News: CMS Investigates Schizophrenia Diagnoses & Antipsychotics

Utilizing quality measures (QMs) in nursing home ratings has been at the forefront of the Centers for Medicare & Medicaid Services’s efforts to track and encourage quality care within nursing homes across the country. However, this system relies on self-reporting and has the capacity for error when it comes to reported diagnoses. Recently, CMS has noted a possible loophole for nursing facilities when it comes to schizophrenia diagnoses and reporting the usage of antipsychotics among their residents. As a result, CMS is conducting audits of select nursing homes to determine if self-reported numbers are correct, or if unnecessary antipsychotic drugging is being hidden behind schizophrenia diagnoses.

Schizophrenia in Nursing Homes

Comparatively, schizophrenia is one of the rarest mental disorders. On average, schizophrenia affects about 0.3-0.7% of people around the world. That’s only about 21 million people total. However, one in nine nursing home residents has been reportedly diagnosed with schizophrenia. A number that does not sit right with CMS.

“Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.”

Katie Thomas, Robert Gebeloff and Jessica Silver-Greenberg, The New York Times

Most recently, CMS noted that a number of nursing homes have reported schizophrenia diagnoses as well as a low number of antipsychotic prescription. While low antipsychotics use is a good thing, when paired with higher rates of schizophrenia, it is possible that a loophole in the CMS reporting system is being abused. Even worse, it could mean the problem of antipsychotic over-usage has not been solved after all. 

Self-Reporting Loophole

The way CMS has set up their QMs rating system does not require facilities to include the use of antipsychotics for schizophrenic patients as part of their overall antipsychotic usage. Steps have been taken to dissuade the use of antipsychotics among nursing home residents, but a recent study found schizophrenia diagnoses have increased exponentially, and seemingly without explanation. The question is then, are nursing homes using schizophrenia as a way to hide their use of antipsychotics? In other words, are residents still being unnecessarily chemically restrained?

“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.”

The Consumer Voice

The Audit

According to the official CMS memorandum on the audits, they conducted similar investigations in 2016. These audits were conducted as onsite surveys to investigate erroneous schizophrenia coding that would explain the increase in diagnoses. They found erroneous coding in multiple facilities which has ultimately led to their latest move to audit all facilities. CMS will be looking for the appropriate “documenting, assessing, and coding a diagnosis of schizophrenia in the MDS for residents in a facility.” 

Pilot audits already conducted by CMS found inaccurate coding, insufficient diagnostic procedures, and an absence of comprehensive documentation and evaluations. All of this leads CMS to believe that continued antipsychotic use has been masked by schizophrenia diagnoses, resulting in the chemical restraint of hundreds of residents against their will and without proper procedure. 

Facilities targeted for auditing will receive notice from CMS as well as instructions. They’re also allowed to ask questions during the audit, and will have a chance to discuss the audit results with CMS at the end. Additionally, any facility found to have inaccuracies will have their quality measures rating adjusted as follows:

• The Overall QM and long stay QM ratings will be downgraded to one star for six months (this drops the facility’s overall star rating by one star).

• The short stay QM rating will be suppressed for six months.

• The long stay antipsychotic QM will be suppressed for 12 months.

Why This Matters

Put simply, this matters because it is a major part of nursing home transparency and quality of care standards. No resident should be subjected to unnecessary chemical restraint via antipsychotics and it is illegal to do so. Residents and their families should be aware of this issue and adamant about receiving proper evaluations and medical advice when it comes to medication, especially antipsychotics. Especially because antipsychotics can lead to the loss of independence, over-sedation, confusion, increased respiratory infections, falls, and strokes. Essentially, the use overuse of antipsychotics is a hidden abuse that nursing homes and care facilities should not get away with.

If you or a loved one has been the victim of nursing home abuse or neglect, call Gharibian Law (877-875-1119) today for a free consultation and the best legal representation.