Medicaid:

Oversight of Institutions for the Mentally Retarded Should Be Strengthened

HEHS-96-131: Published: Sep 6, 1996. Publicly Released: Oct 7, 1996.

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Pursuant to a congressional request, GAO reviewed the role of the Health Care Financing Administration (HCFA), state agencies, and the Department of Justice (DOJ) in overseeing quality of care in intermediate care facilities for the mentally retarded (ICF/MR), focusing on: (1) deficient care practices occurring in large ICF/MR; (2) whether state agencies identify all serious deficiencies in these institutions; and (3) weaknesses in HCFA and state oversight of ICF/MR care.

GAO found that: (1) despite federal standards, HCFA and state agency oversight, and continuing Justice Department investigations, serious quality-of-care deficiencies continue to occur in some large public ICFs/MR; (2) insufficient staffing, lack of active treatment needed to enhance independence and prevent loss of functional ability, and deficient medical and psychiatric care are among those deficiencies that have been frequently cited; (3) in a few instances, these practices have led to serious harm to residents, including injury, illness, physical degeneration, and death; (4) states, which are the key players in ensuring that these institutions meet federal standards, do not always identify all serious deficiencies nor use sufficient enforcement actions to prevent the recurrence of deficient care; (5) direct federal surveys conducted by HCFA and Justice Department investigations have identified more numerous and more serious deficiencies in public institutions than have state surveys; (6) furthermore, even when serious deficiencies have been identified, state agencies' enforcement actions have not always been sufficient to ensure that these problems did not recur; (7) some institutions have been cited repeatedly for the same serious violations; (8) although HCFA has recently taken steps to improve the process for identifying serious deficiencies in these institutions and to more efficiently use limited federal and state resources, several oversight weaknesses remain; (9) moreover, state surveys may lack independence because states are responsible for surveying their own institutions; and (10) the effects of this potential conflict of interest raise concern given the decline in direct federal oversight of both the care in these facilities and the performance of state survey agencies.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: The agency has not been fully responsive to this recommendation. The agency did assess the effectiveness of its survey approach in identifying serious deficiencies, however, it has not examined the effectiveness of its survey approach in ensuring that problems are corrected and do not recur. Nationwide training of state agency surveyors on the use of the new survey was conducted, and the agency's analysis of survey data showed the process to be effective at identifying serious deficiencies in large public ICFs/MR. Increases occurred in the number of cited deficiencies, serious condition of participation violations, and facilities cited for placing residents in serious and immediate jeopardy. The results of this analysis were used to modify the agency's surveyor training curriculum. The agency has also established a federal oversight contract to monitor the performance of state survey agencies in ensuring that serious deficiencies are identified and corrected. In fiscal year 2003, the contractor will be preparing new surveyor training modules for those areas where it has identified weaknesses in state survey agency performance.

    Recommendation: To improve HCFA oversight of large public ICF/MR, the Administrator, HCFA, should assess the effectiveness of its new survey approach in ensuring that serious deficiencies at large public ICF/MR are identified and corrected.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Implemented

    Comments: HCFA instructed its regional offices to conduct federal surveys in 2 percent of all ICF/MR in fiscal year 1997, including at least one large public facility in each state. This effort was intended to bring the number of federal surveys back up to the 1990 level. The regional offices accompanied state surveyors on 42 surveys of large public facilities. HCFA's analysis of the resulting data showed that more deficiencies and more serious deficiencies are being cited both on federal surveys and on surveys of large public ICF/MR overall. The greatest increase in citation rates for serious deficiencies has been on surveys where a federal surveyor was present. Some regional offices have significantly increased their presence on surveys of large public institutions, with one region attempting to be present on 20 percent of all such surveys. HCFA intends to sustain this increased level of federal attention, and expects that regional offices will conduct at least one federal survey in a large public facility per year.

    Recommendation: To improve HCFA oversight of large public ICF/MR, the Administrator, HCFA, should take steps, such as enhanced monitoring of state survey agencies or direct inspection of institutions, to address the potential conflict of interest that occurs when states are both the operators and inspectors of ICF/MR.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  3. Status: Closed - Implemented

    Comments: HCFA requested and received legislative authority to implement a wider range of enforcement mechanisms for the ICF/MR program. The Balanced Budget Act of 1997 (Public Law 105-33) contained a provision to explicitly authorize alternative sanctions for non-compliant ICF/MR (H.R. 2015, Title IV, Subtitle H, Chapter 6, Sec. 4752). HCFA has developed guidance for states on implementing alternative sanctions. These new sanctions include: (1) a directed plan of correction in which state surveyors can specify the actions a deficient facility must take to come back into compliance; (2) directed in-service training where the surveyor can specify certain basic or remedial training that must be provided to facility staff; and (3) state monitoring where the state survey agency can place an independent observer in the facility to monitor the care provided and corrective actions taken.

    Recommendation: To improve HCFA oversight of large public ICF/MR, the Administrator, HCFA, should determine whether the application of a wider range of enforcement mechanisms would more effectively correct serious deficiencies and prevent their recurrence.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

 

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