MDS Alert

Bombshell study reveals substandard care in SNFs.

Brace yourself for intensifying scrutiny of your discharge and care planning, thanks to a scathing report by the HHSOffice of Inspector General (OIG) on skilled nursing facilities (SNFs).

"Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements," which the OIG released on Feb. 27, uncovered that SNFs are slipping up in several key areas, such as discharge and care planning, billing for therapy services, and even quality of care.

The OIG based the study on medical record reviews of a stratified simple random sample of SNF stays in 2009, according to an analysis by Evvie Munley, a senior health policy analyst with Washington, D.C.-based Leading Age. The OIG focused on stays 21 days or longer. Reviewers were RNs, with consult as needed from physical, occupational and speech therapy.

Bad news: Many SNFs are not developing proper care plans "and they are not providing adequate care," said Judy Kellis, team leader for the OIG’s Office of Evaluations and Inspections in New York City, in a recent agency podcast. "In 15 percent of stays, facilities didn’t provide the care the patient needed."

Take a Hard Look at Your Care Planning

In 2009, 37 percent of SNFs did not meet quality-of-care requirements, the OIG finds. Of those SNFs, either the plan of care did not meet Medicare requirements or the care was not administered according to the plan. These problematic care plans for SNF stays accounted for $4.5 billion.

"We found that in one out of five stays, patients had problems that weren’t even addressed," Kellis said. "In one case, the facility didn’t have any plans to monitor the drugs a patient was on, even though those drugs could have serious side effects."

Reviewers also discovered instances of poor-quality care related to wound care, medication management and therapy, the OIG charges. These findings not only raise concerns about what Medicare is paying for, but also "demonstrate that SNF oversight needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge planning."

Beware of Overdoing Therapy Services

"In other cases, facilities were doing too much, as opposed to too little," Kellis noted. "… by providing unnecessary services that offer no benefit to the patient and could actually cause harm. We have seen this with therapy services because facilities have a financial incentive to provide more therapy than a patient needs."

Example: "In one case, a facility provided intense physical therapy to a patient with terminal lung cancer," Kellis related. Although the patient didn’t want the therapy, it continued five days per week for five weeks.

"In another case, a patient received hours and hours of high-level physical therapy, even though she had a dislocated hip and should not have been moving," Kellis said.

And the OIG points out in the study that this is not the first time it’s uncovered questionable practices at SNFs. From 2006 to 2008, SNFs increasingly billed for more expensive levels of care, even when those levels are not necessary, the OIG states.

Improve Your Discharge Planning Now

Discharge planning was another red-flag area in the OIG’s study. In about one-third of cases, SNFs didn’t provide enough information when the patient moved to another setting, Kellis charged. "This can be dangerous because many patients have complex conditions and they often take many medications," and this can also lead to unnecessary hospitalizations, which are both expensive and bad for the patient, she noted.

Specifically, 31 percent of stays had one or more missing elements from the discharge plan, the OIG says. And these stays accounted for $1.9 billion in Medicare payments. One-quarter of all SNF claims in 2009 were incorrect, accounting for $1.5 billion in total Medicare reimbursements.

Get Ready for Quality-Linked Payments?

Problem: "The way Medicare pays nursing facilities right now offers few incentives to provide high quality care," Kellis said. "Medicare should use its purchasing power to ensure that facilities provide good care and transitions for patients."

Heads up: CMS agreed with all five of the OIG’s recommendations, which are that CMS should:

1. Strengthen the regulations on care planning and discharge planning;

2. Provide guidance to SNFs to improve discharge and care planning;

3. Increase surveyor efforts to identify SNFs that do not meet discharge and care planning requirements and to hold these SNFs accountable;

4. Link payments to meeting quality-of-care requirements; and

5. Follow up on the SNFs that failed to meet discharge and care planning requirements or that provided poor-quality care.

Link: To view the entire study report, "SNFs Often Fail to Meet Care Planning and Discharge Planning Requirements," go to http://go.usa.gov/2CDC.