March 1, 2013

162017_132140396847214_292624_nIn a report issued on February 27, 2013 by the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services, it was reported that a study of a random sample of medical records from Skilled Nursing Facilities (“SNF,” which are commonly referred to as nursing homes) from 2009 found that Medicare paid approximately $5.1 billion for stays in which SNF did not meet quality-of-care requirements, including poor quality care related to wound care, medication management, and therapy (for fiscal year 2012, Medicare paid $32.2 billion for SNF services). The study’s purpose was to determine the extent to which SNF developed care plans that met Medicare requirements, provided services in accordance with care plans, and planned for beneficiaries’ discharges as required.

SNF are required to develop care plans that address problem areas identified in beneficiaries’ assessments, include measurable objectives and detailed time-frames, and are completed by an interdisciplinary team. These requirements help to ensure that beneficiaries’ needs are addressed and that care plans provide clear, individualized instructions about the most appropriate care for each beneficiary.

The study found that for 37% of SNF stays, the SNF did not develop care plans that met requirements or did not provide services in accordance with care plans, costing Medicare approximately $4.5 billion for these stays. For 31% of SNF stays, the SNF did not meet discharge planning requirements, costing Medicare approximately $1.9 billion for these stays (for 16% of SNF stays, SNF did not have summaries of the beneficiaries’ stays or statuses at discharge; for 23% of SNF stays, SNF did not have post-discharge plans of care).

The recent study found that for 26% of SNF stays, SNF care plans did not meet at least one of the requirements. For 19% of SNF stays, SNF developed care plans that did not address one or more problem areas identified in the beneficiaries’ assessments (on average, beneficiaries had seven problem areas identified in their assessments). For 7% of SNF stays, SNF care plans did not include measurable objectives or detailed time-frames. For 15% of SNF stays, SNF failed to provide at least one service at the frequency or duration prescribed in the care plans.

Prior OIG reports regarding SNF found as follows: 74% of SNF surveyed in 2007 had at least one deficiency related to quality of care; SNF often did not develop appropriate care plans or provided all services identified in care plans for psychosocial services; nearly all SNF records reviewed failed to meet one or more Medicare requirements for beneficiary assessments or care plans regarding atypical antipsychotic drugs (95% of claims for atypical antipsychotic drugs for elderly nursing facility residents were for off-label use and/or the condition specified in the black-box warning; 50% of such claims were not for medically accepted indications); from 2006 to 2008, SNF increasingly billed for higher paying categories, even though beneficiary characteristics remained largely unchanged; and, SNF billed one-quarter of claims in error in 2009, resulting in $1.5 billion in inappropriate Medicare payments (for 47% of claims, SNF misreported information on the beneficiary assessment, which is used to create care plans).

For 2009, SNF were found to have provided inappropriately high levels of therapy to beneficiaries given their conditions, billing for a higher payment category than was appropriate for 20% of all claims. For approximately half of these claims, SNF billed for ultrahigh levels of therapy when they should have billed for lower levels of therapy or no therapy at all.

The Centers for Medicare & Medicaid Services (“CMS”) contracts with State Survey and Certification agencies to determine whether nursing facilities are in compliance with Medicare requirements. The State agencies conduct periodic surveys of each facility. If facilities are out of compliance with one or more requirements, surveyors cite them for deficiencies. In 2011, 22% of facilities surveyed did not meet care planning requirements, 14% did not provide services in accordance with care plans, and 1% did not meet the discharge planning requirements. When facilities are cited for deficiencies, CMS or the State may choose to impose a number of different enforcement actions depending upon the scope and severity of the deficiencies found, including requiring a plan of correction, denying future payment, or terminating the provider agreement.


If you or someone you know were injured or otherwise harmed during a nursing home stay, you should promptly contact a local nursing home attorney (medical malpractice attorney) who may agree to investigate your nursing home claim for you and represent you in a nursing home claim, if appropriate.

Click here to visit our website or telephone us toll-free at 800-295-3959 to be connected with nursing home lawyers (medical malpractice lawyers) in your state who may be able to assist you with your nursing home claim.

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