Categories: Initiatives

Advancing Excellence & CMS Discuss Final Rule

Roll out of the Centers for Medicare & Medicaid Services’ (CMS’) final rule on requirements of participation for nursing homes will take place over the next two years via a three-phase process, according to Karen Tritz, CMS director of the Division of Nursing Homes.

Speaking at the Jan. 31 meeting of the Advancing Excellence in Long Term Care Collaborative (AELTCC), Tritz emphasized the group’s importance to the agency’s implementation and information gathering process. She asked members for feedback and input as CMS tackles what appears to be the simultaneous launch of multiple new initiatives related to the rule.

In addition to new interpretive guidance and revised f-tag numbers, nursing homes in all 50 states will see a new survey process by the end of Phase II, in Nov. 2017, Tritz reported.

Also scheduled for completion by the end of Phase II is an updated State Operations Manual (SOM), with an advance copy of it to be publicly available by early this summer.

Tritz offered the following overview of the rule, which she noted is the result of a number of provisions from the Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which include the following compliance and ethics programs:

  • Quality Assurance and Performance Improvement (QAPI);
  • Reporting suspicion of a crime;
  • Increased discharge planning requirements; and
  • Staff training.

“Think of the rule as raising the bar on quality,” Tritz told the room full of roughly two dozen representatives of stakeholders in post-acute and long-term services and supports.

AELTCC member Cheryl Phillips, MD, senior vice president of Public Policy & Advocacy for LeadingAge, expressed apprehension about the rule’s emphasis on holding providers more accountable for resident discharges. “I am concerned about a discharge when an individual elects to go to a setting that we would not select for them,” she told Tritz. “The way the regulatory language appears now is that if a nursing home is participating in the discharge in any way—even if they are attempting to make a bad discharge as good as possible—then they are held accountable for a bad outcome.”

Tritz acknowledged Phillips’ concern as legitimate and offered clarification: “If the individual wants to go, you’re not going to keep them,” she said. “So we would look at what the documentation and discussion to determine that it’s very clear that you would not have chosen this setting.”

Len Russ, American Health Care Association immediate past-chair, suggested that the advent of managed care and other payment models could further complicate discharge issues, particularly because corporate office MCO staff appear to be making decisions about discharges while the nursing home must bear responsibility for implementing them. “They have no consequences,” Russ said, referring to the managed care entities. “It appears that the rule will sometimes hold facilities responsible for decisions that they don’t make. From a regulatory standpoint, [MCOs] are increasingly the ones making the decision, while clinicians are having less and less decision making power.”

Tritz noted that Russ’ point was well taken, adding that she is interested in “where there are intersections and disconnects with regard to his concerns and the regulations.”

The new regulations also have the potential to impact certified nurse assistants (CNAs) across a number of areas, including their formal inclusion in the interdisciplinary team for care planning, the performance improvement process, and a number of additional educational requirements in the coming years.

Overall, AELTCC members were impressed with Tritz’ presentation as well as the ability to have an open and honest discussion that only the Collaborative can facilitate. A number of members expressed appreciation for their ability to have personal and direct interactions with CMS, as it allows them to prepare their constituents as they continue along the journey toward full implementation of the new rule.

For her part, Tritz was appreciative of the Collaborative’s feedback, especially given that it represents a uniquely broad array of stakeholder perspectives.