OIG Recommends CMS Analyze 3-Day Requirement for SNF Stays and Infection Control Surveys

October 29, 2021
Policy Snapshot

Last week, the Office of Inspector General (OIG) published its OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs annual report. This year’s report focused on the top 25 unimplemented recommendations that would most positively affect Department of Health and Human Services (HHS) programs. Included on the list were recommendations that “CMS should analyze the potential impacts of counting time spent as an outpatient toward the 3-night requirement for skilled nursing facility (SNF) services so that beneficiaries receiving similar hospital care have similar access to these services” and “CMS should assess the results of infection control surveys of nursing homes and revise surveys as appropriate, and clarify expectations for States to complete backlogs of standard surveys and high priority complaint surveys that were suspended in the early months of the pandemic.”

The report notes that beneficiaries with similar post-hospital care needs have different access to and cost sharing for SNF services depending on whether they were hospital outpatients or inpatients. “We found an increased number of beneficiaries in outpatient stays pay more and have more limited access to SNF services than they would as inpatients. We also found hospitals continue to vary in how they use inpatient and outpatient stays, even though the policy was intended to promote consistency among hospitals.”

The OIG notes that CMS still needs to conduct an updated analysis about whether, and to what extent, beneficiaries failed to qualify for Medicare coverage of their SNF services, because some or all of their time spent in the hospital was as an outpatient. “CMS should also reanalyze the potential impacts of counting time spent as an outpatient toward the 3-night requirement for SNF Medicare coverage.”

Currently, in response to the president’s March 2020 declaration of a national emergency concerning the COVID-19 outbreak, CMS temporarily waived the requirement for a 3-day prior hospitalization for coverage of a SNF stay. The waiver allows temporary emergency coverage of SNF services without a qualifying hospital stay for beneficiaries who experience dislocations or are otherwise affected byCOVID-19.

The report also notes that nursing home residents are vulnerable to infectious diseases because of age and underlying medical conditions and that during the COVID-19 crisis, nursing homes have been extremely hard hit by infections and deaths. “From March 23 to May 30, 2020, States conducted onsite surveys at 31 percent of nursing homes. However, rates of surveys varied across the States. During the same time period in 2019—under normal operations—53 percent of nursing homes received an onsite survey. Surveys conducted during this timeframe in 2020 resulted in cited deficiencies for fewer nursing homes (only 3 percent of those surveyed), in part because of the limited scope and reduced time for onsite surveyors due to COVID-19,” the report stated.

The OIG recommended that in “order to ensure that nursing home surveys perform their critical function, further action by CMS to implement the recommendation should include continued assessment of and improvements to infection control surveys, as appropriate, and should address standard and complaint survey backlogs.”

Read the entire report.