CMS revises standards to strengthen oversight of nursing home inspections

As part of CMS’s efforts to improve nursing home resident safety and respond to concerns about inconsistent and untimely inspections, CMS has revised the State Performance Standards System (SPSS) process. The updates to the SPSS aim to enable CMS and State Agencies to address areas of concern more effectively and ultimately improve beneficiary safety and the quality of their care (CMS Letter to State Survey Agency Directors, Admin Info: 20-02-ALL, October 17, 2019).

Structural changes

Included in the changes to the SPSS guidance is a new non-scored tier of measures that includes frequency run-rates and State Performance Indicators. Frequency run-rates measure goals during the fiscal year will be published in the form of a quarterly data extract. These frequency run-rates will be useful to assess mid-year progress made towards meeting Frequency measures during the fiscal year. The State Performance Indicators will help identify underlying causes for inadequate performance in one or more of the scored performance measures.

Domain changes

Within the Frequency Domain, a new process for State Survey Agencies to request permission from CMS to exclude surveys from frequency measure calculations is included in the guidance. It was also updated to include an evaluation of the timely completion of initial certification surveys for the End Stage Renal Disease (ESRD) program. Sub-domains were established within the Quality Domain that focus on the standard survey and complaint survey processes, separately. The method of evaluating and the criteria associated with the documentation of deficiencies was revised to reduce subjectivity and burden. Finally, the Enforcement Domain was renamed “Coordination of Provider Noncompliance,” to more accurately reflect the role of State Survey Agencies.

Guidance

The guidance provides instructions to Regional Offices on how to evaluate State Survey Agency performance. Measures should be calculated according to the specific instructions for each measure in the guidance and the scores should be entered into the database within the CMS SharePoint site. The guidance provides a timeline for the evaluation period along with deadlines. For each measure that is scored as “not met,” the State Survey Agency should develop and implement a corrective action plan that will address identified problems. The guidance also provides direction as to how and when the Regional Office should follow-up on progress toward making corrections.

Kusserow on Compliance: DOJ announces record-breaking $1B Medicare fraud case

The Department of Justice (DOJ) in Miami reported what it called the largest single criminal health care fraud case ever brought against individuals. It involved a $1 billion scheme involving numerous Miami-based health care providers. The DOJ brought charges against the owner of more than 30 Miami-area skilled-nursing and assisted-living facilities, a hospital administrator, and a physician’s assistant. The charges included conspiracy, obstruction, money-laundering and health care fraud. Philip Esformes was named as having been at the top of a complex fraud scheme, along with Odette Barcha, and Arnaldo Carmouze. Using Esformes’ network of Miami-Dade skilled-nursing and assisted-living facilities, the scheme involved filing false Medicare claims over the last 14 years for services that were not necessary or in some instances not provided.

The DOJ reported that the network of skilled nursing homes and assisted living facilities provided access to thousands of Medicare and Medicaid beneficiaries. Many of these individuals did not qualify for skilled nursing home care or for placement in an assisted living facility, but were admitted anyway where they received medically unnecessary services that were billed to Medicare and Medicaid. Charges include allegations that they received kickbacks in order to steer these beneficiaries to other health care providers, who also performed medically unnecessary treatments that were billed to Medicare and Medicaid.

Ten years ago, Esformes paid $15.4 million to resolve civil federal health care fraud claims for unnecessarily admitting patients from his assisted living facilities into a Miami-area hospital. The fraudsters subsequently continued to engage in their fraudulent practices, employing sophisticated money laundering techniques to hide the scheme.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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