CMS Announces Proposed Rule Update for Long-Term Care Facilities

On July 16, 2015, following an announcement at the White House Conference on Aging, the Centers for Medicare & Medicaid (CMS) issued a long-awaited proposed rule that would revise the requirements that long-term care (LTC) facilities must meet to participate in the Medicare and Medicaid programs. This major proposal marks the first comprehensive review and revision of the LTC conditions of participation since 1991. As CMS notes, the population of nursing homes has changed substantially since 1991— becoming more diverse and more clinically complex. About 1.5 million US residents receive care from more than 15,000 long-term care facilities or nursing homes across the country that participate in Medicaid and Medicare. According to the American Health Care Association, CMS is the largest payer of long-term care services in the country. About 64% of individuals in nursing homes are Medicaid beneficiaries, and 14% are covered by Medicare.

CMS stated that the revisions were designed to align requirements with current clinical practice standards to improve safety, quality, and effectiveness of care provided to Medicaid and Medicare beneficiaries residing in LTC facilities.

CMS identified the facility-based assessment requirements as a “central feature” to these proposed revisions. Assessments will include the physical characteristics of the home; the number, acuity levels, and the range of diagnoses of residents; and the content of comprehensive patient-centered care plans for each resident—which now must be developed within 48 hours of admission—in order to determine what resources are necessary to care for the facility’s residents competently during both day-to-day operations and emergencies.

Other requirements for LTC facilities include the provision of food and nutrition by competent staff that take into consideration residents’ personal and medical needs; limits on the number of residents who may share a bedroom (no more than two); the availability of private, in-room toilet facilities; and compliance with laws regarding smoking.

CMS is also instituting a competency requirement for determining sufficient nursing and direct care staff, based on the facility assessment. Extensive and specific requirements around training all staff—openly defined to include individuals providing services under a contractual arrangement and volunteers—are designed to protect residents from abuse, neglect, mistreatment or misappropriation of property.

In conformance with requirements in the Affordable Care Act, the Proposed Rule adds extensive and specific compliance program requirements. LTC facilities must develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on systems of care, outcomes of care, and quality of life. Improvements to practices during the transition of care from one facility to another and during the ordering and receipt of laboratory, radiology, and other diagnostic services, are intended to promote continuity of care. To the same end, LTC facilities are encouraged, although not required, to participate in health information exchange through the use of electronic health records.

New requirements related to behavioral health services, including the treatment of mental and psychosocial illnesses through pharmacological and non-pharmacological interventions, are also included. Many of the provisions are aimed at limiting unnecessary use of antipsychotic medications in older adults, a problem that has received a lot of recent attention. Another common problem among LTC residents that has received a lot of recent attention—antibiotic resistance—was also addressed: LTC facilities are now required to establish an antibiotic stewardship program, including antibiotic use protocols and antibiotic monitoring.

In its regulatory impact statement, CMS estimates that the total projected cost of this rule would be ~$729 million in the first year and ~$638 million annually thereafter.

Given the significance of the Proposed Rule, the CMS is accepting public comments through September 14th at the Federal Register website (https://1.usa.gov/1I2XxNZ). Although CMS anticipates that it may take a long period of time to implement the changes, the LTC industry should immediately begin to consider the practical implications of the new requirements. —Kara Rosania