16 Feb In two Program Guidances, the OIG described four broad categories of risk areas unique to nursing facilities. What are they? Exp
Please answer the following 2 questions. Thank you!
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1. In two Program Guidances, the OIG described four broad categories of risk areas unique to nursing facilities. What are they? Explain each.
2. Nursing facilities are advised to concentrate their compliance efforts on their “risk areas.” What are a couple ways that a facility can determine what its risk areas are?
Please provide comprehensive responses to demonstrate that you understand the material
Chapter 17
Nursing and Long Term Care Facilities
Learning Objectives
Familiarity with LTC facility types and services
Appreciate scope of nursing facility industry
Compliance program mandate for nursing facilities
Benefits of a compliance program for a nursing facility
Primary compliance risk areas in nursing facilities
Prevalence of fraud in nursing facilities industry
Introduction
The terms “nursing facility” and “long term care facility” encompass a wide range of institutions designed to meet different needs of elderly, disabled, and terminally ill people.
Nursing home
Independent living community
Assisted living facility
Residential care facility
Compliance Program Mandate
The health reform law of 2010 requires that nursing facilities implement a compliance program designed to prevent/detect legal violations and promote quality of care.
Recommended 8 components of a program.
Compared to OIG’s 7-component program.
OIG will review nursing homes’ implementation of compliance plans.
Benefits to a Nursing Facility of a Compliance Program
While nursing facilities have a legal obligation to operate a compliance program, they also benefit in several ways from compliance activities.
Fewer false or inaccurate claims
Facilitate reports of potential problems
Speedy correction, fewer legal problems
Demonstrates good corporate citizenship
Improve quality of care
Basic Elements of Good Compliance Programs
Written standards, policies, and procedures
Compliance Officer and Compliance Committee
Training and Education
Lines of Communication
Auditing and Monitoring
Disciplinary Guidelines
Responding to Misconduct
Risk Areas Unique to Nursing Facilities
Quality of care
Resident safety
Residents’ rights
Submission of accurate claims
Federal Anti-Kickback Statute
Stark Physician Self-Referral
Supplemental payments
Medicare Part D enrollment
HIPAA privacy and security
7
Quality of Care
Areas of concern described in OIG Program Guidances for Nursing Facilities (2000)
Quality risk areas added in 2008
Sufficient staffing
Comprehensive resident care plans
Medication management
Psychotropic medications
Resident Safety
Promote resident safety
Monitor resident interactions
Screen facility employees
Residents’ Rights
discriminatory admission/denial of access to care.
verbal, mental or physical abuse, corporal punishment and involuntary seclusion.
inappropriate use of physical/chemical restraints.
failure to ensure that residents have personal privacy and access to their personal records.
denial of a resident’s right to participate in care and treatment decisions.
failure to safeguard residents’ financial affairs.
Submission of Accurate Claims
Inaccurate reporting of resident case-mix
Improper utilization of therapy services
Goods or services furnished by an individual or entity that has been excluded
Restorative and personal care services to residents
Federal Anti-Kickback Statute (I)
Provision of free goods or services to an existing or potential referral source.
Provision or receipt of goods or services at non-FMV rates
Arrangements with physicians to provide medical director, quality assurance, and other services
Federal Anti-Kickback Statute (II)
Discounts offered to customers that submit claims to Federal health care programs
Hospice offer of free nursing services for non-hospice patients to induce referrals of hospice patients
Hospital payments to reserve beds in nursing facilities to induce referrals of patients from the nursing facilities to the hospital
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