Department of Health and Human Services

OFFICE OF
INSPECTOR GENERAL

FOUR STATES DID NOT COMPLY

WITH FEDERAL WAIVER AND STATE
REQUIREMENTS
IN OVERSEEING
ADULT DAY CARE CENTERS AND
FOSTER CARE HOMES

Inquiries about this report may be addressed to the Office of Public Affairs at
[email protected].

Daniel R. Levinson
Inspector General

May 2019
A-05-19-00005
 Office of Inspector General
https://oig.hhs.gov

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the
health and welfare of beneficiaries served by those programs. This statutory mission is carried out
through a nation-wide network of audits, investigations, and inspections conducted by the following
operating components:

Office of Audit Services

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with
its own audit resources or by overseeing audit work done by others. Audits examine the performance of
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intended to provide independent assessments of HHS programs and operations. These assessments help
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress,
and the public with timely, useful, and reliable information on significant issues. These evaluations focus
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of
departmental programs. To promote impact, OEI reports also present practical recommendations for
improving program operations.

Office of Investigations
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and
misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50
States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department
of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI
often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General

The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering
advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal
operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In
connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides
other guidance to the healthcare industry concerning the anti-kickback statute and other OIG enforcement
authorities.
 Notices

THIS REPORT IS AVAILABLE TO THE PUBLIC

at https://oig.hhs.gov

Section 8M of the Inspector General Act, 5 U.S.C. App., requires

that OIG post its publicly available reports on the OIG website.

OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS

The designation of financial or management practices as

questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: May 2019
Report No. A-05-19-00005

Why OIG Did This Review Four States Did Not Comply With Federal Waiver
Prior Office of Inspector General
reviews of State agencies that serve and State Requirements in Overseeing Adult Day
vulnerable adults who receive Care Centers and Foster Care Homes
services through waiver programs
have identified multiple health and
safety issues that put vulnerable
What OIG Found
adults at risk. These reviews included The four States did not comply with Federal waiver and State requirements in
adult day care services received at overseeing centers and homes. Our reviews found violations of health and
adult day service centers (centers) in safety and administrative requirements at 96 of the 100 centers and homes
Minnesota, Illinois, Wisconsin, and reviewed. Specifically, we found 1,141 instances of noncompliance with
Mississippi and services received at health and safety and administrative requirements.
adult foster care homes (homes) in
Minnesota. We continue to perform State officials in Minnesota, Wisconsin, and Mississippi said that most
similar reviews in other States. instances of noncompliance occurred because of low staffing levels that
limited the States’ oversight and monitoring of facilities and because of
Our objectives were to (1) summarize insufficient training on State requirements. State officials in Illinois and
the results of our previous reviews of Minnesota said that the absence of templates for State-required
States’ compliance with Federal and administrative records and unclear State requirements contributed to
State requirements for overseeing noncompliance with numerous health and safety and administrative
centers and homes and (2) identify requirements. Noncompliance with health and safety and administrative
actions that the Centers for Medicare requirements puts vulnerable adults in the care of the centers and homes at
& Medicaid Services (CMS) could take risk.
to help States comply with the
requirements. What OIG Recommends and CMS’s Comments
We recommend that CMS work with the States reviewed to ensure that the
How OIG Did This Review instances of noncompliance with health and safety and administrative
We reviewed Federal waiver and requirements identified in this report are corrected; assist all States in
State requirements for centers and ensuring the health and safety of vulnerable adults by offering technical
homes where vulnerable adults assistance on staffing models in centers, homes, and other home and
received services through programs community-based services (HCBS) settings; review current training the States
in Minnesota, Illinois, Wisconsin, and provide to centers and homes; and ensure the health and safety of vulnerable
Mississippi. We selected 20 centers adults by offering technical assistance on possible templates for administrative
in each State and 20 homes in records in centers, homes, and other HCBS settings.
Minnesota on the basis of their
geographic location and other In written comments on our draft report, CMS concurred with our findings and
factors. This series of reviews began recommendations and described corrective actions that it will take in
in January 2016 and ran through response to our recommendations.
March 2017.

The full report can be found at https://oig.hhs.gov/oas/reports/region5/51900005.asp.

 TABLE OF CONTENTS

INTRODUCTION ........................................................................................................................... 1

Why We Did This Review.................................................................................................. 1

Objectives ......................................................................................................................... 1

Background ....................................................................................................................... 1
Medicaid Home and Community-Based Services Waiver .................................... 1
Elderly Waiver Program........................................................................................ 2
Adult Day Care Services ........................................................................................ 2
Adult Foster Care Services .................................................................................... 2
State Requirements and Monitoring Activities .................................................... 3

How We Conducted This Review ..................................................................................... 3

FINDINGS ..................................................................................................................................... 3

State Agencies Did Not Ensure That Centers and Homes Complied With
Health and Safety Requirements ................................................................................... 4

State Agencies Did Not Ensure That Centers and Homes Complied With
Administrative Requirements ....................................................................................... 7

Causes of Noncompliance With State Requirements ...................................................... 8

RECOMMENDATIONS ................................................................................................................. 8

CMS COMMENTS ........................................................................................................................ 8

APPENDICES

A: Audit Scope and Methodology ................................................................................... 9

B: Related Office of Inspector General Reports............................................................ 10

C: Additional Photographs of Noncompliance.............................................................. 11

D: CMS Comments ........................................................................................................ 13

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WHY WE DID THIS REVIEW

Many States operate programs for the elderly under a Federal waiver to their Medicaid State
plan. These programs typically fund home and community-based services (HCBS) for people
aged 65 and older who are eligible for medical assistance and may require the level of care
provided in a nursing home but choose to live in the community. Such services may be received
in an adult day care center (center) or provided in a family adult foster care home (home).

Prior Office of Inspector General reviews of State agencies that serve vulnerable adults who
receive services through waiver programs have identified multiple health and safety issues that
put vulnerable adults at risk. These reviews included adult day care services received at centers
in Wisconsin, Mississippi, Illinois, and Minnesota, and adult foster care services received at
homes in Minnesota. We continue to perform similar reviews in other States.

OBJECTIVES

The objectives of our audit were to (1) summarize the results of our previous reviews of four
States’ compliance with Federal waiver and State requirements for overseeing centers and
homes and (2) identify actions that the Centers for Medicare & Medicaid Services (CMS) could
take to help States comply with the requirements.

BACKGROUND

The Medicaid program provides medical assistance to low-income individuals and individuals
with disabilities. The Federal and State Governments jointly fund and administer the Medicaid
program. At the Federal level, CMS administers the Medicaid program. Each State administers
its Medicaid program in accordance with a CMS-approved State plan. The State plan
establishes which services the Medicaid program will cover. Although the States have
considerable flexibility in designing and operating their Medicaid programs, they must comply
with applicable Federal requirements.

Medicaid Home and Community-Based Services Waiver

Section 1915(c) of the Social Security Act authorizes the U.S. Department of Health and Human
Services to waive certain Medicaid statutory requirements so that a State may offer HCBS to a
State-specified target group of Medicaid beneficiaries who need a level of institutional care that
is provided under the Medicaid State plan.

Before the enactment of section 1915(c), the Medicaid program provided limited coverage for
long-term services and support in noninstitutional settings but offered full or partial coverage
of institutional care. Section 1915(c) was enacted to enable States to address the needs of

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1
individuals who would otherwise receive costly institutional care by furnishing cost-effective
services that allow them to remain in their households and communities.

Federal regulations for section 1915(c) waivers require States to provide assurance that
necessary safeguards will be taken, including implementing adequate standards for provider
participation, to protect the health and welfare of individuals served under the waiver and to
assure financial accountability for funds expended for those services (42 CFR § 441.302).

The State agency must also provide assurances that State certification requirements will be met
for services or for individuals furnishing services that are provided under the waiver (42 CFR
§ 441.302(a)(2)).

CMS recognizes that the design and operational features of a waiver program will vary
depending on the specific needs of the target population, the resources available to the State,
service delivery system structure, State goals and objectives, and other factors. A State has the
latitude to design a waiver program that is cost-effective and employs a variety of service
delivery approaches, including participant direction of services.

Elderly Waiver Program

A State agency administers and operates an elderly waiver program under a 1915(c) waiver to
its Medicaid State plan.1 An elderly waiver program funds HCBS for people aged 65 and older2
who are eligible for medical assistance and require the level of care provided in a nursing home
but choose to live in the community. Services may include adult day care or adult foster care.

Adult Day Care Services

Adult day care is a service provided for a partial day in a center that provides services that
include health monitoring, medical care, transportation, meals, and social and recreational
activities to the aged and disabled.

Adult Foster Care Services

Family adult foster care is a licensed living arrangement that provides food, lodging,
supervision, and household services but may also provide personal care and medication
assistance.3 Providers are homeowners who are also the primary caregivers for Medicaid
beneficiaries in their home.

1
In Wisconsin, the program is called the Family Care Program.

2
The Illinois program includes individuals aged 60 through 64 who are physically disabled, Mississippi’s program
includes individuals with disabilities aged 21 to 64, and Wisconsin’s program includes older family members and
adults with physical or developmental disabilities.

3
We performed our adult foster care review in Minnesota.

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State Requirements and Monitoring Activities

To protect the health and safety of vulnerable adults, State agencies must ensure that the
centers and homes follow State requirements established in the application for waiver services.
These requirements include health and safety and administrative requirements. Certain State
agencies monitor centers and homes using certification or licensed inspectors who perform
routine inspections. Although it is not a requirement, certain State agencies attempt to
perform recertification or relicensing visits every 2 to 3 years, depending on the State.

HOW WE CONDUCTED THIS REVIEW

We reviewed Federal waiver and State requirements for centers and homes where vulnerable
adults received services through programs in Wisconsin, Mississippi, Illinois, and Minnesota.
We selected 20 centers in each State and 20 homes in Minnesota on the basis of their
geographic location and other factors, such as center occupancy capacity and history of health-
and safety-related violations. The reviews covered various periods ranging from January 2016
through March 2017.

We conducted this performance audit in accordance with generally accepted government

auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.

Appendix A contains the details of our audit scope and methodology, and Appendix B contains
a list of the individual reports on each State covered in this report.

FINDINGS

All four States we reviewed did not comply with Federal waiver and State requirements in
overseeing centers and homes.

We found violations of health and safety and administrative requirements at 96 of the 100
centers and homes reviewed. Specifically, we found 1,141 instances of noncompliance with
health and safety and administrative requirements (Figure 1).

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 FC = foster care.

State officials in Minnesota, Wisconsin, and Mississippi said that instances of noncompliance
occurred in part because of low staffing levels that limited the States’ oversight and monitoring
of facilities, while officials in all four States indicated that insufficient training on State
requirements also contributed to noncompliance. State officials in Illinois and Minnesota said
that the absence of templates for State-required administrative records and unclear State
requirements contributed to noncompliance with numerous health and safety and
administrative requirements. Noncompliance with health and safety and administrative
requirements puts vulnerable adults in the care of the centers and homes at risk.

STATE AGENCIES DID NOT ENSURE THAT CENTERS AND HOMES COMPLIED WITH
HEALTH AND SAFETY REQUIREMENTS

Centers and homes must comply with State requirements to ensure the health and safety of
vulnerable adults receiving services there. Although requirements vary from State to State,
centers and homes must provide a safe, nonhazardous environment. Providers generally must
ensure that their facilities and grounds are safe and clean and free of hazards and that
hazardous chemicals are stored in areas not accessible to Medicaid beneficiaries. In Illinois,
centers must ensure that exit areas are always clear of equipment and debris and are equipped
with monitoring or signaling devices to alert staff to vulnerable adults leaving the center
unattended. In Minnesota, a provider generally must ensure that knives are inaccessible to
vulnerable adults, unless used with appropriate supervision; the home is free of structural
hazards; the home is clean; and weapons are stored separately in locked areas.

We determined that centers and homes in all States we reviewed did not comply with health
and safety requirements. Specifically, we found a total of 400 instances of noncompliance with

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State requirements on health and safety. Findings ranged from 18 instances in Illinois to 194
instances in Mississippi (Figure 2).

For example, in Mississippi, we found water damage and mold in a participant bedroom
(Photograph 1); in Minnesota and Wisconsin, we found chemicals and a sharps biohazard
container accessible to vulnerable adults (Photograph 2). In Mississippi and Illinois, we also
found unsecured chemicals.

Photograph 1: A bedroom had water Photograph 2: Chemicals and a sharps

damage and mold (MS). biohazard container were accessible
(WI).

In Minnesota, we found knives left out in the open to at least one vulnerable adult residing in
the foster home who had either a physical aggression towards others or had a medical
condition (i.e., dementia) that could pose a danger to self or others when kitchen knives are

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easily accessible (Photograph 3). In Illinois, several pieces of equipment blocked an exit, making
it difficult for participants to leave, if necessary (Photograph 4).

Photograph 3: Knives were easily Photograph 4: Several pieces of

accessible in a home (MN). equipment blocked an exit at a center (IL).

In Mississippi, we found a dead rodent on the floor of a center’s bathroom (Photograph 5), and
in Minnesota, we found multiple carbon dioxide-powered handguns4 that were accessible just
outside a vulnerable adult’s bedroom in a foster care home (Photograph 6).

Photograph 5: A dead rodent was in a Photograph 6: CO2 handguns were easily

center’s bathroom (MS).
accessible outside a bedroom in a home
(MN).

In addition, Appendix C contains photographs of other health and safety violations identified in
the four States.

4
The manufacturer cautions that the handguns are not toys, adult supervision is required, and that misuse or
careless use may cause serious injury or death.

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STATE AGENCIES DID NOT ENSURE THAT CENTERS AND HOMES COMPLIED WITH
ADMINISTRATIVE REQUIREMENTS

Centers and homes must comply with State requirements on administration. Among other
requirements, centers must have a sufficient number of employees with the necessary skills to
provide essential administrative and direct care functions to participants. States also require
background checks on employees before they have direct contact with adults served by the
program. In addition, Illinois requires that centers maintain records of employees with direct
participant contact who have received flu vaccines, and Mississippi requires participants and
employees to receive a tuberculin skin test prior to admission or employment. Other
requirements are that centers maintain job descriptions for employees and ensure that
employees receive orientation and training that is pertinent to their job responsibilities within
required timeframes. Additionally, in Minnesota, centers and homes must generally complete
a program abuse-prevention plan and review it annually, while Illinois requires centers to
maintain quality improvement systems, which they must review at least annually, through staff
and community agency surveys.

We determined that centers and homes in all States we reviewed did not comply with
administrative requirements. Specifically, we found a total of 741 instances of noncompliance
with State requirements on administration. Findings ranged from 25 instances in Minnesota
homes to 370 instances in Mississippi centers (Figure 3).

We found violations of staffing and training requirements at many of the centers and homes in
all States. For example, in Mississippi, some facilities did not have a qualified administrator,
program director, or licensed social worker on staff. All States had at least one center that did
not have proper background checks on file for at least one employee before the employee had
direct contact with vulnerable adults. Illinois did not ensure that centers maintained proper

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documentation of whether employees received flu vaccines before having direct contact with
participants, and Mississippi did not ensure that all centers had employees or beneficiaries
complete tuberculin screening tests prior to employment or admission. Additionally, some
centers in all States did not provide orientation or annual training within the required
timeframe. Minnesota did not ensure that all centers and homes completed program abuse-
prevention plans or reviewed program abuse-prevention plans within the required timeframe.
Finally, Illinois did not ensure that all centers followed the requirement that staff and agency
surveys be taken and used to conduct reviews of their quality improvement systems.

CAUSES OF NONCOMPLIANCE WITH STATE REQUIREMENTS

State officials in Minnesota, Wisconsin, and Mississippi said that instances of noncompliance
occurred in part because of low staffing levels that limited the States’ oversight and monitoring
of facilities, while officials in all four States indicated insufficient training on State requirements
also contributed to noncompliance. State officials in Illinois and Minnesota said that the
absence of templates for State-required administrative records and unclear State requirements
contributed to noncompliance with numerous health and safety and administrative
requirements. Noncompliance with health and safety and administrative requirements puts
vulnerable adults in the care of the centers and homes at risk.

RECOMMENDATIONS

We recommend that CMS:

• work with the States reviewed to ensure that the instances of noncompliance with
health and safety and administrative requirements identified in this report are
corrected;

• assist all States to ensure the health and safety of vulnerable adults by offering technical
assistance to look at staffing models in centers, homes, and other HCBS settings;

• work with all States to review current training the States provide to centers and homes;
and

• assist all States to ensure the health and safety of vulnerable adults by offering technical
assistance to look at possible templates for administrative records in centers, homes,
and other HCBS settings.

CMS COMMENTS

In written comments on our draft report, CMS concurred with our findings and
recommendations and described corrective actions that it will take in response to our
recommendations. CMS’s comments are included in their entirety as Appendix D.

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 APPENDIX A: AUDIT SCOPE AND METHODOLOGY

SCOPE

We reviewed Federal waiver and State requirements for centers and adult foster homes where
vulnerable adults received services through the programs in Wisconsin, Mississippi, Illinois, and
Minnesota. We selected 20 centers in each State and 20 adult foster homes in Minnesota on
the basis of their geographic locations and other factors, such as center occupancy capacity and
history of health and safety-related violations. The reviews covered various periods ranging
from January 2016 through March 2017.

To evaluate the State agencies’ oversight of State requirements for centers and homes, we
conducted unannounced site visits at the selected facilities in each State.5 We conducted
fieldwork at the entities in all four States beginning in June 2016 in Minnesota through
October 2017 in Wisconsin.

METHODOLOGY

To accomplish our objectives, we:

• reviewed applicable Federal laws and State regulations for centers and adult foster care
homes,

• discussed with State officials how the States monitor their centers and adult foster care
homes,

• developed a health and safety checklist from State requirements as a guide for
conducting site visits,

• conducted unannounced site visits at the 20 centers in each State we selected for
review,

• interviewed State officials to inquire about the causes of center noncompliance, and

• discussed the results of our reviews with State and CMS officials.

We conducted this performance audit in accordance with generally accepted government

auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.

5
In Wisconsin, we conducted an announced site visit at one center because the center had intermittent closures
due to limited participant attendance.

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 APPENDIX B: RELATED OFFICE OF INSPECTOR GENERAL REPORTS

Report Title Report Date Issued

Number

Wisconsin Did Not Comply With Federal Waiver A-05-17-00030 10/15/2018

and State Requirements at All 20 Adult Day
Service Centers Reviewed
Mississippi Did Not Comply With Federal Waiver A-04-17-00116 8/20/2018
and State Requirements at All 20 Adult Day Care
Facilities Reviewed
Illinois Did Not Comply With Federal Waiver and A-05-17-00028 7/24/2018
State Requirements at 18 of 20 Adult Day Service
Centers Reviewed
Minnesota Did Not Comply With Federal Waiver A-05-17-00009 5/30/2018
and State Requirements for All 20 Adult Day Care
Centers Reviewed
Minnesota Did Not Comply With Federal Waiver A-05-16-00044 10/31/2017
and State Requirements for 18 of 20 Family Adult
Foster Care Homes Reviewed

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 APPENDIX C: ADDITIONAL PHOTOGRAPHS OF NONCOMPLIANCE

Photograph 7: Electrical wiring was Photograph 8: Smoke detector wiring

exposed (MS). was uncovered (MN).

Photograph 9: Participants were exposed Photograph 10: Participants were

to an unsanitary environment (MS). exposed to a dirty kitchen area (MN).

Photograph 11: An insufficient outdoor Photograph 12: A game table partially

activity area was provided for blocked an exit (IL).
participants (MS).

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 Photograph 13: A rust-covered floor drain Photograph 14: A participant
and peeling paint in a bathroom (MN). unloading area was unsafe (MS).

Photograph 15: A wall in a bathroom had Photograph 16: Rust covered a bathroom
holes (WI). radiator (WI).

Photograph 17: Facilities were not safe Photograph 18: One area contained
and clean (MS). exposed nails (MS).

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 APPENDIX D: CMS COMMENTS

( '~ DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medica·d se,vtces

!•,~~ ~
Administrator
Washington, DC 20201
Date: MAR 28 2019

To: Daniel R. Levinson

Inspector General
Office of Inspector General

From: Seema Verma

Administrator
Centers for Medicare & Medicaid Services

Subject: Office of Inspector Draft Report: "Four States Did Not Comply With Federal
Waiver and State Requirements in Overseeing Adult Day Centers and Foster Care
Homes" (A-05- 19-00005 )

The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the OIG draft report on states' compliance with federal waiver and state
requirements for overseeing adult day service centers and foster care homes. CMS expects states
to be in compliance with health and safety requirements and is committed to supporting the
health and welfare of beneficiaries that receive these services under Medicaid Home and
Community Based Services (HCBS) waivers.

Monitoring patient safety and quality of care provided through home and community-based
services is an essential part ofCMS's oversight efforts and requires coordinated efforts between
the federal govemment and the states. Although requirements vary across states, HCBS
providers must provide a safe, nonhazardous environment. To protect the health and safety of
vulnerable adults, state agencies must ensure that the centers and homes follow state and federal
requirements established in the application for waiver services. State agencies monitor providers
such as centers and homes u sing certification and licensed inspectors who perform routine
inspections.

To assist with monitoring for compliance with federal requirements, HHS issued an
informational bulletin in 2014 that identified four areas related to the Health and Welfare
assurances within 1915 (c) HCBS waivcrs 1• The bulletin outlined assurances that states need to
include in new waivers and renewals submitted after June I, 2014, such as that states must
identify and seek to prevent instances ofabuse, neglect, exploitation, and unexplained death, that
an incident management system is in place, that state policies and procedures for the use or
prohibition of restricti ve interventions are followed, and that providers are monitored agai nst a

1 https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/3-

cmcs-qualit y-memo-narrati ve. pdf

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 state's overall health care standards. CMS updated the Waiver Application and Teclu1ical Guide
consistent with this guidance.

hi addition . the HCBS settings regulatio1i2. finalized in 2014. also enhanced the quality ofhome
and conummity-based services and provided additional protections to individuals that receive
services under these Medicaid authorities tlu·ough compliance actions including initiating a
moratorium 0 11 waiver enrollment. withholding o f a portion of Federal payments for waiver
services until compliance is achieved. or other actions detennined necessa1y by tile Secretary to
address non-compliance and ensure health and welfare of waiver recipients 3. HHS also
continue, to prnvide technical assistance to states as they develop HCBS 1915(c) waiver or
renewal applications to assist in compliance with federal requirements.

Further. CMS will be conductiug a national survey regarding incident management systems used
for home and conununity-based services. The puq)ose of this survey is to help identi±~r best
practices that states have adopted in identifying and reporting incidents. responding to reported
incidents. collecting infonnation. training individuals involved in incident management, and
employing tactics to prevent incidents. CMS will use this infonnation to info1111 the provision of
future training activities and technical assistance.

OIG's reconunenclations and CMS· responses ai·e below.

OIG Recommendation
CMS should work with the states reviewed to ensure that the instances of noncompliance with
health and safety and administrative requiremen ts identified in this report are co1ncted.

CMS Respon5e
CMS concurs with this reconun endation. CMS will work with the states reviewed to ensure that
the instances of noncompliance with health and safety and administrative requirements identified
in this report aJ'e co!l'ected. When deemed appropriate, CMS has the ability to utilize compliance
actions including initiating a moratorium on waiver emollment, or withholding a portion of
federal payments for waiver services until compliance is achieved.

OIG Recommendation
CMS should assist all states to ensure the health and safety of vulnerable adults by offering
technical as.sis·tance to look at staffing models in centers, homes, and other HCBS settings.

CMS Respon5e
CMS concurs with this reconun endation. CMS will continue to offer teclmical assistance to
states. as requested. regarding staffing models in centers. homes. and other HCBS settings.

2 79 FR 2948

'42 C.F.R. § 441.304(g)(3)

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 OIG Recommendation
CMS should work with all states to review current training the states provide to center:. and
homes.

CMS Response
CMS concurs with this recommendation. CMS will offer technical assistance to states, as
requested. regarding Ctlll'ent state-provided training to centers and homes. In addition. based on
the results of the national survey described above. CMS will share best practices states have
utilized regarding training activities conducted.

OIG Recommendation
CMS should assist all states to ensure the health and safety of vulnerable adults by offering
teclmical assistance to look at possible templates for administrative records in centers. homes.
and other HCBS settings.

CMS Response
CMS concurs with this recommendation. CMS will continue to offer technical assistance to
states as requested. Additionally. based on the results ofthe national survey described above.
CMS will share best practices states have utilized regarding identifying, collecting and reporting
incidents.

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