- CMA Home Health Survey | Medicare Beneficiaries Likely Misinformed and Underserved
- Build Back Better Act: House and Senate Nursing Home Provisions Compared
- CMS Will Now Post All Civil Money Penalties Imposed Against Nursing Facilities
- Vaccination of Nursing Home Staff Correlated with Fewer Cases and Deaths among Residents
- FREE WEBINAR | Medicare Coverage of Home Health Services
- Our Strength is Our Community
A survey conducted by the Center for Medicare Advocacy over the past year indicates that home health aide services are not available in an amount even approaching the benefit as defined by Medicare law. In addition, agencies and 1-800-Medicare provided information that was inconsistent and often inaccurate.
- Download and read the full report at: https://medicareadvocacy.org/wp-content/uploads/2021/12/CMA-Survey-Medicare-Home-Health-Underservice.pdf
The Build Back Better Act is currently under consideration in the Senate after being passed in the House of Representatives in November. Over the weekend, on December 11, the Senate Finance Committee released its draft language for the reconciliation bill, which runs 1,180 pages. Two new nursing home provisions were added to the five that were included in the House-passed bill, bringing the total to seven nursing home-specific provisions. The two new provisions center around increasing the number of facilities that participate in the Special Focus Facility program to at least 3.5 percent of all facilities (amounting to an increase from about 88 facilities to approximately 550) and providing $800 million in grant funding to states to improve staffing and infection control in long-term care institutional settings.
The Center for Medicare Advocacy has been advocating for all five of the original nursing home provisions to be included in the Senate version of the bill. We partnered with Connecticut State Long-Term Care Ombudsman, Mairead Painter, to publish this Op-Ed in The CT Mirror about our mutual support for the provisions. While we are pleased the five provisions were carried over into the Senate version (largely unaltered), we are concerned that an important aspect of the Nurse Staffing provision was eliminated. The House version called for periodic studies to identify and establish appropriate minimum staff-to-resident ratios for nursing staff in skilled nursing facilities. The House bill requires the Centers for Medicare & Medicaid Services (CMS) to update staffing regulations to reflect the minimum staffing ratios from the survey findings and recommendations. The Senate version removed the mandate that CMS update its staffing regulations appropriately. Removal of this mandate significantly reduces the impact of the Nursing Staffing provision in terms of increasing the quality of care residents receive.
Below is a side-by-side comparison of the House version of the Build Back Better Act’s nursing home provisions, compared with the Senate’s current version. The current text is not final language, which means that none of these provisions are set in stone.
|Funding to Improve the Accuracy and Reliability of Skilled Nursing Facility Data||(Sec. 30717)Validate measures, data, and information for resident assessment data and direct care staffing informationFor reporting inaccurate information for FY26 – 31, reduction of payment rates by 2 percentage pointsTime: FY2024 – FY2031|
Funding: $50M (FY22 – available through FY31)
|(Sec. 122111)Validate measures, data, and information for resident assessment data and direct care staffing informationFor reporting inaccurate information for FY26 – 31, reduction of payment rates by 2 percentage points Time: FY2024 – FY2031|
Funding: $50M (FY22 – available through FY31)
|Ensuring Accurate Information on Cost Reports||(Sec. 30718)Annual audit of skilled nursing cost reportsTime: Beginning 2023 – 2031 Funding: $250M (FY22 – available through FY31)||(Sec. 122112)Annual audit of skilled nursing cost reportsTime: Beginning 2023 – 2031 Funding: $250M (FY22 – available through FY31)|
|House: Survey Improvements Senate version titled: Survey and Enforcement Improvements for Skilled Nursing Facilities and Nursing Facilities||(Sec. 30719)Conduct reviews of survey and enforcement process and identifying plans to improve (as appropriate)Provide training, tools, technical assistance, and financial supportReview of state survey agencies to identify infection control and emergency preparedness deficiencies Funding: $325M (FY22 – available through FY31)||(Sec. 122113)Conduct reviews of survey and enforcement process and identifying plans to improve (as appropriate)Provide training, tools, technical assistance, and financial supportReview of state survey agencies to identify infection control and emergency preparedness deficienciesFunding: $325M (FY22 – available through FY31)|
|Nurse Staffing Requirements Senate version titled: Nurse Staffing||(Sec. 30720)Conduct study on appropriateness of establishing minimum staff to resident ratios for nursing staff for skilled nursing facilitiesTimeline: No later than 3 years after bill passage and no less frequently than once every 5 years after initial surveyNo later than 1 year after report, CMS update staffing regulations to reflect appropriate minimum staffing ratios from the survey recommendations, using the appropriated fundsFunding: $50M (FY22 – available through FY31)||(Sec. 122114)Conduct study on appropriateness of establishing minimum staff to resident ratios for nursing staff for skilled nursing facilities Timeline: No later than 3 years after bill passage and no less frequently than once every 5 years after initial survey|
Excluded: No later than 1 year after report, CMS update staffing regulations to reflect appropriate minimum staffing ratios from the survey recommendations, using the appropriated fundsFunding: $50M (FY22 – available through FY31)
|Registered Professional Nurses||(Sec. 132000)Require Registered Nurse (RN) on staff 24 hours a day, 7 days a week (Note: Increase from 8 consecutive hours a day, 7 days a week)Time: Before Oct. 1, 2024||(Sec. 122115)Require Registered Nurse (RN) on staff 24 hours a day, 7 days a week (Note: Increase from 8 consecutive hours a day, 7 days a week)Time: Before Oct. 1, 2024|
|Improvements to the Special Focus Facility Program||Not included in the House version, but similar language was included in the Nursing Home Improvement and Accountability Act of 2021 (S.2694/H.R.5169)||(Sec. 122116)Ensure the number of facilities participating in the special focus facility program is not less than 3.5 percent of all facilities starting no later than Oct. 1, 2023Provide mandatory on-site consultation and educational programming for facilities participating in the special focus facility program no later than Oct. 1, 2024Funding: $100M (FY22 – available through FY26)|
|Grants to Improve Staffing and Infection Control in Long-Term Care Institutional Settings||Not included in the House version, but there was a provision in the Nursing Home Improvement and Accountability Act of 2021 (S.2694/H.R.5169) that stipulated “Enhanced Funding to Support Staffing and Quality Care in Nursing Facilities”||(Sec. 122117)Grant funding for at least two of three activities: (1) Provide wage or benefit enhancements to staff who care for residents; (2) Improve and develop training and career development opportunities, including training for infection control; (3) Expand staffing for care of residents to increase staffing ratios.Funding for administrative and technical assistance costs in carrying out the aboveFunding: $800M (FY22 – available through Sept. 30, 2031); $3M (FY22 – available through Sept. 30, 2031)|
In response to questions from reporters, the Centers for Medicare & Medicaid Services (CMS) stated it will now publicly post all civil money penalties imposed against nursing facilities, whether or not the fines have been paid. Until now, CMS apparently did not publicly disclose unpaid fines. CMS’s former policy rewarded bad behavior by facilities – refusal to pay fines – by keeping the federal fines hidden from public disclosure. The change in policy reflects both the importance of the media in identifying and exposing poor public policies and the responsiveness of the Biden Administration and its willingness to undo inappropriate policies of prior administrations.
In June 2021, the Iowa Capital Dispatch reported that an $84,825 fine imposed against Dubuque Specialty Care (and automatically reduced by 35% to $55,136 when the facility chose not to appeal) was not reported on the federal website Care Compare. CMS told reporter Clark Kauffman that CMS posts fines only if and when facility owners pay the fines. Kauffman also reported in June that the federal website indicated that the Iowa nursing facility had no deficiencies, as of its June 10, 2020 inspection, although a survey report a year earlier actually cited a number of serious deficiencies related to infection control.
CMS told Kauffman in December 2021 that it is now publicly posting fines, whether or not the nursing facilities have paid them.
A second reporter, Jocelyn Wiener of CalReports, reviewed federal fines exceeding $100,000 that were imposed against California nursing facilities since 2018, as reported on the federal website qcor. When she compared the qcor information with information reported on Care Compare, she found that only 14 of the 50 large fines were reported on the publicly-facing Care Compare website. She found, for example, that the largest federal fine imposed against a California nursing facility – $912,404, imposed at Northpointe and reduced by 35% to $593,000 when the facility did not appeal – did not appear on Care Compare.
CMS originally gave Wiener multiple reasons that the Northpointe fine could not be found – “representatives said that it must not have the data, the data should be findable in the archives (it wasn’t); it had been more than three years since the Northpointe fine.” On December 7, CMS said it did not post unpaid fines. As Wiener prepared to publish her findings, CMS changed its policy and notified her on that it would post all fines.
The New York Times reported on December 10, 2021 that “Much of the data that powers the [federal Care Compare rating] system is wrong and often makes nursing homes seem cleaner and safer than they are.” The New York Times attributed inadequacies in the Care Compare website to multiple factors: the “secretive appeal process” (both the informal dispute resolution process and the formal appeals process to Administrative Law Judges); the inappropriate classification of deficiencies as causing no harm to residents; surveyors’ expectations of challenges to their citing deficiencies; and survey agencies’ encouraging facilities to improve, rather than citing deficiencies and imposing penalties.
The Center for Medicare Advocacy has reported for a decade on the federal website’s failure to provide the public with accurate information about deficiencies, penalties, and star ratings.
 Clark Kauffman, “CMS: We don’t disclose nursing home fines when the owners refuse to pay,” Iowa Capital Dispatch (Jun. 8, 2021), https://iowacapitaldispatch.com/2021/06/08/cms-we-dont-disclose-nursing-home-fines-when-the-owners-refuse-to-pay/
 Clark Kauffman, “Federal agency says it now discloses all nursing home fines,” Iowa Capital Dispatch (Dec. 13, 2021), https://iowacapitaldispatch.com/2021/12/13/federal-agency-says-it-now-discloses-all-nursing-home-fines/
 QCOR, Quality Certification & Oversight Reports, is at https://qcor.cms.gov/main.jsp
 Jocelyn Wiener, “The case of the vanishing fine: How a massive nursing home penalty eluded consumer detection,” CalMatters (Dec. 15, 2021), https://calmatters.org/health/2021/12/rechnitz-nursing-home-fines/?utm_source=CalMatters+Newsletters&utm_campaign=fab7c297cf-WHATMATTERS&utm_medium=email&utm_term=0_faa7be558d-fab7c297cf-150217021&mc_cid=fab7c297cf&mc_eid=f773cc7d86
 Robert Gebeloff, Katie Thomas, and Jessica Silver-Greenberg, “How Nursing Homes’ Worst Offenses Are Hidden from the Public,” The New York Times (Dec. 10, 2021), https://www.nytimes.com/2021/12/09/business/nursing-home-abuse-inspection.html?searchResultPosition=1
 See CMA, “Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys,” (CMA Alert, Dec. 22, 2011), https://medicareadvocacy.org/special-focus-facility-study-nursing-facilities-self-regulation-cannot-replace-independent-surveys/. See full study, “Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys: A Study of Special Focus Facilities, Their Health Surveys, and Their Self-Reported Staffing and Quality Measures,” https://www.medicareadvocacy.org/wp-content/uploads/2011/12/SFFs-12.2011.pdf
CMA, “Don’t be Fooled by the Federal Nursing Home Five-Star Quality Rating System” (CMA Alert, Oct. 5, 2016), https://www.medicareadvocacy.org/dont-be-fooled-by-the-federal-nursing-home-five-star-quality-rating-system/ CMA, “Nursing Facility’s ‘Quality Measures’ Do Not Reflect Actual Quality of Care Provided to Residents” (CMA Alert, Aug. 9, 2018), https://www.medicareadvocacy.org/nursing-facilities-quality-measures-do-not-reflect-actual-quality-of-care-provided-to-residents/
CMA, “Special Focus Nursing Facilities that ‘Have Not Improved:’ Poor Care for Residents, Overall Ratings Artificially Boosted by 5-Star Ratings in Self-Reported Quality Measures” (CMA Alert, Aug. 15, 2018), https://www.medicareadvocacy.org/special-focus-nursing-facilities-that-have-not-improved/
CMA, “There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities” (CMA Alert, Feb. 14, 2019), https://medicareadvocacy.org/theres-nothing-special-about-how-cms-treats-special-focus-nursing-facilities/. See full Report, “There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities,” at https://www.medicareadvocacy.org/report-theres-nothing-special-about-how-cms-treats-special-focus-nursing-facilities/
CMA, “Nursing Home Compare Inaccurately Reports Civil Money Penalties Imposed Against Nursing Facilities” (CMA Alert, May 30, 2019), https://medicareadvocacy.org/nursing-home-compare-inaccurately-reports-civil-money-penalties-imposed-against-nursing-facilities/
CMA, “‘Graduates’ from the Special Focus Facility Program Provided Poor Care” (CMA Alert, Jun. 20, 2019), https://www.medicareadvocacy.org/graduates-from-the-special-focus-facility-program-provided-poor-care/
CMA, “Nursing Home ‘Quality Measures’ Do Not Reflect Quality of Nursing Home Care” (CMA Alert, Jul. 3, 2019), https://www.medicareadvocacy.org/nursing-home-quality-measures-do-not-reflect-quality-of-nursing-home-care/
CMA, “Poorly Performing Skilled Nursing Facilities: What Happens to Them?” (CMA Alert, Nov. 7, 2019), https://medicareadvocacy.org/poorly-performing-skilled-nursing-facilities-what-happens-to-them/
Analyzing vaccination rates among staff in nursing facilities as of June 13, 2021, researchers find that nursing facilities with the lowest quartile (25%) staff vaccination rates had higher numbers of cases and deaths among residents than nursing facilities with the highest vaccination rates. If all nursing facilities had staff vaccination rates in the highest quartile (82.7% of staff, on average), the researchers calculate that there would have been 4,775 fewer cases among residents (29% of the total cases), 7,501 fewer cases among staff (29% of the total), and 703 fewer resident deaths (48% of the total).
For further information, see “Nursing Home Staff Vaccination and Covid-19 Outcomes,” The New England Journal of Medicine (Dec. 8, 2021), https://www.nejm.org/doi/full/10.1056/NEJMc2115674
Wednesday, January 12, 2021 @ 2 – 3 PM EST
Medicare’s home health benefit offers coverage of a range of services for beneficiaries who qualify, but the benefit is often misunderstood. This free webinar by the Center for Medicare Advocacy will review the services the Medicare home health benefit covers, including skilled nursing; physical, occupational, and speech therapy; medical social services; and home health aides. The webinar will also discuss current challenges and possible strategies for beneficiaries who are trying to access or maintain home health services, especially if they have longer-term, chronic conditions. There will be an opportunity for questions for Center for Medicare Advocacy staff members.
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