1. CMS Updates Evan Shulman, Deputy Director Division of Nursing Homes
Survey and Certification Group
Center for Clinical Standards and Quality

2. Overview Reform of Requirements for Long-Term Care Facilities
Adverse Events
Survey Process Update
National Partnership to Improve Dementia Care
Electronic Submission of Payroll-Based Staffing Information
Nursing Home Five Star Quality Rating System
Enforcement
Skilled Nursing facility Value Based Purchasing (SNF VBP)
Skilled Nursing Facility Quality Reporting Program (SNF QRP)
Initiative to Reduce Avoidable Hospitalizations (CMMI/MMCO Demonstration) 2

3. Reform of Requirements for Long-Term Care Facilities
The proposed rule, CMS 3260-P Reform of Requirements for Long-Term Care Facilities, was published in the Federal Register on July 16, 2015
To view the proposed rule, please visit:
For additional information on these and other Conditions of Participation, visit Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CfCsAndCoPs/1 6_ASC.asp.

4. Background
The requirements for Long-Term Care (LTC) Facilities are the health and safety standards that LTC facilities must meet in order to participate in the Medicare or Medicaid Programs.
The current requirements are found at 42 CFR 483 Subpart B.
These requirements have not been comprehensively updated since 1991 despite significant changes in the industry.
The proposed revisions reflect advances in the theory and practice of service delivery and safety, and implement sections of the Affordable Care Act (ACA).
The proposed rule includes a crosswalk to help readers find where existing provisions have been incorporated. 4 4

5. Proposed LTC Requirements for Participation Themes
Person-Centered Care
Quality
Facility Assessment, Competency-Based Approach
Alignment with HHS priorities
Comprehensive Review and Modernization
Implementation of Legislation

6. Quality
Quality of Care and Quality of Life--overarching principles for every service.
Quality of Life and Quality of Care
Additional special care issues: restraints, pain management, bowel incontinence, dialysis services, and trauma-informed care
Quality Assurance and Performance Improvement (QAPI)
Resources available
Certification/QAPI/nhqapi.html

7. Facility Assessment and Competency-Based Approach
Facilities need to know themselves, their staff, and their residents.
Not a one-size fits all approach
Accounts for and allows for diversity in populations and facilities
Focus on each resident achieving their highest practicable physical, mental, and psychosocial well-being. 7 7

8. Align with Current HHS Initiatives
Advancing cross-cutting priorities
Reducing unnecessary hospital readmissions,
Reducing the incidences of healthcare acquired infections,
Improving behavioral healthcare, and
Safeguarding nursing home residents from the use of unnecessary psychotropic (antipsychotic) medications. 8

9. Comprehensive Review and Modernization:
Bringing it into the twenty-first century
Reorganized
Updated
Consistent with current health and safety knowledge 9

10. Adverse Events in Nursing Homes
Office of Inspector General (OIG) report, Adverse Events in SNFs: National Incidence Among Medicare Beneficiaries in February 2014 (
One in three residents were harmed by an adverse event within first 35 days of stay
59% of events were preventable
37% medication related (e.g., med induced change in mental status, excessive bleeding)
37% resident care related (e.g., falls, exacerbation of pre-existing condition, electrolyte imbalance, pressure ulcer)
26% infection related (e.g., pneumonia, surgical site infection, UTI, c-diff)
Over half of the residents who experienced harm returned to a hospital for treatment

11. Adverse Event/QA&A Survey Trends

12. Adverse Events in Nursing Homes
Survey Tools on Medication Safety Systems
Identify preventable adverse drug events that have occurred or may occur
Determine whether facilities identify residents’ risk factors for adverse drug events and implement individualized interventions to eliminate or mitigate those risk factors
Determine if the facility has implemented effective systems to prevent adverse drug events as well as recognize and respond to adverse drug events that do occur in order to minimize harm for the individual and prevent recurrence of the event

13. CMS Adverse Drug Event Trigger Tool
Released via Survey & Certification Policy Memo NH on July 17,
dicare/Provider- Enrollment-and- Certification/SurveyCertif icationGenInfo/Policy- and-Memos-to-States- and-Regions.html

14. Medication Adverse Event Trigger Tool
Adverse Drug Event (ADE)
Risk Factors
Triggers: Signs and Symptoms
Triggers: Clinical Interventions
Surveyor Probes
Bleeding related to antithrombotic medication use.
Anticoagulant, antiplatelet, or thrombolytic medication use
Concurrent use of more than one antithrombotic medication (e.g., use of aspirin while on anticoagulants)
Elevated PT/INR, PTT
Low platelet count
Bruising
Nosebleeds
Bleeding hums
Prolonged bleeding from wound, IV, or surgical sites
Stat order for PT/INR, PTT, platelet count, or CBC
Abrupt stop orders for medication
Administration of Vitamin K
Transfer to hospital
Is there evidence the facility routinely monitors lab results of all residents on anticoagulant/antiplatelet therapy?
Is there evidence of a system to alert prescribers?

15. Survey Process changes
Interpretive Guidance - Survey Process
Revisions to State Operations Manual Appendix PP
Analysis of Survey Results
Quality Indicator Survey (QIS) and Traditional
National QIS Implementation on hold
See S&C memo NH
Upcoming changes along with new proposed regulations

16. National Partnership to Improve Dementia Care

17. Dementia Care

18. Dementia Care
We have seen a 24.8% reduction in the use of antipsychotic medications (as of Q2 2015)!
Goals:
25% for 2015
30% for 2016…

19. Dementia Care Targeted Surveys
Frequent comments: Geriatric psychiatrists prescribing more medications than IDT would like; physicians deferring to psychiatry and not adjusting medications
Examine the process for prescribing antipsychotic medications
Review resident-level and organizational-level processes
Increased focus in certain states (Texas, Mississippi, Missouri, California, Nebraska, and Illinois)
Evaluating other actions

20. Electronic submission of Payroll-Based Staffing Information
Section 6106 of the Affordable Care Act
Funding provided by the IMPACT Act of 2014
Report staffing levels, turnover, and tenure
Auditable back to payroll data
Collected more frequently than 671/672 forms
Finalized through FY16 SNF PPS Rule as 42 CFR (u) ( /medicare-program-prospective-payment-system-and-consolidated- billing-for-skilled-nursing-facilities)

21. Electronic submission of Payroll-Based Staffing Information
Submission of data through Payroll-Based Journal (PBJ):
Exported file (XML) from automated systems
Manual entry through system provided by
Voluntary submission: October 2015
Mandatory submission: July 2016
More Information: Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data- Submission-PBJ.html

22. Staffing Submission Frequently Asked Questions
“Who are direct care staff?” (Who do we submit data for?)
Submission of data for contract staff
Medical directors and consultants
Staff switching roles or tasks throughout the day
Hours paid vs. hours worked – Must be verifiable
Public posting/Quality Measures/Five Star
Enforcement
Voluntary submission risks (none...So register now!)

23. Nursing Home Five Star Quality Rating System
Early 2015: Revised scoring methodology
Quality Measure recalibration
Staffing calculation adjustment
Two Additional Quality Measures
Long-stay and Short-stay use of antipsychotics
Future changes
Additional Quality Measures (MDS and claims-based)
Payroll-based staffing reporting
Data verification through focused surveys

24. MDS/Staffing Focused Surveys
Based on results from pilot in 2014 (see S&C: NH)
Expanded nationwide
Early findings:
F278 Assessment Accuracy
F356 Posted Staffing
F329 Unnecessary Drugs
F272/F273/F274/F276 Comprehensive Assessment
F221/F221 Phys/Chem Restraints
F353 Sufficient Staffing
Next Steps: Evaluate results and options for FY16 and beyond

25. Other MDS / RAI Activities
Identify opportunities to enhance accuracy of assessing residents’ needs and driving care. Questions can be sent to
Training for providers and State RAI Coordinators to ensure consistency
Changes related to requirements of IMPACT Act of 2014
Harmonization of quality measures and assessment items

26. Provide transparency to the public
Five Star Key Messages
Provide transparency to the public
Provide meaningful information for assessment and differentiation
Serve as one source of nursing home information (“starting point”)

27. Enforcement Analysis of national trends
Imposition of remedies (e.g., CMP, DPNA)
Effectiveness of remedies
Process issues - Facility closure
Special Focus Facility Program Objectives
Improving quality and compliance quicker (reducing length of stay in program)
Reducing “bounce back” or “yo yo-ing”

28. Skilled Nursing Facility Value Based Purchasing (SNF VBP) Program
The SNF VBP Program was authorized by Section 215 of the “Protecting Access to Medicare Act of 2014” (PAMA), which added subsections (g) and (h) to Section 1888 of the Social Security Act
Section 1888(g) authorizes new quality measures for SNFs based on the rate of hospital readmissions of Medicare beneficiaries discharged to a SNF
Section 1888(h) authorizes a VBP program in which Medicare payments to SNFs will be adjusted based on their performance scores on the quality measures established in Section 1888(g)
Only legislative requirement implemented in FY 2016 rulemaking is the all cause, all condition hospital readmission measure (Skilled Nursing Facility Readmission Measure, NQF #2510)
Pursuant to Section 1888(g)(2), resource use measure reflecting an “all-condition risk-adjusted potentially preventable hospital readmission rate” is under development for future adoption
The SNF VBP Program starts in fiscal year More Information:

29. Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program
Topics to be Addressed in Future Rulemaking:
Quarterly confidential feedback reports on SNFs’ measure performance 
Approaches for establishing performance standards, including how to incorporate improvement
Appropriate performance and baseline periods
Performance scoring methodologies and how to translate performance scores into value-based incentive payments
Posting of individual SNF and aggregate performance information on Nursing Home Compare or other website
We received public comments on the FY 2016 SNF PPS proposed rule on these topics, and future policies will be informed by these comments

30. SNF Quality Reporting Program FY 2016 SNF PPS (CMS-1622-P)
The IMPACT Act of 2014 sets forth the requirements for Skilled Nursing Facilities (SNFs) to submit data to CMS. Beginning FY 2018, providers [SNFs] that do not submit required quality reporting data to CMS will have their annual update reduced by 2 percentage points. 30

31. SNF Quality Reporting Program - FY 2016 SNF PPS (CMS-1622-P)
Three finalized post-acute care (PAC) cross-setting measures addressing the following domains:
Skin integrity and changes in skin integrity
Incidence of major falls
Functional status, cognitive function, and changes in function and cognitive function
Finalized data submission compliance deadlines and thresholds:
Failure to submit required quality reporting data to CMS will result in a 2% reduction to the FY 2018 market basket percentage
Finalized SNF QRP Submission Exception and Extension Requirements:
Written request required within 90 days of the date extraordinary circumstances occurred 31

32. Finalized FY 2016 SNF QRP Quality Measures
NQF Measure ID
Measure Title
Data Collection Timeframe
Data Submission Deadline
NQF #0674
Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
10/01/16-12/31/16
May 15, 2017
NQF #0678
Percent of Patients or Residents with Pressure Ulcers that are New or Worsened
NQF #2631*
Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
*Status: NQF endorsed on July 23, 2015 32

33. Possible Quality Measures for Future Years
The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (NQF #2510).
Potentially preventable readmissions measure.
An application of the Payment Standardized Medicare Spending Per Beneficiary (MSPB).
The percentage residents/patients at discharge assessment, who are discharged to the community.
Drug regimen review conducted with follow-up for identified issues. 33

34. More SNF QRP Information
Additional information on the finalized SNF QRP quality measures is available at:
Instruments/NursingHomeQualityInits/SNF-Quality-Reporting-Program- Measures-and-Technical-Information.html
SNF Quality Reporting Program comments or questions:   34

35. Initiative to Reduce Avoidable Hospitalizations among NF Residents
Joint Initiative of the Center for Medicare and Medicaid Innovation (Innovation Center) and the Medicare-Medicaid Coordination Office (MMCO).
Target Population: Long-stay nursing facility Medicare/Medicaid enrollees (Duals)
Primary objectives:
Reduce the frequency of avoidable hospital admissions and readmissions;
Improve the process of transitioning between inpatient hospitals and nursing facilities; and
Reduce overall health care outcomes and spending without restricting access to care or choice of providers.
Seven awardees, called “Enhanced Care and Coordination Providers” (ECCPs), were selected in in AL, NE, MI, NY, NV, IN, and PA and have partnered with over 140 facilities and serve over 16,000 residents each day.

36. Phase One - Clinical Interventions
Placement of supplemental NPs and RNs onsite to deliver direct care, improve communication with existing providers, and enhance the skills of facility staff.
Implementation of INTERACT to improve the identification and treatment of changes in condition without a hospital transfer.
Improved medication reconciliation and management, including targeting the reduction of antipsychotic medications
Implementation of new technologies to aid in assessment of residents and communication of information between providers.
Enhanced palliative care and advance care planning.
Other strategies such as the placement of dental hygienists onsite to improve oral care. 36

37. Phase Two – Payment Model
The model will create a limited number of Medicare Part B benefits and payments to reimburse nursing facilities and practitioners for the treatment of specific conditions.
Intent is to create an incentive for facilities to invest the additional time and resources, beyond what they are required to do today, to furnish services and treat beneficiaries in-house without transferring to the hospital
This model has three components:
Nursing facility payments for the treatment of one of six qualifying conditions* associated with avoidable hospitalizations
Facilities providing a higher level of acute care services onsite would receive additional $218 per day for treatments
Practitioner payments for the treatment of acute changes in condition onsite at the nursing facility
Initial nursing facility visit will be paid at the equivalent of an acute hospital visit
Practitioner payments for care planning
Practitioners would be paid to participate in nursing facility conferences and engage in care coordination discussions
*Pneumonia, Dehydration, Congestive Heart Failure, Urinary Tract Infection, Skin Ulcers/Cellulitis, Chronic Obstructive Pulmonary Disease/Asthma 37

38. Implementation Strategy
Nursing facility participation would generally be limited to the states where the current ECCPs are operating: Alabama, Indiana, Missouri, Nebraska, Nevada, New York, and Pennsylvania
ECCPs would retain their role as the “hub” for the Initiative in their respective states and manage the network of facilities and practitioners
Participating facilities, and their respective practitioners, will form the following groups:
FFS Payment Group: Providers with the PAYMENT MODEL ONLY (no ECCP clinical intervention)
ECCP + Payment Group: Providers with an ECCP clinical intervention ALREADY IN PLACE and the payment model
More information: 38

39. Questions can also be sent to: dnh_triageteam@cms.hhs.gov
Questions and Answers
Questions can also be sent to:

40. Thank you for your participation.40