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Recent Findings by Office of Inspector General Regarding Reporting of Potential Abuse and Neglect at Skilled Nursing Facilities

The Office of Inspector General (OIG) recently released the findings of an audit performed to determine the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries residing in skilled nursing facilities (SNFs). Specifically, OIG looked at beneficiaries who resided in a SNF during 2016 and who also had a hospital emergency room (ER) Medicare claim containing a high-risk diagnosis code. OIG further investigated whether these incidents were properly reported by the SNFs, if Centers for Medicare & Medicaid Services (CMS) and state survey agencies reported findings of substantial abuse to local law enforcement, and the extent to which CMS requires incidents of potential abuse or neglect to be recorded or tracked.

The audit revealed the following findings: (1) In 2016, one in five high-risk hospital ER Medicare claims were the result of potential abuse or neglect of beneficiaries residing in a SNF, including injuries of an unknown source; (2) SNFs failed to report many of these incidents to the survey agencies in accordance with applicable Federal requirements; (3) several survey agencies failed to report some findings of substantiated abuse to local law enforcement; and (4) 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.

Based on these findings, OIG recommended CMS take action to ensure these types of incidents are reported, accomplished by working with survey agencies to improve staff training of SNFs on how to identify and report them. They also recommended CMS require the survey agencies to record and track these types of incidents and that referrals be made to local law enforcement and other agencies.

Audit (A-01-16-00509)

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