type: other

jurisdiction: US

text: b' Department of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n MARYLAND GENERALLY COMPLIED\nWITH REQUIREMENTS FOR MEDICAID\nPAYMENTS MADE TO MULTI-MEDICAL\n CENTER FOR NURSING FACILITY\n SERVICES\n\n\n Inquiries about this report may be addressed to the Office of Public Affairs at\n Public.Affairs@oig.hhs.gov.\n\n\n\n\n Stephen Virbitsky\n Regional Inspector General\n\n May 2013\n A-03-11-00151\n\x0c Office of Inspector General\n https://oig.hhs.gov\n\n\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is\nto protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the\nhealth and welfare of beneficiaries served by those programs. This statutory mission is carried out\nthrough a nationwide network of audits, investigations, and inspections conducted by the following\noperating components:\n\nOffice of Audit Services\n\nThe Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with\nits own audit resources or by overseeing audit work done by others. Audits examine the performance of\nHHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are\nintended to provide independent assessments of HHS programs and operations. These assessments help\nreduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.\n\nOffice of Evaluation and Inspections\nThe Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress,\nand the public with timely, useful, and reliable information on significant issues. These evaluations focus\non preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of\ndepartmental programs. To promote impact, OEI reports also present practical recommendations for\nimproving program operations.\n\nOffice of Investigations\nThe Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and\nmisconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50\nStates and the District of Columbia, OI utilizes its resources by actively coordinating with the Department\nof Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI\noften lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering\nadvice and opinions on HHS programs and operations and providing all legal support for OIG\xe2\x80\x99s internal\noperations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS\nprograms, including False Claims Act, program exclusion, and civil monetary penalty cases. In\nconnection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG\nrenders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides\nother guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement\nauthorities.\n\x0c Notices\n\n\n THIS REPORT IS AVAILABLE TO THE PUBLIC\n at https://oig.hhs.gov\n\n Section 8L of the Inspector General Act, 5 U.S.C. App., requires\n that OIG post its publicly available reports on the OIG Web site.\n\nOFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS\n\n The designation of financial or management practices as\n questionable, a recommendation for the disallowance of costs\n incurred or claimed, and any other conclusions and\n recommendations in this report represent the findings and\n opinions of OAS. Authorized officials of the HHS operating\n divisions will make final determination on these matters.\n\x0c EXECUTIVE SUMMARY\nBACKGROUND\nTitle XIX of the Social Security Act requires the Medicaid program to provide medical\nassistance to low-income individuals and individuals with disabilities. The Federal and State\nGovernments jointly fund and administer the Medicaid program. At the Federal level, the\nCenters for Medicare & Medicaid Services (CMS) administers the program. Each State\nadministers its Medicaid program in accordance with a CMS-approved State plan. Although the\nState has considerable flexibility in designing and operating its Medicaid program, it must\ncomply with applicable Federal requirements. In Maryland, the Department of Health and\nMental Hygiene (State agency) administers the Medicaid program.\nState agencies are authorized to provide nursing facility services to Medicaid beneficiaries.\nFederal regulations (42 CFR part 483 subpart B) require that the nursing facilities provide\nnursing services, rehabilitative services, and medically-related social services for residents under\nthe supervision of a physician. Further, the facility must not employ individuals who have been\nfound guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a\nfinding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of\nresidents or misappropriation of their property (42 CFR \xc2\xa7 483.13(c)(1)(ii)).\n\nMulti-Medical Center (Multi-Medical) is a nursing facility located in Towson, Maryland. Multi-\nMedical is owned and operated by the Genesis HealthCare Corporation. For the period\nOctober 1, 2007, through September 30, 2008, the State agency paid Multi-Medical\napproximately $6.6 million for Medicaid nursing facility services.\n\nOBJECTIVE\nOur objective was to determine whether the State agency complied with Federal and State\nrequirements for Medicaid payments made to Multi-Medical for nursing facility services.\n\nSUMMARY OF FINDINGS\nThe State agency generally complied with Federal and State requirements for Medicaid\npayments made to Multi-Medical for nursing facility services. Of the 110 claims in our sample,\n75 complied with Federal and State requirements. However, 35 of the claims included some\nunallowable services. Services within a claim could be unallowable for one or multiple reasons.\nOf the 35 noncompliant claims, 6 contained more than 1 deficiency:\n\n \xe2\x80\xa2 For 34 claims, some services were not supported by any documentation and some were\n insufficiently supported by the documentation contained in the medical record.\n\n \xe2\x80\xa2 For six claims, orders lacked a physician\xe2\x80\x99s signature to authorize the services.\n\n \xe2\x80\xa2 For two claims, a service was billed that exceeded the allowable limit.\n\nUsing our sample results, we estimate that the State agency improperly claimed $37,401\n($18,701 Federal share).\n\n i\n\x0cIn addition, Multi-Medical had some weaknesses in facility practices. Multi-Medical did not\napply for a background check on 20 employees prior to their hire date, including 8 employees for\nwhom Multi-Medical had not applied for background checks at the time of our review. Also,\nMulti-Medical did not properly report to the State agency three unwitnessed incidents during\nwhich a resident received an injury caused by an unknown source. Because the State agency\xe2\x80\x99s\noversight was not always adequate, it did not ensure that Multi-Medical always complied with\nState and Federal requirements for facility practices.\n\nRECOMMENDATIONS\nWe recommend that the State agency:\n\n \xe2\x80\xa2 refund $18,701 to the Federal Government,\n\n \xe2\x80\xa2 ensure that Multi-Medical has a completed background check performed for all\n employees and that Multi-Medical consistently follows all Federal and State\n preemployment requirements, and\n\n \xe2\x80\xa2 provide education to Multi-Medical to ensure that all unwitnessed incidents that result in\n an injury of unknown source are promptly reported.\n\nMULTI-MEDICAL CENTER COMMENTS\nIn written comments to our draft report, Multi-Medical disagreed with errors reported on 8 of the\n35 claims in our findings. Multi-Medical stated that the lack of a therapist\xe2\x80\x99s initials is not a valid\nreason to disallow a service; a discharge summary provided in lieu of progress notes was an\nacceptable form of support; and physician orders that were incorrectly dated should be allowable.\nMulti-Medical stated that three of the six unwitnessed incidents did not have to be reported\nbecause the beneficiaries were able to provide details of their falls. However, Multi-Medical\nagreed with our second and third recommendations and described the actions it had taken, or\nplanned to take, to address them.\n\nOFFICE OF INSPECTOR GENERAL RESPONSE\n\nWe considered Multi-Medical\xe2\x80\x99s comments and we maintain that the findings and\nrecommendations are valid. We disallowed the services in question because there was not\nsufficient evidence to support that the services were provided on the dates claimed, not because\nthey specifically lacked a therapist\xe2\x80\x99s initials. We did not accept the discharge summary in lieu of\nprogress notes because the discharge summary did not identify any services that may have been\nprovided. The incorrectly dated order had additional discrepancies that called the documentation\ninto question. We therefore continue to support our findings and recommendations.\n\nSTATE AGENCY COMMENTS AND\nOFFICE OF INSPECTOR GENERAL RESPONSE\n\nIn written comments to our draft report, the State agency concurred with our first two\nrecommendations and partially concurred with our third recommendation. The State agency\n\n ii\n\x0cagreed with Multi-Medical that only three of the six unwitnessed incidents should have been\nreported to the State agency and provided additional documentation to support its position. We\nconsidered the State agency\xe2\x80\x99s comments and additional documentation and have removed three\nof the unwitnessed incidents from our findings.\n\n\n\n\n iii\n\x0c TABLE OF CONTENTS\n Page\nINTRODUCTION......................................................................................................................1\n BACKGROUND .............................................................................................................1\n Medicaid Program ................................................................................................1\n Nursing Facility Services .....................................................................................1\n Maryland Nursing Facilities Services ..................................................................1\n Multi-Medical Center...........................................................................................2\n OBJECTIVE, SCOPE AND METHODOLOGY ............................................................2\n Objective ..............................................................................................................2\n Scope ....................................................................................................................2\n Methodology ........................................................................................................2\nFINDINGS AND RECOMMENDATIONS ............................................................................3\n UNALLOWABLE NURSING FACILITY SERVICES ..................................................4\n Services Not Supported........................................................................................4\n Services Not Authorized ......................................................................................4\n Services in Excess of the Allowable Limit ..........................................................5\n Services Not Allowable for Federal Reimbursement ..........................................5\n WEAKNESSES IN FACILITY PRACTICES..................................................................5\n Background Checks .............................................................................................5\n Incident Reports ...................................................................................................6\n\n STATE AGENCY OVERSIGHT .....................................................................................6\n RECOMMENDATIONS ..................................................................................................6\n MULTI-MEDICAL CENTER COMMENTS...................................................................6\n OFFICE OF INSPECTOR GENERAL RESPONSE ........................................................7\n STATE AGENCY COMMENTS AND OFFICE OF\n INSPECTOR GENERAL RESPONSE..........................................................................7\n\nAPPENDIXES\n A: SAMPLE DESIGN AND METHODOLOGY\n B: SAMPLE RESULTS AND ESTIMATES\n C: MULTI-MEDICAL CENTER COMMENTS\n D: STATE AGENCY COMMENTS\n\n\n\n iv\n\x0c INTRODUCTION\nBACKGROUND\nMedicaid Program\nTitle XIX of the Social Security Act (the Act), requires the Medicaid program to provide medical\nassistance to low-income individuals and individuals with disabilities. The Federal and State\nGovernments jointly fund and administer the Medicaid program. At the Federal level, the\nCenters for Medicare & Medicaid Services (CMS) administers the program. Each State\nadministers its Medicaid program in accordance with a CMS-approved State plan. Although the\nState has considerable flexibility in designing and operating its Medicaid program, it must\ncomply with applicable Federal requirements. In Maryland, the Department of Health and\nMental Hygiene (State agency) administers the Medicaid program.\n\nNursing Facility Services\nSection 1905(a)(4)(A) of the Act authorizes State Medicaid agencies to provide nursing facility\nservices to Medicaid beneficiaries. Participating nursing facilities must meet the requirements of\nsection 1919 of the Act and implementing Federal participation regulations (42 CFR part 483\nsubpart B), which describe the services provided and the rights of residents. Nursing facilities\nmust provide nursing and related services and specialized rehabilitative services to attain or\nmaintain the highest practicable physical, mental, and psychosocial wellbeing of each resident.\nServices must be provided by qualified aides and health professionals under the supervision of a\nphysician. Further, the facility must not employ individuals who have been found guilty by a\ncourt of law of abusing, neglecting, or mistreating residents or have had a finding entered into\nthe State nurse aide registry concerning abuse, neglect, mistreatment of residents or\nmisappropriation of their property (42 CFR \xc2\xa7 483.13(c)(1)(ii)).\nCMS reimburses the State Medicaid agency the Federal share of the State\xe2\x80\x99s claimed costs, based\non the Federal medical assistance percentage (FMAP). The State of Maryland\xe2\x80\x99s FMAP for our\naudit period was 50 percent.\n\nMaryland Nursing Facilities Services\nMedicaid State plan attachment 3.1 authorizes nursing facility services for individuals 21 years\nof age or older. The Code of Maryland Regulations (COMAR) implement attachment 3.1.\nCOMAR 10.09.10.04(A) requires the program to cover routine care and supplies, equipment,\nand services when appropriate to meet the needs of the resident as described in 42 CFR Part 483,\nSubpart B.\nNursing facility services are eligible for reimbursement when care is medically necessary,\nadequately described in progress notes in the resident\xe2\x80\x99s medical record, and signed and dated by\nthe individual providing care (COMAR 10.09.07.05(B)). Nursing facilities receive a set per\ndiem rate for basic services and may claim additional specialized services separately. For the\nperiod October 1, 2007, through September 30, 2008, the State agency claimed $1,007,939,098\n($503,991,869 Federal share) for nursing facility services.\n\n\n\n 1\n\x0cMulti-Medical Center\nMulti-Medical Center (Multi-Medical) is a 118-bed nursing facility located in Towson,\nMaryland, that provides short and long-term nursing and rehabilitative care. Multi-Medical is\nowned and operated by the Genesis HealthCare Corporation, a provider of skilled nursing and\nrehabilitative services. For the period October 1, 2007, through September 30, 2008, the State\nagency paid Multi-Medical approximately $6.6 million for Medicaid nursing facility services.\n\nOBJECTIVE, SCOPE, AND METHODOLOGY\nObjective\nOur objective was to determine whether the State agency complied with Federal and State\nrequirements for Medicaid payments made to Multi-Medical for nursing facility services.\n\nScope\nWe reviewed $6,607,174 ($3,303,587 Federal share) of the claims that the State agency paid\nMulti-Medical from October 1, 2007, through September 30, 2008, for nursing facility services.\nWe did not review the State agency\xe2\x80\x99s overall internal control structure because our objective did\nnot require us to do so. We did not review the nursing facility claims in our stratified random\nsample (discussed below) to determine medical necessity. We limited our internal control\nreview to those controls related directly to processing and monitoring nursing facility claims.\nWe conducted survey work at the State agency offices in Baltimore, Maryland, in September\n2010 and fieldwork at Multi-Medical in Towson, Maryland, from January through June 2011 and\nat Genesis HealthCare Corporation\xe2\x80\x99s Headquarters in Kennett Square, Pennsylvania, from June\n2011 through May 2012.\n\nMethodology\nTo accomplish our objective, we:\n\n \xe2\x80\xa2 reviewed Federal and State laws, regulations, and other requirements regarding Medicaid\n reimbursement for nursing facility services;\n\n \xe2\x80\xa2 interviewed State agency officials to gain an understanding of how they administer and\n monitor the Medicaid nursing facility program;\n\n \xe2\x80\xa2 interviewed Multi-Medical personnel to determine their procedures for obtaining\n employee background checks and for reporting incidents to the State agency;\n\n \xe2\x80\xa2 reviewed available background check documentation for all employees working at Multi-\n Medical during the fieldwork portion of our review;\n\n \xe2\x80\xa2 reviewed incident logs and incident reports compiled by Multi-Medical staff;\n\n \xe2\x80\xa2 extracted Multi-Medical\xe2\x80\x99s Medicaid claims from the data provided by the State agency;\n\n 2\n\x0c \xe2\x80\xa2 identified 748 claims for $1,000 or more that the State agency paid during our audit\n period for nursing facility services provided by Multi-Medical;\n\n \xe2\x80\xa2 selected for review a stratified random sample of 110 claims totaling $1,569,585\n ($784,792 Federal share);\n\n \xe2\x80\xa2 reviewed the supporting documentation for all services in each sampled claim to\n determine their allowability;\n\n \xe2\x80\xa2 verified for each sampled claim the number of days of service at the per diem rate for the\n approved level of care;\n\n \xe2\x80\xa2 held discussions with the utilization control agent to better understand the documentation\n requirements;\n\n \xe2\x80\xa2 provided the results of our review to officials from Genesis and Multi-Medical on\n May 29, 2012, and discussed those results with State agency officials on June 21, 2012.\nAppendixes A and B contain details of our sampling and estimation methodologies.\nWe conducted this performance audit in accordance with generally accepted government\nauditing standards. Those standards require that we plan and perform the audit to obtain\nsufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions\nbased on our audit objectives. We believe that the evidence obtained provides a reasonable basis\nfor our findings and conclusions based on our audit objectives.\n\n FINDINGS AND RECOMMENDATIONS\nThe State agency generally complied with Federal and State requirements for Medicaid\npayments made to Multi-Medical for nursing facility services. Of the 110 claims in our sample,\n75 complied with Federal and State requirements. However, 35 of the claims included some\nunallowable services. Services within a claim could be unallowable for one or multiple reasons.\nOf the 35 noncompliant claims, 6 contained more than 1 deficiency:\n\n \xe2\x80\xa2 For 34 claims, some services were not supported by any documentation and some were\n insufficiently supported by the documentation contained in the medical record.\n\n \xe2\x80\xa2 For six claims, orders lacked a physician\xe2\x80\x99s signature to authorize the services.\n\n \xe2\x80\xa2 For two claims, a service was billed that exceeded the allowable limit.\n\nUsing our sample results, we estimate that the State agency improperly claimed $37,401\n($18,701 Federal share).\n\nIn addition, Multi-Medical had some weaknesses in facility practices. Multi-Medical did not\napply for a background check on 20 employees prior to their hire date, including 8 employees for\nwhom Multi-Medical had not applied for background checks at the time of our review. Also,\n\n 3\n\x0cMulti-Medical did not properly report to the State agency three unwitnessed incidents during\nwhich a resident received an injury caused by an unknown source. Because the State agency\xe2\x80\x99s\noversight was not always adequate, it did not ensure that Multi-Medical always complied with\nState and Federal requirements for facility practices.\n\nUNALLOWABLE NURSING FACILITY SERVICES\nOf the 110 claims in our sample, 35 included unallowable services: 34 claims included services\nthat were either not supported by any documentation or were not sufficiently supported, 6 claims\nincluded services for which there was no physician\xe2\x80\x99s signature to authorize the order, and 2\nclaims included a service that exceeded the allowable limit. Six claims contained more than one\ndeficiency.\n\nServices Not Supported\nSection 1902(a)(27) of the Act requires the State plan to provide for agreements with providers\nto keep records necessary to fully disclose the extent of the services provided to Medicaid\nbeneficiaries and to agree to furnish the State agency with such information when requested.\nThe State agency requires that nursing facilities must maintain records for all patients in\naccordance with accepted professional standards and practices. Patient records must include:\n1) documented evidence of assessment of the needs of the patient, of establishment of an\nappropriate plan of initial and ongoing treatment [plan of care], and of the care and services\nprovided; 2) diagnostic and therapeutic orders; and 3) observations and progress notes (COMAR\n10.07.02.20).\n\nFor 34 of the 110 sampled claims, the State agency paid Multi-Medical for some nursing facility\nservices for which there was insufficient supporting documentation.\nFor 31 of these claims, the medical records maintained by Multi-Medical did not sufficiently\nsupport the claimed services. For example, for 1 claim, Multi-Medical claimed 26 units of\nturning and positioning service. However, the documentation supported only 22 units. We\nfound similar errors on 30 other claims.\nFor the remaining three claims, the medical records did not support that Multi-Medical had\nprovided any of the claimed services. For example, the State agency paid Multi-Medical for 11\nbilled units of speech therapy; however, Multi-Medical did not produce documentation to\nsupport that any speech therapy had been provided. Similar errors were found on two other\nclaims.\n\nServices Not Authorized\n\nNursing facility services are eligible for reimbursement under Medicaid only when the services\nare provided under the supervision of a physician (42 CFR \xc2\xa7 483.40). Further, 42 CFR\n\xc2\xa7 483.40(b) states that the physician must: (1) review the resident\'s total program of care,\nincluding medications and treatments, at each visit; (2) write, sign, and date progress notes at\neach visit; and (3) sign and date all orders with the exception of certain vaccines, which may be\n\n\n 4\n\x0cadministered according to physician-approved facility policy after an assessment for\ncontraindications.\n\nFor 6 of the 110 sampled claims, the State agency paid Multi-Medical for nursing facility\nservices for which the order lacked a physician\xe2\x80\x99s signature.\n\nServices in Excess of the Allowable Limit\nThe State agency reimburses providers for physical therapy services, performed by or under\nsupervision of a licensed physical therapist, that are directly related to the physician\xe2\x80\x99s written\nplan of care that specifies the frequency and duration of treatment (COMAR 10.09.07.05).\nCOMAR 10.09.10.09-1 provides for reimbursement of physical, occupational, and speech\ntherapy services in 15-minute increments, with a maximum duration of 1 hour per day.\nFor 2 of the 110 sampled claims, the State agency paid Multi-Medical for nursing facility\nservices that exceeded the allowable limit. For example, for one claim, the State agency paid\nMulti-Medical for five units of physical therapy billed for 1 day of service; however, only four\nunits were allowable. We found a similar error on one other claim.\n\nServices Not Allowable for Federal Reimbursement\nUsing the results of our sample, we estimate that the State agency improperly claimed $37,401\n($18,701 Federal Share) for nursing facility services provided by Multi-Medical that did not\ncomply with Federal and State requirements.\n\nWEAKNESSES IN FACILITY PRACTICES\nFor 20 individuals, Multi-Medical did not apply for background checks prior to their hire dates.\nAlso, Multi-Medical did not properly report to the State agency three incidents of resident injury\nby an unknown source.\n\nBackground Checks\nFederal regulations prohibit nursing facilities from employing individuals who have been \xe2\x80\x9c(A)\n[f]ound guilty of abusing, neglecting, or mistreating residents by a court of law; or (B) [h]ave\nhad a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment\nof residents or misappropriation of their property\xe2\x80\xa6\xe2\x80\x9d (42 CFR \xc2\xa7 483.13(c)(1)(ii)).\n\nSection 19-1902(a) of the Annotated Code of Maryland states that before an eligible employee\nmay begin work for an adult dependent care program, the program must apply for a State\ncriminal history records check or request a private agency to conduct a background check and\nrequest a reference from the potential employee\'s most recent employer.\nMulti-Medical did not apply for a background check prior to hiring 20 employees, including:\n\n \xe2\x80\xa2 12 employees for whom Multi-Medical applied for background checks after their hire\n date and\n\n\n\n 5\n\x0c \xe2\x80\xa2 8 employees for whom Multi-Medical had not applied for background checks at the time\n of our review.\n\nFor example, a nurse\xe2\x80\x99s aide was hired in 2000, but Multi-Medical did not apply for a background\ncheck until 2011. A respiratory therapist began working at Multi-Medical in 2001, but Multi-\nMedical did not apply for a background check until 2005. By not ensuring that all employees\nmet the Federal and State pre-employment requirements for background checks, Multi-Medical\npotentially jeopardized the safety of the adults in its care.\n\nIncident Reports\nFederal regulations require that nursing facilities ensure that \xe2\x80\x9call alleged violations involving\nmistreatment, neglect, or abuse, including injuries of unknown source, and appropriation of\nresident property are reported immediately to the administrator of the facility and to other\nofficials (including to the State survey and certification agency) in accordance with State law\nthrough established procedures (42 CFR \xc2\xa7 483.13(c)(2)).\n\nMulti-Medical did not properly report to the State agency three unwitnessed incidents of a\nresident injury by an unknown source. By not reporting the incidents, Multi-Medical potentially\njeopardized the safety of the adults in its care. Also, because CMS posts this information on its\nNursing Home Compare website, prospective residents were not provided with complete\ninformation to help them find and compare nursing homes and make informed decisions about\nnursing home care.\n\nSTATE AGENCY OVERSIGHT\n\nBecause its oversight was not always adequate, the State agency paid some unallowable claims\nand did not ensure that Multi-Medical always complied with State and Federal requirements for\nconducting background checks and reporting incidents of resident injuries.\n\nRECOMMENDATIONS\nWe recommend that the State agency:\n\n \xe2\x80\xa2 refund $18,701 to the Federal Government,\n\n \xe2\x80\xa2 ensure that Multi-Medical has a completed background check performed for all\n employees and that Multi-Medical consistently follows all Federal and State\n preemployment requirements, and\n\n \xe2\x80\xa2 provide education to Multi-Medical to ensure that all unwitnessed incidents that result in\n an injury of unknown source are promptly reported.\n\nMULTI-MEDICAL CENTER COMMENTS\nIn written comments to our draft report, Multi-Medical disagreed with errors reported on 8 of the\n35 claims in our findings. Multi-Medical stated that the lack of a therapist\xe2\x80\x99s initials is not a valid\nreason to disallow a service; a discharge summary provided in lieu of progress notes was an\n 6\n\x0cacceptable form of support; and physician orders that were incorrectly dated should be allowable.\nMulti-Medical also stated that three of the six unwitnessed incidents did not have to be reported\nbecause the beneficiaries were able to provide details of their falls. However, Multi-Medical\nagreed with our second and third recommendations and described the action it had taken, or\nplanned to take, to address them.\n\nMulti-Medical\xe2\x80\x99s comments are included as Appendix C to this report. The attachment to Multi-\nMedical\xe2\x80\x99s comments was not included because it contained personally identifiable information.\n\nOFFICE OF INSPECTOR GENERAL RESPONSE\n\nWe considered Multi-Medical\xe2\x80\x99s comments and we maintain that the findings and\nrecommendations are valid. We disallowed the services in question because there was not\nsufficient evidence to support that the services were provided on the dates claimed, not because\nthey specifically lacked a therapist\xe2\x80\x99s initials. We did not accept the discharge summary in lieu of\nprogress notes because the discharge summary did not identify any services that may have been\nprovided. The incorrectly dated order had additional discrepancies that called the documentation\ninto question. We therefore continue to support our findings and recommendations.\n\nSTATE AGENCY COMMENTS AND\nOFFICE OF INSPECTOR GENERAL RESPONSE\n\nIn written comments to our draft report, the State agency concurred with our first two\nrecommendations and partially concurred with our third recommendation. The State agency\nagreed with Multi-Medical that only three of the six unwitnessed incidents should have been\nreported to the State agency and provided additional documentation to support its position. We\nconsidered the State agency\xe2\x80\x99s comments and additional documentation and have removed three\nof the unwitnessed incidents from our findings.\n\nThe State agency\xe2\x80\x99s comments are included as Appendix D to this report.\n\n\n\n\n 7\n\x0cAPPENDIXES\n\x0c APPENDIX A: SAMPLE DESIGN AND METHODOLOGY\nPOPULATION\nThe population consisted of Medicaid claims that the State agency paid during the period\nOctober 1, 2007, through September 30, 2008, for nursing facility services provided by Multi-\nMedical Center.\n\nSAMPLING FRAME\nThe sample frame consisted of 748 Medicaid claims totaling $6,607,174 ($3,303,587 Federal\nShare). We identified and removed 19 claims from the population that were less than $1,000.\n\nSAMPLE UNIT\nThe sample unit was a claim. A claim included all services provided to a resident for one month.\nAll services in the claim were reviewed.\n\nSAMPLE DESIGN\nWe used a stratified random sample containing three strata as follows:\n\n Total Medicaid\n Stratum Range Number of Claims Reimbursement\n 1 $1,000.00-$9,999.99 633 $4,467,859\n 2 $10,000.00-$23,699.99 105 1,888,555\n 3 $23,700.00 and above 10 250,760\n Total 748 $6,607,174\n\n\nSAMPLE SIZE\nWe selected a sample of 40 claims from stratum 1, 60 claims from stratum 2, and 10 claims from\nstratum 3, resulting in a total sample of 110 claims.\n\nSOURCE OF RANDOM NUMBERS\nWe used the Office of Inspector General, Office of Audit Services (OAS), statistical software to\ngenerate the random numbers.\n\nMETHOD OF SELECTING SAMPLE ITEMS\nWe consecutively numbered the sample units in stratum 1 and stratum 2. After generating 40\nrandom numbers for stratum 1 and 60 random numbers for stratum 2, we selected the\ncorresponding frame items. We chose all 10 sample items in stratum 3.\n\nESTIMATION METHODOLOGY\nWe used the OAS statistical software to estimate the total amount and Federal share of the\noverpayments.\n\x0c APPENDIX B: SAMPLE RESULTS AND ESTIMATES\n\n\n Sample Results: Total Amounts\n\n\n\n Frame Value of Sample Value of No. of Value of\nStratum Size Frame Size Sample Overpayments Overpayments\n 1 633 $4,467,859 40 $272,458 9 $1,709\n 2 105 1,888,555 60 1,046,367 20 27,136\n 3 10 250,760 10 250,760 6 3,595\n Total 748 $6,607,174 110 $1,569,585 35 $32,440\n\n\n\n\n Estimated Value of Overpayments\n (Limits calculated for a 90-percent confidence interval)\n\n Total Amounts Federal Share\n\n Point Estimate $78,128 $39,064\n\n Lower limit $37,401 $18,701\n\n Upper limit $118,855 $59,428\n\x0c Page 1 of 6\n APPENDIX C: MULTI-MEDICAL CENTER COMMENTS\n\n :fi: Multi-Medical Center\n ... \xe2\x80\xa2 Genesis HealthCare"\'\n\n December 5, 2012\n\nStephen Virbitsky\nOffice of Audit Services, Region Ill\nOffice of Inspector General 7700 York Road\n Towson, MD 21204\nPublic Ledger Building, Suite 316 Tel 410 821 5500\n150 South Independence Mall West Fax 410 512 3520\nPhiladelphia, PA 19106 \'IDD 800 735-2258\n\n\n Re: Report Number A-03-11-00151\n\nDear Mr. Virbitsky:\n\n Multi-Medical Center would like to thank you for the opportunity to comment on the Office of Inspector\n General (OIG) Audit Report dated October 18, 2012 ("Draft Report\'\'). Multi-Medical Center agrees in\n part and disagrees in part with the audit findings. As you requested, this letter provides a statement\n descriqing the nature of the corrective action taken or planned for those findings with which we concur.\n Similarly, we provide a statement of the specific reasons for those findings with which we do not concur\n\xc2\xb7and a statement of any alternative corrective action taken or planned. This letter is timely filed by\n December 5, 2012 which is within the period of 30 days from the date of the Draft Report and the\n request for extensio.n granted by Mr. Leonard D. Picari.\n\nThe. Draft Report included 35 claims with deficiencies. Four of those claims contained deficiencies in\nmore than one category. This resulted in the following number of claims with deficiencies by category\n\n .;~~*~g9~il;~~:i:l;;~\\~m\\:~~\'.l:;)}~~;::t~!i&~~1~!.ii~~;;;;;i:jt~iW~t~t~~~::j;\'iNf.j,f;:tlili!i;\'i~~ i\xc2\xb7N\'i;i!J)\'!~~fJ9riPt~1~~E\\\'/:\n Services Not Supported 31\n Services Not Authorized 6\n Services in Excess of Allowable Limit 2\n\n\n\nI. 31 Claims, Some Services Insufficiently Supported By Documentation.\n\nMulti-Medical Center concurs that 25 of the claims identified by the OIG did not sufficiently support\nbilling of Nursing Facility Services. Many of the claims noted with unsupported services contained billing\ninaccuracies that appeared to be unintention.al and. relative to human error due to manual calculation.\nFor six claims (131 .units), we respectfully disagree with the findings since criteria and documentation\nrequired for reimbursement is present in the medical record and supports the services billed. Of these\nsix claims, two contained more than one deficiency.\n\n A. The Maryland Medical Assistance Program: Nursing FacilitY Assessment and\nReimbursement Handbook (Handbook) outlines the criteria and key documentation that is required for\nreimbursement. In order to bill for therapy services, the following documentation is required (a)\nphysician order; (b) therapy evaluation; (c) treatment plan; (d) daily service record; (e) weekly progress\nnotes. In addition, the Handbook provides an example of a daily service record in the Appendix section\nof the Handbook. We believe that our document contained in the medical records commonly known as.\n\x0c Page 2 of 6\nMr. Stephen Virbitsky\nDecember 5, 2012\nPage 2 of 6\n\n\n\nthe Service Log Matrix conforms to the aforementioned document and satisfies reimbursement\nguidelines. Please see the information below related to specific disallowances.\n\n 1. Insufficient Documentation Relevant to Therapist lnitlols\n\n For five claims, all key documentation was located and provided as outlined in the Handbook to\n SC1tisfy reimbursement requirements. According to the Handbook, a daily service record must\n include date of treatment, treatment modality, minutes for each modality, and total treatment\n minutes. While the therapists for the selected claims in your sample provided additional\n documentation (therapist initialed the service log matrix and progress note), initialing the notes\n is not required and lack of a therapist\'s initials is not a valid reason to disallow service. In the\n instances in which the audit disallowed these services, sufficient documentation was provided\n on the service log matrix pursuant to the Handbook and our internal procedures.\n\n Based upon the information presented above for the five claims, we request reconsideration of\n services billed on the following claims:\n\n\n\n\n 2. lnsu/fident or No Documentation Relevant to Weekly Progress Notes\n\n Per the Handbook, progress notes for therapy services must include an initial assessment note,\n an update status, and discharge instructions on a weekly basis. For two claims, all key\n documentation was located and provided to satisfy those reimbursement requirements.\n\n We noted for one deficiency, 11 units were disallowed sinc.e no documentation was provided.\n The medical record revealed that the start -o f care for therapy services began on 9/4/2008 and\n ended on 9/10/2008. A discharge summary was completed in lieu of a progress note since\n services ended on the aforementioned date. Since the discharge summary has the same\n elements of a progress note, the discharge summary clearly documented the initial assessment,\n update status, and discharge instructions to satisfy the documentation requirements for\n reimbursement purposes.\n\n Deficiencies were noted relevant to missing minutes on weekly progress notes. According to the\n aforementioned documentation requirements for weekly progress notes, inclusion of minutes\n on the note is not a requirement for reimbursement purposes. The minutes in question are\n documented on the service log matrix as previously discussed.\n\x0c Page 3 of 6\nMr. Stephen Virbitsky\nDecember 5, 2012\nPage 3 of6\n\n\n\n Lastly, units were disallowed since no progress note was available in the medical record.\n Specifically, the medical record revealed that a progress note was written on 9/18/2008 and\n services ended on 9/22/2012. As outlined in the Handbook, progress notes must be completed\n at least weekly. Since the time period between the last progress note and discharge summary is\n less than seven days, an additional progress note was not required for reimbursement purposes.\n\n Based upon the information presented above for the two claims, we request reconsideration of\n services billed on the following claims:\n\n\n\n\n * In the 0/G Draft Report, claim was noted with more than one deficiency.\n\n 3. Insufficient Documentation Relevant to Therapy Certification\n\n A. According to the Handbook, therapy evaluations are required for reimbursement\npurposes. The evaluation must include the reason for referral, onset date of the problem, prior and\ncurrent level of functioning, and assessment summary. In addition, the evaluation identifies modalities,\nfrequency of services, and goals and is typically updated every 30 days or sooner, if required, by the\ntherapist and signed by the attending physician or physician extender.\n\n We concur that one recertification was not signed by the physician. Since the Handbook does\n not provide any guidance on unsigned certifications, we referenced the following CMS manual-\n Medicare Benefit Policy Manual Chapter 15: ~overed Medical and Other Health Services. In\n Section 220.1.3 D, the manual outlines the procedure for handling delayed certifications. Since a\n physician order was signed by the physician, the medical record clearly documents the need for\n care and that the patient was under the care of a physician in which a delayed certification\n would be appropriate. For one claim, we obtained a delayed certification for the services in\n question since requirements for a delayed certification were satisfied (see Attachment A).\n\n Based upon the information presented above for one claim, we request reconsideration of\n services billed on the following claim:\n\n\n\n\n B. Corrective Action. As a result of the services Insufficiently supported by\ndocumentation, Multi-Medical Center\'s corrective action will include continuing education to all staff to\ndocument and maintain all necessary entries in the record as required to bill Medicaid for Nursing\nFacility Services as outlined in the Handbook. For each service, Multi-Medical Center strives to ensure\n\x0c Page 4 of 6\nMr. Stephen Virbitsky\nDecember 5, 2012\nPage 4 of 6\n\n\n\nthat the beneficiary\'s medical record includes: (a) physician orders for services if applicable; (b)\ndocumented evidence of assessment of patient\'s needs, establishment of an appropriate and ongoing\ntreatment plan or plan of care, and documentation of care and services provided; (c) observations and\nprogress notes.\n\nII. Six Claims Orders Lacked a Physician\'s Signature to Authorize Services\n\nMulti-Medical Center strives to obtain the prescriber\'s signature on all telephone and monthly\nrecapitulations of computerized pharmacy orders (monthly orders} in accordance with State and Federal\nRegulations. For four claims, we concur that telephone or monthly orders lacked a prescriber\'s\nsignature. We believe that this failure to obtain this signature was due to human error.\n\n A. The medical necessity of the essential services provided of enteral nutrition therapy and\nventilator care were provided under the supervision of a physician which is clearly evident in other\nsections of the medical record. For one enteral nutrition therapy claim and one ventilator care claim (27\nunits in total), we respectfully disagree with the findings since criteria and documentation required for\nreimbursement is present in the medical record and supports the services billed discussed below.\n\n\n 1. Service$ Not Authorized: Enteral Nutrition Therapy\n\n For claim S2-22, a tube feeding order was signed by the Certified Registered Nurse Practitioner\n (CRNP) on 7/24/2008 which contains the rate of administration under the Tube Feeding\n Method/Frequency section on the form (40 ml per hour; hours per day= 20). It appears that the\n CRNP may have incorrectly dated the form 7/24/2008 versus 7/25/2008 since the nightly chart\n check for orders within last 24 hours revealed a Licensed Practical Nurse\'s signature on\n 7/26/2008 at 0200 hrs.\n\n Based upon the information presented above for one enteral nutrition therapy claim, we\n request reconsideration of services billed on the following claim:\n\n\n\n\n 2. Services Not Authorized: Ventilator Care\n\n According to the Handbook, services for ventilator care can be billed for any part of the day in\n which a patient receives artificial ventilation of the lungs by mechanical means through a\n ventilator. The key documentation required for reimbursement purposes includes the following:\n (a) physician order; (b) flow sheet or treatment/medication sheets; (c) other supporting\n documentation as necessary.\n\n For one claim (S2-48), we concur that the physician did not sign the monthly order; however, a\n revision to the original order was noted and signed by the physician on 3/3/08. Specifically, the\n\x0c Page 5 of 6\nMr. Stephen Virbitsky\nDecember 5, 2012\nPage 5 of6\n\n\n\n physician ordered pressure support ventilation (PSV) with settings for up to two hours as\n tolerated. While this order was later discontinued since the patient was unable to tolerate the\n ventilator weaning process per the physician, we believe that reconsideration of the services\n provided under this order should be allowable since the criteria and key documentation were\n properly documented to satisfy reimbursement guidelines.\n\n Based upon the information presented, we request reconsideration of services billed on the\n following claims:\n\n\n\n\n B. Corrective Action. As a result of the services insufficiently supported by lack of\nphysician orders, Multi-Medical Center\'s corrective action will include continuing education to all staff to\nensure orders are signed in accordance with regulatory requirements\n\n\nIll. Services in Excess of the Allowable Limit\n\nMulti-Medical strives to provide an accurate and comprehensive record of all services provided. We\nconcur with the audit findings which appear to be isolated and a result of human error.\n\n\n\nIV. Weaknesses in Facility Practices\n\n 1. Background Checks\n\n Multi-Medical Center strives to obtain the required criminal background checks for all\n employees before they commence employment. Of the eight employees for whom a\n background check had not been completed as of the review five have since terminated\n employment. Background checks for the remaining three have been completed and meet\n published hiring criteria.\n\n Of the 12 employees for whom a background check was completed late, the examples cited by\n the OIG are accurate. However, those examples are outliers. Background checks for five of the\n 12 exceptions were obtained within 65 days of the hire date. Also, despite being late, all of the\n background checks met our hiring criteria, meaning that our patients were not in harms way.\n\nCorrective Action. Multi-Medical Center has strengthened our background check process in the last\nseveral years. The results of this strengthening are evident when learning that the hire date for 17 of\nthe 20 exceptions was prior to 2009.\n\x0c Page 6 of 6\nMr. Stephen Virbitsky\nDecember 5, 2012\nPage 6of6\n\n\n\n\n 2. Incident Reports\n\n Of the six incident reports mentioned in the Draft Report, we concur with three of the findings.\n For the remaining three incidents, we respectfully disagree with the findings since incidents\n were of known source. Specifically, incident reports dated November 11, 2007 and August 25,\n 2008, both alert and oriented patients were able to provide specific details of their falls. On\n another report dated January 25, 2008, the description of the incident was very specific to the\n cause of the fall. Since the three incident reports indicate the source of the injury, we believe\n that these Incidents were not required to be reported as outlined in a memorandum to\n Administrators from the Director, Office of Health Care Quality on April12, 2005.\n\n\n\n\nCorrective Action. As a result of incident reports not reported, Multi-Medical Center\'s corrective action\nwill include continuing education to key staff members to ensure incident reports are appropriately filed\nwith the appropriate regulatory authorities.\n\n\nV. Conclusion\n\nAs discussed in the detail above, Multi-Medical Center acknowledges that some, but not all, of the\nclaims identified by the OIG failed to comply with the applicable State and Federal laws and policies\ngoverning the provision of long term care services to Medicaid beneficiaries. While Multi-Medical\nCenter believes that these claims are anomalous and not representative of Multi-Medical Center\'s\ngeneral compliance efforts, Multi-Medical Center has taken measures to reassess its compliance\nstrategy to ensure that all long term care services are provided in accordance with such laws and\npolicies.\n\nPlease feel free to contact me with any questions or comments.\n\nWith best regards.\n\n Sincerely,\n\n ~ ,v;ll/l\n Bernard Rochowiak\n Administrator\n\x0c APPENDIX D: STATE AGENCY COMMENTS\n\n\n\n\n STATE OF MARYlAND\n Office of Health Services\n\n D~H_MH Medical Care Programs\n\n\n\n Mat)\'land Department of Health and Mental Hygiene\n 20 l W. Preston Street \xe2\x80\xa2 Baltimore, Maryland 21201\n ll.\xc2\xb7lartin ()\'Malle~. Governor- Anthony G. Brown. Lt. Governor-\xc2\xb7 Joshua M. Shartstdn. Sccrdar~\n\n\n April 24, 2013\n\n\nMr. Stephen Virbitsky\nRegional Inspector General for Audit Services\nDepartment of Health and Human Services\nOffice of Inspector General\nOffice of Audit Services, Region Ill\nPublic Ledger Building, Suite 316\n150 S. Independence Mall West\nPhiladelphia, PA 19106\n\nRE: Maryland Generally Complied With Requirements for Medicaid Payments Made to\n Multi-Medical Center For Nursing Facility Services (draft)\n Report A-03~11-00151\n\nDear Mr. Virbitsky:\n\n Thank you for the opportunity to review the above-referenced report. The Maryland\nDepartment of Health and Mental Hygiene (Department) appreciates your conclusion that\nMaryland has generally complied with Federal and State requirements. We also appreciate\nyour recommendations for improving our level of compliance.\n\n We have carefully reviewed each recommendation outlined in the report. We would\nlike to note that two of the recommendations fall under the purview of the Department\'s\nOffice of Health Care Quality (OHCQ), which is separate from the Office of Health Services\n(OHS). We have shared this report with that Office and are sharing their comments.\n\n1. Refund $18,701 to the Federal Government. The Department concurs with this finding.\n In terms of corrective action, the Department contracts with a Utilization Control Agent\n (UCA) to conduct onsite postpayment reviews of claimed services to ensure that service\n is provided and documented in accordance with Federal and State regulations and\n policies. The UCA that was responsible for reviews at the time for which the audit was\n conducted is no longer our contractor. The Department will continue to educate and\n monitor the current contractor on those requirements addressed in the report.\n\n2. Ensure that Multi Medical has a completed background check performed for all\n employees and that Multi Medical consistently follows all Federal and State\n preemployment requirements. OHCQ has reviewed this recommendation and noted that\n recent surveys have not triggered surveyors to review facility practices regarding\n background checks. Nevertheless, OHCQ will assign a surveyor to investigate current\n practices to ensure compliance with requirements.\n\n\n Toll Free l-&77-4MD-DHiVIII \xe2\x80\xa2 TTY lilr Disabkd- rvlal) land Rei a: Service 1-Snn-735-2258\n 1Feh Sile: \\VW\\\\ .dhmh. rnarYiand .!!O..Y.\n\x0c Page 2 of 2\n\n Mr. Stephen Virbitsky\n April 24, 2013\n Page2\n\n\n 3. Provide education to Multi Medical to ensure that all unwitnessed incidents that result in\n an injury of unknown source are promptly reported. We were not provided with resident-\n specific details regarding the incidents on which this recommendation is based .\n However, OHCQ notes its support of Multi Medical\'s disagreement with the findings in\n three incidents. The facility noted that in two cases, the residents were alert and oriented\n and were able to provide specific details of their falls. In the third case, the facility noted\n that the description of the incident was very specific as to the cause of the fall.\n\n In a memorandum dated December 16, 2004, the Centers for Medicare and Medicaid\n Services defines an "injury of unknown source" as an injury in which "both of the following\n conditions are met:\n\n \xe2\x80\xa2 The source of the injury was not observed by any person or the source of the\n injury could not be explained by the resident; and\n \xe2\x80\xa2 The injury is suspicious because of the extent of the injury or the location of the\n injury ... or the number of injuries observed at one particular point in time or the\n incidence of injuries over time." 1\n\n Regarding the three incidents with which the facility concurred, the Department also\n concurs. In a subsequent complaint investigation conducted in November 2011 , OHCQ cited\n the facility for failure to report an injury of unknown origin. The most recent QIS survey\n (August 2012) did not reveal any deficiencies related to failure to report such injuries. The\n Department continues to educate the providers on the reporting of unknown injuries through\n its survey review process.\n\n Again, thank you for the opportunity to review and comment on your findings. If you\n have any questions regarding this response, please do not hesitate to contact either:\n\n Jane Sacco, Division Chief for Long Term Care Services, OHS, at (410) 767-6771 or\n jane.sacco@marvland.gov, or\n\n Margie Heald, Deputy Director for Federal Programs, OHCQ at (41 0) 402-8101 or\n Margie. Heald@marvland.gov\n\n Sincerely,\n\n ~f)~~\n Susan. J. Tucker, Executive Director\n Office of Health Services\n\n cc: Leonard Piccari\n Joseph Girardi\n Mark Leeds\n Susan Panek\n Jane Sacco\n Patricia Nay, M.D.\n Margie Heald, R.N.\n Thomas Russell\n1\n CMS Memorandum (Ref: S&C-05-09) of December 16, 2004 to State Survey Agency Directors. Please note that the\nbold and underlined text are derived directly from this document.\n\x0c'