Does a high number of nursing home resident readmissions to hospitals (i.e., for pneumonia, chronic obstructive pulmonary disease, and heart disease) support potential fraud, waste and abuse allegations based upon substandard quality of care and the subsequent submission of false claims for reimbursement in violation of the False Claims Act?
Compliance Perspective – Readmissions
Policies and Procedures: The Compliance and Ethics Officer with the DON must review the appropriateness of all policies and procedures that potentially reduce readmissions to hospitals. Training: Staff must be trained to adequately assess hospital readmission risk factors in accordance with policies and procedures. Staff should receive training about the most common diagnoses requiring hospital readmission, early identification of resident health changes, and interventions designed to prevent rehospitalization in order to ensure their competency. Audit: An audit will be conducted periodically to assess the quality of care provided for residents who were readmitted to hospitals within 30 days of admission to the nursing home as well as those residents who were not readmitted, and to ensure everything was done in accordance with the provider’s policies and procedures. The results of the audit will be summarized and submitted to the QAPI Committee for evaluation and recommendation, and to the Compliance and Ethics Committee for follow-up.
A recent report from the Centers for Medicare & Medicaid Services (CMS) determined that too many patients from July 2014 to July 2017 were returned to the hospital for care within the month after being discharged. Medicare payments, as a result, will be reduced by $12 million at 66 Indiana hospitals next year. CMS decided that only 17 Indiana hospitals would not be penalized. Thirty-seven other hospitals were deemed exempt from penalties based upon the populations served.
The patients studied had initially been hospitalized for various reasons including, but not limited to, heart failure, heart attacks, pneumonia, chronic lung disease, hip and knee replacements and coronary-artery bypass graft surgeries.
Indiana’s Community Health Network reported that many hospital readmissions came from nursing homes, and involved residents with severe conditions such as pneumonia, chronic obstructive pulmonary disease and heart disease. Community Health Network officials are attempting to reduce the readmissions by “sending community nurse practitioners, pharmacists and social workers to the homes of discharged patients to ensure they continue to receive proper care.”
