Report Template Update  = 04-30-05_rev.15  
Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

C M S
ONSECUTIVE  EDICARE  TAYS 

I I
NVOLVING  NPATIENT AND 

S N F
KILLED  URSING  ACILITIES

Daniel R. Levinson

Inspector General 

June 2007 

OEI-07-05-00340
 Report Template Update  = 04-30-05_rev.15  
Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  Specifically, these evaluations focus on preventing fraud, waste, or 
abuse and promoting economy, efficiency, and effectiveness in departmental programs.  
To promote impact, the reports also present practical recommendations for improving 
program operations. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within HHS. 
OCIG also represents OIG in the global settlement of cases arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  Report Template Update  = 04-30-05_rev.15 
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OBJECTIVES 
To assess services provided to beneficiaries with consecutive Medicare 
stays involving inpatient and skilled nursing facilities (SNF) to 
determine whether: 
1. 	problems existed with the quality of patient care,  
2. 	services were fragmented across consecutive stay sequences, 
3. 	care was medically necessary and appropriate, and  
4. 	documentation was sufficient to determine appropriateness of 
  care. 
BACKGROUND 
In June 2005, the Office of Inspector General issued a report entitled 
Consecutive Medicare Inpatient Stays (OEI-03-01-00430) which found 
that Medicare paid an estimated $267 million for sequences of Medicare 
inpatient stays in fiscal year 2002 that were associated with 
quality-of-care problems and/or fragmentation of services. This current 
study is similar to that 2005 study but assesses stay sequences that 
include at least one SNF stay.  For purposes of this review, we defined 
the term consecutive stay sequence as a sequence of three or more 
individual inpatient and SNF stays for the same Medicare beneficiary 
for which the admission date for each successive stay occurred within 
1 day of the discharge date for the preceding stay.   
Fiscal intermediaries ceased performing routine medical reviews of 
inpatient hospital services in 1982, when the organizations now known 
as Quality Improvement Organizations (QIO) were created. These 
organizations were responsible for routinely reviewing items or services 
provided to Medicare beneficiaries to determine whether the quality of 
services met professionally recognized standards of care. However, 
QIOs do not currently conduct routine case reviews of sequences of 
services for the purpose of identifying potential quality-of-care concerns. 
We reviewed calendar year (CY) 2004 Medicare inpatient and SNF 
services and identified 489,730 consecutive stay sequences.  We selected 
a stratified-cluster sample of 140 consecutive stay sequences.  Three 
internal medicine physicians with geriatric experience reviewed these 
medical records and determined whether care met professionally 
recognized standards of care, such as standards relating to quality of 
care, fragmentation of services, and medically necessary and 
appropriate admissions, treatments, and discharges.  They made these 
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E X E C U T I V E   S U M M A R Y  
determinations both for the consecutive stay sequences and for the 
individual stays within the sequences. 
FINDINGS 
Thirty-five percent of consecutive stay sequences were associated 
with quality-of-care problems and/or fragmentation of services. 
Quality-of-care problems were defined in this review as medical errors, 
accidents, or patient care that did not meet professionally recognized 
standards which significantly contributed to the need for multiple stays.  
Fragmentation of services, in this review, was defined as cases for 
which care provided across consecutive stay sequences may have been 
necessary and appropriate but should have been consolidated into fewer 
stays. Medicare paid an estimated $4.5 billion in CY 2004 for 
consecutive stay sequences associated with quality-of-care problems 
and/or fragmentation of services. 
Eleven percent of individual stays within consecutive stay 
sequences involved problems with quality of care, admissions, 
treatments, or discharges. Medicare paid an estimated $1.4 billion in 
CY 2004 for individual stays associated with quality-of-care problems 
and stays associated with medically unnecessary admission, 
unnecessary treatment, and inappropriate treatment, care setting, and 
discharge. 
Twenty percent of individual stays lacked documentation sufficient for 
reviewers to determine whether appropriate care was rendered. 
Reviewers noted that medical documentation that facilities submitted 
for 20 percent of individual stays was not sufficient to enable reviewers 
to render a judgment as to whether the admission, treatment, and 
discharge were appropriate.  Medicare paid an estimated $3.1 billion for 
individual stays associated with insufficient documentation. 
RECOMMENDATIONS 
In this report, medical review of consecutive stay sequences revealed 
instances of problems with quality of patient care and fragmentation of 
health care services across multiple stays.  Physician reviewers 
examination of medical records for consecutive stays sequences enabled 
the reviewers to analyze and identify the broader impacts of 
quality-of-care problems and fragmentation of services beyond the level 
of an individual inpatient stay.   
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We recommended in our June 2005 report Consecutive Medicare 
Inpatient Stays (OEI-03-01-00430) that CMS (1) direct QIOs to monitor 
the quality of inpatient services provided within sequences of 
consecutive Medicare inpatient stays, (2) encourage QIOs, as 
appropriate, to monitor the medical necessity and appropriateness of 
inpatient services provided within these sequences of consecutive 
Medicare inpatient stays, and (3) reinforce efforts to educate providers 
about the appropriate uses of skilled nursing swing beds. 
The findings from this report are consistent with the quality-of-care 
problems and fragmentation of care that we found in our June 
2005 report. Therefore, we recommend that CMS: 
	 Direct QIOs to monitor for fragmentation and quality of care across 
consecutive stay sequences and the quality of care provided during 
the individual stays within those sequences. 
	 Encourage both QIOs and fiscal intermediaries, as appropriate, to 
monitor the medical necessity and appropriateness of services 
provided within these consecutive stay sequences. 
	 Collaborate with providers to improve systems of care based on 
review results. 
	 Reinforce efforts to educate medical providers on their 
responsibility for ensuring that medical records provide such 
information as may be necessary to determine the quality, medical 
necessity, and medical appropriateness of care provided, thus 
supporting the Medicare payments due. 
AGENCY COMMENTS 
CMS concurred with our recommendations. The agency noted that it 
will place growing emphasis on continuity-of-care issues in all settings 
and on measuring the rate of events such as hospital readmissions. 
CMS is also considering incorporating interventions in the upcoming 
Ninth Statement of Work for the QIO program. The agency also noted 
its efforts with the American College of Physicians to increase 
understanding of the medical home concept and the agency is 
considering folding this concept into the QIO program. CMS will also 
ask QIOs to categorize complaints by type to provide better data on 
lapses in care continuity with an emphasis on documentation. CMSs 
technical comments were incorporated into the report. 
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  T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

Thirty-five percent of consecutive stay sequences were 

associated with quality-of-care problems and/or fragmentation 

of services  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

Eleven percent of individual stays within consecutive stay 

sequences involved problems with quality of care, admissions, 

treatments, anddischarges  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13

Twenty percent of individual stays lacked documentation 

sufficient for reviewers to determine whether appropriate care 

was rendered. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15

R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19

A: 	Estimates and Confidence Intervals for Consecutive Stay 

Sequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  19

B: 	Estimates and Confidence Intervals for Individual 

Stays  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20

C: 	Estimates and Confidence Intervals for Individual  

Stays With Inadequate Documentation. . . . . . . . . . . . . . . . . .  21

D:	  AgencyComments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  22

A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24
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  I N T R O D U C T I O N  

OBJECTIVES 
To assess services provided to beneficiaries with consecutive Medicare 
stays involving inpatient and skilled nursing facilities (SNF) to 
determine whether: 
1. 	problems existed with the quality of patient care,  
2. 	services were fragmented across consecutive stay sequences, 
3. 	care was medically necessary and appropriate, and  
4. 	documentation was sufficient to determine appropriateness of 
  care. 
BACKGROUND 
In June 2005, the Office of Inspector General (OIG) issued a report 
entitled Consecutive Medicare Inpatient Stays (OEI-03-01-00430).  
Medical reviewers determined that 20 percent of consecutive stay 
sequences in fiscal year 2002 were associated with (1) quality-of-care 
problems that significantly contributed to the need for multiple 
inpatient stays and/or (2) fragmentation of health care services across 
multiple inpatient stays. In that study, OIG defined consecutive 
inpatient stays as three or more individual Medicare inpatient facility 
stays for the same Medicare beneficiary, where the admission date for 
each successive stay occur[red] within 1 day of the discharge date for 
the preceding stay.1  Further, OIG defined fragmentation in this study 
as a pattern of unnecessary discharges or transfers across multiple stay 
sequences when the same levels and types of service could have been 
consolidated into fewer stays.  The prior OIG study sampled from a 
population of 63,345 sequences, for which Medicare paid approximately 
$1.9 billion. These sequences specifically excluded skilled nursing 
facility (SNF) stays. OIG estimated that Medicare paid $267 million for 
the consecutive stay sequences with quality-of-care problems and/or 
fragmentation.  Additionally, 10 percent of the individual stays that 
made up the sequences involved problems with the quality of patient 
care, for which Medicare paid an estimated $171 million. 
In the current study, OIG examined consecutive stay sequences that 
included both inpatient stays and SNF stays.  The addition of SNF stays 
1 Inpatient facility stays included acute hospitals, rehabilitative hospitals, psychiatric 
hospitals, and skilled nursing swing beds. 
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increased the number of consecutive stay sequences and dollars 
associated with these sequences by approximately eight times. 
Medicare Part A payments for stays in all facility types included in this 
review totaled $120 billion in calendar year (CY) 2004, the most recent 
year for which data were available at the start of this study. Nearly 
$16.7 billion of these payments were for 489,730 consecutive stay 
sequences, accounting for 1,981,459 individual stays. (See Table 1.) 
Table 1: Medicare Payments for Inpatient and Skilled Nursing Facility Stays, 
CY 2004 
Consecutive Stays  All Stays 
Number of  Medicare  Number of  Medicare 
Type of Facility Stay 
Stays  Payments  Stays  Payments 
Acute Care Hospital  935,508  $8,952,499,534  12,123,844  $93,761,023,094 
Rehabilitation Unit  72,715  $991,306,176  505,102  $6,569,321,017 
Skilled Nursing Swing Beds  43,286  $215,388,291  134,428  $660,605,134 
Inpatient  Psychiatric Unit  31,067  $257,771,449  515,867  $3,276,644,045 
Long Term Hospital  29,409  $946,601,983  125,548  $3,588,510,587 
Critical Access Hospitals  29,059  $152,308,409  288,220  $1,141,454,635 
Other  591  $4,440,495  6,803  $67,875,555 
SNF  Skilled Nursing Facility  839,824  $5,161,047,560  1,791,607  $11,328,459,442 
Totals  1,981,459  $16,681,363,897  15,491,419  $120,393,893,509 
Source: OIG analysis of Medicare claims data, 2006. 
Medicare Payment Systems 
Medicare Part A provides insurance for inpatient care in acute care and 
other types of hospitals and in SNFs. All Medicare payment amounts 
presented in this report reflect payments made from the Medicare 
Hospital Insurance Trust Fund and do not include any payments from 
beneficiaries. Medicare beneficiaries are responsible for payment of 
deductibles and coinsurance. Medicaid or private insurance policies 
may cover these costs. The following payment systems are in place for 
the Medicare-covered stays in our population. 
Acute care hospitals. Section 1886(d)(1)(A) of the Social Security Act (the 
Act) established a prospective payment system (PPS) for Medicare acute 
care hospital services effective October 1, 1983. Under this system, the 
Centers for Medicare & Medicaid Services (CMS) pays hospitals a fixed, 
predetermined amount for each acute care stay, depending on the 
payment category code (i.e., diagnosis related group (DRG)) assigned to 
the stay. 
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Rehabilitation units in acute care hospitals. Section 1886(j) of the Act 
requires a PPS to reimburse care in inpatient rehabilitation units. This 
requirement became effective October 1, 2002. 
Swing beds in acute care hospitals. Section 1888(e) of the Act requires 
that skilled nursing swing beds be incorporated into the SNF PPS. This 
requirement became effective July 1, 2002. Swing beds are located in 
hospitals that have special approval to use these beds, as needed, to 
provide either acute care or skilled nursing care. 
Psychiatric hospitals. CMS published its final rule on a per diem PPS for 
inpatient psychiatric facilities in 69 Federal Register 66922 (2004). 
This requirement became effective on January 1, 2005. 
Long term care hospitals. CMS published its final rule on a per discharge 
PPS approach for long term care hospitals with a DRG-based patient 
classification system that reflects the differences in patient resources 
and costs in long term care hospitals in 71 Federal Register 
27798 (2006). This requirement became effective October 1, 2002, and 
was fully implemented on October 1, 2006. 
Critical access hospitals. Critical access hospitals are paid 101 percent of 
their reasonable costs. 
Skilled nursing facilities. Section 1888(e) of the Act required a per diem 
PPS for SNFs. This requirement became effective July 1, 1998. 
Payment is adjusted for case mix and geographic variation in wages. 
Conditions of Payment for Beneficiary Services 
Section 1156(a) of the Act states [i]t shall be the obligation of any 
health care practitioner and any other person (including a hospital or 
other health care facility, organization, or agency) who provides health 
care services for which payment may be made (in whole or in part) 
under this Act, to assure, to the extent of his authority that services or 
items ordered or provided by such practitioner or person to beneficiaries 
and recipients under this Act(1) will be provided economically and 
only when, and to the extent, medically necessary; (2) will be of a 
quality which meets professionally recognized standards of health care; 
and (3) will be supported by evidence of medical necessity and quality in 
such form and fashion and at such time as may reasonably be required 
by a reviewing peer review organization in the exercise of its duties and 
responsibilities. 
Federal regulation defines professionally recognized standards of health 
care as Statewide or national standards of care . . . that professional 
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peers . . . recognize as applying to those peers practicing or providing 
care within a State.2 For the purposes of this review, standards of care 
involved such issues as quality of care; fragmentation of services; and 
medically necessary and appropriate admissions, treatments, and 
discharges. Additionally, section 1862(a)(1)(A) of the Act limits 
Medicare coverage to services that are medically necessary. Finally, 
section 1833(e) of the Act requires that providers furnish such 
information as may be necessary in order to determine the amounts 
due to receive Medicare payment. Thus, Medicare should pay only for 
services that meet professionally recognized standards of care, are 
medically necessary, and are sufficiently documented. 
Monitoring Responsibilities 
Fiscal intermediaries. Pursuant to section 1816(a) of the Act and 
42 CFR  421.100, CMS contracts with fiscal intermediaries to pay 
claims for health care services provided to beneficiaries by hospitals and 
other inpatient facilities and to ensure that the services rendered by 
these facilities are covered by the program. Fiscal intermediaries are 
also responsible for ensuring that services are medically necessary and 
reasonable and are billed and paid appropriately, as required by 
42 CFR  421.100 and Chapter 1, section 1.2, of the Medicare Program 
Integrity Manual. 
Quality Improvement Organizations. Under the authority of the Peer 
Review Improvement Act of 1982, CMS contracts with groups of 
licensed physicians in each State to ensure that quality, effective, 
efficient, and economical hospital care is provided to Medicare 
beneficiaries. Section 1154(a) of the Act stipulates that Peer Review 
Organizations, now called Quality Improvement Organizations (QIO), 
must review health care services rendered by all types of Medicare 
providers to ensure that the quality of services meets professionally 
recognized standards of health care. QIOs are also responsible for 
ensuring that acute care hospital services provided to Medicare 
beneficiaries are medically necessary and reasonable and are billed 
correctly. 
Section 1886(f)(2) of the Act provides specific actions that the Secretary 
of the Department of Health and Human Services may take when QIOs 
determine that a PPS hospital takes an action with the intent of 
2 42 CFR  1001.2(d). 
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circumventing the PPS.  Actions circumventing the PPS could include 
admitting patients unnecessarily, unnecessary multiple admissions of 
the same individual, or engaging in inappropriate practices designed to 
circumvent the PPS.  Section 4255(C) of the Quality Improvement 
Organization Manual specifies prohibited actions that are considered 
circumventions of the PPS, including inappropriate discharges, 
inappropriate transfers, and inappropriate or early readmissions. If a 
QIO establishes that an acute care hospital has been taking actions 
with the intent of circumventing the PPS, the QIO may deny 
admissions, initiate a sanction report and recommendation, or refer the 
case to OIG for potential termination of its Medicare provider 
agreement. QIOs are required to conduct specific types of case reviews 
to fulfill mandatory requirements, including reviews of beneficiary 
complaints, alleged antidumping violations, and gross and flagrant 
violations.3  Some of the triggers of case reviews (e.g., beneficiary 
complaints) require the QIO to review quality of care.   
QIOs do not currently conduct routine case reviews of sequences of 
inpatient hospital services for the purpose of either identifying potential 
quality-of-care concerns or potential circumventions of the PPS.  
Related Office of Inspector General Work 
In addition to the 2005 report, OIG has conducted a number of other 
reviews of consecutive Medicare stays, including studies to determine 
whether acute care hospitals were engaged in activities to circumvent 
PPS rules. These reviews have focused on the implementation of 
Medicares post-acute care transfer policy and readmissions to the same 
acute care hospital on the same day.  In a report issued in August 2002, 
Review of Medicare Same-Day, Same-Provider Acute Care 
Readmissions in Pennsylvania During Calendar Year 1998 
(A-03-01-00011), OIG examined a sample of medical records and found 
that 63 of 98 readmissions were billed incorrectly because beneficiaries 
were, in fact, admitted to nonacute care units within the hospitals or 
were never actually discharged from the initial admissions. 
In a February 2000 OIG report, Analysis of Readmissions Under the 
Medicare Prospective Payment System for Calendar Years 1996 and 
1997 (A-14-99-00401), OIG identified a large percentage of cases in 
which beneficiaries had three or more multiple, continuous 
3 42 CFR  1004.1. 
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readmissions to the same hospitals. OIG made several 
recommendations, including that CMS review the claims for these 
multiple, continuous readmissions. 
METHODOLOGY 
The methodology for this evaluation was composed of two parts: (1) an 
analysis of Medicare claims for all CY 2004 inpatient and SNF services 
and (2) a medical record review of a sample of inpatient and SNF stays. 
Analysis of Medicare Claims 
We accessed CMSs Medicare Provider Analysis and Review (MedPAR) 
file to analyze data for all Medicare inpatient and SNF stays in 
CY 2004, the most recent data available at the time of our review.4 
We defined Medicare consecutive stay sequences as three or more 
individual stays including at least one inpatient facility stay (i.e., acute 
care, rehabilitative, skilled nursing swing bed, psychiatric, long term 
hospital, critical access hospitals, or other type of inpatient facility) and 
at least one SNF stay for the same Medicare beneficiary for which the 
admission date for each successive stay occurred on the same day or 
within 1 day of the discharge date of the preceding stay. In each 
consecutive stay sequence, the first stay terminated after 
January 1, 2004, and the last stay terminated before 
December 30, 2004. See Figure 1 (next page) for an example of a 
consecutive stay sequence. 
4 The MedPAR file is made up of final action records for all Medicare beneficiaries using 
inpatient facility services. Each record summarizes services provided to a beneficiary 
during an inpatient facility stay from the time of admission to the time of discharge. The 
file is created quarterly from CMSs National Claims History 100 Percent Nearline File. 
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Figure 1: Example of One Consecutive Stay Sequence 
Hospital Stay 
Discharged From Hospital  
and Admitted to SNF 
(Within 1 Day) 
SNF Stay 
Discharged From SNF 
and Admitted to Hospital 
(Within 1 Day) 
Hospital Stay 
Sample Design for Medical Review 
The sampling frame for this evaluation consisted of sequences of three 
or more consecutive inpatient and SNF stays for the same beneficiary. 
Analysis of CY 2004 MedPAR data indicated that Medicare payments 
for consecutive stay sequences, including both inpatient and SNF stays, 
ranged from a low of $1 to a high of $1,262,242.  Therefore, we stratified 
the population of 489,730 consecutive stay sequences based on Medicare 
payment amounts of low (less than $30,000), medium (between 
$30,000 and $55,999), and high ($56,000 or more).  For sampling 
purposes, each consecutive stay sequence was considered a cluster, or 
grouping, of individual stays.  As shown in Table 2, we selected a 
stratified-cluster sample of 140 consecutive stay sequences 
(580 individual stays).  
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Table 2: Sampling Frame Values and Sample Sizes for Medical Review by 
Strata 
Number of 
Number of 
Total Medicare  Number of  Individual 
Stratum  Stratum  Sequences in 
Payments in  Sequences in  Stays in 
Number  Definition  Sampling 
Sampling Frame  Sample Review  Sample 
Frame 
Review 
Sequences with 
Medicare 
1  $5,359,801,140  276,612  45  159 
payments less 
than $30,000 
Sequences with 
Medicare 
2  payments from  $6,262,248,663  157,338  50  201 
$30,000 to 
$55,999 
Sequences with 
Medicare 
3  $5,059,314,094  55,780  45  220 
payments of 
$56,000 or more 
Totals  $16,681,363,897  489,730  140  580 
Source:  OIG analysis of Medicare claims data, 2006. 
Data Collection for Medical Review 
Between March 1 and May 31, 2006, an independent medical review 
contractor collected medical records from inpatient facilities and SNFs.  
This contractors physicians performed medical reviews of these records 
from April 1 to August 31, 2006.  
Medical records.  We identified the names and addresses of the facilities 
that billed Medicare for all stays in each sample consecutive stay 
sequence. We then prepared a series of letters requesting copies of 
electronic and paper-based medical records in support of each stay in 
the sample consecutive stay sequences, and the contractor mailed these 
medical record requests to inpatient facilities and SNFs.  The contractor 
received medical records for all 140 sampled consecutive stay sequences 
(579 individual stays), for a 100-percent consecutive stay sequence 
response rate.5 
5 The medical record for one individual stay was not received.  The Medicare payment for 
this stay was $0.  The physician medical reviewer was able to render conclusions about 
this sequence without this particular stay.  Neither the stay nor the sequence was 
included in the estimates because of the omission. 
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Medical review. The contractor employed three physicians of internal 
medicine with geriatric medical experience to review the medical 
records for the sampled consecutive stay sequences. These reviewers 
used a medical review instrument that OIG and the contractors jointly 
developed that was pretested on 10 sample consecutive stay sequences 
prior to the review of the full sample. The reviewers answered specific 
questions pertaining to each individual stay in the sampled consecutive 
stay sequences. Then, to analyze the nature of these stays, the 
reviewers answered questions about each sequence of stays in its 
entirety as a single episode of care. The medical review instrument 
enabled the reviewers to explain their responses in narrative form. 
Issues for medical review. The reviewers first reviewed the clinical 
records for each individual stay in the sample of consecutive stay 
sequences to determine whether: 
	 there were problems with the quality of patient care during 
the stay (e.g., care that did not meet professionally 
recognized standards, medical errors, or accidents); 
	 the care setting was medically appropriate; 
	 the admission and treatment were medically reasonable and 
necessary; 
	 the treatment provided during the stay was appropriate to the 
type of unit or hospital where it occurred; and 
	 the patient was discharged or transferred appropriately. 
The reviewers then considered each sequence of stays as a whole and 
used their clinical judgment to determine whether: 
	 problems with quality of care significantly contributed to the 
need for multiple stays in the sequence, 
	 services were fragmented across multiple stays in the 
sequence, and 
	 an inappropriate discharge significantly contributed to the 
need for multiple stays in the sequence. 
Data Analysis 
Medical review results. We aggregated the medical review results to 
identify the proportion of consecutive stay sequences, and individual 
stays within those sequences, that physicians cited for quality-of-care 
problems, fragmentation of care, medically inappropriate care setting, 
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I N T R O D U C T I O N  
medically unnecessary admission, medically unnecessary or 
unreasonable treatment, treatment that was not appropriate to the type 
of setting where it occurred, or inappropriate discharge.  We analyzed 
the proportion of stays cited for a particular problem by facility type (no 
results found). We estimated total Medicare payments associated with 
these consecutive stay sequences and individual stays. 
We used SUDAAN software to produce weighted estimates of 
proportions and total payments by error category.  These estimates 
reflect the complex sample design.  Point estimates and confidence 
intervals for all statistics presented in the findings of this report are 
provided in Appendixes A, B, and C. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
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FF II NN DD II NN GG SS   
  FF II NN DD II NN GG SS

Thirty-five percent of consecutive stay  The majority of reviewed Medicare 
sequences were associated with quality-of-care  consecutive stay sequences were 
medically reasonable and 
problems and/or fragmentation of services 
necessary.  However, reviewers 
determined that 35 percent of consecutive stay sequences in 
CY 2004 were associated with (1) quality-of-care problems that 
significantly contributed to the need for multiple stays and/or 
(2) fragmentation of health care services across multiple consecutive 
stays in a sequence. Quality-of-care problems were defined in this 
review as medical errors, accidents, or patient care that did not meet 
professionally recognized standards.  Fragmentation of services in this 
review was defined as a pattern of unnecessary discharges or transfers 
across multiple stay sequences when the same levels and types of 
service could have been consolidated into fewer stays.  Medicare paid an 
estimated $4.5 billion in CY 2004 for consecutive stay sequences 
associated with quality-of-care problems and/or fragmentation of 
services.  This dollar figure represents 27 percent of the total Medicare 
payments in CY 2004 for consecutive stay sequences involving both 
inpatient and SNF stays.  See Appendix A for point estimates and 
confidence intervals. 
Twenty-three percent of consecutive stay sequences were associated with 
quality-of-care problems that contributed to multiple stays 
Medicare paid an estimated $2.7 billion for consecutive stay sequences 
that were associated with quality-of-care problems. Quality-of-care 
problems that reviewers found included medical errors, accidents, 
failure to treat patients in a timely manner, inadequate monitoring and 
treatment of patients, inadequate care planning, and inappropriate 
discharges. 
Some examples of quality-of-care problems identified by reviewers 
include the following: 
	 A patient known to have aspiration problems aspirated a thin 
liquid that a nursing student accidentally provided to him. The 
patient was later transferred to a specialty hospital for 
rehabilitation. Several more transfers followed, including moves 
to a SNF, an acute care hospital, and finally back to a SNF.  Had 
the nursing student not made the error in providing the patient 
the thin liquid, it is unlikely the patient would have required 
multiple stays. 
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F	 I N D I N G S  
	 A patient suffered a stroke and was admitted to an acute care 
hospital. Later, he was discharged to a SNF. The SNF staff 
failed to adequately monitor the patients blood-thinning 
medication.  The patient had to be transferred to an emergency 
room, where he was found to have gastrointestinal bleeding and 
abnormal clotting because of the blood-thinning medication. 
Had the SNF staff adequately monitored the patients 
medication, the complications may have been avoided. 
	 A patient was admitted to an acute care hospital and later 
transferred to a SNF without adequate monitoring of blood 
sugars to ensure stability.  The SNF was not alerted that closer 
than usual monitoring was advisable.  The patients low blood 
sugar was mismanaged and the patients condition was 
compounded because a transfer back to the hospital emergency 
department was delayed.  Had the blood sugar been managed 
appropriately during the first stay, one or more stays could have 
been avoided. 
Twenty percent of consecutive stay sequences were associated with 
fragmentation of services across multiple stays 
Medicare paid an estimated $2.7 billion for consecutive stay sequences 
that were associated with fragmentation of care.6 Fragmentation can 
result from medical mistakes or inappropriate transfers or discharges.  
Reviewers found fragmentation in many consecutive stay sequences 
involving both rehabilitation units and SNFs.  Typically, patients who 
were discharged from acute care hospitals to rehabilitation units during 
a sequence of stays were later discharged directly to SNFs. A reviewer 
commented that transfers and discharges . . . can be potentially 
inappropriate, specifically when dealing with physical and occupational 
rehabilitation. Rehabilitation requires a patient who is alert, 
motivated to work hard, and physically capable of at least 3 hours of 
rehabilitation every day. The vast majority of patient records reviewed 
indicated that the patients lacked one or more of these prerequisites.  
6 Because some sequences were associated with both quality-of-care problems and 
fragmentation of services, the sum of the dollars paid in each subgroup ($2.7 billion and 
$2.7 billion = $5.4 billion) exceeds the total ($4.5 billion).  See Appendix A for overlapping 
projections. 
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F	 I N D I N G S  
Thus, the most appropriate transfer from the acute care hospital would 
have been directly to a SNF. 
Some examples of fragmentation identified by reviewers include the 
following: 
	 A patient who had suffered a stroke had stays in three separate 
facilitiesan acute care hospital, a rehabilitation unit, and a 
SNF. Both admissions subsequent to the acute care hospital 
stay were for rehabilitation.  The reviewer noted, I believe the 
same outcome could have been achieved had the patient been 
directly transferred to a SNF . . . . 
	 After a stay in an acute care hospital for abdominal surgery 
complicated by heart rhythm problems, respiratory failure, and 
antibiotic-induced diarrhea, a patient was discharged to a 
rehabilitation unit.  Because the patient was not making 
progress, the patient was later discharged to a SNF.  The patient 
was later transferred from the SNF back to an acute care 
hospital for care.  The patient was ultimately transferred back to 
the SNF. The reviewer believed care could have been provided 
in an outpatient setting rather than being readmitted to the 
acute care hospital. 
	 A patient was admitted to an acute care hospital for a hip 
fracture and dislocated shoulder.  The patient was later 
transferred to a rehabilitation hospital and later to a SNF for 
rehabilitation. The patient was then readmitted to the acute 
care hospital because of a failed fracture fixation.  The patient 
was then again transferred to a SNF for rehabilitation.  At the 
time of transfer to the first SNF, it was already known that the 
hip surgery had failed and plans could have been made for 
repeat surgery without additional stays. 
Medicare paid an estimated 
Eleven percent of individual stays within 
$1.4 billion in CY 2004 for 
consecutive stay sequences involved problems 
individual stays associated with 
with quality-of-care, admissions,
quality-of-care problems, 
 treatments, or discharges 
inappropriate discharges, 
medically unnecessary treatments, medically unnecessary admissions, 
inappropriate treatments for the setting, and inappropriate settings.  
This dollar figure represents 9 percent of total Medicare payments for 
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FFFFF IIIII NNNNN DDDDD IIIII NNNNN GGGGG SSSSS  
individual stays associated with sequences. See Appendix B for 
confidence intervals. 
Eight percent of individual stays were associated with quality-of-care 
problems 
Medicare paid an estimated $986 million for individual stays within 
consecutive stay sequences associated with quality-of-care problems. 
Quality-of-care problems found included medical staff failing to monitor 
patients; exhibiting poor clinical knowledge; providing poor discharge 
instructions; or failing to properly evaluate, diagnose, and treat 
patients.7 
Reviewers described specific medical errors that resulted in 
quality-of-care problems. Examples of these medical errors included 
drug overdoses, failure to notice worsening symptoms, inadequate 
monitoring of clotting factors leading to gastrointestinal bleeding, 
inadequate monitoring of blood sugar, failure to control blood pressure, 
and electrolyte imbalances. 
Five percent of individual stays were associated with medically unnecessary 
admission and treatment, inappropriate treatment and setting of care, and 
inappropriate discharge 
Medicare paid an estimated $510 million8 for individual stays 
associated with problems such as medically unnecessary admission or 
treatment, treatment that was not appropriate for the setting, and 
inappropriate discharge.9 
Reviewers noted several instances of unnecessary admission and 
treatment, inappropriate treatment, and inappropriate discharge. 
Examples of these included rehabilitative treatments performed in the 
acute rehabilitation setting where the SNF setting would have been 
more appropriate, care the patient needed that was beyond the scope of 
the facility, care of a custodial nature that could have been provided in a 
7 The quality-of-care problems that reviewers found in the individual stays often 
contributed to the need for multiple stays in related sequences; however, there were 
instances in which quality-of-care problems did not lead to multiple stays. Of the 
$986 million associated with quality-of-care problems in individual stays, $335 million 
was associated with individual stays only. 
8 Relative precision of the estimate exceeds 50 percent. 
9 Because some stays were associated with both quality-of-care and other issues, the sum of 
the dollars paid for each subgroup ($986 million + $510 million = $1.5 billion) exceeds the 
total ($1.4 billion). See Appendix B for overlapping projections. 
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FF	 II NN DD II NN GG SS  
home setting rather than in a SNF, a patient whose mental status was 
such that there was little prospect of benefit from an acute 
rehabilitation setting, providers failures to document plans of care, and 
discharges that occurred before patients were stable. 
Twenty percent of individual stays lacked  Reviewers noted that medical 
documentation sufficient for reviewers to  documentation that facilities 
submitted for 20 percent of 
determine whether appropriate care 
individual stays was not sufficient 
was rendered 
to enable reviewers to render a 
judgment as to whether the admission, treatment, and discharge were 
appropriate. Medicare paid an estimated $3.1 billion for individual 
stays associated with insufficient documentation.10 Comments that 
demonstrate reviewers inability to render judgments because of 
insufficient documentation include the following: 
	 It was unclear from the record why the patient could not have 
been treated in the nursing home. 
	 The reveiwer saw no documentation for the discharge or 
readmission. The reviewer also saw no indication of a clinical 
status change on the day leading to the readmission. 
	 The medical record provided no indication of any acute event or 
any transfers. There was no documentation of a hospital 
admission between this and the last SNF stay. 
In 45 percent of individual stays with documentation problems, 
reviewers were unable to render judgments in more than one area. For 
example, a reviewer was unable to determine both quality of care and 
medically necessary treatment for the same individual stay. 
Reviewers could not determine the following (dollars and percentages 
are estimates associated with each bulleted item): 
	 Quality of care  $1.6 billion or 10 percent of individual stays,11 
10 Because some stays were associated with both quality-of-care and other issues, the sum 
of the dollars paid in each subgroup (sum of individually identified documentation 
problems = $5.0 billion) exceeds the total overall dollar estimate ($3.1 billion). 
See Appendix C for overlapping projections. 
11	  Relative precision of the estimate exceeds 50 percent. 
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FF	 II NN DD II NN GG SS  
	 Appropriateness of Discharge  $1.0 billion or 6 percent of 
individual stays, 
	 Medically Necessary Treatment  $897 million or 7 percent of 
individual stays,12 
	 Appropriateness of Treatment Setting  $820 million or 
6 percent of individual stays, and 
	 Medically Necessary Admissions  $720 million or 5 percent of 
individual stays.13 
12 Relative precision of the estimate exceeds 50 percent. 
13 Relative precision of the estimate exceeds 50 percent. 
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FFFFFFE IIIIIIX NNNNNNE DDDDDDC IIIIIIU NNNNNNT GGGGGGI SSSSSSV       E   S U M M A R Y
  R E C O M M E N D A T I O N S  

In this report, medical review of consecutive stay sequences revealed 
instances of problems with quality of patient care and fragmentation of 
health care services across multiple stays.  Physician reviewers 
examination of medical records for consecutive stays sequences enabled 
the reviewers to analyze and identify the broader impacts of 
quality-of-care problems and fragmentation of services beyond the level 
of an individual inpatient stay.   
We recommended in our June 2005 report Consecutive Medicare 
Inpatient Stays (OEI-03-01-00430) that CMS (1) direct QIOs to monitor 
the quality of inpatient services provided within sequences of 
consecutive Medicare inpatient stays, (2) encourage QIOs, as 
appropriate, to monitor the medical necessity and appropriateness of 
inpatient services provided within these sequences of consecutive 
Medicare inpatient stays, and (3) reinforce efforts to educate providers 
about the appropriate uses of skilled nursing swing beds. 
The findings from this report are consistent with the quality-of-care 
problems and fragmentation of care that we found in our June 2005 
report. Therefore, we recommend that CMS: 
	 Direct QIOs to monitor for fragmentation and quality of care across 
consecutive stay sequences and the quality of care provided during 
the individual stays within those sequences.  
	 Encourage both QIOs and fiscal intermediaries, as appropriate, to 
monitor the medical necessity and appropriateness of services 
provided within these consecutive stay sequences.   
	 Collaborate with providers to improve systems of care based on 
review results.   
	 Reinforce efforts to educate medical providers on their 
responsibility for ensuring that medical records provide such 
information as may be necessary to determine the quality, medical 
necessity, and medical appropriateness of care provided, thus 
supporting the Medicare payments due. 
AGENCY COMMENTS  
CMS concurred with our recommendations.  The agency noted that it 
will place growing emphasis on continuity-of-care issues in all settings 
and on measuring the rate of events such as hospital readmissions. 
CMS is also considering incorporating interventions in the upcoming 
Ninth Statement of Work for the QIO program. The agency also noted 
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R E C O M M E N D A T I O N S  
its efforts with the American College of Physicians to increase 
understanding of the medical home concept and the agency is 
considering folding this concept into the QIO program. CMS will also 
ask QIOs to categorize complaints by type to provide better data on 
lapses in care continuity with an emphasis on documentation.  CMSs 
technical comments were incorporated into the report.  The full text of 
CMS comments can be found in Appendix D. 
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RIRR NEEE TCCC ROOO OMMM DMMM UEEE CNNN TDDD I AAAO TTTNIII OOO NNN SSS    
  A P P E N D I X   A  
Estimates and Confidence Intervals for Consecutive Stay Sequences  
Sequence Counts, Point Estimates, and Confidence Intervals for Consecutive Stay Sequences (n=140 Sequences) 
Estimate Description  Point Estimate  95-Percent Confidence Interval 
Medicare payments for sequences associated with quality-of-care problems  $2,688,654,896  $1,687,361,526 - $3,689,948,265 
Percentage of sequences associated with quality-of-care problems  22.6%  14.2% - 31.0% 
Medicare payments for sequences associated with fragmentation of services  $2,709,903,725  $1,655,689,690 - $3,764,117,761 
Percentage of sequences associated with fragmentation of services  19.6%  11.7% - 27.5% 
Total Gross Overlapping Payments  $5,398,558,621 
Total Gross Overlapping Rates  42.2% 
(Payment Overlap)  ($872,077,767) 
(Sequence Overlap)  (7.2%) 
Medicare payments for sequences associated with quality-of-care problems 
and/or fragmentation of services  $4,526,480,859  $3,299,063,111- $5,753,898,598 
Percentage of sequences associated with quality-of-care problems and/or 
fragmentation of services   35.0%  25.6% - 44.4% 
Percentage of Medicare payments for sequences associated with quality-of-care 
problems and/or fragmentation of services  27.4%  20.0% - 34.9% 
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  A P P E N D I X   B  
Estimates and Confidence Intervals for Individual Stays  
Stay Counts, Point Estimates, and Confidence Intervals (n=579 Individual Stays) 
Estimate Description  Point Estimate  95-Percent Confidence Interval 
Medicare payments for stays associated with quality-of-care problems  $986,477,670  $513,855,548 - $1,459,099,811 
Percentage of stays associated with quality-of-care problems  7.5%  4.1% - 10.9% 
Medicare payments for stays associated with inappropriate discharges, 
medically unnecessary treatments, medically unnecessary admissions, 
inappropriate treatments for the setting, and inappropriate settings  $510,250,017  $184,846,299 - $835,653,735 
Percentage of stays associated with inappropriate discharges, medically 
unnecessary treatments, medically unnecessary admissions,  4.8%  2.1% - 7.6% 
inappropriate treatments for the setting, and inappropriate settings 
Total Gross Overlapping Payments  $1,496,727,687 
Total Gross Overlapping Rates  12.3% 
(Payment Overlap)  ($80,965,640) 
(Sequence Overlap)  (1.2%) 
Medicare payments for stays associated with quality-of-care problems, 
inappropriate discharges, medically unnecessary treatments, medically 
unnecessary admissions, inappropriate treatments for the setting, and  $1,415,762,047  $852,393,116 - $1,979,130,977 
inappropriate settings 
Percentage of stays associated with quality-of-care problems, 
inappropriate discharges, medically unnecessary treatments, medically  11.1%  7.0% - 15.2% 
unnecessary admissions, inappropriate treatments for the setting, and 
inappropriate settings 
Percentage of Medicare payments for stays associated with quality-of- 8.6%  5.1% -12.0% 
care problems, inappropriate discharges, medically unnecessary 
treatments, medically unnecessary admissions, inappropriate treatments 
for the setting, and inappropriate settings 
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  A P P E N D I X   C  
Estimates and Confidence Intervals for Individual Stays With Inadequate Documentation 
Stay Counts, Point Estimates, and Confidence Intervals (n=579 Individual Stays) 
Estimate Description  Point Estimate  95-Percent Confidence Interval 
Medicare payments associated with stays for which quality of care could not  $1,565,752,796  $1,017,283,102 - $2,114,222,490 
be determined 
6.7% - 13.2% 
Percentage of stays for which quality care could not be determined  10.0% 
Medicare payments associated with stays for which appropriateness of 
discharge could not be determined  $1,000,347,511  $511,142,511 - $1,489,552,511 
Percentage of stays for which appropriateness of discharge could not be 
determined  6.3%  3.7% - 8.9% 
Medicare payments associated with stays for which medically necessary 
treatment could not be determined  $896,734,826  $394,294,530 - $1,399,175,122 
Percentage of stays for which medically necessary treatment could not be 
determined  6.9%  3.3% - 10.5% 
Medicare payments associated with stays for which medical appropriateness 
of setting could not be determined  $820,031,234  $432,682,287 - $1,207,380,181 
Percentage of stays for which medical appropriateness of setting could not be 
determined  6.0%  3.1% - 8.8% 
Medicare payments associated with stays for which medically necessary 
admissions could not be determined  $719,852,375  $359,083,147 - $1,080,621,604 
Percentage of stays for which medically necessary admissions could not be 
determined  5.2%  2.6% - 7.7% 
Total Gross Overlapping Payments  $5,002,718,752 
Total Gross Overlapping Rates  34.4% 
(Payment Overlap)  ($1,874,844,887) 
(Sequence Overlap)  (14.3%) 
Medicare payments associated with stays for which quality of care, 
appropriate discharges, medically necessary treatments, medically necessary 
admissions, appropriateness of treatments at the setting, and appropriate  $3,127,873,855  $2,292,587,972 - $3,963,159,737 
settings could not be determined 
Percentage of stays for which quality of care, appropriate discharges, 
medically necessary treatments, medically necessary admissions,  20.1%  14.7 - 25.5% 
appropriateness of treatments at the setting, and appropriate settings could 
not be determined 
Percentage of stays for which reviewers were unable to render a judgment in  44.9%  33.1% - 56.8% 
more than one area 
  OEI-07-05-00340  CONSECUTIVE MEDICARE STAYS INVOLVING INPATIENT AND SKILLED NURSING FACILITIES  21  ..
APPENDIX
D
Agency Comments
(,. ~ '~r OEP-T OFHEAm &_ 5IeE eenle lOr' MedlC& Med SeIV
ilinlstriitar
lIAY 11 20 WafngOC201
TO: Danel R. Levin
Inper Geera
FROM:
SUB: Offce  of  Inpetor Geeraos Dra  Reprt:  "Consecutive MedCa Stays
Iivolvig Inpatentand Skiled Nurg  Faclities"  (OEI-07-OS,.340)
Th you.forthe opportity to.  review an conuent on the Ofce of  Inpector  Generl's
Medcae StaY$ Iivolvj Inpatent afdSkilledNuring
(OIG) dr reprt "Consutive 
Facilities" (OEI-07-0S-00340). We  apprciate the OIG'seffort to e~thattheCeters for
Medcar  &  Medcad Servces (CMS) is respndigappriy to  quaity  of car'afd
frgmentation of serice prblems lea4ng to Cpiiu,ve Medica stys.
The CMS is commtted to ensung thati~ beeficiaiesrecve h1gh quaitycaandmwnta
both  the Quity Imrovement Organizon  (QIO) progr~dthSareyandCeI'caon
progr to  ca out ths commtment The OIG'sinpeon ispaculyfuelybeeaus we
ar  curntly exai trsitions of  cae and developing sttegiestore~ tnetate of
rehospitaon. We are  also  conductg the  ContiUity  Asen  Review and EVauation
is inteed to nietrsitioiiSaer for patients.
(CAR) demonstion, which 
om Recommendations
 Dir QIOs to monior forftagmentaon and quaty ofc across consecutive.  sty
seuences and  the quaty  of cae  provided dur the  individua stys within those
setuence.
 Encourge both QIOs and fi intermares, as  approprite, to monitotth meca
necty and appropriatenes of  servce provided with these  consecutive sty
sequences.
 Collarate with providers to imrove  systems of ca bas on  review reults.
 Reiorc effort to educate medca provictersori their reporiibil.ty foterurg th
nec todetine the quaity,
medcal reords provide such informon as may be 
medical necessity, an medca appropriatnesofCa.
CMS Response
We ag with.the remmendation that QIOs pay  greater attention to quaity problems
asociated with consecutive stys.' We plan  to put grwi emphais on contimiity of ca is
OEI-07-05.00340 CONSECUTIVE MEDICARE STAYS INVOLVING INPATIENT AND SKILLED NURSING FACILITIES
22 A P PEN D 
x
D 
fage 2 :- Danel R Levi 
in  all  settgs and OD, Ing:tberateofevelr su ashospita1ressons. Infict we ar 
CoIiiderig InCorpra Ineptionsto addres thispIhleiIn theupmig9i1 Statement of
Work forthe QIO PrOSf 
plac gteiiisOIlworkgwitbprvid~to i1prove ca,whereproblei ate
We 
ideedand1hsreviewreiiorcetlmpluiS Forexple,we have worke witlithe 
AienC8cPllegeof l'hysiciato leamore ahOlit its "ieitahomi:" t(nct, Inwlchca

is cordte fOlapati"tIittfUg aSie site. We havecoideredfoiding such concts Il

di: QIO prgr becus:'we:hfIieveths coneetcouldlead to greatecontiuityofcafor

beeficiaes 
Finy, we 8gi  tl  the problem of ckenon is  imrtt. We beieve th our new

emphas  on  communcaona.ss caseings'forpaei wicol1veepiS(de of a 
wilIcontibut to impi;ving tbprblei In addon, theCMSsUey proces enforc 
 hospita 
coiiitioIiof piueion, whchre. bnth 
 asent ofil nC( for dise plil
th 
and  th prviil)nofplangtQJhose withn~ Wear  as QIOstocagonzcomplants

. bya tby,wehche.wiflcgiViei it I pbeeeul.i i on laes  in ca co1Uty and how we ca imroVi from

Conclusion 
We  appreat thQIG's effol1 in cond,qcits:invegaonofconscutvestysfor.MedCae 
beenciares and ex toni sign pr0Bls onprblemidentied

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23  Report Template Update  = 04-30-05_rev.15 
A P P E N D I X   ~   B
  A C K N O W L E D G M E N T S  
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Gina C. Maree, Deputy Regional 
Inspector General. 
Brian Whitley served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Kansas City regional 
office who contributed to the report include Linda Paddock and Zula 
Crutchfield; central office staff who contributed include Doris Jackson 
and Kevin Farber. 
  OEI-07-05-00340  CONSECUTIVE MEDICARE STAYS INVOLVING INPATIENT AND SKILLED NURSING FACILITIES  24