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Nursing homes are intended to be places of comfort and healing. More than 1.4 million individuals live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation. Most nursing homes in the United States are certified to serve as both skilled nursing facilities, which provide a clinically managed recovery period after a person's illness or injury, and long-term care facilities that deliver health care and services a resident needs for mental or physical conditions not rising to the level of skilled nursing care.
Decades of OIG work on nursing homes has uncovered widespread challenges in providing safe, high-quality care. Our audits, evaluations, and investigations have raised concerns regarding staffing levels, background checks for employees, reporting of adverse events experienced by residents, and other issues.
Proper nursing home care requires a partnership involving Federal, State, and local entities, the provider community, residents, and their families. To protect residents, OIG continually assesses nursing home performance and oversight, monitors the impact of program changes, and uses our enforcement tools to address misconduct. Key goals in OIG nursing home oversight are below.
Protect Residents from Fraud, Abuse, and Neglect and Promote Quality of Care
Nursing homes should be environments that are free of harm. However, criminal and civil enforcement actions involving OIG have uncovered misconduct and grossly substandard care in nursing homes. Bad actors perpetrate criminal activity that targets nursing home residents. In other cases, substandard care can result in harm such as costly medical injury, unsafe conditions, and abuse and neglect of residents.
OIG investigates potential violations to hold accountable those who victimize residents of nursing homes. Patient neglect and inadequate care by nursing facilities is a recurring challenge that OIG works with the Department of Justice to address in False Claims Act cases.
Promote Emergency Preparedness and Response Efforts
Nursing home residents and their families rely on facility administrators to plan and execute appropriate procedures during emergency events such as emerging infectious disease outbreaks, natural disasters, and life safety threats. Noncompliance with preparedness requirements and plans can place residents at increased risk of injury or death during an emergency.
In 2020, OIG quickly pivoted to new work to help protect nursing home residents during the pandemic. These individuals are particularly vulnerable to infectious diseases, such as COVID-19, due to their age and underlying medical conditions.
Strengthen Frontline Oversight
State survey agencies are on the front lines for ensuing nursing home quality and safety. States conduct on-site surveys at nursing facilities to evaluate the care they provide and respond to allegations of noncompliance with Federal requirements from residents, their families, staff, and others.
OIG reports have identified shortcomings in State agencies' effectiveness and recommended improvements to strengthen this safety system for nursing home residents.
Support Federal Monitoring of Nursing Homes to Mitigate Risks to Residents
HHS' Centers for Medicare and Medicaid Services (CMS) has an essential, ongoing responsibility to oversee nursing homes and shares with State agencies the responsibility for ensuring that nursing homes meet Federal requirements for quality and safety. CMS oversees the State process for certifying nursing homes and provides guidance to States regarding the survey process.
OIG examines risks to residents' well-being and recommends ways for CMS to better monitor and mitigate these risks. This work often includes assessments of how CMS is—or could be—leveraging data more effectively for oversight and to make risks more transparent to consumers.
The Office of Evaluation and Inspections conducts national evaluations of HHS programs from a broad, issue-based perspective. The evaluations incorporate practical recommendations and focus on preventing fraud, waste or abuse and encourage efficiency and effectiveness in HHS programs. The most recent nursing home-related evaluations are listed below.
- COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020
- CMS Could Improve the Data It Uses To Monitor Antipsychotic Drugs in Nursing Homes
- CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do More
- Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020
- States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018
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- National Background Check Program for Long Term Care Providers: Assessment of State Programs Concluded in 2019
- Some Nursing Homes' Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased
- CMS Did Not Detect Some Inappropriate Claims for Durable Medical Equipment in Nursing Facilities
- A Few States Fell Short in Timely Investigation of the Most Serious Nursing Home Complaints: 2011-2015
- National Background Check Program for Long Term Care Employees: Interim Report
The Office of Audit Services conducts independent audits of HHS programs and/or HHS grantees and contractors. These audits examine the performance of HHS programs and/or grantees in carrying out their responsibilities and provide independent assessments of HHS programs and operations. These audits help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. The most recent nursing home-related audits are listed below.
- California Did Not Ensure That Nursing Facilities Always Reported Incidents of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Prioritize Allegations Properly
- Georgia Generally Ensured That Nursing Facilities Reported Allegations of Potential Abuse or Neglect of Medicaid Beneficiaries and Prioritized Allegations Timely
- Florida Did Not Ensure That Nursing Facilities Always Reported Allegations of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Assess, Prioritize, or Investigate Reported Incidents
- Iowa Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
- North Carolina Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
- Illinois Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
- New Jersey Did Not Ensure That Incidents of Potential Abuse or Neglect of Medicaid Beneficiaries Residing in Nursing Facilities Were Always Properly Investigated and Reported
- North Carolina Did Not Ensure That Nursing Facilities Always Reported Allegations of Potential Abuse and Neglect of Medicaid Beneficiaries and Did Not Always Prioritize Allegations Timely
- Missouri Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
- Florida Should Improve Its Oversight of Selected Nursing Homes' Compliance With Federal Requirements for Life Safety and Emergency Preparedness
View Reports in Progress
During the COVID-19 pandemic, OIG has identified a spike in the number of reports alleging elder harm and neglect. Also, of great concern is the rise in the number of bad actors preying on Medicare and Medicaid beneficiaries during the public health crisis. In response, our Office of Investigations launched an initiative to raise awareness of fraud and abuse in elder care settings. Learn about Operation CARE.
OIG annually publishes the top unimplemented recommendations that, in our agency's view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and public health and safety if implemented. Recommendations concerning nursing homes that were unimplemented as of August 2020 appear in the table below. Find all top unimplemented recommendations of 2020 here.
OIG annually identifies top management and performance challenges HHS faces as it strives to fulfill its mission. View challenges regarding nursing homes.
Recommendation Relevant Report CMS should develop a fraud prevention model specific to emergency ambulance transports from hospitals to skilled nursing facilities (SNFs) to help ensure that payments for these ambulance transports comply with Federal requirements. Medicare Incorrectly Paid Providers for Emergency Ambulance Transports From Hospitals to Skilled Nursing Facilities, A-09-18-03030 (September 2019) CMS should:
- ensure that when SNF claims are being processed for payment, the Common Working File qualifying inpatient hospital stay edit for SNF claims is enabled and operating properly to identify SNF claims ineligible for Medicare reimbursement;
- require hospitals to provide a written notification to beneficiaries whose discharge plans include post-hospital SNF care, clearly stating how many inpatient days of care the hospital provided and whether the 3-day rule for Medicare coverage of SNF stays has been met (if necessary, CMS should seek statutory authority to do so);
- require SNFs to obtain from the hospital or beneficiary, at the time of admission, a copy of the hospital's written notification to the beneficiary and retain it in the beneficiary's medical record (if necessary, CMS should seek statutory authority to do so);
- require SNFs to provide written notice to beneficiaries if Medicare is expected to deny payment for the SNF stay when the 3-day rule is not met (if necessary, CMS should seek statutory authority to do so);
- educate hospitals about the importance of explicitly communicating the correct number of inpatient days to beneficiaries and whether the inpatient days qualify subsequent SNF care for Medicare reimbursement so that beneficiaries understand their potential financial liability related to SNF care; and
- educate SNFs about their responsibility to submit accurate and valid claims for payment that are supported with documentation that clearly shows that the SNF services qualify for reimbursement.
CMS Improperly Paid Millions of Dollars for Skilled Nursing Facilities When the Medicare 3-Day Inpatient Hospital Stay Requirement Was Not Met, A-05-16-00043 (February 2019) CMS should modify the payments for hospice care in nursing facilities. Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio, OEI-02-16-00570 (July 2018) CMS should:
- evaluate the extent to which Medicare payment rates for therapy should be reduced,
- change the method for paying for therapy, and
- adjust Medicare payments to eliminate any increases that are unrelated to beneficiary characteristics.
The Medicare Payment System for Skilled Nursing Facilities Needs To Be Reevaluated, OEI-02-13-00610 (September 2015) CMS should seek legislation to adjust critical access hospital swing-bed reimbursement rates to the lower SNF rates. Medicare Could Have Saved Billions at Critical Access Hospitals if Swing-Bed Services Were Reimbursed Using the Skilled Nursing Facility Prospective Payment System Rates, A-05-12-00046 (March 2015) CMS should facilitate access to information necessary to ensure accurate coverage and reimbursement determination. Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents, OEI-07-08-00150 (May 2011)
Recommendation Relevant Report CMS should:
- work with the Survey Agencies to improve training for staff of SNFs on how to identify and report incidents of potential abuse or neglect of Medicare beneficiaries,
- require the Survey Agencies to record and track all incidents of potential abuse or neglect in SNFs and referrals made to local law enforcement and other agencies,
- monitor the Survey Agencies' reporting of findings of substantiated abuse to local law enforcement, and clarify guidance to clearly define and provide examples of incidents of potential abuse or neglect.
Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated, A-01-16-00509 (June 2019) CMS should:
- reconsider its position on permitting State agencies to certify nursing homes' substantial compliance on the basis of correction plans without obtaining evidence of correction for less serious deficiencies (deficiencies with ratings of D, E, and F without substandard quality of care);
- revise guidance to State agencies to provide specific information on how State agencies should verify and document their verification of nursing homes' correction of less serious deficiencies before certifying nursing homes' substantial compliance with Federal participation requirements;
- revise guidance to State agencies to clarify the type of supporting evidence of correction that should be provided by nursing homes with or in addition to correction plans;
- strengthen guidance to State agencies to clarify who must attest that a correction plan will be implemented by a nursing home;
- consider improving its forms related to the survey and certification process, such as the Forms CMS-2567, CMS-2567B, and CMS-1539, so that surveyors can explicitly indicate how a State agency verified correction of deficiencies and what evidence was reviewed; and
- work with State agencies to address technical issues with the ASPEN CMS Automated Survey Processing Environment system for maintaining supporting documentation.
CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs To Be Improved To Help Ensure the Health and Safety of Nursing Home Residents, A-09-18-02000 (February 2019)
Last Updated: 06-23-2021