CJ Wolf
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Compliance professionals in the nursing home sector are well aware of the many ways government agencies survey, audit, and enforce regulatory compliance. Nursing homes have seen significant enforcement over the last few years, and the U.S. Department of Health and Human Services Office of Inspector General (OIG) is signaling that scrutiny will continue in a significant way.
The HHS Inspector General, Christi Grimm, highlighted this during her keynote address at HCCA’s Compliance Institute in April 2023. Specifically, she said, “You have heard me say that nursing homes are my top priority. Improving nursing home care for those who need it is front-of-mind for the OIG team.” She also called upon those of us in the compliance profession to do what we can to help. Ms. Grimm stated, “Compliance professionals can help improve nursing homes for people who need them, so that the elderly and people with disabilities have peace of mind, quality of care, and quality of life.”
Past OIG work has identified concerns in nursing home compliance, including weaknesses in areas such as staffing, infection control, and emergency preparedness. There are also challenges ensuring that deficiencies are promptly flagged and remedied, and that incidents of abuse and neglect are reported as required.
The OIG recently outlined a framework that will guide their priorities as they oversee certain aspects of nursing home services. The framework is called the PRO framework, which stands for: Performance, Residents First, and Oversight.
Performance
OIG wants to gain a better understanding of the incentives and causes that drive poor nursing home performance. Once better understood, they want to know what can be done to make those standards and incentives stronger.
Another way to view performance is to see it as nursing home operations and incentives. By way of example, the OIG is conducting new work to better understand the reporting of related party costs, as well as new efforts examining how nursing homes use Medicaid funding to provide direct patient care.
They hope this work with improve understanding about the relationship between spending on care and ownership structure, including private equity. OIG believes that we, as compliance professionals, are well-positioned to look closely at compliance with requirements related to financing and delivery of direct patient care.
Residents First
The whole reason nursing homes exist is because of the patients or residents. Putting residents first is the part of OIG’s framework that will drill down to the bedside experiences of residents and their loved ones.
This means nursing homes, at least from the OIG’s perspective, need to put top priority on the quality of care and quality of life residents experience. Compliance programs in nursing home organizations can make a big difference by identifying risk areas and steps nursing homes can take to reduce risk and improve the experiences of residents and their families.
Currently, the OIG is focusing on a significant concern about potential falsification of schizophrenia diagnoses to justify the use of antipsychotics. In some nursing homes, patients are given antipsychotics to calm them down or make them more docile when doing so is not an appropriate use of those types of medications.
Another area of concern is the abuse and neglect of nursing home residents. The OIG warns that their work in this area could include enforcement through the False Claims Act for the provision of substandard or worthless services, and exclusion of nursing home owners and operators that egregiously fail their residents.
Oversight
The third part of the OIG framework is oversight. What they mean by oversight is not necessarily their oversight, though of course they will perform some direct oversight work. Rather, OIG is referring to the importance of ensuring that those responsible for frontline oversight of nursing home quality and safety are able to detect and remedy instances of noncompliance and substandard care quickly and effectively. For example, Centers for Medicare and Medicaid Services (CMS) and state survey agencies are the eyes and ears on the ground to safeguard resident well-being. Prior OIG work revealed backlogs and performance challenges for CMS and the survey agencies.
Additionally, the OIG believes keeping nursing home residents safe is not just the government’s responsibility. They feel residents and loved ones depend on nursing homes and their care teams to deliver high quality, dignified care. To this end, Ms. Grimm stated that “Compliance activities that are laser-focused on putting residents first by detecting and correcting problems can make a big difference.”
In conclusion, the OIG has stated loud and clear that nursing homes are one of their highest priorities right now. If you or your organization provide nursing home services, now might be a good time to perform a compliance program effectiveness review to ensure the program meets the needs of nursing home compliance.
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