GAO Report Warns that Assisted Living Quality Oversight Lacking: "National Scandal"

According to the Long Term Care Community Coalition (LTCCC) and the Center for Medicare Advocacy (CMA), "assisted living is viewed by seniors and their families as a desirable option for residential care when an individual wishes to avoid the institutional environment characteristic of a typical nursing home. While the assisted living industry has grown rapidly to meet this demand, little is known about the quality and safety provided to residents in these facilities." 

A newly released Report by the Government Accountability Office (GAO) warns that the Centers for Medicare & Medicaid Services (CMS) ability to oversee and regulate the quality of care provided to Medicaid beneficiaries in assisted living communities is severely compromised.  McKnights Senior Living reports that some federal lawmakers and consumer advocates are already pushing for changes in assisted living because of the report’s findings.

The GAO, at the request of a bipartisan group of  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.” The Senators sought “to understand federal and state spending and oversight of care, but as the title suggests, the GAO was unable to respond effectively to the Senators' request because facts were difficult to ascertain. 

State Medicaid agencies in 48 states that covered assisted living services reported spending more than $10 billion (federal and state) on assisted living services in 2014. These 48 states reported covering these services for more than 330,000 beneficiaries through more than 130 different programs. Most programs were operated under Medicaid waivers that allow states to target certain populations, limit enrollment, or restrict services to certain geographic areas.

With respect to oversight of their largest assisted living programs, state Medicaid agencies reported varied approaches to overseeing beneficiary health and welfare, particularly in how they monitored critical incidents involving beneficiaries receiving assisted living services. Although state Medicaid agencies are required to protect beneficiary health and welfare and operate systems to monitor for critical incidents—cases of potential or actual harm to beneficiaries such as abuse, neglect, or exploitation, the GAO found a lack of required monitoring and reporting:

• Twenty-six state Medicaid agencies could not report to GAO the number of critical incidents that occurred in assisted living facilities, citing reasons including the inability to track incidents by provider type (9 states), lack of a system to collect critical incidents (9 states), and lack of a system that could identify Medicaid beneficiaries (5 states).
• State Medicaid agencies varied in what types of critical incidents they monitored. All states identified physical, emotional, or sexual abuse as a critical incident. A number of states did not identify other incidents that may indicate potential harm or neglect such as medication errors (7 states) and unexplained death (3 states).
• State Medicaid agencies varied in whether they made information on critical incidents and other key information available to the public. Thirty-four states made critical incident information available to the public by phone, website, or in person, while another 14 states did not have such information available at all.

The report Highlights summarized:

Oversight of state monitoring of assisted living services by... CMS, an agency within the Department of Health and Human Services (HHS), is limited by gaps in state reporting. States are required to annually report to CMS information on deficiencies affecting beneficiary health and welfare for the most common program used to provide assisted living services. However, states have latitude in what they consider a deficiency. States also must describe their systems for monitoring critical incidents, but CMS does not require states to annually report data from their systems. Under federal internal control standards, agencies should have processes to identify information needed to achieve objectives and address risk. Without clear guidance on reportable deficiencies and no requirement to report critical incidents, CMS may be unaware of problems. For example, CMS found, after an in-depth review in one selected state seeking to renew its program, that the state lacked an effective system for assuring beneficiary health and welfare, including reporting insufficient information on the number of unexpected or suspicious beneficiary deaths. The state had not reported any deficiencies in annual reports submitted to CMS in 5 prior years (emphasis added).

The GAO recommended that CMS provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities. Additionally, the GAO recommended that CMS establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents. Finally, GAO recommended that CMS ensure that all states submit annual reports for Home and Community Based Services (HCBS) waivers on time as required.

HHS agreed with two of the three recommendations, according to the report, but “did not explicitly agree or disagree with [GAO's] third recommendation to require all states to report information on critical incidents to CMS annually.”

“The oversight of the assisted living industry at the state level has failed to protect residents,” the LTCCC and the CMA said in a joint press release.

“This report verifies reports from families over the years indicating that, too often, the “promise” of assisted living is unfulfilled for seniors,” said Richard Mollot, executive director of LTCCC, "Medicare beneficiaries deserve good care and dignity no matter where they access care and services.” 

“State oversight has failed assisted living residents and the taxpayers who help pay for their care,” said Toby S. Edelman, Senior Policy Attorney, CMA; “This national scandal cannot be swept under the rug any longer.”

LTCCC and CMA 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.”

Assisted Living and other community based care programs must be well administered, and  able to produce and demonstrate positive health outcomes for seniors before they will be reliable Aging in Place strategies.