Maine Did Not Comply With Federal and State Requirements for Critical Incidents Involving Medicaid Beneficiaries With Developmental Disabilities

The Maine Department of Health and Human Services (State agency) did not comply with Federal Medicaid waiver and State requirements for reporting and monitoring critical incidents involving Medicaid beneficiaries with developmental disabilities residing in community residences. The State agency did not fulfill many of the participant safeguard assurances it provided to the Centers for Medicare & Medicaid Services in its Medicaid waiver. Specifically, the State agency did not (1) ensure that community-based providers reported all critical incidents to the State agency; (2) ensure that community-based providers conducted administrative reviews of all critical incidents involving serious injuries, dangerous situations, or suicidal acts and submitted their findings within 30 days; (3) report appropriately all restraint usage and rights violations to Disability Rights Maine (DRM); (4) review and analyze data on all critical incidents; (5) investigate and report immediately to the appropriate district attorney's office or to law enforcement all critical incidents involving suspected abuse, neglect, or exploitation; and (6) ensure that community-based providers reported all beneficiary deaths to the State agency appropriately and that the State agency analyzed, investigated, and reported the deaths to law enforcement or Maine's Office of Chief Medical Examiner (OCME).

The State agency failed to demonstrate that it has a system to ensure the health, welfare, and safety of the 2,640 Medicaid beneficiaries with developmental disabilities covered by the Medicaid waiver.

We recommended that the State agency fully implement its own regulations regarding the reporting and monitoring of critical incidents involving Medicaid beneficiaries with developmental disabilities residing in community residences. Specifically, we recommended that the State agency (1) work with community-based providers on how to identify and report all critical incidents; (2) work with community-based providers to ensure that administrative reviews are conducted and reported appropriately; (3) report appropriately all restraint usage and rights violations to DRM; (4) perform trend analysis and analytical procedures, such as a data match, to provide community-based providers with reports that identify patterns and trends to prevent reoccurrences of critical incidents and determine the number and percentage of critical incidents reported in required timeframes; (5) investigate and immediately report to the appropriate district attorney's office or law enforcement all critical incidents involving suspected abuse, neglect, or exploitation; (6) ensure community-based providers report to the State agency all beneficiary deaths and that the State agency analyzes, investigates, and reports these deaths to law enforcement or OCME; and (7) provide training to the State agency's and community-based providers' staffs regarding the home and community-based services waiver and State requirements for critical incident reporting.

In written comments on our draft report, the State agency agreed or partially agreed with all seven of our recommendations and with four of our findings, but it did not agree with two of our findings. Specifically, the State agency disagreed that it did not ensure that community-based providers reported all critical incidents and that it did not investigate or report critical incidents to the appropriate authorities. We maintain that the evidence supports all our findings.