UNCASVILLE, CT — For nursing homes, there is never a good time to be out of regulatory compliance or lax with documentation, but experts say government overseers are now intensifying efforts to keep operators in check. What’s not as clear yet is how intent officials will be on levying penalties, they added.

“I feel like we’re in a heavy compliance era, more than usual,” Alicia Cantinieri, Zimmet Healthcare’s Director of Clinical Reimbursement & Regulatory Compliance for Healthcare, said at the organization’s annual user conference Wednesday. “The Medicare contractors, they are sending a lot more ADR requests, because people ask us for help.

“After a pause because of the pandemic, there’s more pressure and scrutiny. They’re catching up with what was already in place. They’re really scrutinizing coding on the MDS. They’re also now scrutinizing PBL [Payroll-based Journal]. They’re going to be auditing procedures for the QRP and value-based purchasing, which comes back to, is your assessment accurate? So many different things could impact you from that. Lots of audits going on with the contractors and being very into the record. It feels like they’re looking more closely.”

The current climate was shaped by the onset of the COVID-19 pandemic in the US, which came just five months after the start of the Patient Driven Payment Model.

“For years, nobody was audited, and now they’re coming around and doing those audits. So things we might have thought were OK because our claims were being paid, they’re now coming back to us and saying, ‘No, that wasn’t compliant. No, you don’t have the documentation to support what you coded on that assessment, so lots of dollars being recouped based on that. They paused auditing and now they’re back,” Cantinieri told McKnight’s Long-Term Care News Wednesday. “It was a rough time and now CMS is coming back. They’re auditing records from that period. We’re talking 2021 and 2022, and waiver claims are being audited. It depends on the contractor.”

Many of the most-watched moves by CMS stem from the April activation of 900 pages of new surveyor guidance.

Cantinieri said providers should be prepared for the issuance of final changes to the RAI manual, which may come at any time before the start of the new fiscal year on Oct. 1 Therapy stipulations, which may not change drastically but will be emphasized, should get special attention because it’s an “all or nothing” compliance area, she said.

Accuracy, accuracy, accuracy

She also stressed that regulators are leaning more heavily on F-Tag 641, which deals with accuracy of assessments.

“A pattern is considered [only] three inaccuracies,” she noted. She added that CMS will not look to penalize anyone for mere mistakes but rather if there are any indications that errors have been made “willingly and knowingly.” “And instead of being referred back to the state office for review, CMS will report problems directly to the OIG. That’s an investigation. That’s a big change.”

Also new are the “price tags” officials have put on confirmed findings of non-compliance: Up to $1,000 per instance for any individual filing wrongly (and such filings usually come in multiples once one transgression is adjudicated), and $5,000 for anyone deemed to have directed someone else to file falsely, as a “mastermind” of any improprieties.

Regulators also have made it clear that they are not backing off efforts to curb improper antipsychotics use or unnecessary medications.

“They are still sending out letters or coming back and auditing facilities for a second time who didn’t pass the first time, and you cannot opt out of that one,” Cantinieri said.

Staffing, infection control still major draws

One of the clearest signs of a regulatory ramp-up is surveyors who are more attentive than ever to Payroll-Based Journal data, she noted. Since April, surveyors are better trained to examine and cite for insufficient data entry, or numbers that are too low — and they are sometimes making decisions before ever setting foot on campus, Cantinieri emphasized.

“There are penalties not just on survey for not submitting your PBJ data but there’s penalties in your Five Star. Everything is connected to each other,” she pointed out. “That’s another pandemic catch-up.”

She and Zimmet Director of Quality Innovations Amy Greer, who jointly presented on the topic Tuesday, also stressed that CMS is keeping up the heat on infection control and recently enhanced barrier precaution requirements.

“There are a lot of new changes coming out of COVID, and CMS wants to get back into it,”  Greer told McKnight’s Wednesday. “Infection control, staffing and quality measures are always important as well. Especially with the chemical restraints and antipsychotics, CMS is not letting that go — they’re doubling down on that. And they’re tying that into staffing as well. If you have low staffing, are you increasing the use of these medications?”  

“They’re looking at staffing to see if there’s less, yet more incontinence now. They will look at [staffing] sheets. Audits are picking up regarding antipsychotics and schizophrenia too. They’re making sure people aren’t getting cute with that.”

She noted that “a lot of confusion” still exists regarding the use of enhanced barrier precautions, especially in the therapy area. “Do they have to have the gown and gloves — previously, they were told they can’t wear gloves. CMS has yet to go into too much detail with what the therapist’s job is with that.”

“Where they’re also getting everyone on the infection control tag is they’re looking to see if everyone is donning and doffing properly. If they see they’re taking it off the wrong way, that’s an immediate citation,” Greer added.

CMS is “picking up its game” especially in areas like “staffing, and the antipsychotics medications coding and schizophrenia audits. They are not stopping. We’re seeing increases in those. They’re making sure people aren’t misdiagnosing or being cute with the coding to get around exclusions with the measures. I think they finally caught on to that so that’s why they’ve come out with these schizophrenia audits.”

Perhaps the most striking change in survey activity is reflected in the way some teams approach F-812, Food Procurement, Store/Prepare/Serve – Sanitary, the No. 1 or 2 citation in almost every state they serve.

“[Survey team leaders] even tell surveyors don’t go to the pre-conference meeting. Go right to the kitchen, almost like a surprise attack in a way. If they see one staff member without a hairnet or gloves, they can cite right away,” said Greer, who said her observations are based on dozens of onsite visits and mock surveys she has conducted around the country.

“It’s a transition period, for sure,” she said. “I think we’ll see in the next six months or so, especially with all these surveyors trying to catch up, we’re going to see a new wave of where the citations will be. I’m interested to see how many facilities will get the chemical restraint, how many facilities will run into trouble with their PBJ audits. It’s important they’re focusing on these things, especially with the antipsychotic medications. The documentation is vital.”