This Chartbook on Patient Safety includes a section with results from the National Nursing Home Survey on Patient Safety:

National Healthcare Quality and Disparities Report

This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety. A PowerPoint version is also available that users can download for presentations.

CMS has established a Dementia Care Resources page to provide information that was previously housed at the National Nursing Home Quality Improvement Campaign. Additional resources are available through the QIO program.

Adverse events and poor health outcomes are continuing challenges for nursing home residents and staff. Research has shown that many resident harms are avoidable and may be caused by situations in which residents do not receive needed care, often called omissions of care. Omissions of care research in nursing home settings is limited and definitions of omissions of care vary. Therefore, AHRQ has developed a definition of omissions of care for nursing homes intended to be meaningful to stakeholders, including residents and caregivers, and actionable for research or improving quality of care. 

Trends in Deficiencies at Nursing Homes Show That Improvements Are Needed To Ensure the Health and Safety of Residents (A-09-18-02010)

In this data brief, we analyze nursing home deficiencies that were identified by State survey agencies (State agencies) across the Nation for calendar years 2013 through 2017 (review period). This data brief offers the Centers for Medicare & Medicaid Services (CMS) and other stakeholders (e.g., State agencies and nursing home management) insight into deficiency trends at nursing homes nation-wide. It also complements our previous report on State agencies' verification of correction of nursing home deficiencies.

The OIG report, Michigan Disbursed Only Part of Its Civil Money Penalty Collections, Limiting Resources To Protect or Improve Care for Nursing Facility Residents (02-28-2019 | Audit (A-05-17-00019) | Complete Report | Report in Brief) found that the state of Michigan did not fully use available civil monetary penalty (CMP) collections to support nursing facility residents. While the report is specific to Michigan, it suggests some providers across the United States may not be aware of/know how to apply for CMP funds or know what types of projects are likely to receive funding.

How to Apply for CMP Funds

The application process for CMP funds is determined by the state in which the nursing home is located. The process for each state may differ therefore states have their own applications for CMP funds and applicants should use their state specific application and instructions.

Change Package to prevent harm related to medication adverse events, other adverse events, infection, and abuse,and neglect for nursing home residents.

Breakthrough Communities and Technical Assistance

 A Breakthrough Community is a voluntary and customized health care improvement program that is based on a model designed by the Institute for Healthcare Improvement (IHI). Its goal is to achieve “breakthrough” improvement in nursing homes that may be experiencing challenges in one of two program areas: reducing adverse events and/or improving dementia care.

In Breakthrough Communities, nursing homes work with their peers to test interventions that will lead to improvement in quality of life and quality of care for residents of nursing homes.

If you are interested and want to apply, please email CMP-info@cms.hhs.gov.

Technical Assistance To improve dementia care, CMS funds and provides one-to-one Technical Assistance (TA) to a selection of nursing homes through the CMPRP. One-to-one TA will be customized to your nursing home to address unique barriers in improving quality of life and quality of care for residents with dementia.

The purpose of one-to-one TA is to provide education and support to nursing homes’ quality improvement processes, including root cause analysis and the development of a performance improvement plan framework for the improvement of dementia care and ensuring the appropriate use of antipsychotic medications.

If you are interested and want to apply, please email CMP-info@cms.hhs.gov.

Civil Money Penalty (CMP) Funds

About Civil Money Penalty (CMP) Funds

A CMP is a monetary penalty the Centers for Medicare & Medicaid Services (CMS) may impose against nursing homes for either the number of days or for each instance a nursing home is not in substantial compliance with one or more Medicare and Medicaid participation requirements for long-term care facilities.

A portion of CMPs collected from nursing homes are returned to the states in which CMPs are imposed. State CMP funds may be reinvested to support activities that benefit nursing home residents and that protect or improve their quality of care or quality of life.

What CMP Funds Can Be Used For

CMP funds may be used for (but not limited to) the following:

·        Assistance to support and protect residents of a facility that closes or is decertified

·        Time-limited expenses incurred in the process of relocating residents to home and community-based settings or another facility when a facility is closed or downsized pursuant to an agreement with the state Medicaid agency

·        Projects that support resident and family councils and other consumer involvement in assuring quality care in facilities

Facility improvement initiatives, such as joint training of facility staff and surveyors, or technical assistance for facilities implementing quality assurance and performance improvement programs

How to Apply for CMP Funds

The application process for CMP funds is determined by the state in which the nursing home is located. The process for each state may differ therefore states have their own applications for CMP funds and applicants should use their state specific application and instructions.

New Survey process preparation materials, aka Long-term Care Survey Pathways, updated in August 2018.

Central nervous system medication burden and serious falls in older nursing home residents. Hanlon JT, Zhao X, Naples JG, et al. J Am Geriatr Soc. 2017 Jun;65(6):1183-9. Epub 2017 Feb 2. 

CNS medication burden, approximately 3 + standardized daily doses, was associated with an increased risk of serious falls in nursing home residents with recent fall. Clinicians should be vigilant for opportunities to discontinue or decrease the doses of individual CNS medications and/or consider non-pharmacological alternatives. Such interventions that reduce use of CNS medications in nursing homes could reduce fall rates but further research is needed to confirm this.