December 4, 2021

News

News Network

Medicare: Additional Reporting on Key Staffing Information and Stronger Payment Incentives Needed for Skilled Nursing Facilities [Reissued with revisions on Aug. 10, 2021.]

16 min read
<div>What GAO Found Medicare covers short-term care for residents in about 15,500 skilled nursing facilities (SNF) after a hospital stay. GAO's analysis of 2019 staffing data found that almost all SNFs frequently met a federal requirement for a registered nurse (RN) on site for 8 hours per day. Fewer SNFs frequently met two other staffing measures that specify different numbers of nursing hours per resident per day. For example, about half of SNFs frequently met Centers for Medicare & Medicaid Services (CMS) case-mix measures—hours worked per resident that vary based on the medical needs of each SNF's residents—that CMS uses to set SNF staffing ratings. Further, about one-quarter of SNFs frequently met staffing thresholds for minimum RN and total nurse staffing that a CMS staffing study identified as needed to avoid quality problems. SNFs are not subject to these quality thresholds for ratings or as requirements, but many stakeholders have recommended that they be used as SNF staffing thresholds. Percent of Skilled Nursing Facilities (SNFs) That Met Registered (RN) Nurse Staffing Requirement or Measures, 2019 CMS reports certain key staffing information—such as RN overall staffing hours—on its Care Compare website, but does not report other important information. For example, GAO found that average RN staffing hours decreased about 40 percent on weekends, but CMS does not directly report this information. This limits the ability of beneficiaries to make informed choices among SNFs when choosing a facility. GAO estimated that in 2018 Medicare spent over $5 billion on critical incidents that CMS defines as potentially preventable—which are mostly about 377,000 hospital readmissions occurring within 30 days of the SNF admission. Current law directs CMS to make reductions of up to 2 percent to certain SNFs' payments to incentivize them to improve care, but does not address additional reductions. Experts have noted that payment incentives under current law may not be sufficient to motivate SNFs to improve their staffing, which in turn could lead to reductions in critical incidents. Without stronger payment incentives, Medicare is unlikely to reduce the billions in spending on potentially preventable critical incidents or the patient harm that can occur from them. Why GAO Did This Study In 2019, Medicare spent nearly $28 billion on care provided to 1.5 million beneficiaries in SNFs—a type of nursing facilty that provides residents short-term rehabilitation care after a hospital stay rather than long-term nursing home care that Medicare does not cover. SNFs must meet federal standards to participate in Medicare. CMS rates SNFs on factors such as staffing and quality of care and publishes its ratings on the Care Compare website. GAO was asked to examine SNF staffing and rates of critical incidents. This report examines (among other objectives): SNF performance on staffing measures, CMS reporting of staffing information on Care Compare, and Medicare payments for critical incidents. GAO analyzed CMS staffing and critical incidents data, information on Care Compare, and Medicare claims data for 2018 and 2019. GAO also interviewed CMS officials and other stakeholders such as key researchers and beneficiary groups.</div>

What GAO Found

Medicare covers short-term care for residents in about 15,500 skilled nursing facilities (SNF) after a hospital stay. GAO’s analysis of 2019 staffing data found that almost all SNFs frequently met a federal requirement for a registered nurse (RN) on site for 8 hours per day. Fewer SNFs frequently met two other staffing measures that specify different numbers of nursing hours per resident per day. For example, about half of SNFs frequently met Centers for Medicare & Medicaid Services (CMS) case-mix measures—hours worked per resident that vary based on the medical needs of each SNF’s residents—that CMS uses to set SNF staffing ratings. Further, about one-quarter of SNFs frequently met staffing thresholds for minimum RN and total nurse staffing that a CMS staffing study identified as needed to avoid quality problems. SNFs are not subject to these quality thresholds for ratings or as requirements, but many stakeholders have recommended that they be used as SNF staffing thresholds.

Percent of Skilled Nursing Facilities (SNFs) That Met Registered (RN) Nurse Staffing Requirement or Measures, 2019

CMS reports certain key staffing information—such as RN overall staffing hours—on its Care Compare website, but does not report other important information. For example, GAO found that average RN staffing hours decreased about 40 percent on weekends, but CMS does not directly report this information. This limits the ability of beneficiaries to make informed choices among SNFs when choosing a facility.

GAO estimated that in 2018 Medicare spent over $5 billion on critical incidents that CMS defines as potentially preventable—which are mostly about 377,000 hospital readmissions occurring within 30 days of the SNF admission. Current law directs CMS to make reductions of up to 2 percent to certain SNFs’ payments to incentivize them to improve care, but does not address additional reductions. Experts have noted that payment incentives under current law may not be sufficient to motivate SNFs to improve their staffing, which in turn could lead to reductions in critical incidents. Without stronger payment incentives, Medicare is unlikely to reduce the billions in spending on potentially preventable critical incidents or the patient harm that can occur from them.

Why GAO Did This Study

In 2019, Medicare spent nearly $28 billion on care provided to 1.5 million beneficiaries in SNFs—a type of nursing facilty that provides residents short-term rehabilitation care after a hospital stay rather than long-term nursing home care that Medicare does not cover. SNFs must meet federal standards to participate in Medicare. CMS rates SNFs on factors such as staffing and quality of care and publishes its ratings on the Care Compare website.

GAO was asked to examine SNF staffing and rates of critical incidents. This report examines (among other objectives): SNF performance on staffing measures, CMS reporting of staffing information on Care Compare, and Medicare payments for critical incidents. GAO analyzed CMS staffing and critical incidents data, information on Care Compare, and Medicare claims data for 2018 and 2019. GAO also interviewed CMS officials and other stakeholders such as key researchers and beneficiary groups.

Reissued with revisions on Aug. 10, 2021.

On August 10, 2021, this report was corrected to display the first page of written comments from the Department of Health and Human Services, which appears on page 52.
More from:

News Network

  • Religious Freedom Concerns in Russia
    In Crime Control and Security News
    Ned Price, Department [Read More…]
  • Missile Warning Satellites: Comprehensive Cost and Schedule Information Would Enhance Congressional Oversight
    In U.S GAO News
    What GAO Found The U.S. defense and intelligence communities depend on data from overhead persistent infrared sensors. These sensors provide early warning of ballistic missile launches and contribute to other defense and intelligence missions. The planned Next Generation Overhead Persistent Infrared (Next Gen OPIR) system is intended to replace the Space Based Infrared System, which began in the mid-1990s. The Space Force plans to launch the first of five Next Gen OPIR satellites in 2025. The figure below presents a notional depiction of current and planned OPIR systems. Notional Depiction of Current and Planned OPIR Satellite Orbits Despite early steps to speed up development, the Next Gen OPIR program faces significant technical and managerial challenges—such as developing a new mission payload and serving as the lead system integrator for the first time in this area—that are likely to delay the initial launch. Significant schedule delays typically result in cost increases. Although officials are aware of schedule risks, they continue to present an on-track timeline and stable cost estimates in reports to congressional committees. More transparency in schedules and costs would contribute to better Department of Defense (DOD) and congressional oversight and decision-making. The first Next Gen OPIR satellites are intended to provide missile warning capabilities and support other mission partners. DOD has initiated multi-agency efforts to determine how to meet future needs. However, coordination mechanisms are not formalized. Without documenting roles, responsibilities, and plans, DOD risks ineffective collaboration and unsynchronized delivery of warfighter capabilities. Why GAO Did This Study The U.S. Space Force plans to spend around $14.4 billion over the next 5 years to develop the Next Gen OPIR system, comprised of satellites and a ground system to detect and track missiles, among other things. The Air Force experienced significant problems when it developed the predecessor to Next Gen OPIR—it was roughly 9 years late and cost more than three times its initial estimate. A report to the National Defense Authorization Act for Fiscal Year 2019 contained a provision for GAO to review Next Gen OPIR efforts. This report (1) identifies the challenges Next Gen OPIR acquisition efforts face and the extent to which the Space Force is addressing them, and (2) assesses the extent to which Next Gen OPIR capabilities will address missions supported by the current system. GAO reviewed program documentation, acquisition strategies, and Air Force and DOD acquisition guidance, and interviewed DOD officials. GAO assessed this information against acquisition and collaboration best practices. Information that DOD deemed to be sensitive has been omitted.
    [Read More…]
  • U.S.-Russia Joint Statement Addressing the Climate Challenge
    In Crime Control and Security News
    Office of the [Read More…]
  • VA Health Care: Actions Needed to Improve Oversight of Graduate Medical Education Reimbursement
    In U.S GAO News
    The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides training to more than 45,000 medical and dental residents annually through its Graduate Medical Education (GME) program. VHA has established policy for its GME program that details many roles and responsibilities for overseeing VA medical facilities' reimbursements to affiliated academic institutions for residents' salaries and benefits. However, this policy does not define key roles and responsibilities for VHA's central office components, its regional networks, or its medical facilities. For example, VHA's regional networks do not have defined roles and responsibilities for overseeing GME disbursements—contributing to noninvolvement or inconsistent involvement in disbursement agreement oversight. VHA officials reported that they are in the process of updating disbursement agreement policy, but did not indicate if the updates would address all identified concerns. While VHA officials said that VHA's two disbursement agreement oversight mechanisms—facility periodic audits and the Resident Disbursement Audit Process (ReDPro) checklist—are meant to have distinct but complementary purposes, GAO found that VHA policy, guidance, and the tools distributed for these oversight mechanisms did not reflect the distinct purposes officials described. VHA officials said that periodic audits are intended to be a first level of defense and to review actual payments to affiliates, whereas the ReDPro checklist is intended to be a second level of defense, aimed at reviewing the process to see if the rules related to disbursement agreements are being followed by VA medical facilities. However, the ReDPro checklist tool and VHA's recommended periodic audit tool have numerous areas of overlap, including duplicative questions. This overlap causes inefficiencies and unnecessary burden on VA medical facility staff. GAO also found additional weaknesses in the tools, guidance, and training for the two oversight mechanisms. For example, GAO found an unclear ReDPro checklist tool, along with insufficient guidance and training related to conducting the ReDPro reviews. Officials from eight of 13 facilities in GAO's review indicated that the ReDPro checklist instructions were unclear regarding appropriate supporting documents for checklist responses. These weaknesses contributed to errors and inconsistencies in ReDPro responses. the lack of a standard audit tool, and inadequate guidance and training for periodic audit teams that contributed to problematic inconsistencies in the methodologies used by the audit teams and deficiencies in some of the audits conducted. Officials from 10 of 13 facilities in GAO's review indicated that they would benefit from more tools, guidance, or training related to conducting periodic audits. These weaknesses limit the effectiveness of VHA's oversight mechanisms, and put VHA at increased risk of both not being able to identify and correct facilities' lack of adherence to disbursement agreement policy and of possible improper payments to GME affiliates. Under VHA's GME program, VA medical facilities use disbursement agreements to reimburse affiliated academic institutions for residents' salaries and benefits. VHA developed policy related to establishing and administering disbursement agreements, but audits have found that facilities have not always adhered to VHA policy—resulting in improper payments to affiliates. GAO was asked to review VHA policies and procedures related to reimbursements to affiliates for GME. This report examines (1) oversight roles and responsibilities for GME disbursement agreements and (2) VHA's mechanisms for ensuring VA medical facilities adhere to policy. GAO reviewed relevant VHA documents and federal internal control standards and interviewed VHA officials. GAO also reviewed ReDPro checklist responses and documentation from 13 VA medical facilities—selected based on factors including geographic variation, GME program size, and number of affiliates. GAO also visited four of the 13 facilities and interviewed officials at the other nine facilities. GAO is making seven recommendations to VA to define key roles in policy, reduce overlap between the ReDPro checklist and facility periodic audits, and improve the oversight mechanisms' tools, guidance, and training. VA concurred with GAO's recommendations. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.
    [Read More…]
  • Laboratory Owner Pleads Guilty to $73 Million Medicare Kickback Scheme
    In Crime News
    A Florida man pleaded guilty yesterday in the Southern District of Florida for his role in a $73 million conspiracy to defraud Medicare by paying kickbacks to a telemedicine company to arrange for doctors to authorize medically unnecessary genetic testing. The scheme exploited temporary amendments to telehealth restrictions enacted during the COVID-19 pandemic that were intended to ensure access to care for Medicare beneficiaries.
    [Read More…]
  • Secretary Antony J. Blinken Virtual Remarks at the UN Security Council Open Debate on Multilateralism
    In Crime Control and Security News
    Antony J. Blinken, [Read More…]
  • DHS and DOJ Announce Dedicated Docket Process for More Efficient Immigration Hearings
    In Crime News
    Today, Secretary of Homeland Security Alejandro N. Mayorkas and Attorney General Merrick B. Garland announced a new Dedicated Docket process to more expeditiously and fairly make decisions in immigration cases of families who arrive between ports of entry at the Southwest Border.  This new process should significantly decrease the amount of time it takes for migrants to have their cases adjudicated while still providing fair hearings for families seeking asylum at the border.
    [Read More…]
  • Republic of Maldives Independence Day
    In Crime Control and Security News
    Antony J. Blinken, [Read More…]
  • The United States Welcomes the Appointment of Hans Grundberg as the New UN Special Envoy for Yemen
    In Crime Control and Security News
    Antony J. Blinken, [Read More…]
  • Prison Official Pleads Guilty to Accepting Bribes to Smuggle Contraband to Inmates
    In Crime News
    A North Carolina man pleaded guilty today to a bribery and smuggling scheme in which he abused his position as a prison official to funnel drugs and other contraband into Caledonia Correctional Institution.
    [Read More…]
  • Justice Department Charges Resident of Ukraine and Files Case to Halt Unauthorized Debits to Consumer Bank Accounts
    In Crime News
    The Justice Department today announced charges against a U.S. citizen residing in Ukraine for his alleged participation in a scheme to deceive banks. In a related case, the department filed a civil complaint and secured a temporary restraining order against a ring of individuals and corporations allegedly responsible for using the scheme to steal funds directly from thousands of consumers’ bank accounts.
    [Read More…]
  • Domestic Abuse: DOD Needs to Enhance Its Prevention, Response, and Oversight
    In U.S GAO News
    What GAO Found In its May 2021 report, GAO found that the Department of Defense (DOD) met a statutory requirement to collect and report data for incidents that it determined met its criteria for domestic abuse. In fiscal years 2015-2019, DOD determined that over 40,000 domestic abuse incidents met its criteria, of which 74 percent were physical abuse. However, DOD has not collected and reported accurate data for all domestic abuse allegations received, including those that did not meet DOD's criteria, as statutorily required. Thus, DOD is unable to assess the scope of alleged abuse and its rate of substantiation. In addition, despite a statutory requirement since 1999, DOD has not collected comprehensive data on the number of allegations of domestic violence—a subcategory of different types of domestic abuse that constitute offenses under the Uniform Code of Military Justice—and related actions taken by commanders. Improving collection of these data could enhance DOD's visibility over actions taken by commanders to address domestic violence. DOD and the military services have taken steps to implement and oversee domestic abuse prevention and response activities, but gaps exist in key areas, including creating awareness of domestic abuse reporting options and resources, allegation screening, and victim risk assessment. For example, while DOD and the military services have taken steps to promote awareness of reporting options and resources, DOD has not fully addressed challenges in doing so, and may miss opportunities to provide available resources to victims. In addition, the military services perform limited monitoring of installation incident-screening decisions and therefore lack reasonable assurance that all domestic abuse allegations are screened in accordance with DOD policy. DOD and the military services have developed risk assessment tools in accordance with DOD policy, but the Army, the Navy, and the Marine Corps have not ensured their consistent implementation across installations, and may therefore be limited in their ability to identify and convey the need for any critical safety measures for victims of domestic abuse. Finally, GAO found that the military services perform limited oversight of commanders' disposition of domestic violence incidents, referred to as command actions. These command actions can have significant implications, including for victims' eligibility for transitional compensation and Lautenberg Amendment restrictions to firearm possession for alleged abusers. DOD has not assessed the potential risks associated with its current disposition model for domestic violence incidents and the feasibility of potential alternatives that may respond to such risks. Performing such an assessment could provide the department and military services with a better understanding of such risks and their resulting potential impacts. Why GAO Did This Study This testimony summarizes the information contained in GAO's May 2021 report, entitled Domestic Abuse: Actions Needed to Enhance DOD's Prevention, Response, and Oversight (GAO-21-289). Specifically, this testimony discusses the extent to which 1) DOD has met statutory requirements to collect and report complete data on reports of domestic abuse and 2) DOD and the military services have implemented and overseen domestic abuse prevention and response activities, including commanders' disposition of incidents, in accordance with DOD policy.
    [Read More…]
  • NASA Scientist Over the Moon With Homegrown Radish Research
    In Space
    How two video meetings, [Read More…]
  • Michigan Man Pleads Guilty to Conspiring to Defraud the IRS and to Steal Crash Reports from the Detroit Police Department
    In Crime News
    A Birmingham, Michigan, resident pleaded guilty today to conspiring to defraud the IRS and to steal from an organization receiving federal funds, announced Acting Deputy Assistant Attorney General Stuart M. Goldberg of the Justice Department’s Tax Division.
    [Read More…]
  • On the Death of Colombian Defense Minister Trujillo
    In Crime Control and Security News
    Antony J. Blinken, [Read More…]
  • Seattle Software Developer Pleads Guilty to Wire Fraud for COVID-Relief Fraud Scheme
    In Crime News
    A Seattle man pleaded guilty today to one count of wire fraud for carrying out a scheme to defraud several COVID-19 relief programs.
    [Read More…]
  • Public Service Loan Forgiveness: DOD and Its Personnel Could Benefit from Additional Program Information
    In U.S GAO News
    What GAO Found Personnel in the Department of Defense (DOD)—including service members and civilian employees—may be eligible for federal student loan forgiveness through the Public Service Loan Forgiveness (PSLF) program if they remain in public service employment for 10 years while making 120 qualifying loan payments, among other requirements. As of January 2020, Department of Education (Education) data show that 287 DOD borrowers received loan forgiveness, while 5,180 DOD borrowers (about 94 percent) were denied (see figure). The most common reasons for the denials were not enough qualifying payments and missing information on the form. GAO previously reported in September 2019 an overall denial rate of 99 percent for all PSLF applications submitted by borrowers. More information from DOD could help potential applicants be aware of all eligibility requirements. Number of Department of Defense (DOD) Personnel Approved or Denied for Public Service Loan Forgiveness (PSLF), as of January 31, 2020 Note: The “Civilian” categories include all civilian employees within DOD, including the military services. As its administrator, Education has specialized knowledge about the PSLF program but has not shared complete information with DOD. Education officials have not shared with DOD summary information about its personnel who have taken steps to pursue PSLF or service members who may be eligible. Education officials also stated they have not shared the benefits of using the PSLF program together with DOD's student loan repayment program. Education officials have also not updated the student loan guide for service members with specific information on PSLF. Education could take additional steps to improve information sharing about PSLF with DOD personnel. DOD officials expressed interest in obtaining more program information. Collaboration among the departments and updated program information could help DOD officials and its personnel to take full advantage of PSLF. DOD does not widely use the PSLF program for recruitment and retention to promote readiness despite facing challenges in certain specialty career fields. Some DOD officials we interviewed stated that they preferred to use other DOD benefits and incentives that DOD directly controls, such as bonuses or DOD's student loan repayment program. DOD could enhance its recruitment and retention efforts to promote readiness with department-wide and service-specific guidance about how the PSLF program could be used as a tool for such efforts. Why GAO Did This Study At a time when student loan debt continues to mount for many, the PSLF program—established in 2007 and administered by Education—is intended to encourage individuals to pursue careers in public service. Senate Report 116-48 included a provision for GAO to study the effectiveness of the PSLF program at promoting military and civilian recruitment and retention as well as military readiness. GAO's report assesses the extent to which (1) DOD personnel pursue and receive loan forgiveness through the PSLF program, (2) Education has shared information with DOD officials and its military and civilian personnel about the program, and (3) DOD uses the program for recruitment and retention to promote readiness. GAO analyzed student loan data from Education and the PSLF servicer from the beginning of the program through January 2020; reviewed relevant laws, documents, and other information related to PSLF, benefits, recruitment, retention, and readiness; and interviewed DOD and Education officials.
    [Read More…]
  • Transportation Security Administration: Clear Policies and Oversight Needed for Designation of Sensitive Security Information
    In U.S GAO News
    Concerns have arisen about whether the Transportation Security Administration (TSA) is applying the Sensitive Security Information (SSI) designation consistently and appropriately. SSI is one category of "sensitive but unclassified" information--information generally restricted from public disclosure but that is not classified. GAO determined (1) TSA's SSI designation and removal procedures, (2) TSA's internal control procedures in place to ensure that it consistently complies with laws and regulations governing the SSI process and oversight thereof, and (3) TSA's training to its staff that designate SSI.TSA does not have guidance and procedures, beyond its SSI regulations, providing criteria for determining what constitutes SSI or who can make the designation. Such guidance is required under GAO's standards for internal controls. In addition, TSA has no policies on accounting for or tracking documents designated as SSI. As a result, TSA was unable to determine either the number of TSA employees actually designating information as SSI or the number of documents designated SSI. Further, apart from Freedom of Information Act (FOIA) requests or other requests for disclosure outside of TSA, there are no written policies and procedures or systematic reviews for determining if and when an SSI designation should be removed. TSA also lacks adequate internal controls to provide reasonable assurance that its SSI designation process is being consistently applied across TSA. Specifically, TSA has not established and documented policies and internal control procedures for monitoring compliance with the regulations, policies, and procedures governing its SSI designation process, including ongoing monitoring of the process. TSA officials told us that its new SSI Program Office will ultimately be responsible for ensuring that staff are consistently applying SSI designations. This office, which was established in February 2005, will also develop and implement all TSA policy concerning SSI handling, training, and protection. More detailed information on how this office's activities will be operationalized was not yet available. Specifically, TSA officials provided no written policies formalizing the office's role, responsibilities, and authority. TSA has not developed policies and procedures for providing specialized training for all of its employees making SSI designations on how information is identified and evaluated for protected status. Development of such training for SSI designations is needed to help ensure consistent implementation of the designation authority across TSA. While TSA has provided a training briefing on SSI regulations to certain staff, such as the FOIA staff, it does not have specialized training in place to instruct employees on how to consistently designate information as SSI. In addition, TSA has no written policies identifying who is responsible for ensuring that employees comply with SSI training requirements.
    [Read More…]
  • Brownsville man sent to prison for possessing 600 images of Sugar Land minor
    In Justice News
    A 23-year-old south [Read More…]
  • Federal Court Finds Miami-Area Tax Preparer in Contempt for Violating Permanent Injunction
    In Crime News
    A federal court in the Southern District of Florida has held a Miami-area tax preparer in contempt for violating a permanent injunction that barred her from preparing, filing or assisting in the preparation or filing of federal tax returns for others.
    [Read More…]

Crime

Network News © 2005 Area.Control.Network™ All rights reserved.