COFAR blog

The Inspector General’s Office for the U.S. Department of Health and Human Services has responded to our questions about the methodology underlying their report on abuse and neglect in residential facilities for the developmentally disabled in New York State.

As a spokesperson for the Office put it, in an email accompanying the Office’s responses, “I think you will see we were quite thorough in our work.”

I’ll summarize the Office’s responses below.  But we have to disagree with the suggestion that this report was thorough.  A six-page report (actually four pages if you leave out the methodology section) that contains no recommendations concerning a subject as serious and complex as abuse and neglect in a system with thousands of residential facilities and tens of thousands of program recipients cannot by definition be thorough.

As we noted previously, Senator Chris Murphy of Connecticut had asked HHS Inspector General Daniel Levinson in 2013 to investigate the privatized group home system around the country in the wake of exposes in both The Hartford Courant and The New York Times that revealed horrendous cases of abuse and neglect in group homes in their respective states.

A group home in Hudson Falls, NY, where a worker allegedly sexually assaulted a developmentally disabled woman, according to a New York Times report

The report released by the IG on New York State’s residential system is the first of three reports that the Office plans to issue in response to Murphy’s request.  Two additional reports are expected to be released, based on similar reviews in Massachusetts and Connecticut.

What the IG actually did in the first report was to conduct a review of the outcomes of hospital emergency room visits by residents of a selected sample of 12 Intermediate Care Facilities (ICFs) in New York State.  Those 12 ICFs were selected because more than 70 percent of the residents in each of the facilities had had an ER visit in 2012 and 2013.

While some of the ER visits were due to alleged abuse and neglect, the IG concluded that the incidents were reported to the appropriate agencies, and that the “vast majority” of the ER visits were due to underlying medical conditions of the residents.  The report noted that it contained no recommendations, and essentially concluded that the IG had found nothing wrong in the system.

Senator Murphy has not responded to queries from us as to whether he is satisfied with the IG’s work so far in response to his call for the investigation.

Below are the key questions we posed to the IG about the New York report and a summarization of the IG’s responses (not necessarily in the order we posed the questions):

1. What about deaths?

As we previously stated, the IG’s review appears to have been limited to outcomes of persons sent to ERs from a sample of ICFs. Sen. Murphy’s letter to the IG in 2013 specifically requested that Levinson investigate preventable deaths in group homes. In limiting his review to persons taken to ER’s, didn’t Levinson’s study miss deaths in which no one was taken to an ER?

The IG’s response stated that they reviewed all reported deaths involving the 109 residents of the facilities examined during the audit period.  There were a total of 12 reported deaths among the residents in seven of the 12 ICFs.  All 12 reported deaths were from natural causes, the IG stated.

This response demonstrates to us just how limited the selected sample of facilities was that the IG chose to review.  The New York Times reported in 2011 that 1,200 deaths in group homes in the past decade “have been attributed to either unnatural or unknown causes.”

In 2013, The Courant reported “dozens of developmentally disabled people who died in public and private group homes, institutions and nursing homes from 2004 through 2010 in cases where investigators cited abuse, neglect or medical error as a factor.”

As we noted, ICFs are a distinct category of residential facility for the developmentally disabled. They are required to meet strict federal standards for care under the federal Medicaid statute, and tend to serve profoundly disabled and medically involved people.

Also, it’s not clear how many, if any, of the ICFs examined by the IG actually were group homes. Many group homes operate under the Home and Community Based Settings (HCBS) waiver to the federal Medicaid statute, which exempts those homes from ICF requirements.

In their response, the IG’s Office stated that they first used a state computer database to identify Medicaid claims submitted by more than 1,100 residential providers for close to 41,000 intellectually disabled Medicaid beneficiaries in New York State.

The IG then determined that close to 23,000 of those beneficiaries had some 146,000 ER visits charged to Medicaid totaling $1.6 million.

The IG next determined that those beneficiaries resided in 33 state-operated and 395 privately operated ICFs.  Of that total of 428 ICFs, the IG selected 12 for which more than 70 percent of the residents had had an ER visit.  The review involved 109 residents of those 12 ICFs.

But it still isn’t clear to us how many, if any, of the facilities reviewed were actual group homes, which tend to have 6 residents or fewer in them, or why the IG appears to have limited their review to ICFs.

In their response, the IG stated that four of the 12 ICFs in their sample were actually “HCBS Waiver ICFs.”   I sent the IG’s Office a follow-up email to try to clarify this.  As I noted, it is our understanding that a group home or other facility that operates under the HCBS waiver is not considered an ICF, but is an “alternative” to an ICF.   I haven’t yet received a response to that request for a clarification.

The IG’s Office also hasn’t responded to a second follow-up question as to how many, if any, of the 12 ICFs reviewed were actual group homes.  Senator Murphy had asked for an investigation of group homes.

3. Could there be an overlooked variable biasing the results as a result of the IG’s methodology?  For instance, might a group of ICFs have a high percentage of patients admitted to ERs because those are the ICFs with the most medically fragile patients?

The IG’s response to this was that “the entire population in ICF’s is a fragile population,” and that “no bias was involved” in their method of selecting the 12 ICFs for review.

But this answer doesn’t respond to the question, which assumes that there are some differences in the average degree of medical fragility of residents in different ICFs.  Our guess is the IG’s sample is likely to have consisted of the ICFs housing the sickest residents on average. Those residents would be the most likely to die of “natural causes” rather than abuse or neglect.  So that might provide one reason why the IG did not find evidence of abuse or neglect in the deaths of the residents in those facilities.

3. Why did the IG look at data for only two years — 2012 and 2013?  Shouldn’t the IG have examined data over at least a 10-year period?

The IG’s response was that the process of identifying the Medicaid claims for 41,000 beneficiaries over two years took “a great deal of time and manpower,” and that the Office didn’t have the time or resources to do more.

5. Did the investigators interview staff, families etc. in any of the facilities?

The IG responded that all 12 ICFs were visited and that staff and beneficiary records were reviewed.  Apparently no staff or family members were interviewed.

In critiquing this report, we’re not trying to criticize the IG’s other investigations or audits of the health and human services system.  We think the IG took the wrong approach to this particular investigation.  It was an approach that took them nowhere, and the report reflects that.  To that extent, it was a huge missed opportunity.  As we noted in our last post, federal investigations of the privatized group home system have been few and far between.

Rather than using a questionable methodology to try to come up with their own data on abuse and neglect, the IG could have reviewed existing records on abuse and neglect that are available in state agencies in New York State.  At the very least, the IG could have tried to confirm the findings of the Times and the Courant.  Better yet, they could have looked at what actions have been taken in each state to address the newspapers’ findings, and whether those actions have resulted in any improvements that might have been reflected in the state agency data.

It probably goes without saying that the IG should have interviewed families of residents of the facilities they examined.

Despite any implications that might be drawn from the IG’s New York report, we’re sure the problem of abuse and neglect in the group home system has not gone away.  A systematic federal investigation of this problem is still sorely needed.