Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

 

SKILLED NURSING FACILITIES 

OFTEN FAIL TO MEET CARE 

PLANNING AND DISCHARGE 

PLANNING REQUIREMENTS

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 beneficiary’s 

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 
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201) 1

 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 beneficiary’s 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) 2

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) 3

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 beneficiary’s

discharge when facilities anticipate a discharge.

19 

Developing Care Plans and Providing Services. SNFs are required to develop

care plans that describe the beneficiary’s 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 beneficiary’s 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 User’s 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) 4

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 beneficiary’s 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 beneficiary’s 

family, or the beneficiary’s 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 beneficiary’s 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 

beneficiary’s 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. 1395i–3(b)(2)(B). 28 Ibid.

29 CMS, State Operations Manual [SOM], Appendix PP, Tags F279 and F280.
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201) 5

or her new setting. The discharge summary should include a summary of the 

beneficiary’s stay, a summary of the beneficiary’s status at the time of 

discharge, and a post-discharge plan of care.

30 The post-discharge plan of care

should describe what the beneficiary’s and family’s 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 CMS’s 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 CMS’s 

SOM. This manual includes the interpretive guidelines that surveyors follow to determine 

whether a facility complies with Medicare requirements.

33 CMS, SOM, ch. 7.
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201) 6

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) 7

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 

beneficiary’s 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) 8

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) 9

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

Requirements

Percentage of Stays in

Which SNFs Did Not Meet 

Requirements

Medicare Payments for 

Stays in Which SNFs Did 

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) 10

Table 2: Percentage of Stays in Which SNFs Did Not Meet Care Plan

Requirements, 2009

Care Plan Requirements 

Percentage of Stays in Which SNFs 

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 beneficiary’s 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) 11

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 beneficiary’s 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 beneficiary’s 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) 12

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

Discharge Planning Requirement

Percentage of Stays in Which SNFs 

Did Not Meet Discharge Planning 

Requirement

Summary of beneficiary’s 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 beneficiary’s current and prior health, 

including any treatments received and the beneficiary’s 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 beneficiary’s 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) 13

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 beneficiary’s 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) 14

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 lifethreatening risks.

39 The medical record indicated that SNF staff and the 

beneficiary’s 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 

beneficiary’s 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 product’s 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) 15

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 beneficiary’s 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 

beneficiary’s 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) 16

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 

beneficiary’s assessment. To ensure that all of the beneficiary’s 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) 17

should be based on communication among interdisciplinary team members, the 

beneficiary, and the beneficiary’s 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 beneficiary’s 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 beneficiary’s 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 CMS’s 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) 18

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) 19

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 CMS’s efforts to address these issues. For the full text of CMS’s 

comments, see Appendix D. 
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201) 20

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) 21

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. 

Stratum Stratum Description

Number of 

Stays in 

Population

Number of 

Stays in 

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) 22

APPENDIX C

Point Estimates, Sample Sizes, and 95-Percent Confidence 

Intervals for All Estimates Presented in the Report

C-1: Estimates for All Stays

Estimate Characteristic

Sample 

Size Point Estimate

95-Percent Confidence 

Interval

Stays in which skilled nursing facilities (SNF) did not 

meet care plan or service requirements

190 36.7% 29.7%–44.5% 

Payment for stays in which SNFs did not meet care 

plan or service requirements

190 $4.5 billion $3.5 billion–$5.5 billion

Payment for stays in which SNFs did not meet care 

plan requirements

190 $3.1 billion $2.1 billion–$4.0 billion

Payment for stays in which SNFs did not meet 

service requirements

190 $2.0 billion $1.2 billion–$2.8 billion

Stays in which SNFs did not develop care plans that 

met requirements

190 25.6% 19.4%–32.9%

 - Care plans did not address one or more problem 

areas identified in the assessments 

190 19.2% 13.8%–26.0%

 - Care plans did not include measurable 

objectives or detailed timeframes

190 6.8% 3.8%–12.2%

 - Interdisciplinary teams did not complete the care 

plans 

190 2.1% 0.7%–6.0%

The average number of problem areas per 

beneficiary

190 7.0 6.5–7.6

Stays in which SNFs did not provide services in 

accordance with care plans

190 15.4% 10.5%–22.2%

Payment for stays in which SNFs did not meet care 

plan requirements, service requirements, or 

discharge planning requirements

190 $5.1 billion $4.1 billion–$6.2 billion

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-2: Percentage of Stays in Which Beneficiaries Had Problem Areas (Resident 

Assessment Protocols) Identified in Their Assessments 

Resident Assessment Protocol

Sample 

Size Point Estimate

95-Percent 

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) 24

APPENDIX C (CONTINUED)

C-3: Estimates for Stays in Which the Beneficiaries Were Discharged

Estimate Characteristic Sample Size Point Estimate

95-Percent 

Confidence Interval

Stays in which SNFs did not meet discharge 

planning requirements

83 30.9% 21.2%–42.6% 

Payment for stays in which SNFs did not meet 

discharge planning requirements 

83 $1.9 billion $1.1 billion–$2.7 billion

Stays in which SNFs’ discharge planning did not 

include summaries of the stays or statuses at 

discharge

83 16.0% 9.0%–26.9%

Stays in which SNFs’ discharge planning did not 

include post-discharge plans of care

83 23.3% 15.0%–34.4%

Source: Office of Inspector General medical record review, 2012.
APPENDIX D 

Agency Comments 

DEPARTMENT OF HFALTI-I & HUMAN SERVICES 

Adminish'ator 

W<lahlngton, DC 20201 

DATE: 

TO: 

JAN I 7 2013 

Daniel R. Levirnon 

Inspector General 

•"ROM: Moofynl'll\'enncr 

Acti ~Aid 'S.n istrator 

SUBJF£T! 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
Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements (OEI-02-09-00201) 28

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. 
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 OIG’s 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.