On November 3, 2022, the OIG released the results of a recent inspection of a nursing home by the Texas Health and Human Services (HHS) Office of Inspector General Audit and Inspections Division (OIG Inspections). Findings showed that the facility accurately reported 85 percent of reviewed records; however, the facility lacked standard timekeeping procedures. The inspection objective was to determine whether the direct care licensed nursing hours recorded at the nursing home supported the hours submitted to the US Centers for Medicare & Medicaid Services (CMS) in compliance with federal requirements.
The inspection, which reviewed 964 payroll records dating from January 1, 2021, through June 30, 2021, determined that the facility did not have a consistent process for documenting direct care hours provided by licensed nurses. When questioned about the process, the nursing home managers outlined the facility’s multiple methods to register hours spent with clients. However, each of the outlined methods resulted in errors when tested, resulting in the OIG being unable to verify the accuracy of presented reports. This inconsistent documentation method resulted in over-reporting and under-reporting direct care hours spent with clients, leading to errors in claims sent for payment. To address concerns with the nursing home’s documentation, OIG inspectors recommended the facility implement a quality review process to verify that submitted records are complete and all information is correct.
Inspectors also noted that the nursing home did not keep records of daily staffing for nurses with required information, including the facility name, date, total number of nursing hours, staff schedule, and resident census. The facility is required to post this information in a location accessible to residents, staff, and visitors and maintain this record for no less than two years. OIG inspectors recommended the facility develop a process to collect this data and post the information as required. Staffing accountability and documentation are essential for the OIG to verify that the facility is compensated correctly for delivered services.
Upon providing the inspection results, the nursing home management agreed with all of the Texas OIG inspector’s recommendations, indicating corrective actions would be completed in September 2022.
Issue:
In 2020, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) conducted a review of nursing facility staffing levels for 2018. The report revealed staffing levels varied considerably from day to day, which raised concerns some facilities may not fully meet the needs of their residents. Facilities must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to meet the residents’ needs safely and in a manner that promotes each resident’s rights, physical, mental, and psychosocial well-being. Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered.
Discussion Points:
- Review policies and procedures on maintaining daily nurse staffing data and documentation of direct care hours. Update your policies as needed.
- Train appropriate staff to accurately document and report direct care hours worked. Direct care hours worked by administrative staff should be documented in the payroll records before reporting licensed nursing hours to CMS through the Payroll-Based Journal. Document that these trainings occurred and file in each appropriate employee’s education file.
- Periodically audit to ensure that direct care hours worked are accurately reported to the Payroll-Based Journal as required by CMS. Also audit to ensure payroll records are complete and all information is correct. Observe to ensure that F732 Nurse Staffing Information Posting Requirements in the State Operations Manual Appendix PP is followed and includes daily posting of all required information in a clear and readable format and is located in a prominent place readily accessible to residents and visitors.
