The Office of the Inspector General (OIG) at Health and Human Services (HHS) added a significant number of reports to its active Work Plan in 2020. While some, as expected, relate to Infection Control and COVID-19, the bulk of the reports look at long-standing concerns of regulators – and are areas that providers should be focusing on as well. Pressure from the findings of OIG reports often results in the Centers for Medicare & Medicaid Services (CMS) emphasizing compliance in the areas identified by OIG as problematic. In the last decade, we have seen everything from skilled nursing therapy payment reform to new emergency preparedness requirements come on the heels of OIG reports.
Infection Prevention and Control & COVID-19
Not surprisingly, in the midst of the COVID-19 pandemic, OIG added multiple items to its Work Plan that relate to how nursing homes and home health agencies have performed against regulatory expectations, including related to specific guidance issued during the COVID-19 Public Health Emergency (PHE).
- Audit of Nursing Home Infection Prevention and Control Program Deficiencies (May 2020) – This report will review whether the nursing homes selected for the report have Infection Control and Emergency Preparedness Programs in place that meet Federal regulatory requirements.
- Audit of Nursing Homes’ Reporting of COVID-19 Information Under CMS’s New Requirements (June 2020) – OIG is reviewing nursing homes’ reporting of COVID-19-related data that is required to be reported through the CDC NHSN system to determine if the reported data was complete, accurate and reliable.
- Meeting the Challenges Presented by COVID-19: Nursing Homes (June 2020) – OIG is completing a two-part review of nursing homes and the impact that the COVID-19 pandemic has had on them. The first part of the report will review the characteristics of the facilities that were most impacted by the pandemic and the second part will review the strategies used by facilities to minimize the impact of the pandemic.
- Medicaid Nursing Home Life Safety and Emergency Preparedness (March 2020) – Not surprisingly, at some point in March, OIG decided it would be fruitful to look at emergency preparedness, including facilities’ compliance with infectious disease control preparedness (i.e. COVID-19). When is the last time you updated your organization’s EPP?
- Infection Control at Home Health Agencies During the COVID-19 Pandemic (September 2020) – OIG will review HHAs that have been cited for infection prevention and control deficiencies to determine if their policies and procedures are compliant with the March 10, 2020 CMS guidance, “Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)”
- Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency (January 2021) – OIG plans to evaluate the services provided via telehealth by home health agencies during the PHE to see if the services were administered and billed appropriately. This report is expected in FY 2022.
Psychotropic Drug Use
Despite the strides that nursing homes have made to reduce the prescribing of antipsychotics to residents, a concern remains that some providers may be inappropriately using one of the handful of acceptable diagnoses for the use of antipsychotics in nursing homes. Late-life onset of schizophrenia? Not likely. However, approved diagnoses include Huntington’s Disease, Tourette’s Syndrome and schizophrenia. In 2012, OIG published a report (using a sampling of data from 2007) that found that 99% of records it reviewed failed to meet one or more of the Federal requirements for resident assessments or care plans for residents receiving atypical antipsychotic drugs. OIG had initially listed a second report related to nursing home antipsychotic drug use as part of its 2013 Work Plan, but it appeared to have been axed mid-way through 2013. Now it’s back on the table, albeit with a more specific focus.
OIG will be trying to determine if nursing home residents who have been prescribed psychotropic meds have the appropriate diagnoses that would exclude them from being counted in the antipsychotic quality measure.
In the second report, OIG will be looking at how the following items have changed over time – use of psychotropic meds for elderly residents, citations and civil monetary penalties (CMPs) assessed regarding psychotropic drugs and the presence of the exclusionary diagnoses mentioned previously.
- Monitoring Psychotropic Drug Use in Nursing Homes (May 2020) – OIG is reviewing if there are inconsistencies between Medicare claims data for nursing home residents prescribed psychotropic drugs and nursing homes’ self-reported data on residents who have received psychotropic drugs and Medicare claims data regarding diagnoses that would exclude residents from monitoring in the antipsychotic quality measure.
- Assessing Trends Related to the Use of Psychotropic Drugs in Nursing Homes (July 2020) – OIG will review CMS’s progress towards reducing the use of antipsychotic drugs in elderly nursing home residents by reviewing changes over time related to usage trends, citations and CMPs given related to psychotropic drugs, and whether there has been a change in the presence of exclusionary diagnoses that would impact how CMS measures antipsychotic drug use.
Long-Term Care Ombudsmen have identified in the past that facility-initiated discharges are more common than one would think, and OIG plans to review the extent to which nursing homes are compliant with the requirements for this type of discharge.
- Facility-Initiated Discharge in Nursing Homes (November 2020) – This item, which was listed as part of the 2019 OIG Work Plan with the title, “Involuntary Transfers and Discharges in Nursing Homes” appears to have been revised, with the focus on facility initiated discharges instead.
- Nursing Homes’ Compliance With Facility-Initiated Discharge Requirements (November 2020) – This report will look at how CMS, State Survey Agencies and LTC Ombudsmen address facility-initiated discharges and review to what extent nursing homes are meeting regulatory requirements for facility-initiated discharges. This report is expected in FY 2022.
Nursing Home Staffing
Another continued area of focus for regulators and the media is nursing home staffing levels. When the Requirements of Participation (RoPs) for nursing homes were updated a few years back, additional regulations were included related to staff sufficiency. CMS also implemented the use of the auditable Payroll-Based Journal (PBJ), which has since been used to calculate staffing levels. The staffing review that OIG is conducting will look at the data that has been submitted to the PBJ and how CMS is ensuring that data is accurately reported.
- Nursing Facility Staffing: Reported Levels and CMS Oversight (May 2020) – OIG will be putting out two data briefs on nursing home staffing data. One report will describe the staffing levels reported to the Payroll-Based Journal by nursing homes. The second part of the report will review CMS’s efforts to ensure that the staffing data submitted is accurate and what efforts CMS is making to improve resident quality of care. This report, which was originally announced in early 2019 (with an expected issue date of FY 2020), appears to have been pushed back.
OIG added a Work Plan item in January 2021 with an expected issue date of FY 2022 related to Background Checks for Nursing Home employees.
CMS & State Agency Oversight
Don’t worry, it’s not just the providers who are under OIG’s microscope. OIG will be reviewing several aspects of CMS’s work as well, namely its oversight of contracted State Survey Agencies (SAs) and the accuracy of the publicly available data listed on Care Compare. For the majority of 2020, there was limited information on Nursing Home Compare due to the changes to survey & certification activities related to the COVID-19 PHE. That meant that anyone who was looking to use Nursing Home Compare to find care for a relative or loved one was provided with old data that would not represent an accurate picture of the care currently being provided in a particular nursing home.
- Nursing Homes: CMS Oversight of State Survey Agencies (May 2020) – OIG identified in previous work that State Survey Agencies did not do enough to verify that deficiencies had been corrected, and chastised CMS for not providing more guidance to SAs on how to verify substantial compliance had been achieved. In this report, OIG will review CMS’s efforts to work with SAs to improve their performance as well as any barriers/challenges that may impede the Agency’s ability to help State Agencies.
- Accuracy of Nursing Home Compare Website’s Reported Health, Fire Safety, and Emergency Preparedness Deficiencies (August 2020) – OIG stated that it was planning to review the data reported on Nursing Home Compare (now “Care Compare”) to identify whether the information is accurate and reliable for consumer use. Read more here.
- Nursing Home Oversight During the COVID-19 Pandemic (October 2020) – Read about this one on the CMSCG Blog.
One item removed from the OIG Work Plan, which was expected in FY 2020, was the Skilled Nursing Facility Adverse Event Screening Tool.
Read the full OIG Work Plan here.