GAO Report on Assisted Living: Why It’s Not About You

Regulation | April 10, 2018 | by Stephen Maag

Assisted living providers didn’t know what to make of a recent report on Medicaid assisted living services from the U.S. Government Accountability Office (GAO). Steve Maag, director of residential communities at LeadingAge, reassures them that “It’s not about you."

“It’s not about you.”

When we hear that phrase spoken in television or stage dramas, we know right away it’s not good news.

“It’s not about you,” one partner in a romantic relationship might tell the other as a way to cushion the blow of a breakup, and avoid placing blame on the jilted party.

“It’s not about you,” a wife might tell her husband to underscore the fact the entire world doesn’t revolve around him.

Given the negative connotations associated with this popular phrase, I felt a little odd using it to reassure LeadingAge members about a recent report on assisted living released by the U.S. Government Accountability Office (GAO).

“It’s not about you,” I told providers when they called me after reading media reports about MEDICAID ASSISTED LIVING SERVICES: Improved Federal Oversight of Beneficiary Health and Welfare Is Needed.

Assisted living providers didn’t know what to make of the GAO report at first, and I didn’t blame them.

“Government Watchdog Finds Safety Gaps in Assisted Living Homes,” shouted The Hill.

“More Than 20,000 Serious Health and Safety Incidents in First-Ever National Assessment of Quality of Care in Assisted Living Facilities,” declared the U.S. Senate Committee on Finance.

“More Must be Done to Protect Residents of Assisted Living Facilities,” announced The National Consumer Voice.

The sensational headlines were written to grab attention, and they succeeded. But in the process, they missed the whole point of the GAO’s investigation and its report.

What’s Actually in the GAO Report?

Let’s be clear. The GAO was not investigating assisted living communities. It was investigating federal oversight of Medicaid assisted living services.

The report doesn’t call for any new assisted living regulations. It doesn’t critique assisted living providers, or recommend that they take any new approaches to the care they provide. Instead, the GAO aimed its recommendations directly, and solely, at the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies.

Much of the GAO report is simply an overview of the types of assisted living services provided under 132 Medicaid home and community-based services (HCBS) waivers in 48 states. Those states spent more than $10 billion in federal and state funds to provide assisted living services to more than 330,000 beneficiaries in 2014, according to the GAO.

The report also examines how each state oversees its assisted living programs, and the type of information the state collects from these programs so it can monitor the quality of their services. In this area, investigators found significant, and troubling, variations.

For example, 26 out of 48 Medicaid agencies were unable to provide information about the number of “critical incidents” that had occurred in assisted living settings in 2014. States cited several reasons for this serious failure, including their 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).

The remaining 22 states reported a total of 22,921 critical incidents involving Medicaid beneficiaries in their largest programs covering assisted living services, according to the GAO. That fact—reported in one sentence on page 23 of the 46-page report—is where the sensational headlines came from.

The GAO report defines critical incidents as ones that “may cause harm to a beneficiary’s health or welfare, such as abuse, neglect, or exploitation.” But GAO investigators found that State Medicaid agencies varied widely on how they defined critical incidents, and on the amount of information they provided about those incidents to the public.

What You Need to Know about the GAO Report

There are 2 things you should know about the GAO report.

First, LeadingAge participated in the GAO investigation. We met with GAO researchers back in 2016 to educate them about assisted living and about the vital services that assisted living providers deliver with help from Medicaid.

Second, LeadingAge and other provider organizations strongly support the GAO’s call for CMS to:

  • Provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies that states using HCBS waivers are required to include in their annual reports;
  • Establish standard Medicaid requirements for all states to annually report key information on critical incidents; and
  • Ensure that all states submit annual reports for HCBS waivers on time as required.

The Bottom Line

The GAO isn’t saying that assisted living providers aren’t monitoring and measuring critical incidents. It’s saying that states aren’t collecting that information from providers. These limitations in state reporting, in turn, create worrisome gaps in CMS monitoring, according to the report.

It’s clear from the GAO findings that State Medicaid agencies and CMS need to step up their game when it comes to collecting, reporting, managing, and monitoring information about Medicaid assisted living services.

I suspect, as others have suggested, that improved information collection and reporting will shine a welcome spotlight on the high-quality Medicaid assisted living services provided by LeadingAge members.

But most importantly, I’m confident that any effort to make the oversight of Medicaid assisted living more consistent across the country will be good for the older adults we serve.

In the end, those older adults deserve to know that “It’s all about you.”