word cloud gao assisted living medicaid

The Centers for Medicare & Medicaid Services still has not taken action on a recommendation made by the US Government Accountability Office in a January 2018 report on assisted living, the GAO said in a report issued last week.

In a footnote in a report issued Thursday about Medicaid managed care, the independent, nonpartisan agency noted that “In 2018, we recommended that CMS establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents. The agency agreed with the recommendation, but had not taken action to address it as of January 2024.”

The 2018 recommendation referred to was contained in a report titled “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed,” which included a to-do list for CMS related to state reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities.

The 2018 report stated that, for various reasons, 26 of the 48 state Medicaid agencies studied could not report the number of “critical incidents” — such as abuse, neglect or exploitation — that occurred in the assisted living communities located in their states. Additionally, states had varying definitions of what they considered to be critical incidents; all states included physical, emotional and sexual abuse, but seven did not include medication errors, and three did not include unexplained death. Also, although 34 state Medicaid agencies made information on critical incidents available to the public in some way, 14 did not.

At the time, the investigators recommended then that CMS:

  1. Provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities.
  2. Establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living communities, where critical incidents occurred.
  3. Ensure that all states submit annual reports for home- and community-based services waivers on time, as required.

The second recommendation remains unaddressed, according to the GAO. “HHS did not explicitly agree or disagree” with that recommendation, the GAO said in 2018, using wording that differs from its recent report.

The GAO has called out CMS for not addressing the recommendation in reports about the GAO’s “priority open recommendations” issued every year since release of the 2018 report about assisted living: 2019, 2020, 2021, 2022 and 2023.

In its 2023 report, the GAO wrote: “As of January 2023, CMS provided states with technical assistance on critical incident reporting, including providing training and an optional incident reporting template. CMS reported that the agency would have to explore whether establishing standard, annual reporting requirements would require rulemaking. To fully implement this recommendation, CMS needs to establish standard Medicaid reporting requirements for all states to report critical incidents annually. Implementing this recommendation would provide evidence that an effective system is in place, provide information on the extent beneficiaries are subject to actual or potential harm, and allow for tracking trends over time.”

Strengthening Medicaid program integrity is one of four high-risk areas centered directly on HHS and under which this recommendation falls, the GAO said.

Comes up at Aging Committee hearing

Beyond the GAO, the 2018 report and its unaddressed recommendation garnered attention in January when the Senate Special Committee on Aging held a hearing focused on assisted living in response to articles unflattering to the industry published in The Washington Post and the New York Times and KFF Health News.

Sen. Elizabeth Warren (D-MA), a current member of the committee and one of four committee members who had requested the 2018 report in part “to understand federal and state spending and oversight of care,” said: “We need to do more here. At a minimum, the Biden administration should require additional reporting on problems at assisted living facilities. In fact, that is a priority recommendation from the 2018 GAO report. While CMS is making progress on implementing this recommendation, they should finalize it quickly. This has gone on long enough without oversight. And Congress must look at ways to improve accountability, transparency and quality of care in assisted living facilities.”

Now, Sen. Bob Casey (D-PA), chair of the Aging Committee, and the six other Democratic committee members have asked for another GAO study, this one to look at how much federal money is spent on assisted living communities, the cost of assisted living services, and the transparency and availability of that information to consumers.