Health Facility Evaluation and Quality Improvement September 21, 2010
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Health Facility Evaluation and Quality Improvement
September 21, 2010
““The Indiana State Department of Health supports Indiana’s The Indiana State Department of Health supports Indiana’s economic prosperity and quality of life by promoting, protecting, economic prosperity and quality of life by promoting, protecting,
and providing for the health of Hoosiers in their community.”and providing for the health of Hoosiers in their community.”
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Outline
• Nursing Home Evaluation Process and Quality Measures
• Healthcare Quality Improvement Initiatives and Their Outcomes
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Indiana Nursing Home Evaluation Process and Quality Measures
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Overview of Long Term
Care Facilities
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Overview of Indiana Long Term Care Facilities
Long Term Care Facility Types Comprehensive care facility – nursing home
– Skilled nursing facility (SNF)– Nursing facility (NF)– Non-certified comprehensive care (State only)– Residential care beds
Residential care facility Assisted living facility Intermediate care facility for the developmentally disabled
(ICFDD) – group home
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Overview of Indiana Long Term Care Facilities
Number of Indiana Long Term Care Facilities
Certified comprehensive care facilities (nursing homes) – 502 facilities
Non-certified comprehensive care facilities - 3
Comprehensive care facilities with residential care beds – 110
Freestanding residential care facilities – 109
Source: ISDH Data September 2010
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Overview of Indiana Long Term Care Facilities
Indiana Long Term Care Beds
Certified comprehensive care facilities (nursing homes) – 48,636 comprehensive care beds
Certified comprehensive care facilities with residential care beds – 8,256 residential care beds
Non-certified comprehensive care – 1165 comprehensive beds Non-certified with residential beds – 304 residential care beds Freestanding residential care facilities – 8,861 residential beds Total residential beds: 17,421 beds
Source: ISDH Data September 2010
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Survey Process and Findings
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Overview of Nursing Home Survey Process
Survey Frequency
State licensing and federal certification surveys conducted every 9-15 months– Indiana has met that standard
State and federal complaint survey conducted for all complaints based on a priority tier – Indiana has met that standard
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Overview of Nursing Home Survey Process
Number of Nursing Home
Surveys Completed (2009)
Number of Annual Licensing / Certification Surveys (2009) – 533
Number of Complaint Surveys (2009) – 1,459 Number of Annual Life Safety Code Surveys
(2009) – 533
Source: CMS Casper Report
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Indiana Nursing Home Survey Findings
Most Cited Deficiencies (2010) F282: Services provided by qualified persons in
accordance with care plan – 43% of providers F323: Facility is free of accident hazards – 33% F272: Comprehensive assessments – 33% F514: Clinical records – 29% F157: Inform of significant changes – 28% F441: Infection control – 25%
Source: CMS Casper System
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Indiana Nursing Home Survey Findings
Most Cited Immediate Jeopardies (2010) F323: Facility is free of accident hazards – 5 F224: Facility prohibits abuse, neglect – 3 F441: Infection control – 2 F225: Facility does not employ persons guilty of abuse – 2 F314: Pressure ulcers – 2 F223: Residents right to be free from abuse – 2
Source: CMS Casper System
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Indiana Nursing Home Survey Findings
Outcomes: Deficiency free surveys
2005: 47 facilities 2006: 47 facilities 2007: 51 facilities 2008: 59 facilities 2009: 57 facilities 2010: 66 facilities (through Sept. 13)
Source: CMS OSCAR quarterly reports
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Indiana Nursing Home Survey Findings
Outcomes: Deficiency free surveys (% of facilities with no deficiencies)
Indiana Region V National
Q4 2006: 10.60% n/a 8.20% Q4 2007: 11.70% 10.41% 8.30% Q4 2008: 10.78% 9.09% 7.60% Q2 2009: 12.25% 8.77% 7.83%
Source: OSCAR quarterly reports
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Indiana Nursing Home Survey Findings
Outcomes: Immediate jeopardy findings
2006: 91 – Indiana 3rd highest 2007: 106 – Indiana 5th highest 2008: 76 - Indiana 13th highest (68 surveys) 2009: 46 – Indiana 17th highest (35 surveys) 2010: 25 (through September 13)
Source: CMS CASPER data
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Indiana Nursing Home Survey Findings
Outcomes: Immediate jeopardy findings(% of facilities with IJ)
Indiana Region V National
Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89%
Source: OSCAR quarterly reports
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Indiana Nursing Home Survey Findings
Average Number of Deficiencies Per Survey Indiana Region V National
2006: 1.7 1.5 1.5 2007: 2.7 2.4 2.0 2008: 3.0 2.5 2.1 2009: 2.7 2.5 2.1 2010: 2.5 2.2 2.0
Source: OSCAR quarterly reports through Sept 13, 2010
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Indiana Nursing Home Survey Findings
Data Variability Between States
Percent of surveys timely completed Whether state citing all deficiencies Whether citing associated tags
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Indiana Nursing Home Survey Findings
Differences in Surveys BetweenProvider Types Acute Care
– Compliance based on status at time of survey– Regulations based on facility policy
Long Term Care– Compliance determination goes back to previous
annual survey– Regulations based on descriptive requirements
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Indiana Nursing Home Survey Findings
Reporting of Survey Findings
ISDH Nursing Home Consumer Report– All survey reports and plan of corrections will be
added in 2010 to Consumer Report
CMS Nursing Home Compare
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Healthcare Quality Issues Identified Through the Survey Process
Common Root Causes
Appropriate admissions / placement Timely and accurate assessments Care transition and coordination Staff education, training, & sufficiency Negative health care culture
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Healthcare Quality Issues Identified Through the Survey Process
Quality of Care Issues Pressure ulcers Healthcare associated infections Medication errors / patient safety Falls / wandering Behavior management Abuse and neglect
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Health Care Staffing
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Staffing
Staffing Initiatives
Leadership Conference
Staffing Strategies
September 17, 2009 (funded by Civil Money Penalty Fund)
Staffing Study of Long Term Care Facilities (funded by the ISDH Civil Money Penalty Fund)
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Staffing
2009 Long Term Care Staffing Study
Number of administrator changes per facility over past three years – 2.5
Number of director of nursing changes per facility over past three years – 2.8
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Staffing
2009 Long Term Care Staffing Study
Turnover rate for Registered Nurses (RN) – 74.1% (46% nationally)
Turnover rate for LPN – 67% (43% nationally)
Turnover rate for certified nurse aides (CNA) – 98.1% (64% nationally)
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Staffing
ISDH Senior Staffing for Survey Program
Three Division Directors (Acute Care, Health Care Education, Long Term Care) and all seven long term care area supervisors are new within the past three years
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CMS Quality Indicator
Survey System
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Health Care Survey System
Survey Program Quality Improvement
Implement CMS Quality Indicator Survey (QIS) system – Kick-off for QIS system occurred in August 2010– Training of surveyors for QIS surveys to begin in
January 2011
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ISDH Healthcare Quality Improvement Initiatives
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Goals
Promote health care quality and health literacy through educational initiatives
Increase public awareness and focus on a state health issues
Protect the public through oversight of quality of care provided by health care facilities
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Healthcare Quality Improvement Principles
Principles for Improvement
Summarize evidence into checklistsIdentify and mitigate local barriers to
implementationMeasure performanceEnsure all patients reliably receive the
intervention
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Healthcare Quality Competing Interests
OUTCOMESScientificFoundation
Regulatory
Feasibility
Health Care Culture
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SUCCESSFUL AGING
Rowe & Kahn, 1998
AVOIDING DISEASE
&DISABILITY
MAINTAININGHIGH
COGNITIVE& PHYSICAL
FUNCTIONING
ENGAGEMENTWITHLIFE
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Quality Improvement Themes
Evidence-based
System-based
Incorporate care coordination principles
Incorporate assessment tools
Incorporate culture change principles
Include patient and family centered care principles
Measurable outcomes
Plan for continuity after the initiative
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Indiana Health Care Quality Improvement Initiatives
Survey-based Initiatives
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Survey-based Initiatives
CMS Special Focus Facility Program– Adding a facility in October 2010– Will be five special focus facilities– Funded by CMS and state funds
ISDH Consultant Program– Offered to facilities with substandard quality of care findings– Funded through ISDH Civil Money Penalty Fund
CMS Critical Need Nursing Home Project (Through Quality Improvement Organization – Health Care Excel)– Pilot program for 4-5 facilities in northwest Indiana– Funded by CMS grant to Health Care Excel
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Indiana Health Care Quality Improvement Initiatives
Addressing Immediate Jeopardy Level Deficiencies
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Improving Survey Findings
The Challenge
In 2007, Indiana had the 5th highest number of immediate jeopardy findings on nursing homes surveys
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Improving Survey Findings
Quality Improvement Activities
Monthly meetings with provider associations to review findings
Quarterly meetings with advocate organizations to discuss quality of care concerns
Collaborative quality improvement initiatives with healthcare organizations
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Improving Survey Findings
Quality Improvement Activities: CMS and ISDH consistency workgroups
Review of all immediate jeopardy findings by provider associations
ISDH implemented a biweekly long term care newsletter in January 2008 (funded through ISDH Civil Money Penalty Fund)
Implemented collaborative healthcare quality improvement initiatives
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Indiana Nursing Home Survey Findings
Outcomes: Immediate jeopardy findings
2006: 91 – Indiana 3rd highest 2007: 106 – Indiana 5th highest 2008: 76 - Indiana 13th highest (68 surveys) 2009: 46 – Indiana 17th highest (35 surveys) 2010: 25 - Through September 13
Source: CMS CASPER data
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Indiana Nursing Home Survey Findings
Outcomes: Immediate jeopardy findings(% of facilities with IJ)
Indiana Region V National
Q4 2006: 4.50% n/a 2.20% Q3 2007: 5.64% 3.36% 2.17% Q2 2008: 5.08% 3.75% 2.58% Q2 2009: 2.77% 3.23% 2.89%
Source: OSCAR quarterly reports
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Indiana Health Care Quality Improvement Initiatives
Indiana Healthcare
Leadership Conferences
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Healthcare Quality Leadership Conferences
Joint conferences for long term care providers, organizations, associations, and surveyors
Two conferences per year Each conference covers one topic Conferences serve as kick-off for quality
improvement initiatives Funded through the ISDH Civil Money Penalty
Fund
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Healthcare Quality Leadership Conferences
Previous Conferences June 2007: Falls October 2007: Pressure ulcers March 2008: Restraints and behavior management September 2008: Emergency preparedness March 2009: Incontinence September 2009: Staffing March 2010: Healthcare Associated Infections
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Healthcare Quality Leadership Conferences
Planned Conferences
Alzheimer’s and Dementia Care – October 14, 2010 Nutrition and Hydration – March 31, 2011 Abuse and Neglect – Fall 2011 Patient Safety / Medical Errors – Spring 2012
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Healthcare Quality Leadership Conferences
Conference Checklist Attend conferences
Use information and resources to develop education and training program in facility
Implement quality improvement project in facility
Celebrate quality accomplishments
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Indiana Health Care Quality Improvement Initiatives
Indiana Pressure Ulcer Initiative
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Indiana Pressure Ulcer Initiative
Participating Facility and Agencies
Phase 1 Phase 2 Total
Home Health / Hospice 27 13 40 Hospitals 41 7 48 Nursing Homes 94 62 156 Totals 162 82 244
Funded through ISDH Civil Money Penalty Fund
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Indiana Pressure Ulcer Initiative
Indiana incidence of pressure ulcers in long term care facilities
– Q4 2003 – 9.5% (Ranked 36th in US)– Q4 2004 – 9.2%– Q4 2005 – 8.6%– Q4 2006 – 8.4%– Q4 2007 – 8.1%– Q4 2008 – 8.3% (Ranked 36th in US)
Source: CMS GPRA Data
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Indiana Pressure Ulcer Initiative
Initiative Components
Three In-person Learning Sessions Toolkits Six Online education modules –
www.in.gov/isdh/24558.htm Consumer brochure
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Indiana Pressure Ulcer Initiative
Initiative Outcomes: Pressure UlcerRates for all Indiana Nursing Homes
Q1 2008: 8.5% (34th) Q4 2008: 8.3% (36th) Q1 2009: 8.0% (29th) Q2 2009: 7.6% (28th) Q3 2009: 7.3% (26th)
Source: CMS GPRA Data
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Indiana Pressure Ulcer Initiative
Initiative Outcomes: Number of NursingHome Residents with a Pressure Ulcer Q1 2008: 2992 Q3 2008: 2867 Q4 2008: 2899 Q2 2009: 2618 Q3 2009: 2506 Q4 2009: 2664 Q1 2010: 2574 - 14% Statewide Decrease
from Q1 2008Source: CMS GPRA Data
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Indiana Pressure Ulcer Initiative
Initiative Outcomes: One Year CostSavings for Indiana Nursing Homes
300-400 fewer pressure ulcers per quarter
Average cost of over $10,000 per pressure ulcer to heal
For 300 residents, savings of over $12 million in one year
Source: CMS GPRA Data
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Indiana Pressure Ulcer Initiative
Initiative Outcomes: One Year CostSavings for One Unit of One Hospital 2008: 14 pressure ulcers with some stage 3 or 4
2009: 0 pressure ulcers
Average cost of over $30,000 per pressure ulcer to heal
For 14 patients at one hospital, savings of over $420,000 over one year
Source: CMS GPRA Data
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Indiana Pressure Ulcer Initiative
Pressure Ulcer Deficiencies
Year Deficiencies Immediate Jeopardies
2007 195 182008 186 52009 157 42010 96 2 (to Sept. 13)
Source: CMS CASPER Data
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Indiana Health Care Quality Improvement Initiatives
Indiana Healthcare Associated Infection Initiative
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Indiana Healthcare Associated Infection Initiative
Infection Control Deficiencies
Year Deficiencies Immediate Jeopardies
2009 170 02010 137 2 (to Sept. 13)
Source: CMS CASPER Data
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Indiana Healthcare Associated Infection Initiative
Healthcare Associated Infections
Catheter associated bloodstream Catheter associated urinary tract Clostridium difficile Methicillin-resistant Staphylococcus aureus
(MRSA) Surgical site Ventilator associated pneumonia
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Indiana Healthcare Associated Infection Initiative
Indiana will focus on two infections
Catheter associated urinary tract infections
Clostridium difficile infections
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Indiana Healthcare Associated Infection Initiative
Goals of Initiative
Develop a state infection plan
Develop and implement an infection surveillance system
Implement a prevention initiative focusing on two of the infections
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Indiana Healthcare Associated Infection Initiative
Participating Facilities
Ambulatory Surgery Centers - 3 Dialysis (ESRD) Clinics - 2 Home Health and Hospice Agencies - 13 Hospitals - 48 Nursing Homes - 134
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Indiana Healthcare Associated Infection Initiative
Initiative Funding
Centers for Disease Control and Prevention (CDC) Grant
ISDH Civil Money Penalty Fund
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Indiana Health Care Quality Improvement Initiatives
Reducing Restraints
CMS GPRA Target
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Restraint Reduction in Nursing Homes
CMS GPRA Restraint Data
Q4 2003: 6.2% (27th rank) Q4 2004: 5.8% (26th) Q4 2005: 5.8% (30th) Q4 2006: 5.4% (30th) Q4 2007: 4.4% (32nd)
Source: CMS GPRA Data
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Restraint Reduction in Nursing Homes
Quality Improvement Activities
ISDH Leadership Conference on Restraint Reduction in March 2008 (funded by ISDH Civil Money Penalty Fund)
Quality Improvement Organization (QIO) focus on restraint reduction (funded by CMS)
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Restraint Reduction in Nursing Homes
CMS GPRA Restraint Data
Q1 2008: 4.0% (32nd rank) Q2 2008: 3.6% Q4 2008: 3.1% (27th) Q1 2009: 2.8% Q4 2009: 2.3% (22nd) Q1 2010: 2.2%
Source: CMS GPRA Data
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Other Civil Money Penalty Fund Quality Improvement Initiatives
Alzheimer’s and Dementia Care Initiative– Development of 10 education modules– Creation of Alzheimer’s and Dementia
Certification Program– Provided scholarships
Bladder Scanner Study for Incontinence Care
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Quality Improvement Initiatives in Progress
Aide Curriculum Review ProjectHealthcare Quality Resource CenterImplementation of New Regulations
– Life safety code– Infection control – Sept 2009
Implementation of MDS 3.0Care Transition and Coordination
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Indiana Health Care Quality Improvement Initiatives
Medical Error Reporting System
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Indiana Medical Error Indiana Medical Error Reporting SystemReporting System
Based on National Quality Forum’s 27 (now 28) reportable events
In 2002 NQF identified 27 events that are serious, largely preventable, and of concern to the public and providers
Indiana was the second state to use these reporting standards
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Indiana Medical Error Reporting System
Most Reported Events
Stage 3 or 4 pressure ulcers acquired after admission
Retention of a foreign object in patient after surgery
Surgery performed on the wrong body part
Death or serious disability associated with a medication error
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Indiana Medical Error Reporting System
Outcomes Pressure ulcer data as top reportable event
resulted in Indiana Pressure Ulcer Initiative and decrease in pressure ulcers
Increased awareness of medical errors Allocation of resources to patient safety Increase in number and activity of state and
regional patient safety coalitions
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Indiana Health Care Quality Improvement Initiatives
Patient Protection and Affordable Care Act
- Long Term Care Initiatives
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Affordable Care Act Initiatives
Affordable Care Act Includes NursingHome Quality Improvement Activities
Facilities required to implement a Quality Assurance & Performance Improvement Program (QAPI)
Posting of survey reports and plan of corrections on consumer-oriented Website
Disclosure of ownership
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Affordable Care Act Initiatives
Affordable Care Act Includes NursingHome Quality Improvement Activities
CMS Nursing Home Compare to include criminal violations
Improved reporting of staffing
Sanctions for inadequate notice of facility closure
Reduced civil money penalties for some self-reported deficiencies