DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Disabled and Elderly Health Programs Group 
 
 
CMCS Informational Bulletin 
 
DATE:   June 28, 2018 
 
FROM:   Timothy B. Hill, Acting Director, Center for Medicaid and CHIP Services  
 
SUBJECT:    Health and Welfare of Home and Community Based Services (HCBS) Waiver 
Recipients 
 
Introduction 
 
The Center for Medicaid and CHIP Services (CMCS) is releasing this Informational Bulletin to 
address the issues outlined in the January 17, 2018 report titled Ensuring Beneficiary Health 
and Safety in Group Homes Through State Implementation of Comprehensive Compliance 
Oversight1  (the Joint Report) developed by three agencies of the Department of Health and 
Human Services:  Administration for Community Living (ACL), Office for Civil Rights (OCR), 
and Office of Inspector General (OIG). CMS takes the health and welfare of individuals 
receiving Medicaid-funded Home and Community-Based Services (HCBS) very seriously, and 
we are providing the following CMS perspective on the issues raised in the Joint Report for state 
and stakeholder awareness.  
 
This Bulletin addresses one of the three suggestions the Joint Report made to CMS: encourage 
states to implement compliance oversight programs for group homes, such as the Model 
Practices, and regularly report to CMS.  Information contained here is consistent with the March 
12, 2014 Informational Bulletin titled, Modifications to Quality Measures and Reporting in 
 1915(c) Home and Community-Based Waivers2 and will not supplant and/or rescind that 
document.  This release will be the first in a series on this topic of health and welfare. CMS 
intends to issue future guidance highlighting promising practices in effectuating the suggestions 
contained in the Joint Report, along with proposed performance metrics for evaluating the health 
and welfare of individuals receiving HCBS waiver services. 
 
The Joint Report compiled individual audits across four states conducted by OIG to determine 
how states were ensuring the health and welfare of individuals with developmental disabilities 
                                                 
1 https://oig.hhs.gov/reports-and-publications/featured-topics/group-homes/group-homes-joint-report.pdf  
2 https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/3-cmcs-quality-
memo-narrative.pdf   CMCS Informational Bulletin  Page 2 
 
residing in group homes3. In addition, proposed Model Practices for components of a robust 
oversight framework were identified in the Joint Report, including State Incident Management 
and Investigation, Incident Management Audits, State Mortality Reviews, and State Quality 
Assurance.  Each of these is addressed below. 
 
At the outset, CMS acknowledges that ensuring high quality HCBS to Medicaid beneficiaries is 
a shared goal among our state partners, provider communities, beneficiaries and their families 
and caregivers, and other stakeholders.  Medicaid-funded HCBS play a critical role in facilitating 
beneficiary independence and community participation. The information contained here is meant 
to reaffirm CMS commitment to provide necessary technical assistance to states in the 
development, implementation, and improvement of a quality oversight program. We encourage 
states to review this information as they look to strengthen their quality assurance system. 
 
Incident Management and Investigation  
 
A strong system of quality oversight utilizes a framework that defines and captures information 
on potential instances of abuse, neglect, or exploitation and emphasizes the importance of 
awareness and identification of critical incidents.  There is no standard federally defined term for 
critical incident that outlines the scope of reportable incidents, leading to variation across 
states in the Medicaid program, and sometimes even across programs within the same state.  
Based on information contained in the Joint Report, along with the Agencys review of states 
submitted HCBS waiver applications, CMS strongly encourages states to define critical incidents 
to, at a minimum, include unexpected deaths and broadly defined allegations of physical, 
psychological, emotional, verbal and sexual abuse, neglect, and exploitation.  See pages A-iv and 
A-v of the Joint Report for a more comprehensive list of suggested reportable incidents. 
Awareness of critical incidents is the first step states require to determine whether an 
investigation or potential changes to the provision of services is necessary. 
 
CMS supports the information contained in Appendix A of the Joint Report, titled Model 
Practices for State Incident Management and Investigation and finds it consistent with the 
expectations in the March 12, 2014 Informational Bulletin.  Ensuring that the right information is 
generated at the provider/individual level and communicated to the state provides the basis for 
state-conducted review of data for timely trend analysis, investigations of specific incidents 
consistent with waiver materials and state policies, procedures and requirements, as well as 
implementation of any resulting corrective actions. The identification of emerging trends of 
concern is an important analysis for states to perform to determine whether systemic controls are 
in place or need improvement to prevent future incidents of abuse, neglect, and exploitation. 
 
Reporting critical incidents plays an important role in a quality oversight program, and we 
believe that it is necessary to ensure that an approach to incident management is not perceived as 
punitive, but instead as an opportunity to help make quality oversight systems stronger. There is 
                                                 
3 While there is no standard definition of a group home, they tend to be congregate residential settings of various 
sizes in which individuals with a unifying characteristic or diagnosis  such as a developmental disability, mental 
illness, etc. - receive services.  CMCS Informational Bulletin  Page 3 
 
a balance that CMS and the states must strike to ensure that we are encouraging, not 
inadvertently discouraging, providers and other stakeholders to report and resolve critical 
incidents and to be active participants in ongoing quality improvement efforts. 
 
Incident Management Audits 
 
States are encouraged to conduct audits of their incident management systems to ensure that 
information on all occurrences meeting the states definition of a critical incident are reported 
appropriately and lead to investigations to determine the need for any corrective actions.  This is 
consistent with the instructions for administrative oversight in the section 1915(c) Instructions, 
Technical Guide and Review Criteria.  The information contained in Appendix B of the Joint 
Report, titled Model Practices for Incident Management Audits, provides a good resource for 
how these audits could be conducted.  While the OIG audits focused on incidents that led to 
hospital emergency department visits, CMS recognizes that not all emergency department 
utilization is due to abuse, neglect, or exploitation; likewise, not all incidents of abuse, neglect, 
or exploitation result in emergency department visits. States should implement an auditing 
protocol that captures all incidents that are relevant to the states definitions of critical incidents, 
and reflects all locations in which those incidents could occur. 
  
In response to the Joint Reports suggestions to review Medicaid claims data as part of incident 
management audits, CMS acknowledges that potential time lags between service provision and 
claims submission may make this type of review most appropriate on a retrospective basis to 
identify where incidents have been reported and/or not reported consistent with the emergency 
department visits audit, trends, and potential system improvement strategies. 
 
Mortality Reviews 
 
CMS agrees with the role that reviews of beneficiary deaths can have in a states overall quality 
oversight system. CMS also agrees with the information contained in Appendix C of the Joint 
Report, titled Model Practices for State Mortality Reviews.  The distinction on page C-ii of the 
Joint Report is important: while states should require a preliminary review of all beneficiary 
deaths, investigations should focus on deaths that are determined to be unusual, suspicious, 
sudden and unexpected, or potentially preventable, including all deaths alleged or suspected to 
be associated with neglect, abuse, or criminal acts.  CMS recognizes that state Medicaid 
agencies and state operating agencies cannot mandate that autopsies be performed. States are 
encouraged to establish relationships with relevant agencies performing autopsies to maximize 
the likelihood of their performance upon state request. CMS notes the significance of mortality 
reviews in identifying trends in critical incidents and implementing systemic interventions that 
help protect against such critical incidents. 
 
Quality Assurance 
 
Appendix D of the Joint Report, titled Model Practices for State Quality Assurance, brings 
information discussed earlier in the Report together into a comprehensive quality oversight  CMCS Informational Bulletin  Page 4 
 
strategy.  CMS, working with State Associations and representative states, agreed that this was a 
critical need in the states Quality System for Health and Welfare issues and communicated that 
in the 2014 Informational Bulletin.  CMS supports the infrastructure described in Appendix D of 
the Joint Report, including the focus on ensuring the provision of person-centered planning and 
services, and the inclusion of beneficiaries and other stakeholders in the development and 
implementation of a HCBS quality oversight program. 
  
Ensuring the transparency of information associated with HCBS quality oversight is a critical 
step in fully utilizing the perspectives of such a wide array of stakeholders.  States are 
encouraged to establish regular and clear communications with stakeholders, including 
individuals receiving or on a waiting list for HCBS.  All reports generated as part of a states 
HCBS quality assurance program should be published online and made available (in plain 
English and other relevant languages) to stakeholders.  Finally, states are encouraged to identify 
ways to close feedback loops with individuals who are experiencing difficulties in receiving 
HCBS. 
 
Next Steps 
 
CMS encourages states, providers, and other stakeholders to become familiar with the Model 
Practices contained in the Joint Report. They represent sound recommendations in the 
implementation of good quality management programs and are consistent with the March 12, 
2014 Informational Bulletin.  In upcoming guidance, CMS intends to highlight examples of how 
these recommendations are being successfully utilized in the delivery of HCBS.  CMS remains 
available to provide technical assistance on quality oversight to states under the various HCBS 
authorities.  
 
CMS notes the potential availability of enhanced federal matching funds for state activities to 
implement the Model Practices described in the Joint Report.  Enhanced federal administrative 
match of 75% may be available for these activities if they are part of a medical and utilization 
review performed by certain utilization and quality control peer review organizations under 
subsections (b)(6)(i) and (b)(10) of 42 CFR 433.15. CMS encourages states to enlist the 
assistance of qualified entities in this important work. States may contact their CMS Regional 
Office to discuss the possibility of enhanced administrative matching and the development of an 
administrative claiming plan for CMS review and approval.  Likewise, states may also contact 
their Regional Office to determine the availability of 90% federal match for expenditures related 
to development of an automated data processing (ADP) system through the advanced planning 
document (APD) process under 42 CFR 433.112(a). 
 
CMS looks forward to working with states in continued efforts to assist Medicaid beneficiaries in 
maintaining community integration and receiving quality services.