OIG’s nursing home plan emphasizes quality focus
The Department of Health and Human Services’ Office of Inspector General (OIG) released a detailed 40-page draft compliance program for nursing homes last week that in many ways mirrors the plans already released for hospitals, home health clinical labs and others. But unlike those other programs that center on billing issues, the OIG’s draft plan for nursing homes puts a heavy emphasis on quality of care.
Health care attorney Donna Thiel, of Gardner, Carton & Douglas in Washington, DC, says she expected to see a strong quality focus. "It is not a surprise because that is a focus of [OIG Associate Inspector for Legal Affairs] Lew Morris and [Eastern District of Pennsylvania civil division chief] Jim Sheehan and others," she says. "But the fact that they feel they have to guide nursing facilities to focus on quality is very telling."
Thiel also notes the plan’s emphasis on state agency surveys and their role in promoting quality care issues. According to the plan, nursing facilities should look to current and past surveys as a means to identify specific risk areas and regulatory vulnerabilities. "Any deficiencies discovered by annual state agency or federal validation surveys may reflect noncompliance with the program regulations and can be the basis for enforcement actions," the draft asserts.
The draft plan is also long on specifics. "One of the first things that jumped out at me was the elaborate footnotes," says Thiel. "I would recommend that providers look at those because they are very instructive."
Lyndean Olenhoff Brick, a consultant and attorney who specializes in that area, says that nursing homes should take advantage of the level of detail included in the plan. "It is a terrific tool," she argues. "Until now, long-term care and nursing homes have kind of been lost in the shuffle."
"It is very specific in certain areas," adds Brick, of the Chicago-based Murer Consultants. She credits its specificity to the fact that long-term care and skilled nursing facilities are populated by the frail and elderly. Simply the fact that patients sometimes stay 60 or 90 days raises different types of compliance issues.
For example, the OIG warns against the inappropriate use of "chemical restraints," referring to depressants and other drugs used to manage patients.
In the area of kickbacks, Brick says the plan highlights several areas that should be of particular interest to skilled nursing facilities, notably their relationship with hospice and medical directors. "Those are very big abuse areas," she says. In the case of medical directors, Brick says facilities often offer stipends or large payments to medical directors who do little more than make referrals.
Other actions the OIG recommend include the following:
- Make sure there is a comprehensive, accurate assessment of each resident’s functional capacity and a comprehensive care plan that includes measurable objectives to meet residents’ medical, mental, and psychosocial needs.
- Refrain from discriminatory admissions or improper denial of care; verbal, mental or physical abuse, corporal punishment, and involuntary seclusion; and inappropriate use of physical or chemical restraints.
- Refrain from billing for items or services not rendered or provided as claimed; submitting claims for equipment, medical supplies, and services that are medically unnecessary; submitting claims for items or services not ordered; and knowingly billing for inadequate or substandard care.
- Investigate the background of employees by checking with all applicable licensing and certification authorities to verify that requisite licenses and certifications are in order;
- Refrain from routinely waiving coinsurance or deductible amounts without a good faith determination that the resident is in financial need.
The OIG’s draft guidance for nursing homes, which carries a 30-day comment period, is available on the HHS’ Web site at www.hhs.gov. Click on "What’s New."
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