CMS Seeks to Stop Diversion of Some Medicare Advantage Patients from SNFs to Home Health

Table of Content

• Assisted Living
• California nursing homes in high-risk wildfire zones are ill-prepared for emergencies: study
• Protect Residents from Fraud, Abuse, and Neglect and Promote Quality of Care
• Non-Waiver Medicaid Assisted Living and In-Home Care Services
• Support Federal Monitoring of Nursing Homes to Mitigate Risks to Residents
• NY Long Term Home Health Care Program (LTHHC) (HCBS LTHHC Medicaid Waiver)

OIG reports have identified shortcomings in State agencies' effectiveness and recommended improvements to strengthen this safety system for nursing home residents. In 2008, lawmakers created a new nursing home rating system that aimed to streamline information about resident safety, staffing, and "dozens of other metrics" into a star rating system with a high score of five stars and a low score of one star. We're constantly working to make sure the information on Nursing Home Compare is as accurate and informative as possible.

The person looking after him was not told when the man died, or even was informed of his condition after going back to the facility. Top Management ChallengeOIG annually identifies top management and performance challenges HHS faces as it strives to fulfill its mission. In addition to fraud, the Brooklyn-based agency was also cited for cheating aides out of their wages. Engaged in a $2 million fraudulent promissory note scheme when purchasing the facility. New York Attorney General Letitia James sued Cold Spring Hills Center for Nursing Rehabilitation in Woodbury for allegedly diverting over $22.6 million in Medicaid and Medicare funds to the owners' pockets.

Assisted Living

As an example, the Times cites the experience of one nursing home resident, Eunice Hill, at a five-star facility in South Carolina, where medical records indicate that Hill was given a strong antipsychotic on her first day, as well as anti-anxiety medication each day for a week. However, the organization in the data it filed with CMS indicated that it didn't give Hill any antipsychotic medication, and only administered anti-anxiety medication once. Ultimately, Hill died in January 2018, after being rushed to the hospital with kidney failure and severe dehydration in late December 2017. According to the Times, the system when rolled out drew praise from senior-care groups, who said it provided an easily comprehensible snapshot of nursing homes. However, within months of the system's launch, members of a Medicare advisory board warned federal officials that—in an industry with razor-thin margins—the system incentivized nursing homes to misreport their metrics. SSAs are conducting a portion of their unannounced after-hours and weekend inspections to focus on staffing problems during those times.

Billing and PaymentsRecommendationRelevant ReportsCMS should analyze the potential impacts of counting time spent as an outpatient toward the 3-night requirement for skilled nursing facility services so that beneficiaries receiving similar hospital care have similar access to these services. 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. According to the Times, the pandemic hit nursing homes harder than other part of the industry, with nearly one in every 10 nursing home residents dying from Covid-19—and it also suggested that the star-ratings system does little to spotlight which organizations excel at infection prevention and control. In fact, according to the Times, inspectors over a three-year period spotted at least one issue involving potential patient abuse—such as staff acting violently toward residents, or failure to look into injuries—among nearly 1,200 homes with overall five-star ratings.

California nursing homes in high-risk wildfire zones are ill-prepared for emergencies: study

To be eligible, a participant has his or her doctor send a completed Physician´s Order to the local social services district, which then arranges a social and nursing assessment of the individual. A nurse assessor uses the results of the assessments and the physician’s order to recommend an appropriate amount, frequency and duration of services. If you are eligible and have an immediate need for Personal Care Services, more information is available here. In another instance, federal officials categorized the rape of a resident by a staff member at a nursing home in San Diego as a "category F" violation, which designates a lower-level issue that causes "potential, not actual, harm"—and enabled that facility to hold on to its five-star rating. In fact, according to the Times, inspectors determined that incidents of sexual abuse in at least 40 other facilities with five-star ratings did not comprise actual harm or put residents in "immediate jeopardy."

The Clinical Executive Conference will examine trends, challenges and opportunities facing clinical leaders in skilled nursing. CMS solicited comment on various related topics, including how MAOs preauthorize treatment in discrete increments; enrollee timelines to file appeals regarding termination of services; and how reinstatement of services is handled following quality improvement organization decisions. 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.

Protect Residents from Fraud, Abuse, and Neglect and Promote Quality of Care

SSAs will take appropriate enforcement actions against those facilities that fail to provide the required nurse staffing, Verma said. "We're strengthening our enforcement policies to hold nursing homes accountable for the care they provide. As part of this effort, we’re developing new ways to root out bad actors and repeat offenders," Verma said. Real-time last sale data for U.S. stock quotes reflect trades reported through Nasdaq only. Her money will run out all too soon, and she will have to move to a place that takes Medicaid. Does that mean we sign it over at the appropriate time and let Medicaid deal with the problem?

MA organizations will not be restricted in prior authorization and post-claim review, as ways to ensure services meet Medicare coverage rules. CMS raised the issue as part of a proposed rule issued on Dec. 15, stating that MAOs generally cannot apply coverage criteria that is more restrictive than traditional Medicare coverage, as determined by national coverage determination , local coverage determinations and Medicare laws. This also applies to certain “substantive coverage criteria and benefit conditions” that are not governed by an NCD or LCD, including transfers to post-acute settings. 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.

CPSC warns that ‘bomb cyclone’ storm raises risk of carbon monoxide death

In a statement, James said that "Cold Spring Hill's owners put profits over patient care and left vulnerable New Yorkers to live in heartbreaking and inhumane conditions," and encouraged anyone who witnessed some of the alleged abuse and neglect to contact her office. 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. In the lawsuit, filed in California's Superior Court, prosecutors claimed that the organization misrepresented its staffing levels, particularly the hours worked by RNs, and incorrectly discharged and transferred residents to make room for residents who would generate a greater profit. According to the Times, the lawsuit seeks civil penalties—which under California law, in this case, could total $5,000 per violation since seniors and individuals with disabilities are involved—and an injunction against future instances of illegal conduct. Another issue the Times citing in its investigation was imprecisely reported staffing levels, which could mislead consumers about how much time staff is able to spend with each patient or resident.

Ultimately, the Times' investigation found the Covid-19 fatality rate at five-star facilities was just half a percentage point lower than at facilities with lower ratings—and in fact, the fatality rate was slightly lower at two-star facilities than at four-star facilities, the Times reports. The Centers for Medicare & Medicaid Services has launched a review of regulations and processes governing safety and quality of care in the nation's nursing homes, Administrator Seema Verma said. It will still be subject to Medicaid estate recovery, but the net rental income would go to the nursing home, reducing Medicaid’s outlay and ultimate estate recovery claim.

The SSAs visit and survey every Medicare and Medicaid participating nursing home in the nation at least annually to ensure they are meeting CMS' health and safety requirements as well as state licensure requirements. “Ensuring that nursing home emergency preparedness is commensurate with local environmental risks is important for safe-guarding residents,” they added. “Our study suggests that there may be opportunities to better align nursing home emergency preparedness with local wildfire risk,” first author Natalia Festa, of Yale University School of Medicine, said in a statement. Family members of residents reported unclean facilities and broken critical care equipment such as wheelchairs and showers. Residents were routinely neglected, suffered improper wound care, and were not provided adequate nutrition, medication or sanitation, according to the press release. Even before the pandemic, the suit alleges that the owner repeatedly cut staffing at the 588-bed facility, leading to poor working conditions and endangering the residents to potential harm.

In some states, you can shelter these funds for your mother’s benefit in a “pooled disability” or “” trust managed by a nonprofit. This is unlikely to save the money for you because the funds still will be subject to Medicaid estate recovery, but they could be used for whatever might enhance your mother’s life during her remaining years. As fall comes to a close and winter ushers in, the federal government is reminding nursing home operators that they must provide residents access to the latest Covid vaccines and treatment. The report alleges the 588-bed facility used 13 companies and three fraudulent schemes to create the appearance of paying for services for the nursing home when in fact the money was diverted for personal profit, according to the Dec. 16 press release.

Support Federal Monitoring of Nursing Homes to Mitigate Risks to Residents

Providers should also use objective, clear, clinical quality data—such as from The Post-Acute Pathways Explorer—to ensure a common starting point on facility performance. The program provides housekeeping, meal preparation, bathing, toileting, and grooming services. For Medicaid-eligible persons, local social services districts usually contract with home-care agencies that employ aides to provide Medicaid-funded personal care services.

California nursing homes were most likely to be deficient in their use of emergency and standby power systems, the researchers observed. Among the 1,182 facilities identified, the authors then determined that 495 sites were considered “exposed” and 687 were “unexposed.” They defined exposed as those homes with “moderate” to “very high” wildfire risk, using designations from the California Office of the State Fire Marshal. A study conducted by the Commonwealth Fund last month found that if vaccination continued at its current pace, the country faced a potential winter surge of Covid infections that could result in 16,000 hospitalizations and 1,200 deaths per day by March 2023. Another patient who was there for five months after a stroke said she only received three showers in that time. A man who was badly injured in a car crash lost 30 pounds as a result of the care at the rehab center, according to the attorney general, and his condition worsened during his time there. He would later be admitted to the hospital for severe malnutrition, dehydration, a worsening pressure injury and a bone infection in his right foot.