The newly released Office of the Inspector General Report (OIG), “Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements,” comes with a not-so-subtle mention of the $5.1 billion that Medicare paid for inadequate care due to inferior quality of care, inadequate care plans and poor discharge planning. Let’s take a look at the numbers from this report, which uses a random sample of residents from 2009, and what they mean for your nursing home going forward.
Care Plans
- For 37% of stays in the 2009 sample used for this report, care plans were not developed that met requirements or services were not provided in accordance with care plans. The approximate cost to Medicare was $4.5 billion.
- In 19% of the sample, care plans did not sufficiently address resident needs in areas such as ADLs, pressure ulcers, nutrition and falls. Many residents in the sample had multiple areas that needed to be addressed.
- 15% of residents sampled were not provided with at least one service at the frequency or duration that was written in their care plans. The one area that OIG found did not match this pattern was therapy, which it believes is a main cause of Medicare overbilling.
Discharge Planning
- For 31% of the sample, discharge planning requirements were not met.
- 16% of stays were not summarized at discharge, including failure to provide important clinical information.
- 23% of residents in the sample did not have post-discharge plans of care in place. The reviewers noted that sometimes only verbal instructions were given, which is not deemed sufficient.
Other Areas of Poor Quality Care
- Wound care – Several SNFs in the sample did not have detailed information in the medical records, and others provided poor care that resulted in residents’ conditions worsening.
- Medication Management – The area of review in this reported was centered on the off-label use of antipsychotics, which the OIG had already noted was an issue in its May 2011 report, “Medicare Atypical Antipsychotics Drug Claims for Elderly Nursing Home Residents.”
- Therapy – There has been much discussion around the high amount of therapy claims by SNFs to get Medicaid reimbursements in the news recently. The sample for this report reflects the same time period as the OIG’s November 2012 report, “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009.”
What It Means for Your Facility
The OIG made five recommendations to CMS when putting together this report, all of which CMS is taking into consideration. This includes that CMS should be:
- Updating care planning and discharge planning regulations to require that SNFs provide documentation on why they did not provide the services in a care plan.
- Requires an interdisciplinary team to be part of the discharge process, which is not always the case, preventing as much information as possible from being transmitted at discharge.
- Focusing on care plans being individualized, since many of the care plans in the sample were computerized and generic. It said that goals in the care plans must be measurable and timely. We discussed the importance of measurable goals in our recent blog post, “Managing the Survey Process in Your Nursing Home.”
- Ensuring guidance insists that adequate information is provided during discharge planning, which helps with coordinating care and transition from the SNF to the new care setting. This involves having an interdisciplinary team involved to make sure all the residents’ care needs are covered.
- Revising the SOM and surveyor training to focus on providing more citations for not developing individualized care plans or providing specific information on discharge plans. OIG recommends that CMS increase the use of remedies for these citations, and CMS has agreed that it will look to do this.
- Developing additional methods to enforce compliance in care planning and discharge planning by looking being the survey and certification process. This includes insisting SNFs provide good quality by linking payments to their performance.
- Providing to State Survey and Certification Agencies a list of the facilities in the sample that did not meet the care planning or discharge planning requirements or provided poor quality of care in one of the eighteen areas mentioned in this report. The State agencies are expected to place priority on reviewing these facilities and if enforcement is required.
With a $5.1 billion “overpayment” that was mentioned at the beginning of this post, the government is likely to want to ensure that appropriate standards of care are met going forward before they make payments. If you look at this report against the OIG 2013 Work Plan, you will see that the OIG is well on its way to achieving the goals they set. Four areas of focus for the OIG Work Plan that tie directly into this report are Medicare Requirements for Quality of Care in Skilled Nursing Facilities, Use of Atypical Antipsychotic Drugs, Oversight of the MDS Submitted by LTC Facilities, and Oversight of Poorly Performing Facilities. CMSCG wrote a blog post in October 2012 about the OIG 2013 Work Plan, which you can read here to get a better understanding of these goals. The OIG plans to issue additional comprehensive reports in these areas and with them will come recommendations to CMS, which surely means updated enhanced regulations and a rising number of deficiencies in these areas.