OIG to Audit Nursing Home Services Rendered Prior to Inpatient Hospitalizations – Four Steps to Take to Prepare for the Increase in Audits


Efforts to reduce avoidable inpatient hospitalizations among nursing facility residents have been ongoing for years.  As an example of these initiatives, CMS ran a program from 2012 to 2020 focusing on long-stay long-term care facility residents, aiming to reduce hospitalizations.[1] In October, 2022, the Office of Inspector General for the U.S. Department of Health and Human Services (“OIG”) announced a new audit project titled “Potentially Preventable Hospitalizations of Medicare-Eligible Skilled Nursing Facility Residents.”[2] 

The OIG Will Focus on Inpatient Admissions from Nursing Homes Involving Six Conditions

The OIG first stated that its prior work identified nursing facilities with high rates of Medicaid resident transfers to hospitals for urinary tract infections (“UTIs”).  The OIG describes UTIs as being “often preventable and treatable in the nursing facility setting without requiring hospitalization.”[3] A 2019 OIG audit found that nursing facilities often did not provide UTI detection and prevention services in accordance with resident care plans, thereby increasing the chances for infection and hospitalization.[4]

In addition to UTIs, the OIG noted that previous CMS studies found that five conditions were related to 78 percent of the resident transfers to hospitals:  pneumonia, congestive heart failure, UTIs, dehydration, and chronic obstructive pulmonary disease/asthma. The OIG added that sepsis is considered a preventable condition when the underlying cause of sepsis is preventable.  

The OIG Audit Will Examine Nursing Home Care Provided Prior to Certain Medicare and Medicaid Inpatient Admissions

The OIG’s new audit project will involve a review of Medicare and Medicaid claims related to inpatient hospitalizations of nursing home residents with any of the six conditions noted previously. The audit will focus on whether or not the nursing homes being audited provided services to residents in accordance with the residents’ care plans and related professional standards (or whether the nursing homes caused preventable inpatient admissions due to non-compliance with care plans and professional standards).[5] 

How to Prepare for Increased Audit Activity Related to Preventable Inpatient Admissions

The OIG’s newly announced Audit of potentially avoidable inpatient hospitalizations of nursing home residents is likely to lead other state, federal, and commercial audits focusing on this area of concern.  The best way to prepare for increasing audit activity in this area involves the following steps:

  1. Examine the facilities’ policies, procedures, and practices related to the identification of the six conditions identified by the OIG, including the content of care plans and implementation of care plans.
  2. Educate and train all staff on the detection, prevention, treatment, and care planning related to the six conditions, including awareness of the need to avoid preventable hospitalizations.
  3. Conduct a data analysis of trends related to the frequency and cause of inpatient hospitalizations, and craft a response plan to further examine any patterns noted.
  4. Using information from a data analysis or a random sample, conduct an audit (self-audit or with a third-party consultant) to examine how the facility is faring related to the detection, prevention, treatment, and care planning related to the six conditions.

Overall, the reminder that the OIG is continuing to focus on care provided to nursing home residents prior to hospitalizations signals the need for attention in this area.  Please reach out to Nexsen Pruet if you need assistance related to this audit area or other post-acute compliance issues or assistance with defending a claims audit.

[1] https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/InitiativetoReduceAvoidableHospitalizations/AvoidableHospitalizationsamongNursingFacilityResidents
[2] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000733.asp
[3] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000733.asp
[4] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000098.asp
[5] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000733.asp 

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