OIG Nursing Facility Compliance Program Recent Guidance: Quality of Care and Quality of Life Recommendations

Nursing facilities: Are you monitoring quality of care and quality of life concerns as part of your compliance and ethics programs?

On November 20, 2024, the Department of Health and Human Services Office of Inspector General (OIG) published an updated Industry Segment-Specific Compliance Program Guidance (ICPG) document for nursing facilities. OIG tailored the ICPG to risk areas specific to the nursing facility industry segment and recommended compliance measures that facility operators can take to reduce risks.

Why is quality of care a compliance and ethics concern?

A nursing facility serves as both the location in which residents receive medically necessary healthcare services and a home for residents for the duration of care. Consequently, it must prioritize quality of care and quality of life for residents. To participate in and receive payments under Medicare and Medicaid, nursing facilities must comply with regulatory requirements of participation (ROPs)
addressing quality of care and quality of life. ROPs are critical to provide quality care and keep residents safe. Beyond this, failure to provide quality of care and promote quality of life poses a risk of fraud and abuse for nursing facilities. When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, the claim submission includes certifications that the services were provided in compliance with applicable statutes, regulations, and rules. If a nursing facility fails to meet its obligations regarding professional standards of care or promoting quality of life, its claims for reimbursement may be considered false under the federal False Claims Act (FCA).

Examples of quality and safety concerns that can lead to FCA liability include providing medically unnecessary care or grossly substandard services; housing residents in unacceptable or dangerous living conditions; failing to provide residents with appropriate activities; and failing to provide residents with needed psychiatric care. In collaboration with the US Department of Justice (DOJ), state Medicaid Fraud Control Units, and other law enforcement agencies, OIG is increasing focus on substandard quality of care in its investigations and enforcement actions.

OIG highlighted and outlined recommendations for six risk areas within quality of care and quality of life:

1) staffing levels, shortages, and competencies;
2) appropriate resident care plans and resident activities;
3) challenges due to demographic changes in the resident profile, higher resident acuity levels, and behavioral health issues;
4) medication management;
5) appropriate use of medications; and
6) resident safety.