Fraud, Waste, and Abuse: Determination of Compliance with Regard to Pressure Injuries

Jeannine LeCompte, Compliance Research Specialist

Regulation F686 of the Public Health Act requires all Skilled Nursing Facilities (SNF) to prevent the development of pressure ulcer(s) in a resident who is admitted without pressure ulcer(s), “unless the development is clinically unavoidable.” In addition, the SNF is required to “provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.”

A failure to provide these basic requirements will constitute an offense under the fraud, waste, and abuse category of “worthless” services paid for under Medicaid or Medicare. When investigating a breach of these requirements, the Office of Inspector General (OIG) will pose—and answer—the following questions in determining compliance.

For a resident who developed a pressure ulcer after admission, have the staff:

Recognized and assessed specific risk factors and changes in condition that may place the resident at risk for developing a pressure ulcer/pressure injury (PU/PI)?
Defined and implemented interventions for PU/PI prevention in accordance with resident needs, goals, and recognized standards of practice?
Monitored and evaluated the resident’s response to preventive efforts, and revised the approaches as appropriate?
Implemented, monitored, and modified interventions to attempt to stabilize, reduce or remove underlying risk factors; and
Provided treatment to heal it and prevent the development of additional PU/PIs.

For a resident who was admitted with an existing pressure ulcer, or who has one that is not healing, or who is at risk of developing subsequent pressure ulcers, an OIG inspection will determine if the facility is in compliance and if the staff:

Recognized and assessed factors placing the resident at risk of developing a new pressure ulcer or experiencing non-healing or delayed healing of a current pressure ulcer;
Defined and implemented interventions for pressure ulcer prevention and treatment;
Addressed the potential for infection;
Monitored and evaluated the resident’s response to preventive efforts and treatment interventions; and
Revised the approaches as appropriate.

Risk factors include, but are not limited to:

Impaired/decreased mobility and decreased functional ability;
Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus;
Drugs such as steroids that may affect healing;
Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency;
Resident refusal of some aspects of care and treatment;
Cognitive impairment;
Exposure of skin to urinary and fecal incontinence;
Under nutrition, malnutrition, and hydration deficits; and
The presence of a previously healed PU/PI.

Basic or routine care could include, but is not limited to, interventions to:

Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);
Minimize exposure to moisture and keep skin clean, especially of fecal contamination;
Provide appropriate, pressure-redistributing, support surfaces;
Provide non-irritating surfaces; and
Maintain or improve nutrition and hydration status, where feasible.

Noncompliance for F686 may include (but is not limited to) one or more of the following, including failure to:

Accurately or consistently assess a resident’s skin integrity on admission and as indicated thereafter;
Identify a resident at risk of developing a pressure ulcer(s);
Identify and address risk factors for developing a pressure ulcer, or explain adequately why they could not or should not do so;
Implement preventive interventions in accord with the resident’s needs and current standards of practice;
Provide clinical justification for the unavoidable development or non-healing/delayed healing or deterioration of a pressure ulcer;
Provide appropriate interventions, care, and treatment to an existing pressure ulcer to minimize infections and to promote healing;
Implement interventions for existing wounds;
Notify the physician of the resident’s condition or changes in the resident’s wound(s);
Adequately implement pertinent infection management practices in relation to wound care; and
Identify or know how to apply relevant policies and procedures for pressure ulcer prevention and treatment.
Identify whether pain, if present, is being adequately controlled.

Once again, it is clear that compliance with these regulations requires the creation and enforcement of audit tools. It is an investment which can reap huge dividends, both in reputational terms and, ultimately, in keeping the facility from being closed down.