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Possible abuse of group home residents wasn’t adequately tracked in Pa.: federal audit

Patriot-News - 1/22/2020

Pennsylvania missed or didn’t investigate many incidents of developmentally-disabled group home residents being taken to the emergency room or hospitalized for things that could have resulted from neglect or abuse, a federal audit has found. The audit also found lapses in investigating deaths that may have resulted from abuse or neglect.

Meanwhile, a Pennsylvania spokeswoman on Wednesday, noting the audit was based on incidents that happened several years ago, said the state has already made assorted improvements to address the shortcomings.

The audit focused on people covered by Medicaid who were living in groups or receiving services to help them live in the community rather than an institution.

It looked at 2015 and 2016, when Pennsylvania received $4.1 billion in federal funds to provide services for 18,770 people, according to the U.S. Department of Health and Human Services’ Office of Inspector General, which did the audit.

As a condition of receiving the money, the federal government requires Pennsylvania to ensure certain incidents that potentially result from abuse are reported to the state within 24 hours.

These include incidents of abuse, neglect and deaths and some ER visits and hospitalizations, as well as incidents such as missing persons and calls requiring police or firefighters.

Beyond that, other laws impose additional requirements, such as requiring suspicious deaths of people with disabilities to be reported to local police within 24 hours.

The audit concluded that 18,880 ER visits weren’t reported in the two-year period covered by the audit, and that, out of 1,162 ER visits for things potentially resulting from abuse, provider organizations failed to report 307.

As an example of the failings, the audit found that an ER visit involving a women who threatened suicide and had self-inflicted injuries wasn’t reported within 24 hours, and a second ER visit following a suicide attempt by the same woman wasn’t reported.

The full audit can be read here: Pennsylvania Did Not Fully Comply With Federal and State Requirements for Reporting and Monitoring Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities

Other findings include 2,078 hospital stays that weren’t reported and, out of 510 hospital stays that potentially resulted from abuse, 167 went unreported.

Another significant finding involved deaths, with the audit concluding that provider organizations failed to investigate 80 deaths, and local law enforcement didn’t investigate 94 deaths. In addition, the audit found that the results of provider investigations and those of local law enforcement sometimes didn’t match, and the conclusion section of the reports were sometimes left blank.

The audit further found that, in looking at a sample of 13 deaths that met criteria for referral to local law enforcement, two weren’t referred.

Auditors attributed the problems mostly to insufficient controls on the part of the state, and made seven recommendations. The state has already agreed to six of them, according to the audit report.

The state disagreed with a recommendation to record the unreported 24-hour reportable incidents noted in the report. It gave reasons including the time and resources that it would take along with the difficulty of investigating older incidents, and said doing so would have “minimal” impact on people presently receiving services.

In a written statement, the Pennsylvania Department of Human Services said it “has made many advances in incident-management oversight in the 4 to 5 years that have elapsed between the OIG’s evaluation period and the present day.”

These include new regulations to help the department enforce reporting requirements and impose penalties; new reviews of Medicaid ER and hospital claims to find incidents that were unreported or inaccurately reported; strengthening policies related to death investigations; improving the system for reporting possible abuse to local police.

Here is the full response forwarded by press secretary Erin James:

The Department of Human Services (DHS) is committed to continuous improvement in our oversight responsibility to ensure that people served by these programs are receiving the care they need and deserve. Over a period of several years, DHS has worked closely with the OIG on its multi-state review of systems for monitoring and reporting critical incidents involving Medicaid beneficiaries with developmental disabilities. The audit was of 2015-2016 data, and DHS has made many advances in incident-management oversight in the 4 to 5 years that have elapsed between the OIG’s evaluation period and the present day. At a high level, these improvements include the development and implementation of a more sophisticated incident management system, implementation of mortality reviews for all participant deaths, clarification of the types of incidents to be reported, strengthened collaboration with law enforcement, and strengthened protocols for referrals to law enforcement. We look forward to continuing to work with our partners at the county level and providers throughout this system so we may work together to ensure that people we all serve are receiving the care they need safely and any incidents that occur are reported in a timely manner so DHS and our partners are able to investigate thoroughly and mitigate future risk.

As noted in the OIG Report, DHS has also taken action to improve its incident-management practices both independently and as a result of the report’s findings. More details on these improvement activities include:

Promulgation of new regulations that significantly enhance incident reporting and investigation requirements: On Feb. 2, 2020, new regulations will go into effect that will strengthen the department’s ability to enforce incident reporting requirements and implement sanctions for noncompliance; expand the types of incidents that require investigation by a department-certified investigator; and require review and analyses of incidents and conduct and document a trend analyses at least quarterly.

Developing systems to use Medicaid claims for incident oversight: The department has begun reviewing emergency room and hospital claims to identify individuals with certain high-risk diagnosis codes, such as those associated with pressure ulcers and choking events. Findings will be used to identify unreported incidents or incidents that were inaccurately categorized. The department is also working on obtaining and including Medicare claims data in its analysis given that many individuals with intellectual disabilities or autism have both Medicare and Medicaid. Finally, the department has partnered with the University of Pittsburgh on a multi-year predictive analytics project to identify trends in incident-reporting practices and to identify providers with potentially noncompliant incident-management practices.

Strengthening mortality review and death investigation practices: In May 2017, the department modified policies and the incident-reporting system to require investigations for all HCBS waiver beneficiary deaths. Prior to this change, only deaths that occurred in a provider-operated setting were required to be investigated. Most participants in ODP waivers live in family homes, not provider-operated settings, so this is an important change.

Streamlining and expediting referrals of suspected abuse and neglect to law enforcement: In 2018, the department enhanced its incident-reporting system to prompt incident reviewers to better collect and track follow-up actions planned or being conducted (e.g. notifying law enforcement, licensing entities, Department of State, etc.) when abuse or neglect is confirmed as well as when a death is determined to be suspicious. The department also collaborated with the Pennsylvania Office of Attorney General’s Medicaid Fraud Control Unit (OAG) to develop protocols ensuring immediate notification to the OAG when there is reasonable suspicion of abuse or neglect or when a death is determined to be suspicious. This practice has significantly expedited and increased referrals to law enforcement relating to abuse, neglect, or suspicious deaths.

As noted in the report, the Department of Human Services concurred with all but one of the OIG’s recommendations for quality improvement. At the same time, the department recommends that caution be used when drawing conclusions from the report for the following reasons:

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