While we all anxiously await the coming of a new year and what actions Congress will take related to impact on Medicare, Nursing Homes and Therapy Services, there is one thing we can prepare for now.  Each year the U.S. Department of Health & Human Services Office of the Inspector General releases a new Work Plan that introduces projects planned for the upcoming fiscal year—including those established by CMS, public health agencies, the Administration on Aging, and other major entities. For long-term care providers, the OIG Work Plan plays a critical role in helping prepare for compliance audits and risk assessments. The Work Plan focuses on seven different areas including: Medicare Part A and Part B; Medicare Part C and part D; Medicaid Reviews; Legal and Investigative Activities Related to Medicare and Medicaid; Public Health Review; Human Services Reviews; and Other HHS-Related Reviews. In each area, the Work Plan identifies compliance risk areas that subject Medicare and Medicaid providers to audit and enforcement initiatives. Under Medicare Part A and Part B, SNFs are specifically targeted and OIG plans follow-up reports in the following areas: Adverse Events in Post-Acute Care; Quality of Care Requirements; State Agency Verification of Corrections; Oversight of Poorly Performing Facilities; Use of Antipsychotic Drugs; Questionable Billing Patterns for Part B Services; and Oversight of the Minimum Data Set. Overall, OIG will continue its trend to focus their efforts on reviewing potential areas to discover fraud, quality issues and costs.

The OIG 2013 Work Plan spans the entire healthcare industry, covering 37 major areas (nine of which focus specifically on nursing homes). Here is an overview at what is being looked at this year:

  1. 1.      State Agency Verification of Deficiency Corrections: “We will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. Federal regulations require nursing homes to submit correction plans to the State survey agency or CMS for deficiencies identified during surveys. (42 CFR § 488.402(d).) CMS requires State survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction. (State Operations Manual, Pub. No. 100-07, § 7300.3.) A prior OIG review found that one State survey agency did not always verify that nursing homes corrected deficiencies identified during surveys in accordance with Federal requirements. (OAS; W-00-13-35701; various reviews; expected issue date: FY 2013; new start)
  2. 2.      Adverse Events in Post-Acute Care for Medicare Beneficiaries: “We will estimate the national incidence of adverse and temporary harm events for Medicare beneficiaries receiving postacute care in SNFs and inpatient rehabilitation facilities (IRF). We will also identify contributing factors to these events, determine the extent to which the events were preventable, and estimate the associated costs to Medicare. Medicare Part A pays for up to 100 days of care in SNFs and IRFs following a hospital stay of at least 3 days and in cases when a medical professional verifies the need for nursing care and rehabilitation related to the hospitalization. SNFs are the primary providers of post acute care, admitting 85 percent of Medicare beneficiaries receiving facility care following a hospitalization. Medicare expenditures for SNF care have more than doubled in the last decade; Medicare paid $12 billion for SNF care in 2000 and $28 billion in 2011. IRFs provide a far smaller percentage of postacute facility care (11 percent) but like SNFs have experienced rapid growth over the last decade and accounted for $7 billion in Medicare expenditures in 2011. (OEI; 06-11-00370; expected issue date: FY 2014; work in progress)
  3. 3.      Medicare Requirements for Quality of Care in Skilled Nursing Facilities:  “We will review how SNFs have addressed certain Federal requirements related to quality of care. We will determine the extent to which SNFs use the Residential Assessment Instruments (RAI) to develop care plans to provide services to beneficiaries in accordance with the plans of care and to plan for beneficiaries’ discharges. We will also describe any instances of poor quality of care . Prior OIG reports revealed that about a quarter of residents’ needs for care, as identified through RAIs, were not reflected in care plans and that nursing home residents did not receive all the psychosocial services identified in care plans. Federal laws require nursing homes participating in Medicare or Medicaid to use RAIs to assess each nursing home resident’s strengths and needs. (Social Security Act, §§ 1819(b)(3) and 1919(b)(3).) (OEI; 02-09-00201; expected issue date: FY 2013; work in progress)”
  4. 4.      Oversight of Poorly Performing Facilities: “We will identify poorly performing nursing homes and determine the extent to which CMS and States use enforcement measures to improve nursing home performance. We will also identify CMS and States’ follow up actions to ensure that poorly performing nursing homes implement corrective actions. Federal requirements include a survey-and-certification process, with associated enforcement measures, to ensure that nursing homes meet Federal standards for participation in Medicare and HHS OIG Work Plan | FY 2013 Part I: Medicare Part A and Part B Page 10 Medicaid. (Social Security Act, §§ 1819(g) and 1864.) We will examine enforcement decisions by CMS and States resulting from surveys and complaint allegations. (OEI; 06-12-00120; expected issue date: FY 2014; work in progress)
  5. 5.      Use of Atypical Drugs:  “We will assess nursing homes’ administration of atypical antipsychotic drugs, including the percentage of residents receiving these drugs and the types of drugs most commonly received. We will also describe the characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs. According to 42 CFR § 488.3, nursing homes must comply with Federal quality and safety standards, including requiring the monitoring of the prescription drugs prescribed to its residents. Federal requirements, 42 CFR § 483.25(l)(1), also require that nursing home residents’ drug regimens be free from unnecessary drugs. (OEI; 00-00-00000; expected issue date: FY 2014; new start)
  6. 6.      Hospitalizations of Nursing Home Residents:  “We will determine the extent to which Medicare beneficiaries residing in nursing homes have been hospitalized. We will also determine the extent to which hospitalizations were a result of manageable or preventable conditions. Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems at nursing homes. A 2007 OIG review found that 35 percent of hospitalizations during a SNF stay were caused by poor quality of care or unnecessary fragmentation of services. (OEI; 06-11-00040; expected issue date: FY 2013; work in progress)
  7. 7.      Questionable Billing Patterns for Part B Services During Nursing Home Stays:  “We will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents. Part B services provided during a nursing home stay must be billed directly by suppliers and other providers. (CMS’s Medicare Benefits Policy Manual, Pub. 100-02, ch. 8, § 70.) Congress directed OIG to monitor these services for abuse. (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), § 313.) A series of studies will examine podiatry, ambulance, laboratory, and imaging services. (OEI; 06-11-00280; various reviews; expected issue dates: FY 2013; work in progress)
  8. 8.     Oversight of the Minimum Data Set:  “We will determine whether and the extent to which CMS and the States oversee the accuracy and completeness of Minimum Data Set (MDS) data submitted by nursing facilities. Certified nursing facilities are required to complete the MDS for all residents at specified intervals and submit data electronically to the State. States then submit data to CMS, which uses it for a number of programs, including payment, quality monitoring, and consumer information. (OEI; 06-12-00440; expected issue dates: FY 2014; work in progress)”

The release of the OIG 2013 Work Plan serves as a reminder for facilities to develop and implement an effective quality assurance plan. Because the U.S. Government will soon require compliance programs to be instituted in each nursing home by the end of 2013 and a Quality Assurance and Performance Improvement ((QAPI) program soon after, training your staff on ways to reduce risk and improve compliance is now more important than ever.  In addition, OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements.  These can be found at https://oig.hhs.gov/compliance/compliance-guidance/index.asp .  Free educational resources are also listed on the OIG website at https://oig.hhs.gov/compliance/101/index.asp.