CMS sharpens focus on stemming antipsychotic use
JULY 10, 2019
The Centers for Medicare & Medicaid Services (CMS) recently revised the Nursing Home Compare 5-Star Quality Rating System and many skilled nursing facilities (SNFs) found themselves facing lowered ratings. The CMS updates are intended to give consumers clearer information about the quality of care residents receive at different facilities as well as promote quality improvement within the SNFs. One of the 17 Quality Measures used to rate facilities – percent of residents who received an antipsychotic medication – is now weighted more heavily. Use of antipsychotic medications in nursing facilities is prevalent and many facilities are still struggling to keep their usage down.
According to a 2016-2017 report by the Human Rights Watch, in an average week, antipsychotic drugs are given to nearly 200,000 residents who do not have the diagnoses for which the drugs are approved. Residents with dementia or Alzheimer’s disease are often given these drugs for off-label use to treat a number of symptoms for which the Food and Drug Administration has not approved them. Prolonged misuse of antipsychotic medications can put residents in grave danger by impacting their psychosocial health. Symptoms could include: excessive sleeping, social withdrawal, delirium, depression, pain, weight loss from missed mealtimes, decline in mental and physical functioning; increased risk of falls and decline in continence. Critics of the practice believe administering the drugs is equivalent to chemical restraint and that they have been used as a quick fix for inadequate care. CMS has been working to change the way dementia or Alzheimer’s is treated in facilities.
In 2012, CMS launched the Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for nursing home residents with dementia-related behaviors. One of the partnership’s goals is the reduction of unnecessary antipsychotic medication use in nursing homes. In March 2019, CMS released a memo (QSO-19-07-NH) that stated a 38.9 percent reduction in the number of residents receiving antipsychotic medication since 2011. However, CMS identified 1,500 nursing homes, or “late adopters,” that have not improved their antipsychotic medication usage since late 2011. According to the memo, there were 235 “late adopters” that “have been cited for noncompliance with federal regulations related to unnecessary medications or psychotropic medications two or more times since January 1, 2016, and who have not shown improvement in their long-stay antipsychotic medication rates.” CMS divided these facilities into two groups. Group One facilities have had three or more prior deficiencies for unnecessary medications or inappropriate use of psychotropic medications since January 1, 2016. There are 41 facilities in this group. Group Two facilities have had two prior deficiencies for unnecessary medications or inappropriate use of psychotropic medications since January 1, 2016. There were 194 facilities in this group. In the memo, CMS also announced a new enforcement approach for both groups that could impact their payments.
There are consequences for both Group One and Two facilities, if any survey (e.g., recertification, revisit, focused dementia/schizophrenia, and complaint) results in a citation for the following F-tags: F605 (Chemical Restraints), F744 (Dementia Care) or F758 (Psychotropic Medications). Both groups will face a discretionary Denial of Payment for New Admission (DPNA). Additionally, Group One facilities will face a per-day monetary fine. There are no fines for Group Two facilities. Depending on the severity, both groups who receive citations for those three F-tags will have their case transferred from the State Agency to CMS Regional Offices for enforcement.
With CMS strengthening consequences, it’s important that “late adopters” look for other ways to address residents’ dementia-related symptoms. CMS guidance on administering antipsychotic medication encourages attempting alternative non-drug interventions. The approach looks at why an individual is expressing certain behaviors rather than trying to chemically subdue them. The process examines the resident’s environment, physical health and needs to rule out underlying causes. Interventions could include efforts to reduce loneliness, boredom and pain; creation of individualized daily routines, cognitive exercises and ensuring staff consistency and familiarity. These non-drug interventions are truly in the spirit of providing person-centered care. They help facilities conform to residents’ needs rather than trying to force residents to conform to their facility’s environment. This approach may take more time, but it’s better for the resident and ultimately, better than facing a possible deficiency.