OIG Report: Abuse and Neglect of Medicare Beneficiaries

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The Office of Inspector General (OIG) released a report this week that found incidents of potential abuse and neglect at Skilled Nursing Facilities were not always reported and investigated.  The Report in Brief found that an estimated one in five high-risk hospital ER Medicare claims for treatment provided in calendar year 2016 were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in a SNF.  The OIG determined that:

  • SNFs failed to report many of these incidents to the Survey Agencies in accordance with applicable Federal requirements.
  • Several Survey Agencies failed to report some findings of substantiated abuse to local law enforcement. Five Survey Agencies did not report findings of substantiated abuse to local law
  • enforcement for 67 of 69 incidents outside of the OIG sampling frame involving 34 SNFs.
  • CMS does not require all incidents of potential abuse or neglect and related referrals made to law enforcement and other agencies to be recorded and tracked in the Automated Survey Processing Environment Complaints/Incidents Tracking System. Preventing, detecting, and combating elder abuse requires CMS, Survey Agencies, and SNFs to meet their responsibilities.

This OIG review covered 37,607 high-risk hospital ER claims for 34,820 Medicare beneficiaries residing in SNFs during calendar year 2016.  Additionally, OIG and Survey Agencies reviewed supporting documentation for 256 high-risk hospital ER Medicare claims to determine whether the incidents were the result of potential abuse or neglect, and if so, reported to the Survey Agencies. The review included incidents that were not included in the OIG sampling frame to determine whether CMS and the Survey Agencies reported findings of substantiated abuse to local law enforcement. OIG also assessed how CMS tracks all incidents of potential abuse or neglect.

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The 55-page June 2019 OIG Report is well worth the read.  The Report in Brief is also included in the complete report itself.   It’s an eye-opener, to be sure.  Review the report with an eye to what’s happening in your facility.   Check out the representative example on pages 12 and 13 as well as page 16.   OIG Conclusions and Recommendations as well as CMS Comments and the OIG Response are found on pages 17 and 18.