Potentially Preventable Hospitalizations of Medicare-Eligible Skilled Nursing Facility Residents

Be prepared for audits of inpatient hospitalizations with explanations of attempted prevention.

The Centers for Medicare & Medicaid Services (CMS) and its contracted auditors are turning their watchdog eyes toward nursing homes, critical access hospitals (CAHs), and acute-care hospitals.

In October 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a new audit project titled “Potentially Preventable Hospitalizations of Medicare-Eligible Skilled Nursing Facility Residents.”

OIG identified nursing facilities with high rates of Medicaid resident transfers to hospitals for urinary tract infections (UTIs). The OIG described UTIs as being “often preventable and treatable in the nursing facility setting without requiring hospitalization.” A 2019 OIG audit found that nursing facilities often did not provide UTI detection and prevention services in accordance with resident care plans, thereby increasing the chances for infection and hospitalization. In addition to UTIs, OIG noted that previous CMS studies found that five conditions were related to 78 percent of the resident transfers to hospitals: pneumonia, congestive heart failure, UTIs, dehydration, and chronic obstructive pulmonary disease (COPD)/asthma. OIG added that sepsis is considered a preventable condition when the underlying cause of sepsis is preventable.  

OIG’s new audit project will involve a review of Medicare and Medicaid claims related to inpatient hospitalizations of nursing-home residents with any of these conditions. The audit will focus on whether the nursing homes being audited provided services to residents in accordance with the residents’ care plans and related professional standards (or whether the nursing homes caused preventable inpatient admissions due to non-compliance with care plans and professional standards).

What can you do to prepare for these upcoming audits? Review your facilities’ policies, procedures, and practices germane to the identification of the conditions OIG flagged as preventable. Ensure that your policies and procedures lay out definitive steps to prevent or try to prevent these afflictions. Educate and train your staff of detection, prevention, treatment, and care planning related to the conditions. Collect and analyze data of trends of frequency and cause of inpatient hospitalizations and determine whether they could have been prevented – and how.

In summary, be prepared for audits of inpatient hospitalizations with explanations of attempted prevention. You cannot prevent all afflictions, but you can have policies in place to try. As always, it’s the thought that counts – as long as it’s written down.

Programming note: Register now to gain access to Knicole Emanuel’s RACmonitor webcast today on this important topic, “Warning for Acute Care Hospitals: You’re a Target for Overpayment Audits.”