Recommendation: To achieve a better understanding of the effect of certain Personal care services (PCS) services on beneficiaries and a more consistent administration of policies and procedures across PCS programs, the Acting Administrator of CMS should collect and analyze states' required information on the impact of the Participant-Directed Option and Community First Choice programs on the health and welfare of beneficiaries as well as the state quality measures for the Participant-Directed Option and Community First Choice programs.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: The Centers for Medicare & Medicaid Services (CMS) concurred with GAO's recommendation. On December 30, 2016, the agency issued guidance on the Community First Choice program to assist states in submitting information to CMS on the health and welfare of beneficiaries. In March 2019, CMS officials stated that the agency is currently developing the process for states to report this information to CMS. Agency officials also stated they are exploring the value of collecting this information for the Participant-Directed Option program given the limited number of states currently operating under this authority. In February 2020, CMS officials stated that the agency continues to develop policy related to this recommendation.

Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should resume data verification audits to routinely evaluate the quality of selected drinking water data on health-based and monitoring violations that the states provide to EPA. These audits should also evaluate the quality of data on the enforcement actions that states and other primacy agencies have taken to correct violations.

Agency: Environmental Protection Agency
Status: Open
Priority recommendation

Comments: As of July 2020 there has been no change in the status of this recommendation. EPA, as of September 2019, had not resumed data verification audits to routinely evaluate the quality of the data states provide to the agency. The Safe Drinking Water Information System (SDWIS) Prime and the Compliance Monitoring Data Portal (CMDP) will replace the data verification audits in the future. EPA has made SDWIS Prime available through incremental interim releases to state drinking water agencies for exploring and testing but does not expect to fully release it until mid-2020. However, as of August 2019, SDWIS Prime was unavailable while EPA awaited progress on the SDWIS Modernization Project plan. According to EPA, the CMDP will enable utilities and laboratories to report data electronically to primacy agencies with fewer errors and in a more efficient manner; but it is not clear when it will be fully operational. According to data provided by EPA in September 2019, 10 states were using CMDP to varying degrees. EPA information identified another 6 states that plan to transition to CMDP between September and December 2019, 2 states that plan to transition in 2020, and 12 others that may transition in the future. In the meantime, EPA indicated that the agency will complete nine file reviews in 2019 to verify data in agencies that do not currently use CMDP. EPA's actions may improve its ability to oversee states' implementation of the act and provide more complete and accurate information on compliance, but because EPA's systems to replace data verification audits are not yet fully in place, we are keeping this recommendation open.

Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should work with the states to establish a goal, or goals, for the completeness and accuracy of data on monitoring violations. In setting these goals, EPA may want to consider whether certain types of monitoring violations merit specific targets. For example, the agency may decide that a goal for the states to completely and accurately report when required monitoring was not done should differ from a goal for reporting when monitoring was done but not reported on time.

Agency: Environmental Protection Agency
Status: Open

Comments: As of July 2020 there has been no change in the status of this recommendation. EPA is developing the Safe Drinking Water Information System (SDWIS) Prime, with several efforts underway as of September 2019 as we noted under recommendation 1, but until it is fully operational, EPA will not be able to work with states to establish a national goal for the quality of monitoring violations. EPA noted in 2017 that it expected SDWIS Prime to enable the agency and primacy agencies to better understand the nature of system violations and consider developing goals for monitoring and reporting violations. However, according to EPA, SDWIS Prime will not be released until mid-2020. EPA indicated plans to modify the Annual Public Water System Supervision (PWSS) Program Review requirements but the agency states that it is dependent on approval by the Office of the Inspector General. Despite the ongoing delays to address the call in the recommendation for establishing new goals, we are keeping this recommendation open while EPA continues its efforts to implement SDWIS Prime.

Recommendation: To help states identify and address quality-of-care concerns among individuals with developmental disabilities receiving Medicaid HCBS waiver services, the Administrator of CMS should encourage states to (1) include death as a critical incident and conduct mortality reviews if they do not already do so and (2) broaden their mortality review processes if they already include death as a critical incident and conduct mortality reviews.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: As of August 2020, CMS had taken some steps to address this recommendation but additional actions are needed to fully implement it. In June 2018 CMS issued a Medicaid update to states explaining that CMS strongly encourages them to include unexpected deaths in their definition of reportable critical incidents. CMS also stated in the update that states should conduct a preliminary review of all beneficiary deaths and investigations should focus on those deaths determined to be unexpected. Further, CMS has shared with states best practices for state mortality reviews that include, for example, the use of an interdisciplinary review committee and taking actions to address identified quality of care problems. CMS also developed a webinar training (Incident Management 101) to help states improve their incident management systems for the Medicaid HCBS waiver. The webinar outlines the key elements of building a comprehensive incident management system (e.g., establishing a process for conducting investigations of incidents, tracking and trending incidents to help prevent and mitigate incidents from occurring) and reiterates CMS's expectation that states identify and address unexplained deaths on an ongoing basis in order to meet the waiver's health and welfare assurance. In late 2018, CMS planned to include in its revised waiver application questions to determine practices regarding states' review and evaluation of unexpected deaths. In September 2019, CMS officials notified us that it will provide an updated status report on this recommendation in November 2019. As of August 2020, CMS officials have not provided us information regarding its revised waiver application and technical guide. We will update the status of this recommendation when we receive this information.