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Recent OIG Actions Demonstrate Increased Scrutiny of Nursing Facilities

11.30.2018

Recent developments by the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) highlight the increase in scrutiny of nursing facilities. In addition to a topic added in August, the OIG recently updated its Work Plan in November to add another topic focusing on nursing facilities that receive Medicare and Medicaid reimbursement. The Work Plan describes new and ongoing OIG audits and evaluations for DHHS programs and operations, including Medicare and Medicaid. The release of an update provides an opportunity for nursing facilities to review their own operations and practices in order to identify areas for compliance improvement.

The active OIG Work Plan previously identified several risk areas for Skilled Nursing Facilities and Nursing Facilities in the Medicare and Medicaid programs. Those areas already under review include: oversight of nursing facility staffing levels; unreported incidents of potential abuse and neglect; facility reimbursement; prospective payment system requirements; and potentially avoidable hospitalizations of nursing facility residents.

In November, the OIG added a new topic to the Work Plan focusing on the involuntary transfer and discharge of nursing home residents. The OIG notes data from the Long-Term Care Ombudsman Program that shows complaints related to discharge and eviction are noted more frequently than any other issue. This is an area of concern to the Centers for Medicare and Medicaid Services (CMS) because of a belief that an involuntary transfer and discharge of a nursing home resident could be unsafe and traumatic.

With this new topic, the OIG will be examining nursing home compliance with CMS requirements for involuntary transfers and discharges. In addition, the review will examine the extent that State long-term care ombudsmen address involuntary transfers and discharges and the extent to which State survey agencies investigate and take enforcement actions against nursing homes for improper transfers and discharges.

Further evidence of the additional attention that is likely to be focused on nursing facilities can be found in the OIG’s recently issued annual document addressing the top management and performance challenges facing DHHS. Several of the management and performance challenges identified were ensuring program integrity in Medicare and Medicaid, and protecting the health and safety of vulnerable populations; both of these included references to nursing facility services. For example, the OIG noted that skilled nursing facilities pose a heightened risk to the financial integrity of the Medicare program because both OIG and CMS have previously identified high rates of improper payments. Also, the OIG identified a need to address substandard nursing home care in order to protect the health and safety of vulnerable populations.

What should you do with this information?

  • Review current policies and procedures to ensure all necessary requirements of service are addressed.
  • Verify that current and compliant policies and procedures are implemented and followed by staff.
  • Ensure documentation and record-keeping meet service and billing requirements.
  • Conduct internal audits to spot check compliance.
  • Review and update the facility Compliance Plan as necessary.

The recent additions to the Work Plan, along with the inclusion of nursing facility references in the top management and performance challenges for 2018, underscore the heightened scrutiny that nursing facilities should expect to receive in the upcoming year. These topics provide guidance regarding the areas that could come under scrutiny and ultimately can help guide internal compliance activities for your facility. Facilities should review their operations and take the necessary steps now to be better prepared to provide proper and quality care, to achieve and maintain compliance in the current regulatory and audit environment, and to minimize their chances for negative audit findings or rating system scores. 

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