Civil Monetary Penalties Research Articles

250 Civil Monetary Penalties Related to Violations of the Emergency Medical Treatment and Labor Act Involving Patients Arriving or Departing With Law Enforcement

250 Civil Monetary Penalties Related to Violations of the Emergency Medical Treatment and Labor Act Involving Patients Arriving or Departing With Law Enforcement

123 Civil Monetary Penalties Related to Violations of the Emergency Medical Treatment and Labor Act Involving Psychiatric Emergencies: A 5-Year Update

123 Civil Monetary Penalties Related to Violations of the Emergency Medical Treatment and Labor Act Involving Psychiatric Emergencies: A 5-Year Update

Civil Monetary Penalties for EMTALA Violations Involving Minors, 2002-2023.

The Emergency Medical Treatment and Labor Act (EMTALA) is intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (EDs). EMTALA requirements pertain to patients of all ages presenting to dedicated EDs regardless of whether facilities have dedicated pediatric specialty services. This study aims to describe EMTALA-related civil monetary penalty (CMP) settlements involving minors. Descriptions of all EMTALA-related CMPs occurring between 2002 and 2023 were obtained from the Office of the Inspector General web site and reviewed for involvement of minors (<18 years of age) using keywords in settlement summaries. Characteristics of settlements involving minors were described and compared with settlements not involving minors. Of 260 EMTALA-related CMPs, 38 (14.6%) involved minors. Most involved failure to provide a medical screening exam (MSE) (86.8%) and/or stabilizing treatment (52.6%). Seven (18.4%) involved pregnant minors. Eleven (28.9%) involved ED staff directing a patient (or guardian) to another facility, typically by private vehicle, and another involved 2 patients referred to on-campus outpatient clinics without an MSE. One in 7 CMPs related to EMTALA violations involved minors, and 1 in 5 of these minors was pregnant. One-third of CMPs involving minors included ED staff directing patients to proceed to another facility or on-campus clinic without MSE or stabilization. Findings suggest a need for providers to understand EMTALA-specific requirements for appropriate MSE, stabilization, and transfer, and for EDs at hospitals with limited pediatric services to implement policies for the evaluation of minors and protocols for transfer when indicated.

CIVIL MONETARY PENALTIES GOVERNING ASSISTED LIVING: VARIATION ACROSS AND WITHIN STATES

Abstract State survey agencies are responsible for developing minimum requirements for assisted living (AL) communities, including penalties for noncompliance. Civil monetary penalties are a common measure state enforcement agencies use to incentivize regulatory compliance. We searched state statutes and regulations governing licensed AL communities in August 2022 to identify enforceable civil monetary penalties and used descriptive statistics and content analysis to describe regulatory differences within and between states according to license type. Our findings indicate that 48 of 51 states may enforce financial penalties for noncompliance against assisted living communities, though four of these states have one or more license types without applicable monetary penalties. 13 states had differing policies and possible enforceable amounts by license type, so some AL communities are possibly being charged more than others for the same offense within the same state. We found that states took three different approaches to calculating fees, sometimes using multiple approaches depending on the citation and license type. One or more license types in 36 states imposed per-instance fines, per-day fines in 32 states, and per-resident-per-day fines in 3 states. We describe the current landscape of financial penalty enforcement policies for US assisted living communities as well as its implications for state agencies and providers.

The Auditor’s Responsibility for Noncompliance with Laws and Regulations: A Case of Unauthorized Account Activity at Wells Fargo

ABSTRACT In September 2016, the Consumer Financial Protection Bureau (CFPB) announced an enforcement action against Wells Fargo related to improper sales practices. Following investigations revealing widespread abuse by thousands of employees (e.g., opening deposit and credit accounts without customer consent), Wells Fargo paid civil monetary penalties of $185 million and other substantial punitive fees and fines. This case study uses this real-world example to explore the influence of materiality on the scope of an audit, the auditor’s responsibility for detection and communication of noncompliance with laws and regulations (NOCLAR), and the auditor’s consideration of the control environment in the evaluation of internal controls over financial reporting (ICFR). After completing the case, learners are able to discuss relevant professional standards and recognize the impact of materiality considerations on decisions about financial statement misstatements, NOCLAR, and internal control deficiencies. JEL Classifications: M41; M42.

APA’s Government, Policy, and Advocacy Update (November 2022)

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy Update (November 2022)Search for more papers by this authorPublished Online:25 Oct 2022https://doi.org/10.1176/appi.pn.2022.11.11.42APA Joins Letter to Senate on Prioritizing TelehealthAlong with dozens of other health care organizations and corporations, APA wrote a letter to Sens. Charles Schumer (D-N.Y.) and Mitch McConnell (R-Ky.), urging the Senate to pass a two-year extension of the telehealth flexibilities introduced during the COVID-19 public health emergency, while still pushing to make those flexibilities permanent. The letter notes that the House passed the Advancing Telehealth Beyond COVID-19 Act (HR 4040) in July, which extends coverage of telehealth services under Medicare until at least 2024. Currently, the flexibilities are due to expire 151 days after the public health emergency ends.“Virtual care is now a fundamental part of the U.S. health care system, and it will improve patient access to high-quality care and strengthen continuity of care well beyond the COVID-19 pandemic,” the letter states. “Telehealth is helping to address the crisis-level mental health, primary care, and other workforce shortages. Many underserved communities that historically have had limited access to care may now beam in additional support for their workforce as well as top specialists to help save lives and treat critically ill patients. Unfortunately, without statutory certainty for remote care, the hard work of building infrastructure, trust, and relationships with these communities is beginning to stall.”Letter to Sens. Charles Schumer (D-N.Y.) and Mitch McConnell (R-Ky.) Bill Would Allow Civil Monetary Penalties for MH Parity ViolationsSens. Chris Murphy (D-Conn.), Tina Smith (D-Minn.), and Ben Ray Luján (D-N.M.) introduced the Parity Enforcement Act of 2022 (S 4804). The APA-supported bill would allow the Department of Labor to issue civil monetary penalties against insurers and health plans that are not in compliance with the Mental Health Parity and Addiction Equity Act of 2008.“Giving the Department of Labor the authority to impose civil monetary penalties on health plans and insurers for violating the parity law is a critical next step for improved accountability,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in a news release on Murphy’s website. “The Department’s report to Congress earlier this year demonstrated that despite increased transparency, plans and insurers are still falling short of full compliance. We appreciate Senator Murphy’s continued efforts to ensure true mental health parity enforcement.”Murphy, Smith, Luján Introduce Legislation to Give the U.S. Department of Labor Authority to Enforce Mental Health Parity Laws APA Supports Increased Funding and Access to Treatment for Mental, Substance Use DisordersIn comments to the Centers for Medicare and Medicaid Services (CMS), APA emphasized the importance of ensuring access to mental and substance use disorder treatments by supporting coverage and appropriate reimbursement for services, such as those provided via telehealth (including audio only). The comments, signed by APA CEO and Medical Director Saul Levin, M.D., M.P.A., were made in response to CMS’s proposed rule on the 2023 Medicare Physician Fee Schedule and Quality Payment Program (APA Registers Concerns About Potential Cuts to Medicare Physician Payment). APA Supports Efforts to Expand Access to Care to Rural CommunitiesIn late August, APA responded to the Centers for Medicare and Medicaid Services’ (CMS) proposed rule on Conditions of Participation (COP) for Rural Emergency Hospitals (REH) and Critical Access Hospital COP Updates. APA’s letter, signed by APA CEO and Medical Director Saul Levin, M.D., M.P.A., expresses APA’s support for the expansion of health care access in rural communities, while encouraging CMS to further support access to treatment for mental and substance use disorders through these hospitals.Levin highlighted the APA report “The Psychiatric Bed Crisis in the U.S.” in the letter to urge CMS to reconsider an exemption to the 24-hour average length of stay for patients needing inpatient psychiatric care, allowing them to stay in the emergency hospitals until a bed in a facility that most meets the needs of the patient is available. “Putting an artificial average time on patient stay may affect the care the most vulnerable patients are getting, leading to potentially life-threatening decisions,” Levin stated.APA also encouraged the coverage and reimbursement of outpatient treatment services for mental and substance use out of the REH to increase the availability of quality services in rural communities. “There is an opportunity to shore up existing outpatient services and facilitate the implementation of additional services not currently available in the community,” the letter states. ■APA’s letter ISSUES NewArchived

Medicare in 2030 Irretrievably Broken

Medicare in 2030 Irretrievably Broken

California Joins Six States in Setting Standards for MH/SUD Appointment Wait Times

California Joins Six States in Setting Standards for MH/SUD Appointment Wait Times

Why the Proposed CMS Civil Monetary Penalties Imposed on Hospitals is DOOMED for Failure

Why the Proposed CMS Civil Monetary Penalties Imposed on Hospitals is DOOMED for Failure

Medicolegal Sidebar: A Fast Route To A Criminal Indictment-Violating Fraud and Abuse Laws.

Medicolegal Sidebar: A Fast Route To A Criminal Indictment-Violating Fraud and Abuse Laws.

False Claims Act Overview and Implications for Neurologists.

The US Department of Health and Human Services Office of the Inspector General identifies the five most important federal fraud and abuse laws that are most applicable to physicians: the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), the Exclusion Authorities, and the Civil Monetary Penalties LawThe False Claims Act is the US government's primary tool for combating fraud perpetrated through the filing of false claims for federal government reimbursement. Neurologists and companies serving the needs of neurologic patients have not been immune from False Claims Act-related legal action. This article provides an overview of the False Claims Act, uses real-life neurologic cases to illustrate the range of False Claims Act violations and recoveries, and offers some practical compliance suggestions.

The Future of LTC: The Continuing Evolution of the SNF

The Future of LTC: The Continuing Evolution of the SNF

Determining Core Element Achievement in Long-Term Care Facilities Across Tennessee

Background: In 2017, a new antimicrobial stewardship standard was established by the Joint Commission that requires long-term care facilities (LTCFs) to have an antimicrobial stewardship program (ASP) based on current scientific literature. The Tennessee Department of Health (TDH) team sought to ascertain the current state of ASPs across Tennessee and to assist programs with implementation strategies. Utilizing a Centers for Medicaid and Medicare Services’ Civil Monetary Penalties grant, the TDH purchased copies of the National Quality Partners Playbook for Antibiotic Stewardship in Post-Acute and Long-Term Care to provide to LTCFs as incentive to complete a survey that would evaluate their current adoption of core elements. Methods: A self-administered questionnaire on ASP practices was developed and distributed to LCTFs. This survey expanded upon questions from the NHSN 2018 LTCF annual survey. These questions pertained to actionable items facilities are taking to achieve core elements. Achievement of the CDC’s 7 core elements of ASPs was determined based upon a combination of 1 or more responses to the survey questions. The percentage of LTCFs achieving each ASP core element at the regional and statewide level was determined. We also calculated the percentage of LTCFs that achieved all 7 elements versus 5 or more core elements. The analyses and visualizations were performed using SAS 9.4 and Tableau software. Results: Currently, 88 of 316 licensed LTCF facilities in Tennessee have participated in the survey. All regions were represented by EMS region. Based on the results of our survey, 100% of participating facilities have achieved at least 5 core elements, and 78% of participating facilities have achieved all 7 core elements. The core element with the lowest achievement was Accountability at 89%, and reporting and action had the highest achievement (100%). Conclusions: Early results suggest that LTCFs across Tennessee have active ASPs with strong core element achievement. However, we received responses from only 27% of licensed LTCFs. Minimal data are available regarding the current state of LTCF ASPs in Tennessee, and data will continue to be collected and analyzed. Participation may be limited to those already actively engaged in public health efforts, including antimicrobial stewardship. LTCFs that have participated in the initial evaluation will be surveyed at 6 months and 12 months after receipt of playbooks to evaluate their ASP progression and NQP Playbook utilization.Funding: NoneDisclosures: None

A Labor of Love

In recent weeks I have been involved in a labor of love. I have a treasure trove of more than 400 letters written by my father to his mother during his service in World War II, and I have been transcribing them. This has been an experience like none other for me: reading them is like visiting a foreign country that looks strangely familiar at every turn. At this stage in my transcribing, dad and his peers are currently in training at Coleman Field in Coleman, TX, in 1943 to be U.S. Army Air Forces (USAAF) pilots. (The USAAF did not become an independent entity — the U.S. Air Force of today — until September 18, 1947.) His view of being part of the colossal catastrophe of WWII, of being a 20-year-old with his buddies experiencing it all, is fascinating. What he thought and felt before being the recipient of the forces of life that shaped him — before meeting my mother, before knowing me — has been a humbling revelation. What I have discovered thus far is that these green, mostly small-town and rural boys had a vision. They wanted to change and shape America and the world for the better. The word “stewardship” has come to mind for me. The Oxford Dictionary defines stewardship as “the job of supervising or taking care of something.” History shows us that they did indeed take care of something as part of the Greatest Generation. Getting to know these kids who changed the world through their stewardship has prompted a challenge to me: What is my stewardship mission? My answer is to make the post-acute and long-term care space safer, more compassionate, more evidence based — and just all-around better. I choose to do this with stewardship through AMDA – The Society for Post-Acute and Long-Term Care Medicine and the Foundation for PALTC Medicine, and I extend that challenge to you. Your Foundation, the Society’s Board of Directors, and the American Board of PALTC Medicine (ABPLM) continue to align our goals. By cooperating on projects and with funding from the Foundation, we can improve the workforce in geriatrics and demonstrate the value of PALTC clinicians to improving the quality of care. This is stewardship in action. The final proposals for such collaborative efforts are pending, but the potential projects are listed below. The Society’s Board of Directors will:•Develop an accurate registry of skilled nursing facility medical directors across the country.•Create a template for AMDA-related entities to access civil monetary penalty funds (this will vary by state) to use in their quality-improvement activities.•Provide training to clinicians to assume leadership roles in PALTC. ABPLM will:•Continue efforts to raise the visibility of PALTC medical directors and clinicians. This year we will continue to move forward with projects beneficial to the Society’s membership, research, and the Foundation:•Neurologist Ilo Leppik, MD, will be administering a written survey to the membership on epilepsy care in long-term care. He will make a significant donation to the Foundation for our efforts and a donation to the Society per survey completed. Survey takers will receive complimentary access to a recording of the billing and coding session from the conference (a $20 value). Please support the Society, your Foundation, and better epilepsy care by taking the survey.•The Society has a new Learning Management System site up and running. In addition to our popular continuing medical education topics such as billing and coding, it will have a non-CME page, separated by a firewall from the CME topics, where nonbranded state educational disease information from the Society’s Industry Advisory Board partners will reside.•Your Foundation is sponsoring two speakers at the Annual Conference in Chicago: the Friday plenary session presenter, and the speaker who will follow the Anne-Marie Filkin Lecture on Sunday.•No discussion of the Annual Conference is complete without mentioning the Futures Program. Again, your Foundation will be sponsoring this special “meeting within a meeting.” With your support we continue to invest in the future of PALTC through the Futures Program. The Foundation and I look forward to seeing you all in Chicago. We hope to interact with each of you at the “Wall of Caring” to unleash our inner stewardship. Dr. Lett has practiced in the PALTC continuum for more than three decades as a hands-on clinician and medical director. He has served AMDA in multiple capacities including as president, on multiple committees, and is the current chair of the Foundation for PALTC Medicine.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies

IntroductionThe Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition – labor – specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care.MethodsWe reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002–2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements.ResultsOf 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle.ConclusionDespite inclusion of the term “labor” in the law’s title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

LESSONS LEARNED FROM NURSING HOME CIVIL MONETARY PENALTY PROJECTS

Nursing homes must comply with numerous federal/state regulations to receive Medicare and Medicaid funding. Failure to comply with these regulations can result in deficiency citations, and depending on the severity of the deficiency, a resulting Civil Monetary Penalty (CMP). Through the Centers for Medicare and Medicaid Services (CMS) Civil Monetary Penalty Reinvestment Program, CMP funds are reinvested to support activities that benefit nursing home residents and that protect or improve their quality of life or quality of care. This symposium presents some of the unique challenges, successes, failures, and surprise findings from CMP-funded nursing home quality improvement projects in two, predominantly rural Midwestern states: Oklahoma and Kansas. Dr. Williams presents findings of a pilot-study testing an adaptation of a successful family caregiver telehealth support intervention in the nursing home setting and implications for future research. Dr. Sturdevant shares successes, challenges, and unanticipated results from the “It’s Not OK to Fall” project, a comprehensive, 3 year fall prevention project implemented in Oklahoma nursing homes. Lastly, Ms. Round’s paper describes the implementation and findings of a Long-term Care Leadership Academy aimed at improving leadership and team building skills of three levels of nursing home staff, including Administrators/Directors’ of Nursing, RN/LPN charge nurses and certified nursing assistants. Discussant, Dr. Kathleen Buckwalter Ph.D., FAAN, RN, will discuss how principles of nursing home culture change provides a common framework for these projects and conclude by offering suggestions on how promotion of these principles might improve the quality of care provided by nursing homes.

CHANGING THE CULTURE OF ADVANCE CARE PLANNING, DEATH, DYING, AND BEREAVEMENT CARE IN NURSING HOMES

Cultural change, using an Eden Alternative metaphor, means that palliative care becomes ‘the servant of genuine human caring, not its master’. This project, funded through the Georgia Civil Monetary Penalty Fund Reinvestment Program (CMPRP), aimed to gather information from multiple stakeholders to promote changes in the culture of advance care planning, death, dying, and bereavement care in nursing homes. Staff, residents and families from nine nursing homes provided perspectives through qualitative interviews (n=70). Participants were drawn from both small facilities and corporate entities with multiple sites, and included residents in both short and long-stay beds. Qualitative analysis of interview data resulted in the publication and dissemination of Best Practice in Bereavement Care Guides, with separate versions for residents, families, and staff. This presentation will describe this project in terms of the process of consensuses building and obtaining funding, as well as development of the guides through qualitative interview data.

EVALUATING AN INNOVATIVE USE OF CIVIL MONETARY PENALTY FUNDS: THE MA SUPPORTIVE PLANNING AND OPERATIONS TEAM (SPOT)

The Office of the Inspector General reported in 2014, that one in three NH residents experienced an adverse event within 35 days of admissions causing lasting or temporary harm. Thus, state departments of public health (DPH) were implored to invest in improving NH quality and safety. Using Civil Monetary Penalty funds, the Massachusetts DPH, developed the SPOT Initiative to innovatively provide NH teams with technical assistance and training to enhance their federally required Quality Assurance & Performance Improvement (QAPI) programs. Selection criteria included NH Compare 5-Star and MA scorecard ratings and geographic spread. To assess program effectiveness, the SPOT Team collected a range of data in each of the three SPOT years (e.g., QAPI assessments, leadership interviews and surveys, and training evaluations). Results demonstrated the success of the Initiative. Assessment data indicated an increase in QAPI readiness in each subsequent year overall and within of the each QAPI assessment domains (Design and Scope; Governance and Leadership; Feedback, Data Systems, and Monitoring/Systematic Analysis; Performance Improvement Projects and Systematic Analysis/Systemic Action). In Year 1, the overall data collected from the assessments demonstrated that 78% of the NHs that engaged with SPOT had “Not Started” or “Just Started” (1.8/5) implementation of the key QAPI measures. By Year 3, only 13% of NH teams rated themselves in these initial categories, whereas, 57% rated themselves as “Almost There” or “Doing Great” (3.92/5). Further, feedback from most SPOT NH teams was extremely positive as evidenced by high evaluation rankings following initiative learning sessions.

Psychiatric EMTALA Enforcement Has Gone Off the Rails: Comments on "Civil Monetary Penalties Resulting From Violations of EMTALA Involving Psychiatric Emergencies, 2002 to 2018".

Psychiatric EMTALA Enforcement Has Gone Off the Rails: Comments on "Civil Monetary Penalties Resulting From Violations of EMTALA Involving Psychiatric Emergencies, 2002 to 2018".

Civil Monetary Penalties Resulting From Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018.

The objective was to describe characteristics of civil monetary penalties levied by the Office of the Inspector General (OIG) related to violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies. Descriptions of EMTALA-related civil monetary penalty settlements from 2002 to 2018 were obtained from the OIG. Cases related to psychiatric emergencies were identified by inclusion of key words in settlement descriptions. Characteristics of settlements involving EMTALA violations related to psychiatric emergencies including date, amount, and nature of the allegation were described and compared with settlements not involving psychiatric emergencies. Of 230 civil monetary penalty settlements related to EMTALA during the study period, 44 (19%) were related to psychiatric emergencies. The average settlement for psychiatric-related cases was $85,488, compared with $32,004 for non-psychiatric-related cases (p<0.001). Five (83%) of the six largest settlements during the study period were related to cases involving psychiatric emergencies. The most commonly cited deficiencies for settlements involving psychiatric patients were failure to provide appropriate medical screening examination (84%) or stabilizing treatment (68%) or arrange appropriate transfer (30%). Failure to provide stabilizing treatment was more common among cases involving psychiatric emergencies (68% vs. 51%, p=0.041). Among psychiatric-related settlements, 18 (41%) occurred in CMS Region IV (Southeast) and nine (20%) in Region VII (Central). Nearly one in five civil monetary penalty settlements related to EMTALA violations involved psychiatric emergencies. Settlements related to psychiatric emergencies were more costly and more often associated with failure to stabilize than for nonpsychiatric emergencies. Administrators should evaluate and strengthen policies and procedures related to psychiatric screening examinations, stabilizing care of psychiatric patients boarding in EDs, and transfer policies. Recent large, notable settlements related to EMTALA violations suggest that there is considerable room to improve access to and quality of care for patients with psychiatric emergencies.