Sen. Charles Grassley (R-IA) is demanding to know why federal regulators find it a “burden” to audit nursing homes with a high rate of prescribing psychotropic drugs to residents.
The former chairman of the Senate Committee on Aging made clear in his letter to the leaders of the Centers for Medicare & Medicaid Services and its parent agency, the Department of Health and Human Services, that he doubts that CMS is doing enough to protect patients. This, even after CMS announced in January that it would begin auditing nursing homes to determine the appropriateness of schizophrenia diagnoses.
As McKnights Long Term Care News has reported, facilities with a pattern of “inaccurate coding” could see their quality measure downgraded to one star, which would ultimately affect the overall Five-Star Rating.
In his four-page letter sent to CMS Administrator Chiquita Brooks-LaSure and HHS Secretary of Health Xavier Becerra last week, Grassley suggested that the agency is giving “bad actors ‘an out’” by letting facilities admit to errors and commit to making corrections. A CMS memo outlining its off-site audit approach said such admissions would “reduce the burden of conducting audits for CMS and nursing homes, and allow CMS to audit more facilities.”
Grassley’s letter cited a November 2022 investigation from HHS’ Office of Inspector General that found a 194% increase from 2015 to 2019 in the number of nursing home residents reportedly suffering from schizophrenia but lacking a corresponding diagnosis in Medicare claims.
“Unfortunately, the recent report confirms my decades-long concern that nursing homes are misusing potent and potentially lethal psychotropic medications without the requisite diagnosis or oversight,” Grassley wrote in the letter.
However, Rob Leffler, RPh, vice president of clinical services for Kentucky-based Synchrony Pharmacy, and others raised concerns about how and when diagnoses are made in further reporting by McKnights. There is frequently “incomplete admission documentation” for nursing home residents that could be due to a diagnosis made years prior to nursing home admission.
Leffler also noted that hospitals, unlike nursing homes, are not required to try behavioral interventions before prescribing certain drugs and urged CMS to “look beyond the numbers” to understand how facilities are managing residents’ medications.
Use remains high, despite criticism
Still, the volume of antipsychotic prescriptions at nursing homes remains high. A November 2022 report from the HHS OIG on the long-term trends of psychotropic drug use found that low-income residents receiving subsidies had a higher rate of receiving those drugs, Grassley pointed out in his letter. He also noted that while CMS issued 4,321 citations for unnecessary prescriptions, the agency handed out just 706 civil monetary penalties for antipsychotic drugs.
Grassley ended his letter with eight questions he wants CMs to answer by Wednesday (March 1). He said he is looking to understand how CMS believes that offering facilities “the opportunity to forgo an audit by admitting errors and correcting the issue [will] solve the problem of improper use of psychotropic drugs.”
CMS, in its audit memo, said it would “consider” lesser action against providers who self-report erroneous behavior ahead of an audit. Among the lighter punishments could be suppression of quality measure ratings versus a downgrade.
But providers have told McKnight’s in recent weeks that the offer to admit to problematic coding was not an attractive one, considering CMS wasn’t guaranteeing a better outcome.
For his part, Grassley also wants to know why there is a discrepancy between citations and civil monetary penalties, the number of citations issued since 2012 that are “linked to resident harm or immediate jeopardy,” and what step the agency has taken to expand “the required data elements on Medicare Part D claims to include a diagnosis code” that was recommended in 2011 by the Health Department’s inspector general.
