1. The State Performance Standards System—Making a Change
AHFSA Annual Conference
Portland, OR
September 24, 2018

2. Disclaimer
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

3. Quality, Safety & Oversight Group
Bonnie Reed, RN
Technical Director, Division of Nursing Homes
Dominick Esposito, Ph.D.
Vice President, Insight Policy Research
Christina Compher, MHS
Project Manager, Epidemiologist

4. Agenda Background on the need for SPSS changes
SPSS evaluation plan and milestones
Preliminary data analysis
Early RO/SA feedback
Group participation/working session

5. Objectives of the SPSS
An objective, effective, and efficient system to:
Ensure the health and safety of all patients and residents
Ensure effective and consistent application of federal oversight responsibilities (per 1864 Agreement)
Identify improvements to policies or procedures (e.g., revised FOSS)
Identify and remedy issues leading to inconsistency or unidentified noncompliance (placing residents at risk for harm):
Where have we gone too far?
What are we missing?

6. The Need for SPSS Changes
Ensuring the SPSS as a tool is also relevant and accounts for the day-to-day work of ROs and SAs
Reducing the risk of harm for residents requires that the SPSS is effective at gauging State performance at monitoring non-compliance
Assessing State performance can and should be done more efficiently and objectively consistent

7. SPSS Evaluation Plan and Milestones
Analysis of Existing Data
Feedback from SPSS Stakeholders
Recommendations to Improve the SPSS

8. SPSS Evaluation Plan and Milestones
Review of SPSS data to establish patterns and identify outliers
Analysis of the association between deficiency data and quality measures
Analysis of complaints data
Data analysis for both long-term care and other providers (i.e. dialysis facilities, hospitals, hospice, home health, ICF/IID)

9. SPSS Evaluation Plan and Milestones
Feedback from SPSS Stakeholders
Questionnaires on the SPSS for Regional Offices and State Agencies
An AHFSA State Workgroup
Conversations with Regional Office and State Agency Staff

10. SPSS Evaluation Plan and Milestones
Late October ‘18. Evaluation Report
Early November ‘18. Preliminary Recommendations
December ‘18-March ‘19. Testing Phase
Early April ‘19. Final Recommendations

11. Preliminary Data Analysis
Long-term care quality measures matched to F-tags to examine association of quality to deficiencies cited
19 total quality measures (long- and short-stay)
23 total F-tags
Compared average deficiencies per LTC facilities that scored on upper and lower ends of each quality measure
Several commonalities across states to consider

12. Preliminary Data Analysis
Common concern areas
Residents who lose control of bowels/bladder
Residents with a urinary tract infection
Residents with one or more falls
Other areas of concern
Residents with pressure ulcers
Residents who received an antipsychotic medication
Staffing
Hospitalizations

13. Preliminary Data Analysis
Number of States from where Facilities with Lower Quality Scores had Fewer Deficiencies than Facilities with Higher Quality Scores
Quality Measure
Three or Four Years
Two to Four Years
Bowels/Bladder 20 33
Urinary Tract Infection 13 26
Falls 10

14. Preliminary Data Analysis
Long-stay residents who lose control of bowels or bladder
High (low) quality score defined as 35 percent or fewer (60 percent or more) residents with bowels/bladder control issues.

15. Preliminary Data Analysis
Long-stay residents experiencing one or more falls with major injury
High (low) quality score defined as 1 percent or fewer (5 percent or more) residents with one or more falls with major injury.

16. Preliminary Data Analysis
Average Number of Deficiencies per 100 Surveys in 2017; Nursing Homes
Quality Measure
Facilities with Higher Scores
Facilities with Lower Scores
Rehospitalization Rate
Total Deficiencies
408.3
227.7
Substandard Quality of Care
5.0
13.5
IJ Deficiencies
161.0
218.2
ED Visits
268.7
493.9
23.4
162.7
195.6
Success. Discharge to Commty
353.0
240.9
11.4
4.2
170.7
290.6
High/Low quality cutoffs defined as: 21% (rehospitalizations); 11% (ED visits); 50% (Successful discharge)

17. Preliminary Data Analysis
Many LTC Facilities with High Rates of Pressure Ulcers Are Not Cited for Them in 2017
In 23 states in 2017, 75-90% of LTC facilities that had 10 percent or more long-stay residents with a pressure ulcer also did not have any pressure ulcer citations.
A high rate of pressure ulcers was defined as 10 percent or more long-stay residents.
To identify citations for pressure ulcers we used F-tag 314 (Pressure sores (Ulcers)*).

18. Preliminary Data Analysis
Percentage of Long Stay Residents who Received an Antipsychotic Medication
Percentage of States where lower quality facilities had fewer average deficiencies cited than higher quality facilities
High (low) quality defined as 10 percent or fewer (20 percent or more) residents who received an antipsychotic medication.
Analysis of F-tags 329 (Unnecessary Drugs*) and 428 (Drug Regimen Review*).

19. Preliminary Data Analysis
Average Number of Deficiencies per 100 Surveys in 2017; Dialysis Facilities
Quality Measure
Facilities with Higher Scores
Facilities with Lower Scores
Catheter Infection Rate
55.4
60.7
Number of ED Visits
34.0
33.5
Number of Hospital Admissions
29.4
14.5
Dialysis patient deaths
12.5
14.0
Standardized readmission ratio
31.9
30.2

20. Early RO/SA Feedback
Data-driven measures in SPSS more favorable than subjective measures
Some measures are too labor intensive and an inefficient use of resources
Multiple reporting systems make the work more difficult
Sample of cases is too small to properly assess performance

21. Early RO/SA Feedback
Build SPSS into part of the daily workload to make it easier to monitor, evaluate, and improve SA performance
Up to half of SA performance could be rated on work products submitted to ROs
Conduct brief reviews every 1-3 months and provide feedback to SAs immediately

22. Group Participation/Working Session
Topics for Group Breakout Discussions
What SPSS current measures are effective? What new measures should we add to reflect relevant day-to-day activities conducted by State Agencies?
Would adding metrics to gauge surveyor training be valuable? Might better monitoring of surveyor training improve State performance over time? How might implementation work?
How could we incorporate quality measures for different providers into the SPSS to either assess State performance at monitoring non-compliance or inform the SPSS?

23. Group Participation/Working Session
Group Discussion Questions….
Would any potential SPSS changes be more reflective of day-to-day work conducted by State Agencies? What would make it so, if not?
Would a potential change make the SPSS a more effective tool at gauging State performance at monitoring non-compliance? If not, what might?
What would be potential obstacles, barriers, or challenges if a SPSS change was made?