reporting systems make the work more difficult Sample of cases is too small to properly assess performance

Early RO/SA Feedback Build SPSS into part of the daily workload to make it easier to monitor, evaluate, and improve SA performance Up to half of SA performance could be rated on work products submitted to ROs Conduct brief reviews every 1-3 months and provide feedback to SAs immediately

Group Participation/Working Session Topics for Group Breakout Discussions What SPSS current measures are effective? What new measures should we add to reflect relevant day-to-day activities conducted by State Agencies? Would adding metrics to gauge surveyor training be valuable? Might better monitoring of surveyor training improve State performance over time? How might implementation work? How could we incorporate quality measures for different providers into the SPSS to either assess State performance at monitoring non-compliance or inform the SPSS?

Group Participation/Working Session Group Discussion Questions…. Would any potential SPSS changes be more reflective of day-to-day work conducted by State Agencies? What would make it so, if not? Would a potential change make the SPSS a more effective tool at gauging State performance at monitoring non-compliance? If not, what might? What would be potential obstacles, barriers, or challenges if a SPSS change was made?