Federal Watchdog Criticizes Gaps in Assisted Living Regulations

There are major gaps in the regulation of assisted living communities nationwide, and steps should be taken at the federal level to ensure they’re swiftly and properly addressed, according to a recently published report from the U.S. Government Accountability Office (GAO).

The report, titled “Improved Federal Oversight of Beneficiary Health and Welfare is Needed,” came about at the request of four U.S. Senators: Republican Susan Collins of Maine, Republican Orrin Hatch of Utah, Democrat Claire McCaskill of Missouri and Democrat Elizabeth Warren of Massachusetts.

For the report, the GAO conducted a performance audit of state Medicaid agencies between March 2016 and January 2018. The government watchdog concluded that the Centers for Medicare & Medicaid Services (CMS) should begin enforcing new requirements and issuing new guidance on the topic of deficiencies—and senior living industry associations are largely on board with the GAO’s recommendations.


Clear guidance needed

In many ways, a lack of clarity from CMS is to blame for assisted living regulation gaps, according to the GAO.

Specifically, CMS has not offered states clear guidance on what information to include in yearly reports on deficiencies, the report says. Consequently, CMS cannot be sure that it’s receiving complete, consistent and relevant information on deficiencies.


All the while, state Medicaid agencies are required to have systems that monitor critical incidents, which are cases of actual or potential harm to beneficiaries. Despite that requirement, 26 state Medicaid agencies could not tell the GAO how many critical incidents occurred in assisted living communities, the report says.

Plus, different Medicaid agencies tracked different kinds of critical incidents. Every state considered emotional, physical, or sexual abuse as critical incidents, for example, but several states did not identify unexplained death or medication errors as critical incidents.

State Medicaid agencies also vary with respect to whether they make information on critical incidents publicly available, the report says.

To help achieve greater consistency among state Medicaid agencies, the GAO provided three recommendations:

1. “The Administrator of CMS should provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies that states using HCBS waivers are required to report on their annual reports.”

2. “The Administrator of CMS should establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living facilities, where critical incidents occurred.”

3. “The Administrator of CMS should ensure that all states submit annual reports for HCBS waivers on time as required.”

Industry associations supportive

On the whole, senior living industry associations expressed support for the GAO’s three recommendations.

“We agree that safeguards are necessary to ensure high quality care, and that with better data from the states, we can better understand Medicaid’s impact,” National Center for Assisted Living (NCAL) Executive Director Scott Tittle tells Senior Housing News. “NCAL and our state affiliates stand ready to work with policymakers at the national and local levels on strategies that strengthen the gathering of information on home and community-based services, including those in provided in assisted living communities.”

Officials at LeadingAge, meanwhile, believe that the GAO’s recommendations can help improve Medicaid agencies’ accountability.

“We support the GAO’s efforts to improve regulatory oversight between CMS and state Medicaid offices, and to step up information gathering efforts in order to ensure accountability,” Steve Maag, LeadingAge’s director of residential communities, tells SHN.

Argentum similarly supports the GAO’s recommendations, Argentum COO Maribeth Bersani tells SHN.

More than 330,000 Medicaid beneficiaries received assisted living services in 2014, according to the GAO, based on data 48 states reported to the agency.

Nationwide, the average spending per beneficiary on assisted living services in the 48 states in 2014 was approximately $30,000.

Written by Mary Kate Nelson

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