Oversight, Outcomes, and Omission

GAO Recommends More Stringent Oversight of Medical Suppliers

    Last year, the Centers for Medicare and Medicare Services (CMS) paid medical equipment suppliers $8.8 billion. Of those expenditures, an estimated $900 million was improperly paid to suppliers of durable medical equipment (DME), prosthetics, orthotics, and medical supplies — often due to supplier fraud. For many years, the CMS has contracted with the National Supplier Clearinghouse (NSC) to perform watchdog services to verify that suppliers adhere to Medicare’s 21 supplier standards before they are eligible to bill Medicare. The NSC performs these services in two ways: 1) by conducting on-site inspections of supplier businesses and 2) by conducting reviews of suppliers’ documentation.

    In a September report, the Government Accountability Office (GAO) found that the NSC’s efforts to verify compliance to supplier standards were insufficient owing to gaps in two key screening procedures: checking state licensure and conducting on-site inspections. The GAO believes the NSC’s licensure check is inadequate because it relies on self-reported information about the products a supplier intends to provide to Medicare beneficiaries. When this information is compared to the billing submitted by the supplier, they do not match. The GAO found 22 suppliers in three states who had been paid at least $1,000 last year for providing oxygen services when they were not licensed to do so by their state. More than half of the $107 million paid to custom-fabricated prosthetics and orthotics in Florida went to suppliers who had not had their licenses checked. Additionally, 46 of those suppliers were under investigation for Medicare fraud. The GAO also believes that the NSC did not conduct the required on-site inspections of 605 suppliers, nor does the organization require its inspectors to review beneficiary files to determine whether proof of delivery exists and whether the supplier has a real source of inventory.

    The GAO believes the 21 supplier standards are too weak to be effective because they currently do not include measures related to supplier integrity and capability comparable to standards other federal agencies generally apply to contractors. In summary, the GAO recommended that Congress develop more stringent sanctions against non-compliant suppliers and that the CMS improve the process for the NSC licensure verification, on-site inspections, and their own oversight of the NSC. The complete report can be viewed at: https://www.gao.gov/new.items/d05656.pdf.

AMDA Issues Pressure Ulcer Tools for Long-Term Care

    The American Medical Directors Association (AMDA) now has some of its clinical tools posted on the National Quality Measures Clearinghouse website (www.qualitymeasures.ahrq.gov). Among some of the most recently posted are Pressure ulcers: percentage of patients with pressure ulcers with periodic documentation on status of the characteristics of the wound (eg, size, depth, color, induration, odor, discharge). This is one of AMDA’s 12 suggested quantitative process or clinical outcomes measures related to the implementation of pressure ulcer clinical practice guidelines in long-term care. The measures are based on four pillars of the AMDA pressure ulcer management process: Recognition, Assessment, Treatment, and Monitoring.

    Of the estimated $1 billion spent each year on pressure ulcer care, AMDA estimates that $355 million is spent in long-term care settings. Lawsuit claims have increased at an annual rate of 14% and the average court settlement has risen $250,000. A comprehensive clinical practice guideline developed by AMDA, called “We Care: Tool Kit for Implementation of the Clinical Practice Guideline for Pressure Ulcers” can be ordered from: https://www.amda.com.

Surveyor Feedback — Hospital Citation

    After conducting a record review in a hospital, a Medicare surveyor cited the hospital for “failure to assess, plan, implement, and evaluate the care given to Patient X for pressure ulcers.” The findings included:
   • Failure to document the presence of “reddened skin, size, location and stage” upon admission from the emergency room. This also did not comply with the hospital’s own policies and procedures (P&P)
   • More than 8 hours after admission, a Braden assessment was conducted and the patient was deemed to be at “mild risk.” Documentation also revealed a 2-cm x 2- cm Stage I pressure ulcer on the gluteal fold.

    Hospital P&P required that a problem/goal list must be completed within 8 hours of admission. Actions taken were not compliant with hospital policy
   • Three days later, documentation listed the pressure ulcer as a Stage II and the site was described as “black.” Hospital policy defined the description of this area as “devitalized tissue” which required the initiation of a pressure ulcer trending record. This was not completed. Hospital policy also instructed that “black” wounds with eschar were unstageable
   • There was no documentation in the medical record to demonstrate that the patient was turned every 2 hours as directed
   • Documentation in the nursing notes described three different sites of pressure ulcers that were hospital-acquired. Hospital policy required the generation of an unusual occurrence report (UOR) if a pressure ulcer was acquired in the hospital. No such report was filed
   • Five days later, the patient was transferred to a skilled nursing facility. The transfer summary contained no documentation related to pressure ulcers. The patient’s risk was elevated to moderate risk, but there was no documented risk assessment in the medical record to substantiate the change in risk.