The U. S. Department of Health and Human Services (HHS), Office of Inspector General (OIG) recently published an Early Alert report regarding the preliminary results of an ongoing study of potential abuse or neglect in Medicare-certified Skilled Nursing Facilities (SNFs). In the report dated August 24, 2017, the OIG determined that the Centers for Medicare & Medicaid Services (CMS) has inadequate procedures to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are properly identified and reported. The OIG audit is continuing, but the preliminary results were issued because of the importance of detecting and combating elder abuse.
The purpose of the OIG audit was to identify incidents of potential abuse or neglect of Medicare beneficiaries in SNFs and to determine whether those incidents were properly reported and investigated.
The OIG reviewed emergency room records of 134 Medicare beneficiaries for dates of service between January 1, 2015 and December 31, 2016. The OIG reviewed the records for any of twelve diagnosis codes indicative of potential abuse and neglect. Of those 134 records reviewed in 33 states, 96 of the 134 incidents (72%) were reported to local law enforcement. However, 38 incidents (28%) were not reported.
The Social Security Act, Section 1150B (the Act), and the Code of Federal Regulations, Title 42, Section 483.12 require long-term care facilities, including SNFs, to immediately report any reasonable suspicion of crime against residents of the facility. An owner, operator, employee, manager, agent or contractor must report the event to the Secretary and 1 or more law enforcement entities immediately, but not less than 2 hours if the event results in serious bodily injury and within 24 hours if the event does not result in serious bodily injury. The Act provides significant penalties for failing to properly report potential abuse and neglect, including civil monetary penalties of up to $300,000 and exclusion from participation in any Federal health care program. (NOTE: For nursing facilities in Louisiana, additional incident reporting requirements are found in Louisiana Administrative Code, Title 48, Part 1, Section 9727.)
According to the report, the OIG determined CMS does not have adequate procedures to ensure that incidents of potential abuse or neglect are reported to the appropriate authorities. The OIG reached that conclusion based on the fact that CMS does not compare Medicare claims reimbursement data for ER visits with claims data for SNF services to identify potential instances of abuse or neglect. Additionally, the OIG found that CMS has taken no enforcement actions nor imposed any penalties authorized under Section 1150B against SNFs for failure to report incidents of potential abuse or neglect.
The OIG report provides several suggestions to CMS for immediate action including establishing procedures to compare ER claims data with SNF services claims data for Medicare beneficiaries residing in SNFs to identify incidents of potential abuse or neglect. Further, OIG recommended CMS work with HHS to ensure it has the proper authority to impose civil monetary penalties and exclusion provisions of 1150B.
Skilled Nursing Facilities should stay vigilant in reporting potential abuse and neglect of this vulnerable population. CMS will likely be increasing its oversight and enforcement activities in this area as well.
The transcript of the OIG Report, as well as a slideshow, graphics, and additional resources are available here.
Written by: Jacob Simpson