CMS proposes massive new rules for LTC industry

The long-term care industry is facing the challenge of dealing with a massive set of new rules from the Centers for Medicare & Medicaid Services (CMS) that are intended to improve quality of care provided for beneficiaries.

A 403-page proposed regulation released July 13, and promoted by President Obama during the White House Conference on Aging, is filled with proposals designed to slash unnecessary hospital readmissions and infections, increase quality of care and improve patient safety. But, it all comes at a cost.

According to the proposed rule itself, the estimated cost to the industry of complying with all of its requirements would be $729,495,614 in the first year, or approximately $46,491 per facility. The second year cost would be $638,386,760, or $40,685 per facility, based on 15,691 long-term care facilities.       

“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” said Health and Human Services Secretary Sylvia Mathews Burwell. “When a family makes a decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”

Industry concerns

The American Health Care Association (AHCA) expressed concern over the financial impact of the proposed regulations. “We look forward to the opportunity to work with the White House and CMS to ensure that the new rules provide true benefit to patients and residents without unnecessary unfunded burden to providers,” said Dr. David Gifford, senior vice president of quality and regulatory affairs at AHCA. “We would oppose such a large unfunded mandate, especially given the overall narrow margins of 1 percent to 3 percent that MedPAC calculates for skilled nursing care centers,” he said.

The industry terms the requirements “unfunded mandates” because there are no provisions for federal funding to help defray any of the added costs. Instead, they would be borne entirely by the industry.

In its summary of the proposed rule, CMS said the changes are needed “to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These proposals are also an integral part of our efforts to achieve broad-based improvements both in the quality of health care furnished through federal programs, and in patient safety, while at the same time reducing procedural burdens on providers.”

Impact on operations

The proposal is far-reaching and includes requirements that would directly affect facility operations, including staffing and patient care.

For example, CMS seeks to prohibit facilities from employing individuals who have had a disciplinary action taken against their professional license by a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriation of their property.

Provisions include making certain that staff members are properly trained on caring for residents with dementia and in preventing elder abuse. Changes include improving care planning, including discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up and ensuring that instructions are transmitted to any receiving facilities or services.

To strengthen the rights of residents, CMS wants to place limits on when and how binding arbitration agreements may be used.

CMS proposes to require facilities to develop a baseline care plan for each resident, within 48 hours of his or her admission. The plan would include the instructions needed to provide “effective and person-centered care that meets professional standards of quality care.”  

CMS also wants to add a nurse aide, a member of the food and nutrition services staff and a social worker to the required members of the interdisciplinary team that develops the comprehensive care plan.

“We propose to require facilities to document in a resident’s care plan the resident’s goals for admission, assess the resident’s potential for future discharge, and include discharge planning in the comprehensive care plan, as appropriate,” the CMS summary says. In addition, the post-discharge plan of care would have to include a summary of arrangements for the resident’s follow up care.

More specifics

Additional provisions of the proposed regulations include:

  • Clarification that quality of care and quality of life are overarching principles in the delivery of care to residents and should be applied to every service provided.
  • Clarification of requirements regarding a resident’s ability to perform Activities of Daily Living (ADLs).
  • Consideration of whether requirements for the director of the activities program remain appropriate and what should be minimal requirements.
  • Modification of existing requirements for nasogastric tubes to reflect current clinical practice, and to include enteral fluids in the requirements for assisted nutrition and hydration.
  • A new requirement that facilities must ensure that residents receive necessary and appropriate pain management.
  • A requirement for an in-person evaluation by a physician, physician assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital.
  • Allowing physicians to delegate dietary orders to dieticians and therapy orders to therapists.
  • Adding a competency requirement for determining sufficient nursing staff based on a facility assessment, which includes but is not limited to the number of residents, resident acuity, range of diagnoses and content of care plans.
  • Requiring necessary behavioral health care and services to residents in accordance with their comprehensive assessment and plan of care.
  • A requirement that staff must have the appropriate competencies and skills to provide behavioral healthcare and services, which include caring for residents with mental and psychological illnesses and implementing nonpharmacological interventions.

Those are just a sampling of the large number of changes in the rules and new requirements that would be imposed upon long-term care facilities under the regulation, which can be seen here in its entirety.

Clearly, the industry will need to be engaged with CMS as those rules are finalized. The comment deadline is September 6.


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