OIG Record Reviews

Angie SzumlinskiUncategorized

The OIG via the Office of Evaluation and Inspection (OEI) is requesting medical records from long-term care facilities for residents re-hospitalized within 35 days of admission.  All of us have heard about the CMS directives and everyone is working very hard at identifying the root cause of the readmission phenomenon.  We as providers are still in a precarious position as it relates to caring for the frail elderly and should still remember that their health and safety is our first concern.

The goal of the OEI is to access records at a minimum of 800 nursing facilities including SNFs, IRFs and LTC hospitals.  The auditing process will involve the use of a trigger tool modeled after an acute care tool.  The goal of the audit is to assess the hospital discharge process including the communication and collaboration with the post-acute care provider. 

Now that you know what the OEI focus is, do you know what your monthly re-hospitalization rate is?  Is your rate above the national average?  HealthCap Risk Management recommends that you consider performing a root cause analysis on re-hospitalization rates in you facility.  Consider using the following as a guide for developing your internal audit tool:

·        How many re-hospitalizations does your facility average per month?

·        How many of these re-hospitalizations were within 35 days of admission?

·        What is your internal referral review process and who is involved in making the decision to accept or deny a referral?

·        How is the communication with the referral source managed?  Is it electronic? 

·        Once a referral is accepted what is the process for preparing for the arrival?  Do we have a checklist identifying needed equipment, etc.?

·        Do your managers visit resident rooms prior to admission to ensure equipment and safety/assist devices are readily available? 

·        If higher acuity is the goal, has an analysis of staffing been performed to assist in meeting the needs of higher acuity?

·        Is licensed staff adequately trained in new techniques (i.e., PIC lines, trachs, etc.)?

·        What is your process for monitoring subtle/significant changes in medical condition?

·        Is licensed staff trained to assess for changes in condition and what to do to prevent continued decline?

·        Are your physicians and physician extenders on board with avoiding re-hospitalizations when safe to do so?

·        What about resident, family and staff satisfaction in the first 35 days?  Do you have a hospitality model that encourages open communication, grievance   resolution and overall satisfaction?

·        Did you know that many claims occur with <35 days of admission?  When was the last time you “checked the climate” on the units?  Is there obvious dissatisfaction?  Are the units overly quiet? 

This is not an all inclusive list however it serves as a springboard to develop a process of self-evaluation.  Remember we can and should be ahead of governmental audits so that if you are the lucky one that gets a knock on the door you are prepared.  If you have additional questions or would like assistance with the process of root cause analysis for re-hospitalizations under 35 days please contact your HealthCap risk manager.  Also, watch for the HealthCap annual seminar series for 2013 which focuses on this hot topic!