The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, began a national Nursing Home Quality Initiative (NHQI) in November of 2002. With that, a 5-star rating system was implemented to provide the consumer information on level of care to be expected at respective Long-Term Care (LTC) facilities. The ratings (1-5) being based on aggregate data points provided by the facilities and correlated by on-site “audits.” 42 CFR Subpart B - Requirements for Long Term Care Facilities outlines expectations such as (42 CFR § 483.12) freedom from abuse, neglect, and exploitation; (§ 483.24) quality of life; and (§ 483.25), quality of care and, most importantly, (§ 483.75) the requirements for a “an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life”.
Not unlike an ISO 9001-based Quality Management System, the program requires data driven meetings. This data is reported to a State or CMS rep annually, but, unlike ISO 9001, there is no requirement for internal auditing of the QAPI program, or for any independent third-party audits, for compliance. So, what you essentially have is a State representative paying an annual visit and being handed a report that was prepared by those involved in ruining the facility, which becomes the basis for the rating which purports to indicate the quality of care provided. Per the findings as outlined in a NY Times article entitled “Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public” (March 13, 2021), these “Elder Care” facilities are “cooking the books” and failing to report accurate numbers to maintain their 5-star ratings, while life-threatening neglect and abuse is rampant. The state and/or federal representatives responsible for oversight, in failing to take action to address such fraud and conditions, are exacerbating the abuse.
The Social Security Act (SSA) requires any nursing home that does not achieve substantial compliance with Federal requirements within six months be terminated from participation in Medicare and/or Medicaid. Sections 1819(h) and 1919(h) of the Act, as well as 42 CFR §§488.404, 488.406, and 488.408, provide that the CMS or the State may impose one or more remedies in addition to, or instead of, termination of the provider agreement, when the State or CMS finds that a facility fails to comply. In the many instances cited by the NY Times article, failure to comply was exacerbated by fraudulent reporting and cover-up. Of which, the State and/or the CMS were apparently aware. The question then becomes, is the State and/or the CMS, both of which are entrusted with oversight responsibilities, deliberately not viewing false reporting of data in the context of Medicaid fraud as defined in 42 CFR 455.2 and/or as underscored in the “False Claims Act”, 31CFR 3729-3733 (to date, the most effective antifraud law in the United States)? And if so, why not? I suggest someone follow the money trail.
In the short-term, we need to enforce the law as written to prevent tax dollars being spent on facilities that abuse the Elderly. In the long-term, requiring ISO 9001 accreditation for all facilities receiving tax dollars (directly or otherwise) would be consistent with what the Federal government requires of privately-held companies receiving tax dollars indirectly from aerospace, medical device and defense materials and service providers. For about $50K an Elder Care facility could become ISO 9001 certified and they could continue to maintain certification for under 30K per year thereafter. The level of accountability and care would improve significantly, and the public would receive, at last, something approximating the care they expect and deserve.