CMS to Publish Proposed Rule Allowing LTC Pre-Dispute Arbitration Agreements as Condition of Admission

Today (June 8, 2017), CMS is publishing its proposed rule removing prohibitions against binding pre-dispute arbitration provisions in long-term care agreements.  On October 4, 2016, CMS published a final rule entitled “Reform of Requirements for Long-Term Care Facilities.” The final rule amended 42 C.F.R. 483.70(n) to prohibit LTC facilities from entering into pre-dispute arbitration agreements with any resident or his or her representative, or requiring that a resident sign an arbitration agreement as a condition of admission. The final rule required 1) that an agreement for post-dispute binding arbitration must be entered into by the resident voluntarily; 2) that the parties must agree on the selection of a neutral arbitrator; and 3) that the arbitral venue must be convenient to both parties. The arbitration agreement could be signed by another individual only if allowed under state law and all other requirements under the Federal Rule were met.  Particularly, a resident’s admission or right to remain at the facility could not be made contingent upon the resident or his or her representative signing an arbitration agreement.

However, in October 2016, the American Health Care Association and a group of affiliated nursing homes succeeded in obtaining a preliminary injunction in the United States District Court for the Northern District of Mississippi.  The district court held that the plaintiffs were likely to prevail in their challenge to the 2016 final rule. It concluded that it would likely hold that the rule’s prohibition against LTC facilities entering into pre-dispute arbitration agreements was in conflict with the Federal Arbitration Act (FAA), 9 U.S.C. 1 et seq. The court also reasoned that it was unlikely that CMS could justify the rule, or could overcome the FAA’s presumption in favor of arbitration, by relying on the agency’s general statutory authority under the Medicare and Medicaid statutes to establish rights for residents (sections 1891(c)(1)(A)(xi) and 1919(c)(1)(A)(xi) of the Act) or to promulgate rules to protect the health, safety and well-being of residents in LTC facilities (sections 1819(d)(4)(B) and 1919(d)(4)(B) of the Act).  CMS subsequently issued a nation-wide instruction on December 9, 2016, directing state survey agency directors not to enforce the 2016 final rule’s prohibition of pre-dispute arbitration provisions,  while the injunction remained in effect.

Under the recently announced policy change, CMS would retain provisions of the 2016 final rule related to protecting the interests of LTC residents, including the requirement that the agreement be explained to the resident and his or her representative in a form and manner that he or she understands. However, the proposed rule would remove the following:

  • the requirement at §483.70(n)(1) precluding facilities from entering into pre-dispute agreements for binding arbitration with any resident or resident’s representative;
  • the prohibition at §483.70(n)(2)(iii) banning facilities from requiring that residents sign arbitration agreements as a condition of admission to a facility;
  • certain provisions regarding the terms of arbitration agreements.

The proposed rule would retain the requirement that a copy of the signed agreement for binding arbitration and the arbitrator’s final decision must be retained by the facility for 5 years and be available for inspection upon request by CMS or its designee. Comments on the proposed rule must be received at CMS by 5:00 p.m. on August 7, 2017.

2016 Was a Busy Year: Developments in Nursing Facility Arbitration Law

Nursing home arbitration agreements get a bad rap. But as most practitioners in the field know, nursing facility arbitration agreements seem here to stay, at least (possibly) until recently.  Arbitration is thought by many to offer significant flexibility and efficiency vis-à-vis litigation, and proponents in the skilled nursing industry cite arbitration as an important tool to reduce litigation costs – including, of course, the costs associated with “runaway jury” punitive and noneconomic damages verdicts, which can be crippling to industry participants.

The enforceability of nursing facility arbitration agreements has long been a hotly contested issue.  It probably is fair to say that, in general, courts broadly view these agreements as enforceable in a vacuum, but they will approach any particular instance with a healthy degree of skepticism.  Occasionally, state courts have tried to go one step further than analyzing and rejecting nursing facility arbitration agreements on an ad hoc basis and have announced a per se rule against enforceability of such agreements.  That typically does not end well for those courts.

The relatively recent Marmet decision is a good example of this latter scenario.  There, the West Virginia Supreme Court issued a decision in a consolidated group of cases holding that pre-dispute nursing facility arbitration agreements were void as against public policy under state law  The decision was appealed to the U.S. Supreme Court, which granted certiorari and promptly slapped down the state court.  In a (relatively) scathing per curiam opinion, the Court emphasized:  “As this Court reaffirmed last Term, ‘[w]hen state law prohibits outright the arbitration of a particular type of claim, the analysis is straightforward:  The conflicting rule is displaced by the FAA.’  … That rule resolves these cases.  Since that decision, state courts seem to be somewhat more receptive to honoring and enforcing nursing facility arbitration agreements.

In 2016, however, federal regulators attempted to throw a curveball to the skilled nursing industry.  On September 28, 2016, the Centers for Medicare and Medicaid Systems (“CMS”) announced a new rule ostensibly intended “to make major changes to improve the care and safety of the nearly 1.5 million residents in the more than 15,000 long-term care facilities that participate in the Medicare and Medicaid programs.”  As part of this new rule, which would go into effect on November 28, 2016, CMS banned the use of pre-dispute arbitration agreements by nursing homes on a going-forward basis.  It noted that the rule did not apply to existing arbitration agreements (thus avoiding running afoul of the Federal Arbitration Act), and it specifically allowed nursing facilities and plaintiff-residents to agree to arbitrate after a dispute has arisen.  But the sort of prospective arbitration agreement that is presented to residents and potential residents at the time of admission would be prohibited from now on.  Although the rule technically only applied to nursing homes that accepted Medicare and Medicaid funds, as a practical matter, that included virtually all such facilities.

Needless to say, this was a controversial measure.  And the industry did not take it lying down.  On October 17, 2016, a group of trade organizations and nursing facility operators filed a lawsuit in the U.S. District Court for the Northern District of Mississippi challenged the pre-dispute arbitration rule.  On November 7, 2016, the court ultimately agreed with the challengers and entered an order preliminarily enjoining it.  It held in relevant part that a federal agency regulation effectively banning a certain type of arbitration agreement, even on a prospective-only basis, would be flatly inconsistent with the overarching pro-arbitration policy and purpose embodied by the FAA.  On December 9, 2016, CMS capitulated and sent a memorandum to Medicaid state survey administrators announcing that the rule should not be enforced unless and until the litigation was resolved and the injunction was lifted.  Especially in light of the change in administrations, the ultimate status of the pre-dispute arbitration rule is uncertain at best, and it is currently not being enforced.

So where does that leave nursing facility arbitration agreements?  Are facilities free to include them in admissions packets without fear that they will be unenforceable?  The answer to those questions necessarily is a qualified one.  Pre-dispute nursing home arbitration agreements still are not unenforceable per se, but at the same time, they will be looked upon with varying degrees of skepticism by courts.  As noted above, many post-Marmet state courts seem to have gotten the message that animus towards nursing home arbitration agreements will not be tolerated by the federal judiciary.  But “many” does not mean “all” (or even, necessarily, “most”), and there are still a number of states and jurisdictions in which courts appear likely to continue to go out of their way to find reasons as to why any particular arbitration agreement should not be enforced.

As such, it is crucial that any nursing facility or operator of facilities that wants to institute (or continue to use) an arbitration program go to great lengths to dot every “i” and cross every “t” when offering residents the opportunity to enter into an arbitration agreement.  This includes proactively reviewing the form arbitration agreement currently in use to ensure it complies with state contract law requirements, and training admissions staff so that the avoid typical pitfalls when presenting arbitration agreements to residents or prospective residents to sign (e.g., making sure that the resident has capacity to sign or that there is sufficient documentation for a representative to sign on behalf of that individual, making sure that the agreement is properly witnessed and countersigned, etc.).

Litigation over the arbitrability of a nursing facility dispute can itself be so costly and time-consuming that it removes many of the efficiencies and related advantages of arbitration. As is usually the case, it is best to try to address that potential issue on the front end of things.

 

CMS ISSUES CHANGES TO REQUIREMENTS OF PARTICIPATION AFFECTING LTC FACILITIES: ARBITRATION IS OUT—ARE WAIVER OF JURY TRIALS IN?

Effective November 28, 2016, long-term care facilities that participate in Medicare and Medicaid will no longer be able to enter into “pre-dispute” agreements for binding arbitration with their residents.  The Centers for Medicare & Medicaid Services (CMS) issued the final rule on September 28, 2016, after consideration of extensive comments from key stakeholders in the long-term care community regarding proposed revisions.

Under the rule, a facility can ask a resident or a resident’s representative to enter into an arbitration agreement after a dispute arises.  However, the facility must comply with several requirements, such as ensuring that the agreement provides for the selection of a neutral arbitrator and a venue convenient to both parties.  Further, a resident’s right to remain in the facility cannot be contingent upon entering into the arbitration agreement and the agreement cannot contain language that discourages communications with federal, state or local surveyors and other officials.

As one of the more controversial changes, critics of the new arbitration rule have reacted strongly against the change and have commented that this part of the rule “clearly exceeds” CMS’s statutory authority.  In its response to public comments, CMS explains that the Secretary of Health and Human Services has the authority to administer the program under the Social Security Act by setting general practice parameters for payment under Medicare and Medicaid.  CMS further cites to its authority to promulgate regulations for residents’ health, safety and well-being and states that there is “significant evidence that pre-dispute arbitration agreements have a deleterious impact on the quality of care for Medicare and Medicaid patients.”  Nevertheless, there are several legal bases upon which to challenge the agency’s ability to preclude an arbitration agreement.

While CMS’s comments cite to a resident’s waiver of the right to a jury trial as a major factor considered in its decision to disallow pre-dispute arbitration agreements, the final rule does not expressly preclude jury trial waiver provisions within facility admissions agreements.  Jury waivers may help to address runaway verdicts that have become a concern in negligence cases in past years, while still respecting expressed concerns that arbitration presents undue costs to residents and creates an environment of “secrecy.”  Note that state law may vary on whether such waivers are enforceable.

Also remarkable is CMS’s comment that it will not address waiver of class-action litigation in this rule, but rather reserve the issue for consideration during future rulemaking.

The broad-sweeping final rule also contains several other provisions that directly affect compliance programs, training of nursing staff, updating infection and control programs, and other key requirements that long-term care facilities must comply with in order to participate in the Medicare and Medicaid programs.  It is advisable for long-term care facilities to promptly consult with a knowledgeable healthcare attorney to assess modifications to admissions packets and to otherwise establish the framework necessary to comply with the revised Requirements of Participation.

CMS Releases Nursing Home Enforcement Information

On June 3, 2016, the Centers for Medicare and Medicaid Services (CMS) posted information about nursing home provider enforcement from 2006 to 2014 as part of the agency’s “ongoing efforts to ensure transparency, consistency of application of enforcement remedies, and data management to track enforcement actions across the nation.” The report includes general information about nursing home enforcement, frequently asked questions about enforcement, and enforcement reports detailing the distribution of federal enforcement remedies from 2006 to 2014.

The CMS enforcement reports provide information about CMS and state survey agency enforcement actions for all Health Inspection and Life Safety Code Standard and Complaint surveys from 2006 to 2014. The reports show the percent of providers with remedies in effect (rather than imposed) and detail civil monetary penalties by region, as well as the frequency of per day and per instance civil monetary penalties in effect. There is additional data on the number of facilities by region with the following enforcement remedies: denial of payment; discretionary and mandatory denial of payment for new admissions; directed in service training; directed plan of correction; termination; state monitoring; temporary management; transfer of residents; and facility closure.

The CMS report also discusses the impact of the recession that began in December 2007 and officially ended in June 2009. The period before the recession showed an increase in survey activities, initiatives, and deficiency citations, while there was a decline in overall survey activities and enforcement actions after the recession began.

CMS Proposes Rule Updating Nursing Home Conditions of Participation

On July 16, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a lengthy proposed rule revising the requirements that long term care facilities must meet to participate in the Medicare and Medicaid programs. This is the first comprehensive revision of long term care facilities’ conditions of participation since 1991. CMS states that it revised many of the requirements to reflect current clinical practice standards, noting that innovations in resident care and quality assessment practices have emerged since the last revision. Comments on the proposed rule will be accepted until 5 p.m. on September 14, 2015.

Some of the major provisions in the proposed rule include the following.

  • CMS proposes updating resident rights provisions, including addressing roommate choice. Under the proposed rule, a resident has the right to share a room with the roommate of his or her choice.The rooming arrangement could include a same-sex couple, siblings, other relatives, long term friends, or another combination as long as certain requirements are met.
  • The rule proposes a new section that focuses on facility responsibilities, bringing together many of the facility responsibilities dispersed throughout the current regulations. CMS proposes to revise visitation requirements to establish open visitation.
  • The rule would add a new section titled “Comprehensive Person-Centered Care Planning.” This proposal would require facilities to develop a baseline care plan for each resident within 48 hours of admission, which includes instructions about providing effective and person-centered care. This section also adds several other requirements, including expanding the required members of the interdisciplinary care team to add a nurse aide, a member of the food and nutrition services staff, and a social worker.
  • While CMS considered establishing minimum nurse hours per resident day, the proposed rule does not impose minimum staffing numbers or ratios. However, the proposed rule does include some new requirements related to staffing. The proposed rule adds a competency requirement for determining sufficient nursing staff based on a facility assessment. The facility assessment includes the number of residents, resident acuity, ranges of diagnoses, and care plan contents.
  • The proposed rule changes some pharmacy requirements. The rule proposes requiring a pharmacist to review a resident’s medical chart at least every six months when the resident is new, a prior resident returns or is transferred from a hospital or other facility, and during each monthly drug regimen when the resident has been prescribed or is taking a psychotropic drug, an antibiotic, or any drug the Quality Assessment and Assurance Committee has requested be included in the pharmacist’s month review. In addition, there are several proposed revisions to requirements regarding antipsychotic drugs, which the proposed rule revises to be referred to as psychotropic drugs, defined to include any drug that affects brain activities associated with mental processes and behavior.
  • The rule proposes specific requirements for binding arbitration agreements, including provisions to ensure that the agreement is voluntary, not permitting admission to be contingent on signing an arbitration agreement, and not allowing arbitration agreements to prohibit or discourage a resident or anyone else from communicating with federal, state, or local health care or health-related officials.
  • There are several new physical environment provisions in the proposed rule. CMS proposes that facilities certified after the effective date of the regulation accommodate no more than two residents in a bedroom and have a bathroom equipped with at least a toilet, sink, and shower in each room.
  • The proposed rule adds a new section on training requirements setting out all the requirements of an effective training program that facilities must develop, implement, and maintain.
  • There are also new provisions relating to laboratory, radiology, and other diagnostic services; dental services; food and nutrition services; food safety; specialized rehabilitative services; administration; quality assurance and performance improvement; and infection control.

U.S. Supreme Court Declines to Review Oklahoma Case Denying Arbitration in Wrongful Death Case

The United States Supreme Court refused to review a decision by the Oklahoma Supreme Court denying a nursing home’s request to arbitrate a wrongful death claim with a resident’s family members. Thus, the Oklahoma Supreme Court’s decision will stand: family members of a deceased nursing home resident will not be required to arbitrate because they did not sign the arbitration agreement in their personal capacities and their claim is not wholly derivative of the former resident’s claim. Most nursing home arbitration agreements have language stating that the agreement binds a resident’s spouse and heirs, whether or not any claims are brought on behalf of the resident, and that the agreement covers wrongful death claims. Whether or not a court will enforce a provision that heirs arbitrate claims has been the subject of much litigation.

In Boler v. Security Health Care, LLC, the Oklahoma Supreme Court examined cases from other jurisdictions that considered whether a decedent’s heirs are bound by an arbitration agreement signed by or on behalf of the decedent. The Oklahoma high court noted that in states that consider wrongful death actions to be independent and separate causes of action, courts are more likely to hold that beneficiaries are not bound by the arbitration agreement. In contrast, the Oklahoma Supreme Court noted, beneficiaries are more likely held to be bound by a decedent’s agreement to arbitrate in states where wrongful death actions are wholly derivative of the decedent’s claims. Noting that Oklahoma’s wrongful death act created a new cause of action for the losses of the deceased’s spouse and next of kin and that recovery does not go to the estate of the deceased, the Oklahoma Supreme Court explained that wrongful death claims in Oklahoma are not wholly derivative claims. Thus, the court held that a decedent cannot bind beneficiaries to arbitration.

Colorado has taken a different approach from Oklahoma even though Colorado’s wrongful death act also creates a separate cause of action. Colorado’s Supreme Court did not analyze whether a wrongful death claim is wholly derivative or not in deciding whether a decedent can bind his or her heirs to arbitration. Instead, Colorado’s high court in Allen v. Pacheco turned to contract law. Thus, the court examined whether the parties intended to bind a spouse to arbitrate a wrongful death claim. Examining the plain language of the arbitration agreement, the court concluded that the agreement required a spouse to arbitrate her wrongful death claim.

While there is no way to guarantee that a court will enforce an arbitration agreement, this discussion illuminates the importance of knowing the nuances of arbitration case law in order to draft the strongest arbitration agreement possible. It is also advisable to review arbitration agreements periodically to determine whether they should be modified due to developments in the law, particularly evolving case law.

CMS Continues Focus on Dementia Care in Nursing Homes

The Centers for Medicare and Medicaid Services (CMS) continues its focus on dementia care in nursing homes, particularly the overuse of antipsychotic medications. Several years ago, CMS partnered with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve comprehensive dementia care. According to CMS, by 2014 nursing homes achieved a 19.4 percent reduction in antipsychotic drug use, exceeding the first year goal of a 15 percent reduction.

CMS announced in recent surveyor guidance that more needs to be done to address issues relating to the care of nursing home residents with dementia. In addition, CMS stated that the agency and the organizations participating in the partnership announced a new goal to achieve a 30 percent reduction in the use of antipsychotic drugs in nursing homes nationwide by the end of 2016. See Survey and Certification Letter: 15-31-NH.

In fiscal year 2014, CMS invited states to participate in focused pilot surveys related to dementia care. Five states participated in the pilot: California, Minnesota, New York, Illinois, and Louisiana. Each state completed one observational visit and four focused surveys. The purpose of the pilot study was to more thoroughly examine the prescription of antipsychotic medications, assess compliance with federal regulations relating to dementia care in nursing homes, and give insights about survey issues relating to dementia care in order to modify the survey process.

CMS announced that it plans to expand the dementia survey pilot project to additional states during 2015. States may volunteer to use the revised dementia survey tools. According to CMS, the 2015 expanded survey project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications than the 2014 pilot project.

Although CMS has not expanded dementia focused surveys nationwide, the new pilot project indicates the agency’s continued focus on dementia care in nursing homes. Whether or not your state takes part in the expanded pilot project, antipsychotic drug use is examined during the regular survey process. In addition, antipsychotic drug use was added in February 2015 to the algorithm used as part of each nursing home’s quality measure score in the CMS Five Star Rating System that is part of the Nursing Home Compare website. Thus, nursing homes should examine their dementia care, particularly the use of antipsychotic drugs.

Developing a New Way to Detect Pressure Ulcers

Hospitals and nursing homes frequently encounter patients and residents with or at risk of developing pressure ulcers.  Although hospitals and nursing homes make great efforts to prevent pressure ulcers from developing or worsening, there is no method to detect early tissue damage before it is visible. However, interesting new research may develop in to a promising way to confront the challenges of pressure ulcer prevention.

Researchers at the University of California—Berkeley and the University of California—San Francisco have developed an automated sensing device to detect pressure ulcers before they are visible. This early warning device could assist treatment of high risk patients. The automatic sensing device—dubbed a “Smart Bandage”—uses electrical currents to detect early tissue damage from pressure ulcers before they are visible and when early intervention is possible. The Smart Bandage has electrodes that are printed on to a piece of plastic that measure the strength of the electrical signals on the skin. Detecting the change in electrical resistance that occurs when a pressure ulcer has started to form but is not yet visible will allow early detection and treatment of pressure ulcers. According to an article recently published in the journal Nature Communications, the device was tested on a rat model and demonstrated the feasibility of a Smart Bandage for early detection of pressure ulcers.

The Smart Bandage is an interesting development for health care facilities that treat patients or residents who are at risk for pressure ulcers. Pressure ulcers are particularly challenging for nursing homes and are the focus of the Centers for Medicare and Medicaid Services’ (CMS) quality measures rating system for nursing homes. Pressure ulcers are also often a focus of patient or resident litigation against a health care facility. The Smart Bandage could greatly assist health care providers in the challenge of preventing and treating pressure ulcers.

CMS Updates Nursing Home CPR Guidance

HC BLOG_CPROn January 23, 2015, the Centers for Medicare and Medicaid Services (CMS) revised surveyor guidance regarding Cardiopulmonary Resuscitation (CPR) in nursing homes.  The guidance clarifies a facility’s obligation to provide CPR.  CMS requires that nursing home staff maintain current CPR certification through a CPR provider whose training includes hands-on practice and in-person skills assessment.  Online-only certification is not sufficient.  However, the program may have an on-line knowledge component if it also requires an in-person demonstration or skills assessment to obtain certification or recertification.

The revised  surveyor guidance also incorporates CMS’ prohibition against a facility-wide “no CPR” policy because this may prevent implementation of a resident’s advance directives and does not meet the quality standards found in 42 C.F.R. § 483.20(k).  If a resident experiences a cardiac arrest and does not show obvious signs of clinical death, facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the resident’s advance directives or in the absence of any advance directives or a Do Not Resuscitate Order.   Finally, the guidance reiterates CMS’ requirement that CPR certified staff must be available at all times.

CMS Changes Nursing Home Rating System

The Centers for Medicare and Medicaid Services (CMS) announced that it will reveal its new Nursing Home Compare 5-Star Quality Rating System to the public on February 20, 2015.   CMS will change its ratings to raise the bar for achieving a high rating in the Quality Measures category.  Thus, ratings will likely fall for many nursing homes even though there has been no change in the quality of care.

CMS is raising the standards for nursing homes to achieve a high rating in the Quality Measures category by increasing the numbers needed to achieve a particular star category.  According to CMS, in 2008 the initial scoring for the Quality Measures rating was set at a distribution that reflected the status quo with the expectation that there would be progress and changes to the quality measures thresholds over time.  When nursing homes have made progress in raising performance standards, CMS resets the distribution to promote further progress.

In addition to raising performance expectations, CMS is making the following changes to the 5-star rating system:

  • Additional Quality Measures:  CMS added two additional quality measures for antipsychotic medication use in nursing home residents without diagnoses of schizophrenia, Huntington’s disease, or Tourette syndrome.
  • Staffing Algorithms:  CMS adjusted these measures to more accurately reflect staffing levels.
  • Survey Expansion:  CMS announced a plan for State Survey Agencies to conduct specialized, onsite surveys of a sample of nursing homes in the country to assess the adequacy of resident assessments and the accuracy of information reported to CMS that is used to calculate quality measures.

These changes to the 5-Star Quality Rating System are the third major revision to the Nursing Home Compare website since it was launched in 1998.  CMS says that a fourth change is scheduled for 2016.