The Office of the Inspector General (OIG) released a new report on June 12, 2019, “Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated,” which continues the OIG’s look at potential abuse in nursing homes. In August 2017, the OIG issued an “early alert” to The Centers for Medicare & Medicaid Services (CMS) regarding potential physical and sexual abuse of Medicare beneficiaries identified by using emergency room records for diagnoses that could be associated with abuse or neglect (Read CMSCG Blog post “OIG Alert – CMS procedures for potential abuse/neglect in SNFs inadequate” for more details).
The new report is based on a review of high-risk hospital Emergency Room Medicare claims of beneficiaries residing in skilled nursing facilities during CY2016 who were transferred from a SNF directly to an ER. These claims included one or more of the nearly 600 diagnosis codes that the OIG has determined could be associated with a high risk for potential abuse or neglect. The report states that the selected codes were chosen to help identify incidents that could potentially be abuse or neglect but were not coded as such by the treating provider. During its review, OIG determined the following:
- Approximately 1 in 5 high-risk ER Medicare claims (51 of 256 sampled claims) were the result of potential abuse or neglect, including injuries of unknown origin. OIG worked with the State Agencies to determine if claims could be associated with potential abuse or neglect based on documentation review.
- A majority of the identified claims were not appropriately reported to State Agencies by SNFs (43 of 51 in the sample). Several State Agencies, in turn, did not report findings of substantiated abuse to law enforcement as required (67 of 69 incidents). Reasons provided for not reporting these incidents varied by State Agency, including relying on SNFs to report to law enforcement and reporting only “the most serious” cases of abuse.
- CMS also did not ensure that all incidents of potential abuse or neglect were reported as per Federal requirements, and the OIG states that CMS guidance on reporting was not clear, leading to inconsistent interpretation by SNFs. Citing a 2004 CMS S&C memo, OIG found that the clarification for SNF reporting requirements was not clear enough and as a result, both SNFs and State Agencies interpreted the information differently, including related to “injuries of unknown source” and the idea of a “suspicious” incident that should have been reported.
- CMS does not require all potential incidents of abuse or neglect to be entered into the Automated Survey Processing Environment Complaints/Incident Tracking System (ACTS). State Agencies are not required to enter potential incidents into ACTS when a SNF self-reports to the State Agency but a Federal onsite survey is not required, which leads to inconsistent reporting. CMS noted that it is updating its incident-tracking system and expects it to be completed by 2021. The OIG additionally identified that CMS does not require law enforcement referrals to be entered into ACTS which prevents the Regional Offices from fully monitoring these referrals.
OIG Recommendations
The OIG made several recommendations with its report, all of which CMS concurred with.
- OIG recommended that CMS improve training for SNF employees on identifying and reporting incidents of potential abuse or neglect. CMS stated that it has training materials available, but that it has plans in place to issue new guidance specific to the reporting and tracking of facility-reported incidents of potential abuse or neglect.
- OIG recommended that CMS take action to ensure these incidents are identified and reported by clarifying its guidance and providing examples. CMS stated that it will review its Interpretive Guidance to identify where additional examples of abuse or neglect could be added and clarify its guidance on reporting. (CMS Compliance Group has been covering F600 Free from Abuse and Neglect in its Ftag of the Week blog series – view information on the Interpretive Guidance at F600 in these blog posts).
- OIG recommended that CMS require State Agencies to record and track all incidents of potential abuse or neglect in SNFs as well as referrals to law enforcement and other agencies. CMS noted that it will determine if there is a way to expand its current requirements for recording and tracking these items, including expanding how it can track law enforcement referrals.
In a response cited in the report, CMS Administrator Seema Verma also noted that for 2019, Federal Oversight Support Surveys (FOSS) will continue to focus on identifying concerns related to abuse and neglect in skilled nursing facilities. Priorities for 2018 included this area of concern as well as others (Read CMSCG Blog post “Federal Oversight Support Survey (FOSS) Process National Pilot Underway” for more information).
Read the June 12, 2019 Report (A-01-16-00509) here. View the OIG’s second related report also issued on June 12, 2019, on the CMSCG Blog, “OIG Report – CMS Could Identify Potential Abuse/Neglect with Claims Data.”
