Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
S N F
KILLED  URSING  ACILITIES 
 
 
O F T M C
FTEN  AIL  O  EET  ARE 
 
P   D
LANNING AND  ISCHARGE 
P R  
LANNING  EQUIREMENTS
 
 
Daniel R. Levinson  
Inspector General 
 
February 2013 
OEI-02-09-00201   
   
EXECUTIVE SUMMARY:  SKILLED NURSING FACILITIES OFTEN FAIL TO MEET 
CARE PLANNING AND DISCHARGE PLANNING REQUIREMENTS 
OEI-02-09-00201 
 
WHY WE DID THIS STUDY  
 
Skilled nursing facilities (SNF) are required to develop a care plan for each beneficiary and 
provide services in accordance with the care plan, as well as to plan for each beneficiarys 
discharge.  These requirements are essential to ensuring that beneficiaries receive appropriate 
care and safely transition from one care setting to another.  Several Office of Inspector General 
studies and investigations found that SNFs had deficiencies in quality of care, did not develop 
appropriate care plans, and failed to provide adequate care to beneficiaries.  In fiscal year 2012, 
Medicare paid $32.2 billion for SNF services.  This study is part of a larger body of work about 
SNF payments and quality of care.   
 
HOW WE DID THIS STUDY 
 
We based this study on a medical record review of a stratified simple random sample of SNF 
stays from 2009.  The reviewers determined the extent to which SNFs developed care plans that 
met Medicare requirements, provided services in accordance with care plans, and planned for 
beneficiaries discharges as required.  Reviewers also identified examples of poor quality care. 
 
WHAT WE FOUND 
 
For 37 percent of stays, SNFs did not develop care plans that met requirements or did not 
provide services in accordance with care plans.  For 31 percent of stays, SNFs did not meet 
discharge planning requirements.  Medicare paid approximately $5.1 billion for stays in which 
SNFs did not meet these quality-of-care requirements.  Additionally, reviewers found examples 
of poor quality care related to wound care, medication management, and therapy.  These findings 
raise concerns about what Medicare is paying for.  They also demonstrate that SNF oversight 
needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge 
planning. 
 
WHAT WE RECOMMEND 
 
We recommend that the Centers for Medicare & Medicaid Services (CMS):  (1) strengthen the 
regulations on care planning and discharge planning, (2) provide guidance to SNFs to improve 
care planning and discharge planning, (3) increase surveyor efforts to identify SNFs that do not 
meet care planning and discharge planning requirements and to hold these SNFs accountable, 
(4) link payments to meeting quality-of-care requirements, and (5) follow up on the SNFs that 
failed to meet care planning and discharge planning requirements or that provided poor quality 
care.  CMS concurred with all five of our recommendations.
   
 
   
TABLE OF CONTENTS 
 
Objectives .................................................................................................... 1 
Background .................................................................................................. 1 
Methodology ................................................................................................ 5 
Findings ....................................................................................................... 9 
For 37 percent of stays, SNFs did not meet care plan or service 
requirements..................................................................................... 9 
For 31 percent of stays, SNFs did not meet discharge planning 
requirements................................................................................... 11 
Medical reviewers found examples of poor quality care related              
to wound care, medication management, and therapy ................... 13 
Conclusion and Recommendations ............................................................ 16 
Agency Comments and Office of Inspector General Response .... 19 
Appendixes ................................................................................................ 20 
A:  List of the 18 Resident Assessment Protocols ......................... 20 
B:  Sample Design ......................................................................... 21 
C:  Point Estimates, Sample Sizes, and 95-Percent Confidence    
Intervals for All Estimates Presented in the Report ....................... 22 
D:  Agency Comments ................................................................... 25 
Acknowledgments ..................................................................................... 28 
 
 
 
 
   
 OBJECTIVES 
1.  To determine the extent to which skilled nursing facilities (SNFs) met 
Medicare requirements for care planning. 
2.  To determine the extent to which SNFs met Medicare requirements for 
discharge planning. 
3.  To describe instances of poor quality care provided by SNFs.   
BACKGROUND 
SNFs provide skilled nursing care, rehabilitation services, and other services to 
Medicare beneficiaries who meet certain conditions.  In fiscal year (FY) 2012, 
Medicare paid $32.2 billion for SNF services.1  To participate in Medicare, 
SNFs must meet certain quality-of-care requirements.  SNFs must develop a 
care plan for each beneficiary and provide services in accordance with the care 
plan, as well as plan for each beneficiarys discharge.2  These requirements are 
essential to ensuring that beneficiaries receive appropriate care and safely 
transition from one care setting to another. 
The Office of Inspector General (OIG) has identified a number of problems 
with the quality of care provided in nursing facilities.  Notably, OIG found that 
74 percent of nursing facilities surveyed in 2007 had at least one deficiency 
related to quality of care.3  Another OIG report about psychosocial services 
found that SNFs often did not develop appropriate care plans or provide all 
services identified in care plans.4  In another report about atypical antipsychotic 
drugs, OIG found that nearly all records reviewed failed to meet one or more 
Medicare requirements for beneficiary assessments or care plans.5  OIG also 
 
1 Centers for Medicare & Medicaid Services (CMS), 2012 CMS Statistics, Table III.6.  
Accessed at https://www.cms.gov/ResearchGenInfo/02_CMSStatistics.asp on September 14, 
2012.   Note that 9.3 million Americans, or 21 percent of all Medicare enrollees in 2008 (see the 
CMS Web site at https://dnav.cms.gov/), were eligible for both Medicare and Medicaid and 
participated in both programs.  
2 Social Security Act (SSA),  1819(b)(2) and (c)(2), 42 U.S.C.  1395i-3(b)(2) and (c)(2),  
42 CFR  483.20(k) and (l). 
3 OIG, Trends in Nursing Home Deficiencies and Complaints, OEI-02-08-00140, 
September 2008. 
4 OIG, Psychosocial Services in Skilled Nursing Facilities, OEI-02-01-00610, March 2003. 
5 OIG, Nursing Facility Assessments and Care Plans for Residents Receiving Atypical 
Antipsychotic Drugs, OEI-07-08-00151, July 2012. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      1 
   
found quality-of-care problems associated with beneficiaries discharged 
between SNFs and other facilities.6   
Further, recent investigations have found a number of SNFs that failed to 
provide adequate care to beneficiaries.  In one case, five facilities did not 
provide adequate staffing and services to beneficiaries, resulting in 
beneficiaries developing pressure ulcers, malnutrition, dehydration, and side 
effects from not receiving medications.7  In another case, three facilities were 
charged with providing inadequate food and medication to beneficiaries.8  In a 
third case, inadequate staffing caused numerous beneficiaries to develop 
pressure ulcers, some of which were left untreated.9   
This study is part of a larger body of work about SNF payments and quality of 
care.  The first study found that from 2006 to 2008, SNFs increasingly billed for 
higher paying categories, even though beneficiary characteristics remained 
largely unchanged.10  Another study found that SNFs billed one-quarter of 
claims in error in 2009, resulting in $1.5 billion in inappropriate Medicare 
payments.11  Moreover, the study found that for 47 percent of claims, SNFs 
misreported information on the beneficiary assessment, which is used to create 
care plans.  Lastly, an upcoming study will review the quality of care and safety 
of Medicare beneficiaries transferred from acute-care hospitals to SNFs.12   
Medicare Coverage Requirements for Part A SNF Stays   
The Part A SNF benefit covers skilled nursing care, rehabilitation services, and 
other services.  These services commonly include physical, occupational, and 
 
6 OIG, Consecutive Medicare Stays Involving Inpatient and Skilled Nursing Facilities,  
OEI-07-05-00340, June 2007.   
7 Department of Justice (DOJ), Cathedral Rock Nursing Homes and a Nursing Home Operator 
Resolve Criminal and Civil Health Care Fraud Allegations Related to Failure of Care and 
Agree to Pay the United States over $1.6 Million, January 7, 2010. Accessed at 
http://www.justice.gov/usao/moe/press_releases/archived_press_releases/2010_press_releases/j
anuary/cathedral_rock.html on November 10, 2011.   
8 DOJ, Rome Couple Charged With $30 Million Medicare & Medicaid Fraud Through Failure 
of Care at Three Nursing Homes, April 16, 2010.  Accessed at 
http://www.justice.gov/usao/gan/press/2010/04-16-10b.pdf on November 10, 2011.   
9 Keenan Cummings, Nursing Home Puts Residents in Jeopardy, The Daily Athenaeum, 
December 6, 2007.  
10 OIG, Questionable Billing by Skilled Nursing Facilities, OEI-02-09-00202, December 2010. 
11 OIG, Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a 
Billion Dollars in 2009, OEI-02-09-00200, November 2012. 
12 OIG, Adverse Events in Post-Acute Care:  Skilled Nursing Facilities, OEI-06-11-00370, 
forthcoming.  
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      2 
   
speech therapy; skin treatments; and assistance with eating, bathing, and 
toileting.  Medicare covers these services for up to 100 days during any spell of 
illness.13   
To qualify for the SNF benefit, the beneficiary must have been in the hospital 
for at least 3 consecutive days and the hospital stay must have occurred within 
30 days of the admission to the SNF.14  The beneficiary must need skilled 
services daily in an inpatient setting and must require the skills of technical or 
professional personnel to provide these services.15  In addition, these services 
must be ordered by a physician and must be for the same condition that the 
beneficiary was treated for in the hospital.16   
Medicare Requirements Related to Quality of Care 
To ensure quality of care, SNFs are required to develop a care plan for each 
beneficiary and provide services in accordance with care plans.17  Specifically, 
Section 1819 of the SSA requires SNFs to provide services to attain or maintain 
the highest practicable physical, mental, and psychosocial well-being of each 
beneficiary in accordance with the care plan.18  To ensure that beneficiaries safely 
transition to the next care setting, SNFs are required to plan for each beneficiarys 
discharge when facilities anticipate a discharge.19   
Developing Care Plans and Providing Services.  SNFs are required to develop 
care plans that describe the beneficiarys medical, nursing, and psychosocial 
needs and how the SNF will meet these needs.20  Care plans must include 
measurable objectives and timetables and be customized to the beneficiary.21  To 
develop a care plan, SNFs use a tool called the Minimum Data Set (MDS) to 
assess the beneficiarys clinical condition, functional status, and  
 
13 SSA,  1812(a)(2)(A), 42 U.S.C.  1395d(a)(2)(A). 
14 42 CFR  409.30(a)(1) and (b)(1). 
15 42 CFR  409.31(b)(1) and (3) and 409.31(a)(2).   
16 42 CFR  409.31(a)(1) and (b)(2).  Medicare also covers SNF services if the condition 
requiring such services arose when the beneficiary was receiving care in a SNF for a condition 
treated during the prior hospital stay. 
17 SSA,  1819(b)(2) and (c)(2), 42 U.S.C.  1395i-3(b)(2) and (c)(2), 42 CFR  483.20(k). 
18 SSA,  1819(b)(2), 42 U.S.C.  1395i-3(b)(2). 
19 42 CFR  483.20(l). 
20 SSA,  1819(b)(2), 42 U.S.C.  1395i-3(b)(2). 
21 42 CFR  483.20(k)(1).  See also CMS, Revised Long-Term Care Facility Resident 
Assessment Instrument Users Manual Version 2.0 (RAI Version 2.0 Manual), Dec. 2002, rev. 
Dec. 2008,  1.1.  The RAI Manual was updated October 2010 to Version 3.0 (RAI Version 3.0 
Manual); however, we used the 2008 revision of version 2.0 because it was in effect during the 
time period we were studying. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      3 
   
expected and actual use of services.22  SNFs must develop the care plan within  
7 days of this assessment and no more than 21 days after admission.23  
Depending upon the responses to the assessment, different Resident Assessment 
Protocols (RAP) may be triggered that indicate the beneficiary may be at risk 
for certain problems, such as delirium, falls, and pressure ulcers.24  See 
Appendix A for a list of all the RAPs.   
If a RAP is triggered, the SNF must assess the beneficiary further to determine 
whether the beneficiary is at risk of developing, or currently has, the problem 
associated with that RAP.   If so, the SNF must specify in the beneficiarys care 
plan how the SNF will prevent or address the problem.25  If the SNF determines 
that the RAP problem area does not need to be addressed in the care plan, the 
SNF must document the reason in the medical record.26   
An interdisciplinary team that includes at least the attending physician and a 
registered nurse with responsibility for the beneficiary must prepare the care 
plan.27  In addition, to the extent practicable, the beneficiary, the beneficiarys 
family, or the beneficiarys legal representative should participate in the initial 
care planning.28  This participation helps to ensure that the interdisciplinary team 
develops a care plan that addresses all of the beneficiarys needs.29   
Discharge planning.  When the SNF anticipates the discharge of a beneficiary 
to another care setting or home, it must plan for the discharge.  As part of this 
planning, the SNF must develop a discharge summary to help ensure that the 
beneficiarys care is coordinated and that the beneficiary transitions safely to his 
 
22 42 CFR  483.315(e) and 483.20(d); RAI Version 2.0 Manual,  2.3.  The MDS is part of a 
comprehensive assessment called the Resident Assessment Instrument (RAI); the RAI also 
includes Resident Assessment Protocols and Utilization Guidelines.  CMS implemented a new 
version of the MDS for FY 2011.  The new version puts more focus on assessing the beneficiary 
for certain MDS items through interviews with the beneficiary rather than on observations or 
document reviews.  See RAI Version 3.0 Manual,  1.5.   
23 SSA,  1819(b)(3)(C), 42 U.S.C.  1395i-3(b)(3)(C); 42 CFR  483.20(b)(2)(i);  
42 CFR  483.20(k)(2)(i).  See also RAI Version 2.0 Manual,  2.2 and 2.3.  Specifically, the 
admission assessment must be completed within 14 days of the admission date, and the care 
plan must be completed within 7 days of the completion of the admission assessment. 
24 RAI Version 2.0 Manual,  4.1 and 4.2.  As of October 1, 2010, CMS updated the RAPs and 
renamed them Care Area Assessments (CAA).  See RAI Version 3.0 Manual, ch. 3, section V.   
25 RAI Version 2.0 Manual,  4.2. 
26 Ibid.,  4.6. 
27 SSA,  1819(b)(2)(B), 42 U.S.C. 1395i3(b)(2)(B). 
28 Ibid. 
29 CMS, State Operations Manual [SOM], Appendix PP, Tags F279 and F280. 
 
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or her new setting.  The discharge summary should include a summary of the 
beneficiarys stay, a summary of the beneficiarys status at the time of 
discharge, and a post-discharge plan of care.30  The post-discharge plan of care 
should describe what the beneficiarys and familys preferences for care are, 
how the beneficiary and family will access these services, how care should be 
coordinated if continuing treatment involves multiple caregivers, and what 
education or instructions should be provided to the beneficiary and his or her 
family.31 
Monitoring by State Surveyors 
CMS contracts with State Survey and Certification agencies to determine 
whether nursing facilities are in compliance with Medicare requirements.32  The 
State agencies conduct periodic surveys of each facility.  If facilities are out of 
compliance with one or more requirements, surveyors cite them for deficiencies.  
In 2011, 22 percent of facilities surveyed did not meet care planning 
requirements, 14 percent did not provide services in accordance with care plans, 
and 1 percent did not meet the discharge planning requirements. 
When facilities are cited for deficiencies, CMS or the State may choose to 
impose a number of different enforcement actions depending upon the scope 
and severity of the deficiencies found.33  These actions include requiring a plan 
of correction, denying future payment, or terminating the provider agreement.   
METHODOLOGY   
We based this study on a medical record review of a stratified simple random 
sample of Part A SNF stays from calendar year 2009.   
Selection of Sample for Medical Review 
Using CMSs National Claims History File, we first identified all Part A SNF 
claims with dates of service in 2009.  We grouped these claims by stay using the 
admission dates and identified the stays that ended in 2009.  We then grouped 
these stays into three strata defined by the length of the stay and the number of 
claims.  We selected a stratified simple random sample of 245 stays.  See 
 
30 42 CFR  483.20(l). 
31 CMS, SOM, Appendix PP, Tags F283 and F284.  
32 CMS, SOM, ch. 1,  1004 and 1016.  The surveys are conducted in accordance with CMSs 
SOM.  This manual includes the interpretive guidelines that surveyors follow to determine 
whether a facility complies with Medicare requirements. 
33 CMS, SOM, ch. 7. 
 
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Appendix B for more information about how we selected the sample.  We used 
this sample to meet the objectives of this study and a companion study.34  In our 
companion study, we included all stays.  However, for this study, we focused on 
the stays that were 21 days or longer, because care plans must be completed 
within 21 days of admission to a SNF.  This resulted in a sample of 190 stays 
that projects to 1,104,692 stays in the population.   
Medical Record Review 
We used a contractor to collect the medical records for each of the beneficiaries 
associated with the sampled stays.  The contractor requested the medical record 
for each stay, which included the care plan; the beneficiary assessment, 
including the MDS and RAP information; and the post-discharge care plan; as 
well as physician orders, progress notes, therapy records and logs, and other 
documentation of the services that the beneficiary received.  We had a  
100-percent response rate.  
We also contracted with medical record reviewers, who consisted of three 
registered nurses, each of whom had at least 12 years of SNF experience; and a 
physical therapist, an occupational therapist, and a speech therapist.  The nurses 
reviewed the records and consulted with the therapists as needed.  The 
reviewers used a standardized data collection instrument that was developed in 
accordance with the Medicare requirements related to care planning, provision 
of services, and discharge planning.  The reviewers also identified any instances 
of poor quality care that they determined to be egregious.  The instrument was 
developed in collaboration with the reviewers and tested on a sample of stays.35  
The reviewers conducted the medical review between April and 
September 2011. 
Analysis 
Care Planning and Provision of Services.  To determine the extent to which 
SNFs developed care plans and provided services in accordance with care plans, 
we analyzed the data from the medical record review.  We identified the stays in 
which the care plans:  (1) did not address one or more RAPs (hereinafter 
referred to as problem areas) and provided no explanation in the medical 
 
34 The companion study is Inappropriate Payments to Skilled Nursing Facilities Cost Medicare 
More Than a Billion Dollars in 2009, OEI-02-09-00200, November 2012. 
35 We conducted a preliminary review of a separate sample of 10 stays to test the instrument and 
to ensure consistency among the reviewers. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      6 
   
records; (2) lacked measurable objectives and detailed timeframes, i.e., duration 
or frequency; or (3) were not completed by an interdisciplinary team.   
For each stay, we determined whether care plans contained measurable 
objectives and detailed timeframes for the following eight categories of 
services:  (1) scheduled toileting plans or bladder retraining programs, 
(2) parenteral IV or feeding tubes, (3) skin treatments, (4) speech therapy, 
(5) occupational therapy, (6) physical therapy, (7) respiratory therapy, and 
(8) restorative nursing services.   
Next, we identified the stays in which the SNFs did not provide services in 
accordance with care plans.  Using the same service categories, we determined 
whether the duration and frequency of services provided was consistent with the 
duration and frequency called for in the care plans.  We did not include 
instances when frequency was not applicable, such as the use of a specialized 
mattress, or when the duration of a service was understood without additional 
documentation, such as the dressing of a wound until it has healed.  We also did 
not include instances when the SNFs changed the duration or frequency of 
services and provided explanations in the medical records.  For example, if the 
record indicated that services were missed because the beneficiary refused 
treatment or was ill, we considered the frequency of services provided to be 
consistent with the care plan.   
Using our sample results, we estimated the percentage of all stays in the 
population that the care plans did not meet one or more Medicare requirements.  
We also estimated the percentage of all stays in the population in which the 
SNFs did not provide services in accordance with the care plans.   
Discharge Planning.  To determine the extent to which SNFs planned for each 
beneficiarys discharge, we identified each stay that did not have a summary of 
the stay and status at discharge and post-discharge plan of care.  We based this 
analysis on stays for which the SNFs should have planned for the beneficiaries 
discharge.  Specifically, the analysis included 83 stays in which the beneficiaries 
were discharged to another institutional setting (e.g., another nursing facility or 
a hospital) or to the community (e.g., a group home or the beneficiaries own 
homes).36  Using our sample results, we estimated the percentage of all stays in 
 
36 This analysis did not include stays in which the beneficiaries died, went to the hospital 
unexpectedly because of medical emergencies, or remained in the SNFs after the Part A stays 
ended.  
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      7 
   
the subpopulation described above in which the SNFs did not meet discharge 
planning requirements.   
Poor Quality Care.  As part of the medical record review, we asked the 
reviewers to identify examples of poor care that that they determined to be 
egregious.  We analyzed their responses and grouped them into common areas 
of concern.     
Limitations  
This report was based solely on a medical record review.  It does not identify all 
instances of poor quality care.  It highlights examples that reviewers determined 
were egregious on the basis of their review of the medical records.  Reviewers 
did not systematically review the records for poor quality care provided during 
each stay.  
Standards  
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency. 
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      8 
   
FINDINGS 
For 37 percent of stays, SNFs did not meet care plan or 
service requirements 
For 37 percent of stays, the SNFs did not develop care plans that met requirements 
or provide services in accordance with care plans.  Medicare paid approximately 
$4.5 billion for these stays, which did not meet these quality-of-care requirements.  
See Table 1 for the percentage of stays in which SNFs did not meet care plan and 
service requirements.  See Appendix C-1 for the point estimates and confidence 
intervals.   
Table 1:  Percentage of Stays in Which SNFs Did Not Meet Care Plan or Service 
Requirements, 2009 
Percentage of Stays in  Medicare Payments for 
Which SNFs Did Not Meet  Stays in Which SNFs Did 
Requirements  Requirements  Not Meet Requirements 
Care plan requirements  25.6%  $3.1 billion 
Service requirements   15.4%  $2.0 billion 
   Total  36.7%  $4.5 billion 
Source:  Office of Inspector General medical record review, 2012. 
 
Note:  The rows do not sum to the total because some stays met neither the care plan requirements nor the 
service requirements. 
 
    For 26 percent of stays, SNFs did not develop care plans that met 
    requirements 
SNFs are required to develop care plans that address problem areas identified in 
beneficiaries assessments, include measurable objectives and detailed timeframes, 
and are completed by an interdisciplinary team.  These requirements help to 
ensure that beneficiaries needs are addressed and that care plans provide clear, 
individualized instructions about the most appropriate care for each beneficiary.  
For 26 percent of stays, the SNFs care plans did not meet at least one of the 
requirements.  See Table 2 for the percentage of stays in which SNFs did not meet 
the specific requirements.   
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      9 
   
Table 2:  Percentage of Stays in Which SNFs Did Not Meet Care Plan 
Requirements, 2009 
  Percentage of Stays in Which SNFs 
Care Plan Requirements   Did Not Meet Care Plan Requirements  
Care plans address problem areas identified in the 
assessments  19.2% 
Care plans have measurable objectives and 
detailed timeframes*  6.8% 
Care plans are developed by an interdisciplinary 
team  2.1% 
   Total  25.6% 
Source:  Office of Inspector General medical record review, 2012.                                                                  
Note:  The rows do not sum to the total because some stays did not meet two or more care plan requirements.        
* The requirement states that both measurable objectives and timeframes must be in the care plan.  The 6.8 
percent represents the stays in which either measurable objectives or timeframes were missing.    
 
For 19 percent of stays, SNFs developed care plans that did not address one or 
more problem areas identified in the beneficiaries assessments.  For example, 
in one stay, the SNF made no plans to monitor a beneficiarys use of  
antipsychotic medication that had potentially severe adverse reactions.  In 
another stay, the SNF did not address the psychosocial needs of a beneficiary 
who had anxiety and made repeated health complaints.  On average, 
beneficiaries had seven problem areas identified in their assessments.  Some of 
the more common areas included activities of daily living, pressure ulcers, 
nutrition, and falls.  See Appendix C-2 for the point estimates and confidence 
intervals for all 18 problem areas. 
For 7 percent of stays, the SNFs care plans did not include measurable 
objectives or detailed timeframes.  These objectives and timeframes are 
intended to ensure that SNFs provide appropriate care in duration and frequency 
and that they monitor progress.  Additionally, for 2 percent of stays, an 
interdisciplinary team did not complete the care plans.  In one case, only one 
individual completed the care plan, and this care plan was completed after the 
beneficiary was discharged from the facility. 
The reviewers further observed that care plans were not always customized to 
the beneficiaries needs.  One reviewer noted that care plans often had generic 
interventions or approaches and that there was not always evidence that the care 
plans for problem areas were developed using the information collected in the 
assessments.  Another reviewer agreed, noting that the records had many 
perfect computer-generated care plans that were not individualized or 
customized for the beneficiaries.  One reviewer also noted that sometimes the 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      10 
   
records had little to no documentation that the care plans were implemented.  
This reviewer noted that information on restorative nursing services, toileting 
programs, and preventive wound care was sometimes missing from the records.   
For 15 percent of stays, SNFs did not provide services in 
accordance with care plans  
For 15 percent of stays, SNFs failed to provide at least one service at the 
frequency or duration prescribed in the care plans.  Reviewers found several 
examples in which SNFs provided more services than were indicated in the care 
plans; these examples commonly involved therapy.  SNFs have an incentive to 
provide more therapy than indicated in the plan of care because the amount of 
therapy that SNFs provide to beneficiaries largely determines the amount that 
Medicare pays SNFs.  In one example, the SNF provided therapy for 
12 continuous days without an explanation for the need for that amount of therapy.  
In another example, the SNF continued providing therapy even though the 
beneficiary had met all therapy goals. 
Reviewers also found examples in which SNFs provided fewer services than were 
indicated in the care plans.  In one example, the beneficiary was scheduled to 
receive assistance with toileting at least three times a day; however, the record 
showed that this assistance was provided much less often.  In another example, the 
beneficiary was scheduled to receive assistance with activities of daily living 
every day; however, these activities were performed for the first few days and then 
stopped without any explanation.  
For 31 percent of stays, SNFs did not meet discharge 
planning requirements 
SNFs must provide a plan for each beneficiary being discharged to another facility 
or to home.  The plan must have a summary of the beneficiarys stay and status at 
discharge, as well as a post-discharge plan of care.  These requirements help 
ensure that care is coordinated and that the beneficiarys needs are met after 
discharge.  Not having this information can lead to inadequate care or even to 
serious medical errors and life-threatening situations.   
For 31 percent of stays, the SNFs failed to meet at least one of the discharge 
planning requirements.37  Medicare paid approximately $1.9 billion for these 
stays.  See Table 3 for the percentage of stays in which SNFs did not meet 
 
37 The point estimate is 31 percent with a 95-percent confidence interval of 21 to 43 percent. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      11 
   
discharge planning requirements.  See Appendix C-3 for the point estimates and 
confidence intervals. 
Table 3:  Percentage of Stays in Which SNFs Did Not Meet Discharge 
Planning Requirements, 2009 
Percentage of Stays in Which SNFs 
  Did Not Meet Discharge Planning 
Discharge Planning Requirement   Requirement  
Summary of beneficiarys stay and status at 
discharge  16.0% 
Post-discharge plan of care  23.3% 
   Total  30.9% 
Source:  Office of Inspector General medical record review, 2012.                                                                 
Note:  The rows do not sum to the total because some stays did not meet either requirement.                                                                   
 
For 16 percent of stays, SNFs did not have summaries of the beneficiaries stays 
or statuses at discharge.  Such summaries ensure that the next care provider has 
the necessary information regarding the beneficiarys current and prior health, 
including any treatments received and the beneficiarys response to them.  
Additionally, for several of the stays for which SNFs had summaries, the 
reviewers noted that the summaries had only minimum information, such as the 
statement Has done well.  The reviewers also found a few discharge-status 
summaries that contained no clinical information; this information is essential to 
ensuring a safe transition for the beneficiary to another care setting.  In one case, 
the discharge status contained only the statement [D]ischarged in stable 
condition, vital signs.  The summaries may have lacked clinical information 
because physicians were not always part of the teams that completed them.  For 
example, the reviewers noted that sometimes the discharge statuses were written 
by therapists and included only information regarding the beneficiaries functional 
levels and therapy goals. 
For 23 percent of stays, SNFs did not have post-discharge plans of care.  Such 
instructions are essential to ensuring that the beneficiarys needs are met after 
discharge.  In one example, the beneficiary needed specific instructions about her 
medication; however, the medical record noted that this was not provided.  The 
reviewers also noted several instances when the medical records indicated that 
staff provided only verbal instructions to the beneficiaries.  
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      12 
   
Medical reviewers found examples of poor quality care 
related to wound care, medication management, and 
therapy  
The medical reviewers found a number of egregious examples of poor quality 
care that were related to wound care, medication management, and therapy.   
Wound care 
The medical reviewers identified three instances in which SNFs provided poor 
wound care that may have resulted in the beneficiaries condition worsening.  
Wound care refers to the various treatments provided to heal wounds, which may 
include application of dressings to the wound and the removal of nonviable tissue.  
The following two examples illustrate the issues that the reviewers found. 
  A beneficiary was admitted to a SNF with a pressure ulcer.  During her stay, 
the beneficiary developed three other pressure ulcers.  The SNF had 
difficulty tracking and treating each wound properly, which made healing 
more difficult.  In addition, nursing notes regarding the treatment provided 
for each wound were confusing and inconsistent.  
  Another beneficiary developed a heel ulcer during her stay.  The SNF 
provided inadequate wound care and neglected to provide interventions 
aimed at relieving pressure on the heel.  The ulcer worsened considerably 
over the course of 2 months.  
Furthermore, one medical reviewer observed that several SNFs did not 
include detailed information about wounds in the medical records.  The 
reviewer noted that SNFs may not want to call attention to any pressure 
ulcers acquired during a beneficiarys stay.  SNFs are required to report 
such instances to CMS.  CMS then includes this data in its Nursing Home 
Compare Web site, which provides information to the public about each 
nursing facility.38 
   
 
38 For more information on the data collected for Nursing Home Compare, see 
http://www.medicare.gov/NursingHomeCompare.  
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      13 
   
Medication Management 
The medical reviewers identified five instances in which SNFs did not 
appropriately manage beneficiaries medications.  The following two 
examples illustrate such issues.   
  A beneficiary with dementia was given an antipsychotic drug during her 
SNF stay.  This drug has a black-box warning that it is not approved for 
patients with dementia-related psychosis and may result in severe or life-
threatening risks.39  The medical record indicated that SNF staff and the 
beneficiarys roommate saw that the beneficiary was more confused, was 
agitated, and was not sleeping well after using the drug.  However, the SNF 
did not address these issues in any way. 
  Another beneficiary was given an antipsychotic drug when she did not have 
a diagnosis for psychosis and her care plan did not indicate that she had a 
mood disorder.  The physician noted that the beneficiary was confused while 
on the drug, but he still increased the dosage.  A month later, the 
beneficiarys family complained that the physician and SNF staff were 
trying to sedate the beneficiary with the drug.     
These examples illustrate some of the same issues found in a previous OIG 
study.40  That study found that 95 percent of claims for atypical antipsychotic 
drugs for elderly nursing facility residents were for off-label use and/or the 
condition specified in the black-box warning.41  Although physicians are not 
prohibited from prescribing drugs for off-label use or for conditions specified in 
the black-box warning, Medicare will pay only for drugs that are used for 
medically accepted indications.  The study found that 50 percent of claims did 
not meet this criterion. 
   
 
39 If drug manufacturers or the Food and Drug Administration (FDA) determines during the 
approval process or after a drug has been approved for marketing that the drug may produce 
severe or life-threatening risks, FDA requires that drug manufacturers include a boxed warning 
(also referred to as a black-box warning) on the products labeling to warn prescribers and 
consumers of these risks.  See 21 CFR  201.57(c)(1). 
40 OIG, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents,  
OEI-07-08-00150, May 2011. 
41 Off-label use is the term used to describe the provision of a drug for an indication other 
than the one approved by FDA.  
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      14 
   
Therapy 
The medical reviewers identified two instances in which SNFs provided 
inappropriately high levels of therapy to beneficiaries given their conditions.  The 
following illustrate these issues.   
  A beneficiary received hospice care for terminal lung cancer and bone 
metastasis prior to SNF admission.42  During the beneficiarys SNF stay, the 
SNF provided her with physical therapy 5 days a week for 5 weeks.  The 
medical record showed that the beneficiary participated in therapy at first, 
but at some point, she did not want to continue.  However, the SNF 
continued the therapy at the same intensity for the remainder of her stay 
until she was discharged to home with hospice care. 
  Another beneficiary had a dislocated hip and could not bear weight on that 
side.  Even though the beneficiary should not have been ambulating, the 
SNF provided ultrahigh levels of physical therapy to the beneficiary for 
the entire stay.43   
These examples are consistent with the findings from a previous OIG study.44  
That study found that SNFs billed for a higher payment category than was 
appropriate for 20 percent of all claims in 2009.  For approximately half of 
these claims, SNFs billed for ultrahigh levels of therapy when they should have 
billed for lower levels of therapy or no therapy at all.  For some of these claims, 
the reviewers determined that the amount of therapy indicated in the 
beneficiarys medical record was not reasonable and necessary.  As noted 
earlier, the amount of therapy that the SNF provides to the beneficiary largely 
determines the amount that Medicare pays the SNF. 
   
 
42 Metastasis is the spread of cancer from one part of the body to another. 
43 Ultrahigh therapy is the highest level of therapy a beneficiary may receive under the SNF 
payment system.  It is 720 minutes or more of therapy per week.  Medicare generally pays the 
most for this level of therapy.  
44 OIG, Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a 
Billion Dollars in 2009, OEI-02-09-00200, November 2012. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      15 
   
CONCLUSION AND RECOMMENDATIONS 
SNFs are required to provide care planning and discharge planning for 
beneficiaries.  These requirements are essential to ensuring that beneficiaries 
receive appropriate care and safely transition from one care setting to another.  
For 37 percent of stays, SNFs did not develop care plans that met requirements 
or provide services that were consistent with care plans.  For 31 percent of 
stays, SNFs did not meet discharge planning requirements.  Medicare paid 
approximately $5.1 billion for stays in which SNFs did not meet these 
quality-of-care requirements.  Additionally, reviewers found a number of 
examples of poor quality care related to wound care, medication management, 
and therapy.   
These findings raise concerns about what Medicare is paying for.  They also 
demonstrate that CMS should do more to strengthen its oversight of SNFs to 
ensure that they perform appropriate care planning and discharge planning for 
beneficiaries.  
We recommend that CMS: 
Strengthen the Regulations on Care Planning and Discharge 
Planning 
CMS should revise the regulations on care planning and discharge planning to 
reflect current standards of practice and to address the vulnerabilities identified in 
this report.  For example, CMS should strengthen the requirement that services be 
provided in accordance with care plans.  Specifically, it should require SNFs to 
document in the medical records the reasons why they did not provide services in 
accordance with the care plans, similar to the existing requirement for SNFs to 
document the reasons why they did not develop care plans to address identified 
problem areas.  CMS should also add a requirement that discharge planning be 
conducted by an interdisciplinary team, including a physician.  
Provide Guidance to SNFs To Improve Care Planning and Discharge 
Planning 
CMS should provide guidance to SNFs about care planning and discharge 
planning to ensure that SNFs make improvements in these areas.  The guidance 
should reiterate and expand on the requirements.  For care planning, it should 
emphasize the importance of addressing the problem areas identified in the 
beneficiarys assessment.  To ensure that all of the beneficiarys needs are met, the 
guidance should stress that the care plan must be customized to the beneficiary 
and include measurable objectives and timeframes.  In addition, the care plan 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      16 
   
should be based on communication among interdisciplinary team members, the 
beneficiary, and the beneficiarys family.  CMS should also emphasize that the 
care plan should be treated not as a documentation exercise but rather as an 
integral step in meeting the beneficiarys needs.  
For discharge planning, the guidance should state that the discharge summary 
needs to provide an adequate clinical picture of the beneficiary and detailed 
individualized care instructions to ensure that care is coordinated and that the 
beneficiary transitions safely from one care setting to another.  CMS should 
clarify the type of information that should be included in the discharge summary 
and specify that an interdisciplinary team, including a physician, should develop 
the summary of the beneficiarys stay and status at discharge.  
Increase Surveyor Efforts To Identify SNFs That Do Not Meet Care 
Planning and Discharge Planning Requirements and To Hold These 
SNFs Accountable 
State surveyors are CMSs primary tool to verify that SNFs are meeting care 
planning and discharge planning requirements and to enforce these requirements.  
CMS should increase surveyor efforts to make SNFs more accountable.  It should 
provide more detailed guidance to surveyors to improve the detection of 
noncompliance, particularly for discharge planning.  Specifically, CMS should 
revise its interpretive guidelines in the SOM and train surveyors to ensure that 
they cite facilities that are not developing individualized care plans or are not 
developing specific discharge plans that involve an interdisciplinary team, 
including a physician.   
In addition, CMS should increase the use of existing enforcement remedies when 
SNFs do not meet care planning and discharge planning requirements.  CMS 
should determine when enforcement actions should be taken for SNFs that are out 
of compliance with these requirements and which actions are most appropriate, 
such as increased State monitoring, a directed plan of correction, or civil monetary 
penalties.   
Link Payments to Meeting Quality-of-Care Requirements 
CMS should develop and expand alternative methods beyond the State survey and 
certification process to promote compliance and make improvements in the areas 
of care planning and discharge planning.  CMS should link SNF payments more 
closely to meeting the requirements.  To do so, it could build upon lessons learned 
from existing pay-for-performance incentive programs that reward SNFs for 
quality and improvement in care.  For example, CMS could incorporate quality 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      17 
   
measures for care planning and discharge planning in its Skilled Nursing Facility 
Value-Based Purchasing program.   
Follow Up on the SNFs That Failed To Meet Care Planning and 
Discharge Planning Requirements or That Provided Poor Quality 
Care 
We will provide CMS with a list of SNFs that failed to meet care planning and 
discharge planning requirements or provided poor quality care.  When one 
problem is found, it may indicate a wider problem in the facility.  CMS should 
provide the list to State Survey and Certification agencies to prioritize these 
facilities for review and determine whether enforcement actions are needed. 
 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      18 
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with all five of our recommendations.  CMS concurred with our 
first recommendation and stated that it is conducting a comprehensive review of 
the requirements for participation for long term care facilities to ensure that the 
regulations are effective and these facilities provide quality care.  In addition, it 
has reached out to several external stakeholder groups for public input on these 
issues. 
CMS concurred with our second recommendation and stated that its contractors, 
the Quality Improvement Organizations, are enrolling nursing homes in the 
Nursing Home Quality Care Collaborative.  This initiative uses a menu of 
actionable items to improve the overall quality of care being received by 
residents and their quality of life.  One of the items focused on in this initiative 
is care planning.  CMS has also assembled a workgroup to identify areas of the 
SOM that might better address the discharge planning requirements. 
CMS concurred with our third recommendation and stated that it will consider 
ways to increase oversight of care planning and discharge planning issues in 
SNFs.  With regard to increasing the use of existing enforcement remedies, 
CMS stated that it will review the current citations related to care planning and 
discharge planning, including the severity determinations and enforcement 
actions taken, and work to develop ways to improve its enforcement efforts. 
CMS concurred with our fourth recommendation and stated that it will consider 
incorporating care planning and discharge planning in future nursing home 
demonstrations.  Finally, CMS concurred with our fifth recommendation and 
stated that it will analyze the survey data and determine appropriate methods to 
strengthen enforcement of CMS requirements.   
We support CMSs efforts to address these issues.  For the full text of CMSs 
comments, see Appendix D. 
 
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      19 
   
APPENDIX A 
 
List of the 18 Resident Assessment Protocols 
 
Activities 
Activities of daily living functional/rehabilitation potential 
Behavior symptoms 
Cognitive loss 
Communication 
Dehydration/fluid maintenance 
Delirium 
Dental care 
Falls 
Feeding tubes 
Mood state 
Nutritional status 
Physical restraints 
Pressure ulcers 
Psychosocial well-being 
Psychotropic drug use 
Urinary incontinence and indwelling catheter 
Visual function 
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      20 
   
APPENDIX B 
 
Sample Design 
We used this sample design to meet the objectives of this study and our 
companion study, Inappropriate Payments to Skilled Nursing Facilities Cost 
Medicare More Than a Billion Dollars in 2009, OEI-02-09-00200.  For this 
study, we analyzed stay-level data from strata 2 and 3, for a total of 190 stays.     
   Number of  Number of 
Stays in  Stays in 
  Stratum  Stratum Description  Population  Sample 
  1  Length of stay less than 21 days 
  in 2009 and 3 or fewer claims in 
  2009  1,264,073   55 
2  Length of stay 21 or more days 
  in 2009 and 3 or fewer claims in 
  2009  435,893   45 
3  Stays with over 3 claims in 2009 
  (by default, length of stay is more 
  than 21 days)  668,799   145 
   Total     2,368,765   245 
 
Source:  Office of Inspector General medical record review, 2012. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      21 
   
APPENDIX C 
 
Point Estimates, Sample Sizes, and 95-Percent Confidence 
Intervals for All Estimates Presented in the Report  
 
C-1:  Estimates for All Stays 
 
Sample  95-Percent Confidence 
Estimate Characteristic  Size  Point Estimate  Interval 
Stays in which skilled nursing facilities (SNF) did not  190  36.7%  29.7%44.5% 
meet care plan or service requirements 
Payment for stays in which SNFs did not meet care  190  $4.5 billion  $3.5 billion$5.5 billion 
plan or service requirements 
Payment for stays in which SNFs did not meet care  190  $3.1 billion  $2.1 billion$4.0 billion 
plan requirements 
Payment for stays in which SNFs did not meet  190  $2.0 billion  $1.2 billion$2.8 billion 
service requirements 
Stays in which SNFs did not develop care plans that  190  25.6%  19.4%32.9% 
met requirements 
     - Care plans did not address one or more problem  190  19.2%  13.8%26.0% 
areas identified in the assessments 
     - Care plans did not include measurable  190  6.8%  3.8%12.2% 
objectives or detailed timeframes 
     - Interdisciplinary teams did not complete the care  190  2.1%  0.7%6.0% 
plans 
The average number of problem areas per  190  7.0  6.57.6 
beneficiary 
Stays in which SNFs did not provide services in  190  15.4%  10.5%22.2% 
accordance with care plans 
Payment for stays in which SNFs did not meet care  190  $5.1 billion   $4.1 billion$6.2 billion 
plan requirements, service requirements, or 
 
discharge planning requirements 
Source:  Office of Inspector General medical record review, 2012. 
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      22 
   
 
APPENDIX C (CONTINUED) 
 
 
C-2:  Percentage of Stays in Which Beneficiaries Had Problem Areas (Resident 
 
Assessment Protocols) Identified in Their Assessments 
 
   
Sample  95-Percent 
 
Resident Assessment Protocol  Size  Point Estimate  Confidence Interval 
 
Activities of daily living functional/rehabilitation 
  potential  190  86.1%      80.5%90.3% 
 
Pressure ulcers  190  81.0%      74.7%86.0% 
 
  Nutritional status  190  69.1%     61.9%75.5% 
  Falls   190  61.4%      53.9%68.5% 
 
Dehydration/fluid maintenance  190  55.4%      47.7%62.8% 
 
  Urinary incontinence and indwelling catheter  190  54.0%      46.3%61.5% 
  Cognitive loss  190  53.1%      45.4%60.6% 
 
Psychotropic drug use  190  44.2%      36.8%51.9% 
 
  Mood state  190  40.9%     33.6%48.7% 
  Psychosocial well-being    190  40.4%      33.1%48.1% 
 
Communication  190  33.5%      26.8%40.9% 
 
Visual function  190  22.5%      16.8%29.5% 
 
  Dental care  190  21.7%     16.0%28.7% 
Delirium  190  15.4%      10.5%22.2% 
Behavior symptoms  190  10.6%       6.7%16.4% 
Activities   190  8.0%       4.9%12.8% 
Feeding tubes  190  5.5%      3.0%9.6% 
Physical restraints  190  1.3%       0.3%5.5% 
 
Source:  Office of Inspector General medical record review, 2012. 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      23 
   
APPENDIX C (CONTINUED) 
C-3:  Estimates for Stays in Which the Beneficiaries Were Discharged 
 
95-Percent 
Estimate Characteristic  Sample Size  Point Estimate  Confidence Interval 
Stays in which SNFs did not meet discharge  83  30.9%      21.2%42.6%        
planning requirements 
Payment for stays in which SNFs did not meet  83  $1.9 billion  $1.1 billion$2.7 billion 
discharge planning requirements  
Stays in which SNFs discharge planning did not  83  16.0%  9.0%26.9% 
include summaries of the stays or statuses at 
discharge 
Stays in which SNFs discharge planning did not  83  23.3%  15.0%34.4% 
include post-discharge plans of care 
 
Source:  Office of Inspector General medical record review, 2012. 
 
 
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      24 
  APPENDIX D 
Agency Comments 
DEPARTMENT OF HFALTI-I & HUMAN SERVICES 
Adminish'ator 
W<lahlngton, DC 20201 
DATE:  JAN  I 7 2013 
TO:  Daniel R. Levirnon 
Inspector General 
"ROM:  Moofynl'll\'enncr 
Acti~Aidm'S.nistrator 
SUBJFT!  Office ofIuspector General (OIG) Draft Report: "Skilled Nursing Facilities Often Fail 
to Meet Care Planning and Discharge Plann.ing Requirements" OEI-02-09-00201 
The Centers for Medicare & Medicaid Services (CMS) would like to thank the OIG for the 
opportunity to review and comment on the subject O!G draft report. CMS recognizes the 
importance and impact of effective care planning and discharge planning on the quality of life 
and care for nursing home residents. The OlG's objectives for this report are to determine the 
extent to which skilled nursing facilities (SNFs) met Medicare requirements for care planning 
and discharge planning, and describe instances of poor quality care provided by SNFs. 
The CMS responses to the OIG recommendations are discussed below. 
QlG Recommend!ttio.n 1 
The OIG .recoiumends thal CMS strengthen the regulations on care planning and discharge 
planning. 
(;MS Response 
The CMS concurs with this recommendation. Care planning and discharge planning are 
important aspects of providing quality care. CMS is currently conducting a comprehensive 
review of the requirements for participation for long term care facilities to ensure that the 
regulatiorn are effective and these facilities provide quality care. The applicable regulatory 
provisions in 42 Cr"R Part 483, Subpart B are being reviewed for possible areas of improvement 
to ensure the health and safety of long-term care residents. Our review of these regulations 
includes consideration of timeliness, resident-centeredness, and quality impmvement. In 
addition, CMS has reached out to several external stakeholder groups for public input on their 
key co.ncerns and suggestions on tbe~e iss ues. We apprecia te this timel.y and informative OIG 
report and will consider the results and recommendations of this study as we conclude our 
regulations rev iew process, 
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)  25   
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      26 
   
 
 
 
   
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      27 
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 
General. 
Judy Kellis served as the team leader for this study.  Other Office of Evaluation 
and Inspections staff from the New York regional office who conducted the study 
include Judy Bartlett.  Central office staff who provided support include 
Berivan Demir Neubert, Kevin Farber, Sandy Khoury, Christine Moritz, 
Sue Nonemaker, and Julie Taitsman.  
 
 Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201)      28 
   
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 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.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/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 for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.