The Office of the Inspector General found substandard care at a number of skilled nursing facilities. Their investigation found the following:
For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet
discharge planning requirements. Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements.
Based on these findings, OIG made the following recommendations:
- Strengthen the regulations on care planning and discharge planning. CMS should require SNFs to document in the medical records the reasons why they did not provide services in accordance with the care plans
- Provide guidance to SNFs to improve care planning and discharge planning.
- Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable. CMS should provide more detailed guidance to surveyors to improve the detection of noncompliance, particularly for discharge planning. Specifically, CMS should revise its interpretive guidelines in the SOM and train surveyors to ensure that they cite facilities that are not developing individualized care plans or are not developing specific discharge plans that involve an interdisciplinary team, including a physician.
- Link payments to meeting quality-of-care requirements. CMS should incorporate quality measures for care planning and discharge planning in its Skilled Nursing Facility Value-Based Purchasing program
- Follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality care. OIG will provide a list of SNFs that failed to meet these requirements in this survey and will ask CMS to provide the list to State Survey and Certification agencies.
One question is how well the study actually measures quality. The analysis was based on a medical record review of only 190 stays. Further, much of the concerns over quality of care deal with poor documentation of care quality rather than actual care quality. For instance, the authors note that many SNFs did not provide plans of care or document discharge plans. Sometimes therapy was provided without justification. Justifying the therapy need in the record is ideal, but failure to indicate a need does not necessarily mean that the patient does not have any need. Although care plans and discharge plans these are best practices, documenting quality of care is not the same as actual quality of care.
Some of the quality of care issues, however, are certainly real.
For example, in one stay, the SNF made no plans to monitor a beneficiary’s use of antipsychotic medication that had potentially severe adverse reactions. In another stay, the SNF did not address the psychosocial needs of a beneficiary who had anxiety and made repeated health complaints.
Overall, however, actual quality of care problems appear less prevalent. The medical reviewers identified three instances in which SNFs provided poor wound care that may have resulted in the beneficiaries’ condition worsening and five instances in which SNFs did not appropriately manage beneficiaries’ medications. Although ideally quality of care should be 100 percent, this translates into a 4.2 percent poor care rate. There were other instance where therapy was overused, but this indicates overprovision of care rather than a lack of quality.