Nursing Homes: Opportunities Exist to Facilitate the Use of the Temporary Management Sanction
Highlights
The nation's 1.4 million nursing home residents are a highly vulnerable population of elderly and disabled individuals for whom remaining at home is no longer feasible. The federal government plays a key role in ensuring that nursing home residents receive appropriate care by setting quality requirements that nursing homes must meet to participate in the Medicare and Medicaid programs and by contracting with states to conduct routine inspections--called standard surveys--and complaint investigations. To encourage compliance with quality requirements, Congress has authorized certain enforcement actions, known as sanctions, such as civil money penalties or termination from participating in the Medicare and Medicaid programs. The Centers for Medicare & Medicaid Services (CMS) is responsible for imposing federal sanctions, typically on the basis of states' recommendations. One sanction--temporarily replacing a home's management--has been used infrequently. According to CMS guidance, temporary management may be used instead of termination in cases where nursing homes place residents at risk of death or serious injury--referred to as immediate jeopardy--or place residents at widespread risk of actual harm. CMS requires that a nursing home remove any immediate jeopardy within a short time frame of 23 calendar days after the survey or complaint investigation in which it was cited, with or without the assistance of temporary management. Otherwise, CMS will terminate the home from Medicare and Medicaid. In some cases, the nursing home's owner may choose to sell the home to a new owner while the home is still under temporary management. Congress was interested in information on why the temporary management sanction has been used infrequently to address nursing home quality problems and asked us to study this issue. Specifically, we focused on (1) CMS and states' experience with the use of federal temporary management and its effectiveness in achieving compliance in the short and longer term; and (2) obstacles to the use of federal temporary management and how such obstacles could be addressed. Congress also asked us to examine whether changes in ownership occurred when nursing homes were under federal temporary management and to identify obstacles to such ownership changes.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | To address obstacles to the use of the federal temporary management sanction, the Administrator of CMS should work with states to create and maintain a list or lists of qualified temporary managers on either a regional or national basis. | June 2011 - CMS discussed the recommendation with states and in March 2011 issued civil money penalty regulation permitting CMP moneys to be used for the "Development and maintenance of temporary management or receivership capability such as but not limited to, recruitment, training, retention or other system infrastructure expenses." However, as specified in Sec 488.415(c), a temporary manager's salary must be paid by the facility. (See 42 CFR 488.433(e).) In August 2011, agency officials also said they continue to facilitate State-Federal workgroup meetings to examine whether the temporary management sanction makes sense and, if so, whether it could be strengthened. CMS anticipated... having an update on the issue in the next few months.
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| Centers for Medicare & Medicaid Services | To address obstacles to the use of the federal temporary management sanction, the Administrator of CMS should work with states to develop additional information that identifies best practices for states and regional offices, including when and how to use the sanction, the essential qualifications for temporary managers, and alternative funding sources available for temporary management, such as civil money penalties funds. | September 2017: CMS developed training materials for State Agency Directors which includes guidance on when and how to use the temporary management sanction as well as links to existing guidance on essential qualifications for temporary managers. Specifically, the mandatory State Agency Director Orientation Course includes guidance and examples of when it is appropriate to impose a temporary manager, discussion of the kinds of problems that may be created by the temporary management requirement, and links to relevant sections of the CFR and State Operations Manual that provide temporary management guidance. In addition, CMS developed an eight module, web-based training course for...
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| Centers for Medicare & Medicaid Services | To help ensure the longer-term compliance of nursing homes that have successfully returned to substantial compliance under temporary management, the Administrator of CMS should develop guidance for states to enhance their oversight of such homes, such as implementing reactivation of temporary management if the home does not maintain substantial compliance over the 2 years following the conclusion of the sanction. | September 2018: CMS provided its FY2016 to 2017 Nursing Home Action Plan policy letter which included an Enforcement Strategic Plan that outlined action plan steps for improved enforcement actions, such as tracking of enforcement remedies through data reports, conducting quarterly calls with regional offices and states to discuss enforcement trends and improvement opportunities, providing additional web-based training for regional offices and states, and revising Chapter 7 of the State Operations Manual (SOM) to expand the circumstances where remedies must be imposed. While not specific to homes that have returned to substantial compliance under temporary management, these action plan...
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