The GAO has issued a report entitled “Medicaid: Financial Characteristics of Approved Applicants and Methods Used to Reduce Assets to Qualify for Nursing Home Coverage.” The report highlights ways applicants in Florida, New York, and South Carolina reduce their countable assets to qualify for Medicaid nursing home coverage, including (1) spending countable resources on goods and services that are not countable towards financial eligibility, such as prepaid funeral arrangements; (2) converting countable resources into noncountable resources that generate an income stream for the applicant (e.g., an annuity or promissory note); (3) giving away countable assets as a gift to another individual (which could lead to a penalty period that delays Medicaid nursing home coverage); and (4) for married applicants, increasing the amount of assets a spouse remaining in the community can retain (e.g., through the purchase of an annuity). The report does not include recommendations.
On May 20, 2014, CMS is hosting another call to discuss the National Partnership to Improve Dementia Care in Nursing Homes, which includes as a goal reducing the use of unnecessary antipsychotic medications in nursing homes. This call will focus on efforts to monitor enforcement rates and track surveyor training completion; the role that activity professionals play in the mission to improve dementia care; and nonpharmacologic care approaches.
In early April, Reed Smith hosted an enlightening, industry-leading conference on post-acute care in Washington, D.C. The conference, entitled “Reed Smith 2014 Washington Health Care Conference: Focus on Post-Acute Care," brought together a panel of experts to discuss episodic care, bundling models, and alternative payment and delivery systems. The conference also featured other speakers who presented from the perspective of investors and Capitol Hill, along with a keynote address from American Enterprise Institute resident scholar Dr. Norman Ornstein.
Policy Discussion on Payment Models
The conference started with a panel discussing bundling initiatives and other alternative payment models. The panel featured Barbara Gage, Ph.D., Fellow and Managing Director of Engelberg Center for Health Care Reform at the Brookings Institution; Judy Feder, Ph.D., Professor at Georgetown University; Vincent Mor, Ph.D., Professor at Brown University School of Medicine; and James Michel, Director for Medicare Research & Reimbursement at the American Health Care Association (“AHCA”). The panel brought with them decades of experience in health care policy and research, and a deep knowledge of post-acute care providers’ current reimbursement systems, in addition to models expected to reform payment for post-acute services in the future.
Dr. Gage spoke first, and introduced bundling by discussing the triple aim adopted by the Centers for Medicare & Medicaid Services (“CMS”): achieve better care for patients, better communities’ health, and lower costs by improving the health care system. She explained how new payment models—including bundled payment initiatives and accountable care organizations—strive to accomplish the above-mentioned triple aim. Gage discussed whether the post-acute setting in which a patient receives treatment distinguishes the patient’s outcome and the level of resources that different post-acute settings (e.g., home health, skilled nursing facilities (“SNF”), inpatient rehabilitation facilities (“IRF”), or long-term acute care hospitals (“LTCH”)) furnish to patients. Gage described in great detail the arguments in favor of bundled payments, emphasizing that one of the benefits of a bundled payment model is that it forces communication across all care settings.
Dr. Feder, on the other hand, urged caution as reimbursement moves to new models. She stressed that bundled payment models, for example, create powerful incentives to potentially reduce or limit the care furnished to patients, and therefore could result in reduced quality of care. Feder explained that bundling is not new, and that, e.g., payers have bundled in the inpatient hospital setting for 30 years. Feder pointed out that when Medicare implemented diagnosis-related groups in the inpatient hospital prospective payment system, hospital length of stay “dropp[ed] like a stone.” Feder underscored that the biggest challenges arise from patients whose health is deteriorating, and explained that the number of home health visits, for instance, are the lowest when patient acuity is the highest. In order to ensure adequate, appropriate, and high-quality care for patients, Feder suggested that policymakers thoughtfully develop and implement any new payment system over time, and incorporate quality mechanisms that serve to protect patients. Feder suggested that good patient data and strong accountability measures are essential to any bundled payment program.
After Feder spoke, Dr. Mor took the podium and analogized capitation versus fee-for-service as being “between the devil and the deep blue sea.” He further explained that fee-for-service reimbursement models have encouraged runaway costs and increased utilization, and that there is a lack of provider accountability and responsibility. In contrast, he explained that in capitation reimbursement models, there is an inherent incentive to deny care. Mor discussed how policymakers can ensure patients receive quality care from providers, and raised a number of thought-provoking questions, such as whether a SNF or other post-acute provider should be responsible for rehospitalization after the discharge of a patient, and whether low rehospitalization reflects overall high-quality care. Mor urged the development of a common assessment tool that includes hospital assessment data in order to more accurately measure post-acute quality and case-mix. He also recommended that CMS use the “Welcome to Medicare” assessment and other periodic beneficiary assessments to obtain risk profiles for patients. Mor ended his presentation by suggesting that while capitation models—such as bundling—are preferable to fee-for-service because one entity is responsible for patients’ care, capitation models face challenges as well, including how to properly measure case-mix and outcomes.
James Michel from AHCA noted the operational challenges associated with bundled payments. For example, it is difficult for post-acute providers to assume the responsibility for patients after the post-acute provider discharges a given beneficiary. Michel also stated that the Center for Medicare & Medicaid Innovation Bundled Payments for Care Improvement initiative’s models incentivize low-cost providers to participate, but providers who recognize they have higher costs than the community average will not participate because of the risk that they will miss the spending target, resulting in a payment to the government. Michel noted that AHCA has developed its own bundled payment proposal, in part to preserve a process in which patients and their families can decide where the patient should be treated after an acute stay. The AHCA bundled payment proposal includes four proposed episodes (e.g., major respiratory condition and septicemia) that would account for approximately 60 percent of all SNF care and more than 50 percent of all post-acute care.
Wall Street Perspective
Jay Barnes, a Senior Vice President for Healthcare Investment Banking at Jefferies, LLC, spoke from the Wall Street perspective, addressing the current appetite for deals in the post-acute space. He described a tepid outlook for post-acute investment stemming from the uncertainty of the future payment models and the changing regulatory landscape, particularly with regard to LTCHs. He informed attendees that the private equity market has been non-existent in the post-acute space because it is challenging to create projection models when future reimbursement for post-acute care remains murky. He explained that the post-acute transactions occurring are largely driven by real estate. For example, Barnes described the recently announced Emeritus Senior Living and Brookdale Senior Living merger as driven by real estate.
Cate McCanless, Senior Policy Analyst at Brownstein Hyatt Farber Schreck, provided an insightful overview of Medicare activity on Capitol Hill. She explained that Congress has focused on post-acute care because of the perceived “comfortable” margins achieved by post-acute providers (according to the Medicare Payment Advisory Commission). McCanless also described the outlook for the discussion draft of the Improving Medicare Post-Acute Care Transformation (“IMPACT”) Act of 2014, released by the House Ways and Means Committee Chairman Dave Camp (R-Mich.) and Ranking Member Sandy Levin (D-Mich.), along with Senate Finance Committee Chairman Ron Wyden (D-Ore.) and Ranking Member Orrin Hatch (R-Utah), March 18, 2014. The IMPACT Act draft includes one measure discussed by Mor during the bundling panel: the reporting of common data across post-acute providers, and the required reporting by acute-care hospitals of patient assessment data gathered in advance of discharge. McCanless also explained that while there has been some Congressional momentum in eliminating Medicare's sustainable growth-rate (“SGR”) formula in order to move to an alternative payment model, such momentum may lose steam this year now that a temporary patch has been enacted, because eliminating the SGR would be expensive, and it is an election year. McCanless pointed out certain post-acute policy proposals that would result in cost savings, such as reducing the SNF payment update by 1.1 percent, which would save an estimated $12 billion, and equalizing certain payments for SNFs and IRFs, which would save an estimated $1 billion; these provisions could be targets for offsets for future Medicare reforms.
Impact of Political Polarization on Health Policy
Dr. Norman Ornstein, noted observer of Congress and politics, and keynote speaker at Reed Smith’s inaugural Health Care Conference, closed the session with a thoughtful discussion regarding the current state of American politics. He described not just the polarization, but also the tribalism, of American politics today, depicting a broken American political system where opposing parties have adopted a mantra of, “if you support it, I am against it.” Despite Ornstein’s bleak description of the current state of politics, he offered some suggestions for reform, including incentivizing citizens to vote. He argued that if more of the American public is engaged, politicians must meet in the middle on at least some policy debates.
In all, the inaugural Reed Smith Health Care Conference led to provocative discussions and a deeper understanding of the political climate and policy recommendations likely to impact—or even transform—post-acute care in the not-so-distant future. We look forward to next year’s conference.
The OIG has released its “Compendium of Priority Recommendations,” which lists 25 priority issues for which the OIG has open recommendation and that, if implemented, would best protect the integrity of HHS programs. The 25 top priorities are as follows:
- Medicare Policies and Payments: address wasteful Medicare policies and payment rates for clinical laboratories, hospitals, and hospices; improve controls to address improper Medicare billings by community mental health centers, home health agencies, and skilled nursing facilities; detect and recover improper Medicare payments for services to incarcerated, unlawfully present, or deceased individuals; maximize recovery of Medicare overpayments; improve monitoring and reconciliation of Medicare hospital outlier payments; ensure that Medicare Advantage Organizations are implementing programs to prevent and detect waste, fraud, and abuse; and improve controls to address questionable billing and prescribing practices for Part D prescription drugs.
- Medicare Quality of Care and Safety Issues: address adverse events in hospital settings; improve care planning and discharge planning for beneficiaries in nursing home settings; address harm to patients, questionable resident hospitalizations, and inappropriate drug use in nursing homes; improve nursing home emergency preparedness and response; and ensure hospice compliance with Medicare conditions of participation.
- Medicaid Program Policies and Payments: ensure that state claims and practices do not inappropriately inflate federal reimbursements; ensure that states prevent, detect, and recover improper payments and return the federal share of recoveries to the federal government; assist states to better align Medicaid drug reimbursements with pharmacy acquisition costs; ensure that Medicaid Information Systems are fully functional; and address Medicaid managed care fraud and abuse concerns.
- Medicaid Quality of Care and Safety Issues: ensure that Medicaid home- and community-based care service providers comply with quality and safety requirements; and ensure that States improve utilization of preventive screening services for eligible children.
- Oversight of Food Safety: improve oversight of dietary supplements; and improve oversight of food inspections and traceability.
- HHS Grants and Contracts: improve oversight of grantee compliance, quality assurance, and conflicts of interest; and improve oversight of Medicare contractor performance and conflicts of interest.
- HHS Financial Stewardship: reduce improper payments and fraud; and correct deficiencies found in financial statement audits.
Note that some of these recommendations would require additional authority or other legislative change.
Reed Smith Hosting Washington Health Care Conference: Focus on Post-Acute Care on April 4, 2014 - One Week Left to Register
On April 4th, 2014, Reed Smith will host its inaugural Washington Health Care Conference at The Mayflower Renaissance Hotel in Washington, D.C. With a keynote from Dr. Norman Ornstein, this year’s conference will focus on post-acute care, bringing together leading industry professionals for a discussion on several important issues, including:
Governing in Polarized America: The Prospects for Policy in 2014 and Beyond (Keynote)
- Dr. Norman Ornstein, Resident Scholar, American Enterprise Institute, and weekly columnist for National Journal and The Atlantic
Policy discussion on episodic care, bundling models, and alternative payment and delivery systems
- Mike Cheek, Vice President for Medicaid and Long Term Care Policy, American Health Care Association
- Judy Feder, Professor, Georgetown University McCourt School of Public Policy, and Urban Institute Fellow
- Dr. Barbara Gage, Fellow, Managing Director, Engelberg Center for Health Care Reform, Brookings Institution
- Dr. Vincent Mor, Ph.D., Florence Pirce Grant Professor of Community Health, Public Health Program, Brown University School of Medicine
Wall Street perspective: the current appetite for deals
- Jay Barnes, Senior Vice President, Healthcare Investment Banking, Jefferies LLC
Hill briefing on Medicare legislation
- Cate McCanless, Senior Policy Advisor, Brownstein Hyatt Farber Schreck
Limited seating is still available for this complimentary program. If you are interested in registering, please email Lindsay Korenich at email@example.com. For more information about this conference, click here.
The OIG released a report on March 3, 2014, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries,” that examines the national incidence rate, preventability, and cost of adverse events in skilled nursing facilities (SNFs). This report is an outgrowth of a series of studies about hospital adverse events. For purposes of this report, the OIG defined an adverse event as harm to a patient or resident as a result of medical care in a health care setting that resulted in a prolonged SNF stay or hospitalization (including emergency room visit), permanent harm, life-sustaining intervention, or death. Based on a small sample of individuals discharged from hospitals to SNFs with SNF stays that ended in August 2011 (a total of 653 Medicare beneficiaries), the OIG estimates that 22% of Medicare beneficiaries experienced adverse events during their SNF stays and 11% of Medicare beneficiaries experienced temporary harm events during their SNF stays. The OIG’s physician reviewers determined, based on review of the patients’ medical record, that 59% of these adverse events and temporary harm events were clearly or likely preventable. More than half of the residents who experienced harm were rehospitalized, with an estimated Medicare cost of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011 (or roughly 2% of inpatient hospital spending).
The OIG observes that the preventable nature of many of the events it identified indicates an opportunity for SNFs to significantly reduce the incidence of resident harm events. To that end, the OIG recommends that the Agency for Healthcare Research and Quality (AHRQ) and CMS raise awareness of nursing home safety and reduce resident harm through methods the agencies previously used to promote hospital safety. For instance, OIG recommends that the agencies collaborate to create and promote a list of potentially reportable nursing home events to help nursing home staff better recognize and reduce harm (but AHRQ and CMS should specify that they do not require external nursing home reporting of these events). Likewise, the OIG recommends that AHRQ and CMS encourage nursing homes to report adverse events to Patient Safety Organizations. CMS also should include potential events and information about resident harm in future guidance to nursing homes on the development of Quality Assurance and Performance Improvement (QAPI) programs pursuant to the ACA. Finally, the OIG recommends that CMS instruct state agency nursing home surveyors to review facility practices intended to identify and reduce adverse events. AHRQ and CMS concurred with the OIG’s recommendations.
On February 26, 2014, CMS is hosting a call to discuss the National Partnership to Improve Dementia Care in Nursing Homes, which includes as a goal reducing the use of unnecessary antipsychotic medications in nursing homes. This call will focus on the role of surveyors in the implementation of the partnership, the importance of leadership, and the correlation between proper pain assessment and antipsychotic medication use.
A recent OIG report, "Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring,” examines the extent to which Medicare nursing home residents are hospitalized. The OIG found that in FY 2011, nursing homes transferred one quarter of their Medicare residents to hospitals for inpatient admissions in FY 2011, and Medicare spent $14.3 billion on these hospitalizations. Septicemia was the most common condition requiring the hospitalization of nursing home residents, and nursing homes located in Arkansas, Louisiana, Mississippi, and Oklahoma had the highest annual rates of resident hospitalizations. The OIG concludes that the higher-than-average resident hospitalization rates of some nursing homes in FY 2011 suggest that some hospitalizations could have been avoided through better nursing home care. The OIG recommends that CMS develop a quality measure that describes nursing home resident hospitalization rates and assess this measure during surveys of nursing homes. CMS concurs with OIG’s recommendations, and is already working on developing a hospitalization measure for all nursing home residents and a re-hospitalization measure for Medicare skilled nursing facility residents. CMS also concurs in adding these measurers to the quality measures surveyors review.
CMS is hosting a call on November 25, 2013 to discuss progress to date in implementing the National Partnership to Improve Dementia Care in Nursing Homes. The partnership is focused on delivering person-centered, comprehensive, and interdisciplinary care and reducing the use of unnecessary antipsychotic medications in nursing homes. The target audience for the call is consumer and advocacy groups, nursing home providers, surveyor community, prescribers, professional associations, and other interested stakeholders.
CMS Finalizes Medicare/Medicaid Requirements for Long Term Care Facilities Providing Hospice Services
On June 27, 2013, CMS published a final rule that revises the requirements that an institution must meet to qualify as a skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid program with regard to hospice services. Specifically, the rule requires SNFs and NFs that chose to arrange for the provision of hospice care through an agreement with one or more Medicare-certified hospice providers to have in place a written agreement with the hospice that specifies the roles and responsibilities of each entity. As in the October 22, 2010 proposed rule, the final rule provides that the LTC facility that arranges for the provision of hospice care under a written agreement must designate a member of the facility’s interdisciplinary team to be responsible for working with hospice representatives to coordinate care provided by the LTC facility and hospice staff to the resident. The final rule adds language to clarify, however, that the LTC representative must have a clinical background, function within their state scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The rule also clarifies that if a facility chooses not to arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice, it must assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. The rule is effective August 26, 2013.
On July 10, 2013, CMS is hosting a provider call on its National Partnership to Improve Dementia Care in Nursing Homes. This initiative focuses on delivering person-centered, comprehensive, and interdisciplinary dementia care, while reducing the use of unnecessary antipsychotic medications in nursing homes (and eventually other care settings).
On March 19, 2013, CMS published a final rule that adopts, with technical changes and a few clarifications, a February 18, 2011 interim final rule implementing an ACA provision imposing notification requirements in connection with closure of a Medicare skilled nursing facility (SNF) or Medicaid nursing facility (NF). Under the rule, in the case of a long-term care (LTC) facility closure, the SNF or NF administrator must provide written notification of the impending closure and a plan for the relocation of residents to the state survey agency at least 60 days prior to the impending closure (or, if the Secretary terminates the facility’s participation in Medicare or Medicaid, not later than the date the Secretary determines appropriate). Notice and the plan also must be provided to residents, their legal representatives or other responsible parties, and the state LTC Ombudsman. While the ACA authorizes civil monetary penalties (CMPs) of up to $100,000 and exclusion for an administrator's failure to comply with this provision, CMS is finalizing the lower levels of CMPs established in the interim final rule in recognition that there are cases in which an administrator may not have had control over implementing notice procedures. The final rule therefore sets CMPs of: a minimum of $500 for the first offense; a minimum of $1,500 for the second offense; and a minimum of $3,000 for the third and subsequent offenses (CMS states that interpretive guidelines are being developed that will establish criteria for determination of CMP amounts). CMS also provides appeal rights for an individual who is subject to administrator sanctions under the rule. The final rule is effective April 18, 2013 (although note that the statutory closure notice requirements are effective March 23, 2011).
The Centers for Medicare & Medicaid Services (CMS) published a proposed rule on February 7, 2013 that it estimates would save health care providers $676 million annually by streamlining unnecessary, obsolete, or excessively burdensome regulations and making reforms to the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The provisions of the wide-ranging proposal would affect numerous policy areas; among other things, the proposed rule would:
- Revise the requirements ambulatory surgical centers (ASCs) must meet in order to provide radiological services that are integral to procedures offered by the ASC and provide that a qualified doctor of medicine or osteopathy must supervise the provision of radiologic services (eliminating the requirement that ASCs meet the hospital condition of participation (CoP) requirement to have a radiologist supervise the provision of radiologic services);
- Permit qualified dietitians to order patient diets under the hospital CoPs;
- Revise the nuclear medicine services CoP to remove the requirement for direct supervision of hospital in-house preparation of radiopharmaceuticals;
- Eliminate a requirement that critical access hospitals (CAHs), rural health clinics (RHCs), and federally qualified health centers have a physician on site at least once in every two-week period, and eliminate the requirement that a CAH develop its patient care policies with the advice of at least one member who is not a member of the CAH staff;
- Allow long-term care facilities to apply for an extension of the August 13, 2013 deadline for installing automatic sprinkler systems;
- Eliminate a transplant center data submission requirement and an automatic re-approval survey process.
- Make a number of clarifications pertaining to CMS regulations governing proficiency testing referrals under CLIA, including establish policies under which certain PT referrals by laboratories would not generally be subject to revocation of a CLIA certificate.
- Address a variety of other issues, such as hospital reclassification of swing-bed services, hospital medical staff, hospital governing bodies, practitioners permitted to order hospital outpatient services, and potential changes to reduce barriers to the provision of telehealth, hospice, or home health services in an RHC.
CMS will accept comments on the proposed rule until April 8, 2013.
On January 31, 2013, CMS is hosting a call on its National Partnership to Improve Dementia Care in Nursing Homes. The partnership is focused on improving dementia care through the use of individualized, person-centered care approaches, which CMS hopes will reduce the use of unnecessary antipsychotic medications in nursing homes and eventually other care settings. The CMS call will provide information on the goals of the national partnership, quality measures, and ongoing outreach efforts. The target audience for the call includes consumer and advocacy groups, nursing home providers, surveyors, prescribers, professional associations, and other interested stakeholders. Registration is required to participate in the call.
On December 13, 2012, the Senate Finance Committee held a hearing to focus on improving care for beneficiaries dually eligible for Medicare and Medicaid. In addition, the House Energy and Commerce Subcommittee held a hearing entitled "State of Uncertainty: Implementation of Patient Protection and Affordable Care Act Exchanges and Medicaid Expansion." On December 20, 2012, the Senate Judiciary Committee was scheduled to consider S. 1560, the Nursing Home Resident Pain Relief Act of 2011, which would make amendments to the Controlled Substances Act that are intended to help ensure that nursing home residents have timely access to pain medication in emergency situations. Note that the markup has been postponed and not rescheduled at this time.
OIG Report on Criminal Convictions of Nurse Aides with Substantiated Findings of Abuse, Neglect, & Misappropriation
A new OIG study provides baseline information for an ACA-mandated report on the extent to which nurse aides with substantiated findings of abuse, neglect, and/or misappropriation had previous criminal convictions that could have been detected through background checks. Based on a review of state records, the OIG found that 19% of nurse aides who received a substantiated finding of abuse, neglect, and/or misappropriation of property during 2010 had at least one conviction in their criminal history records prior to their substantiated finding (the majority of which was for crimes against property, including, burglary, shoplifting, and writing bad checks). The OIG calculates that nurse aides with substantiated findings of abuse or neglect were 3.2 times more likely to have a conviction of crime against persons than nurse aides with substantiated findings of misappropriation, who in turn were 1.6 times more likely to have a conviction of crime against property than nurse aides with substantiated findings of abuse or neglect. The report, “Criminal Convictions for Nurse Aides with Substantiated Findings of Abuse, Neglect, and Misappropriation,” is available here.
The OIG recently followed up on a 2010 report which found that CMS did not report all adverse actions against providers to the Healthcare Integrity and Protection Data Bank (HIPDB) as required. The OIG found that as of April 1, 2012, CMS improved its reporting of adverse actions for durable medical equipment (DME) suppliers, but not for other types of providers. For instance, the HIPDB contains no reports of nursing home terminations since June 2010, and it still did not contain adverse actions that CMS imposed against laboratories, managed care plans, prescription drug plans, and monetary penalties against nursing homes. The OIG therefore restated its 2010 recommendation that CMS report all required adverse actions to the HIPDB within required timeframes.
On July 23, 2012, the Department of Health and Human Services (HHS) published a notice soliciting public comments on the development of a new long-term care facilities strategy module of the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination. This module will be part of a broader plan to reduce healthcare-associated infections (HAIs) in acute care hospitals, ambulatory surgical centers, and end stage renal disease facilities, and to increase healthcare personnel influenza vaccination coverage. Comments on the draft document will be accepted until August 22, 2012.
CMS has released its 2012 Nursing Home Action Plan, which discusses CMS strategies to: (1) enhance consumer engagement; (2) strengthen survey processes, standards, and enforcement; (3) promote quality improvement; (4) create strategic approaches through partnerships; and (5) advance quality through innovation and demonstration.
OIG Reviews Nursing Facility Compliance with Rules for Residents Receiving Atypical Antipsychotic Drugs
The OIG has issued a report entitled “Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs.” Based on a small random sample of nursing facility resident records (375 records) from 2007, the OIG found that few records included evidence that the facilities met all federal requirements related to resident assessments and/or care plans for residents receiving antipsychotic drugs. In particular, most of the records in the sample did not contain evidence of compliance with federal requirements for care plan development, while smaller percentages of records lacked evidence of compliance with federal resident assessment requirements, evidence that planned interventions for antipsychotic drug use actually occurred, or documentation that staff considered the Resident Assessment Protocol for psychotropic drug use as required. The OIG therefore recommends that CMS: (1) improve the detection of noncompliance with federal requirements for residents receiving antipsychotic drugs; (2) address noncompliance with these requirements, and (3) provide methods for nursing facilities to enhance the development and usefulness of resident assessments and care plans. CMS concurred with all of the recommendations. The agency noted that subject to resources, CMS intends to pilot-test a focused review of resident assessments, care plans, and medication use in a sample of nursing homes in FY 2013 to help identify needed improvements in the survey process.