Basis of Review
This waiver compliance review is being conducted to ensure provider agencies are providing Personal Support Work (PSW) services to the individuals, and are billing correctly under the code of 55D. The review also examined the accuracy of the service agreements between the individuals and their PSW's. The review took a further look at the timeliness and overall completion of the required forms. This review was conducted to analyze 55D PSW bills vs contractual agreements; furthermore, reviews were conducted of rates paid directly to the PSW as a result of self-reporting.
Method of Review
Targeted Review: Looking at all 55D PSW Providers, a selection was made of those providers billing over $500,000 for FY 17. The number of agencies meeting the selection criteria was 6. The targeted list for the review was selected by generating a list of 30 individuals from each of these 6 agencies. The 30 individuals had the highest billings for 55D for 55D.
Random Sample Review: The representative random sample of all 55D billing was created using RAOSOFT software and generating a list of 221 random individuals from the remaining agencies.
The agencies were contacted and requested to submit service agreements and any relevant documentation regarding individuals in the sample.
The documentation was received and reviewed to assure timely agreements were completed and signed by all parties involved. This procedure was done to assess the timeliness of the agreements and validity of the signatures on the documentation. The review took a look at negotiated rates and hours and assured compliance.
Findings
Targeted Review: The sample drew a total of 180 individuals. A total of 38 people out of 180 reviewed were found to be not compliant or 22% which included timeliness of agreement, signature issues, rates and maximum hours. And 142 were found compliant or 78%. Under the target review sample under the not compliant status the following were found as a reason: 10 exceeded maximum hours allotted and 28 signatures were missing.
Random Sample Review: A total of 221 individuals were drawn for the sample size. A total of 72 were found to be not compliant or 33%, and 149 were found to be compliant or 67%. Under the random sample under the not compliant status the following were found as a reason: 9 missing signatures, 11 exceeded maximum hours allotted and 73 late signatures.
A number of reasons for a not compliant rating would include but not limited to as follows: late signatures on the service agreement, missing signatures, missing service agreements or exceeding the maximum total of hours allotted for the month for the individual.
A number of agencies had to be contacted to obtain additional information or the original information was never received. Also staff contacted agencies to assure what was reported paid to the PSW as to some agencies were at a -0- difference between billed and paid which would not cover any overhead. In addition several agencies reported a higher figure paid to the PSW vs what was billed leaving a negative balance (14 occurrences random review). A number of agencies provide an agency based model were a group of PSW workers provide care for an individual. In these cases we took an average of the PSW hourly salary and used this in our analysis of billed vs paid salary to analyze overhead costs incurred by the agencies. In addition 1 bill submitted was incorrectly (random review) and will be backed out of the system.
| Review Type |
Agencies in Review |
Individuals in Review |
Compliant |
Non-Compliant |
% of Compliance |
% of Non-Compliance |
| Targeted |
6 |
180 |
143 |
37 |
21% |
79% |
| Random Sample |
46 |
221 |
149 |
72 |
33% |
67% |
| Review Type |
Agencies in Review |
Individuals in Review |
Compliant |
Non-Compliant |
% of Compliance |
% of Non-Compliance |
| Targeted |
6 |
180 |
143 |
37 |
21% |
79% |
| Random Sample |
46 |
221 |
149 |
72 |
33% |
67% |
Actions Taken
Agencies were contacted and asked to send in additional information, corrective action plans, or additional questions that needed a response. For example, an agency was questioned in regards to a bill and they responded that the billing submission was incorrect and will be backed out of the ROCS system. Another example was that agencies sent in a corrective action plan to address late, missing or non- existent service agreements between the Individual and service worker.
Also, 4 of the 5 Agencies from the targeted review were asked to meet with Director Fenton to discuss some of the issues that were occurring with the billings and service agreements that were reviewed for this project.
