Now that you’ve had time to read and relish the nine new items on the OIG Work Plan for nursing homes, let’s review the repeat favorites. Just as a reminder, if these are the target areas that the OIG is concentrating on, make them your target areas as a part of your compliance and internal audit plan.

Here we go!

1) Adverse Events in Post-Acute Care for Medical Beneficiaries

The OIG will continue to look at and estimate the national incidence of adverse and temporary harm events for Medicare beneficiaries in post-acute settings. In addition, they will examine if these events were preventable and also identify contributing factors. What does this mean? An adverse event is basically something “bad” that happens to our residents that could have been prevented. This can include house-acquired pressure ulcers, falls or medical errors. Are we doing everything we can to prevent these errors that should or could have been avoided?


2) Medicare Requirements for Quality of Care in Skilled Nursing Facilities

In prior reports the OIG determined that a quarter of residents’ needs were not reflected in the care plans. The OIG will continue to focus on a facility’s use of the Resident Assessment Instrument (RAI) to develop an effective care plan. Facilities need to ask themselves the hard question – are care plans meaningful and individualized enough to drive the care that our residents require? In particular, are we looking at the psychosocial needs of our residents? Does our staff have the skills and the training even if our care plans are complete?


3) Oversight of Poorly Performing Facilities

The OIG will look to see the extent to which CMS and states use enforcement measures to improve nursing home performance. The goal here: stay off the list of poorly performing facilities! Make sure you can prove your performance with data, metrics, and proof of training through record-keeping.


4) Hospitalization of Nursing Home Residents

Avoiding hospitalization and rehospitalization is a big issue for hospitals and post-acute care providers based on the OIG’s Work Plan demands and as a result of the Affordable Care Act. In 2007, the OIG determined that 35% of hospitalizations during a nursing home stay were caused by poor quality of care or poor transition of care. Nursing facilities have to start taking a close look at their hospitalization rates and determine the root cause of these hospital admissions by accessing resources like the INTERACT II tool to track rehospitalization, and train on the most common care issues that trigger rehospitalization.


5) Questionable Billing Patterns for Part B Services During Nursing Home Stays

Congress directed the OIG to monitor part B services and billing patterns associated with nursing homes for abuse. There will be a series of studies that will examine podiatry, ambulance, laboratory and imaging services. Take a close look at your relationships and vendors that you have partnered with.

Traditionally, facilities have made the focus of compliance programs on monitoring and auditing billing practices. While this is certainly important, the OIG has sent us a serious message loud and clear. A majority of the 2013 Work Plan addresses quality of care issues. This requires facilities to take a close look at their internal quality assurance programs, training programs, and data and record-keeping practices in order to prove they are delivering the right care in the right way to provide the best results for the resident.