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Challenge 5: Ensuring Quality in Nursing Home, Hospice, and Home- and Community-Based Care

Why This Is a Challenge

An elderly Asian man in a wheelchair, enjoying the outdoors, aided by a nurse

As the median age of Americans continues to rise and as more Americans live with chronic medical conditions, the Department faces challenges in ensuring that beneficiaries who require nursing home, hospice, or home- and community-based services (HCBS) receive high quality care. It is critical that these services be available, allowing beneficiaries to receive the care they need in the setting that best serves their needs and preferences. High quality nursing home and HCBS programs are important for the continued well-being of people who need ongoing assistance with daily living, as well as those who need additional help recuperating from hospital stays or other acute care. Hospice care provides comfort for terminally ill beneficiaries by reducing pain and addressing physical and other needs. High quality nursing home, hospice, and HCBS personal care services can often prevent the need for disruptive and costly hospitalizations.

OIG continues to identify various problems with nursing home and hospice care. For example, in reports on nursing homes, OIG raised concerns about the frequency of preventable adverse events due to substandard care, the extent to which nursing homes comply with federal regulations for reporting abuse and neglect, and the lack of monitoring of nursing homes' resident hospitalization rates. With respect to hospice care, OIG has raised concerns about insufficient monitoring of hospice service use, as well as inadequate oversight of hospice certification surveys and hospice-worker licensure requirements.

It is critical to ensure effective oversight of HCBS programs and Medicaid-paid personal care services. HCBS programs are important, in part, because they allow beneficiaries whose needs and preferences are better served by remaining in their own homes or other community-based settings to avoid or delay institutionalization. These programs offer many advantages for promoting beneficiary choice and preferences, but OIG efforts have revealed persistent payment, compliance, and quality vulnerabilities.

Progress in Addressing the Challenge

The Department continues to take steps to improve the quality of nursing home, hospice, and HCBS programs. Through its Web site and in various outreach strategies, CMS is providing guidance to nursing homes on how to meet newly expanded quality assessment and performance improvement (QAPI) activities required under the Affordable Care Act. Adding to this effort is a recent proposed rule that outlines actions CMS intends to take to remove obsolete or unnecessary provisions affecting nursing homes' ability to carry out these and other requirements. CMS also published rules strengthening nursing home requirements in areas such as emergency preparedness, dementia care, and infection control.

The Department has also taken steps to improve the quality of services beneficiaries receive in hospice settings and from HCBS programs. To improve hospice care, CMS proposed rules that would update the hospice quality reporting program and reform hospice payment methodologies. For HCBS programs, CMS finalized rules covering minimum quality expectations for providers, new administrative flexibilities for states running HCBS programs, requirements for person-centered planning in these services, and enforcement actions CMS can take against HCBS programs out of compliance with requirements. The Department also entered into a contract with the National Quality Forum to begin work on the development of a national quality measure set for HCBS.

OIG continues to pursue enforcement actions against nursing homes, hospices, and HCBS providers that render substandard care. CMS and OIG work closely with law enforcement partners at DOJ and through the federal Elder Justice Interagency Working Group to promote better care for older adults and to prosecute providers committing abuse or neglect. Additionally, state Medicaid Fraud Control Units (MFCUs), which receive oversight and funding from OIG, devote substantial resources to the investigation and prosecution of abuse and neglect in Medicaid-funded facilities, such as nursing homes and board-and-care homes.

The decision to force a nursing home to shut down or stop serving federal health care program beneficiaries is never taken lightly, as the experience of being transferred is traumatic to displaced beneficiaries, and locating nearby facilities to adequately serve them can be challenging. Therefore, OIG invests substantial efforts in helping facilities improve. OIG has developed an innovative quality-oriented corporate integrity agreement process to work with nursing home providers so they may better serve beneficiaries. OIG has placed nearly 40 nursing home companies (covering more than 750 facilities) under corporate integrity agreements that include quality-monitoring provisions designed to ensure that beneficiaries receive the care they deserve.

What Needs To Be Done

The Department should continue to prioritize quality of nursing home, hospice, and HCBS. OIG has offered recommendations to assist the Department in this mission. For example, OIG recommended that the Department monitor how often nursing home residents are hospitalized and develop resources that can be used to help nursing home staff reduce the incidence of adverse events in nursing homes. OIG has also recommended that the Department seek to link payments for services to meeting quality-of-care requirements and work with OIG to hold providers that have rendered substandard care accountable, thereby preventing additional harm to vulnerable beneficiaries. Further, the Department should promulgate the regulations mandated under section 6102 of the Affordable Care Act concerning compliance and ethics programs for nursing homes. Such regulations could assist nursing homes in preventing and detecting fraud, waste, and abuse and promoting quality of care.

Recently, Congress passed two laws that gave the Department new tools to improve the quality of care in nursing homes and other post-acute care providers. The Protecting Access to Medicare Act of 2014 (PAMA) establishes a value based payment program for nursing homes under which incentive payments will be made to high performing providers. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) includes new reporting requirements for nursing homes and other post-acute care providers, including standardized admission and discharge patient assessments. IMPACT also includes requirements that hospice programs be surveyed at least once every 36 months and that oversight entities perform chart reviews, in some cases, of hospice episodes longer than 180 days. The Department should use these tools to improve the care people receive in these settings.

Lastly, the Department should ensure the integrity of Medicaid-funded personal care services by establishing minimum federal qualification standards for providers; improving CMS's and states' ability to monitor billing and care quality; and issuing operational guidance for claims documentation, beneficiary assessments, plans of care, and supervision of personal care attendants. The Department should also issue guidance to states regarding adequate prepayment controls and help states access data necessary to identify overpayments.

Key OIG Resources

Management Challenge 6: The Meaningful and Secure Exchange and Use of Electronic Health Information

Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201