SURVEY AND CERTIFICATION must conduct complaint surveys within proscribed time frames any time a serious problem is alleged. The CMS monitors specific data reported by nursing homes such as the Minimum Data Set (MDS) and the administrative data from the Online Survey Certification and Reporting System (OSCAR) and uses these aggregate data sets to provide a comprehensive view of the individual receiving care in the nursing home. State Survey and Certification Agencies focus on quality of care furnished to residents as measured by indicators of medical, nursing and rehabilitative care, dietary and nutrition services, activities and social participation, sanitation, infection control, and the physical environment. Our performance goals to improve the rates of physical restraints and pressure ulcers in nursing homes represent the Agency's commitment to protect its beneficiaries. We know that targeted quality improvement initiatives improve the quality of care and Medicare Quality Improvement Organizations (QIOs) are leaders in these efforts. Quality improvement in nursing homes is a major focus of the QIOS under the 7th Scope of Work (SOW). In fact, the QIOs will be supporting CMS's efforts to publicly report the quality of care in nursing homes. The Nursing Home Quality Initiative is a multipronged effort that consists of 1) CMS's continuing regulatory and enforcement initiatives conducted by State survey agencies; 2) new and better consumer information on the quality of care in nursing homes; 3) community-based quality improvement programs offered by QIOS; and 4) collaboration and partnership to leverage knowledge and resources. QIOS will work with nursing home providers to improve performance on agreed upon measures and to implement quality improvement projects and will work with the stakeholders, including the State Survey & Certification agencies to improve care. Together, these activities will help us achieve our annual nursing home performance goals. For now, CMS will maintain the targets for FY 2004 nursing home quality goals while we carefully assess trends and explore alternate measurement approaches for these goals. Physical Restraints - The CMS's efforts to reduce the use of physical restraints through the State Survey and Certification Program have been successful. Use of restraints in nursing homes has decreased from 17.2 percent in 1996 to 10.0 percent in 2001, and we achieved our FY 2001 target. Although we have achieved a large reduction in the use of physical restraints in recent years, we believe that current program efforts are achieving smaller reductions in restraint use than they have previously. Interim FY 2002 data (September 2002) was 9.8 percent; final data for this goal is expected in early 2003. The CMS is exploring ways to further reduce physical restraints as we maintain the current target at 10 percent. SURVEY AND CERTIFICATION Pressure Ulcers - The CMS is concerned about the increase in pressure ulcer prevalence over the FY 2000 baseline and about the gap between the target and the measured rate. We did not meet our FY 2001 target of 9.6 percent, since reported rates were at 10.5 percent. The interim performance for FY 2002 is 10.4 percent (September 2002) against a target of 9.5 percent; final performance results will be available in early 2003. We believe that this increase in prevalence may stem in part from a number of factors: an artifactual effect due to facilities' change in coding behavior resulting in reporting of pressure ulcers that would not previously have been reported; and an increase in case-mix (severity of illness) of the nursing home population. We are working to better understand and address these variables. Also, we are developing a program to educate providers about more accurate assessment and coding, as well as new protocols aimed at onsite audit procedures that will verify the accuracy of nursing homes' Minimum Data Set (MDS) assessments. We are maintaining our target of 9.5 percent, as we reevaluate our future methodology for this performance goal. Survey and Certification Budget - Our goal to improve the survey and certification budget process moved CMS from the "cost" based approach to a "price" based methodology, which uses national standard measures of workload and costs to project individual State workloads and budgets. The CMS met its FY 2002 target to allocate the FY 2002 budget increase to the State Survey and Certification budget using a price-based methodology. The CMS analyzed the combined national average survey times for long term care facilities. Any State that exceeded by 15 percent or more the combined national average survey time for long term care facilities was provided an FY 2002 base budget that assumed the FY 2001 funding level. All other States received a FY 2002 base budget increase proportionate to each State's FY 2001 budget. Also in FY 2002, CMS finalized its FY 2002 performance standards for State survey agencies. Discussion: "Physical restraints" are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. According to the law, restraints can only be imposed to treat the resident's medical symptoms, to ensur safety and only upon the written order of a physician (except in emergency situations). Restraints should never be used for staff convenience or to punish the resident. The reduction of the use of physical restraints is one of CMS's major quality initiatives. The prevalence of physical restraints is an accepted indicator of quality of care, and considered a quality of life measure for nursing home residents. The use of physical restraints can cause incontinence, pressure sores, loss of mobility, and other morbidities. Many providers and consumers still mistakenly hold, however, that restraints are necessary to prevent residents from injuring themselves. One of the main ways in which CMS can promote reduced use of physical restraints is through the State Survey and Certification Program. State and CMS surveyors who conduct annual inspections of nursing homes pay close attention to nursing homes' use of restraints and cite nursing homes for deficient practices when they discover that residents are restrained without clear medical reason. In establishing performance goals for the quality area, CMS focused on measures that have been recognized as clinically significant and/or closely tied to care given to beneficiaries. Individuals in nursing homes are a particularly vulnerable population, and consequently, it is an area of considerable importance. A significant portion of benefit dollars in both Medicare and Medicaid pay for care in nursing homes. Although not yet updated for FY 2002, 19 percent of benefit dollars under Medicaid and nearly 6 percent SURVEY AND CERTIFICATION for Medicare were associated with nursing home expenditures in FY 2001. In the short term, CMS will continue to maintain a level target of 10 percent for restraints in Nursing Homes. We are evaluating possible effective interventions and measures. Coordination: The CMS's coordination includes State survey agencies and CMS Data Source(s): Currently data on the use of physical restraints are contained in the Online Survey and Certification and Reporting (OSCAR) database. In the future, as the Minimum Data Set (MDS) information becomes more widely available, CMS plans to use these data to further refine this goal. Verification and Validation: Data are verified during annual, onsite surveys. The measure used for this goal is the prevalence of restraint use at the time of the survey (OSCAR) and is self reported by the facility. During these surveys, surveyors perform resident observations, which include interviews and validation of the number of residents in restraints reported by the facility. During record review, surveyors identify the documentation of the medical symptom and the assessment and care plans associated with physical restraint use. Discussion: "Pressure ulcer" refers to any lesion caused by unrelieved pressure resulting in damage to underlying tissues. The development of pressure ulcers is an undesirable outcome that can be prevented in most residents except in those whose clinical condition impedes the prevention of pressure ulcer development. Currently, CMS is in the process of revising and enhancing the interpretive guidelines for surveyors to include: adding information regarding the location of current clinical practice guidelines; enhancing the definitions related to pressure ulcer identification; providing an overview of current processes and practices for the prevention and treatment of pressure ulcers; and revising the investigative protocol for determining if pressure ulcer development was avoidable by the facility. In addition, after this information is in final form, it is planned that educational opportunities regarding the final products will be provided to both surveyors and providers utilizing nationally recognized clinical experts in pressure ulcer care. In addition, CMS is working with Quality Improvement Organizations (QIOS) to assist nursing homes with the development and evaluation of quality improvement programs to improve the prevention and treatment of pressure ulcers. The prevalence of pressure ulcers in nursing homes appears to have decreased slightly from FY 2001 to 2002. The CMS is still concerned about the increase in pressure ulcer prevalence over the FY 2000 baseline and about the gap between the target and the measured rate. The interim performance for this goal is 10.4 percent against a target of 9.5 percent as of September 2002. Final performance results for the FY 2002 pressure ulcer target will be obtained in early 2003. The CMS believes that this increase in prevalence may stem in part from a number of factors, including facilities' change in coding behavior leading to their reporting pressure ulcers that would not previously have been reported and an increase in case-mix (severity of illness) of the nursing home population. |