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OIG Report Reveals that CMS’s Ten-Year Effort to Stop Illegal Drugging of Nursing Home Residents Has Failed

 Report Connects Illegal Drugging to Inadequate Staffing and Finds it Disproportionately Impacts Low-Income Nursing Home Residents

On November 17, 2022, the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) released a report documenting the failure of an over ten-year effort by the Centers for Medicare & Medicaid Services (CMS) to reduce the inappropriate use of psychotropic medications in nursing homes. CMS defines a psychotropic drug as any drug that affects brain activities associated with mental processes and behavior. The OIG report found that despite reducing the use of some inappropriate medications, nursing homes began to use other drugs to improperly sedate and restrain residents.

In 2011, CMS announced a “national partnership” to reduce the inappropriate use of antipsychotic medications in nursing homes. The partnership was created in response to the widespread practice of nursing homes illegally using medications to sedate residents rather than providing other direct care-based interventions. This practice is often referred to as using “chemical restraints.” The partnership sought to work with federal and state agencies, providers, stakeholders, and others to reduce the use of these medications.

Over the years, CMS has touted the success of the partnership, noting a steady decline in the use of antipsychotics. However, the OIG report found that this reduction was smoke and mirrors. While antipsychotic use may have declined, the use of other psychotropic drugs, such as anticonvulsants and antidepressants, both of which carry an increased risk of death for older individuals and other severe side effects, increased.

From the report:

"While the use of one category of psychotropic drug-antipsychotics-decreased from 31 percent in 2011 to 22 percent in 2019 the use of another category of psychotropic drug -anticonvulsants- increased. Anticonvulsants showed an increase in use among nursing home residents from 28 percent to 40 percent during the same period."

Importantly, the reduction in antipsychotic use is questionable. As explained below, as CMS turned its focus on antipsyhcotic use many nursing homes began inappropriately diagnosing residents with schizophrenia to mask antipsychotic use. As a result, it is unclear how much the inappropriate use of antipsychotics actually decreased.

In addition, the OIG report found that:

  • Between 2011 and 2019, 80% of Medicare long-stay residents (individuals residing in nursing homes for over 100 days) were prescribed a psychotropic drug.
  • Nursing homes with lower RN staffing numbers were associated with higher use of antipsychotic drugs.
  • Nursing homes with higher percentages of residents with low-income subsidies had higher use of psychotropic drugs in 2019.
  • From 2015-2019, there was a 194% increase in the number of residents diagnosed with schizophrenia without a corresponding diagnosis before their admission to the nursing home.
  • By not collecting data on Medicare Part D claims, CMS is limited in its ability to effectively conduct oversight of psychotropic drugs.

These findings confirm what Consumer Voice and other advocates have known for years, nursing homes with insufficient staffing often rely on inappropriate medications to sedate residents rather than providing care. This practice often has a disproportionate impact on low-income residents.

Additionally, the rise in schizophrenia diagnoses is mainly attributable to CMS’s creation of a quality measure based on antipsychotic use. CMS uses a quality measure that excludes residents with schizophrenia diagnoses when calculating antipsychotic use. The OIG report confirms that this exclusion has resulted in nursing homes inappropriately diagnosing residents with schizophrenia in order to prescribe antipsychotic medications and avoid repercussions from regulators.

The OIG report made several recommendations, including an increased effort by CMS to use data to identify the inappropriate use of medications to chemically restrain residents and to require Medicare Part D prescribers to provide diagnosis codes when prescribing psychotropic medications. Currently, CMS does not require a diagnosis, and as a result, CMS must inspect the resident’s medical records, in order to determine the reason a psychotropic medication is being prescribed. This inefficiency, having to inspect medical records physically, severely inhibits oversight and enforcement.

Consumer Voice has long been concerned about the illegal use of medications to chemically restrain nursing home residents. Recently, Lori Smetanka, Executive Director of Consumer Voice, authored an article decrying the practice and noting the increase of antipsychotic use during the pandemic. The OIG report reveals that the current approach by CMS is not working. Despite claiming for years that it was partnering with stakeholders to decrease the use of antipsychotics and other psychotropic medications, nothing has changed.

The OIG report directly connects the illegal drugging of nursing home residents with inadequate staffing. It confirms the need for a minimum staffing standard, promised by the Biden Administration earlier this year. Until a minimum staffing standard is implemented, nursing homes will continue to find ways, such as illegal drugging, to avoid investing in staff. In addition to a minimum staffing standard, CMS must increase penalties for nursing homes that illegally drug residents. CMS must fulfill its regulatory role and protect nursing home residents.

You can go here to access more information and resources on the illegal use of medications to chemically restrain nursing home residents.

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