CMS Under-Reports Elder Abuse

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Original story posted on: June 19, 2019

Recent report from HHH/OIG faults CMS.

A recent study by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) revealed a concerning series of findings related to the under-reporting of instances of potential abuse and/or neglect of elderly Medicare patients.

Every year, tens of thousands of elderly patients being cared for in skilled nursing facilities (SNFs) present in emergency departments seeking treatment related to one of 580 diagnosis codes that were determined by the OIG to correlate with high risk for potential abuse or neglect. The OIG study related to such visits found that despite federal requirements that they are reported, the majority of such visits were, in fact, not. As one might expect, the failure to report in turn disallowed the Centers for Medicare & Medicaid Services (CMS) and state survey agencies from reporting findings of substantiated abuse occurring in SNFs to local law enforcement, tracking such incidents, or putting in place any form of remediation or corrective action. 

The OIG report went on to identify potential root causes for the dramatic under-reporting, citing a lack of clarity in the CMS reporting requirements as a leading cause. The report also includes a series of recommendations aimed at addressing the severe under-reporting, including training for SNF staff, clarification of reporting requirements and guidelines, and more stringent incident tracking requirements. But there are other potential alternate causes worth considering, including SNF staff’s inability to effectively assess whether an injury might be associated with abuse or neglect, and the possibility that a staff member may be reluctant to speculate about potential abuse (and in doing so, implicate a co-worker). Ultimately, the primary issue is not the failure to report or track incidents, but the unnoticed victimization of elderly patients and the subsequent inability to appropriately care for them.

Patients who present in the emergency department from SNFs (or from home) who appear depressed, confused, and/or agitated may be victims of elder abuse. Even if they are not, they should be evaluated by a psychiatrist in order to yield accurate diagnoses, provide effective treatment recommendations, and assess whether the patient’s condition might be the result of elder abuse.

A psychiatric evaluation would directly contribute to meeting the OIG’s goal of protecting our most vulnerable citizens, ensuring timely and accurate incident reporting, and most importantly, ensuring that these patients receive the care and protection that is their right. Once a more effective and independent assessment and reporting protocol are in place, the data collected on these incidents would enable both CMS and survey agencies to analyze trends and put in place meaningful regulatory measures to prevent future incidents.

Additionally, having an independent physician assess patients and report any suspected abuse or neglect directly to the appropriate authorities would remove the burden on SNF staff to accurately diagnose potential victims of elder abuse, and possibly have to report an incident that might indirectly result in punitive action against a co-worker.

Programming Note:

Listen to Dr. Seward report this story live during Monitor Monday, June 24, 10-10:30 a.m. EST.

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Kathy Seward, MD, CHCQM-PHYADV

Kathy Seward, MD, CHCQM-PHYADV is a medical director of coordination of care at a five-hospital system in southeastern North Carolina.  She is also the chief medical officer and co-founder of qlēr Solutions, Inc., a telemedicine company that provides psychiatric care to patients throughout the United States. Seward is a member of the RACmonitor editorial board.

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