On June 28, 2018, the Center for Medicaid and CHIP Services (CMCS) issued an informational bulletin to address the issues outlined in a report from January 2018, “Ensuring Beneficiary Health and Safety in Group Homes Through State Implementation of Comprehensive Compliance Oversight.” This report was developed by the three agencies of the Department of Health and Human Services; Administration for Community Living (ACL), Office for Civil Rights (OCR), and Office of Inspector General (OIG).

The bulletin addresses one of the three suggestions the Joint Report made to CMS: “Encourage states to implement compliance oversight programs for group homes, such as the Model Practices, and regularly report to CMS.”

 The guidance contained in the bulletin addresses:

• Incident Management and Investigation including: strongly encouraging states to define critical incidents to, at a minimum, include unexpected deaths and broadly defined allegations of physical, psychological, emotional, verbal and sexual abuse, neglect, and exploitation. Recognizing that reporting critical incidents plays an important role in a quality oversight program, we believe that it is necessary to ensure that an approach to incident management is not perceived as punitive, but instead as an opportunity to help make quality oversight systems stronger. CMS and the states must strike a balance to ensure that we are encouraging, not inadvertently discouraging, providers and other stakeholders to report and resolve critical incidents and to be active participants in ongoing quality improvement efforts.
• States are encouraged to conduct Incident Management Audits of their incident management systems to ensure that information on all occurrences meeting the state’s definition of a critical incident are reported appropriately and lead to investigations to determine the need for any corrective actions.
• Mortality reviews – while states should require a preliminary review of all beneficiary deaths, investigations should focus on deaths that are determined to be “unusual, suspicious, sudden and unexpected, or potentially preventable, including all deaths alleged or suspected to be associated with neglect, abuse, or criminal acts. Also, states are encouraged to establish relationships with relevant agencies performing autopsies to maximize the likelihood of their performance upon state request.
• Quality Assurance – CMS wants to assure that the focus is on ensuring the provision of person-centered planning and services, and the inclusion of beneficiaries and other stakeholders in the development and implementation of an HCBS quality oversight program.
• Next Steps – CMS encourages states, providers, and other stakeholders to become familiar with the Model Practices contained in the Joint Report. It also notes the potential availability of enhanced federal matching funds for state activities to implement the Model Practices described in the Joint Report. Enhanced federal administrative match of 75% may be available for these activities if they are part of a medical and utilization review performed by certain utilization and quality control peer review organizations.

Contact Carol Ferenz with any questions.