Medicaid patients in Maine who had critical incidents involving neglect, exploitation, or abuse were not investigated and reported immediately, according to an audit from the Department of Health and Human Services.
Auditors conducted the investigation after it was discovered there were cases of abuse and fatalities of patients with developmental disabilities in group homes.
"Our objective was to determine whether the Maine Department of Health and Human Services complied with federal waiver and state requirements for reporting and monitoring critical incidents involving Medicaid beneficiaries with developmental disabilities residing in community-based settings," the report states.
If someone has a developmental disability, he may have a physical or mental impairment that is severe or chronic that is likely to continue as the person ages. The Medicaid Home and Community-Based Services Waiver program provides funds for these individuals to avoid institutionalization and live in the community. In order to receive approval for this waiver, states must prove they are taking safeguards to protect the health and welfare of these beneficiaries.
The report found that 2,640 Medicaid patients in Maine had critical incidents, which are defined as occurrences that have an adverse effect on the safety, rights, dignity, and welfare of disabilities. Once a critical incident occurs, it is required that the event be reported immediately and a written report must be submitted.
The audit, however, found that the agency did not comply with requirements to report all critical incidents. "The State agency failed to demonstrate that it has an adequate system to ensure the health, welfare, and safety of the 2,640 Medicaid beneficiaries with developmental disabilities covered by the Medicaid waiver," the report states.
Auditors found 104 incidences that were labeled high-risk and found that none of these were reported to the state. A majority of these—39 percent—were head injuries. There was one instance, in which a Medicaid beneficiary had a jagged laceration to her left ear that required suturing and needed treatment at an emergency room, but this incident was not reported.
In addition to not reporting critical incidents, auditors found that providers did not try to suggest preventive care or find a cause for illness.
"Community-based providers reported through [Enterprise Information System] to the State agency 8,678 critical incidents involving serious injuries, dangerous situations, and suicidal acts for 1,781 beneficiaries during our audit period," the report states. "The state agency, however, was unable to provide us with copies of the 8,678 administrative reviews associated with these critical incidents."
There were also cases of Medicaid beneficiaries who were subject to physical or verbal abuse, sexual abuse, or neglect and roughly 98 percent of these cases were not reported.
"Examples of the rights violations not sent to [Disability Rights Maine] included threats or intimidation by the staff in group homes, denial of access to religious services, denial of access to medical treatment and unnecessary restraint or use of unapproved restraint techniques, such as floor takedowns," the report said.
The inspector general recommended that critical incidents be reported and monitored in accordance with the regulations to protect beneficiaries from harm. While the state did not agree with all of the auditors' recommendations, it said it was committed to protecting Medicaid beneficiaries.
"The Department is confident that current practices are in line with many of the OIG's recommendations offered and serve to protect individuals with developmental disabilities in Maine," said Ricker Hamilton, the acting commissioner of Maine's DHHS. "The Department appreciates the opportunity to respond to the OIG draft report and to resolve the outstanding issues and recommendations."