In the April 2016 OIG Compendium of Unimplemented Recommendations, the Office of the Inspector General (OIG) reminds the Centers for Medicare & Medicaid Services (CMS) that it provided recommendations in its reports that have not been fully addressed. As part of the March 2014 Compendium of Priority Recommendations, the OIG made recommendations to address resident harm and questionable resident hospitalizations through better identification of and reduction of adverse events.
A February 2014 OIG report had found that 50% of adverse and temporary harm events during SNF stays were preventable. That report reviewed three clinical categories of adverse events:
- Medication-related events
- Ongoing resident care-related events
- Infection-related events
In an effort to reduce the number of adverse drug-related events in nursing homes, CMS announced that in July 2015 that it would implement a few focused survey format, the Focused Survey on Medication Safety Systems. CMS included a draft tool for facilities to use for risk management of medication systems, the Adverse Drug Event Tool.
While CMS has made steps towards implementing the OIG recommendations related to adverse drug events, the Agency is still developing a list of adverse events for the two other adverse event categories mentioned above – patient care events and infection events. The full list and related guidance is planned for final release in 2017, so nursing homes should potentially be prepared for some new focused surveys related to these two types of events. CMS has already announced that it will be conducting an Infection Control survey pilot, and the new Quality Measures announced in March will also put providers under the microscope even further as they work to provide the highest quality of care.
