CMS should require state Medicaid agencies to ensure that the agencies providing home- and community-based services (HCBS) to individuals with developmental disabilities (DD) track, study and report on the causes of death of patients receiving HCBS DD services in order to protect theses vulnerable patients, according to a recent report of the Government Accountability Office (GAO). GAO studied the practices of 14 states and surveyed the remaining states to determine whether states have adopted six components of comprehensive mortality review found to improve quality of care.
HCBS DD services allow individuals to remain in the community instead of receiving long-term care in institutions. State Medicaid agencies fund the services through HCBS waiver programs. Usually, the state agency responsible for DD services sets standards for providers.
Deaths due to poor quality care
Investigations have revealed that some patients' deaths reported as natural actually were caused by neglect, abuse or poor quality care. For example, failure to furnish meals consistent with a patient's plan of care may result in the patient choking to death or contracting a fatal case of pneumonia by aspirating food into the lungs. For example, a provider told the family that a patient had died of a heart attack, but autopsy findings showed that the patient had choked on part of a sandwich which was suppose to be pureed according to his plan of care.
Components of a comprehensive mortality review
GAO studied the states' requirements for review of deaths in the HCBS DD waiver programs looking for basic components including: (1) treatment of a patients death as a "critical incident" that providers must report to a state agency; (2) screening individual deaths using standard information to decide whether further investigation is warranted; (3) the existence of a process for review of the cause of death by local officials; (4) routine participation of a physician in each review; (5) aggregation of data to identify quality issues; (6) documentation of the review process, findings and recommendations; and (7) acting on the findings by providing guidance or requiring training of facility staff.
GAO found that all 14 states required HCBS providers to report patient deaths, and most of them had adopted some of the basic components of mortality review. The states differed in their implementation of the requirements. For example, some states required all deaths to be reported while others required reporting of unexpected deaths, deaths caused by a previously undiagnosed condition or those involving neglect or abuse. GAO's research showed that an initial, standardized review of every death is basic to a comprehensive mortality review.
Thirteen of the 14 states studied had mortality review processes that included some of the basic components. Texas had no standard policy but referred suspicious deaths to investigative authorities.
Additional components
GAO determined that there were four additional components required for a comprehensive mortality review program: (1) use of independent, statewide multidisciplinary committees; (2) participation of external stakeholders in the review; (3) taking statewide action to improve care as a result of their findings; and (4) publicly report their findings.
Four states, Connecticut, Massachusetts, Minnesota and Ohio, incorporated all four of the additional components of mortality review. Most of the others used one or more of the additional components. Six used interdisciplinary review committees to provide additional oversight. Seven routinely involved individuals external to the agency, such as staff from the protection and advocacy agency. Some state officials stated that the participation of external stakeholders fostered independence of the review committee and shared accountability.
GAO found that CMS provided little oversight of states' reviews of deaths in the HCBS DD waiver programs. The only documented expectation was that deaths be reported to the state agency.
GAO recommended that CMS provide information to states about the basic and additional components of mortality reviews, encourage states to implement or expand their mortality review processes to incorporate the additional components; and set an expectation that state Medicaid agencies report all deaths to the state office of advocacy and protection.
The report is available at http://www.gao.gov/new.items/d08529.pdf.
Source: GAO Report No. 08-529, May 23, 2008.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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