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CMS Announces Actions to Combat the Illegal Drugging of Nursing Home Residents

January 18, 2023

The Centers for Medicare & Medicaid Services (CMS) announced new steps to protect nursing home residents from inappropriate diagnosing of schizophrenia which often results in the improper use of antipsychotic medications to sedate and chemically restrain residents. In addition, CMS announced that it would now post on Care Compare citations that are under dispute by nursing homes.

Inappropriate Diagnoses of Schizophrenia

In 2008, CMS introduced a quality measure in its Care Compare rating system that calculated the percentage of long-stay residents (over 100 days) that were receiving antipsychotic medications. This measure was introduced to combat the practice of some nursing homes illegally using antipsychotic medications to sedate residents with dementia or other increased care needs, rather than providing appropriate hands-on care interventions. The measure, however, excluded residents with certain diagnoses, including schizophrenia, Huntington’s disease, and Tourette syndrome. As a result, some nursing homes began to improperly diagnose residents with schizophrenia, to disguise the use of antipsychotics to sedate residents rather than provide appropriate hands-on care interventions. The improper use of antipsychotic medications is extremely dangerous and can lead to a variety of poor health outcomes for residents, even death.

In the new guidance, CMS acknowledges that there has been a steady rise in schizophrenia diagnoses since the quality measure was introduced. This announcement comes on the heels of a report from the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) which found that from 2015-2019 there was a 194% increase in the number of residents diagnosed with schizophrenia who did not have that diagnosis prior to admission to the nursing home. It is important to note that it is extremely rare for schizophrenia to suddenly occur in older people. The onset of schizophrenia generally occurs in someone’s late teens through their twenties. Importantly, the OIG report directly connected illegal drugging of nursing home residents with inadequate staffing in nursing homes.

CMS announced that it will begin to conduct audits of nursing homes with high rates of schizophrenia diagnoses and “examine the facility’s evidence for appropriately documenting, assessing, and coding a diagnosis of schizophrenia.” Facilities that have “inaccuracies” will have their Quality Measure Rating adjusted in the following ways:

  • The Overall QM and long-stay QM ratings will be downgraded to one star for six months(this drops the facility’s overall star rating by one star).
  • The short-stay QM (under one hundred days) rating will be suppressed for six months.
  • The long-stay antipsychotic QM will be suppressed for 12 months.

While Consumer Voice has expressed significant concern with the accuracy of CMS’s Quality Measure, we support these actions. The Quality Measure rating often inflates a facility’s overall 5-Star rating on Care Compare. This action will help incentivize compliance and make sure the public is aware of these illegal practices in nursing homes.

More Must Be Done

Despite today’s announcement more must be done to protect residents. Importantly, CMS announced no other enforcement action against facilities who are found to be using this illegal practice. Additional penalties, including civil monetary penalties, should be assessed. Additionally, CMS should take steps to penalize medical professionals that inappropriately diagnose residents with schizophrenia to illegally prescribe antipsychotics.

Further, CMS must take steps to address problems identified by the recent OIG report. The report looked at the use of antipsychotic medications over the past ten years. While a reduction in antipsychotics was identified, the report found that this reduction was offset by facilities using other mind-altering drugs (psychotropic drugs) to sedate residents. CMS must take action to monitor the increased use of other drugs to chemically restrain residents.

Most importantly, CMS must implement a minimum staffing standard, as promised last year. As noted, the OIG report directly connected the use of drugging with inadequate staffing. Understaffed facilities often drug and sedate residents because they have inadequate staff to provide proper direct care interventions. Requiring facilities to have enough staff will directly address the problem of illegal drugging of residents.

CMS Will Now Post Citations Under Dispute

Also included in today’s announcement was a change in policy regarding the posting of violations on the Care Compare website. CMS’s policy has been that it does not post violations or citations that are in the dispute process. This process can take six months, but sometimes years, and results in consumers not being aware of deficient practice in nursing homes. CMS will now post these citations on Care Compare. Consumer Voice applauds this step as it increases transparency for consumers.

Both of these announcements were part of President Biden’s list of historic reforms announced last February. While today’s announcement regarding schizophrenia diagnoses is a promising first step, much more needs must be done to protect nursing home residents. Stay tuned for more on this issue from Consumer Voice.

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