How to prepare your facility for new CMS off-site anti-psychotic medication audits

April 13, 2023
April 19, 2023
Polaris Group
April 19, 2023

New CMS audits are on the horizon to reduce unnecessary use – is your facility prepared?

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Antipsychotic drug use among nursing home residents

Antipsychotic drugs, a type of medication to treat psychosis, have faced mounting criticism for being used as chemical restraints for nursing home residents, particularly in under-staffed facilities. Unfortunately, there are significant side effects associated with these drugs (including death) and as such, nursing homes are required to report the number of residents taking antipsychotic drugs.

A troubling 2021 New York Times investigation revealed that 1 in 9 nursing home residents has received a schizophrenia diagnosis (compared with 1 in 150 people in the general population), likely in an attempt to skirt CMS reporting rules. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care from being over-sedated. A Health Affairs article estimates that 15,000 nursing home residents die each year from off-label antipsychotic use.

Plans for the CMS Off-Site Audits

Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. If an audit identifies that a facility has a pattern of inaccurately coding residents as having schizophrenia, the facility’s Five-Star Quality Measure Rating on the Care Compare site will be negatively impacted with stiff penalties. For audits that reveal inaccurate coding, CMS will downgrade the facility’s Quality Measure ratings to one star for six months, which would drop the Overall Star Rating as well. The short stay Quality Measure rating will also be suppressed for six months, and the long stay antipsychotic Quality Measure will be suppressed for 12 months. CMS will monitor each facility’s data to determine whether facilities have addressed the identified issues and if downgrades should be reversed.

CMS has shared their pilot audits and found significant issues across the country including inaccurate MDS coding of residents with a diagnosis of schizophrenia. For example, there was an absence of comprehensive psychiatric evaluations and behavior documentation, residents only had sporadic behaviors documented, and behaviors were related to dementia, not schizophrenia.

How Polaris Group Consulting Can Help Prepare Your Facility

These pilot findings are notable as they outline surveyor expectations for the off-site review.

If a facility has never audited its record to specifically review schizophrenia behavior documentation, a proactive, third-party audit may be in order. Now is the time to audit and review resident documentation for psychiatric notes to avoid impacting the star rating and to ensure residents are receiving the medication and care they deserve.

Polaris Consulting offers customized and comprehensive consulting resources to ensure your organization is maintaining substantial compliance.  Our suite of services is tailored to identify trends, provide education and training, and conduct documentation and coding audits that improve resident outcomes and financial viability. For more information, contact us here.

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