Improve Home and Community-Based Incident Management Systems to Protect Vulnerable Populations

Home and community-based (HCBS) waiver program delivery models continue to shift in response to COVID-19. States must consider the implications of these changes on incident management, which safeguards participants in waiver programs from abuse, neglect, and exploitation (ANE).

The new HCBS landscape has presented challenges for states as well as opportunities to consider more proactive and innovative ways to manage and prevent incidents:

• HCBS populations are at higher risk for adverse health outcomes, since COVID-19 disproportionately impacts the elderly and those with chronic conditions.
• Individuals receiving treatment in HCBS settings may face challenges, such as unmet daily needs, due to worker shortages and medical supply limitations.
• Existing concerns of protecting individuals from ANE among HCBS programs have been amplified.

These weaknesses have exposed a need for more flexible policies and procedures to better report, track, and investigate incidents.

States have acted quickly to modify their HCBS waiver programs and adjust their delivery models due to COVID-19.

As of January 2021, 47 states, including the District of Columbia, had submitted requests for changes to waiver operations (Centers for Medicare & Medicaid Services (CMS) Appendix K submissions), ranging from amendments to access and eligibility, modifications of service scope or coverage, or changes to requirements supporting the health and welfare of individuals, including state’s incident reporting processes and requirements.

The table below provides a high-level summary of requested changes.

Appendix K Change Requests to Health and Welfare

Requested changes submitted in Appendix K demonstrate the importance of the flexibility around states’ approaches to incident management. As states transition from emergency orders, they will need to consider how these operational changes will impact their policies and processes post-COVID-19.

Incident management systems should maintain continuous communication and coordination, despite operational and administrative disruptions.

Lessons learned during COVID-19 can be leveraged for long-term improvements to the accuracy, efficiency, and consistency of incident management systems. As a result, states should conduct a robust evaluation of current incident management processes to determine areas of improvement.

Figure 1: Activities to Improve Incident Management Systems

States should consider three key strategies when evaluating current systems and processes in relation to the effects of the COVID-19 pandemic.

1. Capitalize on changes made to incident reporting and investigation requirements

Multiple states requested, in their Appendix K submissions, one or more modifications to their reporting or investigation process.

• States that requested modifications to reporting requirements expanded their definition of reportable incidents to include COVID-19 cases and modified reporting timelines.
• States that requested changes to their investigation processes such as suspending the requirement to conduct investigations centered around staffing deviations or service interruptions due to COVID-19 and modifying investigation timelines.

These temporary changes provide states with the opportunity to develop sustainable solutions, identify promising operational practices, and mitigate risks. Relaxing timeline requirements reduces the burden on providers when reporting incidents in the short-term.

As states look ahead and begin transitioning out of emergency orders, they can explore longer-term solutions by evaluating the design of the incident management process itself. In this instance, states may want to identify opportunities to improve reporting efficiency by understanding the following:

• Can providers report online?
• Does the system ask for an overly burdensome amount of information?
• How is the incident reporting data managed?

States can inform future incident management system design changes by reviewing how quickly they were able to adopt procedural changes within their systems. For example, states requiring critical incident reports for participants who tested positive for COVID-19 can review how they disseminated new operational guidelines and ensured compliance.

2. Improve the processes for reporting incident management quality findings to CMS

Past audits by the US Government Accountability Office (GAO) reveal that states face challenges responding to or adequately addressing CMS requirements regarding health and welfare. For instance, the GAO identified deficiencies in states’ abilities to report data from their incident management systems, such as the number of incidents, the type of incidents, or the location or type of facility in which the incident occurred.

Failure to comply with federal and state requirements for reporting and monitoring critical incidents hinders states’ abilities to trend incidents over time and can potentially result in delayed responses. These limitations also restrict CMS’ ability to effectively monitor how well states are assuring participant health and welfare.

As states work to improve the administration and oversight of their waiver programs, they can consider making improvements to not only the performance measures used to monitor incident management systems, but also their approach to report mandated requirements to CMS. Outcome-based performance measures are a powerful tool in gauging waiver program quality, and states can leverage these measures to monitor the impact of incident management systems. Additionally, better CMS reporting supports the provision of more targeted guidance. 

3. Use Appendix K changes as the basis to complete a gap analysis of incident management systems

States that have made temporary Appendix K modifications must also understand the inherent risks associated with certain changes to incident management processes. For example, modifications that relax reporting timeline requirements may negatively impact states that already face challenges with reporting critical incidents in a timely manner. Changes to policies and procedures regarding reporting timelines can create cultural shifts within state systems and further encumber timely reporting when temporary modifications are lifted.

Some states have also relaxed staff training requirements to create more flexibility within their incident management systems to respond to COVID-19. Within their Appendix K submissions, states have also relaxed or suspended training requirements due to staffing shortages. Staff training preserves the efficiency and efficacy of incident management systems.

As states transition back to policies and procedures, they should consider closely monitoring key activities of their incident management system, such as:

• Reporting on all critical incidents and/or reasonable suspicions of abuse or neglect
• Reporting on the correct severity level on reported incidents
• Performing proper data collection on all incidents reported
• Ensuring appropriate action steps were identified in all incident reports to prevent similar incidents
• Reviewing and analyzing data on all critical incidents

Audits conducted by the Office of the Inspector General have revealed that states often fail to perform one or more of these activities. States that are not prepared to address the potential risks and consequences tied to these modifications may find themselves facing additional issues in the future.

Ultimately, states that have adopted modifications should observe how these changes have affected current processes and develop a transition plan to ensure that changes are reverted when normal operations resume.

Co-authored by Nancy Kim and Kathy Lin, Guidehouse