The OIG Work Plan for FY 2015 was posted on October 31, 2014 and summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. The Work Plan describes the primary objectives and provides for each review its internal identification code and the year in which they expect one or more reports to be issued.

There are no new areas identified for nursing homes in this years work plan.  Areas pertaining to nursing homes are the following:

Medicare Part A billing by skilled nursing facilities

We will describe changes in SNF billing practices from FYs 2011 to 2013. Prior OIG work found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. OIG also found that SNFs billed one-quarter of all 2009 claims in error; this erroneous billing resulted in $1.5 billion in inappropriate Medicare payments. CMS has made substantial changes to how SNFs bill for services for Medicare Part A stays. (OEI; 02-13-00610; various reviews; expected issue date: FY 2015)

 Questionable billing patterns for Part B services during nursing home stays

We will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents during stays not paid under Part A (for example, stays during which benefits are exhausted or the 3-day prior-inpatient-stay requirement is not met). A series of studies will examine several broad categories of services, such as foot care. Congress directed OIG to monitor Part B billing for abuse during non-Part A stays to ensure that no excessive services are provided. (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, § 313.) (OEI; 06-14-00160; various reviews; expected issue date: FY 2015) 

State agency verification of deficiency corrections

We will determine whether State survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. A prior OIG review found that one State survey agency did not always verify that nursing homes corrected deficiencies identified during surveys in accordance with Federal requirements. Federal regulations require nursing homes to submit correction plans to the State survey agency or CMS for deficiencies identified during surveys. (42 CFR § 488.402(d).) CMS requires State survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction. (State Operations Manual, Pub. No. 100-07, § 7300.3.) (OAS; W-00-13-35701; W-00-14-35701; various reviews; expected issue date: FY 2015)

Program for national background checks for long-term-care employees

We will review the procedures implemented by participating States for long-term-care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting background checks. We will determine the outcomes of the States’ programs and determine whether the programs led to any unintended consequences. Section 6201 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary of Health and Human Services to carry out a nationwide program for States to conduct national and State background checks for prospective direct patient access employees of nursing facilities and other long-term-care providers. The program is administered by CMS. To carry out the nationwide program, CMS has issued solicitations for grant awards. All States, the District of

Columbia, and U.S. territories are eligible to be considered for a grant award. OIG is required under the ACA to submit a report to Congress evaluating this program. This mandated work is ongoing and will be issued at the program’s conclusion, as required. (ACA, § 6401.) (OEI; 07-10-00420; expected issue date: FY 2015; ACA)

Hospitalizations of nursing home residents for manageable and preventable conditions

We will determine the extent to which Medicare beneficiaries residing in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home

setting. A 2013 OIG review found that 25 percent of Medicare beneficiaries were hospitalized forany reason in FY 2011. Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems in nursing homes. (OEI; 06-11-00041; expected issue date: FY 2015)

The intent of the OIG corporate compliance effort is that facility staff will self-audit their performance and ensure its conformity with regulations and applicable laws.  Nursing facility personnel can implement quality assurance and performance improvement efforts for each of the five categories to determine if they are in compliance or whether corrective action is needed to be made to processes or systems to ensure that identified problems are addressed and do not recur.

Read the Work Plan http://go.usa.gov/7kXP

Sheila Capitosti

VP of Clinical and Compliance Services