Provider update: July 14, 2020
To:All ADvantage and State Plan Personal Care Providers
Subject:FY2021 ADvantage and State Plan Personal Care Provider Audits
Date:July 14, 2020
This bulletin is to advise you of the Medicaid Services Unit-Quality Assurance/Improvement (MSU-QAI) activities and process updates for Fiscal Year (FY) 2021, as related to Provider Agency audits performed by the Department of Human Services, Aging Services (DHS/AS).
An annual audit of your agency will be conducted during FY2021 (July 1, 2020 – June 30, 2021).
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 of meeting all contractual and policy requirements.
The format of the FY2021 audit tool is unchanged from the last fiscal year. A copy of each audit tool that relates to the service(s) your agency provides is attached. This includes: ADvantage Adult Day Health (ADH), ADvantage Assisted Living (AL), ADvantage Case Management (CM), ADvantage Home Care (HC) and State Plan Personal Care (SPPC).
The Case Management Comparison Worksheet, also attached, is an optional checklist to be utilized by the ADvantage Case Manager and Case Management Supervisor to ensure Member's needs and abilities, including Personal Goals identified on the UCAT, Nurse Evaluation, and IDT Assessment/Reassessment document are addressed in the Member's Plan and Goals.
The Lead Auditor will send a notification via Harmony Note, 5 to 10 calendar days prior to the audit, to inform your agency's CQI Contact of the upcoming scheduled audit. Due to the COVID-19 pandemic, all audits will be completed by reviewing the Harmony database only. 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. Members will be contacted by telephone to answer Member Perception conditions. These conditions 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 two weeks from the date the preliminary report was sent to your agency.
The Final Audit Report will be sent via Harmony Note. 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 reports, will be sent via Harmony Note.
New scoring and remediation guidelines will be implemented for FY2021. The overall system score requirement has been decreased from 95% to 85%. Specific conditions related to the health and safety of the Member have been identified as "critical." These critical conditions are highlighted gray on each audit tool. Please refer to the following table for the new 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% - 85%||99.9% - 85%||Agency 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% - 85%||Any critical conditionwith a score of 84.9% or less||POC and PRNext Annual Audit will consist of critical conditions only.|
|||84.9% - 0%||Any condition with a score of 84.9% or less||POC and PRNext Annual Audit will consist of all audit conditions.|
If your agency is required to complete a POC for an Annual Audit, you will be subject to a Follow-Up Audit. Remediation will not be required after a Follow-Up Audit unless your agency's referral status is involved. The Follow-Up Audit and Final Audit Report processes will be conducted in the same manner as the Annual Audit. Follow-Up scoring and remediation is as follows:
|Overall System Score||Remediation|
|99.9% - 85%||Agency is required to bring all conditions into compliance without reporting to QAI.|
|84.9% - 0%||Agency is required to bring all conditions into compliance.Agency is offered a QAI Advisement.|
Audit Based Off-Referral
Provider agencies that score less than 70% on an Annual Audit will be removed from the Certified Agencies Report for a minimum of 90 calendar days. HC or SPPC scores of less than 70% will result in removal of both HC and SPPC services. In addition to completing the appropriate remediation activities, a QAI Advisement will be conducted. The agency must then score 80% or greater on the Follow-Up Audit to be placed back on the Certified Agencies Report. If the agency scores less than 80% on the Follow-Up Audit, the agency remains removed from the Certified Agencies Report for a minimum of 90 additional calendar days and completes further training as required.
Delinquent submission of any remediation document may result in the agency's removal from the Certified Agency Report 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 Settings, along with the requirements set forth by ADvantage Program Contractual Documents and State policy.
Financial/Staffing Quality Reviews
Financial/Staffing Quality Reviews (FSQR) are not conducted by the MSU-QAI department on an annual schedule at this time. All ADvantage providers may be subject to an unscheduled FSQR to ensure the integrity of provider billing for ADvantage waiver services.
The QAI Advisor 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 Certified Agencies Report due to Annual Audit score of less than 70%. Providers, as well as lead auditors, may also request advisement sessions for agencies requiring or requesting assistance from the QAI Advisor.
Electronic signatures are not accepted at this time. Any document requiring a signature must have a signature obtained using paper and pen.
Please be advised that auditors are expected to always maintain an established professional code of ethics.
- Auditors are 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 are expected 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 contractual documents or any concerns related to decisions and processes from Aging Services Medicaid Services Unit-ADvantage Administration (MSU-AA) should be submitted via Harmony Provider Question.
Finally, MSU-QAI and the MSU-AA continue to provide trainings for Provider Agencies. These trainings are now being conducted virtually. Although these workshops 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:
If you have questions concerning the content of this bulletin, please submit a Provider Question through Harmony, with an Inquiry Type of Audit Question.
We appreciate your commitment to provide quality services to Members of the ADvantage Waiver and State Plan Personal Care Programs. Thank you for what you do every day and for your dedication to the people we serve.
- Consumer-Focused Quality Care Review Tool(s)
- Case Management Comparison Worksheet
AGING SERVICES | MEDICAID SERVICES UNIT
ADvantage Administration | State Plan Personal Care
Office: 918-933-4900 | CareLine: 800-435-4711