Improving Practice with New DOH and DHS Strategic Planning

It’s time to take action! As part of the Department of Health and Human Services (HHS) four year update to its strategic planning, the Center for Clinical Standards and Quality/Survey & Certification Group, Division of Nursing Homes (DNH) released the 2016/2017 Nursing Home Ac on Plan May 20, 2016. The “Action Plan for Further Improvement of Nursing Home Quality” (the “Plan”) is effective immediately. This month’s article will deliver a summary of the Plan and the Comprehensive Strategies that DNH intends to employ to achieve the stated goals. The Plan is available on the CMS website

For industry stakeholders, the Plan provides the framework for our own quality and operational improvement. We can use the Plan to better identify community and company goals and opportunities to achieve them. Understanding how CMS and DNH are approaching quality and safety, especially as it relates to the survey process, can make our own action plans more clear.

The stated mission of DNH is “to optimize the health, safety and quality of life for people living in nursing homes. Through our ongoing projects we strive to: enforce the current requirements to ensure the basic health and safety of people living in nursing homes; promote quality of care and quality of life by interpreting regulations and guidance and promoting resident-centered quality care so that they are consonant with current clinical and organizational practice standards; and work with CMS Regional Offices to ensure consistent application of regulations, guidance and enforcement across the country.”

The Plan aligns with CMS’ efforts to continue to improve nursing home safety and quality through four main goals:

  1. Better Care and Lower Costs
  2. Prevention and Population Health
  3. Expanded Health Care Coverage
  4. Enterprise Excellence

Principles in Action and Comprehensive Strategies

The Plan outlines five inter-related and coordinated approaches – or principles of action – for nursing home quality and comprehensive strategies. Below, I summarize the principles and strategies. 

Principle 1: Enhance Consumer Awareness and Assistance

Through availability of relevant, timely information, DNH can significantly assist consumers while actively managing their own care and hold the health care system accountable for the quality of services and support that should be provided. The DNH seeks to provide an increasing array of understandable information that can be readily accessed by the public.


A. Five-Star Quality Rating System - CMS and DNH will continue to increase the information and data on Nursing Home Compare and improve the Five Star Rating System

B. Improving Staffing Data on the CMS website - Starting July 1, 2016, CMS will collect quarterly payroll-based staffing data nationwide, which implements Section 6106 of the Affordable Care Act. DNH designed, developed, and implemented a pilot system to collect this data between 2010 and 2012. Nursing homes voluntarily submitted data in October 2015.

Principle 2: Strengthen Survey Processes, Standards and Training

The DNH is engaged in several ongoing initiatives to improve the effectiveness of annual nursing home surveys (standard surveys), and the investigations prompted by complaints (complaint surveys) from consumers of family members about nursing homes. By strengthening the survey processes, the DNH believes that State Agencies will drive improvement at the population level in nursing homes. This is likely to reduce the number of adverse events and preventable healthcare-acquired conditions, leading to lower per-capita costs.


A. Interpretive Guidance to Surveyors - On July 16, 2015, CMS published a Notice of Proposed Rulemaking (NPRM) that would revise the requirements that nursing homes must meet to participate in the Medicare and Medicaid programs. Once the rule is final, DNH must develop revised interpretive guidance to address the new regulatory requirements. DNG is also using this as an opportunity to review the existing interpretive guidance for clarity, effectiveness, and updated standards of practice. Besides the guidance, DNG continues to provide improved methods of communicating this information. 

B. Improvements to the Nursing Home Improvement Process - The DNH expects to continue to make improvements so the states participating in the Quality Indicator Survey (QIS) have the support to conduct surveys effectively and to realize the benefits of the QIS process. Since the May 2015 survey methodology status report from DNH that provides a high- level summary of the work done to examine nursing home survey methodologies for efficiency and effectiveness, CMS has been talking with stakeholders to explore those aspects of the survey processes working well at identifying quality issues and those aspects that could be improved. CMS’ intent is to build on the best of both Traditional and QIS processes in developing a single revised survey methodology that can be implemented nationwide.

C. Fire Safety and Life Safety Code in Nursing Homes - The DNH initiatives to reduce nursing home fires focus on four action themes: 

  1. Better Protection (such as improved standards)
  2. Better Information and Reporting (such as improved information on the Web)
  3. Better Monitoring (such as more DNH validation surveys)
  4. Better Enforcement (such as improved methods of citing deficiencies)

The DNH continues to move toward better fire protection for nursing homes. With CMS, the Plan includes sustaining increases in validation surveys for Life Safety Code (LSC) to promote oversight and effective implementation of LSC surveys by states through contractor. The Plan also includes continued assessment of the optimal frequency of LSC surveys of nursing homes within the context of other health and safety priorities and options for greater efficiency in nursing home surveys, especially in relation to the life safety code inspections. 

A. Surveyor and Regional Office Training - The DNH continues to add resources to the Web-Based Training (WBT) curriculum. To make training more readily available, DNH created and piloted the Virtual Classroom (Blackboard) version of the LSC Basic and other courses. Classroom training for basic courses and satellite broadcasts and webcasts have been increased and archived by CMS for later viewing.

B. Long Term Care Surveyor Training and Testing - The Surveyor Minimum Qualifications Test (SMQT) ensures surveyor candidates demonstrate the knowledge, skills and abilities required to observe and evaluate compliance of LTC facilities with Federal requirements. Surveyor candidates must successfully complete the SMQT to independently survey long-term care facilities. The SMQT will be reviewed and assessed for current questions for retention, editing or discarding with additional research, creation, and validation of new test questions.

C. Complaint Investigation Process – To improve consistency in complaint investigation procedures and survey investigations, substantiation/decision making and reporting results, ongoing work focuses on an evaluation of how complaint intake cases were triaged, and the outcomes of the complaint investigations. These evaluations will inform the intake and triage training that is under development. DNH staff are contributing members of the workgroup that is developing web-based investigative skills training webinars.

D. Infection Control in Long-Term Care - Healthcare associated infections (HAIs) are largely preventable, but occur far too o en in nursing homes. The high incidence of HAIs in nursing homes is due to multiple factors including, but not limited to understated facilities, staff without the training or me to prevent infections early, over-treatment with antibiotics increasing clinical complexity of the average nursing home resident.  Other action plans include developing an infection control surveyor worksheet used during 10 pilot nursing home surveys to assist in strengthening the nursing home survey process and assess for new an bio c stewardship requirement and conducting 40 hospital and LTC surveys (one hospital and one LTC facility in that hospital’s catchment area). Use of survey findings to develop an ac on plan to improve infection control and prevention in each facility and during transitions of care, and o er technical assistance to each facility to implement the ac on plan are included. DNH will also develop infection control webinars and other trainings for surveyors, initiating investigation into development of an infection control training for nursing home providers, and revising policy guidance for F441 as needed.

E. State Performance Standards – besides improvements made to the State Performance Standards System (SPSS), DNH will work toward increased improvements for quality surveys by finalizing SPSS protocols; developing national reports to support the evaluation of the SPSS and to allow for continuous monitoring by the States and Regional Offices; monitoring State performance and require that States develop and implement corrective action plans to address identified problems.

Principle 3: Improve Enforcement Activities  

The DNH is dedicated to maintaining an enforcement system centered on promoting quality resident-centered health and safety to nursing home residents and compliance with federal requirements. To improve our current enforcement reports, DNH will continue to work in partnership with Regional Offices (RO’s), States, consumer advocates, national associations, and others. 


A. Enforcement Policies – Efforts to improve enforcement actions include tracking the imposition of enforcement remedies through development of National, Regional and State-specific data reports; Conducting calls with each Regional Office to discuss enforcement trends, issues, concerns and enforcement improvement opportunities; Providing additional enforcement training; revising the Standard Operations Manual (SOM) to expand the circumstances where remedies must be imposed, clarify guidance and ensure appropriate and consistent national application of enforcement policies and remedies; Improving reports to monitor and track Special Focus Facilities; evaluating the use and application of the CMP Analytics Tool for efficiency and consistency; DNH is also drafting guidance for citing IJ.

B. Federal Civil Money Penalty (CMP) Fund - The Affordable Health Care, Elder Justice, and Social Security Acts authorizes the use of CMPs to further the mission of CMS by generating innovative thought and processes in the areas of reduction of adverse events, enhanced staffing, and improved dementia care in adult long-term care facilities. The outcomes from the CMP solicitation might become the foundation for national implementation. The multi -year CMP solicitation is being drafted, and upon publication
will specifically state CMP fund parameters and Office of Management and Budget (OMB) auditing requirements.

C. Monitor Civil Monetary Penalty Amounts - DNH will monitor CMP Analytics Tool usage for consistency in applying enforcement remedies and meet with ROs to discuss results of analysis of national enforcement remedies; and DNH will make State Opera ons Manual revisions that apply to the range of per instance CMPs.

D. Special Focus Facilities (SFF) - DNH will develop several pilot programs in various CMS Regions and may make additional policy adjustments to the SFF program. The pilot programs evaluate other interventions for the SFF program. As part plan, DNH will post all SFF names on Nursing Home Compare website; develop further guidance on enforcement op ons for SFFs; and make phone calls to the Regions of SFF nursing homes exceeding 12 months and the 18 months “last chance” survey.

E. Notice of Facility Closure of Nursing Homes - In April 2011, a Survey & Certification Group memorandum was issued to the State Survey Agency Directors highlighting the Affordable Care Act “Notification of Facility Closure” with a copy of the interim file rule. In August 2013, a Group memorandum was issued providing surveyor guidance for the final rule and regulations. DNH’s ac on plan includes finalizing guidance for “Notification of Facility Closure”; and finalizing collection procedure for Sanctions for Nursing Home Administrators.

Principle 4: Promote Quality Improvement

DNH promotes comprehensive quality improvement programs in several key areas, including reductions in using physical restraints, the prevalence of preventable pressure ulcers and reduction in unnecessary an psychotic medication. To achieve these quality improvement goals, CMS’ participation in the Advancing Excellence in America’s Nursing Homes Campaign and support of the national “culture change” movement continues to grow. The principles behind culture change are principles of person-centered care – embracing individualized approaches to care. 


A. Maintenance of Minimum Data Set (MDS) 3.0 – As part plan to seek standardization, while keeping the identification of residents’ needs as the primary objective of the MDS assessment, DNH will include a national expansion of MDS/Staffing Focused Survey; revisions to the MDS 3.0 assessment tool for improved resident assessment, and inclusion of standardize items related to the “Improving Medicare Post-Acute Care Transformation Act of 2014” (IMPACT Act); revisions to the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, MDS 3.0; State Resident Assessment Instrument (RAI) Coordinator’s Training – Classroom training; MDS/RAI Provider Training; and MDS 3.0 and Quality Measure updates.

B. Quality Assurance and Performance Improvement (QAPI) - Since passage of the Affordable Care Act, DNH has embarked on a mission to develop and disseminate technical assistance, tools and resources to assist nursing homes establish best practices in quality management and safety systems to prevent adverse events. In the summer of 2013, DNH launched its QAPI webpage for nursing homes. This webpage contains a set of tools and resources designed to help nursing homes implement the foundations of QAPI.  As continued improvement as part of the Plan, DNH will continue to add Tools/Resources to the QAPI Webpage; develop Nursing Home surveyor training; develop Nursing Home Consumer materials; and develop of Focused Survey on Medication Safety Systems (Adverse Events).

C. National Partnership to Improve Dementia Care in Nursing Homes - Based on continued evidence that nursing home residents are at risk for adverse events due to polypharmacy and overuse of many types of medications, CMS has undertaken a national partnership with collaborative parties both internally and externally. To continue improvement, DNH plans to revise focused survey tools based upon surveyor feedback and pilot data analysis; conduct focused dementia care surveys in selected states; continue coordination of efforts and alignment of strategies between the National Nursing Home Collaborative, Advancing Excellence in America’s Nursing Homes Campaign, National Partnership to Improve Dementia Care in Nursing Homes and QAPI, and training for surveyors, providers, prescribers.

Principle 5: Create Strategic Approaches through Partnerships

No single approach or individual can fully assure better health care. Rather, DNH seeks to combine, coordinate, and mobilize many people and techniques through a partnership approach. Effective quality assurance in nursing homes is best achieved through the combined, motivated, and coordinated approach by many stakeholders in the health care system. The Nursing Home Quality Care Collaborative launched in April 2015 by CMS and the QIN-QIO, strive to instill quality and performance improvement practices, eliminate healthcare- acquired conditions, and improve resident satisfaction by focusing on the systems that impact quality. 


A. Collaboration between State Agencies (SAs) and QIOs - The QIOs are contractors for CMS that provide free assistance to hospitals, nursing homes and other providers of care
for Medicare beneficiaries to address issues related to better clinical outcomes for patients, program efficiencies, and cost savings to the Medicare Trust Fund. In my work, I have assisted in creating relationships between our client communities and management and the QIO. The relationships have proven invaluable for education, survey, and quality improvement. 

The Plan for 2016/2017 is to broaden and strengthen the collaboraTIon. Check out the work the QIOs are doing HERE.

B. Advancing Excellence in America’s Nursing Homes Campaign – This national campaign, started in 2006, helps nursing homes and others coordinate their energy and resources and aligns with other current initiatives such as the National Partnership to Improve Dementia Care in Nursing Homes, CMS GPRA goals, Quality First, Campaign for Quality Care, and the culture change movement. These actionable goals are: 

Goal 1: Consistent Assignment 

Goal 2: Hospitalizations

Goal 3: Person-Centered Care 

Goal 4: Staff Stability 

Goal 5: Infections 

Goal 6: Medications 

Goal 7: Mobility 

Goal 8: Pain 

Goal 9: Pressure Ulcers 

Continued progress toward meeting these goals is part of the Plan for DNH. 

C. Nursing Home Convergence - The DNH actively participates in the CMS Nursing Home Convergence workgroup, which aligned and coordinate the efforts of multiple components across CMS who work to improve quality of care and quality of life for nursing home residents and staff. The group will continue to engage stakeholders, residents, and families as it strives to accomplish its mission. 

D. National Background Check Program – The DNH and CMS, with its contractor, will continue to provide technical assistance to applicants for the ninth solicitation of grants for the National Background Check Program. CMS has awarded more than $57 million to 25 States and U.S. Territories to design comprehensive national background check programs on direct patient access employees prior to employment.

Using this blue-print, communities, operators, managers and owners can establish goals, objectives, and plans aligned with the 2016-2017 Nursing Home Action Plan and be more front and center in the changes and continued efforts of CMS and its collaborators to address quality improvement and safety. 

Rebecca Adelman