CMS 372 Report - OMB Control Number: 0938-0272

372 - Annual Report on Home and Community-Based Services Waivers

State:

Waiver Base:

0247

Report Status:

ACCEPTED

Begin Date:

End Date:

Initial Submission Date:

Report Period Year:

Waiver Year:

Report Type:

Initial Report

Lag Report

TE Report

Unduplicated Participants:

Days of Waiver Enrollment:

Average Length of Stay:

Total Waiver Expenditures:

Total Reported Expenditures:

APC Waiver Services (Factor D):

APC for State Plan Services (D'):

APC Total (D + D'):

Factor G Value:

Factor G' Value:

APC Total if no waiver (G + G'):

D + D' <= G + G':

$12,491 <= $38,068

Level/s of Care:

ICF/MR

Hospital

Additional Information (use if needed):

B. Factor C and D Variances:
	1.  The actual factor C value (580) is lower than the approved estimate in the Waiver (850).  Please explain the reason for the difference in the additional information box on the web-based 372 form (just below the level of care).  Does the State expect this trend to continue?
State Response: 
The number of clients served by the waiver was an estimate. The actual number of clients that are served by the waiver is directly associated with the amount of State matching dollars appropriated by the Utah State Legislature. The number served during a specific year may be lower than the estimates when the State Legislature does not appropriate additional monies for caseload growth.  In these cases, as individuals attrite, new individuals are not brought in to replace them.  As a result of limited funding, the State does not always utilize the maximum amount of capped waiver slots approved by CMS.    

2.  The actual factor D value ($6,739) is higher than the approved estimate in the Waiver ($4,981).  Please explain the reason for the difference in the additional information box on the web-based 372 form (just below the level of care).  Does the State expect this trend to continue?
State Response: 
The factor D table numbers provided during the initial waiver application were estimates.  During the 2010 waiver renewal, the State made adjustments to the factor D table estimates based off the actual utilization data for the previous waiver period. 

3.   The actual factor D’ value ($5,752) is less than the approved estimate in the Waiver ($7,317).  Please explain the reason for the difference in the additional information box on the web-based 372 form (just below the level of care).  Does the State expect this trend to continue?
State Response: 
The factor D' numbers provided during the initial waiver application were estimates.  During the 2010 waiver renewal, the State made adjustments to the factor D' table estimates based off the actual utilization data for the previous waiver period.

Note: Average Per Capita (APC)

Annual Number of Section 1915c Waiver Recipients and Expenditures:

(Specify each service as in the approved waiver)

Service Name	Level of Care	Expenses	Participants
-- Other If Other, specify: Adult Day Health Services	NF	$164,418	177
-- Other If Other, specify: Homemaker Services	NF	$1,458,731	469
-- Other If Other, specify: Respite Care Services	NF	$221,707	50
-- Other If Other, specify: Respite Care Services LTC Facility	NF	$22,538	20
-- Other If Other, specify: Waiver Case Management Services	NF	$800,112	576
-- Other If Other, specify: Enhanced State Plan Supportive Maintenance Home Health Aide	NF	$48,817	14
-- Other If Other, specify: Adult Companion Services	NF	$292,242	177
-- Other If Other, specify: Chore Services	NF	$12,840	34
-- Other If Other, specify: Environmental Accessibility Adaptations	NF	$23,171	32
-- Other If Other, specify: Home Delivered Supplemental Meals	NF	$244,437	266
-- Other If Other, specify: Medication Reminder Services	NF	$18,672	38
-- Other If Other, specify: Personal Attendant Services Participant employed	NF	$272,468	46
-- Other If Other, specify: Personal Attendant Services Agency employed	NF	$66,517	12
-- Other If Other, specify: Personal Attendant Program Training	NF	$0	0
-- Other If Other, specify: Personal Emergency Response Systems Response Center Service	NF	$109,047	389
-- Other If Other, specify: Personal Emergency Response Systems Purchase, Rental & Repair	NF	$1,070	30
-- Other If Other, specify: Personal Emergency Response Installation, Testing & Removal	NF	$533	16
-- Other If Other, specify: Specialized Medical Equipment Supplies, Assistive Technology	NF	$30,325	189
-- Other If Other, specify: Transportation Services - nonmedical	NF	$120,787	115

Assurances:

Assurances were submitted with the initial report. (If you are submitting a lag report this item must be checked.)
All provider standards and health and welfare safeguards have been met and corrective actions have been taken where appropriate
All providers of waiver services were properly trained, supervised, and certified and/or licensed, and corrective actions have been taken where appropriate.

Documentation:

Provide a brief description of the process for monitoring the safeguards and standards under the waiver:

The SMA conducted the following monitoring during FY 2010: FY 2009 Annual Review During FY 2010, the SMA conducted the FY 2009 Review for the Aging Waiver. This review addressed the assurance: “The State provides financial accountability for the waiver.” The number of participants served by the Aging Waiver in FY 2009 was 581. Based on this number, a Confidence Level of 95%, a Confidence Interval of 5, and a Response Distribution of 10%, one hundred and twelve (112) individuals were selected for this review. The sample was randomly selected from a list of participants who had started receiving waiver services by July 1, 2008. The operating agency had an opportunity to comment on the findings and provide relevant additional information. The final report was issued October 25, 2010. The review presented observations and analysis of the data for the Financial Accountability assurance. Recovery of funds was required for all deficiencies. All recovery of funds has been completed. Critical Incidents/Events The SMA tracks and investigates all critical incidents/events that occur to participants receiving services from the Aging Waiver. There were two critical incident investigations involving Aging Waiver participants during the time period July 1, 2009 through June 30, 2010. Both were incidents of abuse/neglect/exploitation. One involved neglect and verbal abuse, the other involved financial exploitation of the waiver participant. All incidents have been resolved and safeguards were put in place to assure the health and safety of all participants. The Division of Aging and Adult Services (DAAS) conducted the following monitoring during FY 2010: FY 2010 Annual Area Agencies on Aging (AAA) Review During FY 2010, DAAS conducted Administrative and Financial Reviews of 9 AAAs that have been designated by the operating agency to provide a number of operating agency responsibilities and case management services. The two remaining AAA reviews occurred in FY 2011 and will be included in the FY 2011 reports. The Administrative reviews addressed the assurances: Level of Care, Service Plans, Health and Welfare, and Qualified Providers. Samples of 95 records were selected from the AAAs based on the number of Aging Waiver participants served by each AAA. The AAA review findings are submitted to the SMA for review on an ongoing basis throughout the year. Deficiencies are addressed by the AW Manager with the AAA either at the time of the review and/or in a follow up training. T he DAAS auditor conducted financial reviews for nine AAAs, addressing the assurances of Financial Accountability, Qualified Providers and Service Plans. Samples of 52 participant records were selected from the AAAs based on the number of Aging Waiver participants served by each AAA. The AAA review findings are submitted to the SMA for review on an ongoing basis throughout the year. Deficiencies are addressed by the DAAS auditor at the time of the review and by monitoring the AAA for completion of corrections and/or recovery of funds as appropriate.

Findings of Monitoring:

No deficiencies were detected during the monitoring process;
Deficiencies were detected.

Provide a summary of the significant areas where deficiencies were detected, (Note: Individual reports or assessment forms for waiver individuals and/or providers disclosing deficiencies and which document the summary are not necessary):

The SMA identified the following significant deficiencies in the SMA FY 2009 Annual Review Assurance: Financial Accountability Sub Assurance: Claims are coded and paid for in accordance with the reimbursement methodology specified in the Aging Waiver State Implementation Plan. • Performance Measure: Claims paid for services may not exceed the amount, duration and frequency of services identified on a participant’s Comprehensive Care Plan. Deficiency #1: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7019 individual claims (99.32 %) for 101 of the participants did not exceed the amount authorized on the Care Plan. 11 participants had a total of 48 individual claims that exceeded the amount authorized on the Comprehensive Care Plan. • Performance measure: Claims can only be paid for services identified on a participant’s Comprehensive Care Plan. Deficiency #2: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7055 individual claims (99.83%) for 106 of the participants were paid for services that were correctly documented on the Comprehensive Care Plan. 6 participants had a total of 12 individual claims that were paid for services not documented on a valid care plan. • The Aging Waiver is the payer of last resort: Deficiency #3: A total of 7067 individual claims were reviewed for the one hundred and twelve (112) participants in the sample. Of the claims reviewed, 7062 individual claims (99.92 %) for one hundred and seven (107) of the participants used the Aging Waiver as payer only when the Medicaid State Plan benefit was not available. Five (5) participants had a total of five (5) individual claims for medical supplies that were paid by the Aging Waiver but were available through the Medicaid State Plan Benefit. • Billing Error: The Aging Waiver paid claims for medical supplies in which the payer listed on the care plan was the Medicaid State Plan. Claims showed Aging Waiver paid for medical supplies in error. Deficiency #4: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7062 individual claims (99.92 %) for 107 of the participants had claims that showed the correct payer was billed. 5 participants had a total of 5 individual claims for medical supplies in which the State Plan Benefit was listed as payer on the care plan, but the services were paid in error by the Aging Waiver • Billing Error (Aging Waiver Services paid for non-waiver services). Deficiency # 5: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7064 individual claims (99.95 %) for 109 of the participants billed the Aging Waiver correctly for Aging Waiver service. 3 participants had a total of 3 individual claims for non- waiver services that were paid by the Aging Waiver in error and should have been billed to the Medicaid State Plan Benefit. • Billing Error (Duplicate Claims Paid): Deficiency # 6: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7063 individual claims (99.94 %) for 108 of the participants had claims that were paid for services correctly. 3 participants had a total of four 4 individual claims for services that were billed in duplicate in error. • Billing Errors: Claims Paid for Services not on the care plan, which were not authorized by the AAA. Deficiency # 7: A total of 7067 individual claims were reviewed for the 112 participants in the sample. Of the claims reviewed, 7054 individual claims (99.81 %) for 107 of the participants had claims paid for services that were on the care plan correctly. 5 participants had a total of 13 individual claims that were paid for services not on the care plan, and were not authorized by the AAAs. These claims were paid in error. DAAS identified the following significant deficiencies in the FY 2010 Annual Area Agencies on Aging (AAA) Review: Level of Care Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver. • Performance Measure: Number and percentage of participants for whom level of care was screened at the time a substantial change in health status occurred, including at the conclusion of an inpatient stay in a medical institution, to determine if the individual continued to meet nursing facility level of care. Deficiency #1: 90 of 95 (94.7%) participant records reviewed showed a screening was not conducted at the conclusion of an impatient stay in a medical institution. Assurance: Financial Accountability Sub Assurance: Claims are coded and paid for in accordance with the reimbursement methodology specified in the Aging Waiver State Implementation Plan. • Performance Measure: Claims paid for services may not exceed the amount, duration and frequency of services identified on a participant’s Comprehensive Care Plan. Deficiency #2: 39 of 52 (75%) participant claims reviewed verified that the claims paid for services did not exceed the amount, duration and frequency of services identified on the care plan. 13 participant claims showed services with amounts billed over the amount authorized on the care plan. • Performance Measure: Number and percentage of claims paid for services identified on a participant’s Comprehensive Care Plan. Deficiency #3: 46 of 52 (88.46%) participant claims reviewed verified that all claims paid for services were present on the care plan. 6 participant claims paid were not present on the participants’ care plan. • Performance Measure: Number and percentage of participant claims that paid for services using approved waiver codes and rates. Deficiency #4: 45 of 52 (86.53%) participant claims reviewed verified that all waiver codes for services were correct. 7 participant claims paid had incorrect waiver codes for services. Deficiency #5: 46 of 52 (88.46%) participant claims reviewed verified that providers billed at the correct rate as per the AW Negotiated Rate Sheet. 6 participant claims paid showed services which the provider billed at a higher rate than the AW Negotiated Rate Sheet.
Deficiencies have been, or are being corrected.

Provide an explaination of how these deficiencies have been, or are being corrected as well as an explanation of what steps have been taken to ensure the deficiencies do not recur:

The SMA has identified the following corrections of the significant deficiencies: Deficiency #1: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the process for the recovery of funds for $4,097.66 has been accomplished. Deficiency #2: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $719.21 has been accomplished. Deficiency #3: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $451.16 has been accomplished. Deficiency #4: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $517. 45 have been accomplished. Deficiency #5: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $175.06 has been accomplished. Deficiency #6: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $596.20 has been accomplished. Deficiency #7: The following action was taken to correct the deficiency. Medicaid Operations is currently processing the recovery of funds. This issue will be resolved when the recovery of funds for $272.80 has been accomplished. DAAS has identified the following corrections of the significant deficiencies: Deficiency #1: The following action was taken to correct the deficiency. The DAAS Manager addressed the requirement for a LOC screening to be conducted following a hospital discharge with each administrative nurse case manager that did not conduct the post hospitalization LOC screening. The importance of instructing the client/family to contact the case manager when a hospitalization occurs was also addressed with the case managers. Deficiency #2: The following action was taken to correct the deficiency. Corrections were sent to Medicaid Operations for the processing of the recovery of funds for all overages discovered. Deficiency #3: The following action was taken to correct the deficiency. Corrections were sent to Medicaid Operations for the processing of the recovery of funds for all services that were not present on the care plan that were discovered. Deficiency #4: The following action was taken to correct the deficiency. Correct waiver codes were sent to Medicaid Operations for reprocessing the claims that had incorrect codes. Deficiency #5: The following action was taken to correct the deficiency. Corrections were sent to Medicaid Operations for the reprocessing of claims paid for higher rates than documented on the AW Negotiated Rate Sheets.

Certification:

I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:

Signature:

Date:

Phone Number:

Contact Information (optional):

Contact Person:

Phone Number: