1. Nursing Homes- Facility Reported Incidents & Complaints
Elaine Soong, CMS
August 6, 2019
AHFSA Conference, New Orleans, LA

2. Overview
General issues related to complaints and facility- reported incidents
GAO/OIG reports and Congressional activity
Data related to complaint surveys
Facility reported incidents- Reporting
Timelines for CMS guidance

3. General Comments and State Concerns
Uneven reporting – Over and under-reporting
Which cases?
What information?
Staffing challenges in the state survey agencies
Responding timely to allegations

4. GAO Report – Nursing Home Abuse Investigations in Oregon1
Summary
In Oregon, complaints and facility-reported incidents were investigated by Adult Protective Services, not the State Survey Agency.
What to expect
CMS will be reviewing State policies to assure that they are consistent with Federal requirements.
1GAO. CMS Needs to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations That Persisted in Oregon for at Least 15 Years. GAO R (Washington, DC: April 2019).

5. OIG Report –Using Medicare Data to Identify Potential Abuse and Neglect2
Summary
“CMS did not identify the Medicare claims that indicate potential abuse or neglect because, according to CMS officials, it did not extract data consisting of Medicare claims containing the 17 diagnosis codes related to abuse or neglect. The lack of a data extract impeded the ability of CMS or of public and patient safety organizations to pursue legal, administrative, and other appropriate remedies to ensure the safety, health, and rights of Medicare beneficiaries.”
2HHS-OIG. CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect. OIG-A (Washington, DC: June 2019).

6. OIG Report – Reporting of Potential Abuse/Neglect in Nursing Homes3
Summary
One in five high risk ER Medicare claims were the result of potential abuse/neglect.
SNFs failed to report incidents to SAs.
SAs failed to report substantiated abuse to local law enforcement.
CMS does not track referrals to law enforcement.
3HHS-OIG. Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated. OIG-A (Washington, DC: June2019).

7. OIG Reports What to expect
CMS is revising its interpretive guidance related to reporting potential abuse and neglect. CMS plans to provide examples and clarify existing guidance. Training will be updated accordingly.
CMS will review options for tracking incidents and SA referrals, including to law enforcement.
CMS is exploring options under the COPs for other provider types regarding reporting to law enforcement.

8. Volume of Complaint Surveys – National
Source: QCOR (7/18/19)

9. Average Number of Complaint Surveys Per Facility By State– FY 2018
Source: QCOR (7/18/19)

10. Percentage of Facilities with Deficiencies from Complaint Surveys, All S/S, By State– FY 2018
Source: QCOR (7/18/19)

11. Percentage of Facilities with Deficiencies, S/S=G or Above-National
Source: QCOR (7/18/19)

12. Percentage of Facilities with Deficiencies, S/S=J or Above-National
Source: QCOR (7/18/19)

13. Percentage of Facilities with Defs at Abuse, Neglect, or Exploitation, All S/S
Source: QCOR (7/18/19), Tags F223, F224, F600, F0602, F603

14. Percentage of Facilities with Defs at Abuse, Neglect, or Exploitation, All S/S, By State-FY 2018
Source: QCOR (7/18/19), Tags F223, F224, F600, F602, F603

15. Percentage of Facilities with Defs Related to Responding to Alleged Violations, All S/S
Source: QCOR (7/18/19), Tags F225, F609, F610

16. Percentage of Facilities with Defs Related to Responding to Alleged Violations, All S/S, By State-FY 2018
Source: QCOR (7/18/19), Tags F225, F609, F610
Source: QCOR (7/18/19)

17. Facility Reported Incidents- Reporting
Examples of what is reported
Examples of what information to include in the report

18. Timelines for CMS Guidance
Phase 2/3 Guidance-Appendix PP
Chapter 5 of the State Operations Manual
Available training

19. Questions?