SOURCE (Service Options Using Resources In Community Environments) GACCP Summer Conference 2011

Presenters Heather Fries, BA, MS Edith DeLoach, LPN John Albright, MHA CEO of Nightingale Services GACCP Board Secretary Chairman of Billing Committee Edith DeLoach, LPN Director of Quality Assurance for Nightingale Services John Albright, MHA Director of Licensure & Expansion for Nightingale Services

Presentation Overview Required Documentation for Community Service Providers 17 GMCF UCR Criteria for Source PSS Audit Specific SOURCE Forms Reviewed by GMCF Policy Requirements for Onsite Review Recoupable Deficiencies Appeals Process Post SOURCE Audit

SOURCE PROVIDED DOCUMENTATION Source Chapter 903.5(A) Program Admission Upon completion of enrollment and initiation of services, case manager will provide the following completed documents to all community service providers: MDS-HC, SOURCE Assessment Addendum, and MDS-HC signature page (Apx. T) RN signature and date SOURCE Level of Care Placement Instrument (Apx. F) Must contain Physician and RN signatures with dates Level of Care Justification The SOURCE Carepath Member Version of Carepath Rights and Responsibilities Authorization for Release Member Referral Form Member Information Form (MIF) Advance Directives (If Applicable) Direction’s to the Member’s Home All Services Ordered Must Be Listed on the Appendix F….ONLY EXCEPTION is if the member is not due for a reevaluation and the new service ordered does not require a reevaluation/reassessment….The services added on the Carepath and indicated as ordered by physician.

17 UCR Medical Record Audit Criteria Member Version of the Care Path MDS-HC Provider Referral Form Supervisory Visits Clinical Progress Notes Service Record Form Services and Frequency of Visits According to P.O.C Provider/Nursing Care Plan Quality of Care Emergency Procedure Plan Advance Directives Directions to Client’s Home Recommendations Other Deficiencies Billing Discrepancies Level of Care Criteria Correction/Alteration of Records

1. Member Version (Pg 1)

Member Version (Pg 2)

2. MDS - HC ****MDS-HC: Multi Data Set – Home Care*****

3. Provider Referral Form

Clinical Progress Notes 4. Supervisory Visits > Every 62 days for clients receiving more than 24 units of service per week > Every 92 days for clients receiving 24 units or less of services per week Clinical Progress Notes > RN must review, sign, and date all entries made by non-licensed staff

6. Service Record Form (Task Sheet) > Documentation adequately supports the services billed 7. Services and Frequency of Visits According to P.O.C > All services must be rendered with a certified LOC and be reflected on the Member Referral Form and MIF

8. Provider/Nursing Care Plan > Must Reflect SOURCE Care Plan and be formulated by an RN and reviewed during each Supervisory Visit. Quality of Care > Must meet professionally recognized standards of health care.

10. Emergency Procedure Plan > Must have written plan Advance Directives > Must have documentation in the clinical record indicating whether or not an AD has been executed

12. Directions to Client’s Home > Must Be Specific and Up to date Recommendations > DMA’s UR may recommend a reduction in the level of services

Billing Discrepancies 14. Other Deficiencies > Provider must comply with all of the Department’s requirements applicable to the category of service in which the provider participates Billing Discrepancies > Documentation supports every unit billed

16. Level of Care

17. Correction/Alteration of Records > Must be corrected according to current standards of medical practice. > Corrections shall evidence the error, the correction, the initials of the corrector, and the date of the correction. Example: PSS 3x/wk PSS 2x/wk (3/21/2011)

UCR Audit Policy Requirements Maintain Clinical Records of All Members RN’s MUST Have a Current Unrestricted License LPN’s MUST Have a Current Unrestricted License CNA‘s must have Current Unrestricted Certification or 40 Hrs of Training Documented in the Personnel File with Current CPR and First Aid Certification Provider’s must be currently, fully licensed by DCH CPR and First Aide Certification Must Have Both on the Card

UCR Audit Policy Requirements Program Evaluations Done Annually Provider’s P&P’s comply with Requirements as outlined by: Part I: Medicaid/PeachCare for Kids P&P’s (Ch 100 – 500) Part II: CCSP PSS P&P’s (Ch 600 – 1000) Providers will not be reimbursed for services furnished, ordered, or prescribed in relation to an individual or entity who has been terminated from the SOURCE Program. Providers may not employ or contract with a person, partnership, or corp. previously terminated ****6**** Program Evals must be maintained and used to improve the quality of services provided

Recoupable Deficiencies Possible Recoupment Supervisory Visits Not Conducted within the Required Timeframe Service Record Form (Task Sheet) Quality of Care Correction/Alteration of Records Level of Care Expired or Member Doesn’t Meet Requirements Member under Appeals Process Guaranteed Recoupment Billing Deficiencies Over Bill, No Supporting Documentation Service Record Form is directly tied to Billing Deficiencies…..Must have documentation to support every unit that was billed Quality of Care Must Meet Current professional standards of health care Correction/Alteration of Records must be done in the correct format Level of Care…..Must meet the qualifications for Nursing Home Placement, Signed by Physician and Certified by the SOURCE RN

Appeals Process SOURCE MEMBER IN APPEAL Continue Services if Member is in the Appeal Process You will continue to be reimbursed while appeal is in place If recipient is denied the LOC at the appeal, then you would discharge at that time If the reviewer looks at a record that is in appeal for LOC denial and there is no current LOC, then the reviewer will not recoup on the absence of the LOC See CCSP manual Section 605.1D EXCEPTION (April 1, 2011…pg VI-39 top of page), of which SOURCE is bound to this policy statement)

Post SOURCE UR Audit Plan of Correction Recoupment Payment Must be Done within 15 Days of receipt of Final Report All Deficiencies must be addressed, regardless if Administrative Review is requested Recoupment Payment Payment must be made within 30 Days of receipt of Final Report Administrative Review Only Pertains to Recoupment Amount Must be Requested within 30 Days Do Not Issue Payment Until Admin Review Decision is Granted I STRONGLY RECOMMEND…AT ANY TIME DURING AN AUDIT IF YOU HAVE QUESTIONS…PLEASE CONTACT MR LEROY ALTMAN FOR CLARIFICATION

Questions?