To:  All ADvantage and State Plan Personal Care Providers

Subject:  FY2023 ADvantage and State Plan Personal Care Provider Audits

Date:  October 26, 2022
 

This bulletin is to advise you of the Oklahoma Human Services (OHS), Community Living, Aging and Protective Services (CAP), Medicaid Services Unit-Quality Assurance/Improvement (MSU-QAI) activities and process updates for Fiscal Year (FY) 2023, as related to Provider audits.

An annual audit of your agency will be conducted during FY2023 (July 1, 2022 – June 30, 2023).

Audit Tool

The Consumer-Focused Quality of Care Review (CFQCR) tool serves as a guide for the MSU-QAI team and does not strictly dictate exactly what is to be audited; nor will the document restrict additional audit activities which may become necessary as a result of information gathered during an audit.  Any supplementary review will not go beyond your agency's responsibility for meeting all contractual and policy requirements.

The format of the FY2023 audit tool is unchanged from the last fiscal year.  A copy of each audit tool, as well as QAI Reminders that relate to the service(s) your agency provides, can be found in the 9. Audit Tools folder of the Harmony Library Site.  This includes ADvantage Adult Day Health (ADH), ADvantage Assisted Living (AL), ADvantage Case Management (CM) and ADvantage Home Care (HC) and State Plan Personal Care (SPPC).

The Case Management Comparison Worksheet, also found in the Library Site, is an optional checklist to be utilized by the ADvantage Case Manager and Case Manager Supervisor to ensure the Member's needs and abilities, including Personal Goals identified on the UCAT, Nurse Evaluation, and IDT Assessment/Reassessment documents, are addressed in the Member's Plan and Identified Needs.
 

Audit Process

For ADH and AL audits, the Lead Auditor will contact your agency’s Continuous Quality Improvement (CQI) Contact 10 to 14 days prior to the audit, to schedule the audit which will be conducted during an onsite visit to the facility.    

For CM, HC and SPPC audits, the Lead Auditor will send a notification via Harmony Note the month prior to the audit to inform your agency's CQI Contact of the upcoming scheduled audit.  These audits will be completed by reviewing the Harmony database only.  At this time, no information will be requested to be transmitted electronically to the auditor.  Formal notice will be sent if there is a change to this process. 

For all audits, Members will be contacted by telephone to answer Member Perception questions.  The answers to these questions do not affect your agency's audit score; however, Member responses will be recorded on the audit report. 

Once the audit is complete, the Lead Auditor will send the Preliminary Audit Report via Harmony Note to your agency's CQI Contact along with instructions should you choose to refute the audit findings.  The response time to submit refute documentation is five (5) business days from the date the preliminary report is sent to your agency. 

The Final Audit Report will be sent via Harmony Note to your agency's CQI Contact.  If it is determined that a Plan of Correction (POC) is needed, an electronic POC template will accompany the final report along with instructions for submitting the POC.  Once the POC is approved, an electronic Progress Report (PR) template, including the due dates of the required progress reports, will be sent via Harmony Note. 

Audit conditions scored as “Not Met” are placed into categories of Notice of Findings or Remediation Required based on the overall system score and the score of the individual condition. The category determines whether the agency will be required to bring the condition into compliance independently or be required to submit a POC.  Specific conditions related to the health and safety of the Member have been identified as "critical."  These critical conditions are noted by bold font on each audit tool.  Please refer to the following table for the scoring and remediation guidelines:

Compliance Level	Overall System Score	Condition Score	Remediation Activity
Full Compliance	100%	100%	None. *Next Annual Audit will consist of critical conditions only.
Notice of Findings	99.9% - 86%	99.9% - 86%	Provider is required to bring the condition into compliance without reporting to QAI. *Next Annual Audit will consist of critical conditions only.
Requires Remediation	99.9% - 86%	Any critical condition with a score of 85.9% or less	POC and PR *Next Annual Audit will consist of critical conditions only.
	85.9% - 0%	Any condition with a score of 85.9% or less	POC and PR *Next Annual Audit will consist of all audit conditions.

*Full audits are required at least every other year regardless of the compliance level of the previous year. 

If your agency is required to complete a POC for an Annual Audit, you will be subject to a Follow-Up Audit.  The Follow-Up Audit will consist of the conditions requiring a POC along with the Member(s) who received the “Not Met” score on each condition.  If the auditor is unable to apply the condition to that original Member, alternate Members will be utilized until a score can be obtained.  This process will ensure the POC resulted in compliance of the deficient condition within your agency.

The Follow-Up Audit and Final Audit Report processes will be conducted in the same manner as the Annual Audit.   Remediation will not be required after a Follow-Up Audit unless your agency's referral status is involved.

Audit-Based Removal from the Certified Agencies Report (Off-Referral)

Providers that score less than 70% on an Annual Audit will be removed from the Certified Agencies Report (CAR) for a minimum of 90 calendar days and the Audit-Based Training and Support Process will be implemented. (A HC or SPPC score less than 70% will result in removal of both HC and SPPC services from the CAR.)  The Provider must score 80% or greater on the Follow-Up Audit to be returned to the CAR.  If the Follow-Up Audit score is less than 80%, the Provider will remain removed from the CAR until the next Annual Audit.

The due date of a POC is found on the POC template.  The due dates of the PRs are sent via Harmony Note and are also found on the PR template.  Delinquent submission of any remediation document may result in your agency's removal from the CAR for a minimum of 90 calendar days from receipt of the document. 

Home & Community Based Settings Providers - Assisted Living and Adult Day Health

ADH and AL reviews will include emphasis on the final rule from the Centers for Medicare and Medicaid Services (CMS) regarding Home and Community Based (HCB) Settings, along with the requirements set forth by ADvantage Program Certification Documents and State policy.  All AL and ADH providers must be in 100% compliance with the CMS rules for HCB Settings by March 2023.

Financial/Staffing Quality Reviews

Financial/Staffing Quality Reviews (FSQR) will be conducted by the MSU-Informatics Unit at the same time as the MSU-QAI annual CM audit.  Results of the FSQR will be sent via Harmony Note to your agency's CQI Contact.  When this Note is added, it may include a request to back out units due to documentation not available to support units billed.

All ADvantage Providers may be subject to an unscheduled FSQR to ensure the integrity of provider billing for ADvantage waiver services.

QAI Advisement

The QAI Advisor or designee will be utilized to complete agency-specific advisement sessions with new provider agencies to introduce the audit process and tools, and with provider agencies removed from the CAR due to an Annual Audit score of less than 70%.  Providers, as well as lead auditors, may also request advisement sessions for agencies requiring or requesting individual assistance. Advisements will be conducted annually with ADH and AL Providers to continue to ensure compliance with the CMS rules for HCB Settings.

New This Year

To ensure annual Performance Measure compliance, the MSU-QAI team will be confirming the CQI Manager for each Provider has completed the OKLMS Adult Maltreatment Training.  The auditors will be reviewing to verify the Adult Maltreatment Certificate was uploaded into Harmony, as previously instructed, during the audit time frame.  If the certificate is not found, the CQI Manager will be notified via Harmony and provided with a due date to have this completed.  This requirement will not be scored on the audit tool this year; however, the Provider’s FY2023 audit cannot be finalized until the OKLMS training is completed by the CQI Manager and the certificate saved in Harmony.  This requirement will be added to the audit tool and scored for FY2024. 

Other Information

Please be advised that auditors are expected to always maintain an established professional code of ethics. 

• Auditors have been instructed to NOT discuss the anticipated audit results with the Provider.  The Preliminary Audit Report will be submitted via Harmony Note once the audit is completed.

• Auditors have been advised to accept refute documentation; however, decisions regarding amendments to the final report will NOT be decided at that time.  Your agency will receive a Final Audit Report that will indicate if an amendment was made.

• Auditors have been directed to refrain from giving suggestions or recommendations to the Provider regarding processes to use with their staff to aid in complying with Program Standards.  This information may be requested of and provided by the QAI Advisor.

• Any questions from the Provider regarding the formation of certification documents or any concerns related to decisions and processes of CAP, Medicaid Services Unit-ADvantage Administration, should be submitted via Harmony Provider Question.

Finally, the MSU continues to offer professional development trainings for Provider Agencies.  These are conducted virtually.  Although these trainings are not mandatory, we hope that you will make plans to attend.  For information regarding upcoming trainings and registration, please visit the ADvantage Administration website at:

https://oklahoma.gov/okdhs/services/aging/advantageadmin.html

Thank you for your commitment to provide quality services to Members of the ADvantage Waiver and State Plan Personal Care Programs.  We appreciate you and your dedication.

If you have any questions regarding the information provided above, please feel free to contact us via Harmony Provider Question.

COMMUNITY LIVING, AGING AND PROTECTIVE SERVICES (CAP)
MEDICAID SERVICES UNIT (MSU)
ADvantage Administration | State Plan Care Unit | Medical Eligibility Services
Office: 918-933-4900 | CareLine: 800-435-4711