Office of the Medicaid Inspector General Home Health and Personal Care Audit Protocols James R. Kaiser

OMIG Audit Process Engagement Letter Entrance Conference Field Work- 200 Service Sample Exit Conference Draft Audit Report Final Audit Report

Audit Protocols The protocols that have been developed are Drafts. Audit protocols are not static documents. Findings will be added, deleted, and refined as more audits are done. New audits will have the expertise of Nursing staff which will add a clinical perspective to the reviews.

No Documentation That Service Was Provided If the provider records lack sufficient documentation to show that the billed service was provided, the claim will be disallowed. Evaluated on a case by case basis. Opportunity to produce additional documentation. If documentation supports fewer hours than billed, the difference will be disallowed.

Billed for Services in Excess of Order or Not Consistent With POC Services billed that exceed the frequency(# of days) or number of hours per visit may be disallowed. Pattern of billing will be analyzed. Extenuating circumstances will be considered.

Missing Documentation of Nursing Supervision HH- RN Supervisory visit required every 14 days. The sampled claim will be disallowed if a direct supervisory visit with the aide present is not conducted within 30 days. PCA- RN Supervisory visits are required every 90 days. The sampled claim will be disallowed if a direct supervisory visit was not done within 120 days. This finding will only apply in Counties where the responsibility for nursing supervision lies with the provider.

Billed Medicaid Prior to Authorized Practitioner’s Signature All sampled services that were billed prior to the date of the practitioner’s signature on the order that covers this service will be disallowed.

Practitioner Signed Order/POC Beyond Required Time Frame HH- Initial signed orders are required within 30 days of start of care, change in POC, or recertification. The claim will be disallowed if the related order has not been signed within 60 days of the start of care, change in POC, or recertification. HH- POC’s need to be reviewed every 60 days. The claim will be disallowed if the review associated with this service is signed over 90 days from the previous review.

Comprehensive Assessment Not Completed/Late HH- A disallowance will be taken if more than 120 days has elapsed since the completion of the last comprehensive assessment. As providers should be re- evaluating each case on a 60 day POC recertification cycle, if the assessment is documented as part of the POC, this will not be an issue. The initial assessment should be completed within federal guidelines.

Billed With Incorrect Rate Code In the event that documentation supporting the sampled claim indicates that a rate code with a lower reimbursement rate should have been billed, the difference between the rates will be disallowed.

Billed Services Included in the Rate of a Resid. Health Care Setting If the billed services are included in the rate of the facility where the patient resides, the claim will be disallowed.

Billed Service Covered by Other Insurance If a sampled service was covered by third party insurance in whole or in part, the amount that Medicaid paid incorrectly will be disallowed.

Ordering Practitioner Conflicts With Claim Practitioner The ordering practitioner on the order related to the sampled service will be compared with the practitioner listed in the claim. Where the information differs and no documentation is provided to explain the discrepancy, the claim is subject to a partial disallowance.

Failure to Initiate the Completion of the Criminal History Check All sampled services provided after 9/1/06 for an employee hired after 9/1/06 will be disallowed if the provider or it’s contractor failed to initiate a criminal background check within specified time frames or appropriately follow up on results that require further action.

Failure to Complete Required Training HH- Sampled services provided by a CHHA or CHHA contract employee who has not completed the basic training requirements will be disallowed. The training program must be from a DOH or SED approved program. PCA- Personal Care Aides are required to complete 40 hours of training. PCA’s trained by another agency require a certificate, reference check, and competency evaluation. Services provided by employees who have not completed the required training will be disallowed.

Failure to Complete Required In- Service Training HH- Home Health Aides are required to have 12 hours of in-service training annually. If this requirement is not met over a 15 month period, the service will be disallowed. PCA- Personal Care Aides are required to have 6 hours of in-service training annually. If this requirement is not met over a 15 month period, the service will be disallowed.

Missing Certificate of Immunization Sampled services provided by an employee lacking required certification of immunizations will be disallowed.

Failure to Complete Required Annual Health Assessment HH- Sampled Services provided by a CHHA or CHHA contract employee who did not receive an annual health assessment within the previous 16 months will be disallowed. PCA- Sampled services provided by an employee who did not receive an annual health assessment in the previous 14 months will be disallowed.

Missing Documentation of a PPD Skin Test or Follow-Up HH- Home Health Aides are required to complete an annual PPD test. Sampled services provided by an employee who has not had a PPD skin test within the previous 16 months of employment will be disallowed. PCA-Personal Care Aides are required to complete an annual PPD test. Sampled services provided by an employee who has not had a PPD test within the previous 14 months of employment will be disallowed. Services provided by employees where the agency did not provide a PPD test at the time of hire or did not follow-up on a positive test will be disallowed.

Failure to Complete Required Orientation Visit PCA- A supervisory nurse must conduct an orientation visit in the patient’s home with the aide present within 7 calendar days of the aide being assigned to the case. Services will be disallowed if the agency records do not document the orientation visit.

Services Billed for An Employee in the Absence of Performance Eval PCA- Personal Care Aides are required to have a documented annual assessment. Services provided by an aide who has not had this assessment in the previous 14 months will be disallowed.

Failure to Complete Annual In- Home Visit PCA- Services provided by Personal Care Aides who did not have an annual in- home visit will be disallowed.

Services Performed by an Excluded Relative PCA- Services provided by relatives excluded by regulation from performing such services will be disallowed.

Incomplete Personnel Record Regulations require extensive documentation related to employment history, applications, dismissals along with requirements identified throughout the protocols. Services provided by employees with incomplete personnel records will be disallowed.