Medicaid Audit: Lessons for NJ Personal Care Agencies

The Office of Inspector General (OIG) recently audited New Jersey’s personal care program and found deficiencies as a result of noncompliance with Federal and State requirements by some personal care agencies. Based on the audit result, the OIG asked the State to return $32,236,308 in Federal Medicaid reimbursement for personal care services that the OIG claimed did not meet Federal and State requirements.

NJ Personal Care Program

New Jersey’s personal care aides assist the elderly, people with disabilities, and individuals with chronic or temporary conditions remain in their homes and communities. Assistance is provided with activities related to daily living, such as bathing, dressing, light housework, medication management, meal preparation, and transportation. Personal care assistance is considered a non-medical service.

Federal law requires that personal care services be authorized by a physician in accordance with a plan of treatment and be provided by an individual who is qualified to provide such services and who is not a member of the individual’s family. The services must also be furnished in a home, or at the State’s option, in another location.

New Jersey’s regulations expand on the federal requirements and further require personal care agencies to maintain a beneficiary’s clinical records, including a personal care aide activity assignment sheet (activity sheet). New Jersey also requires physician certification of a beneficiary need for the personal care services. Furthermore, a registered nurse is required to (1) prepare a plan of care in accordance with the physician’s certification, (2) perform an initial assessment and reassessment of the beneficiary’s need for personal care services every 6 months, and (3) provide direct supervision of the beneficiary’s personal care aide at least every 60 days. The personal care agency must also provide the aides with 12 hours per year of in-service education.

OIG Reports on State Deficiencies

In reviewing New Jersey’s personal care services program, the OIG found a number of deficiencies demonstrated by certain personal care service providers.  Out of a random sample of 100 claims the OIG’s auditors found (1) failure to document or meet the nursing supervision requirements in 8 claims; (2) failure to document or meet the in-service training qualifications in 4 claims; (3) lack of physician’s certification in 3 claims; (4) lack of nursing assessment in 3 claims; (5) no clinical file in 2 claims; (6) no plan of care in 2 claims; (7) lack of service documentation in 2 claims; (8) no provision of services in 1 claim.

The State partially concurred with the OIG’s recommendation that the State issue a refund to the Federal government but it also objected to the OIG’s audit methodology.

The OIG’s report highlights the importance of implementing an effective compliance program. When implemented, an effective compliance would assist personal care agencies in identifying costly gaps in its operations, such as missing or incomplete documentation, and help improve patient care by improving coordination between nursing, personal care aides and the individual’s physician. Personal care agencies should also take note that the state watchdog, NJ Medicaid Fraud Division, has identified this provider as a target for audits in the agency’s most recent workplan.

If you have any questions regarding the OIG report mentioned in this article, New Jersey’s personal care program, Medicaid audits, or have other health law questions, please contact our office.