RISE summarizes recent regulatory-related headlines.
CMS proposes rule to create minimum staffing standards in nursing homes
A newly issued proposed rule aims to create national minimum nurse staffing standards in nursing homes.
“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” said HHS Secretary Xavier Becerra, secretary of the U.S. Department of Health and Human Services, which issued the proposed rule through the Centers for Medicare & Medicaid Services (CMS), in a statement. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce.”
Under the proposal, nursing homes that participate in Medicare and Medicaid must meet specific nurse staffing levels that promote safe, high-quality care for residents. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident per day and 2.45 hours of care from a nurse aide per resident per day, which exceeds existing standards in nearly all states. Indeed, CMS estimates approximately three quarters of nursing homes would have to strengthen staffing in their facilities. As the long-term care sector continues to recover from the COVID-19 pandemic, the proposed standards take into consideration local realities in rural and underserved communities through staggered implementation and exemptions processes.
The proposed rule also calls for nursing homes to ensure a registered nurse is on site 24 hours per day, seven days per week and to complete robust facility assessments on staffing needs. Facilities must also provide staffing that meets the needs of the individual residents they serve, which may require higher levels of staffing above the proposed minimum standards. In addition, CMS proposes states collect and report on compensation for workers as a percentage of Medicaid payments for those working in nursing homes and intermediate care facilities.
CMS also announced a national campaign to support staffing in nursing homes. As part of the HHS Workforce Initiative, CMS will work with the Health Resources and Services Administration (HRSA) and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives, such as scholarships and tuition reimbursement. This staffing campaign builds on other actions by HHS and the Department of Labor to build the nursing workforce.
CMS and HHS-OIG take 5 actions to tighten nursing home enforcement
In addition to the proposed rule, CMS and the HHS Office of the Inspector General announced the following actions to increase transparency, enhance enforcement of existing standards, increase accountability, and ensure safe and high-quality care for the 1.2 million seniors who live in nursing homes:
- Increase audits of nursing home staffing
- Improve nursing home inspections to ensure cited deficiencies receive the appropriate consequence
- Ensure taxpayer funds go toward safe, high-quality care: HHS-OIG will analyze of how nursing homes may profit at the expense of taxpayers and residents by using services, suppliers, or facilities controlled by parties they own rather than from vendors who might charge a more competitive price
- Crack down on inappropriate antipsychotic prescribing practices and risks
- Enhance resident safety during emergencies: HHS-OIG will undertake a national study of nursing home preparedness and key challenges and identifying practices to strengthen protections for residents
cMS suspects auto renewals to blame for inappropriate Medicaid, CHIP disenrollments
CMS this week sent a letter to all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands requiring that they determine whether their eligibility systems have an issue that could cause people, especially children, to be disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP) even if they are still eligible for coverage. If so, CMS requires they act immediately to correct the problem and reinstate the coverage.
“CMS has learned of additional systems and operational issues affecting multiple states, which may be resulting in eligible individuals being improperly disenrolled,” the letter states. “These actions violate federal renewal requirements and must be addressed immediately.”
Following the end of pandemic-era conditions for Medicaid coverage, states across the country have resumed regular processes for renewing individuals’ Medicaid and CHIP enrollment. One of the strongest tools that states must keep eligible people enrolled in Medicaid or CHIP coverage during this process is conducting auto-renewals (also known as “ex parte” renewals). Federal regulation requires states to use information already available to them through existing reliable data sources (e.g., state wage data) to determine whether people are still eligible for Medicaid or CHIP. Auto-renewals make it easier for people to renew their Medicaid and CHIP coverage, helping to make sure individuals are not disenrolled due to red tape.
CMS believes that eligibility systems in a number of states are programmed incorrectly and are conducting automatic renewals at the family-level and not the individual-level, even though individuals in a family may have different eligibility requirements to qualify for Medicaid and CHIP, according to the announcement. For example, children often have higher eligibility thresholds than their parents, making them more likely to be eligible for Medicaid or CHIP coverage even if their parents no longer qualify. This conflicts with existing federal Medicaid requirements and may have a disproportionate impact on children.
The letter urges states to take the following actions:
- Pause procedural disenrollments for those individuals impacted
- Reinstate coverage for all affected individuals
- Implement one or more CMS-approved mitigation strategies to prevent continued inappropriate disenrollments
- Fix state systems and processes to ensure renewals are conducted appropriately and in accordance with federal Medicaid requirements
OIG: One-quarter of Medicaid enrollees with HIV may not have received critical services in 2021
A new OIG study finds that nationwide, one in four of the 265,493 Medicaid enrollees with HIV identified in the study did not have evidence of one or more critical services in 2021. In addition, there was no evidence that four percent of the enrollees received any of the three services in 2021, which may mean they were at greater risk of negative health impacts and HIV transmission.
The Medicaid program plays a critical role in ensuring that people with HIV receive care that can improve their ability to achieve and maintain viral suppression. In 2018, Medicaid covered an estimated 40 percent of all nonelderly people with HIV in the U.S. People with HIV who are covered by Medicaid also tend be part of populations disproportionately impacted by HIV overall, including Black and Hispanic/Latino people, OIG said.
The watchdog reviewed the extent to which the Medicaid enrollees who had HIV diagnosis in their Medicaid or Medicare claims data had evidence of critical services to identify potential gaps in care in 2021. The review included both enrollees with Medicaid only and those who were enrolled in both Medicaid and Medicare (dual-eligible enrollees). Analysts determined whether these enrollees had evidence in their Medicaid and Medicare claims data of three medical services that are critical for all people with HIV according to HHS guidelines: medical visits (in-person or telehealth), viral load tests, and antiretroviral therapy (ART) prescriptions.
The findings indicate that further action is required to ensure enrollees receive HIV care. OIG is particularly concerned that more than 11,000 enrollees didn’t have evidence of receiving any of the three services reviewed. These services are recommended by HHS for all people with HIV and are vital to their overall health as well as the prevention of HIV transmission within the general population.