The Office of Inspector General (OIG) determined the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries residing in skilled nursing facilities who had an ER Medicare claim in 2016 with a high-risk diagnosis code, whether these incidents of potential abuse and/or neglect were properly reported by the SNFs, whether the Centers for Medicare and Medicaid Services (CMS) and State Survey Agencies reported findings of substantiated abuse to local law enforcement, and finally the extent to which CMS requires incidents of potential abuse or neglect to be recorded and tracked.

This review encompassed 37.607 high-risk hospital ER claims for 34,820 Medicare beneficiaries residing in SNFs during 2016. The OIG and Survey Agencies reviewed documents detailing incidents and determined if they were the result of abuse or neglect, and if they were found to be so, reported to the Survey Agencies. The OIG also reviewed incidents outside of the sample frame to determine if CMS and the Survey Agencies reported substantiated abuse to local law enforcement. Lastly, the way CMS tracks all incidents of potential abuse and neglect was scrutinized.

OIG discovered that an estimated one in five high-risk ER Medicare claims for treatment provided in calendar year 2016 were the result of potential abuse or neglect, including injuries from unknown sources, of beneficiaries residing in an SNF. SNFs were found to fail to report many of these incidents to Survey Agencies in accordance with applicable Federal requirements. Next, several of those Survey Agencies failed to report some findings of substantiated abuse to local law enforcement. Finally, OIG found that CMS is not insisting that all incidents of aforementioned kind and subsequent referrals be recorded and tracked in the Automated Survey Processing Environment Complaints/Incident Tracking System. There is a failure to meet expectations and fulfill responsibilities from all three organizations.

The OIG has stated that CMS needs to take steps to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are identified and reported by working with Survey Agencies to improve training for staff of SNFs on how to identify and report incidents of potential abuse or neglect, requiring 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, and monitoring the Survey Agencies’ reporting of findings of substantiated abuse to local law enforcement.

Read about the study HERE.