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HCFA ROLLS OUT ABUSE AND NEGLECT TRAINING:

Providers Are Urged to Press for State Training

The Center for Medicaid and State Operations of the Health Care Financing Administration (HCFA) officially unveiled its new Abuse and Neglect Detection and Prevention Training at a Train-the Trainer course held May 2-3 in Baltimore, Maryland. The training was developed for application across a variety of provider types including Long Term Care Facilities (nursing homes), Home Health Agencies, Psychiatric Hospitals, and Intermediate Care Facilities for persons with Mental Retardation (ICFs/MR) and Waiver programs. HCFA’s training curriculum included a Train-the-Trainer content guide, as well as a Participant guide for direct surveyor/reviewer training.

The training course was offered to state agency and regional office trainers, surveyors and training coordinators, and included HCFA headquarters and regional office staff. ANCOR, as well as several other national provider and advocacy organizations, were invited to the two-day training session.

HCFA asked the state representatives at the two-day Train-the-Trainer session to provide training to their state’s surveyors/reviewers within 90 days. Although the training directive was targeted to state surveyors/reviewers, HCFA suggested that providers could also benefit from the training curriculum. HCFA encouraged states to find ways to offer the training to their provider communities.

The new Abuse and Neglect Detection and Prevention Train-the-Trainer curriculum does not represent any new regulation placed on providers. The curriculum provides surveyors/reviewers with a tool to use during the survey/review process—a way of organizing the process—to identify the presence of abuse and neglect.

Background

The Center for Medicaid and State Operations (CMSO) organized a workgroup in 1998 to identify what HCFA could do to bring about national attention and to correct the egregious cases of abuse affecting the elderly and people with disabilities. The issue had been spotlighted in the mid-1990s in relation to nursing homes; however, by the end of the decade, the problems of abuse and neglect were receiving attention in other settings.

In September of 1996, the Government Accounting Office (GAO) released a report concluding that the level of Federal oversight of institutions for persons with mental retardation should be increased. The report identified the potential for conflict of interest when states are both the operators and inspectors of ICFs/MR. In 1997, during partnership surveys of ICFs/MR, HCFA became alarmed by the number of serious and immediate jeopardy issues that were being cited during surveys. According to HCFA, in 1998, there were nearly 70 national media notices exposing cases of abuse and neglect and illicit restraints resulting in death, torture, and fraudulent behavior of staff toward people with developmental disabilities.

To combat these issues of abuse and neglect, HCFA undertook former President Clinton’s initiative Strategic Approach for Improvements to the Survey and Certification Program for Nursing Homes, and simultaneously established an Abuse and Neglect Prevention Forum. The initial focus was on beneficiaries who live in nursing homes as well as people with developmental disabilities who reside in congregate living settings (including individuals with developmental disabilities in Home and Community-Based Waiver Programs). However, HCFA broadened the effort to include home health agencies and psychiatric hospitals following reports of abuse and neglect of individuals receiving these services.

The Abuse and Neglect Prevention Forum included advocates, State agencies, providers (including ANCOR), and representatives from internal and external organizations and met for a year. The Forum identified Seven Key Components that form the basis of a comprehensive, proactive approach to the detection and prevention of abuse and neglect: prevent, screen, identify, train, protect, report and investigate, and respond. (A description of each of the components is located at the end of this article.) The intended impact of this framework is to encourage the initiation of proactive measures that will eliminate or reduce the factors that bring about abuse and neglect.

A number of different terms and definitions existed in Federal, state and local law, regulation, and guidelines for most entities; however, there was no single definition of abuse and neglect cross-cutting Medicare and Medicaid programs. The HCFA Forum looked at these definitions and established a single definition to apply to all certified Medicare and Medicaid entities.

To reflect HCFA’s concern that crisis situations in which the health and safety of individuals are at risk are accurately identified and thoroughly investigated as quickly as possible, Appendix Q (Guidelines for Determining Immediate Jeopardy) of the State Operations Manual was revised to include new material including the new Guidelines standardizing the Definitions of Immediate Jeopardy, Abuse and Neglect across all certified Medicare and Medicaid provider types, guidelines for determining immediate jeopardy, Recommended Key Components of Systematic Approach to Prevent Abuse and Neglect, and the process surveyors use in making a determination of immediate jeopardy.

What Does This Mean for Surveyors/Reviewers?

HCFA’s recommended review guidelines for surveyors/reviewers are offered for the purpose of facilitating the effective review of providers’ policies, practices, and overall approach to detecting and preventing the abuse and neglect of individuals to whom Medicaid and Medicare services are provided. It is HCFA’s hope that the identified Seven Key Components of an integrated approach to the detection and prevention of abuse and neglect will provide a framework for structuring the survey/review process to explore the depth and breadth of providers’ efforts at detection and prevention.

HCFA’s training curriculum is intended to provide a framework to guide surveyors/reviewers in the following ways:

• The focus of the curriculum is to provide a generic approach to the detection and prevention of abuse and neglect that can be applied across a variety of provider settings.

• The emphasis of the content is directed toward identifying the best practices in the approach to establishing and/or implementing policies, processes, or procedures that allow providers to detect the occurrence, and prevent the reoccurrence, of abuse and neglect. [NOTE: While there is no expectation that providers will have all of the identified practices in place, it is important for surveyors/reviewers to have a baseline from which to make a determination of a providers’ effectiveness at detecting and preventing abuse and neglect.]

• The Seven Key Components are to be utilized as a comprehensive proactive approach to the detection and prevention of abuse and neglect. The emphasis of the training is to explore whether providers have integrated abuse and neglect detection and prevention activities into their overall organizational operations, such as program assessment, planning, implementation, monitoring, and quality improvement.

• The materials and information provided are intended to supplement the ongoing survey/review process as opposed to creating an additional task. The aim of the training is to provide surveyors/reviewers with a tool that will allow them to integrate the exploration of providers’ abuse and neglect detection and prevention efforts into all aspects of the survey/review process.

What Does This Mean for Providers?

It is important that providers know what guidance is given to surveyors/reviewers and how it is to be used in the survey/review processes. Remember, this guidance is intended to provide a generic approach that can be applied across a variety of provider settings—including ICFs/MR and waiver programs.

Surveyors/reviewers are advised to utilize the recommended review guidelines within the context of their specific survey/review practices, and with the knowledge that not all provider settings will approach abuse and neglect detection and prevention in the same way. Although the approach HCFA presented is designed for application generically across a variety of provider settings, each provider’s efforts to address abuse and neglect should be viewed within the context of their regulatory requirements and restrictions, and their available resources.

While some of the information contained in the curriculum may be corroborated in regulation, it is not a regulatory guide. The curriculum is designed to be universally applicable to all provider types regardless of the regulatory language used. It is written with a focus on detection and prevention and with the understanding that surveyors/reviewers need to know and understand what constitutes an effective, proactive approach to the detection and prevention of abuse and neglect.

It is designed to give surveyors and reviewers basic information that can be applied during survey and review processes. Through observation and discussion during the survey/review process, the surveyor/reviewer can ascertain whether the provider has in place an integrated approach for preventing and detecting abuse and neglect—and whether that approach is understood by the individuals served as well as by the staff.

HCFA will be working with state training coordinators to ensure that the training to surveyors/reviewers takes place within 90 days. Sometime following the May training, HCFA transmitted a letter to state training coordinators regarding this training approach.

In addition to HCFA’s encouragement that this curriculum be passed along to providers, individual state representatives at the Baltimore training also emphasized the importance of providing this training to providers in their state. ANCOR was pleased to hear state representatives echo the need for this training to be offered to providers. However, there is no requirement that the state offer this training to any providers.

ANCOR believes that all stakeholders should be provided an opportunity to benefit from the same information that surveyors/reviewers receive on this important issue of abuse and neglect. In order for there to be an effective loop in this national effort to eliminate and reduce abuse and neglect, it is imperative that providers of supports to people with mental retardation and other disabilities receive the same training and guidance, as well as understand the Federal and state expectations regarding abuse and neglect prevention, presented at the Baltimore Train-the-Trainer course.

ANCOR will provide more information on HCFA’s Abuse and Neglect Detection and Prevention training at its September 2001 Governmental Activities Seminar. However, ANCOR recommends that providers take the following steps as soon as possible:

• State the Rationale: Let your state know that, as a provider, you would benefit from participation in your state’s efforts to implement HCFA’s Abuse and Neglect Detection and Prevention training. In order to provide an integrated approach to abuse and neglect prevention, it would be wise for states also to provide an integrated approach to training—one that involves providers as well as surveyors/reviewers.

• Create the Demand: All ANCOR members—including state provider associations—should contact their state’s office responsible for Medicaid surveys and reviews and request scheduling for training of HCFA’s Abuse and Neglect Detection and Prevention training.

• Plan Forums: Work with other providers in your state to create local or state forums at which the state trained surveyors/reviewers can provide the training to a critical mass of providers.

• Institute Your Own Train-the-Trainer and Integrated Approach: Select someone from your organization to receive the training. Create a train-the-trainer approach and involve your agency’s staff in an integrated system to detect and prevent abuse and neglect. Make sure that your agency’s approach to abuse and neglect prevention is also communicated to individuals who receive services and their families.

(NOTE: Information on Appendix Q (revised and transmitted August 25, 2000 as part of the State Operations Manual and made effective September 25, 2000) was presented by HCFA at ANCOR’s 2000 Governmental Activities Seminar and again during the December 13^th audio conference on the HCFA Federal Look-Behind ICFs/MR Surveys. Information on Appendix Q was also included in the December 23, 2000 electronic mail Washington Insiders Club Update #20-42 and in the February 2001 LINKS and. The State Operations Manual and Appendix Q can be download from HCFA’s web page at Appendix Q http://www.hcfa.gov/pubforms/pub07pdf/pub07pdf.htm )

HCFA's Seven Key Components to Reduce, Detect, and Prevent Abuse and Neglect.

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