Federal Reports

The nursing home complaint process is a critical safeguard to protect vulnerable residents of nursing homes. CMS relies on the States' respective survey agencies to serve as the front-line responders to address health and safety concerns raised by residents, their families, and nursing home staff. State survey agencies must conduct onsite investigations within certain timeframes for the two most serious levels of complaints-those that allege serious injury or harm to a nursing home resident and require a rapid response to address the complaint and ensure residents' safety. However, previous reports by OIG and the Government Accountability Office found that States did not conduct onsite investigations within the required timeframes for some of these complaints.

OIG conducted a healthcare inspection to assess allegations of delays in patients receiving transcatheter aortic valve replacement (TAVR) procedures at the VA Palo Alto Health Care System (system) Palo Alto, CA, due to Veterans Health Administration (VHA) policy requirements. We received complaints alleging: Patient A’s TAVR was delayed; VHA’s requirement that TAVR procedures occur in a hybrid operating room (HOR) is too stringent and not the community standard; patients were “affected” by the HOR requirement for the TAVR procedure; the system requested and was denied a waiver of the HOR requirement for TAVR procedures; HOR construction delays prevented system TAVR program implementation; and to avoid delays in patient care, the system enrolled patients in research studies so they could undergo TAVR procedures. We did not substantiate Patient A experienced a delay in obtaining the TAVR procedure. Once Patient A was recommended for a TAVR, the procedure was completed within a timeframe consistent with his medical needs. We substantiated VHA requires TAVR procedures be performed in a HOR. VHA reviewed best practices and obtained expert consensus to establish this requirement. We substantiated patients were affected by VHA’s requirement that TAVR procedures be performed in a HOR as the system did not have a HOR and was unable to perform non-research TAVR procedures. However, we found the system referred patients for care. We substantiated that construction on a TAVR HOR was not completed on the projected date and affected the system’s program. Patients obtained the TAVR procedure through other services during that time. We substantiated that system providers enrolled patients in TAVR procedure research studies. We were unable to determine if by doing so, they avoided delays in care. We identified lapses in the documentation necessary to maintain accurate records including communication and continuity of care. We made one recommendation.

The Centers for Medicare & Medicaid Services (CMS) contracted with National Government Services (NGS) to process Part B claims under Medicare contract 00630. CMS requested that we perform an audit of NGS's Medicare Part B final administrative cost proposal for the last three quarters of fiscal years 2011 and 2012.

The Centers for Medicare & Medicaid Services (CMS) contracted with National Government Services (NGS) to process Part A claims under Medicare contract 00130. CMS requested that we perform an audit of NGS's Medicare Part A final administrative cost proposal for the last three quarters of fiscal years 2011 and 2012.