Closeup of nurse making notes near patient's bed

The Centers for Medicare & Medicaid Services will begin auditing nursing homes this month to determine whether residents’ schizophrenia diagnoses are accurate and appropriately coded, the agency announced Wednesday. 

The off-site audits are part of an initiative to curb excessive use of antipsychotic drugs in the nation’s eldercare facilities, CMS said. The audit will coincide with adjustments to quality measure star ratings based on erroneous schizophrenia coding. Audits that find a pattern of inaccurate coding may lead to a quality measure downgrade to one star, potentially affecting the facility’s overall Five-Star rating.

Disputed citations will now be shown on Nursing Home Care Compare.

“CMS is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use,” the agency stated in a memo outlining the changes.

Progress notwithstanding

“Significant progress” has been made in decreasing the inappropriate use of antipsychotics, CMS Administrator Chiquita Brooks-LaSure said in an accompaying statement. In fact, a national effort to reduce the unnecessary use of these drugs in nursing homes has led to a 40% decrease in unnecessary prescriptions over the past decade, according to David Gifford, MD, chief medical officer of the American Health Care Association/National Center for Assisted Living.

But more needs to be done, Brooks-LaSure insisted. An October 2022 federal report found that 80% of nursing home residents are receiving some form of psychotropic drug, according to the Long Term Care Community Coalition, a patient advocate. And the actual rate of antipsychotic prescriptions in nursing homes is likely buried under “questionable” diagnoses of schizophrenia, according to a New York Times report from 2021.

“People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications,” Brooks-LaSure said.

Updates effective immediately

The updates are effective immediately, according to the CMS memo. Facilities selected for an audit will receive a letter requesting documentation. Auditors will look for evidence of appropriate documentation, and assessment and coding of the schizophrenia diagnosis in the Minimum Data Set (MDS).

Facilities will have the opportunity to ask questions before the audit and to seek clarification about audit results, the memo states. 

Perform your own audits, LeadingAge urges admins 

Facilities should be proactive in addressing potential issues now, Janine Finck-Boyle, VP-health policy and regulatory affairs of LeadingAge, recommended in a Wednesday member call. 

Administrators should inform and educate medical staff about appropriate diagnosis and coding, she said. This includes looking at current diagnoses of schizophrenia and working with psychiatrists, attending physicians and the medical director to audit the facility MDS and review documentation. Administrators can also work with the facility MDS coordinator or coder, and reach out to their quality improvement organization and other sources of support, she said.

Industry applauds oversight, questions penalties

AHCA/NCAL and LeadingAge support the move toward greater prescribing oversight and transparency, but pushed back on CMS’s plans to penalize facilities through Care Compare citations. 

Some diagnoses of schizophrenia are made by physicians who are not directly affiliated with the facility, and some prescriptions for antipsychotics are already in place upon admission, they noted. 

“[D]ramatically downgrading entire ratings based on a single measure results in misleading information and causes more consumer confusion,” ACHA/NCAL’s Gifford told McKnight’s Long-Term Care News

“According to medical literature, there are still some situations where these medications may be necessary and beneficial to certain patients, including those with schizophrenia and hallucinations,” he added.

AHCA/NCAL has asked CMS to expand its education outreach about the proper use of antipsychotics to physicians, hospitals, community settings and families. Gifford also recommended that physicians who improperly diagnose residents with serious mental health issues in order to continue an antipsychotic regimen be reported and investigated.

Citation transparency

Federal watchdogs said CMS’s move to publicly reveal appealed nursing home citations is a long time coming. U.S. Sen. Bob Casey (D-PA), leader of the Special Committee on Aging, called on CMS in May 2022 to begin doing so. He argued that the prior system of waiting until a dispute was resolved often leaves residents and their families in the dark for months about “potentially serious health and safety violations.”

For its part, CMS said that the number of citations under dispute is typically small, but that they can include “severe instances of non-compliance.”

In the past two years, for example, CMS fielded 80 deficiencies across 67 surveys identified as Immediate Jeopardy (IJ) that went through the dispute resolution process. IJ deficiencies place the health and safety of residents at risk for serious injury, serious harm, serious impairment or death.

“Waiting to post these citations leaves consumers without knowledge of serious citations,” it stated in the Wednesday memo.

Schizophrenia diagnoses have snowballed

Efforts to reduce antipsychotics in nursing homes may have had unintended consequences. The evidence suggests that some nursing home stakeholders may have resorted to dubious diagnoses to hide sky-high antipsychotics use.

A 2021 New York Times report found that schizophrenia diagnoses in the nation’s facilities had skyrocketed to 70% since federal health agencies began publicly disclosing data on antipsychotic prescribing in 2012. One federal oversight agency revealed that in 2018 there was no record of treatment for schizophrenia in about one-third of residents who were diagnosed with the disorder, the Times reported. And a separate study published in 2021 found that more schizophrenia diagnoses were recorded for Black U.S. nursing home residents with dementia after the launch of a federal initiative to reduce antipsychotic use in these settings.

Nursing homes deserve credit for progress made in reducing their reliance on antipsychotics, said Katie Smith Sloan, president and CEO of LeadingAge, in response to the CMS announcement. She acknowledged the challenges of implementing alternatives to these drugs, particularly in light of current staffing shortages. But the organization supports a stepped up enforcement approach if needed, she said.

“[T]his is a serious quality of care and quality of life issue for residents. Inappropriate use of potent drugs can compromise a person’s overall health,” she said.