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Key Issues in Long-Term Services and Supports Quality

Appendix Table 1: GAO Reports on Nursing Home Quality
U.S. Government Accountability Office (US GAO). (2016). Nursing Homes: consumers could benefit from improvements to the nursing home compare website and five-star quality rating system. GAO-17-610. Washington, DC, November.
U.S. Government Accountability Office (US GAO). (2016). Skilled nursing facilities: CMS should improve accessibility and reliability of expenditure data. GAO-16-700. Washington, DC, September.
U.S. Government Accountability Office (US GAO). (2011). Nursing homes:  More reliable data and consistent guidance would improve CMS oversight of state complaints investigations. GAO-11-280. Washington, DC, April.
U.S. Government Accountability Office (US GAO). (2010). Nursing homes: Complexity of private investment purchases demonstrates need for CMS to improve the usability and completeness of ownership data. GAO-10-710. Washington, DC.
U.S. Government Accountability Office (US GAO). (2009). Nursing homes: Addressing the factors underlying understatement of serious care problems requires sustained CMS and state commitment. GAO-10-70. Washington, DC.
U.S. Government Accountability Office (US GAO). (2009). Medicare and Medicaid participating facilities: CMS needs to reexamine state oversight of health care facilities. GAO-09-64, Washington, DC, February 13, 2009.
U.S. Government Accountability Office (US GAO). (2009). CMS’s special focus facility methodology should better target the most poorly performing homes, which tended to be chain affiliated and for-profit.  GAO-09-689. Washington, DC, August, 2009
U.S. Government Accountability Office (US GAO).  (2008). Medicaid home and community-based waivers:  CMS should encourage states to conduct mortality reviews for individuals with developmental disabilities.  GAO-08-529. Washington, DC, May 23.
U.S. Government Accountability Office (US GAO). (2008). Nursing homes: Federal monitoring surveys demonstrate continued understatement of serious care problems and CMS oversight weakness. GAO-08-517, Washington, DC, May 9, 2008.
U.S. Government Accountability Office (US GAO).  (2007). Nursing home reform: Continued attention is needed to improve quality of care in small but significant share of homes. GAO-07-794T, Washington, DC, May 2, 2007.
U.S. General Accounting Office. (US GAO). (2004). Assisted Living: Examples of State Efforts to Implement Consumer Protections.  US GAO-04-684.   Washington, DC.
U.S. General Accounting Office. (US GAO). (2004). Nursing home fire safety:  Recent fires highlight weaknesses in federal standards and oversight.   US GAO-04-660.  Washington, DC.

U.S. General Accounting Office (GAO). (2003). Nursing home quality: Prevalence of serious problems, while declining, reinforces importance of enhanced oversight. Report to Congressional Requesters. GAO-03-561. Washington, DC.

U.S. General Accounting Office (GAO). (2002). Nursing homes: Quality of care more related to staffing than spending.  Report to Congressional Requestors. GAO/HEHS-02-431R. Washington, DC.
U.S. General Accounting Office (GAO). (1999). Nursing homes: additional steps needed to strengthen enforcement of federal quality standards. Report to the Special Committee on Aging, U.S. Senate. GAO/HEHS-99-46. Washington, DC.
U.S. General Accounting Office (GAO). (1999). Nursing homes: Complaint investigation processes often inadequate to protect residents.  Report to Congressional Committees. GAO/HEHS-99-80. Washington, DC.
U.S. General Accounting Office (GAO). (1999). Assisted living:  Quality of care and consumer protection issues.  GAO/T-HEHS-99-111.  April 26. Washington, DC.
Appendix Table 2: Long-term services and supports Providers, 2014
Provider type Number of Providers Ownership Type (%) Chain-Affiliated (%) Medicare and Medicaid Certification
For-Profit Non-Profit Government
Nursing homes 15,640 70 24 6 56 97% Medicare, 95% Medicaid
Hospices 4,000 60 26 14 NA 93% Medicare, NA Medicaid
Residential Care Facilities 30,200 82 17 1 56 0% Medicare,

47% Medicaid

Home Health Agencies 12,400 80 15 5 NA 99% Medicare, 78% Medicaid
Personal Care and Other HCBS N/A N/A N/A N/A N/A N/A
NOTE:  N/A=Not Available SOURCE: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, US Department of Health and Human Services (2016).  Long-term services and supports providers and services users in the United States: Data from the national study of long-term services and supports providers, 2013-2014. Vital and Health Statistics. 3 (38). Hyattsville, M.D. https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf;   National Hospice and Palliative Care Organization (2015).  NHPCO Facts and Figures: Hospice Care in America. www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf
Appendix Table 3: Long-term services and supports Consumers, 2014
Provider type Number of Consumers Age Race/Ethnicity Medical/Functional Status
65 or Older Under 65 White Black, Hispanic, or Other
Nursing homes 1.38 million 85% 15% 76% 24% 50% have dementia; 88-97% need help with bathing, dressing or toileting
Hospices 1.3 million 94% 6% 84% 16% Principal diagnosis: 37% cancer, 45% dementia; 36% have care in a private residence
Residential Care Facilities 835,200 93% 7% 84% 16% 40% have dementia; 39-62% need help with bathing, dressing or toileting
Home Health Agencies 4.93 million 82% 18% 75% 25% 31% have dementia; 73-97% need help with bathing, dressing or toileting
Personal Care and Other HCBS 2.3 million* N/A N/A N/A N/A N/A
SOURCE: Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, US Department of Health and Human Services (2016).  Long-term services and supports providers and services users in the United States: Data from the national study of long-term services and supports providers, 2013-2014. Vital and Health Statistics. 3 (38). Hyattsville, MD, https://www.cdc.gov/nchs/data/series/sr_03/sr03_038.pdf; National Hospice and Palliative Care Organization (2015).  NHPCO Facts and Figures: Hospice Care in America. www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf    NA=Not Available *Medicaid only from Ng T, Harrington C, Musumeci M, and Ubri, P. (2016). Medicaid home and community-based services programs: 2013 data update.  Washington, DC: The Kaiser Commission on Medicaid and the Uninsured. October.  http://kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2013-data-update/
Appendix Table 4:  Summary of Federal Long-term services and supports Quality Requirements
Law Year Major Provisions
Federal Statutes
Nursing Home Reform Act (part of Omnibus Budget Reconciliation Act of 1987) 1987 -Strengthened and aligned quality standards and processes governing nursing homes participating in Medicare and Medicaid

-Established more rigorous inspection procedures with required focus on care quality and intermediate sanctions for violations

-Mandated standardized Minimum Data Set, including periodic comprehensive needs assessments (at least annually) of nursing home residents for care planning

-Required nursing homes to provide sufficient nursing, medical and psychosocial services for residents to attain and maintain their highest possible physical and mental functional status

-Set minimum requirements for licensed nursing staff, including “sufficient staff” to meet resident needs and at least one RN on the day shift and one licensed vocational or practical nurse on the evening and night shifts.

-Focused on care outcomes (e.g., incontinence, immobility, pressure ulcers), protection of residents’ rights, and establishing quality of life standards

Affordable Care Act, including the Nursing Home Transparency and Improvement Act, the Elder Justice Act, and Patient Safety and Abuse Act 2010 -Required detailed nursing home ownership reports, Medicare cost reports, and staffing data from payroll records

-Reformed complaint reporting procedures

-Expanded CMS Nursing Home Compare website, quality assurance and improvement program, and staff criminal background checks

-Increased focus on quality improvement, complaint reporting, and elder abuse prevention

-Authorized federal quality reporting program for inpatient rehabilitation facilities, long term care hospitals, and hospices and a two-percentage point reduction in the annual payment update for failure to comply

-Allowed voluntary expansion of state home and community based services

Protecting Access to Medicare Act 2014 -Established Medicare skilled nursing facility value-based purchasing methodology based on hospital readmissions (30-day all cause and 30-day potentially preventable)

-Quarterly reports posted on Nursing Home Compare as of October, 2017

-Final payment incentive implementation beginning in 2019

Improving Medicare Post-Acute Care Transformation (IMPACT) Act 2014 -Standardized assessment data submission and quality measures across long-term services and supports hospitals, skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities

-Established payment rate penalties for failure to comply

-Requires surveys of all Medicare-participating hospices every three years.

Federal Quality Regulations
Nursing Homes Conditions of Participation 1991, 2016 -Details quality requirements for providers participating in Medicare and Medicaid under Nursing Home Reform Act

-Comprehensively revises to emphasis person-centered care, care quality, quality of life, facility assessment, and staff competency with three year phase-in; align with current federal initiatives regarding reducing unnecessary hospital readmissions, lowering rate of healthcare acquired infections, improving behavioral healthcare, and preventing unnecessary use of psychotropic medications; and implement ACA requirements for compliance and ethics program, quality assurance and performance improvement program, reports of suspected crimes, staff training on dementia and abuse, and improved discharge planning

Nursing Home Fire and Life Safety 2016 -Establishes requirements for certified nursing facilities
Hospice Conditions of Participation 2009 -Establishes the requirements for eligibility, benefits, patient care, organizational environment, covered services, payment and coinsurance
CMS Medicare and Medicaid Home Health Agency Conditions of Participation 2017, Delayed to 2018 -Expands patient rights and comprehensive patient assessments, integrates communication system between home health agency and patient’s physicians, requires data-driven, agency-wide quality assessment and performance improvement program, requires expanded patient care coordination, and simplifies the organizational structure
Medicaid Home and Community-Based Settings 2014 To receive payments for Medicaid home and community-based services, settings must comply with requirements that include, for example, person-centered planning, privacy, choice of roommate, access to food, and other issues related to autonomy and choice.

 

Sub-regulatory Guidance
CMS Long Term Care Facility State Operations Manual 2017 -Provides guidance to state surveyors to determine whether the 2016 conditions of participation are met
CMS Hospice Survey Manual 2015 Provides guidance to state surveyors to determine whether the conditions of participation are met
CMS Home Health Agency Survey Manual 2012 Provides guidance to state surveyors on the imposition of deficiencies and sanctions for violation of quality standards, including civil monetary penalties, directed in-service training, directed plan or correction, payment suspension, temporary management, and informal dispute resolution
CMS Home Health Agency Survey Manual 2015 Provides guidance to state surveyors to determine whether the conditions of participation are met
SOURCES: Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987).  Public Law 100-203. Subtitle C: nursing home reform.  Signed by President, Washington, D.C., December 22, 1987; Patient Protection and Affordable Care Act (ACA). Public Law 11-48. March 23, 2010; Centers for Medicare & Medicaid Services. (2016). SNF quality reporting program (IMPACT Act 2014). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-IMPACT-Act-2014.html; Centers for Medicare & Medicaid Services. (2016). Improving Medicare post-acute care transformation act (IMPACT Act) of 2014 and Protecting access to Medicare Act of 2014.  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html; U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2016).  Medicare and Medicaid programs:  Reform of requirements for long-term services and supports facilities. 42 CFR Parts 405, 431, 447, 482, 483,485, 488, and 489. Final Rule. Federal Register, 81 (192). October 4. 68688-68872 https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities; Centers for Medicare & Medicaid Services (CMS). (2017). State operations manual. Appendix PP. Guidance for surveyors for long term care facilities. Revision 26, 08-17-17.  Baltimore, MD. https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/downloads/som107ap_pp_guidelines_ltcf.pdf; CMS State Operations Manual Appendix I – Survey Procedures for Life Safety Code Surveys (2016). Revisions. 09/09/2016; Centers for Medicare & Medicaid Services (2013).  Medicare and Medicaid Hospice Conditions of Participation (2009). https://www.gpo.gov/fdsys/pkg/CFR-2013-title42-vol3/pdf/CFR-2013-title42-vol3-part418.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_i_lsc.pdf  Centers for Medicare & Medicaid Services (2017). Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies. 42 CFR 409-488. https://www.federalregister.gov/documents/2017/01/13/2017-00283/medicare-and-medicaid-program-conditions-of-participation-for-home-health-agencies; https://www.federalregister.gov/documents/2017/07/10/2017-14347/medicare-and-medicaid-programs-conditions-of-participation-for-home-health-agencies-delay-of-effectivedate; https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf
 Appendix Table 5: CMS Nursing Home Compare Quality Measures as of 2017
Population Measures
Short-stay residents (100 days or less) Nine measures including the percent of residents with:

-moderate to severe pain*
-pressure ulcers that are new or worsened*
-seasonal influenza vaccine
-pneumococcal vaccine
-antipsychotic medication*
-improvements in function*
-any cause hospital readmission*
-community discharge for 100 days without readmission*
-outpatient emergency department visit *

Long-stay residents (101 days or more) Fifteen measures including the percent of residents with:

-falls with a major injury*
-urinary tract infections*
-moderate to severe pain*
-high risk residents with pressure ulcers*
-loss of bowel or bladder control
-use of a bladder catheter*
-physical restraints*
-need increased help with activities of daily living*
-weight loss
-depressive symptoms
-antipsychotic medication*
-seasonal influenza vaccine
-pneumococcal vaccine
-ability to move independently worsened*
-antianxiety or hypnotic medication.

NOTE: *=items included in the five-star rating system.
SOURCE:  Centers for Medicare & Medicaid Services (CMS). (2017). Nursing Home Compare.  https://www.medicare.gov/nursinghomecompare/search.html?   Centers for Medicare and Medicaid Services (CMS). (2017). Design for nursing home compare:  five-star quality rating system: users guide.  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf
Appendix Table 6: Hospice Compare Quality Measures
Data Source Description
Hospice Compare Provider performance on National Quality Forum endorsed measures:

-treatment preferences
-beliefs and values addressed (if desired by patient)
-pain screening
-pain assessment
-dyspnea screening
-dyspnea assessment
-patients treated with opioid who are given bowel regimen

Consumer Assessment of Healthcare Providers and Systems Hospice Survey Reflects care experiences of informal caregivers (i.e., family and friends) of patients who died in hospice care
SOURCE: Centers for Medicare & Medicaid Services (CMS). (2017) Hospice Compare website. https://www.medicare.gov/hospicecompare/;  https://data.medicare.gov/Hospice-Compare/National-CAHPS-Hospice-Survey-data/sj42-4yv4
Appendix Table 7:  Home Health Compare Quality Measures
Data Source Measures
CMS Home Health Compare website* Includes 23 process and outcome measures in four categories:

-managing daily activities
-managing pain and treating symptoms
-preventing harm
-preventing unplanned hospital admissions

Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey -How often home health team provided care in a professional way
-How well team communicated
-Whether team discussed medicines, pain, and home safety
-Patient rating of overall care
-Whether patient would recommend agency to friends and family
SOURCE: Centers for Medicare & Medicaid Services. (2017). Medicare home health compare. http://www.medicare.gov/homehealthcompare/search.html; Home health consumer assessment of healthcare providers and systems (CAHPS) (2017).  https://homehealthcahps.org/Default.aspx?tabid=88.   *Measures are from the Outcomes and Assessment Information Set (OASIS), except for 2 claims data measures (clients who had to be readmitted to hospital or receive ER care after recent hospital stay).
Appendix Table 8: Medicaid Home and Community-Based Waiver Services Quality State Requirements
Regulations Measures
CMS Medicaid Home and Community-Based Services Reporting Requirements (2014) States must:

-develop and measure waiver performance in 14 areas, such as administration, financial integrity, level of care, provider qualifications, and service planning and delivery.
-demonstrate on an ongoing basis that they identify, address, and seek to prevent instances of abuse, neglect, exploitation and unexplained death.
-have an incident management system that effectively resolves incidents and prevents further similar incidents to the extent possible.
-have policies and procedures for the use or prohibition of restrictive interventions (including restraints and seclusion).
-establish and monitor health care standards for service providers.

SOURCE:  Centers for Medicare & Medicaid Services, Department of Health and Human Services. (2014). Medicaid program: State plan home and community-based services, provider payment reassignment, and home and community-based setting requirements for community first choice and home and community-based services (HCBS) waivers. 42 CFR Parts 430, 435, 436, 440, 441 and 447.  Federal Register.  2014-00487. January 10.  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-10-2.html  https://www.medicaid.gov/medicaid/hcbs/downloads/hcbs-setting-fact-sheet.pdf.
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