Missouri Nursing Home Patient Rescued from Sinkhole

Healthcare Compliance Perspective:

The Compliance and Ethics Committee must ensure that an effective elopement and emergency preparedness program is in place.

A wheelchair-bound, elderly nursing home resident wandered away from the facility and became trapped when she fell into a sinkhole that recently opened up behind the nursing home facility. The fire department was called in after someone called them late that night to report that the woman was trapped in a sinkhole.

The local Fire Department responded to a call asking for assistance around 10:30 p.m. regarding a woman trapped in a sinkhole near a major street.
Apparently, the woman had been missing for an undetermined amount of time when staff from the nursing home found her and called the EMS and fire department. After she was rescued from the sinkhole, she was taken to a local hospital for treatment.

Former Nurse Convicted of Stealing Patient Information, Files over $1M in Fraudulent Claims with IRS

Healthcare Compliance Perspective:

Compliance and Ethics Committees must be cognizant of the potential financial value associated with identify theft, and must ensure an effective Privacy and Data Security Program is in place.

A federal jury in Tallahassee found a former nurse who worked in a nursing home for 12 months in 2011 and 2012, guilty of “wire fraud, theft of government funds, possession of unauthorized access devices and aggravated identity theft.” The victims were people and patients at the nursing home where the former nurse had been employed and where she had filed more than “$1 million in fraudulent income tax claims.”

The IRS investigation uncovered a notebook in the woman’s car containing personal information on over 150 people including 26 residents of the nursing home. The woman received about $141,790 in refunds from the 2011 falsely submitted claims. She used this money to pay her personal bills-mortgage, car repairs, and other personal expenses.

The woman’s sentencing hearing for her conviction is scheduled for January 4, and she could receive as much as 20 years in prison for each count of wire fraud, up to 10 years for each theft of government funds and a 2- year sentence for aggravated identity theft.

Former President of Harris County Medical Society and Affiliated Facilities Settle Allegations of Medicare Fraud

Healthcare Compliance Perspective:

If sidestepping standard medical procedures to boost profits result in substandard care, claims for reimbursement may constitute fraud.

The former president of the Harris County Medical Society in Houston, Texas and others entered into an agreement to pay $1,575,000 to settle allegations of Medicare fraud.

An endoscopy nurse formerly employed by a Houston hospital’s surgical center blew the whistle. She alleged that the former medical society president and other physicians who performed colonoscopies at the hospital where she worked, failed to meet established medical standards. A standard colonoscopy takes between 20 minutes and an hour. She claimed he procedures were done in 2 minutes, on average, and were essentially worthless. She alleged the risk of precancerous lesions could be missed, colonoscopies took as little as two minutes, and sanitation guidelines were avoided. She also claimed that she was fired the day after she complained to corporate officers.

Former Nursing Home Biller Charged With Medicaid Fraud

Healthcare Compliance Perspective:

An effective Compliance and Ethics Program must focus on verifying the authenticity and sufficiency of departmental checks and balances.

Michigan’s State Attorney General has charged a former nursing home biller in Michigan with embezzling payments received from the nursing home’s residents, and attempting to hide what she was doing by issuing more than $600,000 in fraudulent Medicaid billings.

The 40-year-old woman is accused of committing the alleged crimes over a period of five years from 2011 to 2016. Additionally, the woman has also been charged with cocaine possession at the time of her recent arrest.

After the police received a complaint from the nursing home, they suspected that fraud might be involved; so, they notified the Attorney General’s Office. Consequently, the woman will be arraigned in court next week on a total of 12 charges.

The nursing home has alleged that cash payments from or on behalf of the residents were not entered into the facility’s accounting system and deposited appropriately. Investigators, in their follow-up investigation, found evidence that the accused former biller allegedly kept the money; then, fraudulently billed Medicaid for more than $600,000 to cover-up the misappropriated payments and forestall being detected earlier.

The accused woman faces “six counts of Medicaid fraud, three counts of false pretenses, one count of embezzling from a vulnerable adult, one count of continuing a criminal enterprise and one count of cocaine possession.” The maximum penalty connected to the charges totals 32 years.

Scenario – Pressure Ulcers

By: Linda Winston, RN, MSN, BS, DNS-MT, RAC-CT

A resident with stage IV pressure ulcers and receiving IV antibiotics, along with his mother, reported that the resident’s treatments were not being done. A nurse signed that treatment had been done on 8/24, but upon inspection, the date on the dressing that was in place was 8/23.

When a resident enters a skilled nursing facility with a pressure injury/ulcer, according to the State Operation Manual Appendix PP F314/F686 Pressure Ulcers, “Based on the comprehensive assessment of a resident, the facility must ensure that-(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.”

When a nurse does not complete a treatment, but signs that the treatment was completed, this act does not meet professional standards, and the facility is at risk for noncompliance. Appendix PP further states “Key elements of non-compliance to cite deficient practice” could include the facility failed to “Provide treatment, consistent with professional standards of practice, to an existing pressure injury.”

It is important for facilities to have a comprehensive pressure injury/ulcer system that ensures care and treatment of a resident’s pressure injury/ulcer is based on assessment and performed in accordance with the resident’s plan of care and physician orders. Additionally, another important element is competency based education and evaluation of staff’s performance in care and treatment of pressure injury/ulcer upon hire and annually, along with an ongoing monitoring and auditing of pressure injury/ulcer practice.

When completing a comprehensive review of your facility’s pressure injury/ulcer system, please refer to the State Operation Manual Appendix PP, F686 Skin Integrity – Pressure Ulcers, that becomes effective November 28, 2017, by visiting https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf.

SNF Emergency Preparedness: Emergency Power Supplies

While it might seem obvious that all skilled or long-term nursing facilities should have access to emergency power supplies as part of any emergency preparedness plan, it is not often known that this will become a legal obligation in terms of the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule, which is due for implementation on November 15, 2017.

Failure to adhere to this regulation can lead to severe financial penalties and even disbarment from the entire Medicaid/Medicare structure.

Concern over this issue came to the fore when an official report following Hurricane Sandy in September 2014 found that 89 percent of hospitals reported experiencing critical challenges during that storm, and 35 percent of facilities lost power completely.

The Final Rule guidelines demand that any emergency preparedness plan contain written guidelines for the storage of emergency fuel and associated equipment and systems as required by the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA).

The Centers for Medicare and Medicaid Services (CMS) has issued a specific requirement in this regard, ordering all facilities to adopt the NFPA guidelines.

The Final Rule explains it this way: The NFPA guidelines mean that a hospital’s alternate source of power (for example, a generator), “and all connected distribution systems and ancillary equipment, must be designed to ensure continuity of electrical power to designated areas and functions of a healthcare facility.”

In addition, the “rooms, shelters, or separate buildings housing the emergency power supply must be located to minimize the possible damage resulting from disasters such as storms, floods, earthquakes, tornadoes, hurricanes, vandalism, sabotage, and other material and equipment failures.”

It is also part of the Final Rule guidelines that generators are located in accordance with the requirements found in NFPA codes which require hospitals that build new structures, renovate existing structures, or install new generators to place backup generators in a location that will be free from possible flooding and destruction.

In addition, all facilities must show that they have tested their emergency and stand-by-power systems on a monthly basis.

Facilities should also consider emergency procedures which would address the loss of power in a way that would allow them to continue operations without outside electricity.
This could be achieved by, for example, diverting patients to a nearby facility that has sufficient power and is within a reasonable commuting distance.

The rules also require all skilled and long-term care facilities to have a plan for how they will keep emergency power systems operational during an emergency—with the only exception being if they are evacuated.

This means that there must be some storage of fuel to power generators built into the plan, although it is not specified how much fuel is required—something which is practical given that it is unlikely that anybody can predict with certainty how long a major emergency might last.

Pharmacy Chain Agrees to Pay Almost $2.7M to Settle Claims It Recycled Drugs

Healthcare Compliance Perspective:

Skilled nursing facilities and long-term care pharmacies must audit the appropriate disposal of unused medications. Compliance Officers must audit the effectiveness of these audits.

To settle federal claims for the illegal recycling of unused medications from a nursing home, a pharmacy chain will pay nearly $2.7 million. Federal prosecutors also claim that the chain “overcharged insurance programs for diabetic test strips.”

The pharmacy chain runs several retail pharmacies, a mail-order prescription service and makes deliveries to numerous nursing homes and agencies across western Pennsylvania.

The pharmacy scheme involved two employees who picked up unused prescription drugs from nursing homes. These unused prescriptions had been prescribed for deceased residents who no longer needed the medications. Instead of destroying the medications, as is legally required, the picked-up drugs would be taken back to the pharmacy and be recycled to fill other prescriptions. This meant that older, unused drugs were intermixed and relabeled with newer drugs-a violation of federal law.
The two former employees charged in the scheme each face up to five years in prison. One of the two pled guilty to conspiracy and will be sentenced in October. The other was just recently charged.

No patients were harmed in the scheme.

Pleas in Freezing Death of Alzheimer’s Patient

Healthcare Compliance Perspective:

Failure to provide adequate supervision and response to alarms intended to prevent accidents and hazards to skilled nursing facility residents constitutes substandard care, and represents potential false claims.

Failure to respond to an alarm and providing misleading or inaccurate information on a medical chart are the reasons behind the charges that they failed to do their jobs against two former nursing home employees in Grand Rapids, Michigan. The accused workers will enter their pleas to those charges this week.

The elopement of an 85-year-old woman with Alzheimer’s from the nursing home happened almost one year ago, and resulted in the woman’s death due to hyperthermia after 7 hours outside in the night’s freezing temperatures.

One of the former employees faces up to a maximum penalty of one-year in jail for allegedly “providing misleading or inaccurate information on a medical chart.” The log sheet that records half-hour bed checks on the residents included the deceased woman even though she had left the facility. The former worker admitted to investigators that she had heard an alarm go off, but she was with another resident and did not check to see if anyone had left the building.

The other former employee has already pleaded “no contest” to “second-degree vulnerable adult abuse for allowing the woman to get outside unnoticed.” She will be sentenced in November and faces a possible four years in prison.

The family of the deceased resident is suing the nursing home.

Modifications to the Quality of Patient Care Star Rating Algorithm for Home Health Agencies

By ShirleyAnn Janulewicz RN, BSN, PHN

Patient Care Star Rating is an important tool which encourages providers to strive for higher levels of quality care and helps direct overall health system improvement. Consumers can utilize this information, thereby empowering them to compare agencies and choose the best agency for their loved ones’ care.

In January, proposed changes include to remove the Influenza Immunization Received for the Current Flu Season based on the Outcome and Assessment Information Set (OASIS data), and to add a measure: Emergency Department use without hospitalization (claims-based data). Stakeholders support removal of the Influenza Measure, but do not support the addition of the Emergency Department use measure.

CMS held a meeting to obtain input from Medicare-certified home health agencies. They presented the background on the current Quality of Patient Care Star Rating Methodology, the 9 measures selected, and the criteria used for selecting these measures. Home health agencies must be able to report 5 of the 9 measures to have a star rating computed, which means 20 episodes in which each of these measures were utilized. During the meeting, graphs were used to demonstrate how the ratings of the July 2017 Home Health Compare went up slightly, regardless if they were small or large, rural or urban agencies, when the flu measure was removed.

This conference call was sponsored by CMS Medicare Learning Network (MLN). To review the event materials, visit the CMS MLN Events website, and select the event from the list. An audio recording and transcript will be available approximately 2 weeks after the event.

Succeeding with the New Home Health Agency CoP’s

By ShirleyAnn Janulewicz RN, BSN, PHN

As per a webinar I attended which focused on 3 parts: Comprehensive Assessment, Care Planning, & QAPI, the key to succeeding with the new Conditions of Participation (CoP’s) is taking action now to prepare for these changes.

Per Medicare regulations, the Occupational Therapist (OT) is still not able to perform the comprehensive assessment to qualify the patient for Medicare, but can perform the successive assessments. Timeliness of completion of the assessment within 5 days is key, and the psychosocial aspect including a cognitive assessment is needed, because agencies now need to include the patient’s desires and goals in their assessment to make it more patient-centered. Also, the willingness and availability of caregivers must be documented, so involve Social Workers for resources. Update policies to reflect these changes, and ensure all staff are educated on these changes so everyone is on the same page with their understanding.

Care-Planning needs to be individualized for each patient, with documentation that the patient participated in the planning. Discharge planning must be started on admission and documented. Verbal orders must now be timed in addition to being dated, so train and educate staff to start this now so it becomes ingrained. Everyone involved in the care of the patient must be notified of any and all changes, and the patient must be given written instructions on the name and phone number of the Home Health Agency (HHA) Clinical Manager. Each agency will determine how best to notify the PCP signing the Home Health Certification and Plan of Care Form 485 of all the changes, be it weekly, biweekly or monthly.

The HHA Governing body is responsible for oversite of the QAPI program, with an initial update, then quarterly to annual updates. A HHA can utilize dashboards with Key Performance Indicators (KPI) with real-time data. A yes/no audit tool will help with tracking, and chart audits are important to identify weak spots in the agency. These will help trend and track data between clinicians to determine if the issue identified is across the board or confined to only a few clinicians. The HHA needs to perform a root cause analysis to determine how best to proceed. Although the reporting on the Performance Improvement Project (PIP) does not go into effect until 7/13/18, agencies should be choosing a topic and collecting documentation now, so when they have to report, they will be ready. Do the right thing, start now.

Reference: Webinar by Diane Link RN, MHA of BlackTree Healthcare.