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IHSS Uniform Statewide Protocols

IHSS Uniform Statewide Protocols

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IHSS Uniform Statewide Protocols

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  1. IHSS Uniform Statewide Protocols for Program Integrity Activities California Department of Social Services Adult Programs Division October 2013

  2. background • On July 24, 2009, ABX4 19 required CDSS to convene a state and county stakeholders’ workgroup to address the key requirements pertaining to IHSS Program Integrity. • The goal of this workgroup was to develop protocols clarifying roles and responsibilities for the implementation and execution of standardized program integrity measuresin IHSS. • Toward that end, the legislation amended sections of the California Welfare and Institutions Code (WIC). • Of particular importance was the workgroup’s intent to eliminate duplicated effortsamong different agencies and minimize any inconvenience or disruption for IHSS program participants.

  3. BACKGROUND • The workgroup formed by the CDSS includes representatives from CDSS, the Department of Health Care Services (DHCS), the California Department of Justice (DOJ) Bureau of Medi-Cal Fraud and Elder Abuse, county staff, district attorneys’ offices, IHSS recipients, and advocacy groups representing IHSS recipients and providers to ensure sufficient diversity in addressing the protocols.

  4. The measures DATA SHARING AND STATEWIDE COORDINATION UNANNOUNCED HOME VISITS DIRECTED MAILINGS PROGRAM INTEGRITY TRAINING

  5. DATA SHARING AND STATEWIDE COORDINATION Purpose The purpose of data sharing and statewide coordination is to develop a coordinated and standard process for fraud referrals and investigationsthat fosters collaborative working relationships across jurisdictions. This includes a standard for deciding when and how to refer a case for fraud investigation. • Definitions • Complaint: Any program integrity concern/allegation identified or received by the State or county. • Triage: The process whereby the authorized staff person reviews a complaint of suspected fraud and determines whether or not the complaint becomes a fraud referral. • Fraud Referral: A complaint that has been triaged and referred to a law enforcement agency for fraud investigation. • Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

  6. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2248 – IHSS Complaint of Suspected Fraud IHSS Consumer Information A. Receipt of Initial Complaint B. Reason Behind Complaint C. Qualitative Information to Help Others Understand the Complaint

  7. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2248 – IHSS Complaint of Suspected Fraud IHSS Consumer Information A. Receipt of Initial Complaint B. Reason Behind Complaint C. Qualitative Information to Help Others Understand the Complaint

  8. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2248 – IHSS Complaint of Suspected Fraud(cont.) D. Case File Information D. Case File Printouts Triage: How Should This Case Be Handled? E. What Decision Was Made Through Triage? F & G. What Was the Outcome?

  9. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2248 – IHSS Complaint of Suspected Fraud(cont.) Fraud Referral Process • Complaints determined appropriate for investigation will become fraud referralsand follow one of two paths, depending on whether or not the county has a Memorandum of Understanding (MOU) with DHCS. • Counties without an MOU with DHCS shall send all IHSS fraud referrals over $500 directly to DHCS for investigation. • Counties who have an MOU with DHCS willabide by the terms of that MOU. Referral? >$500? MOU? Triage Investigate in accordance with the MOU Yes Yes Yes No No No DHCS referral Drop- no action, or administrative action County investigate, or DHCS referral

  10. DATA SHARING AND STATEWIDE COORDINATION • Form SOC 2245 – Fraud Data Reporting • Definitions • Administrative Action: Any action taken on a case by IHSS administration. These actions may include: overpay recovery, reduction in hours, case termination, etc. • Early Detection Savings: Any future savings achieved by terminating or reducing hours on a case. Data is reported as hours saved in a single month. • Investigation: The work of law enforcement to review a fraud referral. • Prosecution: Using the court system to prove or disprove criminal activity, and to pursue restitution and/or conviction.

  11. DATA SHARING AND STATEWIDE COORDINATION • Form SOC 2245 – Fraud Data Reporting • Definitions • Administrative Action: Any action taken on a case by IHSS administration. These actions may include: overpay recovery, reduction in hours, case termination, etc. • Early Detection Savings: Any future savings achieved by terminating or reducing hours on a case. Data is reported as hours saved in a single month. • Investigation: The work of law enforcement to review a fraud referral. • Prosecution: Using the court system to prove or disprove criminal activity, and to pursue restitution and/or conviction.

  12. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2245 – Fraud Data Reporting (cont.) Section I. Fraud Complaints Section II. Early Detection Savings Section III. Fraud Investigations - Completed

  13. DATA SHARING AND STATEWIDE COORDINATION Form SOC 2245 – Fraud Data Reporting(cont.) Section IV. Prosecutions - County Section V. Totals ($) Sections VI.1. and VI.2. Comments

  14. Unannounced home visits • Purpose • The purpose of the UHV by county staff is to ensure that the services authorized are being provided at a level that meets the recipient’s needs, allowing him/her to remain safely in his/her home, and to validate the information in the case file. • Definition • An unannounced home visit (UHV) is an unscheduled visit conducted by trained county IHSS staff in the home of an IHSS recipient who has been selected using specific indicators. • Per WIC Section 12305.71(c)(3), It is a monitoring tool: • (c)(3) Monitoring the delivery of supportive servicesin the county to detect and prevent potential fraud by providers, recipients, and others and maximize the recovery of overpayments from providers or recipients. • As appropriate, in targeted cases, to protect program integrity, this monitoring may include a visit to the recipient's home to verify the receipt of services. • The exact date and time of a home visit shall not be announced to the supportive services recipient or provider. • The department, in consultation with the county welfare departments, shall develop protocols for followup home visits and other actions… The protocols shall include, at a minimum, all of the following: • (i) Information sent to the recipient's home regarding the goals of the home visit, including the county's objective to maintain program integrity by verifying the receipt of services, the quality of services and consumer well-being, and the potential loss of services if fraud is substantiated…

  15. Unannounced home visits Form SOC 2247 – IHSS UHV Findings Report Prepare for UHV from Case File Provide Important Consumer Information to the Trained UHV Staff Must Carefully Document Each Step Taken Must Document Findings of the UHV

  16. Unannounced home visits Form SOC 2247 – IHSS UHV Findings Report(cont.) Allows UHV Staff to Recommend Next Steps to County IHSS Staff County IHSS Staff and UHV Staff Can Provide Qualitative Communication to Each Other County IHSS Staff Determines the Steps to Take Based on the UHV Findings & Recommendations

  17. Unannounced home visits Procedures No Contact or Entry denied • In the event that contact is not made or entry is denied, UHV staff must perform all of the following activities to make contact within 45-60 calendar days: • A letter to the recipient • A telephone call to the recipient • A second UHV attempt • A second telephone call • A third UHV attempt • Termination Notice of Action Notice of Action to the Recipient • If, after all required attempts of contact have been made, no UHV has been conducted, counties shall send the recipient a Notice of Action (NOA) indicating that the recipient’s IHSS is being discontinued for failure to comply with program requirements. • The NOA shall contain the reason for the discontinuation of services , the steps taken prior to issuance of the NOA , and the applicable law. Once the NOA is issued, the process continues to resolution.  

  18. Unannounced home visits Procedures(cont.) States the Purpose of the Home Visit Explains the requirement to cooperate with a Home Visit Provides Important Educational Reminders Provides an Opportunity for the Consumer to Contact the County

  19. DIRECTED MAILINGS Purpose The purpose of directed mailings is to convey program integrity concerns, inform IHSS providers of appropriate program rules and requirements, and express the consequences for failing to adhere to them. Definition A directed mailing is a standardized letter with required information and customizable areas, including a plain-language reason why the provider received the letter, and county contact information.

  20. DIRECTED MAILINGS Procedures Addressed to the IHSS Provider Provides the Reason the Letter Was Sent Copied to the IHSS Consumer Provides Important Program Integrity Reminders Provides an Opportunity for the Provider to Contact the County

  21. DIRECTED MAILINGS Procedures(cont.)

  22. DIRECTED MAILINGS Procedures(cont.) General • Counties shall select indicators from the indicator list provided by CDSS • Conduct data pulls to determine each mailing group, and • Create a directed mailing list of providers who all share the indicator. Preparation • Counties shall send CDSS the list of providers to receive the directed mailings prior to mailing. • CDSS shall cross reference the county mailing list against previous mailings, and ensure that the county is aware of any duplication or repeat mailings. • Counties shall review the returned list and determine, for each repeat name, whether or not to include in the mailing. • Counties shall customize the letter to include a reason for the mailing from the reasons list and county contact information, and conduct the mailing.

  23. DIRECTED MAILINGS Procedural Exceptions Unforeseeable Circumstances If a county experiences an unforeseeable emergency which prevents it from conducting a data pull or its required annual directed mailing, it may request that CDSS conduct the data pull or directed mailing on its behalf. Zero-Result Data Pull • If a county conducts a data pull and gets no results, it shall conduct a second data pull based on a different indicator, or different combination of indicators. • If the second data pull also returns no results, the county shall conduct a third data pull using an indicator or a combination of indicators which have not yet been tried. • If the third pull results in no matches, the county shall notify CDSS. • CDSS will evaluate the obligation of that county to send a directed mailing for that year, and may conduct a data pull for the county at its discretion. • On the second consecutive year that a county conducts three zero-result data pulls, CDSS shall conduct a data pull and send the resulting set to the county, who shall use the set to conduct a directed mailing.

  24. PROGRAM INTEGRITY TRAINING Social Worker Training Academy

  25. IHSS Uniform Statewide Protocols Questions? Questions Can Be Emailed to: IHSS-PI@dss.ca.gov