The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released its Work Plan for 2013. The publication summarizes the new and ongoing reviews that OIG plans to pursue with respect to HHS programs.
The purpose of the Work Plan is to safeguard the integrity of the Medicare and Medicaid programs and the health and welfare of their beneficiaries.
OIG repeatedly emphasizes these core values: integrity, credibility, and impact; that is, ensuring providers act with independence and objectivity, build on a tradition of excellence and accountability, and yield results that are tangible and relevant.
With respect to skilled nursing facilities (SNFs), the Work Plan highlights three new areas of inquiry and five carryover items from 2012.

New Items

■ State agency verification of deficiency corrections. OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing home recertification surveys. Per federal regulations, nursing homes are required to submit correction plans to the state survey agency or CMS for deficiencies identified during surveys. CMS then requires state survey agencies to verify the correction of identified deficiencies through onsite reviews or by obtaining other evidence of correction.

■ Use of atypical antipsychotic drugs. Nursing homes must comply with federal quality and safety standards, including requiring the monitoring of the prescription drugs prescribed to its residents.
OIG will assess nursing homes’ administration of atypical antipsychotic drugs, including the percentage of residents receiving these drugs and the types of drugs most commonly received.

OIG will be looking for similar characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs.

■ Oversight of the Minimum Data Set submitted by long term care facilities. Nursing homes are required to complete the Minimum Data Set (MDS) for all residents at specified intervals and submit data electronically to the state. States then submit data to CMS, which uses it for its various programs, including payment, quality monitoring, and consumer information. OIG will determine whether CMS and states oversee the accuracy and completeness of MDS data submitted.

Carryover Items

The following summarizes the list of items that OIG has carried over from the 2012 Work Plan:

■ Adverse events in post-acute care for Medicare beneficiaries. OIG will study the national incidence of adverse events for Medicare beneficiaries receiving post-acute care in SNFs as well as contributing factors to these events. One primary focus will be to determine the extent to which the events were preventable and estimate the associated costs to Medicare.

■ Medicare requirements for quality of care in skilled nursing facilities. OIG will review how SNFs have addressed federal quality of care initiatives. One focus will be on using the Residential Assessment Instrument (RAI) to develop care plans to provide services to beneficiaries in accordance with the plans of care and to plan for discharges.

OIG will also describe any instances of poor quality of care. This item comes as a result of a study that revealed that about a quarter of residents’ needs for care, as identified through RAIs, were not reflected in care plans.

■ Oversight of poorly performing facilities. OIG will identify poorly performing nursing homes and determine the extent to which CMS and states use enforcement measures to improve nursing home performance.

Additionally, OIG will examine CMS and states’ follow-up actions and enforcement decisions by CMS and states resulting from surveys and complaint allegations.

■ Hospitalizations of nursing home residents. OIG will have renewed focus on the extent to which hospitalizations were a result of manageable or preventable conditions. OIG believes hospitalizations are indicative of quality-of-care problems in nursing homes.

■ Questionable billing patterns for Part B services during nursing home stays. OIG will continue to review questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided. Congress specifically directed OIG to monitor these services for abuse.

OIG will study podiatry, ambulance, laboratory, and imaging services.

Health care providers need to monitor the regulatory changes and act appropriately. This means providers should reach out and seek advice on how to begin adapting to the new culture of compliance required by OIG.
Elliot Zemel is a health care attorney and can be reached by e-mail at