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New Enforcement Initiatives in Dementia Care Could Affect SNFs' Five-Star Rating

New Enforcement Initiatives in Dementia Care Could Affect SNFs' Five-Star Rating

On March 27, 2015, the Centers for Medicare and Medicaid Services (“CMS”) announced the next phase of its ongoing initiative to improve dementia care in SNFs. CMS is inviting states to volunteer for the next phase of its focused Dementia Care Survey pilot project, to be conducted in FY2015. California plans to participate.

CMS also announced the addition of two new measures of antipsychotic use to the algorithm it uses to calculate each facility's quality measure score under the controversial yet influential CMS Five Star Quality Rating System.

CMS first launched the National Partnership to Improve Dementia Care in Nursing Homes in 2012. One of its primary goals was to improve and expand the use of non-pharmacological approaches to care and reduce antipsychotic medication use in long-stay nursing facility residents. CMS documented a 19.4 percent reduction in antipsychotic drug use in United States nursing facilities by the end of 2014; its goal by the end of 2016 is a 30 percent reduction. As a part of this initiative, CMS is piloting focused Dementia Care Surveys to develop surveyor tools, training, and guidance on issues related to the unique requirements of dementia care.

The voluntary pilot Dementia Care Surveys to be conducted in FY2015 will employ survey tools recently revised by CMS. During a pre-pilot development phase, CMS developed Dementia Care Survey worksheets and process materials based on input from surveyor, clinical, and industry sources. These materials were first tested in three facilities in one state, and revised based on that experience. During the FY2014 phase of the Dementia Care Survey pilot, CMS selected five volunteer states (California, Minnesota, New York, Illinois, and Louisiana) to test new surveyor worksheets and processes focused on dementia care in nursing facilities. Once selected, these states received revised versions of the new Dementia Care surveyor worksheets. CMS held a one-hour joint training session with all five states, along with individual follow-up calls with each state to address questions. An experienced CMS consultant accompanied each volunteer state’s survey team on its first focused Dementia Care survey.

During the first phase of the Dementia Care Survey pilot, the most commonly cited tags were F309 (Care of a Resident with Dementia), F329 (Unnecessary Use of Medications), F520 (Quality Assessment and Assurance), and F279 (Develop Comprehensive Care Plans). Few citations reached an actual harm level (G or above) due to surveyors' difficulty linking  the use of antipsychotic medications with actual harm.

In its March 27, 2015 announcement, CMS noted that it had added two measures of antipsychotic use to the algorithm it used to calculate facilities’ five-star ratings on February 13, 2015. One measure focuses on long stay residents, the other on short-stay residents. Both measures were previously reported on the CMS website, but they were not used in calculating a facility’s quality measure or overall quality ratings.  The recent link to the Five-Star System is designed to capture nursing facilities' serious attention.

Based on these results, and given increased surveyor focus on the use of medications in dementia care, nursing facilities should strongly consider evaluating their residents receiving dementia care for treatment alternatives to antipsychotic medication. They should also perform focused assessments of their compliance with tags F309 (Care of a Resident with Dementia) and  F329 (Unnecessary Use of Medications) in particular.  It may be appropriate to engage third-party consultants to perform this analysis. 

CMS plans to conduct a conference call in early summer for state agencies interested in discussing and participating in the FY2015 expansion of the Dementia Care survey pilot. CMS will also provide webinar training for state agencies participating in the pilot. To request more information from CMS regarding this survey pilot, contact Michele Laughman via email at  

Additional information regarding data collected by the National Partnership can be found at

Please do not hesitate to contact the authors if you have any questions.

For More Information, Please Contact:

Pamela Kaufmann
Pamela Kaufmann
San Francisco, CA