The U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) recently updated its Work Plan in August 2018 to add an additional topic focusing on nursing facilities that receive Medicare and Medicaid reimbursement. The Work Plan describes new and ongoing OIG audits and evaluations for DHHS programs and operations, including Medicare and Medicaid. The OIG updates its Work Plan throughout the year and the release of an update provides an opportunity for nursing facilities to review their own operations and practices in order to identify areas for compliance improvement.

The OIG conducts investigative activities that involve allegations of fraud, waste, and abuse in all of DHHS’s programs. Medicare and Medicaid constitute a significant amount of its work. Areas that the OIG can investigate include billing for services not rendered, provision of medically unnecessary services and misrepresented services, patient harm, and the solicitation and receipt of kickbacks. In addition to performing investigations, the OIG is also involved in facilitating compliance in the health care industry and the exclusion of individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs.

The active OIG Work Plan previously identified several risk areas for Skilled Nursing Facilities (SNF) and Nursing Facilities (NF) in the Medicare and Medicaid programs. Those areas already under review include: unreported incidents of potential abuse and neglect; facility reimbursement; prospective payment system requirements; and potentially avoidable hospitalizations of nursing facility residents.

In August, the OIG added a new topic to the Work Plan which will focus on the Centers for Medicare and Medicaid Services (CMS) oversight of nursing facility staffing levels. The overall concern is the impact of staffing levels on residents’ quality of care. The Medicare requirements of participation include that a facility must provide sufficient nursing staff on a 24-hour basis and a registered nurse for at least eight consecutive hours per day, seven days a week.

With this new topic, the OIG will be examining nursing staffing levels that are reported by facilities electronically to CMS’s Payroll-Based Journal. In addition, the review will address the efforts by CMS to ensure data accuracy and improve quality of care by examining the enforcement of minimum requirements and incentivizing high quality staffing above minimum requirements.

To further emphasize the increased focus on staffing level requirements, this addition to the OIG Work Plan comes less than four months after the issuance of letter QSO-18017-NH from the CMS Director of the Quality, Safety and Oversight Group to State Survey Agency Directors. That letter addressed the transition to Payroll-Based Journal Staffing Measures, staffing data audits, and the requirement for registered nurse staffing in facilities.

What should you do with this information?

The Work Plan provides insight into the areas that could come under scrutiny and ultimately can help guide internal compliance activities for your facility.

These audits and evaluations by the OIG serve as an important reminder that facilities must remain vigilant with their reporting and documentation. Also, it is essential that facilities are familiar with applicable requirements for the provision of services, especially staffing, and remain current with policies, rules, and regulations. The recent issuance of letter QSO-18017-NH in April and the addition to the Work Plan in August indicates it is also a good time for SNFs and NFs to review their compliance plan and internal policies to verify that they address all necessary requirements for the provision of services.

Facilities should review their operations and take the necessary steps now to be better prepared to provide proper and quality care, to achieve and maintain compliance in the current regulatory and audit environment, and to minimize their chances for negative audit findings or rating system scores.

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