The US Department of Health and Human Services (HHS) Office of Inspector General (OIG) has announced that they will be enhancing their focus on potentially preventable hospitalizations of Medicare-eligible skilled nursing facility (SNF) residents.
Prior OIG work identified SNFs with high rates of Medicaid enrollee transfers to hospitals for a urinary tract infection (UTI), a condition that is often preventable and treatable in the nursing facility setting without requiring hospitalization. The audits disclosed that the SNFs often did not provide UTI prevention and detection services in accordance with its residents’ care plans, increasing the residents’ risk for infection and hospitalization.
Previous Centers for Medicare & Medicaid Services (CMS) studies found that five conditions (pneumonia, congestive heart failure, UTIs, dehydration, and chronic obstructive pulmonary disease/asthma) constituted 78 percent of the long-term care resident transfers to hospitals.
Additionally, sepsis is often considered a preventable condition when the underlying cause of sepsis is preventable.
The OIG’s review of claims showed that SNF residents often present with one of these six conditions (pneumonia, congestive heart failure, UTIs, dehydration, chronic obstructive pulmonary disease/asthma, and sepsis) on inpatient hospitalization. The OIG will review inpatient hospitalizations of SNF residents with any of these six conditions and determine whether the SNF provided services to residents in accordance with their care plans and professional standards of practice (42 CFR § 483.21 and 42 CFR § 483.25).
Issue:
Facilities must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Facility staff should be aware of each resident’s current health status and regular activity, and be able to promptly identify changes that may indicate a change in health status. Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff who is involved. It is critical to identify potential issues early so that interventions can be applied to prevent a condition from worsening or becoming acute. Staff are expected to know how to identify residents’ changes in conditions, and what to do once one is identified.
Discussion Points:
- Review your policies, procedures, and staffing guidelines to ensure they are designed to result in provision of quality care for residents. Review your Facility Assessment as required by F838 to ensure it addresses the needs of all residents. Update your policies and Facility Assessment as necessary.
- Train staff on their responsibility to provide safe, high quality nursing care, or to provide support services that help meet resident needs. Train staff to create and learn baseline information for residents and to be able to use the information to compare behavior and activity levels each day to identify slight or obvious changes that may signal the start of a change in condition.
- Periodically audit to ensure staff are following policies for delivering safe, quality nursing care and support services. Ensure your Facility Assessment is current, thoroughly assesses the needs of all residents, and determines the resources required to provide high quality resident care and services. Audit resident care plans to ensure they are regularly followed and updated as needed.
