Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Missouri's Oversight of Certified Individualized Supported Living Provider Health and Safety Could Be Improved in Some Areas

Why OIG Did This Audit

States operate home and community-based services (HCBS) waiver programs under a waiver to their respective Medicaid State plans. States must ensure the health and welfare of the recipients of the service. Media coverage nationwide has highlighted injuries and deaths of these individuals, which were caused by abuse, neglect, and medical errors.

Our objectives were to determine whether Missouri: (1) exercised adequate oversight of individualized supported living (ISL) providers to ensure the health and safety of Medicaid recipients with developmental disabilities residing in ISL settings and (2) established infection control and prevention standards to prepare ISL providers for an emergency situation similar to the COVID-19 pandemic.

How OIG Did This Audit

We identified 218 Missouri-certified ISL providers that claimed a total of $132 million in Medicaid reimbursement during the quarter ended September 30, 2020. We selected 30 ISL providers and reviewed their most recent certification survey documentation and health and safety policies. We then selected 17 of those ISL providers for in-person site visits to their offices to review additional documentation.

What OIG Found

Missouri exercised oversight of ISL providers to ensure the health and safety of Medicaid recipients with developmental disabilities residing in ISL settings; however, improvements could be made. The State could not locate some of the certification survey supporting documentation for some of the providers, and the State completed some of the providers' certification surveys several months after the expiration of the providers' 2-year certification period. Furthermore, Missouri did not require providers to perform periodic background screenings of staff after hire. In addition, most of the 17 providers that we selected for site visits were missing at least some documentation of staff training, staff background screenings, staff driver's licenses, recipient rights reviews, or recipient monitoring. For our second objective, Missouri had infection control and prevention guidelines in place, and all 30 ISL providers had related policies, but the State did not have guidelines for refresher training of provider staff periodically after hire. Although Missouri established health and safety requirements and guidelines for ISL providers and exercised related oversight, some of those requirements and guidelines could be strengthened and Missouri's oversight could be improved to ensure the health and safety of recipients.

What OIG Recommends and Missouri Comments

We recommend that Missouri: (1) maintain all supporting documentation for certification surveys, (2) work to improve completion timeliness of the surveys, (3) consider strengthening background screening requirements for ISL providers to include periodic screenings of staff after hire; (4) continue to monitor ISL providers to ensure that they maintain documentation to support recipient health and safety; and (5) consider strengthening infection control and prevention guidelines for ISL providers to include periodic training of staff after hire. Missouri agreed with our first recommendation, concurred in part with our fifth recommendation, and described corrective actions that it planned to implement. Missouri did not concur with our second and third recommendations and disagreed in part with our fourth recommendation. We revised part of one finding and our fourth recommendation, slightly revised the phrasing of our third and fifth recommendation, and maintain that the rest of our findings and recommendations remain valid. We commend Missouri for the corrective actions that it described. We also acknowledge that Missouri and the ISL providers and recipients faced significant challenges during our audit because of the COVID-19 pandemic.

Filed under: Centers for Medicare and Medicaid Services