Medicaid Services Update
To: All ADvantage and State Plan Personal Care Providers
Subject: FY2022 ADvantage and State Plan Personal Care Provider Audits
Date: August 24, 2021
This bulletin is to advise you of the Oklahoma Human Services, Community Living, Aging and Protective Services (CAP), Medicaid Services Unit-Quality Assurance/Improvement (MSU-QAI) activities and process updates for Fiscal Year (FY) 2022, as related to Provider audits.
An annual audit of your agency will be conducted during FY2022 (July 1, 2021 – June 30, 2022).
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 of meeting all contractual and policy requirements.
The format of the FY2022 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), 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 Management 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
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. Due to the Public Health Emergency (PHE), 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 has been changed to 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 reports, will be sent via Harmony Note.
New scoring and remediation guidelines were implemented in FY2021. The overall scoring requirement was decreased from 95% to 86%. Individual 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:
Annual Audit |
|||
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% |
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% - 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 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. Follow-Up scoring and remediation is as follows:
FOLLOW-UP AUDIT |
|
Overall System Score |
Remediation Activity |
99.9% - 86% |
Agency is required to bring all conditions into compliance without reporting to QAI.
|
85.9% - 0% |
Agency is required to bring all conditions into compliance. |
Audit Based Removal from the Certified Agencies Report (CAR) (Off-Referral)
Provider agencies that score less than 70% on an Annual Audit will be removed from the CAR 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 offered. The agency must score 80% or greater on the Follow-Up Audit to be placed back on the CAR. If the agency scores less than 80% on the Follow-Up Audit, the agency remains removed from the CAR for a minimum of 90 additional calendar days, completes further training as required, and may be subject to a Special Audit.
The due date of a POC is found on the POC template. The due dates of the PRs are sent via Harmony Note along with the PR template. Due date reminders will no longer be provided. 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 Contractual 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) are not conducted by the MSU-QAI department on an annual schedule at this time; however, a CM FSQR will be conducted by the MSU-Informatics unit at the same time as the MSU-QAI annual 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.
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 from the CAP, Medicaid Services Unit-ADvantage Administration should be submitted via Harmony Provider Question.
Finally, the MSU-QAI and the MSU-AA continue to provide trainings for Provider Agencies. These trainings are 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:
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
