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. https://www.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* |
|
| Long-stay residents (101 days or more) | Fifteen measures including the percent of residents with:
-falls with a major injury* |
|
| 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 |
| 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 |
| 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. |
| 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. | |