An Office of Inspector General (OIG) audit found that California did not ensure that nursing facilities always reported incidents of potential abuse or neglect of Medicaid beneficiaries transferred to hospital emergency departments. In addition, the OIG also found in their audit that California did not always comply with requirements for prioritizing allegations.
The objective of the OIG audit that was released on June 9, 2021, was to determine whether California ensured that nursing facilities reported incidents of potential abuse or neglect of for transfers to hospital emergency departments, and if California complied with Federal requirements for recording, prioritizing, and investigating allegations of abuse or neglect.
The audit covered 4,965 claims with selected diagnosis codes for Medicaid beneficiaries who resided in California nursing facilities and were transferred to hospital emergency departments from July through December 2017. A statistical sample consisted of 18 incidents with diagnosis codes that indicated a significant risk of abuse or neglect and 100 incidents with diagnosis codes that indicated risk of abuse or neglect.
Of the 118 sampled incidents reviewed, 81 were not the result of potential abuse or neglect; therefore, nursing facilities were not required to report those incidents to the State. However, of the remaining 37 incidents, 8 were the result of potential abuse or neglect and should have been reported to the State. Two of those were reported in a timely manner, four were not reported in a timely manner, and two were not reported to the State at all.
Although California did issue guidance to nursing facilities on the proper reporting of potential abuse or neglect, facilities did not always report incidents, or did not report them in a timely manner. For the other 29 incidents, nursing facilities provided documentation that did not contain sufficient information to determine whether the incidents were the result of potential abuse or neglect; therefore, the State was unable to determine whether the requirements for reporting were met.
Additionally, the OIG audit found that California complied with Federal requirements for recording allegations of abuse or neglect and generally complied with requirements for investigating allegations; however, it did not always comply with requirements for prioritizing allegations. Specifically, of the 118 sampled incidents, the State received 16 allegations. Eight were properly prioritized by the State, but eight were not. According to State officials, changes in CMS requirements contributed to inconsistencies in prioritizing complaints.
The OIG recommended the following to California:
- Strengthen guidance to nursing facilities on reporting incidents of potential abuse or neglect of Medicaid beneficiaries, and
- Ensure that its staff are regularly trained on updated Federal and State requirements to ensure that appropriate priorities are assigned to allegations of abuse or neglect.
California agreed with both of the OIG’s recommendations and described actions that it planned to take to implement the recommendations, including issuing a notice to remind nursing facilities of their obligation to report incidents of potential abuse or neglect, and developing new training material for field staff.
The OIG’s Full Report can be accessed at: California Did Not Ensure That Nursing Facilities Always Reported Incidents of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Prioritize Allegations Properly, A-09-19-02005 (hhs.gov).
The OIG’s Report in Brief can be accessed at: California Did Not Ensure That Nursing Facilities Always Reported Incidents of Potential Abuse or Neglect of Medicaid Beneficiaries and Did Not Always Prioritize Allegations Properly, A-09-19-02005 (hhs.gov).
Issue:
All leaders of nursing facilities must be able to recognize abuse and neglect and know the steps that should be taken when mistreatment is suspected. If abuse is not reported in the appropriate time frame, it can be seen as immediate jeopardy with harm, and be considered provision of substandard quality of care, resulting in sanctions and civil or criminal charges.
Discussion Points:
- Review your policies and procedures on abuse and neglect and the reporting of abuse. Update them as necessary.
- Train all staff on what is considered abuse and neglect, and the steps that should be taken when it is suspected. Offer the training during new employee orientation, repeat at least annually, and more often if needed. Document that the training occurred, and record in each employee’s education file.
- Periodically audit staff understanding to ensure that they are aware of the steps that should be taken if they suspect abuse or neglect, and their reporting options, including accessing the anonymous hotline if necessary. Additional information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 7 Resident Rights, Policy RR 1.1 Freedom from Abuse, Neglect, and Exploitation.
