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Anthony Cirillo

OIG Scrutinizes ALs for HCBS and Care Plans

By February 8, 2013

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Under the 1915(c) waiver, the Centers for Medicare & Medicaid Services (CMS) may waive certain requirements to allow State Medicaid programs to cover home and community-based services (HCBS) for beneficiaries residing in assisted living facilities (ALF).

The Office of Inspector General completed a study late last year to identify the costs and types of HCBS covered under 1915(c) waivers for Medicaid beneficiaries residing in ALFs. Data from 35 State Medicaid programs were reviewed and 7 States with the highest numbers of beneficiaries receiving these services were closely examined. These were Georgia, Illinois, Minnesota, New Jersey, Oregon, Texas, and Washington.

A random sample of 150 beneficiaries were examined. State survey agency inspection reports for ALFs in which beneficiaries from the sample resided were also reviewed as were plans of care associated with the beneficiaries.

In 2009, 35 Medicaid programs reported that, under 1915(c) waivers, they covered various HCBS for beneficiaries in ALFs at an annual cost of $1.7 billion. Each State had federally mandated provider standards; however, ALFs in the seven selected States did not always comply with them, and federally required plans of care did not always meet Federal requirements.

In the seven States, 77 percent of beneficiaries received HCBS under the waiver in ALFs cited for a deficiency being non-compliant for at least one State licensure or certification requirement. Nine percent of beneficiaries' records did not include plans of care required by the States. Further, 42 percent of the federally required plans of care did not include the frequency of HCBS furnished, as required. Five of the seven States also required that plans of care specify the beneficiaries' goals and the interventions to meet them. In these 5 States, 69 of 105 plans of care for beneficiaries receiving these services in ALFs did not meet that requirement. Two of the seven States also required that plans of care be signed by beneficiaries or their representatives. In these 2 States, 12 of 25 plans of care for beneficiaries receiving HCBS in ALFs did not meet that requirement.

The OIG recommend that CMS issue guidance to State Medicaid programs emphasizing the need to comply with Federal requirements for covering HCBS under the 1915(c) waiver. CMS concurred with the recommendation.

Yippee. So all that and all we get is agreement to emphasize the need for plans of care. Seems like there should be more meat to it. Regardless, assisted living providers cannot provide a quality experience of care to residents if there is not a documented plan of care. That is at least the cost of entry into the business. And consumers would be wise to do their homework to know which provider organizations develop quality plans of care for their residents.

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