Regulators announce changes to nursing home rating system for safety of patients

January 20, 2023

On Wednesday, January 18, federal regulators said that they will begin penalizing nursing homes that give residents a false label of schizophrenia—a practice that many facilities have used to skirt restrictions on antipsychotic drugs, which can be especially dangerous for older people, reports The New York Times.

In the announcement, officials at the Centers for Medicare and Medicaid Services said that facilities inflating the number of residents with schizophrenia could be punished with a lower ranking in the federal ratings system used to evaluate the quality of nursing homes.

The move—part of a broader effort by the Biden Administration to beef up regulation of nursing homes—could close a loophole that some nursing homes have exploited to sedate dementia patients who would otherwise require expensive round-the-clock care.

Under the federal rating system, nursing homes must report the number of their residents taking antipsychotic drugs. But facilities are allowed to exclude residents who have certain other medical diagnoses, including schizophrenia.

In a 2021 investigation, The New York Times reported that, since 2012, when nursing homes were first required to report how many residents had received such drugs, the share of residents with a questionable schizophrenia diagnosis has soared by 70%. That year, one in nine residents had a schizophrenia diagnosis; in the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.

“We support transparency for consumers and ensuring nursing home residents are properly diagnosed and receive the right care,” said Dr. David Gifford, the chief medical officer at the American Health Care Association, which represents nursing homes, adding, “Our members have been active partners in a national effort to reduce the unnecessary use of antipsychotics in nursing homes, which in the past decade, has decreased by 40 percent,” he added.

A 2021 report by a federal oversight agency concluded that nearly 33% of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition. The Medicare agency, which oversees nursing homes, said it would conduct an audit of medical records in nursing homes to evaluate whether the diagnoses were correct.

Black nursing home residents have been disproportionately affected by the surge in schizophrenia diagnoses. A 2021 study found that Black Americans with dementia have been 1.7 times as likely as white residents to be diagnosed with schizophrenia.

In its latest announcement, the Medicare agency said it already has conducted a handful of audits of nursing homes’ medical records and spotted instances of residents saddled with phony diagnoses. Some nursing homes failed to perform psychiatric evaluations of the residents. Among those that did, some classified symptoms of dementia as signs of schizophrenia instead.

The agency also said it would begin publishing citations against nursing homes even while the facilities were appealing the charges. The New York Times reported that thousands of problems uncovered by state health inspectors had been hidden from public view because they were being appealed by the nursing homes, in a secretive process. In many cases, inspectors had uncovered dangerous conditions that violated federal regulations, but the nursing homes were allowed to keep their high ratings during the appeals, which sometimes had lasted for years.

The Medicare agency said that, although the number of hidden citations is relatively small, the practice has obscured serious charges. Over the past two years, the agency said, 80 citations that placed residents in “immediate jeopardy” went through the appeals process and were not published on the site.

Research contact: @nytimes