A report publicly released Monday by the Government Accountability Office contains a to-do list for the Centers for Medicare & Medicaid Services related to state reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities. Some federal lawmakers and consumer advocates, however, say they will push for changes in assisted living because of the report’s findings.

The GAO, at the request of a bipartisan group of four senators, surveyed all state Medicaid agencies (including Washington, DC) for the report, titled “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed.” Kentucky, Louisiana and West Virginia said they do not pay for home- and community-based services in assisted living communities via Medicaid waivers, so the report does not include data from them.

See McKnight’s Senior Living’s exclusive interview with the report’s author here: 

“Report is ‘new territory,’ GAO director says.”

State Medicaid agencies spent more than $10 billion in federal and state funds on assisted living services in 2014, according to the watchdog organization. Those programs served more than 330,000 beneficiaries.

The senators had requested the study in part “to understand federal and state spending and oversight of care,” they wrote in a 2015 letter, but the GAO found that the facts sometimes were difficult to ascertain.

The GAO, for instance, found 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.

The investigators recommended that CMS Administrator Seema Verma provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities. Additionally, the GAO recommended that Verma establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents. And third, the office said Verma should ensure that all states submit annual reports for HCBS waivers on time as required.

The Department of Health and Human Services agreed with two of the three recommendations, according to the report, but “did not explicitly agree or disagree with our third recommendation to require all states to report information on critical incidents to CMS annually.”

Lilly Hummel, JD, MPA, senior director of policy and program integrity at the National Center for Assisted Living, told McKnight’s Senior Living that assisted living operators in some states most directly may be affected by the report when their states seek to implement new reporting requirements related to the recommendations.

“In some states, the monitoring system and the critical incident management reporting system meet CMS requirements, and I actually wouldn’t anticipate any changes. The state may already have robust monitoring processes in place,” she said. “In other states, it could be that CMS … will put out more guidance to states or states will in some way modify their critical incident reporting system … so there may be new reporting requirements for assisted living.”

Overall, however, Hummel said, “The recommendations have much stronger implications for the Medicaid state offices than for assisted living providers directly, because the recommendations are all aimed squarely at the guidance that CMS needs to be issuing to states — what data the states should be collecting and then reporting back to CMS. So the evaluation and the findings really focus on the CMS oversight process and the reporting process. At this point, I’m not anticipating, just looking at these findings, broadscale changes for assisted living.”

NCAL, she added, “support[s] efforts to report any incidents of abuse, neglect or exploitation. So whether it’s with CMS, the Hill, other provider groups or consumer groups, we look forward to any collaboration to ensure that there is appropriate reporting.”

More comments

Argentum Chief Operating Officer Maribeth Bersani:

“Argentum is supportive of the GAO recommendations to ensure CMS has the information necessary for adequate oversight of Medicaid beneficiaries residing in assisted living communities. We look forward to working with the Senate, CMS and other stakeholders to implement these recommendations.”

LeadingAge Director of Residential Communities Steve Maag:

“We support the GAO’s efforts to improve regulatory oversight between CMS and state Medicaid offices, and to step up information gathering efforts in order to ensure accountability.”

National Center for Assisted Living Executive Director Scott Tittle:

“NCAL appreciates the diligent work of the Government Accountability Office to help Congress better understand Medicaid in assisted living. All Medicaid recipients deserve the utmost care, and the vast majority of assisted living providers who participate in the program are providing it. We agree that safeguards are necessary to ensure high-quality care, and that with better data from the states, we can better understand Medicaid’s impact. NCAL and our state affiliates stand ready to work with policymakers at the national and local levels on strategies that strengthen the gathering of information on home- and community-based services, including those in provided in assisted living communities.”

Leaders at Argentum and LeadingAge also told McKnight’s Senior Living that they support the GAO’s work and value adequate oversight to ensure quality resident care in assisted living. (See the accompanying box, “More comments.”)

And although Hummel pointed out that the report doesn’t address potential changes in the overall operation of Medicaid or in the licensing of assisted living communities, some lawmakers and consumer advocates suggested Monday that they would be pushing for changes that more directly could affect providers.

“I plan to pursue legislation to address these groundbreaking findings,” Sen. Elizabeth Warren (D-MA), one of the four senators who had requested the report in 2015, said in a statement. The report, she said, “finds that thousands of seniors face serious health and safety risks in their assisted living facilities.”

Another requester, Sen. Susan Collins (R-ME), chair of the Senate Special Committee on Aging, said that “the GAO uncovered a number of troubling issues at some assisted living communities” and said she would “continue to work with my colleagues to support policies that improve the well-being of seniors who receive care at these facilities.”

Sen. Claire McCaskill (D-MO), who was ranking member of the Senate Aging Committee when she requested the analysis with her colleagues, echoed Collins’ remarks, saying that the report “shows a troubling breakdown” of care and safety in assisted living. “I’m looking forward to working with my colleagues on both sides of the aisle to turn our deep frustration at these findings into action, to better protect our seniors and ensure they’re getting the best care possible,” she added.

And Sen. Orrin Hatch (R-UT) indicated that more federal efforts were planned, saying, “Today’s report underscores the importance of improved reporting at assisted living facilities and starts the conversation on how we can make it better.”

Consumer advocates offered ideas about how to “make it better,” too.

“The oversight of the assisted living industry at the state level has failed to protect residents,” the Long Term Care Community Coalition and the Center for Medicare Advocacy said in a joint press release.

The organizations said their “near-term recommendations” for the federal government include that state and federal websites similar to Nursing Home Compare be developed for assisted living communities, with validated information on staffing, inspection results, complaints and critical incidents. The two organizations also recommend that the federal government “take immediate steps to protect assisted living residents by enacting sensible standards to ensure safety and dignity.”

The GAO’s report, Brian Lee, executive director of Families for Better Care, told McKnight’s Senior Living, “is 100% confirmation of the one thing we know about assisted living facility quality, and that is there’s a whole lot we still don’t know about the quality of care being offered to our parents and grandparents as the alternative to a nursing home. Normalizing the reporting and publishing of facility deficiencies would certainly be a great first step to benefit consumers that is long overdue.”