In an earlier post, we talked about the CMS “focused surveys” to examine the dementia care provided at a handful of nursing homes in a few states, including California. The survey teams found many examples of poor dementia care by applying enhanced criteria related to antipsychotic use. The application of the criteria could dramatically improve dementia care in nursing homes if CMS and the state survey agencies ever decide to assess real penalties for bad care.
In four of the nursing home surveys completed in California, CMS demanded true person-centered care, finding that pre-packaged care plans with generic check boxes were inconsistent with the individualized attention that people with dementia need to thrive. Good care plans must include proposed interventions that are specifically tailored for each resident, based on their preferences and prior work experience, to maximize their self-expression and socialization. Nursing home staff members must make an effort to not only gather personal information about each resident’s personality and past, they must incorporate that information to enhance the resident’s quality of life.
The focused surveys were noteworthy for scrutinizing other aspects of dementia care that typically get a pass from regulators. Dementia diagnoses require evidence of medical evaluation and careful assessment, and could not be loosely based on a resident’s age and an episode of “confusion” or “forgetfulness.” Staff must act on consultant pharmacist recommendations to reduce or eliminate problematic psychotropic drug use. The use of psych drugs must be continuously re-evaluated, particularly when “symptoms” decrease or side effects are observed. Finally, non-drugging options, including “psychological support,” must be explored before psychotropic drugs are used.
The results of the California focused surveys demonstrate the potential strength and the weakness that have characterized the CMS national initiative to end antipsychotic misuse and improve dementia care in nursing homes. The surveys brought pointed investigation and considerable insight into each evaluation. Poor dementia care that had floated along as the acceptable community standard was held to account and exposed as the myopic, deflating failure that has plagued institutionalized care for decades.
On the other hand, no enforcement actions were taken despite the myriad regulatory violations that were uncovered, including many cited as causing harm to residents. This is typical. Abusive or dangerous drugging practices wielded against resident with dementia almost never lead to enforcement action. It’s nice that CMS took a thorough approach to reviewing dementia care being provided at a few nursing homes but can we expect better care when – even within this token approach – there are virtually no negative consequences for bad care? Over three years have passed since CMS announced its initiative. Millions of dollars have been spent to educate nursing homes on how to meet regulatory standards that have already been around for ages. When are they going to mean something?
To see the focused survey reports, click on the following: