Advocacy Alert Comments

INSTRUCTIONS TO SUBMIT COMMENTS ELECTRONICALLY:

1. Copy and paste the model comments into a new document. The document title may vary, we suggest including your organization name and the rule reference number. 
   (Ex: PioneerNetworkCMS2435P)
   
   
2. Include a paragraph describing your organization in the indicated area in the model comments (second paragraph)
   
   
3. Include your organization name and contact information at the end of the comments (indicated)
   
   
4. If possible (but not necessary), include on your letterhead with an electronic signature
   
   
5. Submit your comments to CMS through the link provided below (complete all required information on the submission page and attach your comments as a PDF or Word file using the function on the page)

[Insert organizational letterhead/logo]

August XX, 2010

Dr. Donald Berwick
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-2435-P
P.O. Box 8012
Baltimore, MD 21244-8012

RE: CMS-2435-P

Dear Dr. Berwick:

We appreciate the opportunity to comment on the Center for Medicare & Medicaid Services' (CMS) proposed rule 42 CFR Part 488 related to civil money penalties for nursing homes under the Medicare and Medicaid programs. We applaud Congress and the Administration's focus on promoting improvements in the health, safety and overall well-being of nursing home residents. We are pleased to provide input to help strengthen this proposal.

[Insert paragraph description of your organization here]

We strongly support the Department's overall goal of giving the CMS a more prominent role in directing quality improvement in nursing homes. We urge the Agency to prioritize culture change transformation in long term care settings as a successful quality improvement tool. Comments are organized around incorporating culture change transformation in CMS-led quality improvement initiatives. We recommend three changes to § 488.433 (Civil money penalties: Uses and approval of civil money penalties imposed by CMS) of the proposed rule:


We describe each specific recommendation below.

I. Increase the amount of civil money penalty funds directed to CMS

In accordance with § 6111 of the Affordable Care Act, the proposed rule would set aside a portion of civil money penalty funds to support activities that benefit nursing home residents. We urge the Agency to revise the proposed rule to increase the amount of civil money penalty funds that are directed to CMS for activities to protect or improve the quality of care for residents from 50 percent to 90 percent. We believe this division of funds more accurately reflects the focus and importance given to improving the health and well being of nursing home residents by Congress and the Administration, which is reflected in the Affordable Care Act.

As written, the proposed rule states: Fifty percent of the collected civil money penalty applicable to Title XVIII will be deposited with the Department of Treasury in accordance with § 488.422.

We urge the Department to revise this language to say: Ten percent of the collected civil money penalty applicable to Title XVIII will be deposited with the Department of Treasury in accordance with § 488.422.

II. Promote culture change as a successful strategy for improving nursing home quality

"Culture change" is the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected. Culture change transformation may require changes in organization practices, physical environments, relationships at all levels and workforce models. Culture change transformation leads to better health outcomes for consumers and direct care workers, and results in overall quality improvements in nursing home care.

We strongly encourage the Department to revise the proposed rule to promote evidence-based culture change in nursing homes as a strategy to improve nursing home quality. As written the proposed rule states: The remaining collected civil money penalty funds may not be used for survey and certification operations but must be used entirely for activities that protect or improve the quality of care for residents.

We recommend revising the language to say: The remaining collected civil money penalty funds may not be used for survey and certification operations but must be used entirely for evidence-based culture change transformation, and other activities that protect or improve the quality of care for residents.

In the Affordable Care Act and in other places, Congress and the Administration have signaled strong support of culture change in long term care. For example, Section 6114 of the Affordable Care Act includes a pilot project to develop best practices for nursing homes that are involved in the culture change movement. In order to advance important quality improvement initiatives we must ensure that funding streams are available. Section 6114 includes language concerning development of funding streams for culture change. Civil money penalty funds seem to be ideal for fulfilling this portion of the legislative mandate. Directing additional funds to CMS and promoting evidence-based culture change initiatives is consistent with Congress and the Administration's position, and will help to transform long term care and spur real improvements in quality and outcomes for residents.

III. Issue specific guidance requiring culture change to be incorporated into any quality improvement activities supported by civil money penalty funds

The proposed rule articulates several approved uses for civil money penalties and reiterates that CMS must approve other uses of these funds. We urge CMS to include a requirement that approval of quality improvement activities is dependent upon the inclusion of evidence-based culture change initiatives. We believe this will encourage more nursing homes to consider adopting culture change initiatives as they take steps to modernize and improve care for residents.

Specifically, we recommend creating a new subsection (f) in §488.433 where approved uses of civil money funds are described, to include:


As previously stated, culture change transformation leads to better outcomes for nursing home residents and direct care workers, which contribute to overall quality improvement. This requirement is consistent with Congress and the Administration's support of culture change and the priority given to nursing home quality initiatives. This is also consistent with the recommendations above, which encourage the Department to promote culture change as a means of quality improvement.

Again, we thank you for the opportunity to comment on the proposed notice. We offer our expertise and additional insight as you proceed and reiterate the importance of promoting effective strategies, like culture change, as we work towards improving nursing home care and quality for residents. If you wish to discuss any of these comments further, please do not hesitate to contact us.

Sincerely,

Name
Title
Organization
Contact Information

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