Fraud, Waste, and Abuse: Deficiency Citations and Severity Levels in Pressure Injuries
Jeannine LeCompte, Compliance Research Specialist
The extent to which a Skilled Nursing Facility (SNF) is exposed to charges of fraud, waste, and abuse in terms of noncompliance to the prevention and treatment of pressure injures has been categorized by section F686 of the Public Health Act.
Should a facility be accused of providing services under Medicaid and Medicare which are classed as “worthless”—in that they have not properly prevented or treated pressure injuries, the Office of Inspector General (OIG) will launch a formal investigation.
Once this investigation has been completed and the data reviewed, the investigators then determine the severity of the deficient practice(s) and the resultant harm or potential for harm to the resident.
Should that investigation find that there has indeed been a transgression, the OIG uses four “severity levels” in determining the seriousness of the offences. The key elements which the OIG uses in determining these levels are:
- The degree of harm (actual or potential) related to the facility’s noncompliance. This includes the level of serious injury, impairment, death, compromise or discomfort, or the potential therefore.
- The immediacy of correction required.
First, the investigators must determine whether the most severe level—Level 4—“Immediate Jeopardy” exists. Breaches at this stage can have severe consequences for both staff and the facility.
Severity Level 4 is defined as “Immediate Jeopardy to Resident Health or Safety” and occurs when the facility’s noncompliance has resulted in, or is likely to cause, serious injury, harm, impairment, or death to a resident. Residents admitted with Stage 4 pressure ulcers are also classed under this category when the injuries have shown no signs of healing.
If immediate jeopardy is ruled out, then an OIG investigation will switch to “Level 3” categorization.
Level 3 is defined as noncompliance that results in actual harm, and can include, but may not be limited to, clinical compromise, decline, or the resident’s ability to maintain and/or reach his/her highest practicable well-being.
Examples of avoidable negative outcomes may include, but are not limited to, the development of avoidable Stage 3 pressure ulcer(s); the failure to provide for pressure redistribution, or inappropriate treatment/dressing changes, a wound increased in size or failed to progress toward healing as anticipated, or the resident experienced untreated pain.
If none of these apply, then an OIG investigation will look at “Level 2” considerations, which are defined as “No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy.”
This means that noncompliance has resulted in minimal discomfort and/or has the potential to compromise the president’s ability to maintain or reach his/her highest practicable level of well-being.
“Level 1” is the least onerous, and is the result of noncompliance which leads to “an avoidable Stage 1 pressure ulcer,” which is defined as an injury with “No Actual Harm with Potential for Minimal Harm.”
Although Severity Level 1 pressure injuries are not formally counted as infractions, they are indicative of a systematic problem, and no facility should ignore them.
It is highly damaging for a facility to be investigated for these infractions, and only the strict application of compliance tools and regular staff training provides an effective countermeasure. All SNFs should have, as a matter of course, auditing tools, reporting procedures, and upward feedback procedures in place to ensure the highest quality of care—and to provide legal protection.
