The vast majority of this doesn’t apply directly to long-term care. Emergency preparedness is included, and obviously it does apply. However, most of the guidance for the LTC-specific emergency preparedness changes is still to come.

Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-20-07-ALL

DATE: December 20, 2019

TO: State Survey Agency Directors FROM: Director Quality, Safety & Oversight Group

SUBJECT: Burden Reduction and Discharge Planning Final Rules Guidance and Process

Memorandum Summary

• On September 30, 2019, the Centers for Medicare & Medicaid Services (CMS) published the Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule, as well as the Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies Final Rule.

• This policy memorandum provides guidance to the CMS Regional Offices (ROs), the State Survey Agencies (SAs) and the Accrediting Organizations (AOs) regarding the changes to the regulations and our approach for updating the State Operations Manual (SOM) and applicable surveyor systems.

A few months ago, we provided members with a list of the top ten federal deficiencies since January of 2019. Since then, articles have delved deeper into the top four citations. This month, we will examine the number five and six top citations, explore common reasons that facilities struggle to meet these regulations, and discuss why surveyors cite them.

As a reminder, the top ten deficiencies are:

1. F880 - Infection prevention and control

2. F689 - Free of accidents, hazards/supervision/devices

3. F812 - Food procurement/storage

4. F656 - Develop/implement comprehensive care plan

5. F684 - Quality of care

6. F761 - Label/storage of drugs and biologicals

7. F657 - Care plan timing and revision

8. F758 - Free from unnecessary psychotropic med/prn use

9. F677 - ADL care for dependent residents

10. F550 - Resident rights

(The citations above in red have the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)

The LTCSP Procedure Guide provides instruction on the procedural and software steps necessary for completing the Long-term Care Survey Process. Surveyors use the Procedure Guide for all standard surveys of SNFs and NFs, whether freestanding, distinct parts, or dually participating. The LTCSP steps are organized into seven parts: 1) offsite preparation; 2) facility entrance; 3) initial pool process; 4) sample selection; 5) investigation; 6) ongoing and other survey activities; and 7) potential citations. Below is a broad overview of the key onsite parts of the LTCSP (parts 3 – 7).

Last month, we provided members with a list of the top ten federal deficiencies since January of 2019. As a reminder, the top ten deficiencies are:

1. F880 - Infection prevention and control

2. F689 - Free of accidents, hazards/supervision/devices

3. F812 - Food procurement/storage

4. F656 - Develop/implement comprehensive care plan

5. F684 - Quality of care

6. F761 - Label/storage of drugs and biologicals

7. F657 - Care plan timing and revision

8. F758 - Free from unnecessary psychotropic med/prn use

9. F677 - ADL care for dependent residents

10. F550 - Resident rights

(The citations above in red reflect the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)

This month, we will take a deeper dive into the number three and four top citations and explore common reasons that facilities are struggling to meet these regulations.

CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in October 2019.

October 2019 Revisions

In October 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected the health inspection and quality measure domains. This section provides details on these changes.

Ratings changes for facilities that receive the abuse icon: To make it easier for consumers to identify facilities with instances of non-compliance related to abuse, starting in October 2019, CMS added an icon to highlight facilities that meet either of the following criteria: 

1. Harm-level abuse citation in the most recent survey cycle: Facilities cited for abuse where residents were found to be harmed (Scope/Severity of G or higher) on the most recent standard survey or on a complaint survey within the past 12 months. 
2. Repeat abuse citations: Facilities cited for abuse where residents were found to be potentially harmed (Scope/Severity of D or higher) on the most recent standard survey or on a complaint survey within the past 12 months and on the previous (i.e., second most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13 to 24 months ago). 

Nursing homes that receive the abuse icon have their health inspection rating capped at a maximum of two stars. Due to the methodology used to calculate the overall rating, the best overall quality rating a facility that receives the abuse icon can have is four stars. 

Removal of quality measures related to pain: CMS removed two quality measures (QMs) from the Nursing Home Compare website and the Five-Star Quality Rating System in October 2019. These measures are: 

• Percentage of short-stay residents who report moderate to severe pain. 
• Percentage of long-stay residents who report moderate to severe pain. 

As a result of dropping these two measures, the cut-points for the long-stay, short-stay, and overall QM ratings changed. These changes were made to maintain, as close as possible, the same distribution of short-stay and long-stay QM ratings as were posted on Nursing Home Compare in July 2019.