Medicaid

Medicaid provides more than $5 billion each year to support state institutions that house and care for the mentally retarded. Despite federal standards, serious quality-of-care problems exist at some institutions. Insufficient staffing, lack of treatments to enhance patients' independence and functional ability, and deficient medical and psychiatric care are some of the shortcomings that have been cited most frequently. In a few cases, these practices have led to injuries, illness, physical degeneration, and even death for some residents. States, which play a key role in ensuring that these institutions meet federal standards, do not always identify serious deficiencies and sometimes do not take adequate enforcement measures to prevent the recurrence of poor care. Although the Health Care Financing Administration has tried to improve the process for spotting serious deficiencies in these institutions and has sought to make more efficient use of limited federal and state resources, oversight weaknesses persist. Moreover, state surveys may lack independence because states are responsible for surveying their own institutions. This potential conflict of interest raises concern given the decline in direct federal oversight of both care in these facilities and the performance of state surveying agencies.

GAO found that: (1) despite federal standards, HCFA and state agency oversight, and continuing Justice Department investigations, serious quality-of-care deficiencies continue to occur in some large public ICFs/MR; (2) insufficient staffing, lack of active treatment needed to enhance independence and prevent loss of functional ability, and deficient medical and psychiatric care are among those deficiencies that have been frequently cited; (3) in a few instances, these practices have led to serious harm to residents, including injury, illness, physical degeneration, and death; (4) states, which are the key players in ensuring that these institutions meet federal standards, do not always identify all serious deficiencies nor use sufficient enforcement actions to prevent the recurrence of deficient care; (5) direct federal surveys conducted by HCFA and Justice Department investigations have identified more numerous and more serious deficiencies in public institutions than have state surveys; (6) furthermore, even when serious deficiencies have been identified, state agencies' enforcement actions have not always been sufficient to ensure that these problems did not recur; (7) some institutions have been cited repeatedly for the same serious violations; (8) although HCFA has recently taken steps to improve the process for identifying serious deficiencies in these institutions and to more efficiently use limited federal and state resources, several oversight weaknesses remain; (9) moreover, state surveys may lack independence because states are responsible for surveying their own institutions; and (10) the effects of this potential conflict of interest raise concern given the decline in direct federal oversight of both the care in these facilities and the performance of state survey agencies.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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