​In a blog post on the Trump administration’s strategies for ensuring safety and quality in skilled nursing facilities (SNFs), Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), focused on enhanced enforcement efforts to strengthen oversight of facilities.

The post, “Ensuring Safety and Quality in Nursing Homes: Part 2 of the Five-Part Strategy Deep Dive,” described how this “second pillar” of the CMS strategy for SNFs is working to clarify and bolster the work of state survey agencies (SSAs) and address adequate staffing levels, among other steps.

In August, Verma authored a blog on the first pillar of SNF strategy: Strengthening Oversight. In addition to the current blog, three more posts are to come on Increasing Transparency, Improving Quality, and Putting Patients Over Paperwork.

In addressing enforcement, she said CMS enhancements start with oversight of SSAs “and clearly communicating our expectations to them and to nursing homes, so they have no question about how we measure performance.”

As an example, Verma said the agency has seen inconsistency related to how SSAs perform their role to ensure SNFs meet federal health and safety standards. This led to a revision of the program last year to include new ways to use data to monitor performance, and ensure states are protecting residents from harm consistently across the country.

“Moving forward, we’re looking at ways to set clearer timelines for SSAs, so they know the expectations for arriving onsite to investigate allegations of abuse and neglect, and if necessary, refer to law enforcement for additional action,” she said.

In response to the Verma blog, Holly Harmon, vice president of quality, regulatory, and clinical services for the American Health Care Association (AHCA), says the group appreciates CMS’ effort to ensure quality care in all of the nation’s nursing homes.

“We are glad to see CMS work to improve the state survey agency oversight process. Inspectors should be held to the same standards on thoroughness, completeness, and timeliness as providers,” she says.

“There should be more emphasis placed on the timeliness of survey inspections and follow-up visits, as this greatly affects providers’ timelines to correct citations and avoid unnecessary fines.”

Further, AHCA encourage CMS to look at how to reduce the enormous variation in how states and regional offices interpret regulations and enforce them. “The transparency CMS has adopted with sharing information has brought this variation to light, but more must be done,” Harmon says. “AHCA will continue to work with Congress and CMS to continue our mission to improve lives by delivering common-sense solutions.”

Verma also wrote about improving the quality of life for residents, calling it a major tenet of any enforcement policy. She pointed to the long-held CMS concern about “the prevalence of antipsychotic medication use in nursing home settings where these are not clinically indicated” as one of its priority areas.She pointed to the long-held CMS concern about “the prevalence of antipsychotic medication use in nursing home settings where these are not clinically indicated” as one of its priority areas.

She pointed to the long-held CMS concern about “the prevalence of antipsychotic medication use in nursing home settings where these are not clinically indicated” as one of its priority areas.She pointed to the long-held CMS concern about “the prevalence of antipsychotic medication use in nursing home settings where these are not clinically indicated” as one of its priority areas.

Despite progress by SNFs in recent years to reduce the number of improperly prescribed antipsychotics, some facilities still lag behind CMS standards. “We call nursing homes that have high rates of antipsychotic medication use ‘late adopters,’ as they are late in adopting improvement strategies to lower their overall high use of these medications,” she said.

In 2019, Verma said the agency put late adopters on notice by introducing new tools to correct the problem, including the use of discretionary Denials of Payment for New Admissions, meaning late adopters may lose the ability to seek Medicare reimbursement in some instances.

On the issue of staffing, CMS is monitoring adherence to federal statute on the number of registered nurses that SNFs employ to help care for patients and residents.

To bring all facilities into compliance with these regulations, CMS started holding SNFs accountable through a the Payroll Based Journal (PBJ) reporting tool and “directed SSAs to harness the PBJ staffing data using a targeted strategy to address a troubling issue we were seeing in staffing on weekends,” Verma said.

Lastly, she said CMS is taking “a hard look at the fines we impose on nursing homes for noncompliance, civil money penalties (CMPs).”

Some of these fines can reach into the hundreds of thousands of dollars, and the size and duration of a CMP can depend on a variety of factors. “Sometimes, large CMPs are a useful tool to incentivize nursing homes to come back into swift compliance with federal rules. But in recent years, we have found a high level of variation in the CMPs levied across the country,” Verma said.

Read the blog at https://www.cms.gov/blog/ensuring-safety-and-quality-nursing-homes-part-2-five-part-strategy-deep-dive.