October 1999

A Performance Audit of Home Health Care Oversight

HOME HEALTH CARE
IN PENNSYLVANIA

Minimum Standards Usually Met, But
More Can Be Done To Ensure Quality Care

Pennsylvania Department of the Auditor General
Auditor General Robert P. Casey, Jr.

 

 

Letter From the Auditor General

October 26, 1999

 

 

The Honorable Thomas J. Ridge
Governor
Commonwealth of Pennsylvania
Harrisburg, Pennsylvania 17120

Dear Governor Ridge:

This report contains the results of the Department of the Auditor General's performance audit of home health care oversight in Pennsylvania and covers the period July 1, 1996, to April 20, 1999. The audit was conducted pursuant to Section 402 of The Fiscal Code and in accordance with Government Auditing Standards, issued by the Comptroller General of the United States, which require, inter alia, that audit organizations maintain independence so that their opinions, conclusions, judgments, and recommendations will be impartial and will be viewed as impartial by knowledgeable third parties.

Chapter I of the report discusses the results of our audit of the licensure and certification process performed by the Department of Health. Although the Department of Health was timely in conducting licensure inspections and certification surveys, the timing was so predictable-and the issues surveyed so standard-that agencies could have temporarily hidden deficiencies. Chapter II reports on the Department of Health's complaints and sanctions systems; it also details how Health does not impose sanctions on home health care agencies that have been cited for serious deficiencies. Chapter III discusses the payment process for billings and claims, while Chapter IV reports on quality of care issues.

Our approach included a review of applicable federal and state statutes, regulations and program policies. We also obtained and analyzed data, examined case records, interviewed caregivers, surveyed program recipients and examined various documents relating to the programs.

The contents of the report were discussed with management of the Departments of Aging, Health, and Public Welfare, and their written responses are incorporated into our report.

On behalf of the Department of the Auditor General, I want to acknowledge the cooperation extended to us by the Department of Aging and the Department of Health, and by some of the management and staff of the Department of Public Welfare.

Sincerely,
 
Robert P. Casey, Jr.
Auditor General

 


Contents

Results in brief

Introduction: Home health care’s emerging role

Background: Home health care in Pennsylvania

Audit objectives

Chapter I: Licensure and Certification

--Objectives and Methodology

--Conclusion 1

--Conclusion 2

--Conclusion 3

--Conclusion 4

--Conclusion 5

--Conclusion 6

--Conclusion 7

--Conclusion 8

Chapter II: Complaint System and Sanctions

--Objectives and Methodology

--Conclusion 1

--Conclusion 2

Chapter III: Payments for Billings and Claims

--Objectives and Methodology

--Conclusion 1

--Conclusion 2

--Conclusion 3

--Conclusion 4

Chapter IV: Quality of Care

--Objectives and Methodology

--Conclusion 1

--Conclusion 2

--Conclusion 3

--Conclusion 4


Appendices

 

Appendix A: Organization Chart

Department of Aging

 

Appendix B: Organization Chart

Department of Health

 

Appendix C: Organization Chart

Department of Public Welfare

 

Appendix D: Audit Sample

Methodology and Description

 

Appendix E: Medicare

Conditions of Participation

 

Appendix F: Sample Survey Form (1 of 4)

Appendix F: Sample Survey Form (2 of 4)

Appendix F: Sample Survey Form (3 of 4)

Appendix F: Sample Survey Form (4 of 4)

 

Appendix G: Summary List of

Deficiencies of 22 Home Health Agencies

 


Results in Brief

In 1997, nearly 250,000 Pennsylvanians confined to their homes because of illness or injury received home health services paid for with government dollars. Footing the bill were the federal Medicare program, the state’s Medicaid program, and two state non-Medicaid programs. Services provided were skilled nursing care on a part-time or intermittent basis, physical and occupational therapy, speech language pathology services, medical social services, and part-time or intermittent personal care related to the treatment of illness or injury. In all cases, in order for public funds to be used for these services, a physician was required to (1) certify that care in the home was necessary and (2) establish an appropriate plan of care.

The use of home health services grew dramatically from 1990 to 1997, as did the number of home health agencies that provided the care. In 1990, for example, the nation had 5,642 Medicare-certified home health agencies, including 249 in Pennsylvania. By 1997, the nation’s home health agencies had nearly doubled to 10,524, including 381 in Pennsylvania.

Unfortunately, there was also waste, fraud, and abuse that occurred with this rapid growth. While agencies received payments based on documentation they provided, in many cases they billed the government for services that were not medically necessary and/or should not have been paid for with public dollars.

For these reasons, government-paid home health care benefits fell under increasing federal scrutiny. To curb the rising and unsustainable costs, the federal government imposed limits on payments made to home health agencies. In addition, from mid-September 1997 to mid-January 1998, there was a moratorium on home health agencies entering the Medicare program.

As of January 1, 1999, there were 9,263 Medicare-certified home health agencies, including 370 in Pennsylvania. Although these numbers show a slowed growth of home health agencies, the oversight of home health care should be no less important. In Pennsylvania, home health care falls under the oversight of three state agencies: the Department of Health, the Department of Public Welfare, and the Department of Aging.

  • The Department of Health (Health) is responsible primarily for licensing and inspecting Pennsylvania’s home health agencies, and for resolving complaints;
  • The Department of Public Welfare (DPW) is responsible for processing claims and making payments under the Medical Assistance (Medicaid) program; and
  • The Department of Aging (Aging or PDA) is responsible for the oversight of the non-Medicaid OPTIONS program and the Medicaid-funded PDA Waiver program.

During our performance review for the period July 1, 1996, through April 20, 1999, we found that the three state agencies had mixed records in their oversight responsibilities.


Although the Department of Health generally ensured that minimum standards were met, it must go beyond those minimum standards to ensure better care and safety for home health patients.

The Department of Health should be commended for ensuring that agencies are licensed and inspected in a timely manner, and for making sure that comprehensive patient care plans are developed and followed. In these ways, Health has contributed to quality care for Pennsylvanians in home health care settings.

Our audit showed that there is much more work to be done, however, and that Health’s commitment should be greater. For example, although Health was timely in conducting licensure inspections and certification surveys, the timing was so predictable—and the issues surveyed were so standard—that agencies could have temporarily hidden deficiencies. By better staggering its surveys, by conducting unannounced additional inspections, and by expanding its surveys beyond the standard issues, Health could achieve more realistic results.

 

In cases where deficiencies were found, there was generally no on-site follow-up but rather a self-certified compliance. We question the appropriateness of this "honor system" in an oversight setting where people’s health—indeed, their lives—are at stake.

When Health did cite agencies for deficiencies, we found no sanctions imposed—no provisional licenses, no revocations, no fines—even in one instance where Health found deficiencies following a child’s death. Just as sanctions can be an incentive to compliance, the lack of sanctions can deter it.

The lack of survey documentation thwarted our ability to draw conclusions in several areas. For example, we could not determine conclusively whether Health enforced in-service training requirements for home health aides or appropriately evaluated them for competency. It is our position that when Health does not enforce these types of licensing and certification requirements, or when it retains no documentation to show otherwise, then patients and their families cannot be confident of the state’s protective oversight. The issue therefore becomes larger than licensure and certification requirements. In short, it becomes one of quality care.

We also noted that Health does not require home health agencies to cross-check names of home health aides with Health’s existing Nurse Aide Registry to identify nurse aides with abuse histories.

We looked for reasons to explain why Health does not go beyond the minimum requirements to ensure quality care for home health patients in this Commonwealth. One factor—the commitment and dedication of resources—stands out. We note that, during the period of our audit, Health’s Division of Home Health had varying oversight responsibilities for more than 400 other facilities, including rural health clinics, hospices, birth centers, end-stage renal disease facilities, comprehensive outpatient rehab facilities, and outpatient physical therapy/speech pathology facilities. With responsibilities so numerous, the Division of Home Health may have staffing constraints that do not allow for expanded surveys, additional unannounced inspections, or on-site follow-ups when deficiencies are found.

 

Whatever the reason, however, it is Health’s responsibility to take action to improve its oversight by going beyond the minimum requirements. If more staff is needed, Health must take action to request it or to move it from areas less critical. If sanctions are needed to illustrate seriousness and to demonstrate its commitment to improving deficient facilities, then Health must take action to impose those sanctions available to it.


Recommendations for the Department of Health

In the report that follows, we make ten recommendations for the Department of Health:

  1. Health should stagger the timing of its surveys not only to meet time requirements but also in a way that timing is not as predictable as in past practice. [p. 17]
  2. Health should periodically survey selected agencies to ensure their compliance with all 12 Medicare conditions of participation. [pp. 18-19]
  3. Health should use significant growth as a determinant in identifying home health agencies for on-site surveys [p. 21]
  4. Health should develop and disseminate universal measurement criteria to guide agencies in their competency evaluations of home health aides. [p. 23]
  5. Health should require that home health agencies report annually whether the aides they employ have completed the required 12 hours of in-service training. [p. 25]
  6. Health should retain all survey documentation so that results can be supported and, if necessary, independently verified. [p. 27]

  7. Health should require home health agencies to check the existing long-term care Nurse Aide Registry to verify that home health aides are not among the nurse aides banned from employment in nursing homes. [p. 30]
  8. Health should evaluate and, if necessary, add to its complement of surveyors in order to expand its oversight function. [p. 33]
  9. Health should make use of the full range of sanctions for home health agencies that do not comply with applicable laws and regulations. [p. 46]
  10. Health, along with Public Welfare and Aging, should require home health agencies to review the Medicheck list to ensure the agencies do not conduct business with entities precluded from Medicaid participation. [p. 63]

The implementation of these recommendations will expand the Department of Health’s existing commitment to its oversight of home health care in Pennsylvania. Visible action must begin with the senior staff at Health and continue throughout the entire organization.


The Department of Public Welfare, with one exception, should be commended for ensuring that public funds pay for home health services that are authorized, approved, allowable, and provided.

The Department of Public Welfare, according to our audit, has implemented various controls to safeguard against unnecessary or inappropriate use of Medicaid funds for home health care services. The Surveillance and Utilization Review Subsystem is one such control.

By interviewing DPW staff and by reviewing documentation related to the above system, we were able to gain assurances that it was operating as intended.

In addition, we visited 20 home health care agencies and reviewed 94 patient files to evaluate whether DPW monitored claims and payments made under the fee-for-service component of its Medicaid program. Our evaluation enabled us to conclude that DPW, except as noted below, ensured that public funds paid for home health care claims that were properly authorized, approved, allowable, and actually provided.

The exception to DPW’s effective oversight occurred in the Michael Dallas Model Waiver program serving 29 homebound children. In just one sample, we found that DPW’s oversight staff allowed $24,000 in improperly supported claims; in another sample, we found that the quality and quantity of care and services were not provided according to patients’ plans as required. Ultimately, we concluded that DPW compromised the quality of care to the Michael Dallas Model Waiver patients by not exerting adequate oversight of its waiver program staff.


Recommendations for the Department of Public Welfare

We make the following three recommendations:

  1. DPW should more actively and carefully monitor the Michael Dallas Model Waiver program to ensure that invoices can be supported by original documentation. [p. 57]
  2. DPW should require home health agencies under its oversight to review the Medicheck list to ensure they do not conduct business with entities precluded from Medicaid participation. [p. 63]
  3. DPW should ensure quality care for children in the Michael Dallas Model Waiver program by improving compliance with program requirements, specifically in records retention, patient and family communications, and written updates of patient care. [p. 70]

The Department of Aging has effectively monitored the two programs for which it is responsible.

The Department of Aging should be commended for its oversight of the OPTIONS home health program funded by state lottery proceeds, as well as the PDA Waiver program funded by Medicaid dollars.

The OPTIONS program, administered by a majority of the 52 Area Agencies on Aging, included home health care expenditures of $5.17 million. We visited five Area Agencies on Aging and reviewed 18 reports. Our evaluation allowed us to determine that the Department of Aging ensured that the agencies provided fiscal and administrative oversight of their home health providers.

For the PDA Waiver program, we reconciled bills and claims with treatment programs in order to determine that the Department of Aging had ensured the propriety of payments for billings and claims. In that way, we also determined that treatment plans had been followed, a major factor in determining that quality care had been provided.


Recommendation for the Department of Aging

We make the following recommendation:

  1. The Department of Aging should require the home health agencies under its oversight to review the Medicheck list to ensure they do not conduct business with entities precluded from Medicaid participation. [p. 63]

 

 

Home Health Care

In Pennsylvania:

Minimum Standards

Usually Met, But

More Can Be Done

To Ensure Quality Care

A Performance Audit of Home Health Care Oversight

Pennsylvania Department of the Auditor General

Auditor General Robert P. Casey, Jr.

 

 

October 1999


Introduction

The role of home health care continues to emerge.

Federal Medicare and state Medicaid programs allow people with illnesses or injuries to receive skilled nursing, therapy, and related services in their homes rather than in health care facilities. Home health care is the term used to describe such care.

According to a report by the U.S. General Accounting Office (GAO), home health care was one of Medicare’s fastest-growing benefits during much of the 1990s.1 For example, home health care expenditures represented 3.2 percent of total Medicare spending in 1990; by 1997, they had jumped to 9 percent. In fact, while the overall Medicare program grew annually by 8 percent from 1990 to 1997, the home health care portion grew annually by an average of 25.2 percent. GAO also found that, during that same period, home health care users per 1,000 Medicare beneficiaries grew from 57 to 109, with the average number of visits per user going from 36 to 73.

GAO’s report summarized this growth as follows:

Dramatically rising expenditures resulted in home health care consuming about $1 of every $12 of Medicare outlays in fiscal year 1997 compared with $1 of every $40 in 1989. This growth was primarily due to more beneficiaries receiving services and more home health visits being provided to each user. While changes in practice patterns and in the need for home health care contributed to this increased utilization, the inappropriate delivery of services as well as fraudulent billing practices also added to Medicare’s spending.

Congress addressed home health care spending and oversight in the Balanced Budget Act of 1997 (the Act), which required changes in the way home health care benefits were paid. The Act mandates a change from cost-based payments to a prospective-based system using fixed, predetermined rates. An interim system implemented October 1, 1997, is now in place.

 

A result of the interim payment system is that some home health agencies have closed. The home health care industry in particular has raised concerns about these closures, claiming that patients’ access to home health services has been reduced. The GAO report examined these concerns and found that, even though closures continue, there is little evidence that patient access has been decreased and, in fact, that closures have been secondary to the rapid growth.

Despite GAO’s conclusion that patient access has not been impaired, and even though rapid growth rates had slowed by 1998 and payment issues are being addressed, there is still reason to be concerned about home health care’s emerging role. The oversight of home health care agencies and services is of particular interest as patients continue to rely on such care. Exact definitions and models of home health care vary across the nation and even within a single state. In addition, even with federal standards to assist in measuring the adequacy and effectiveness of state-funded home health care, states may apply those standards differently. The lack of clear definitions and uniform enforcement gives rise to concerns among home health care recipients, families, patient advocates, and government watchdogs. For example, is the industry being monitored effectively? Is it growing too quickly for the applicable state agencies to keep pace? How do we know if the quality of care is adequate? Are our tax dollars being spent for care that is not only allowable but actually provided? Do consumers know enough about home health care to make wise decisions? All are questions that we set out to answer for the people of Pennsylvania.


Background

Home health care oversight in Pennsylvania was audited for the period of
July 1, 1996, to
April 20, 1999.

The report that follows discusses results of a performance audit of Pennsylvania’s program for Medical Assistance Home Health Care Services for the period of July 1, 1996, to April 20, 1999.2

Concerned about the emerging role of home health care, the National State Auditors Association (NSAA) chose home health care as its topic for a 1998 joint audit in which state audit agencies could choose to participate. The Pennsylvania Department of the Auditor General, led by Auditor General Robert P. Casey, Jr., agreed to accept the lead role in this multi-state project contingent on two parameters: first, that a minimum of eight states participate in the joint audit; and, second, that the participating states pursue four common objectives. Eleven state audit agencies3 chose to participate, and they identified core objectives in four areas: licensure and certification, complaint systems and sanctions, payments and billings, and quality of care. Fieldwork started early in 1998, with the 11 agencies planning first to audit home health care in their own states and later to combine the resulting reports into a consolidated report.


Administration and oversight of home health care services in Pennsylvania are shared by three state agencies.

In defining home health care in Pennsylvania, we reviewed pertinent laws cited and provided by the three state agencies responsible for home health care services in this state: the Department of Aging, the Department of Health, and the Department of Public Welfare. By reviewing the laws and other materials and documents, and by interviewing staff from the three agencies, we determined that the Department of Public Welfare administers the major share of public funds to support home health care programs, followed by the Department of Aging. The Department of Health licenses home health agencies and conducts certification surveys for the federal Health Care Financing Administration (HCFA); the Department of Health also investigates complaints about home health care providers.

All three state agencies provided different—although similar—definitions of home health care4 5 6 based on relevant laws or documentation. For purposes of this audit, we chose to define home health care services using parameters agreed to by the 11 participating NSAA states and that encompass the pertinent criteria from the three Pennsylvania agencies’ definitions. Therefore, the parameters that determine home health care services include the following:

  • The services are authorized by a physician or other health care professional;
  • The services are of a medically related nature and do not include ancillary services such as housekeeping, transportation, and meal preparation; and
  • The services are provided by a state-licensed, state-regulated, or HCFA-certified provider.

Pennsylvania pays for home health care services for eligible persons through its Medicaid fee-for-service and waiver program components, and also through non-Medicaid programs. In planning our audit, we requested that the Department of Public Welfare provide us with a list of program areas that include home health care services within the parameters listed above.


 

The Medicaid fee-for-service program pays for most state home health care coverage.

The Medicaid fee-for-service program funds specific and medically necessary home health care services that are provided to eligible recipients by enrolled program providers. Recipients of such services must be certified as homebound due to injury or illness, with "homebound" meaning that the recipient’s condition restricts him or her from leaving the residence without assistance.


Waiver programs pay for home health care services beyond those normally covered by Medicaid.

Requested by states and authorized by the federal government, waiver programs allow state Medicaid programs to extend their home health care coverage beyond that covered in the state plan.7 As such, services normally covered only if provided in a hospital or nursing facility are covered in a home- or community-based setting. The programs are evaluated annually for cost effectiveness; services must cost no more than they would cost if provided in an institutional setting. Waivers are initially granted for three years and may be renewed for five-year periods. Examples of waivers in Pennsylvania include the following:

  1. The Pennsylvania Department of Aging Waiver covers individuals 60 and over who are eligible for nursing facility care but choose to receive their care at home or in a community setting. During our audit period, this waiver was offered through 13 Area Agencies on Aging covering 21 counties that had nursing home bed shortages.
  2. The Managed Care Waiver covers services to homebound patients of certain managed care providers who are awarded contracts through a competitive bidding process. During our audit period, this waiver was available in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
  3. The Acquired Immune Deficiency Syndrome/Human Immuno Virus Waiver covers services to homebound AIDS/HIV patients.

  4. The Michael Dallas Model Waiver covers services to homebound children needing a medical device to stay alive.
  5. The Mental Retardation Waiver covers services for mentally retarded persons who would otherwise need care in an intermediate care facility for the mentally retarded.
  6. The Omnibus Budget and Reconciliation Act Waiver covers services for inappropriately institutionalized mentally retarded/developmentally disabled persons.
  7. The Early Intervention Waiver covers persons with mental retardation and other related conditions and is targeted to infants, toddlers, and families.
  8. The Independence Waiver covers developmentally disabled persons who otherwise would reside in a nursing facility.

Two non-Medicaid programs also
pay for home health care.

The Family-Based Mental Health Program provides mental health services to previously institutionalized individuals now residing in a community or home setting. Begun in July 1998, the program addresses the psychiatric needs of those individuals with the goal of allowing them to live at home or in the community on a long-term basis.

The OPTIONS Program provides 14 long-term care services to homebound frail and disabled adults so they can reside at home or in the community rather than in a long-term care facility. Funded by state lottery proceeds and administered by the Department of Aging, OPTIONS covers people 60 and older who need assistance with multiple activities for daily living, and also people 18 and over who are clinically eligible for nursing home care.


Four programs
were selected for further testing and review.

To carry out this performance audit, we chose a sample representative of Pennsylvania’s full spectrum of home health care programs. Our strategy was to examine the program with the largest expenditures, which is the Medicaid fee-for-service component, and to review at least two waiver programs and one non-Medicaid program.

Therefore, we selected the following four programs for testing and review:

  • Medicaid fee-for-service component
  • Pennsylvania Department of Aging Waiver program
  • Michael Dallas Model Waiver program
  • OPTIONS program

Audit Objectives

In conjunction with the National State Auditors Association, we established the following four broad objective areas:

  1. Licensure and Certification - Determine if the state agency is ensuring that providers are meeting state licensure/certification requirements and if those requirements are sufficient.
  2. Complaint System and Sanctions - Determine the adequacy of the state agency’s process to monitor complaints about service providers.
  3. Payments for Billings/Claims - Determine whether the services billed for clients by the providers are properly authorized, approved, allowable, and provided.
  4. Quality of Care and Case Management Practices - Determine whether the appropriate state agency has procedures in place to ensure that quality care is provided to clients.

Our report is divided into four chapters that address each of these objective areas and their methodologies, as well as our conclusions and recommendations.

Please note that additional detail is included in the appendices.


Chapter I:

Licensure and Certification

In the area of licensure and certification, we determined whether the Department of Health ensured that home health care providers met the applicable licensure and certification requirements and if those requirements were sufficient. Specifically, we studied (a) whether Health conducted the necessary survey/inspection procedures prior to licensure and certification and (b) whether Health’s surveys were sufficient to ensure provider compliance with applicable laws, rules, and regulations.

At the start of our audit in early 1998, there were 103 home health agencies that were state-licensed only; there were 370 agencies that were both state-licensed and certified to participate in the Medicare/Medicaid program.8

 

Licensing

State law requires home health agencies to obtain a license annually from the Department of Health.9 Regulations also require Health to conduct an annual survey, which may or may not include an on-site inspection. The annual license is issued only after the survey shows that the applicant complies with home health agency rules and regulations, and that the agency provides services that are safe, efficient, and adequate for patients’ care, treatment, and comfort. In years when Health does not conduct an on-site survey of a particular agency, the agency must respond to a written survey instrument. The written instrument fulfills the annual survey requirement and affords Health a tool—albeit a limited one—to ascertain if the agency remains in compliance with the law.

In cases where an agency has had numerous deficiencies or a serious specific deficiency, Health has the option to issue a provisional license for a period of less than a year. Provisional licenses are not issued for periods exceeding six months and may not be renewed more than three times.

According to Health, there has never been a provisional license issued to a home health agency in Pennsylvania. The absence of provisional licensing might suggest that all home health agencies in Pennsylvania have complied with the necessary minimum standards and have had few or no deficiencies; on the other hand, it could also suggest that Health has demonstrated unusual forbearance in noting deficiencies and assessing sanctions.

 

Certification

For agencies choosing to participate in the Medicare and Medicaid programs, there is a HCFA certification process. This process is conducted concurrently with the state licensing process, and home health agencies that meet the federal certification requirements are deemed to be in compliance with the state licensure requirements.

For each of the first three years, an on-site visit is required for certification renewal; after that period, on-site visits for recertification take place every 12, 24, or 36 months based on specific determinants spelled out by HCFA. For example, a 12-month on-site survey is required for agencies with less than three years of Medicare approval or with a Medicare condition deficiency in the last two years or with a complaint-based deficiency citation since the last survey or with a change in ownership since the last survey. On the other hand, a 36-month on-site survey interval is allowed for agencies with no Medicare condition deficiencies in the last three years and no other deficiencies in the last standard survey and no complaints that resulted in deficiency citations.

Home visits are another part of the certification survey procedure. Generally, three to five home visits are made for each licensed home health agency.

Surveys—whether for certification or licensure—review standards of care, personnel qualifications, maintenance of clinical records, and resolution of complaints.

 

Objectives and Methodology

In order to address the broad objective of ensuring that providers met state licensure/certification requirements and if those requirements were sufficient, we established more specific objectives as follows:

  • Determine whether Health conducted the necessary inspections before issuing a license;
  • Determine whether the inspections ensured that providers complied with the appropriate laws, regulations, and rules; and
  • Determine if Health ensured that agencies maintained compliance with the federal conditions of participation in the Medicare program.

Our work employed the following methodology:

  • We obtained and reviewed state and federal laws and regulations to determine the licensing requirements for Pennsylvania home health agencies.
  • We interviewed Health personnel to determine the policies and procedures for licensure and certification surveys, and also to obtain an overview of the staff training and continuing education programs.

  • We performed procedures to determine if Health verified that home health agencies conducted criminal background checks of their employees. State law requires these checks.
  • We reviewed Health’s files to ensure that deficiencies cited during surveys were followed up, and also to determine the licensure and certification histories for 53 home health care agencies, some of which were selected at random, and others according to our auditors’ professional judgment.
  • We conducted site visits to 20 of those agencies to determine compliance with specific conditions of participation, including verification of home health aide competency and evaluations, professional licenses, and annual agency program evaluations.
For the 53 agencies we selected for file review, our methodology included the following:
  • We reviewed any applicable survey deficiency reports issued by Health, and we followed up to verify that the agency had corrected the deficiency within 90 days.
  • We analyzed the three most recent surveys of each agency to determine if Health staggered the timing so that agencies will be less able to predict when a survey would occur.
  • We analyzed the patient census numbers for each agency for the three most recent surveys to determine if there were large increases that, in turn, should trigger an on-site survey.
  • We determined if the agency had branch offices and, if so, how Health surveyors verify compliance for branch offices.
  • We reviewed nine files for agencies that were licensed after July 1, 1997, to verify that eligibility was determined and surveys conducted prior to licensure and acceptance into the Medicaid program.

The Department of Health ensured that home health agencies were surveyed and inspected prior to initial and subsequent licensure, but it should do more to ensure greater safety and care of home health patients.

Conclusions and Recommendations

Our testwork from the 20 home health agency visits and the 53 agency file reviews disclosed the following results:

  • All agencies were appropriately licensed.
  • All agencies had been surveyed and inspected by Health prior to licensure.
  • Health completed its surveys for each agency in accordance with HCFA survey frequency guidelines.
  • Health surveyors completed the appropriate number of clinical record reviews and home visits at each of the agencies; the surveyors performed additional clinical record reviews in cases where the number of home visits fell short of the required number.
  • Of the 28 agencies with deficiencies, two had repeat deficiencies that, according to our follow-up reviews, were corrected within the 90-day mandated time period.

Additionally, our interviews with Health surveyors disclosed that all surveyors had received the required initial training and orientation for the Health Facilities Quality Examiner position. (We noted, however, that unlike many occupations or professions, Health surveyors have no continuing education or annual training requirements.)

Health should be commended for its timeliness in meeting the federal guidelines required for Medicare certification and state licensure, and for monitoring compliance with related minimum standards. But, as our testing disclosed, there are issues left unaddressed when Health limits its oversight to just the minimum requirements, or when it interprets and/or enforces those minimum requirements leniently. In particular, we note the following:

  • Health did not stagger the timing of its surveys, resulting in home health agencies being able to predict when they would be surveyed and to prepare for those surveys. See
  • Conclusion 1. [p. 16]

  • More than 96 percent of the surveys we reviewed were standard surveys, meaning they assessed compliance with only five of the 12 conditions10 required for participation in Medicare. See Conclusion 2. [p. 18]
  • A significant increase in census numbers did not trigger a survey as suggested by a GAO report. See Conclusion 3. [p. 20]
  • There were inconsistencies in home health aide competency evaluation programs. See Conclusion 4. [p. 22]
  • Health did not appear to enforce adherence with in-service training requirements for home health aides. See
  • Conclusion 5. [p. 25]

  • Health surveyors did not retain documentation from certain survey areas. See Conclusion 6. [p. 27]
  • Health did not require home health agencies to cross-check the names of potential home health aides with Health’s existing Nurse Aide Registry. See Conclusion 7. [p. 29]
  • Health may lack the staff to expand its oversight capabilities. See Conclusion 8. [p. 32]

We further note that, in instances where Health cited home health agency deficiencies, it followed up only by indirect means. Specifically, Health did not conduct on-site follow-up visits to verify implementation of the required corrective action plan but instead relied on written documentation from the agency that the problem had been remedied. It appears that Health did not have adequate resources available to conduct on-site follow-up visits.

An area in which Health ensured nearly 100 percent compliance was in its monitoring of the requirement that home health agencies must conduct criminal history background checks of all agency employees.11 12 In fact, in our visits to 20 agencies, we found that background checks had been conducted for all but two of the 264 employees whose records we reviewed.


Conclusion 1:

While meeting the time requirements, Health conducted its licensure and certification surveys with predictability that allowed agencies to prepare for their evaluations.

Although Health appeared to have surveyed home health agencies within the required timelines, it did so with such predictability that the agencies were able to prepare for their surveys. Indeed, our auditors observed instances in which home health agency staff members commented on their preparation for surveys and certifications.

We were able to analyze the predictability from our sample of 53 providers. Of the 53, there were 46 that had undergone at least two surveys during the period covered by our audit. Of the 46, there were 37 that had undergone yet a third survey. Thus, for our testwork assessing the timing of surveys, our total sample was 83, the sum of 46 and 37. The table below shows the results for the 46 having at least two surveys, the 37 having three surveys, and the combined analysis for both segments.

Our analysis disclosed that 49.4 percent of the surveys—nearly half—were conducted within 15 days of the anniversary date of the previous survey. In addition, more than a quarter (25.3 percent) were performed within 16 to 30 days of the anniversary date of the previous survey.

Survey Timing Analysis

Number of Days from Anniversary Date of Previous Survey

 

0 – 7

days

8 – 15 days

16 – 30 days

31 – 45 days

> 45

days

(46) Providers with at least two surveys*

14

15

9

4

4

Percent (%)

30.4%

32.6%

19.6%

8.7%

8.7%

CUMULATIVE PERCENT

30.4%

63.0%

82.6%

91.3%

100%

(37) Providers with an additional survey

9

3

12

5

8

Percent (%)

24.3%

8.1%

32.4%

13.5%

21.7%

CUMULATIVE PERCENT

24.3%

32.4%

64.8%

78.3%

100%

Combined Results for the (83) surveys

23

18

21

9

12

Percent (%)

27.7%

21.7%

25.3%

10.8%

14.5%

CUMULATIVE PERCENT

27.7%

49.4%

74.7%

85.5%

100%

* We were unable to perform this test on 7 of the 53 providers that had only one survey occur during our test period.

 

This analysis illustrates that it would be possible almost 75 percent of the time for an agency to predict when Health might conduct its survey, thereby making that survey akin to an announced inspection. It is questionable that a survey which is expected—and prepared for—would result in a true and accurate depiction of an agency’s everyday operation.

It’s important to note, however, the competing concerns that make this issue sensitive. On one side is the necessity to conduct surveys within given time requirements (an annual survey, for example); on the other side is the desirability to survey a real-life, unstaged situation. While we commend Health on the overall timeliness of surveys, the potential exists for agencies to temporarily hide deficiencies as a result of the predictability of survey timing.

Recommendation:

Health should stagger the timing of its surveys not only to meet federal frequency requirements, but also to make them less predictable.

Department of Health Response:

The Department of Health has also concluded that using a variable survey schedule could enhance its current survey process. Health is already implementing this approach through the use of an Access database. The creation of two additional Health Facility Quality Examiners positions in SFY 1999/2000 will also provide flexibility in scheduling on-site visits and managing the inspections.

Conclusion 2:

In 96 percent of their surveys, Health surveyors limited their evaluations of home health agencies to a standard survey that looked at just half of the 12 conditions required for Medicare participation.

 

In accordance with HCFA guidelines, Health surveyors initially limit their evaluation of agencies to the standard survey and then expand only if they find problems. The standard survey is required by statute13 to assess the quality of care and scope of services the agencies provide as measured by indicators of medical, nursing, and rehabilitative care. The standard survey assesses compliance with 5 of 12 conditions of participation plus one standard associated with a sixth condition that HCFA believes best evaluates patient care.

The 12 conditions are included in Appendix E of this report, along with the standards related to each condition.

Because of this limited evaluation, most home health agencies are certified and recertified without ever demonstrating compliance with all of the conditions of participation. In fact, of the 136 surveys we reviewed at the 53 agencies,14 we found that 131—over 96 percent—were standard surveys. The remaining five surveys included four that were partially extended and only one that was extended.15 Stated another way, Health extended its survey to include all 12 conditions at just one of 28 home health agencies (of the 53) that had been cited for at least one deficiency.

During interviews, Health surveyors told us they would expand the number of files reviewed when a substandard of care was identified and/or when a pattern of deficiencies was noted, but we were unable to verify this practice.

Recommendation:

Health should periodically survey selected agencies to ensure their compliance with all 12 Medicare conditions of participation. For the selected agencies, this procedure

Department of Health Response:

The Department of Health concurs with this recommendation. Although the federally mandated standard survey only requires assessment of 6 of the 12 conditions of participation, Health will survey selected agencies for compliance with all 12 conditions of participation in accordance with state licensure regulations. Health will continue to use federal survey protocols for recertification purposes.

Conclusion 3:

Health did not use an agency’s significant growth as a trigger to determine survey frequency.

In planning this audit and developing our objectives and procedures, we reviewed numerous reports and studies of home health care programs. One such study we reviewed was conducted by the GAO16 and disclosed an important variable that HCFA survey frequency guidelines omit. That variable, the growth rate of an agency, can be determined by examining an agency’s census between two periods. If an agency shows significant growth, there is a probability of significant increase in workload that, if not managed well, may prove detrimental to the home health agency and its patients.

We reviewed census data of the 53 providers in our sample to determine their growth rate for the years surveyed. We used two measures to determine significant growth:

  1. An increase rate of at least 25 percent; and
  2. An increase number of at least 100 patients.

We note that two measures were selected rather than one because of the difficulty in determining true significant growth applicable to both small and large agencies. Small agencies, including those in their initial formation, would meet the first measure but not the second, while large agencies with a census in the thousands would generally meet the second measure but not the first.

We applied these measures to our sample of 53 providers for their two most recent surveys. The results are shown in the following table.

 

Significant Growth Measures for 53 Home Health Agencies

 

Measures

Yes

No

Growth rate of 25% or more

21

26

Patient increase of 100 or more

15

32

Satisfied both measures

11

36

Insufficient data to determine

6

--

 

Of the 11 agencies that satisfied both measures, the range for the patient increase measure was a high of 4,295 (corresponding rate was 37.71 percent) and the low was 113 (corresponding rate was 152.70 percent). For growth rate, the high was 644.83 percent (corresponding patient increase was 374) and the low was 35.71 percent (corresponding patient increase was 135).

Recommendation:

Health should use significant growth as a determinant in identifying home health agencies for on-site surveys. Agencies experiencing rapid growth should be given priority consideration for more frequent or unannounced visits to ensure that the increased growth has not had a negative effect on quality of care.

Department of Health Response:

The Department of Health concurs with this recommendation. Based on a review of the annual data collection reports submitted with licensure renewal application packets, home health agencies identified as having significant growth will be given consideration for more frequent, unannounced visits.


Conclusion 4:

Health did not require home health agencies to follow standard criteria in evaluating aide competency.

Federal regulations17 require all home health aides to successfully complete a competency evaluation program. In fact, there are 12 specific areas (plus an option to add another) in which a registered nurse must conclude that an aide is competent before the aide can care for a patient. In order to determine if aides were being judged accurately and consistently from one agency to another, we reviewed 133 home health aide files at 20 different agencies. Unfortunately, because our analysis showed that agencies apply significantly different methods and criteria to evaluate an aide’s competency, we were unable to assess compliance with this requirement. Further, we were unable to follow up on the procedures used by Health surveyors to assess compliance since surveyors did not maintain survey documentation in this area. Therefore, we were unable to draw conclusions about Health’s effectiveness in evaluating aide competencies.

What we were able to assess is the variety of criteria and measurement instruments. Of the 20 agencies we reviewed, 17 used examinations as a form of evaluating aide competency, but the exams themselves were vastly different and ranged in length from 20 to 90 questions. Minimum passing grades varied, too, from as low as 60 percent to as high as 80 percent. Also varying was the setting in which aide skills were observed; some skills were observed in lab settings, which allow more control, and others were evaluated at bedside, which allows greater interaction with patients. Finally, at least one of the agencies required an aide to complete a self-administered checklist that a nurse evaluated, but we could find no documentation of the nurse’s evaluation.

Several problems exist when Health does not apply standard evaluation criteria from agency to agency. First, there is a risk that patient care might be compromised if aide competencies are measured too leniently. Second, there is a risk that less qualified aides may eventually pool in certain agencies where competencies are measured by easier-to-reach standards. Third, there is a risk that, in the absence of a uniform measurement with which to make comparisons, Health will be unable to judge agencies equally.

Of particular interest is our observance of one agency’s practice where 40 of 59 employees were classified on personnel lists as home health aides but, according to agency officials, were actually personal care assistants. When we compared the job description for home health aide to the description for personal care assistant, we found the responsibilities to be nearly identical. We are aware of no state or federal requirements for personal care assistants to undergo 12 hours of annual in-service training; nor is there a requirement for personal care assistants to undergo competency evaluations. We were unable to examine if this one agency’s practice is indicative of a trend whereby agencies classify home health aides as personal care assistants in order to avoid in-service training requirements. That question is one for future study.

Recommendations:

Health should develop and disseminate universal measurement criteria to guide agencies in their competency evaluations of home health aides. These measurement criteria should include a standardized test, a required minimum passing score, and a standardized checklist to document competency skills. Additionally, Health surveyors should retain documentation of the related survey work for a specified time period.

Department of Health Response:

The Department of Health recognizes there may be value to universally applied home health agencies’ competency evaluations of home health aides. Some home health agencies use the National League of Nursing Competency Evaluation and Skills Assessment Instrument to assess their aides. Health has begun a search for additional assessment instruments and will evaluate their applicability for use by home health agencies. Health will further assess whether to recognize one or more existing instruments or to select or develop a single one.


Conclusion 5:

Health did not appear to enforce adherence to in-service training requirements for home health aides.

Federal regulations18 require that home health aides receive a minimum of 12 hours of in-service training during each 12-month period. Yet Health did not monitor compliance with home health aide in-service education and training requirements in a way that could be independently verified. Specifically, surveyors did not maintain documentation related to their survey efforts in this important area.

In the absence of documentation from Health as the oversight agency, we turned to the personnel records at the home health agencies themselves. We found that six of the 20 agencies19 we visited, or nearly a third, could not provide documentation that the aides had completed the in-service training requirement. In fact, for 70 percent of the aides whose files we reviewed, the six agencies could not document compliance with all 12 hours of in-service training in the most recent 12-month period.20

Therefore, according to our own sampling of agency aide files, the requirement for aide in-service training was not met.

We note that Health did not cite those same agencies in the most recent survey. But, with no ability to review Health’s supporting documentation, we were unable to either confirm or dispute Health’s position. A requirement for agencies to report their compliance efforts in aide in-service training would be one way to monitor this area, and Health should consider it.

Recommendations:

Health should require that home health agencies report annually whether the aides they employ have completed the required 12 hours of in-service training. At the very least, Health should retain its documentation to support its verification of these training requirements.

Department of Health Response:

The federal regulations require home health agencies to provide 12 hours of in-service training in every 12-month period although they do not specify the manner in which the agencies should maintain this information. The Department of Health monitors compliance with this requirement during on-site survey record reviews. Documentation since February 1999 leads Health to conclude that a recommended record keeping format for home health agencies to document in-service training would be useful. Health will develop a technical advisory on this and issue it to home health agencies.


Conclusion 6:

Health surveyors did not retain documentation in certain survey areas.

The fact that health surveyors did not retain survey documentation in certain areas is troubling. Specifically, in Conclusion 4 [p.22], we noted that the lack of survey records (along with a lack of uniform testing standards) precluded us from forming audit conclusions about the measurement of the aide competency requirement. In Conclusion 5 [p. 25], we noted that Health’s non-retention of survey records prevented us from verifying that Health had enforced in-service training requirements for home health aides.

We also noted during our audit that health surveyors did not retain documentation from surveys in which other professional staff records were evaluated and, therefore, we could not verify Health’s survey efforts in that area.

Finally, there were cases in which Health surveyors did not maintain documentation from their surveys in which they reviewed clinical records. In those cases, because we had no way to identify the applicable branch locations for those records, we were unable to determine whether branch locations were adequately surveyed. We note here that the GAO has questioned the adequacy of branch operation oversight of home health agencies in general,21 and our audit lends additional weight to the GAO’s concerns.

Not retaining records and documentation in any survey from which conclusions are drawn is a serious issue, and we strongly suggest that Health take action to retain survey documentation even when it may not be specifically required by statute.

Recommendation:

Health surveyors should be required to retain survey documentation so that results can be supported and, if necessary, independently verified.

Department of Health Response:

The Department of Health concurs with this recommendation. Since February 1999, surveyors have been retaining additional documentation in areas identified by the audit.


Conclusion 7:

Health has not required home health agencies to cross-check the names of potential home health aides with Health’s Nurse Aide Registry.

The Department of Health does not maintain a registry of home health aides that employers could check before or after hiring. Further, in the absence of such a registry, Health does not require potential home health aide employers to search a similar and existing registry used for nursing home care. This federally mandated registry, called the Pennsylvania Nurse Aide Registry, is maintained by Health and contains information on more than 123,000 nurse aides in Pennsylvania. It is available either online (www.health.state.pa.us/qa/ltc) or by phone (1-800-852-0518).

Health’s Nurse Aide Registry is used for long-term care settings, particularly nursing homes. In fact, nursing homes must check to see if potential nurse aides are enrolled in the Nurse Aide Registry and have no record of resident abuse, neglect, or misappropriation of residents’ personal property.22 A nurse aide who is not enrolled or not in good standing on the registry may not be employed in any nursing facility that receives Medicare or Medicaid reimbursement. In short, the registry represents an effective screening mechanism to safeguard the health and well-being of nursing home patients.

But the registry also assumes significance for home health care patients in this way: Even though the term "nurse aide" is technically different from the term "home health aide," it is entirely possible for nurse aides to apply for home health aide positions. The resultant risk is that a home health agency can unknowingly hire a home health aide with a history of abuse in a long-term care setting.

Our review of 995 home health aides disclosed two such instances in which nurse aides with abuse histories were hired as home health aides.

The first case involved a home health aide whose physical abuse of a nursing home resident was substantiated through Health’s hearing and appeals process.

Specifically, the home health aide—during former employment as a nurse aide in a nursing home—had used such excessive force with a resident that the resident required emergency room treatment. Even though the incident occurred in early 1996 and the registry didn’t contain the abuse information until 11 months later (to allow for completion of the hearing and appeals process), the registry eventually did contain this important information that subsequent home health care employers could have utilized.

The second case, like the first, involved a former nurse aide who physically abused a nursing home resident.

By not requiring agencies to check the Nurse Aide Registry until a home health registry is established, the Department of Health is failing to take advantage of an existing safeguard for home health care patients.

Recommendations:

In the short term, Health should require that home health agencies check Health’s existing long-term care Nurse Aide Registry to verify that home health aides are not among the nurse aides banned from employment in nursing homes. In the longer term, Health should either include home health aides in the Nurse Aide Registry or develop and implement a separate Home Health Aide Registry.

Department of Health Response:

The Department of Health does not currently have the statutory authority to require that home health agencies check the existing long term care Nurse Aide Registry, to require that home health aides be included in this registry or to develop a separate home health aide registry. Health will further review and evaluate each of these recommendations.

Auditor Comment:

The Department of the Auditor General disagrees with Health’s response to this recommendation. The federal regulation which dictates the content of the required nurse aide registries clearly authorizes the inclusion of home health aides. See 42 Code of Federal Regulations Section 483.156(a)(3)(1998). Furthermore, there does not appear to be any state or federal law or regulation prohibiting Health from developing a separate Home Health Aide Registry or from requiring home health agencies to check such a registry and/or the existing Nurse Aide Registry. Therefore, we reiterate our recommendation for Health’s further consideration.


Conclusion 8:

Health has provided staff coverage to meet minimum survey frequency standards but lacks additional staff to expand oversight capabilities.

An issue warranting further investigation is whether staffing levels within Health are adequate to provide sufficient confidence and flexibility in the oversight of the home health care agencies. Critical to this process are the number of health care surveyors, their availability, and the volume of surveys.

The Department of Health’s Division of Home Health is responsible for providing oversight to more than 400 home health agencies. Each facility is licensed, and the majority take part in the Medicare/Medicaid program, meaning they are certified via survey every 12 to 36 months. The Division of Home Health employs seven surveyors to perform these surveys. In addition to their responsibility for home health agencies, the surveyors are also responsible for conducting surveys for end-stage renal disease facilities, hospices, comprehensive outpatient rehabilitation facilities, outpatient physical therapy/speech pathology entities, rural health clinics, and birth centers. These areas account for an additional 500+ facilities.

During the course of this audit, we requested additional data via letter and phone calls regarding issues such as average time required for surveys and number of surveys performed. From the limited information we received, we have summarized Pennsylvania’s survey activity for fiscal year 1997 in the table that follows:

 

Facility Type

No. of Surveys Conducted

Home health agencies (Medicaid/Medicare)

168

Home health agencies (state-licensed only)

74

End-stage renal disease

12

Hospice

19

Comprehensive outpatient rehab

2

Outpatient speech therapy

10

Rural health clinics

6

Birth centers

5

Total

296

 

While we acknowledge the efforts to date by the Division of Home Health in meeting the minimum standards required, the limited number of surveyors has restricted the Division of Home Health’s ability to expand its oversight to perform additional procedures and testing necessary to strengthen the overall survey function.

Recommendation:

Health should evaluate and, if necessary, expand the complement of surveyors to provide for additional survey and oversight activities required to enhance confidence in the oversight function. Additional surveyors would provide flexibility to perform unannounced inspections outside the regular survey cycle, agency trend analysis, expanded surveys, and deficiency follow-up.

Department of Health Response:

Two additional Health Facility Quality Examiner positions were approved for the Department of Health this state fiscal year to address increased survey and oversight activities including unannounced inspections outside regular survey cycles, on-site follow-ups on deficiencies related to patient care and expanded surveys. Health will continue to periodically assess workload and full-time equivalents.


Chapter II:

Complaint
System
and
Sanctions

The Division of Home Health investigates and resolves complaints about home health agencies. Written and telephoned complaints are forwarded to the Division of Home Health from Health’s central office, the regional surveyor, and other agencies. There is a toll-free hotline number, 1-800-222-0989, to take complaints. Federal regulations23 require the review of all believable allegations of resident neglect and abuse and misappropriation of resident property. The regulations also require the documentation of investigations.

If a complaint investigation results in findings of deficiencies, Health may impose sanctions on the health care provider. Sanctions may also result from licensure or certification deficiencies identified by survey or inspection.

Objectives and Methodology

Our broad objective was to determine the adequacy of the Division of Home Health’s complaint monitoring process for service providers. Specifically, we set out to determine whether complaints were reviewed in a timely manner and whether the process of investigating and resolving complaints was adequate. We also determined whether sanctions have been imposed on home health agencies and, if so, the reasons and resolutions.

We employed the following methodology:

  • We reviewed federal and state laws, policies, guidelines, and directives in order to learn the requirements that Health must follow to investigate and resolve complaints.
  • We reviewed Health’s new complaint policy begun June 1998, and we interviewed Health representatives to document the process for receiving and investigating complaints.

  • We interviewed all seven surveyors to determine and document the survey procedures used to ensure that agencies document and resolve complaints.
  • We telephoned the five field offices and the central office after regular business hours to learn how complaints were recorded and investigated when these offices were closed.
  • We reviewed all complaints documented by Health for a seven-month period (June 24, 1998, through January 31, 1999) following implementation of its new complaint policy to determine if Health complied with that policy.
  • We conducted site visits at 20 selected agencies and reviewed complaint policies and procedures, as well as the complaint log for the last year.
  • We reviewed Health’s provider files of 53 agencies in order to document any complaints found in these files.
  • We determined whether home health agencies had been sanctioned either as the result of complaint investigations or for violating licensure or other laws.

The Department of Health has been proactive in resolving complaints but not in assessing sanctions for licensing deficiencies.

Conclusions and Recommendations

Health appeared to take a proactive approach in handling the complaints it received in a limited time period and under newly implemented procedures for resolving complaints. See Conclusion 1. [p. 36]

In the area of enforcement, Health took a very lenient approach in resolving licensing deficiencies, thus providing no incentive for agencies to avoid future non-compliance. Specifically, Health failed to initiate, let alone implement and enforce, sanctions in cases involving deficiencies—including one that we reviewed involving the death of a toddler under home health care. See Conclusion 2. [p. 37]


Conclusion 1:

Health has
implemented
procedures to ensure
that complaints
about home health
agencies are
adequately
documented, investigated,
and resolved.

 

Federal regulations24 require agencies to notify patients (both orally and in writing) that Pennsylvania has a toll-free Home Health Agency hotline. On June 24, 1998, Health implemented a new policy and procedures to handle the investigation and resolution of complaints made via its hotline number of 1-800-222-0989. In its new policy, Health expanded its previous complaint process, further defining the classification of complaints and the time period in which complaints must be investigated.

We reviewed Health’s implementation of its new policy and procedures and found that, between June 24, 1998, and January 31, 1999, Health recorded and investigated 32 complaints related to home health care. We noted that all complaints were investigated on time in accordance with the new policy.

In addition, we visited 20 agencies and, through inquiries, gained assurances that patients were being informed of the hotline number and its purpose. By also reviewing the complaint log at each of the agencies for the same time period, we confirmed that complaints were documented, investigated, and resolved in a timely manner. Therefore, we have no recommendations concerning Health’s new policy and procedures for handling complaints about home health agencies.25

Department of Health Response:

The Department of Health’s current complaint investi-gation procedures regarding home health agencies ensure that all such complaints are investigated and resolved in a timely manner and adequately documented. Health is committed to continually monitoring the effectiveness of these procedures and improving them as necessary.


 

Conclusion 2:

Health has not imposed sanctions on agencies that have been cited for deficiencies.

Pennsylvania’s Health Care Facilities Act allows Health to suspend, revoke, refuse to renew, or limit a license; to suspend admissions; or to issue a provisional license for any of the following reasons:

  1. A serious violation of statute or regulations which seriously threatens the health, safety and welfare of patients;
  2. Failure of an owner (i.e., provider) to submit a reasonable timetable for correction of deficiencies;
  3. The existence of a pattern of cyclical deficiencies extending over a period of two or more years;
  4. Failure by a provisional licensee to correct deficiencies in accordance with the submitted and agreed-upon timetable;
  5. Fraud or deceit in obtaining or attempting to obtain a license;
  6. Lending, borrowing, or using the license of another licensee, or in any way knowingly aiding or abetting the improper granting of a license;
  7. Incompetence, negligence or misconduct in operating the home health agency or in providing services to individuals;
  8. Mistreating or abusing individuals cared for by the home health agency;
  9. Serious violation of the laws relating to Medicaid or Medicare reimbursement; and
  10. Serious violation of other applicable federal or state laws.

In addition, the Health Care Facilities Act also sets forth procedures for Health to follow when it finds a violation of law—whether it’s the aforementioned Act, regulations adopted pursuant to it, or federal law. The violation of law can be found during surveys or in special inspections or investigations, including those resulting from complaints. When found, a violation triggers a written notice to the home health agency. At that point, the agency must either take action to remedy applicable deficiencies or submit a plan of correction with a specific completion date. In the meantime, when a deficiency poses a significant threat to the health or safety of patients, Health may ban admissions or revoke a license.

When it notifies an agency of a violation, Health may also assess a civil penalty of up to $500 for each deficiency every day that it continues, starting with the date the agency receives the notice and continuing until Health confirms the correction. In the worst case, if the home health agency cannot or will not come into compliance, Health may take the matter to court either to appoint temporary management of the agency or to close it.

We were unable to find any instances in which Health imposed sanctions or issued a provisional license to agencies with deficiencies. Yet in our sample alone, we found evidence of deficiencies that, because of either volume or severity, cause us to question Health’s history of not imposing sanctions.

The evidence we found includes the following:

  1. A complaint about a child who died while under home health agency care resulted in a deficiency citation but no sanctions.
  2. More than half of the 53 agencies we sampled had been cited for deficiencies—78 deficiencies altogether in 37 surveys of 28 agencies.26

Each of these issues is addressed in the following pages.


Complaint about a Child’s Death27

Health’s records show that in late July 1997, a mother called the home health hotline to complain about an agency that cared for her daughter from January that year until mid-July when the child died. Health’s documentation of the call is reproduced below:

[The mother] said that she had been complaining to this agency [the home health agency] for some time about them sending out inexperienced nurses to care for her daughter. She said these nurses are right out of school and they do not know how to operate the sophisticated equipment needed to care for her daughter, nor do they know how to change a [tracheotomy] tube.

[The mother] said her daughter was being cared for by a nurse from [the home health agency] when she left the house [that evening] to go to the movies. She said when she left, her daughter was fine. She said later that evening she received a telephone call that her daughter was at [hospital], and she was dead. She was told that her daughter died from lack of oxygen.

[The mother] said the nurse said that after she left, [the child] pulled out the trache tube and [the nurse] put it back in. The nurse said that [the child] then went to sleep. The nurse said she went to the bathroom and when she came out [the child] was unconscious. The nurse supposedly called 911 and when they got there [the child] was dead. [The mother] said all this just does not add up. She said her daughter should never have died because of lack of oxygen because there is oxygen beside her crib.

[The mother] said the medical examiner said the little girl appeared to be healthy, and there was simply a lack of oxygen.

A Health surveyor acknowledged the mother’s complaint in a letter to her dated five days later. Also on that date, the surveyor conducted an unannounced inspection at the home health agency.

There was one deficiency found during that unannounced inspection—violation of a standard that personnel practices and patient care must be supported by appropriate, written personnel policies. Specifically, the agency could not document that eight of eight nurses reviewed had undergone an orientation program "…to familiarize home care providers with the policies and procedures…" of the agency. Further, seven of the eight nurses had received no specific "private duty orientation" for the child who died. The eighth nurse, who was the nurse on duty at the time of the child’s death, appeared to have undergone an orientation specific to the child’s case; but Health’s surveyor could find no documentation showing who conducted the orientation.

Health required the home health agency to submit a plan of correction but imposed no sanctions. Health reported its action to HCFA on a Medicare/Medicaid complaint form containing a preprinted list of 20 possible actions in addition to requiring a plan of correction only. The list of actions, none of which Health chose, included those as severe as license revocation or suspension of Medicare certification, and those less severe such as special monitoring, the completion of a "directed" plan of correction, the imposition of a fine, or the issuance of a provisional license.

There are several issues about the handling of this situation which Health should address:

  1. In cases where deficiencies are found, and either death or serious impairment of a patient’s health, safety, or welfare has occurred, should Health take action more severe than imposing a non-directed plan of correction and conducting a non-site follow-up?
  2. Was Health’s investigation thorough? The investigation report makes reference to a hotline complaint—received from an early intervention program provider several days prior to the mother’s complaint—about this same incident and about concerns related to the specific nurse and another child under her care. But Health’s documentation revealed no written acknowledgement to this provider about her complaint and no investigative follow-up about the information she provided.

Number of Deficiencies

We noted on page 34 that more than half of the 53 agencies we sampled had been cited by Health for deficiencies—28 agencies with a total of 78 deficiencies spanning 37 surveys.

The number of deficiencies varied from a low of one to a high of ten. Most agencies surveyed more than once during the period of our review had at least one survey where no deficiencies were found. There was no pattern, however, to show that agencies with deficiencies typically came through their next survey cycle with no deficiencies, or vice versa. There were several cases where the same category of deficiency was repeated in a subsequent survey, but this repetition was not prevalent in our sample.

The severity of deficiencies varied. In some cases, patients’ records were incomplete or assessments were not documented; in others, plans of care or doctors’ orders were not followed. These types of deficiencies could have serious effects on patients’ medical conditions if inadequate or inappropriate information about patients results in incomplete or improper care.

In the case of an agency with ten deficiencies, the nurse practiced unacceptable infection control procedures, not washing hands between patient visits and after care was given, using the same thermometer for three patients without proper cleansing, and using a kitchen trash can to dispose of a needle used to test blood sugar.

Examples of deficiencies from five agencies, along with possible effects on patients, are detailed on pages 42-44.28

 

Deficiencies of Home Health Agency #1 and Possible Effects

Date

Deficiency cited because:

Effect on patients could be:

12/97

Agency failed to distribute written information to patients describing applicable state law.

Patients not aware of the law may tolerate unlawful/unsafe situations without complaint.

12/97

Agency did not tell patients that state hotline can be used to complain about implementation of advanced directives, which are patient instructions about the use of life-sustaining devices and/or termination of care.

A patient’s decision about termination or continuation of life support may not be carried out.

12/97

For 11 of 11 patients, agency did not include discharge planning information in the patient’s plan of care.

Services may not be in place at discharge, compromising recovery.

12/97

For two of four patients, agency failed to require physical therapists to contact patient’s physician to approve additions to the plan of care.

Physical therapy not based on physician orders or added to plan without physician approval may be inappropriate for the patient’s medical condition and may compound that condition.

12/97

For three of four patients, agency failed to require physical therapists to obtain physician orders for specific procedures and their frequency and duration.

12/97

For two of four patients, agency did not require physical therapists to participate in developing a plan of care.

Patients may receive duplicate or contraindicated services.

12/97

For seven of 11 patients, agency failed to require a skilled nurse to assess patients for functional capabilities; or the nurse only partially assessed patients.

Patient may not receive all services needed to function fully.

12/97

For two of three patients visited, the skilled nurse followed clinically unacceptable infection control procedures. Nurse did not wash hands between patient visits and after care was given, used the same thermometer for three patients without proper cleansing (although it was sheathed), and disposed of lancet (needle) and blood sugar test strip in a kitchen trash container rather than a suitable protective container.

Patient is at risk for infection, resulting in serious health issues. Others in contact with unclean areas are at risk, too, for accidental needle puncture and transmission of infectious diseases resulting from improper disposal of needle.

12/97

For two of four patients, agency did not require physical therapists to provide clinical notes concerning patients receiving physical therapy services.

Patients may not receive proper follow-up care, thereby slowing or hindering recovery.

12/97

In 7 of 11 cases, the agency did not require the skilled nurse to document patients’ initial assessments; in 11 of 11 cases, the agency failed to have complete plans of care; in two of four cases, physical therapists failed to provide clinical notes and complete plans of care.

Quality care is compromised when care is not coordinated among caregivers.

No sanctions were imposed for these 10 deficiencies. In addition, Health did not conduct an on-site visit to verify agency’s documentation that it had corrected the cited deficiencies.

 

Deficiencies of Home Health Agency #2 and Possible Effects

Date

Deficiency cited because:

Effect on patients could be:

10/97

 

In 8 of 11 patient records reviewed, agency failed to show documentation that patient medications were reviewed for contraindicated medications, i.e., medications that shouldn’t be taken together or in conjunction with certain others.

Medicines could be rendered ineffective or could cause significant side effects or adverse reactions, possibly life-threatening.

10/97

Agency could not provide evidence that 8 of 9 home health aides met required competencies in areas such as safe transfer techniques and ambulation, oral hygiene, toileting and bathing.

Patients can be injured during falls. They can experience skin breakdown conditions because of improper handling or bathing; and mouth sores or dental problems from inadequate oral hygiene. Further, if caregivers are unable to accurately assess patient vital signs, appropriate treatment may be missed and the patient’s condition may be compromised.

10/97

Agency failed to show in 8 of 9 personnel files that a registered nurse observed and evaluated certain subject areas such as reading and recording temperature, pulse, and respiration; toileting; safe transfer techniques; and ambulation.

10/97

Agency failed to maintain documentation that a registered nurse observed procedures such as those named above prior to aides performing these procedures independently on patients.

There were no sanctions imposed for these four cited deficiencies. Health followed up with what it indicated was a "nonsite revisit" to verify that deficiencies were corrected.

 

Deficiencies of Home Health Agency #3 and Possible Effects

Date

Deficiency cited because:

Effect on patients could be:

2/98

Agency did not ensure that social worker was properly qualified, i.e., had a master’s degree from a school with the proper accreditation. The social worker was qualified as a social work assistant but was not supervised by a qualified social worker as required.

If a practitioner is unqualified to provide care, patients may not receive the care they need or may receive inappropriate care.

No sanctions were imposed and no on-site verification of compliance was conducted.

 

Deficiencies of Home Health Agency #4 and Possible Effects

Date

Deficiency cited because:

Effect on patients could be:

10/97

For three of eight patients, agency failed to ensure that medical records contained appropriate information. For first patient, skilled nursing assessment was not completed at start of care; daily nurse visits were missed 11 times in four weeks; and on one occasion there were no instructions written by nurse for the home health aide to follow. For second patient, there was no start-of-care nursing assessment or a plan of care. For third patient, a supervisory visit was made one week after the time required and there was no patient discharge summary.

Thorough medical records and initial assessment provide a baseline for patient, which is important to determine changes in the status of patient’s condition. Failure to keep the required visits could slow or hinder the improvement of the patient and could also result in missing changes in patient’s condition.

1/97

Requirements not met in the following area: clinical records—discharge summary.

Services needed may not be in place or available at discharge, compromising recovery.

Sanctions were not imposed for either of these deficiencies, nor was compliance verified on-site.

 

Deficiencies of Home Health Agency #5 and Possible Effects

Date

Deficiency cited because:

Effect on patients could be:

10/97

In four of 15 cases, agency professional staff did not alert the physician to changes that altered patients’ plan of care. Examples: 5 of 8 physical therapy visits missed; blood was drawn without a documented order; 2 social work visits out of 5 were missed; and 12 of 16 home health aide visits were missed.

The physician-ordered plan of care is vital for patients to reach their maximum potential. Any deviation from this plan can hinder patients’ full recovery.

10/96

Five of five aides did not have competency evaluation tests.

Incompetent caregivers endanger patients and compromise care.

10/95

Requirements not met in the following area: patient’s right to be informed and to participate.

Patient may tolerate unlawful or un-safe conditions without complaint.

10/95

Requirements not met in the following area: coordination of patient services.

Patients may receive duplicate or contraindicated services.

10/95

Requirements not met in the following area: conformance with physician’s orders.

Patients may receive inappropriate therapy that may compound their condition or hinder recovery.

10/95

Requirements not met in the following area:

supervision of home health aide.

Patients may receive ineffective care that goes unrecognized.

No sanctions were imposed following any of these citations (1995, 1996, 1997), and no on-site verifications were conducted.

Although the home health agencies in our sample differed in the number, type, and severity of deficiencies for which they were cited, they shared the following:
  • Health required them to prepare a correction plan, which is typically a few sentences or paragraphs.
  • Health did not conduct on-site visits to verify that corrections were made.
  • No sanctions were imposed.

This absence of sanctioning sends a signal to home health agencies that they will face no adverse consequences for violating applicable laws, a perception that can produce complacency in compliance. Ultimately, quality care is compromised and the safety of patients in home health care settings becomes a serious concern.

We also note that the federal requirements for on-site surveys have been relaxed, resulting in a decrease in the number of on-site surveys. Specifically, Health is now able to extend the time periods between surveys for as long as 36 months. This longer time period between surveys, coupled with the historical absence of sanctions, lends even more support to a home health agency’s perception that noncompliance has few consequences.

Our recommendation follows on the next page.

Recommendation:

Health should make use of the full range of available sanctions, including civil monetary penalties as a first resort, for home health agencies that fail to comply with applicable laws and regulations. Not only will the use of sanctions bring direct consequences to bear on agencies for non-compliance, but it also will assure home health care patients that Health is acting to protect their health, safety, and welfare.

Department of Health Response:

The Department of Health agrees that sanctions have a direct impact on home health agency regulatory compliance with applicable laws and regulations. Therefore, Health will develop a strategy to more effectively use the full range of sanctions, including civil monetary penalties, consistent with the Health Care Facilities Act.


Chapter III:

Payments
for Billings
and Claims

The Pennsylvania Department of Public Welfare (DPW) administers the Medicaid program, which totaled $6.2 billion for fiscal year ended June 30, 1997. Part of the Medicaid program includes home health services, which are covered under the following conditions:29

  1. The services must be medically necessary. Specifically, they must be ordered by and included in the plan of treatment established by the recipient's attending physician. Included are skilled nursing care, home health aide services, physical and occupational therapy, speech pathology and audiology services, and certain medical/surgical supplies.
  2. The services must be provided to eligible recipients. An eligible recipient must be physician-certified to be homebound because of illness or injury.
  3. The services must be administered by home health agency providers enrolled in the Medicaid program, including professional corporations, practitioners, and/or partnerships of practitioners.

DPW makes its payments directly to the enrolled Medicaid providers; it subjects all claims for payment to utilization control.30 If requested, providers are required to furnish DPW or its designated agents with medical and fiscal records.

In the fiscal year ended June 30, 1997, providers filed more than 437,000 home health care claims.

Objectives and Methodology

Our objective for this portion of the audit was to determine whether the services billed for clients by the providers were properly authorized, approved, allowable, and provided.

To accomplish that objective, we employed the following methodology:

  • We reviewed federal and state laws, policies, guidelines, and directives to gain an understanding of the billing and claims payment process.
  • We reviewed 11 programs that met our criteria for home health care expenditures for the fiscal year ended June 30, 1997, as shown in the following table:

Home Health Care Expenditures by Program for FY1997

Program Name

Home Health Care Expenditures

Processing Agency

MA Fee-For-Service

$ 58,667,851 (a)

DPW (MAMIS)

PA Department Of Aging Waiver

3,448,407 (a)

DPW (MAMIS)

Managed Care

Undetermined - capitated payment(d)

DPW (MAMIS)

AIDS/HIV Waiver

81,062 (a)

DPW (MAMIS)

Michael Dallas Model Waiver

2,443,157 (a)

DPW (MAMIS)

Mental Retardation Waiver

7,481,470 (b)(e)

DPW

OBRA Waiver

168,604 (b)

DPW (MAMIS)

Early Intervention

Initial Year - no expenditure data

DPW

Independence Waiver

Initial Year - no expenditure data

DPW (MAMIS)

Family-Based Mental Health Program

Initial Year - no expenditure data

DPW

OPTIONS Program

5,232,347 (c)

Aging

(a) - Unaudited amount obtained from Medical Assistance Management Information System (p. 45) tapes from DPW.
(b) - Unaudited amount obtained from HCFA 372 Reports provided by DPW.
(c) - Unaudited amount obtained from Aging Financial Report RPT74097. Includes state and other funding sources.
(d) - Capitated payment is an amount paid monthly to health maintenance/managed care organizations for each client enrolled regardless of type of service. In the managed care component of Medicaid, expenditures for home health care services could not be isolated because of this per capita basis for payment.
(e) - Unaudited amount obtained from DPW internal expenditure report.

 

  • We selected the following program areas for further review:
  1. Medicaid fee-for-service (the largest Medicaid program area)
  2. The PDA Waiver program (Medicaid)
  3. The Michael Dallas Model Waiver program (Medicaid)
  4. Aging’s OPTIONS program (a non-Medicaid program)
  • We interviewed representatives of DPW, Aging, and individual home health agencies to confirm our understanding of the billings/claims process.
  • We interviewed DPW staff and reviewed reports on the Surveillance and Utilization Review Subsystem (SURS), a system that monitors the Medical Assistance Management Information System (known as MAMIS). MAMIS is the computerized system used to process claims for reimbursement.
  • We visited 20 home health agencies, some of which we selected at random and others which we selected according to our auditors’ professional judgment based on certain criteria.31 The visits were made for the following purposes:
  1. to confirm physicians’ orders for specific services;
  2. to determine that the claims made were for the actual services provided; and
  3. to determine that documentation (e.g., time cards, nurses’ notes) was available to support claims.
  • We selected and visited five county Area Agency on Aging offices.
  • We selected and reviewed billing records for 94 Medicaid and 49 OPTIONS clients as shown in the table that follows:

Billing Records Reviewed and their Amounts

Program Component

Client

Sample

Sample Facilities With Clients*

No. of Invoices**

Amount of Invoices

Medicaid fee-for-service

81

14

155

$ 175,626

PDA Waiver (Medicaid)

2

1

6

$ 10,236

Dallas Model Waiver (Medicaid)***

11

6

43

$ 561,446

OPTIONS Program (no Medicaid funds)

49

5

40

$ 157,086

Totals

143

N/A

244

$904,394

*Represents the number of facilities in our sample of 25 that included patients for the program.
**Including managed care invoices where applicable.
***We reviewed invoices for a four-month period for 11 patients in a total of six agencies.

 

With one exception, there has been effective oversight of billings received and payments made for the home health programs we audited.

Conclusions and Recommendations

Conclusion 1 addresses DPW’s generally effective oversight of payments made to recipients of home health benefits under the fee-for-service component and the PDA Waiver program. [p. 51]

Conclusion 2 discusses problems with DPW’s oversight of the Michael Dallas Model Waiver program. [p. 55]

Conclusion 3 addresses the Department of Aging’s effective oversight of agencies that participate in the OPTIONS home health care program. [p. 59]

Conclusion 4 finds that DPW’s computerized surveillance and utilization program to monitor Medicaid expenditures is effective. [p. 61]


Conclusion 1:

DPW ensured the appropriateness and accuracy of home health care claims and payments for its fee-for-service component and the PDA Waiver program.

DPW is the single state agency responsible for administering the Medicaid program, which assists with the cost of medically necessary health care for eligible recipients.

 

Medicaid Fee-for-Service Component

Because Medicaid is an entitlement program, meaning that all Medicaid-eligible recipients are entitled to receive benefits under the program, the total funding is not capped. Medicaid recipients in Pennsylvania are covered primarily under the fee-for-service program or, if residing in a designated area, under a managed care plan. In each case, a Medicaid-enrolled physician initially evaluates recipients and oversees treatments. The treatments are carried out by registered nurses, licensed practical nurses, and aides employed by Medicaid-enrolled health care providers.

DPW is responsible for ensuring that reimbursements for claims submitted from service providers are reasonable, necessary, and accurate, and that documentation is available to support all claims. When we visited the 20 home health care agencies in our sample and reviewed the 94 patient files, we were able to evaluate whether DPW fulfilled its responsibilities in Medicaid’s fee-for-service component by comparing prescribed services from care plans with the services billed on invoices for at least a two-month period.

In making our comparisons, we completed the following steps:

  • We reviewed time cards or related documents for staff who provided care.
  • We reviewed clinical notes (i.e., nurses’ notes, aides’ notes).
  • We reviewed billing records for the selected patients.
  • We reviewed billing transmittals sent to DPW for payment.

We then reviewed the plans of care to ensure that services billed were actually provided and were consistent with the physician-prescribed services. Our reviews disclosed no discrepancies or errors in the Medicaid fee-for-service billings, leading us to conclude that the applicable agencies appropriately billed for home health services, and that reimbursements for claims were reasonable, necessary, accurate, and documented. Therefore, we have no recommendations.

Data from unaudited DPW financial reports show that home health care expenditures in the fee-for-service component of the Medicaid program totaled $58.7 million, nearly one percent of the total Medicaid expenditures for fiscal year ended June 30, 1997.

 

Department of Aging Waiver Program

Beginning April 1, 1995, the Pennsylvania Department of Aging received federal authority32 to offer Medicaid home health care coverage to a targeted group of Medicaid-eligible Pennsylvania aged and disabled residents who, but for the provision of such services, would require nursing facility care. Known as the PDA Waiver, the program was initially approved for three years.

At the beginning of our audit period, the PDA Waiver program was offered through 13 Area Agencies on Aging, or AAAs, covering 21 counties. The program was capped at 2,400 slots, although there were plans to expand statewide. In its admin-istration of the waiver program, Aging maintains agreements with each provider to establish provisions for processing payments. The payments themselves are made by DPW.

To evaluate DPW’s performance in ensuring the appropriateness and accuracy of PDA Waiver billings and claims, we determined which patients in our sample of 20 home health agencies were receiving those services. We obtained a sample of two patients and performed the following procedures:

  • We reviewed clients’ care plans.
  • We reviewed billing records for clients.
  • We reviewed clinical notes (i.e., nurses’ notes, aides’ notes).
  • We reviewed billing transmittals sent to DPW for payment.

Our tests disclosed no instances of deficiencies or errors for the PDA Waiver client records we reviewed, again leading us to conclude that the applicable agencies appropriately billed for and provided home health services, and that reimbursements for claims were reasonable, necessary, accurate, and documented. Therefore, we have no recommendations.

At fiscal year end 1997, home health care expenditures for the PDA Waiver totaled $3.4 million.

 

Department of Public Welfare Response:

The Department of Public Welfare (DPW) acknowledges the positive conclusion issued by the Department of the Auditor General that DPW ensures the appropriateness and accuracy of home health care claims and payments under its fee-for-service component and the Pennsylvania Department of Aging Waiver program.

 

Department of Aging Response:

The Department of the Auditor General reported that there were no instances of deficiencies or errors for the Pennsylvania Department of Aging (PDA) Waiver client records reviewed and concluded that the applicable agencies appropriately billed for and provided home health services and that reimbursements for claims were reasonable, necessary, accurate, and documented.

Aging wishes to acknowledge the commitment and professionalism of the Department of Public Welfare in ensuring the integrity and accuracy of this program.

Conclusion 2:

DPW did not ensure the appropriateness and accuracy of claims and payments for the Michael Dallas Model Waiver program.

Ordinarily, there are federal requirements that must be met in order for the state Medicaid program to pay for specific health care services. However, the federal government will waive some of those requirements if states request a waiver based on certain criteria. For example, if Medicaid is set up to pay only for institution-based services for patients, the state could request what is known as a waiver program33 so that it could also pay for those same services when they are home- and community-based.

One such program in Pennsylvania is the Michael Dallas Model Waiver program. The Michael Dallas Model Waiver allows Medicaid to pay for services provided to homebound children who depend on a medical device to replace or compensate for a vital body function and to avert an immediate threat to life.

Our review of the Michael Dallas Model Waiver evaluated two areas: payments for billings/claims and quality of care. The quality of care issues are included in Chapter IV of this report, while billings and claims are discussed in the following paragraphs.

Home health care agencies send all invoices for waiver services directly to DPW waiver staff for review. The staff verifies that total hours billed do not exceed authorized hours for home health care services as designated in the care plan; staff also verifies and approves charges and rates for services rendered. Only then are the invoices submitted to the claims processing contractor. Subsequently, the contractor submits computer tapes to the Medical Assistance Management Information System, or MAMIS, for still further processing. Finally, payments are generated.

We were able to verify that this process was in place through interviews with Michael Dallas Model Waiver staff and also through examination of 11 patients’ billing records maintained at DPW’s Michael Dallas Model Waiver office. Our audit procedures included recalculating invoices to verify that the hourly rates and hours worked were correct and reasonable.

Records retention criteria34 contained in the waiver plan require that records documenting the audit trail must be maintained for a minimum of three years by the Medicaid agency and also by waiver service providers. Therefore, to further evaluate billing amounts and to verify the 11 billing records we had examined at the Michael Dallas Model Waiver office, we visited the six home health care agencies that served the 11 homebound patients. We reviewed documentation of the claims for all 11 children by applying the following procedures:

  1. We reviewed time sheets, nurses’ notes, and/or other documentation used to verify hours worked by professional staff, and we traced that information to invoices submitted to DPW for a four-month period during the 1996-97 fiscal year.
  2. We reviewed certifications and licenses for nurses and professional staff who provided care to the Michael Dallas Waiver program children.

Our audit procedures disclosed that one agency in our sample of six had the following deficiencies:

One Agency’s Deficient Practices for the Michael Dallas Model Waiver Program

Description of Deficient Practice

Dollar Value

38 cases where hours invoiced could not be reconciled with time sheet and/or other supporting documentation

$ 9,520

1 case where time sheets for the entire month of December 1996 could not be located

12,880

4 cases where hours listed on time sheets varied from hours listed on invoices

720

4 cases of missing nurse notes where time sheets and invoices indicate hours worked

896

Total Improperly Supported Claims

$ 24,016

Also at that agency, we found documentation indicating a questionable circumstance whereby the same nurse provided 12-hour shifts of nursing care every day—i.e., no days off—for more than two years.

At another agency, we found a deficient practice in which the agency could provide no documentation to support invoices for 27 eight-hour shifts of nursing care totaling $9,100.

We concluded that, for the Michael Dallas Model Waiver program, DPW could have prevented the problems referred to in the preceding narrative had it exerted more oversight of its waiver program staff. Specifically, DPW should emphasize and monitor compliance with requirements concerning invoice documentation.

Recommendation:

DPW should more actively and carefully monitor the Michael Dallas Model Waiver program to ensure that invoices can be supported by original documentation.

Department of Public Welfare Response:

Out of 78 days audited for payment of waiver services, nursing agency staff were able to submit additional documentation to the Department of Public Welfare’s (DPW’s) Michael Dallas Model Waiver program staff, verifying that payments were valid for 70 of the total days audited.

Concerning the finding that one agency permits a single nurse to consistently work 12-hour shifts for a specific client with no days off, DPW learned from the agency that the family is reluctant to have another nurse staff this case. The family provides full-time care when the nurse is scheduled off. Due to the extremely fragile condition of this client, disrupting the rapport in the home with new nurses would prove very unsettling to the family and might adversely affect the child’s medical stability; therefore, DPW will take no action in this instance.

DPW will notify providers by letter that the amounts paid for undocumented nursing shifts will be recovered. Providers will also be notified by letter that DPW will conduct periodic intensive reviews of nursing care documentation and hours invoiced, as well as time sheets for specific time periods and clients. This will result in all agencies being monitored semi-annually. DPW will conduct on-site provider visits if major discrepancies are discovered in billing or quality of care. Long-term planning includes on-site monitoring visits in the client’s homes.


Conclusion 3:

The Department of Aging effectively administered its OPTIONS home health care component.

The Department of Aging offers 14 long-term care home-based services that enable frail and disabled older adults to live in their own homes rather than in nursing homes. The services are covered by the OPTIONS program that targets eligible persons 60 and older who need assistance with multiple activities of daily living. OPTIONS also targets disabled persons 18 and over who are clinically eligible for nursing home care.

The OPTIONS program is not funded by Medicaid; rather, its funds are derived from Pennsylvania State Lottery proceeds. OPTIONS is administered by Aging through its contracts with 52 Area Agencies on Aging (AAAs). Of the 52 AAAs, there were 43 that reported home health care expenditures for the fiscal year ended June 30, 1997.

Based on unaudited financial reports, we determined those expenditures to be $5.23 million, or 2.2 percent of the total block grant expenditures of $232.86 million.

AAAs maintain agreements with—and make payments directly to—each home health service provider. Aging provides working capital to the AAAs through monthly payments that represent 1/12th, or 8.33 percent, of the total yearly allocation.

Aging is responsible for ensuring that the AAAs maintain both fiscal and administrative oversight of their home health care providers. We visited five AAAs to determine whether Aging was ensuring they were carrying out their oversight responsibilities effectively.

For each AAA, we performed the following procedures:

  • For four months, we traced activity reports by client to the total monthly units of service in the program ledger.
  • We verified that units of service provided were consistent with units of service specified in care plans.
  • We recalculated total program year budgets based on the prescribed guidelines.

Based on our site visits and our review of 18 Home Health Evaluation/Monitoring reports for the 1997/98 fiscal year, we were able to gain assurance that Aging effectively monitored the AAAs’ oversight of their providers. Therefore, we have no recommendations.

Department of Aging Response:

The Department of the Auditor General has expressly confirmed that both the Department of Aging and the statewide network of 52 Area Agencies on Aging (AAAs) are effectively monitoring the fiscal and administrative oversight of home health care providers in the OPTIONS program. This effective administration of 14 long-term care home-based services enables frail and disabled older adults to live in their own homes rather than nursing homes. Aging is resolute in its mission to enhance the quality of life of older Pennsylvanians by empowering the community, the family and the individual.


Conclusion 4:

DPW has an effective Surveillance and Utilization Review Subsystem to identify deficiencies and/or high risk areas.

In addition to reviews such as ours where billings and payments are reconciled manually with individual patient care plans and other documentation, there are also several computerized systems that look at Medicaid data from Pennsylvania’s home health agencies. In fact, DPW is required by federal law35 to implement a statewide surveillance and utilization control program of its Medicaid expenditures. The program should safeguard against unnecessary or inappropriate use of Medicaid services, prevent excess payments, assess the quality of services, and control their usage.

In 1981, in order to provide these safeguards and controls by identifying deficiencies and/or high-risk areas, DPW implemented the computerized Surveillance and Utilization Review Subsystem (SURS). Currently administered by DPW’s Bureau of Program Integrity, SURS monitors claims information processed through the Medical Assistance Management Information System (MAMIS).

We conducted interviews and reviewed documentation received from DPW officials to gain assurance that SURS was operating as intended. We found that HCFA performed periodic reviews of SURS as required by the federal government, and that the most recent review (dated fiscal year end 1995) resulted in an overall score of 99.11 percent. That score exceeded the passing threshold of 90 percent.

HCFA has discontinued its review of SURS because such review is no longer mandated by federal regulations. However, Health’s Bureau of Program Integrity and its related computerized monitoring system were evaluated during our overall audit of the Commonwealth’s financial statements for the fiscal year ended June 30, 1997.36 We reviewed the related memos and workpapers from that audit to gain further assurance of the effectiveness of SURS and other fraud and abuse utilization and monitoring systems used by DPW.37

From our review, we found that SURS reports are generated quarterly and reviewed by DPW examiners for "red flags." Such red flags might include providers with any of the following:

  • High volume of claims;
  • Numerous high dollar single claims;
  • High total dollar amount of claims for a period;
  • High average claim amount;
  • Billing for services incompatible with Medicaid regulations;
  • Billing for unnecessary services; and
  • Billing for services inappropriate for patients’ health needs or contrary to customary standards of practice.

DPW examiners also follow up on complaints and/or tips about home health care providers. Upon review of a complaint or tip, the examiner determines if further investigation is warranted, including detailed file and record reviews of an agency or patient, site visits, telephone calls, interviews, or any other fact-finding means.

If an investigation results in a finding whereby a provider, individual, agency, pharmacy, or other participant is found to have violated Medicaid policies, the violator is listed on a monthly report called the Medicheck list. Violators on the Medicheck list are precluded from participating in the Medicaid program; accordingly, any claim that includes the violator will be denied. A monthly update is sent to all Medicaid providers and is applicable to hospitals, pharmacies, medical suppliers, nursing homes, home health agencies, laboratories, independent medical clinics, and county assistance offices.

 

Recommendations:

The Departments of Public Welfare, Health, and Aging should require home health agencies under their oversight to review the Medicheck list to ensure they do not conduct business with entities precluded from Medicaid participation.

In addition, when Health conducts its licensure/certification surveys, it should use the list for a sample of the surveys. When Aging conducts its quality assurance monitoring reviews, it should also conduct checks against the list.

To further assure that violators are precluded from participation, surveyors for Health and Aging should routinely request a list of subcontractors used by Medicaid-enrolled providers and then cross-reference a sample of those subcontractors with the Medicheck list.

Department of Health Response:

The Department of Public Welfare has added the Department of Health to its monthly distribution list for the Medicheck list. Health will use the Medicheck list as part of its survey process. When conducting on-site surveys at home health agencies, Health will verify the status of the agencies’ subcontractors to the Medicheck list.

The Department of Public Welfare’s Office of Medical Assistance Programs prepares the Medicheck list and will not pay for services prescribed, ordered, or rendered by the providers listed on it, including subcontractors. DPW, through its Medical Assistance Bulletin publication, informs providers of this by transmitting a complete copy of the Medicheck list to home health agencies in January and July of each calendar year. Monthly updates to the complete Medicheck list are also transmitted to home health agencies through the Medical Assistance Bulletin process.

The Medical Assistance Bulletin states, "It is necessary for you [i.e., the Medicaid provider] to examine the Medicheck List and monthly issued updates to assure that an order for a service, a provided service, or a prescription is not initiated by individuals who are no longer permitted to participate in the Medical Assistance Program." The bulletin further states that "The Department [DPW] will not pay for any services prescribed, ordered, or rendered by the providers listed in...the Medicheck List...." This assures that home health agencies are aware of providers, entities, and other individuals with which they may be subcontracting who are precluded from participation in the Medicaid program.

Department of Public Welfare Response:

The Auditor General’s positive conclusion indicates the success of the Department of Public Welfare’s (DPW’s) efforts to have an effective Surveillance and Utilization Review Subsystem.

DPW sends the Medicheck list to all providers semi-annually and provides monthly updates between those mailings. DPW’s Michael Dallas Model Waiver program staff will remind all providers via letter, that they should check the list to prevent contracting with non-approved providers.

Department of Aging Response:

The Department of Aging’s cooperative agreement contract with the Area Agencies on Aging (AAA) addresses the subjectability to Aging Program Directives (APDs), state and federal laws and regulations, heretofore and hereafter, for delivery and funding of services to elderly persons. The AAAs, as contractors to Aging, ensure that any subcontractors comply with all applicable state and federal requirements. Additionally, the AAAs are responsible for the quality and quantity of the General Terms and Conditions agreement. Further, the Cooperative Agreement requires that contractors and subcontractors certify that they are not under suspension or disbarment by the Commonwealth, any other state, or the federal government. If suspension or disbarment occurs during the term of the Agreement, the Commonwealth has the right to require the contractor to terminate with the subcontractor. Adherence to all federal and state laws and regulations applicable to the delivery and funding of social services to elderly persons and functionally disabled adults is also required within the contract agreement between a AAA and a contractor of home health care services.

Regarding Aging conducting checks against the Medicheck list during its Quality Assurance Monitoring review, Aging will further review and evaluate this recommendation.


Chapter IV:

Quality of Care

For someone facing the possibility of institutional care, home health care might be viewed as the ideal alternative. A spectrum of services—skilled nursing care for medical needs, home health aide services for personal needs, physical therapy to restore movement and strength, speech language pathology to restore speaking skills, occupational therapy to achieve independence in daily living, social services to assess emotional factors—are all provided in a single setting, the home. With adequate support from family or others, the patient remains in a familiar, comfortable setting.

The same familiarity and comfort, however, can also disguise risk. A home setting by its very nature is likely to be more private than an institutional setting, and abuses of the system might be more difficult to monitor, much less control. Therefore, proper safeguards are imperative to protect the patient and to ensure that quality care is not compromised.

A patient undergoing treatment by a home health agency has a reasonable expectation that his or her medical, nursing, and social needs can be adequately met by that agency. Those needs are identified in a client assessment; then a written, comprehensive care plan is developed based on those needs. It is established, signed, and periodically reviewed by a doctor of medicine, osteopathy, or podiatry; and it includes diagnoses as well as related elements, including the following: mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injuries, and instructions for timely discharge and referrals.

In preparing for this audit, we determined that numerous federal and state laws have been enacted to ensure that persons receiving home health services receive quality care. The Departments of Aging, Health, and Public Welfare share the responsibility for this quality care by monitoring how well home health agencies in Pennsylvania adhere to these laws. The agencies themselves have the responsibility to follow the laws as well.

 

Objectives and Methodology

Our broad objective was to determine whether the appropriate state agencies have procedures in place to ensure that quality care is provided to clients. Specifically, we determined whether the Departments of Aging, Health, and Public Welfare had these procedures in place, and whether assessments were conducted and care plans developed to ensure that each resident received appropriate services. We also determined whether agencies themselves were in compliance with requirements.

We employed the following methodology:

  • We examined the federal regulations mandating that assessments and care plans be completed regularly for all residents.
  • We reviewed the responsibilities of the Departments of Aging, Health, and Public Welfare with respect to the quality of care for Pennsylvania home health care clients.
  • We selected 20 home health agencies for site visits.
  • We visited those 20 home health agencies and performed a review to answer the following quality of care questions:
  1. Does the patient have a written plan of care signed by his or her attending physician?
  2. Did a registered nurse perform the initial visit and evaluation?
  3. Did the number of visits conducted equal the number requested on the care plan?
  4. Where applicable, was the care plan reviewed as required every 62 days by the attending physician and home health agency personnel to determine adequacy and appropriateness of continuation of care?

We traced specific elements from resident assessments to individual care plans for 94 patients.

  • We surveyed 100 percent of Michael Dallas Model Waiver recipients. (Of the 29 recipients, we received 15 responses.)
  • For the non-Medicaid OPTIONS program, we visited five of the 52 Area Agencies on Aging to determine if they adequately monitored home health agencies providing care for the clients in their program.

With the exception of one program, we found that quality care had been provided to home health care patients.

Conclusions and Recommendations

Our audit found that quality care was compromised in one program, the Michael Dallas Model Waiver program. See Conclusion 1. [p. 69]

For the remaining programs that we audited, we found that effective oversight had contributed to overall quality care. See Conclusions 2, 3, and 4. [pp. 72, 74, and 75]


Conclusion 1:

DPW did not provide effective oversight of agencies providing care to Michael Dallas Model Waiver recipients.

The Michael Dallas Model Waiver program, which is described in Chapter III, provides home health services to homebound children who depend on a medical device to replace or compensate for a vital body function and to avert an immediate threat to life.

The waiver program document sets forth the following federally mandated requirements:

  • The initial determination of level of care must be performed by a physician.
  • The plan of care must be developed by a registered nurse, physician, and/or a case manager.
  • The plan of care must be maintained at DPW’s Michael Dallas Model Waiver office.
  • The plan of care must be reviewed at least every six months and updated for changes in condition, if necessary.
  • The case manager is responsible for maintaining regular communication with the client and/or client's family, caregivers, and service provider to ensure that quality and quantity of care and services are provided in accordance with the service plan.

In addition, there are DPW-imposed guidelines (federally approved) that specify the following:

  • At six-month intervals, care documents must be resubmitted to waiver staff.
  • At two-month intervals, short notes describing client progress must be submitted to waiver staff by the case manager.
  • On a regular basis, case managers must maintain communication with the client, the client’s family, and service providers.

In order to determine whether the requirements and guidelines were followed, we randomly selected six of the 29 patients and reviewed their respective case management records maintained at DPW’s Michael Dallas Model Waiver office. For all six of the homebound children whose records we reviewed, we found no evidence that care documents were updated at six-month intervals. We also found no evidence of two-month progress notes. In addition, when we reviewed the 15 responses from our survey of family members or guardians of these 29 children, we found that "regular" communication by case managers occurred with a frequency ranging from once in two weeks to once in a year.

Our review also disclosed one case in which the case manager was employed by the same agency that provided the care, creating a situation with an apparent conflict of interest. The question of whether a case manager can provide objective oversight of his or her own employer is one that neither the manager nor the employer should be put in a position to address.

Ultimately, we concluded that, for the Michael Dallas Model Waiver program, DPW compromised patients’ quality care by not exerting adequate oversight of its waiver program staff.

Recommendation:

The Department of Public Welfare should ensure quality care for children in the Michael Dallas Model Waiver program by improving compliance with waiver program requirements, specifically records retention, communications with patients and families, and written updates of patient care.

Department of Public Welfare Response:

Because of an apparent misunderstanding of the specific documents requested for this audit, care plans, case management records, progress notes, and communication records of parental contacts, which are kept in separate folders from financial records, were not provided for review. These records are retained at the Department of Public Welfare’s (DPW’s) Michael Dallas Model Waiver (MDMW) program office. DPW would be happy to provide these additional documents for review if desired.

In the instance cited of a case manager being employed by the same agency providing the nursing care for a specific client, DPW does not agree that this represents a conflict of interest. The MDMW program restricts case managers from providing direct care. The case manager referenced here does not provide such care, nor does she bill the MDMW for her services; rather, she performs case management functions to ensure the continuation of quality care to the client. Services provided are coordination of medical services, home visits, emotional support to the family, and submission of all required care plans to DPW. Because of their diverse and complex medical problems, it is extremely difficult to find qualified case managers for these medically fragile children.


Conclusion 2:

Health ensured that home health agencies developed and followed comprehensive written care plans for patients.

 

 

During our site visits to the 20 home health agencies, we examined samples of resident assessments and care plans. Our reviews of clinical records for 94 clients disclosed the following:

  • In all 94 files, the patient had a written plan of care signed by his or her physician.
  • In all 94 files, a registered nurse performed the initial visit and evaluation.
  • In all 94 files, the frequency of visits was according to plan.
  • Where applicable, a registered nurse performed supervisory visits every two weeks.

Of the 94 patients, there were 36 who had received services in excess of 62 days. For these patients, our review disclosed the following:

  • In all 36 files, the plan of care was reviewed every 62 days by physician and staff.
  • In 31 of the 36 files, a 62-day summary was completed and sent to the attending physician.

The results of our testing revealed that home health agencies developed care plans in accordance with needs documented during the initial assessment of patients. Further, Health ensured—as part of its routine inspection process—that home health agencies complied with these requirements. Therefore, we have no recommendations in this area.

Department of Health Response:

The Department of Health recognizes the crucial need to have proper safeguards in place to protect home health care patients and to ensure that the quality of their care is not compromised. It is for this reason that Health ensures—as part of its routine inspection process—that home health agencies develop and follow comprehensive written care plans for each of their patients.


Conclusion 3:

DPW has made
contributions to
quality care
through its computerized
monitoring systems.

DPW has procedures in place via several computerized systems—the SURS and MAMIS systems—to identify high-risk areas and deficiencies. Identifying these areas has advantages not only for financial integrity, but also for quality of care issues. In this sense, DPW has made positive contributions to home health care, and we have no further recommendations.

Department of Public Welfare Response:

The Department of Public Welfare (DPW) acknowledges the Auditor General’s positive conclusion regarding the contributions DPW has made to quality care through its computerized monitoring systems.

Conclusion 4:

Aging has demonstrated effective oversight and administration of the two programs for which it is responsible.

When we determined that Aging had ensured the propriety of payments for billings and claims for the PDA Waiver program, we did so in part by reconciling bills and claims with treatment plans and related documentation. In that way, we determined that treatment plans had been followed, a major factor in determining that quality care had been provided.

In the non-Medicaid OPTIONS program also administered by Aging, we reviewed Quality Assurance Care Management reports for the five Area Agencies on Aging where we made site visits. Based on our review of four reports for the fiscal year ended June 30, 1997, and one for the fiscal year ended June 30, 1996, we found no deficient care or billing practices. Therefore, we have no recommendations.

Department of Aging Response:

The Department of the Auditor General had, during its testing of the Pennsylvania Department of Aging (PDA) Waiver Program, determined that Aging had ensured the propriety of payments for billings and claims which were, in turn, reconciled with treatment plans and related documentation. In assessing that treatment plans had been followed, it was concluded that quality care had been provided. The Department of Aging strives to ensure that the propriety of the Waiver program is upheld and maintained and is committed to the provisions of quality home health care for all older Pennsylvanians.

In the review of the non-Medicaid OPTIONS program, the Department of the Auditor General determined from its testing that there was not deficient care or billing practices. Aging acknowledges the Auditor General’s comments and reaffirms its commitment to effective over-sight and administration for all aspects of the OPTIONS program as part of Aging’s mission to ensure that the highest levels of quality care are not compromised.


 

ENDNOTES

 

1The May 1999 GAO report is entitled Medicare Home Health Agencies - Closures Continue with Little Evidence Beneficiary Access is Impaired.

 

2The audit was conducted in accordance with Government Auditing Standards issued by the Comptroller General of the United States.

 

3In addition to Pennsylvania, participating states originally included Arizona, Delaware, Illinois, Kansas, Kentucky, Michigan, Missouri, New York, Ohio, and Texas; after the project began, however, Delaware and Kansas were unable to continue.

 

4The Department of Public Wellfare defines "home health services" in its regulations at 55 Pa. Code Section 1249.2 (1999) as follows: "[n]ursing services, home health aide services, physical therapy, occupational therapy or speech pathology and audiology services provided by a home health agency and medical supplies, equipment and appliances suitable for use in the home . . ."

 

5The Department of Aging's January 1998 OPTIONS manual states that home health care "includes home health services, nursing services, occupational therapy, physical therapy, and speech therapy provided to individuals to enable them to remain in the community."

 

6The Health Care Facilities Act defines a "home health agency" as follows: "An organization or part thereof staffed and equipped to provide nursing and at least one therapeutic service to persons who are disabled, aged, injured or sick in their place of residence. The agency may also provide other health-related services to protect and maintain persons in their own home." This law can be found at 35 P.S. Section 448.802a (Supp. 1999).

 

7The name "waiver" program is used because states are permitted to request a waiver of certain federal rules that normally would not cover community-based treatment alternatives.

 

8In mid-July 1999, the number of state-licensed-only facilities was 72; Medicare/Medicaid-certified, 341. The decrease is attributable to payment limits imposed by the interim payment system implemented by HCFA as it moves from a cost-based method of payment to a prospective payment system of fixed, predetermined rates for home health services.

 

935 P.S. Section 448.806(a) (Supp.1999)

 

10A sixth condition is also evaluated in part.

 

11This requirement went into effect on July 1, 1998. The law, an amendment to the Older Adults Protective Services Act, can be found at 35 P.S. Section 10225.502(a) (Supp. 1998).

 

12The Philadelphia Inquirer published a June 25, 1999, article entitled "Debt to society paid, they'll be fired anyway" which presents different points of view about the law. A spokesman for the Pennsylvania Health Care Association is quoted as saying the industry supports the law. On the other hand, an associate director for Resources for Human Development suggests the law does not make exceptions for people who have rehabilitated themselves. An attorney for Community Legal Services in Philadelphia is quoted as saying that CLS will challenge the law in court.

 

13The federal law can be found at 42 United States Code Annotated Section 1891(c)(2)(C)(i)(II) (Supp. 1999).

 

14Some of the 53 agencies had been surveyed more than one time during the period of our audit.

 

15A partially extended survey is expanded beyond the requirements of a standard survey but does not include all 12 Medicare conditions of participation. An extended survey, on the other hand, covers all 12 conditions.

 

16The GAO study is dated December 16, 1997, and entitled Medicare Home Health Agencies: Certification Process Ineffective in Excluding problem Agencies. Regarding how the rapid growth of home health agencies might trigger a survey, the study says this: "HHAs are resurveyed every 12 to 36 months, depending on a variety of factors, but rapid growth and high utilization rates, which may indicate potential problem HHAs, are not included among these factors."

 

17The regulations can be found at 42 Code of Federal Regulations Section 484.36(b) (1998).

 

18The regulations can be found at 42 Code of Federal Regulations Section 484.36(b)(iii) (1998)

 

19We visited 20 agencies and reviewed 133 personnel files. Six of the 20 agencies did not have documentation of 12 hours of in-service training.

 

20At the six agencies, we reviewed the personnel files of 44 aides. In 31 of those files, there was no evidence of the required 12 hours of in-service training.

 

21A GAO study dated December 16, 1997, entitled Medicare Home Health Agencies: Certification Process Ineffective in Excluding Problem Agencies, says this: "Many HHAs operate branch offices, but these offices are not subject to the same oversight afforded the parent offices."

 

22The information for this paragraph comes from the Pennsylvania Department of Health's website.

 

23The regulations can be found at 42 Code of Federal Regulations Section 488.335 (1998).

 

24The regulations can be found at 42 Code of Federal Regulations Section 484.10(f) (1998).

 

25Our examination of home health agency files revealed a matter that did not occur during the period of our review of the complaint process because it concerned two complaints made prior to Health's June 24, 1998, implementation of its new policy. The two complaints were from two different individuals but were related to the same serious incident (see page 35), yet only one complaint appears to have generated follow-up correspondence and investigation.

 

26Our sample consisted of 53 agencies for which we examined 136 surveys completed during calendar years 1994 through 1998. We also reviewed the 53 agencies' licensure/certification files.

 

27This complaint was received during the period prior to Health's June 1998 implementation of new policy and procedures for handling complaints, which we addressed in the first part of this chapter.

 

28Appendix G lists the deficiencies for the other 23 agencies but in less detail.

 

29These conditions are defined more specifically in Chapter 1249 of the Medical Assistance Manual (55 Pa. Code Section 1249.1 et seq. (1999)).

 

30In order to review the utilization of and payment for all Medicaid services, DPW has established procedures in accordance with the Social Security Act. The part of the Social Security Act addressing utilization control procedures can be found at 42 United States Code Annotated Section 1396a(a)(30)(Supp. 1999).

 

31Please see appendices for more information regarding selection criteria.

 

32This authorization was granted pursuant to Section 1915(c) of the Social Security Act, which can be found at 42 United States Code Annotated Section 1396n (Supp. 1999).

 

33The Medicaid home and community-based services waiver (HCBSW) program was authorized by Section 1915(c) of the Social Security Act. This law can be found at 42 United States Code Annotated 1396n(c) (Supp. 1999).

 

34The records retention criteria appear in the waiver plan document in an appendix entitled "Audit Trail."

 

35The regulation can be found at 42 Code of Regulations Section 456.3 (1998).

 

36That statewide financial statement audit includes our Single Audit of all federal program dollars administered by the Commonwealth, including DPW.

 

37Although our July 1997 audit disclosed no problems with SURS, we note there was a finding concerning Medicaid program administration exclusive of home health care issues.