The Health & Human Services (HHS) Office of Inspector General (OIG) updated on October 17 a “Recommendations Tracker”  outlining the top unimplemented recommendations of 2024. Among the 33 unimplemented recommendations, four are directly related to nursing homes. Descriptions, below:

Psychotropic Drug Use

A November 2022 report focused on trends of psychotropic drug use in nursing homes found that approximately 80% of Medicare long-stay nursing home residents from 2011-2019 were prescribed psychotropic drugs. Efforts by the Centers for Medicare & Medicaid Services (CMS) to reduce antipsychotic usage in nursing homes coincided with an increase in the use of anticonvulsants, resulting in the overall use of psychotropic medications remaining constant during this period. OIG also found that from 2015 to 2019, reporting of schizophrenia diagnoses on the Minimum Data Set (MDS) and the number of residents who lacked corresponding schizophrenia diagnoses in Medicare claims and encounter data increased by 194%. OIG concluded that by not collecting diagnoses on Medicare Part D claims, CMS limited its ability to effectively conduct oversight on psychotropic drugs. OIG recommended that CMS expand required data elements on Medicare Part D claims to include a diagnosis code and use data to identify nursing homes or nursing home characteristics that are associated with a higher use of psychotropic drugs to focus oversight on nursing homes in which trends may signal inappropriate use.

CMS concurred with the recommendation to use data to identify trends and focus oversight on nursing homes where inappropriate use may be occurring. CMS described actions taken to address this issue, including survey process changes to target inappropriate use of anticonvulsants and analysis of data to identify trends. The OIG Recommendations Tracker notes that the last update on this recommendation was received in April 2024 and the next update is expected in April 2025.

CMS non-concurred with the recommendation to expand required Medicare Part D elements to include diagnosis codes, claiming that it lacks the statutory authority to require prescribers to include diagnosis codes on prescriptions. CMS further raised concerns that this could result in delays in care due to rejected claims and stated that there are other ways to monitor psychotropic drug use. The Recommendations Tracker notes that the last update was received in June 2024 and the next update is expected July 2025.

Infection Control

A January 2023 report, the second in a three-part series focusing on the nursing home experience during the COVID-19 pandemic in 2020, found that more than 1,300 nursing homes had COVID-19 infection rates of 75% or more of Medicare beneficiaries during the spring and fall surges of 2020. The report also found that high infection rates were not associated with high numbers of deficiencies on infection control surveys or with staffing levels at or below Medicare minimum requirements, leading OIG to question the effectiveness of survey processes and the adequacy of staffing requirements. OIG recommended that CMS improve how surveys identify infection control risks and strengthen guidance on assessing the scope and severity of those risks. The OIG Recommendations Tracker states that CMS non-concurred with this recommendation; however, the report states that CMS neither concurred nor non-concurred, but instead provided information about the survey process and pandemic-era prioritizations. The Recommendations Tracker indicates that OIG last received an update on this recommendation in May 2024 and the next update is expected August 2025.

Facility-Initiated Discharges

A March 2024 report on facility-initiated discharges found that nursing homes were sometimes noncompliant in providing required documentation during facility-initiated discharges. OIG reported that nursing homes often failed to provide timely notification to residents of discharges and frequently omitted information in discharge notices. When notification was provided, only about one half of nursing homes provided required notice to the ombudsman program. OIG recommended that CMS require nursing homes to systematically document facility-initiated discharges in a way that is accessible to CMS and states to enhance oversight. CMS did not concur with this recommendation and recommended that OIG consider the recommendation closed. CMS stated that tracking of facility-initiated discharges is not a regulatory requirement and would be resource intensive. CMS further pointed out that tracking facility-initiated discharges would not improve oversight of compliant vs. noncompliant discharges. The Recommendations Tracker notes that this recommendation remains open and unimplemented and an update is expected May 2025.