Compliance Risk Assessment Considerations for the New Year

Compliance Risk Assessment Considerations for the New Year

As we enter 2025, nursing home providers face many regulatory and administrative challenges. January is a good time to conduct a compliance risk assessment that considers the updated nursing facility specific compliance program guidance released in November 2024 by the HHS Office of Inspector General (OIG). The guidance highlights key compliance risk areas for SNF/NF providers and identifies considerations and strategies to overcome potential compliance pitfalls we face in the coming year….

The Nursing Facility Industry Segment-Specific Compliance Program Guidance is intended to guide facilities when implementing, evaluating and updating their compliance and quality programs.  The four key areas of potential risk for non-compliance identified include 1) Quality of care and Quality of life, 2) Medicare and Medicaid billing requirements 3) Federal Antikickback Statutes and 4) Other risk areas (including HIPAA privacy, security, and breach notification rules).  Let’s review some of these high-risk topics and consider potential risk mitigation action items that should be included in your Compliance/QAPI work plans…

Quality of Care/Quality of Life

Nursing facilities expressly agree to comply with regulations related to standards of care as a condition of payment under the Medicare and Medicaid program.  The failure to provide quality of care and promote quality of life poses a significant risk of fraud and abuse for nursing facilities.  The provision of substandard quality of care has increasingly been cited as the basis for investigations and enforcement activities.  In addition, claims submitted for reimbursement of nursing home services when substandard quality of care has been identified in rendering those services may be considered false claims under the statutes.

Common Risk Areas for Quality of Life/Quality of Care

a) Staffing levels, Shortages and Competencies: Nursing facilities are required to have sufficient staff with the appropriate competencies and skills to provide services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. CMS issued a staffing rule which established minimum nurse staffing levels aimed at reducing the risk of residents receiving unsafe, low-quality care.   The OIG emphasizes that higher acuity residents requires higher staffing levels and when staffing deficiencies lead to “grossly substandard care and poor clinical outcomes, the Government may prioritize bringing an enforcement action

Compliance Considerations to identify and mitigate staffing risks:

• Conduct a staffing needs assessment to assess current staff needs and staff competencies based on the current resident population
• Utilize a data driven approach to identify care needs, required skills and staff competencies
• Seek input from the direct care staff to assist in identifying any gaps or lack of resource that impact the ability to meet the care needs of the resident population
• Validate the accuracy of the PBJ staffing reports on an ongoing basis

b) Appropriate Resident Care Plans: The development of person-centered comprehensive care plans aimed at addressing all resident needs and providing activity choices that meet interest and support resident well-being is essential to Quality of Life/Quality of Care compliance. OIG investigations have identified that resident care plans have not always met these requirements and may issue citations when care plans fail to reflect resident’s needs and when services are not provided as established in the plan of care.

Compliance Considerations to identify and mitigate care plan risks:

• Develop care plan policies and staff training that encourage the inclusion of the resident and direct care staff in the interdisciplinary care planning process.
• Conduct ongoing care plan audits to evaluate whether the care needs are appropriately addressed
• Conduct regular rounding to validate implementation of pertinent care plan interventions
• Provide substantive education and training to address any gaps identified

c) Medicare Management and the Appropriate Use of Medications: Poor medication management including inappropriate or overprescribing of medications may result in adverse events and have significant negative consequences. Facilities are required to have systems in place to ensure that each resident’s medication regimen is accurate and appropriately prescribed. Residents should be free from any unnecessary medication, adverse medication events or errors, and medications should be reviewed at least monthly by the consultant pharmacist.

Compliance Considerations to identify and mitigate medication management risks:

• Implement a review process to identify the incidence and frequency of medication errors. Use a QAPI driven systems approach to determine root causes develop processes to prevent recurrence
• Develop processes to audit documentation to validate the support of the appropriateness of high-risk medications, such as psychotropic medications, including antipsychotic and anticonvulsant medications. The documentation should include an indication for use with specific symptoms, conditions, or behaviors that the medication is prescribed to treat.
• Audit MDS accuracy to ensure coding is accurate for each resident and not driven based on a desire to impact the quality measure
• Provide comprehensive IDT training to address any gaps identified

d) Resident Safety: Resident safety is an essential component of high-quality care particularly given the large number of residents who have mobility limitations and chronic medical or behavioral conditions.  Proactive monitoring is critical for abuse and neglect prevention, patient safety, emergency preparedness, infection control and facility-initiated discharges.

Compliance Considerations to identify and mitigate Resident Safety risks:

• Establish and maintain a confidential reporting mechanism for staff, contractors, residents, family members, guardians, visitors, and others to enable confidential reporting—without fear of retaliation.
• Ensure effective communication systems to facilitate the immediate reporting of resident harm to a facility administrator and other officials, including the State Survey Agency, as required by law
• Develop robust systems and processes to proactively monitor adverse events and quality-of-care issues including elopement risk, falls and accidents, and other high risk areas
• Define specific corrective action and a timeline to complete all remedial efforts. Track progress against deadlines and confirm completion of all remedial efforts to prevent recurrence.
• Use prior safety incidents, program lapses and systems gaps as learning experiences.  Develop training and education focused on proactive prevention of future issues

Medicare and Medicaid Billing Requirements

Ensuring compliance with Medicare and Medicaid billing requirements should be a core function of nursing facility compliance program operations. Nursing facilities should take proactive measures to ensure compliance with program rules, including conducting regular reviews to ensure billing and coding practices are current and accurate, as well as performing regular internal billing and coding audits.

Compliance Considerations to Identify and mitigate Medicare Billing Risks:

• Develop and implement a robust Triple Check process to be conducted prior to claims submission to validate compliance with requirements of payment.
• Audit physician certification/recertification processes for timeliness and accurate completion in accordance with the regulations
• Conduct 3^rd-party MDS accuracy audits to confirm that coding accurately reflects residents’ characteristics and comorbidities
• Focus on high-risk areas under PDPM and provide focused competency-based training related to any issues identified during audits. Address MAC-TPE outcomes in education plans in follow up to your facility’s 5-claim probe review and/or other medical review findings from 2024.
• Audit clinical documentation and confirm that services provided to residents are individualized, skilled, and medically necessary and that coding of services reflects services as rendered.
• Assess the accuracy of therapy service provision to validate that service provision is appropriate and meets medical necessity criteria and that services are clearly skilled, individualized and justified for the full intensity and duration of care. If therapy is the primary skilling service for your facility, consider a 3rd party risk assessment consultation which includes conducting therapy treatment observations in addition to documentation reviews.

Contact Proactive for assistance in developing a risk mitigation plan for 2025. Our team of post-acute care consultants can help to drive care quality and reimbursement accuracy through comprehensive care plan reviews, MDS coding audits, clinical program support and Compliance/QAPI Program consultation. Make Proactive part of your team with a budget-friendly Annual Partner Plan in 2025.

[i] Nursing Facility Industry Segment-Specific Compliance Program Guidance

Nursing Facility Industry Segment-Specific Compliance Program Guidance | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services

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