Reimbursement under the new Patient Driven Payment Model, staff background checks, infection control programs, facility-initiated transfer or discharge of a resident and the use of psychotropic drugs are several new skilled nursing facility (“SNF”) areas of audit and focus of Department of Health and Human Services Office of Inspector General (“OIG”).
OIG publishes updates monthly to its Work Plan to describe OIG’s new and continuing audit and enforcement priorities. These updates, along with the existing priorities already in the Work Plan, are useful for SNFs to identify compliance program risk areas, improve policy development and manage audit and other risk management efforts.
Significant COVID-19-Focused Audit Activities
Of the new areas of focus mentioned in the Work Plan, a number of COVID-19 specific topics are of particular significance to SNFs, including:
- Meeting the Challenges Presented by COVID-19
OIG is embarking on a nationwide, three-part study to examine how the pandemic affected SNFs. The first part will analyze the extent to which Medicare beneficiaries residing in nursing homes were diagnosed with COVID-19 and describe the characteristics of those who were at greater risk. The second part will describe the characteristics of the nursing homes that were hardest hit by the pandemic, those facilities with high numbers of residents who had COVID-19. The third part will describe the strategies SNFs used to mitigate the challenges of COVID-19.
- Reporting of COVID-19 Information Under CMS’s New Requirements
In 2020, the Centers for Medicare & Medicaid Services (“CMS”) added a requirement that SNFs must report COVID-19 data, such as information on suspected and confirmed infections, and deaths among residents and staff, to the Centers for Disease Control and Prevention through its National Healthcare Safety Network system. The data must be reported in a standardized format at least weekly. OIG will assess SNFs’ reporting of CMS-required information related to the COVID-19 public health emergency and if the data reported by SNFs were complete, accurate and reliable.
- Infection Prevention and Control Program Deficiencies
The OIG will audit select SNFs to determine whether the selected SNFs have programs for infection prevention and control and emergency preparedness in accordance with Federal requirements.
PDPM and Reimbursement
Another OIG focus area is SNF reimbursement. SNFs provide skilled nursing care and rehabilitation services such as physical, speech and occupational therapy to beneficiaries who need assistance after hospitalization. In October 2019, CMS implemented a new payment system for determining Medicare Part A payments to SNFs. Specifically, CMS implemented the Patient Driven Payment Model (“PDPM”), a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payments groups under the SNF Prospective Payment System. The OIG will determine whether Medicare payments to SNFs under PDPM complied with Medicare requirements.
Background Checks for Employees
Federal regulation 42 CFR 483.12(a)(3) provides beneficiaries who rely on long-term care services with protection from abuse, neglect and theft by preventing prospective employees with disqualifying offenses from being employed by these care providers and facilities. The OIG will review and determine whether Medicaid beneficiaries in SNFs in certain states were adequately safeguarded from caregivers with a criminal history of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, according to Federal requirements.
Compliance with Facility-Initiated Discharge Requirements
OIG will examine the extent to which SNFs meet CMS requirements for facility-initiated discharges of a resident from a SNF.
Assessing Trends Related to the Use of Psychotropic Drugs
A prior OIG examination found that SNF residents who were prescribed antipsychotic drugs were at risk for harm. CMS concurred with some OIG recommendations and developed new initiatives. OIG will examine the changes over time for the following: (1) the use of psychotropic drugs for SNF residents; (2) citations and civil monetary penalties assessed to SNFs regarding psychotropic drugs; and (3) the presence of diagnoses that exclude SNF residents from CMS’s measure of the use of antipsychotic drugs.
Practical Takeaways
SNFs should familiarize themselves with the Work Plan and use it to help identify potential risk areas in their organizations. The Work Plan is an important tool in maintaining an effective compliance program and may help prevent government scrutiny and enforcement activity.
If you have questions or would like additional information about this topic, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com; or
- Your primary Hall Render contact.
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Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
