Assisted living communities were among the healthcare settings associated with incidents of potential abuse or neglect of Medicare beneficiaries in an audit of claims data, prompting a review of data to identify patterns and improve reporting of such incidents.
The Department of Health & Human Services Office of the Inspector General released a report with results earlier this month, following up on a 2019 report and providing recommendations for actions the Centers for Medicare & Medicaid Services can take.
The audit identified 30,258 claims from January 2019 through December 2020 that contained diagnosis codes indicating the treatment of injuries potentially caused by abuse or neglect. The data showed that almost 7% of potential abuse and neglect incidents (2,320 incidents) allegedly were perpetrated by healthcare workers, 11% (3,546) occurred in healthcare settings and 24% of potential incidents (7,298) were not reported.
Of the 100 claims sampled, 93 “contained evidence of potential abuse or neglect” of Medicare beneficiaries — 14 were allegedly perpetrated by healthcare workers, 17 were related to incidents that occurred in medical facilities, and 18 were related to incidents that were not reported to law enforcement.
Investigators determined that 17 of the 93 Medicare claims associated with potential abuse or neglect occurred in medical facilities, including assisted living communities (two claims), nursing homes (12 claims), group homes (two claims) and a doctor’s office (one claim).
The report noted that group homes and assisted living communities are covered by state regulations regarding the reporting of potential abuse or neglect. “We classified assisted living facilities as medical facilities because they are generally regulated or licensed by the states and frequently employ certified nursing assistants, who are certified or licensed by the states,” the authors wrote.
LeadingAge said that the report has the potential to affect policies in CMS-certified settings, including how abuse and neglect is identified, reported and surveyed.
Based on the findings, the OIG recommended that CMS identify trends and high-risk areas in Medicare claims containing diagnosis codes indicating potential abuse or neglect. Investigators also recommended that the agency ask contractors to conduct targeted claim reviews to identify patterns of unreported incidents.
In addition, the investigators recommended that CMS develop and share guidance and best practices with providers to ensure compliance with state reporting laws, and to consider the results when assessing whether existing conditions of participation requirements for reporting abuse or neglect should be strengthened.
CMS agreed with the findings and indicated that it would develop and share guidance with providers on reporting incidents of potential abuse or neglect. The agency also said that it will evaluate evidence of abuse and neglect when assessing the need for revisions to existing conditions of participation.
Read more about the OIG report on the website of sister publication McKnight’s Long-Term Care News.
