Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care - Finding 2

MassHealth Paid Adult Foster Care and Group Adult Foster Care Providers for Services That Did Not Have Supporting Caregiver / Direct Care Aide Log Documentation.

Overview

MassHealth paid AFC and GAFC providers for services that did not have supporting caregiver / direct care aide log documentation. Specifically, caregiver / direct care aide logs were incomplete or missing for 116 out of the 119 members from our telehealth member sample who received AFC or GAFC services. In addition, caregiver / direct care aide logs were incomplete or missing for 103¹³ out of the 128 members in our non-telehealth member sample who received AFC or GAFC services.

Below is a summary of the caregiver / direct care aide log documentation issues.

Documentation Issue	Number of Telehealth Members from Sample: Out of 119*	Number of Non-Telehealth Members from Sample: Out of 128*
Caregiver / direct care aide log not received	86 (72%)	29 (23%)
Activity of daily living (ADL) and instrumental activity of daily living (IADL) codes not present	19 (16%)	29 (23%)
Caregiver / direct care aide initials not present	36 (30%)	43 (34%)
Caregiver / direct care aide signature not present	20 (17%)	7 (5%)
No care manager or registered nurse / licensed practical nurse signature	35 (29%)	36 (28%)
Caregiver / direct care aide log not reviewed every 30 days	63 (53%)	82 (64%)
Incorrect modifier code	2 (2%)	1 (1%)

*      Some of the members had multiple documentation issues and were included in more than one category.

The lack of adequate documentation calls into question whether all of the services from caregivers and direct care aides were delivered and makes it impossible to determine whether services were necessary or appropriate for members.

Authoritative Guidance

According to 130 CMR 408.433(C)(2) and (3), registered nurses / licensed practical nurses and care managers must review AFC caregivers’ logs at least once every 30 days.

According to 130 CMR 408.434(C),

The AFC caregiver must

       (1)  supervise and assist with ADLs and IADLs of a member that is necessary for the                            member’s health and well-being;

       (2)  monitor and report any nonurgent or nonemergency changes in the member’s medical              condition to the member’s AFC provider. In cases of emergency, the AFC caregiver must                report directly to the most appropriate provider and follow up with the AFC provider;

       (3)  maintain of the qualified setting; . . .

       (4)  complete a caregiver log;

       (5)  send the completed caregiver log at the end of each month to the program’s registered              nurse where it is maintained as part of the member’s file.

According to 130 CMR 408.524(B)(1), (2), and (5), the program director, registered nurse / licensed practical nurse, and care manager must review GAFC direct care aides’ logs every 30 days.

According to 130 CMR 408.524(C)(2)(a),

(2)  The responsibilities of the GAFC direct care aide include:

       (a)  provision of hands-on or cueing and supervision with ADLs and IADLs, of a member in                accordance with the individual’s GAFC plan of care and that is necessary for the                            member’s health and well-being including, but not limited to, identifying when a crisis                intervention is necessary; . . .

       (e)  sending the completed direct care aide log at the end of each month to the nurse where              it is maintained as part of the member’s file.

According to 130 CMR 450.205,

(B)  All providers must maintain complete patient account records. . . .

(D) All records including, but not limited to, those containing signatures of medical professionals authorizing services . . . must, at a minimum, . . . comply with generally accepted standards for recordkeeping within the applicable provider type.

Reasons for Issue

MassHealth does not have an effective monitoring process in place to ensure that caregivers / direct care aides of AFC and GAFC providers properly document care in their logs to support that members are receiving needed care or that care that was billed and paid was actually delivered by qualified caregivers / direct care aides.

Recommendation

MassHealth should establish an effective monitoring process to ensure that caregivers / direct care aides of AFC and GAFC providers properly document care in their logs.

Auditee’s Response

MassHealth agrees with this recommendation. As discussed above, MassHealth actively engages in provider education and program integrity activities to promote and monitor AFC and GAFC compliance with provider requirements. This includes the provision of provider education on requirements to train caregivers and direct care aides on care log documentation requirements, as well as provider audits to monitor compliance with program requirements, which includes review of caregiver / direct care aide logs.

As noted in response to Finding 1, above, from 2022 to present, MassHealth has initiated 92 audits of AFC and GAFC providers (approximately 3 audits per month) and has issued 49 initial notices of overpayment and sanction, which outline MassHealth’s audit findings and initiates the recovery process for identified overpayments and sanctions.

Auditor’s Reply

We commend MassHealth for implementing stronger monitoring controls over AFC and GAFC providers.

13.    Out of these 103 members from our non-telehealth member sample, 8 were GAFC members.

 

Date published:	September 4, 2024