OIG Fall 2025 Semiannual Report: New Compliance Pressures for Skilled Nursing Providers


The Fall 2025 Semiannual Report to Congress from the Office of Inspector General (OIG) offers more than a summary of enforcement activity; it provides a window into how healthcare oversight is evolving. While the report spans the full healthcare landscape, its themes carry meaningful implications for skilled nursing facilities (SNFs), particularly as regulators continue to scrutinize quality, documentation, and data integrity.

A Growing Enforcement Footprint

At a high level, the OIG reported approximately $19 billion in total monetary impact for fiscal year 2025, reflecting recoveries, cost savings, and identified overpayments. This reinforces both the scale and seriousness of federal oversight.

Just as important as the dollar amount is how enforcement is being carried out. The report highlights a continued shift toward:

  • Data analytics to identify outliers
  • Cross-agency collaboration
  • Proactive identification of risk areas

For SNFs, this means oversight is no longer solely reactive. It is increasingly predictive and data-driven.

 

Quality of Care Is No Longer Just a Survey Issue

The report and related OIG enforcement activity continue to highlight persistent concerns in nursing homes, including:

  • Staffing shortages
  • Infection control deficiencies
  • Failures to meet basic care standards
  • Gaps in employee background checks

While these issues are familiar, the implications are evolving. When these deficiencies result in harm or when providers bill for services that do not meet required standards, they may escalate beyond survey citations into enforcement actions.

Key Shift:

  • Quality Concerns → Regulatory Citations
  • Quality Failures → Potential Fraud & Enforcement Exposure

This reframes quality as not just a clinical priority, but a compliance and financial risk.

 

 

Data Accuracy & Fall Reporting Concerns

A separate OIG report released during the same period found that 43% of falls with major injury were not reported in required resident assessments. While this finding is not from the Semiannual Report itself, it reflects a broader concern about the reliability of reported data.

For SNFs, this raises important questions about:

  • Accuracy of Minimum Data Set (MDS) reporting
  • Alignment between internal incident logs and submitted data
  • Whether reported outcomes reflect actual clinical events

Facilities with unusually low rates of adverse events may not appear high-performing. Instead, they may instead appear inconsistent or inaccurate when compared to other data sources.

 

Documentation & Payment Integrity Expectations

Across healthcare programs, the OIG continues to identify improper payments tied to insufficient or unsupported documentation. While much of the focus is on Medicare Advantage, the expectation applies broadly.

For SNFs, this reinforces a fundamental principle:

  • If it is not documented, it is not defensible

Areas that warrant particular attention include:

  • Skilled need justification
  • Therapy services and intensity
  • PDPM drivers and coding accuracy
  • Hospitalization and rehospitalization documentation

As analytics become more advanced, billing patterns that deviate from peers or that lack supporting documentation are more likely to be flagged.

 

Workforce Compliance Is a Risk Area

The OIG’s identification of failures in background checks and registry screenings signals that workforce compliance is under increasing scrutiny.

This elevates HR processes into the compliance spotlight. SNFs should ensure:

  • Background checks are completed prior to hire
  • Abuse and neglect registries are consistently queried
  • Documentation is complete and auditable

Inconsistent hiring practices are no longer just operational gaps; they are potential compliance vulnerabilities.

 

Growth Attracts Scrutiny

The report also highlights areas of rapid spending growth across healthcare, reinforcing a consistent OIG pattern: high-growth areas attract attention.

While not SNF-specific, the implication is clear. Providers should closely monitor trends such as:

  • Therapy utilization patterns
  • Length of stay variations
  • High-acuity coding categories
  • New or expanding service lines

Any significant deviation from industry norms should be understood, explainable, and documented.

 

The Bigger Shift: From Reactive to Predictive Oversight

Taken together, the Fall 2025 report reflects a broader transformation in how oversight is conducted.

Then:

 Now:

Surveys

Data Analytics

Complaints

Pattern Recognition
Retrospective Audits

Outlier Identification

 

Facilities may face scrutiny not because of a specific event, but because their data suggests risk.

 

 

What SNF Leaders Should Do Now

To align with this evolving environment, providers should focus on:

  • Validating Data Accuracy
    • Ensure MDS, incident reporting, and documentation align
  • Strengthening Internal Audits
    • Focus on falls, therapy utilization, and coding
  • Aligning Documentation with Billing
    • Every billed service should be clearly supported
  • Auditing HR Compliance
    • Apply the same rigor as clinical reviews
  • Monitoring Internal KPIs
    • Identify and investigate outliers early

 

Your Power Points

The Office of Inspector General is not just identifying problems; it is signaling how providers will be evaluated moving forward.

For SNFs, success will depend on the ability to ensure that all of the items below are consistently aligned and defensible.

Care is Delivered → Care is Documented → Care is Reported → Care is Billed  

Today, the question isn’t simply whether care occurred. It’s whether you can prove it in a way that stands up to scrutiny.

 

 

Written By:

Sheena Mattingly, M.S. CCC-SLP, RAC-CT  |  Executive Vice President of Quality & Compliance

About Sheena:

Sheena Mattingly is a Speech Language Pathologist and the Executive Vice President of Quality and Compliance for Healthcare Therapy Services, Inc. Sheena has a passion for advocacy and is the Chair of the Advion Compliance Committee, addressing critical and emerging topics including: policy development, corporate compliance strategy, artificial intelligence in healthcare, and denials management. She is active in her advocacy role for post-acute care providers by meeting with legislators on Capitol Hill to discuss issues that directly impact providers, clinicians, and patient care. Sheena serves as a member of the Advion Data Compliance Committee, which allows her to present data findings to CMS that ultimately shape fair and sustainable payment methods.

5 Million Steps Forward — One Clear Direction: Better Outcomes.


HTS was thrilled to welcome the OneStep team onsite to connect with our operations and therapy teams at Providence Health Care!
During the visit, HTS was honored with a special award recognizing 5,000,000 recorded measurements across our organization — a milestone that reflects our therapists’ commitment to data-driven care and better patient outcomes.

Through our partnership, HTS has invested in bringing OneStep technology to every partner location. Using AI and smartphone-based innovation, OneStep enables clinicians to assess and train across 33 gait and balance measures.

“OneStep has been a game-changer for our patients and residents. It’s increased awareness, helped prevent falls, and made people more invested in their balance health.”
Jennifer Collins, Executive VP of Operations
Our partnership with OneStep goes beyond implementation. HTS actively pilots and tests new features alongside the OneStep team — helping shape the future of digital gait analysis and mobility measurement in real-world clinical settings. By collaborating with innovators like OneStep, we’re proud to help lead the way in bringing cutting-edge technology into post-acute rehabilitation.
Thank you to the OneStep team for your incredible partnership — and to our therapists who continue to embrace innovation and advance the standard of rehabilitation care. We’re excited for what’s ahead! 🙌

Spring Into Energy

 

It’s Spring! The sun is out and the days are longer, making it the perfect time to move a little more. After months of winter, many of us feel slower or low on energy. Small daily habits can help you feel stronger, steadier, and more lively.

 

5 Energy Boost Tips

 

  1. Move Daily: Any movement, such as walking, stretching, or household chores, can help your body feel more awake and energized. Try to move a little each day.

 

  1. Pace Yourself: Break chores or daily tasks into small steps and take short rests in between. This helps keep your energy steady and prevents fatigue.

 

  1. Fuel Your Body: Choose protein-rich snacks like yogurt, cheese, or nuts, and sip water throughout the day. Staying nourished and hydrated helps keep your energy steady.

 

  1. Get Sunlight: Spend a few minutes outside or by a sunny window. Sunlight helps wake up your body, lift your mood, and support energy for the day.

 

  1. Stay Social: Spend time with friends, call a family member, or join a group activity. Connecting with others can naturally lift your energy and lift your spirits.

 

How Therapy Can Help

Talk with your doctor to see if therapy could help you stay active and confident. Physical therapy improves strength and balance. Occupational therapy makes daily tasks easier and safer. Speech therapy supports memory and communication. Together, therapy can help you enjoy your favorite activities with more energy.

HTS Advocacy in Action: Major Wins in 2025!


In 2025, HTS played a pivotal role in ADVION’s national advocacy initiatives, with Sheena Mattingly, EVP of Quality & Compliance, serving as HTS’s primary representative. Through her leadership, HTS brought real-world insight to national policy discussions, directly impacting long-term care and therapy services.

 

Key ADVION Advocacy Wins in 2025

Through ADVION, national advocacy led to meaningful improvements for post-acute and long-term care providers:

  • Provider Relief: ADVION successfully advocated for a 5% increase to the 2026 conversion factor of the physician fee schedule, supporting financial stability for post-acute and long-term care providers.
  • Telehealth: ADVION secured 3 different short-term extensions of telehealth authority, ensuring continued access for patients and therapy services.
  • (RTM) & Telehealth: CMS finalized important changes, reducing the RTM reporting window from 16 days to 2–15 days and made all provisional therapy codes permanent on the telehealth list.
  • Prior Authorization Relief: UnitedHealthcare now allows 6 therapy visits (PT, OT, SLP) in a beneficiary’s initial plan of care without a clinical review, reducing administrative burden and improving patient access.

 

HTS Leadership in ADVION

Sheena Mattingly served in multiple leadership roles within ADVION, driving HTS’s influence in national advocacy:

  • Member, Data Advocacy Committee: Actively participated in national data advocacy initiatives with the goal of presenting data-driven recommendations to CMS that support the greater good of the long-term care (LTC) community. Contributed clinical, compliance, and operational insight to ensure advocacy efforts reflect real-world provider challenges.
  • Chair, Compliance Committee: Led discussions focused on regulatory interpretation, risk mitigation, and compliance best practices, while supporting guidance and education on evolving regulations and enforcement trends.
  • Mentor, Emerging Leaders Program: Served for the third consecutive year, providing leadership development, professional guidance, and industry perspective to rising healthcare leaders.

 

Grassroots Advocacy Efforts

  • Protect Medicaid: Advocates sent over 1,500 letters to Members of Congress opposing reductions to Medicaid funding in the One Big Beautiful Bill Act.
  • Telehealth & 2025 Physician Fee Schedule: Advocates sent 17,165 letters urging Congress to extend and restore the telehealth authority and provide relief from PFS cuts.

 

As we reflect on 2025, we are proud of the progress made through our partnership with ADVION and the unwavering dedication of our team. Together, we have strengthened long-term care policies, reduced barriers for therapy services, and supported providers in delivering high-quality care.

HTS remains committed to advancing this work, bringing practical, frontline insight to advocacy initiatives and helping ensure that policies reflect the needs of both providers and patients. We look forward to continuing our collaboration with ADVION and the broader long-term care community to build on these successes and drive even greater impact.

Indiana Medicaid Rates Are Shifting, and PDPM Is Just Around the Corner


Change is underway for nursing facility Medicaid reimbursement in Indiana, and while some updates take effect sooner than others, all of them are worth providers’ attention now.

An official announcement has been released outlining changes to Nursing Facility Medicaid rates effective State Fiscal Year (SFY) 2027, along with continued planning for the future implementation of the Patient Driven Payment Model (PDPM). The full announcement is posted on the Myers and Stauffer website.

 

What’s Changing for SFY 2027 Medicaid Rates

For SFY 2027, Indiana will adjust the Minimum Data Set (MDS) reporting period used to calculate Medicaid Case Mix Indexes (CMIs). Instead of relying on more recent assessments, Medicaid CMIs for SFY 2027 will be based on MDS data reported during SFY 2026. Specifically, assessments from September 1, 2024, through August 31, 2025, will be used, with data weighted by Medicaid days.

The resulting Medicaid CMI will be applied to both semi-annual rate periods in SFY 2027. Rates effective July 1, 2026, will reflect this calculated CMI, including any revisions resulting from MDS reviews for that reporting period. That same CMI will also apply to the January 1, 2027, rate period, again incorporating any changes identified through the review process.

 

PDPM: Not Here Yet, But Getting Closer

While Medicaid rate changes are imminent, PDPM implementation remains a future event. Indiana continues to target SFY 2028, effective July 1, 2027, for adopting PDPM for nursing facility rate setting. Although discussions are still ongoing, the announcement provides insight into the structure Indiana plans to use when PDPM is implemented.

Indiana’s PDPM approach will rely on the PDPM Nursing Component and will use Medicare PDPM Nursing Component CMI weights that were in effect on October 1, 2023. The low-needs resident classification will be eliminated under PDPM, and Interim Payment Assessments (IPAs) will be considered valid for resident classification and assignment of days. These design choices signal a meaningful shift from the current case-mix methodology and underscore the importance of accurate and timely MDS reporting.

 

Preliminary PDPM Reports: A Practice Run with Purpose

Providers have already begun receiving Preliminary PDPM Time-Weighted CMI Resident Roster Reports. While these reports are not being used for reimbursement at this time, they serve as an early look at how resident classification and case mix may appear under PDPM.

The first set of preliminary reports, covering Q4 2025, was posted on December 10, 2025, through the Indiana MDS Web Portal. Providers are encouraged to review these reports carefully, paying close attention to assessment sequencing, submission accuracy, classification logic, and coding. Identifying and correcting issues now will help facilities avoid complications once PDPM becomes operational.

 

Your Power Points

Although PDPM reimbursement is still on the horizon, the direction is clear. MDS accuracy today will directly influence Medicaid rates tomorrow. Facilities that actively monitor preliminary reports, address data issues, and stay informed as guidance evolves will be better positioned for a smoother transition.

Additional communication is expected as PDPM implementation approaches, and providers should continue monitoring updates from Myers and Stauffer.

 

Questions or Need Clarification?

Providers with questions regarding SFY 2027 Medicaid rates or PDPM reporting should contact Myers and Stauffer directly at 317-816-4122 or via email at INHelpDesk@mslc.com or LTCdept@mslc.com. The full announcement is available on the Myers and Stauffer website for reference.

 

Written By: Sheena Mattingly, EVP of Quality & Compliance

Shutdown Rules, Survey Reality: What Providers Need to Know Now

A federal government shutdown creates uncertainty across many areas of healthcare oversight, and survey activity is no exception. To address this, the Centers for Medicare & Medicaid Services (CMS) has re-issued updated guidance clarifying how Survey & Certification activities must be handled during a partial, temporary federal government shutdown.

The revised guidance, QSO-26-01-ALL REVISED, was issued to State Survey Agencies and confirms that CMS’ long-standing contingency framework remains in place. While the memo is updated, the core expectations for survey operations during a shutdown have not changed.

The full QSO can be accessed here.

 

CMS’ Core Position During a Shutdown

CMS reaffirmed that during a federal shutdown, Survey & Certification work is legally limited to activities necessary to protect resident health and safety. In practical terms, this means that routine oversight and administrative survey functions are paused unless there is a direct connection to preventing harm or addressing serious safety risks.

This limitation is not discretionary, it is driven by federal law governing agency operations during a lapse in appropriations.

 

Survey Activities That Are Paused

Under the updated QSO, CMS confirmed that the following activities will not continue during a shutdown:

  • Standard (annual) recertification surveys
  • Initial Medicare certification surveys
  • Complaint investigations that are triaged at non-harm levels
  • Most revisit surveys
  • Informal Dispute Resolutions (IDRs)
  • Routine certification processing and related actions

For providers, this means that many expected survey-related timelines may temporarily stall, even though facilities remain responsible for ongoing compliance.

 

Survey Activities That May Still Occur

CMS also clarified that some survey activity may continue when it is directly tied to resident safety or Medicare participation. These include:

  • Complaint investigations involving Immediate Jeopardy or actual harm
  • Actions required to address serious life-safety concerns
  • Revisits conducted only when necessary to prevent mandatory termination from Medicare participation

These activities are narrowly focused and are intended to ensure that critical risks to residents are addressed, even during a shutdown.

 

What the Re-Issued Guidance Means for Providers

Although CMS has updated and re-issued the QSO, the agency emphasized that the same shutdown framework remains in effect. The revised memo does not introduce new survey categories or expectations; instead, it reinforces existing policy and provides confirmation that prior guidance still applies.

Providers should not interpret a pause in routine survey activity as a relaxation of compliance obligations. Standards remain in effect, and survey activity may resume once the shutdown ends.

 

Ongoing Monitoring

HTS will continue to monitor CMS communications related to the federal shutdown and Survey & Certification activity. HTS Partners will be notified promptly if CMS issues additional clarification or changes to this guidance.

 

Power Points

During a federal government shutdown, survey activity becomes narrowly focused on resident health, safety, and Medicare participation. CMS’ updated QSO-26-01-ALL REVISED confirms that while many routine surveys pause, enforcement tied to serious risk continues.


Written By: Sheena Mattingly, EVP of Quality & Compliance

Why Your Body Feels Different After Winter

As winter comes to an end, you may notice that your body does not feel quite like it used to. Your joints may feel stiff, your muscles might seem weaker, or you may feel a little unsteady walking across the room. You are not imagining it. Many adults notice these changes after spending more time indoors during the winter months.

When we move less, even for a short time, our bodies can start to change. Muscles that are not used as often can lose strength faster than expected. Joints may feel stiff when they are not moved regularly. Balance can also be affected as the small muscles and reflexes that help keep you steady become weaker. Paying attention to these changes early can help prevent bigger problems later on.

 

You may benefit from therapy if you have noticed any of the following:

  • Increased Stiffness in Your Joints
  • Walking Slowly
  • New Aches or Soreness
  • Poor Balance and Falls
  • Trouble Climbing Stairs
  • Needing More Effort to Get Up From a Chair
  • Feeling More Tired During Everyday Activities
  • Difficulty Getting Back to Activities You Enjoy

 

How Therapy Can Help:

Physical and occupational therapy focus on helping you move better. This can mean walking with more confidence, getting dressed more easily, or safely returning to the activities that matter most to you.

If any of these signs sound familiar, talk with your doctor about whether therapy may be right for you. Our therapy team is here to help you feel stronger, move more comfortably, and stay independent.

Beyond the Chart: How CMS Is Validating SNF MDS Data in 2026

CMS has launched a new SNF Data Validation Process to verify the accuracy of quality measure data derived from the Minimum Data Set (MDS) used in both the Skilled Nursing Facility Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program. This is not the typical admission-to-discharge audit many providers are used to. Instead, it targets specific MDS assessment timeframes tied to quality measures and clinical documentation.

 

How This Differs from Traditional Audits

  • The data validation process does not review full admissions through discharge charts.
  • CMS selects a small number of MDS assessments per facility (up to 10) to validate specific elements that drive quality measures (e.g., functional status, pressure injuries, falls, infections).
  • The focus is on accuracy of MDS coding, and documentation must support the specific date ranges identified in the selection notification.

 

Selection and Notification

  • CMS randomly selects eligible SNFs (those that submitted at least one MDS assessment in the relevant timeframe) on a rolling basis throughout the year. SNFs can only be selected once within a fiscal year.
  • Notifications are posted in the iQIES MDS 3.0 Provider Preview Reports folder and will be clearly labeled (e.g., Initial Selection Notification, Second Selection Notification). Some providers have already received notification.
  • Providers must actively monitor their iQIES folders; these notices are not broadly emailed.

 

Documentation Submission: Key Rules

Required Format

  • All requested documentation must be submitted in PDF format.
  • No other formats will be accepted.

 

Exact Naming Convention

CMS requires a strict naming convention for each PDF submission: CCN_ValidationID.pdf

 

Where:

  • CCN = the six-digit CMS Certification Number assigned to the facility.
  • Validation ID = the unique identifier CMS uses for that specific sampled assessment.

Example: A facility with CCN 111111 and a sample ID 1234 should submit: 111111_1234.pdf

This helps CMS track files precisely and reduces processing delays.

 

Timeframe for Records

  • Only include documentation within the date range specified in the selection notice.
  • Do not include unrelated records outside the targeted assessment window.

 

What Not to Include

To protect resident privacy and meet CMS guidelines:
❌ No Social Security Numbers
❌ No resident face sheets or unnecessary identifiers
❌ No documentation outside the requested date range

CMS explicitly states that submitted files should not contain resident SSNs or face sheets, and should be limited to what is necessary to support the MDS data elements under review.

 

Security and Submission Logistics

All files are stored in a secure CMS environment with encryption and access controls.

  • Requested medical records are uploaded through a secure CMS portal.
  • Providers receive automated email confirmations when files are uploaded successfully.
  • A second email confirms when all documents have been verified as submitted.

 

Deadlines and Compliance

  • Once selected, SNFs have 45 calendar days to submit all required documentation.
  • Failure to respond within this timeframe can result in noncompliance, potentially triggering a 2% reduction in Medicare Annual Payment Update for the applicable QRP/VBP year. Noncompliance is measured by response, not the results of the audit.

 

Your Power Points

  • This process is for data validation, not a full chart audit.
  • Documentation must be PDF only with a strict naming convention.
  • Only include records for the requested date ranges. Do not include extra files, SSNs, or face sheets.
  • Check iQIES regularly for selection notices and deadlines.

 

For more information: Skilled Nursing Facility Validation Program: Frequently Asked Questions

Being prepared now with processes for naming, compiling, and submitting MDS-related documentation will help you stay compliant, protect reimbursement, and support accurate quality reporting.

 

Written By: Sheena Mattingly, EVP of Quality & Compliance

Therapy Myth-Busters

Many older adults hold misconceptions about therapy that can prevent them from getting the care they need. Let’s bust some common myths and see how therapy can support your health, independence, and quality of life.

 

Myth #1: “I’m too frail for therapy.”

Reality: Frailty isn’t a reason to skip therapy—it’s a reason to do it! Gentle, guided exercises can boost your energy, mobility, and confidence.

 

Myth #2: “Falling is just part of getting older.”

Reality: Falls aren’t normal. Therapy improves balance and safety while lowering your risk of falling.

 

Myth #3: “Speech therapy is only for stroke patients.”

Reality: Speech therapy supports safe swallowing, clear speech, memory, and overall communication for many conditions, not just strokes.

 

Myth #4: “I don’t need therapy. I can still get around on my own.”

Reality: Therapy helps you maintain independence and stay active. Even if you move well now, it can prevent future decline and reduce fall risk.

 

Myth #5: “I’ll never regain what I’ve lost.”

Reality: Progress is possible. Therapy supports recovery at your pace, helping you regain confidence and function.

 

How Therapy Can Help You

Our on-site therapy department offers personalized programs in physical, occupational and speech therapy. Ask your doctor for a referral and discover how therapy can help you stay strong, safe and independent.

Using CPT 97530 Correctly: The “-ing” Code Misunderstood

In skilled nursing facilities, CPT 97530 (Therapeutic Activities) is one of the most functionally rich, clinically powerful interventions therapists can provide. Yet despite its value, it is often misunderstood, misapplied, and underutilized.

Many clinicians refer to 97530 as the “–ing code” because it involves engaging patients in doing meaningful, functional activities. However, a common misconception persists: that any activity or education falls under 97530. In reality, education alone does not meet the criteria for 97530, and selecting it simply because teaching occurred is a coding error. 

What 97530 Actually Is

The CPT definition of 97530 is “therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.”

This includes clinician-directed, functional task-oriented activities such as:

  • Lifting
  • Carrying
  • Handling
  • Reaching
  • Transferring
  • Transporting

It is not just performing an activity, it is the therapist’s analysis, grading, cueing, environmental setup, and clinical problem-solving during the functional task that make the service skilled.

 

What 97530 Is Not

97530 is Not:

  • Verbal instruction without active performance
  • Watching a demonstration
  • A passive experience
  • Simply “any activity the patient completes”

If you are educating, you bill the most appropriate code for the service being taught (e.g., 97535 for self-care training). Education paired with functional performance may fall under 97530, but education by itself does not.

 

Are We Underutilizing 97530?

There is a strong possibility that 97530 is used less than it should be. This is not because clinicians are doing less functional retraining, but because they default to other codes when they’re actually providing therapeutic activities.

For example, if the patient is actively practicing sit-to-stand transfers with graded cueing to improve functional mobility, that activity is almost certainly therapeutic activities, even if the therapist is also instructing them.

 

Accurate Use of 97530 is About Ensuring:

  • The code matches the intervention
  • Documentation reflects the skilled service performed
  • The patient receives functional, meaningful therapy aligned with SNF goals

 

Coding Tips for Everyday Compliance:

  • Understand CPT coding definitions
  • Code only what is actually performed
  • Report only skilled minutes
  • Ensure documentation supports each code billed
  • Follow payer and regulatory rules
  • Remember: each minute billed must reflect skill, intent, and necessity

 

Clinicians are the heart of the compliance team. Coding is not just billing. It’s a clinical integrity practice. Accurate, intentional coding protects patients, clinicians, and the SNF.

 

Written By: Sheena Mattingly, EVP of Quality & Compliance