PowerPoint Presentation

for Program Integrity ActivitiesIHSS Uniform Statewide ProtocolsCalifornia Department of Social ServicesAdult Programs DivisionOctober 2013

Welcome to the Webinar on implementing the Uniform Statewide Protocols for Program Integrity Activities in the In-Home Supportive Services (IHSS) program.

Purpose: to provide training and technical assistance through-Overview of the protocolsDiscuss standard definitionsWalkthrough the forms

Detailed guidance in:ACIN I-13-13 Released the protocolsACL 13-83 ImplementationACIN I-66-13 and ACIN I-66-13E Program Integrity Training

1backgroundOn 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 measures in IHSS.

Toward that end, the legislation amended sections of the California Welfare and Institutions Code (WIC).

Of particular importance was the workgroups intent to eliminate duplicated efforts among different agencies and minimize any inconvenience or disruption for IHSS program participants.2

To provide a background

On July 24, 2009ABX 4-19 amended WIC Section 12305 (particularly 12305.7, .71, and .82)CDSS establish a state and county stakeholders workgroupaddress new requirements pertaining to IHSS program integrity.

The deliverable expected of this workgroup-Recommendation to CDSS (ACIN I-13-13)Including framework of PI protocols clarify state and county PI roles and responsibilitiesSignificantly reduce duplication of effortsProtect IHSS participant wellbeing and preserve their dignity2BACKGROUNDThe 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.

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The workgroup was established in March, 2010.

It included representatives from CDSS, DHCS, DOJ, county IHSS staff, and district attorneys offices.

In 2011, IHSS recipients, advocacy groups, and providers unions were added to enhance diversity to the workgroup.

Over a two-year period:full workgroup met 7 times,numerous subcommittee and focus group meetings, and DSS conducted 3 public meetings

June 2012, the workgroup completed the Report of Recommendations to CDSS, and inMarch 2013, CDSS released the protocols based on the recommendations of that group. September 2013, the ACL 13-83 was released with implementation guidelines and timelines.

The measures, forms, and letters we will present today are a direct result of this workgroup effort. The forms are available at the website: cdss.ca.gov under the Forms tab.3The measuresUNANNOUNCED HOME VISITSDIRECTED MAILINGSDATA SHARING AND STATEWIDE COORDINATION

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PROGRAM INTEGRITY TRAINING

The specific measures addressed in the protocols includeData Sharing and Statewide CoordinationUnannounced Home VisitsDirected MailingsProgram Integrity Training for county staff, provided by CDSS through the Social Worker Training Academy4DATA SHARING AND STATEWIDE COORDINATION5Definitions

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. Purpose

The purpose of data sharing and statewide coordination is to develop a coordinated and standard process for fraud referrals and investigations that fosters collaborative working relationships across jurisdictions.

This includes a standard for deciding when and how to refer a case for fraud investigation.

The first of those measures

Data Sharing and Statewide Coordination- the effort to foster strong and effective working relationships between state and county agencies.

Common definitions used throughout this section

A complaint is any program integrity concern reported to or discovered by State or county.

Triage is the process of initial review, to determine if a complaint should be forwarded to investigators as a fraud referral.

A fraud referral is a complaint that has been triaged and determined that it should be forwarded to a law-enforcement agency for fraud investigation.

Fraud is an intentional deception or misrepresentation with the knowledge that the deception could result in some unauthorized benefit. [WIC 12305.8(a)]

56DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2248 IHSS Complaint of Suspected Fraud

IHSS Consumer InformationA. Receipt of Initial ComplaintB. Reason Behind ComplaintC. Qualitative Information to Help Others Understand the Complaint

To track suspected fraud at the case level, counties will use the IHSS Complaint of Suspected Fraud Form, the SOC 2248.

It allows county staff to complete some basic information in order to file an initial complaint of suspected fraud.

The person completing the form should add as much information as possible to initiate review.

The form is not determinative. Nothing about it should be read as an assumption of fraud.No prohibition against County employee Seen driving Seen working- true. It might turn out that the whole basis of the complaint isAbuse Stealing not fraud- true. Report them anyway for recipient well-being.

67DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2248 IHSS Complaint of Suspected Fraud

IHSS Consumer InformationA. Receipt of Initial ComplaintB. Reason Behind ComplaintC. Qualitative Information to Help Others Understand the Complaint

To track suspected fraud at the case level, counties will use the IHSS Complaint of Suspected Fraud Form, the SOC 2248.

It allows county staff to complete some basic information in order to file an initial complaint of suspected fraud.

The person completing the form should add as much information as possible to initiate review.

The form is not determinative. Nothing about it should be read as an assumption of fraud.No prohibition against County employee Seen driving Seen working- true. It might turn out that the whole basis of the complaint isAbuse Stealing not fraud- true. Report them anyway for recipient well-being.

78DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2248 IHSS Complaint of Suspected Fraud (cont.)D. Case File InformationD. Case File PrintoutsE. What Decision Was Made Through Triage?

Triage:How Should This Case Be Handled?F & G. What Was the Outcome?

This form, the SOC 2248, replaces the MC 609 for reporting of suspected IHSS fraud.Follows the case all the way through to the outcome.This form is not submitted to CDSS nor DHCS.It is retained by the county.

See a logical flow- Initial complaint information on page 1,Additional case info on page 2,Section E for the result of triage, and Section F for the final outcome

Data from the SOC 2248 is aggregated onto the SOC 2245 Fraud Data Reporting Form, and that is submitted quarterly to CDSS.Well walk through the SOC 2245 in a moment89DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2248 IHSS Complaint of Suspected Fraud (cont.)

Fraud Referral ProcessComplaints determined appropriate for investigation will become fraud referrals and 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 will abide by the terms of that MOU.

Referral?MOU?>$500?YesYesYesNoNoNoDrop- no action, or administrative actionCounty investigate, or DHCS referralDHCS referralInvestigate in accordance with the MOUTriage

Process for fraud referrals.

Remember that fraud referrals are complaints that are deemed appropriate for investigation, through a standardized triage process.

Fraud referral process depends on two factors: the $ figure and whether or not the county has a Memorandum of Understanding (MOU) with the Department of Health Care Services. Check with your supervisor to determine if your county has an MOU with DHCS.

For cases of suspected fraud involving an amount: Up to $500 The county has the option to investigate locally or refer to DHCS Greater than $500, and county has an MOU Abide by the terms of the MOU Greater than $500 and NO MOU Refer it to DHCS for investigation

9DATA SHARING AND STATEWIDE COORDINATION10Form 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.

Counties are responsible for reporting statistical data to CDSS on a quarterly basis. The form for counties to use to report this statistical data is the SOC 2245. The SOC 2245 provides a county-level summary of fraud complaints received, administrative actions taken, savings from early detection, fraud complaints referred, investigations, and prosecutions that occurred each quarter in the county.

Definitions that apply throughout this section

An administrative action- overpay recovery, service hours reduction, case termination

Early detection savings is any future savings achieved by terminating or reducing monthly service hours on a case.

An investigation is the work of law enforcement to review a fraud referral.

Prosecution is the act of using the court system to prove or disprove criminal activity. Could result in dismissal, plea deal, conviction, and/or court-ordered restitution.

10DATA SHARING AND STATEWIDE COORDINATION11Form 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.

Counties are responsible for reporting statistical data to CDSS on a quarterly basis. The form for counties to use to report this statistical data is the SOC 2245. The SOC 2245 provides a county-level summary of fraud complaints received, administrative actions taken, savings from early detection, fraud complaints referred, investigations, and prosecutions that occurred each quarter in the county.

Definitions that apply throughout this section

An administrative action- overpay recovery, service hours reduction, case termination

Early detection savings is any future savings achieved by terminating or reducing monthly service hours on a case.

An investigation is the work of law enforcement to review a fraud referral.

Prosecution is the act of using the court system to prove or disprove criminal activity. Could result in dismissal, plea deal, conviction, and/or court-ordered restitution.

1112DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2245 Fraud Data Reporting (cont.)Section I. Fraud ComplaintsSection II.Early Detection Savings

Section III.Fraud Investigations - Completed

The SOC 2245 should represent a logical flow

Section I tracks complaints that were received that quarterby source, and by the outcome of the triage.

Section II tracks Early Detection Savings. For example, a case worker discovered that the number of people reportedly living in the household was incorrect, filed a complaint, and the complaint was returned for an administrative action, which resulted in a reduction of 5 hours per month. This is recorded:in Section II.A (Line 17) as 1 case reduced, in II.A.1 (Line 21) as 1 reduction based on misrepresented household composition, in Section II.B (Line 23) as 5 hours reduced, and in II.B.1 (Line 27) as 5 hours based on misrepresented household composition. In state fiscal year 2011/12, counties reported 3,227 cases with terminations or reductions, for a total of 265,875 monthly hours reduced statewide.

Section III tracks actual fraud investigations that were completed in that quarter. by type of fraud, outcome of the investigation, and estimated dollar amount involved.1213DATA SHARING AND STATEWIDE COORDINATIONForm SOC 2245 Fraud Data Reporting (cont.)

Section IV. Prosecutions - CountySection V.Totals ($)Sections VI.1. and VI.2.Comments

Section IV- tracks the prosecutions that occurred in that quarter, by outcome.

Section V- to report the dollar amount of loss that was identified that quarter.

And Section VI is for comments.

13Unannounced home visits14

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 recipients 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 services in 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

The second measure of the protocols is Unannounced Home Visits.

Unannounced Home Visits are unscheduled visits conducted by trained county IHSS staff in the home of the IHSS consumer who has been selected using specific indicators.

Trained staff Designated county staff that has completed the Program Integrity Training Module through SWTA.This webinar meets the trained criteria, and additional information can be found in ACINs I-66-13 and I-66-13E.

The primary purpose of an Unannounced Home Visit is to verify the consumers well-being. What parts of WIC stand out?Monitoring the delivery of supportive servicesto verify the receipt of supportive servicesto maintain program integrity by verifyingReceipt of svcsQuality of svcs, andConsumer well-being.

It is also an opportunity to briefly discuss any concerns, particularly program integrity concerns, with the consumer.

14Unannounced home visits15Form SOC 2247 IHSS UHV Findings ReportMust Carefully Document Each Step TakenProvide Important Consumer Information to the Trained UHV Staff

Prepare for UHV from Case FileMust Document Findings of the UHV

The entire UHV process must be documented using the UHV Findings Report, the SOC 2247.

General identifying infoCase file infoDetailed documentation of the UHV processFindings of the UHV

15Unannounced home visits16Form SOC 2247 IHSS UHV Findings Report (cont.)County IHSS Staff and UHV Staff Can Provide Qualitative Communication to Each OtherAllows UHV Staff to Recommend Next Steps to County IHSS Staff

County IHSS Staff Determines the Steps to Take Based on the UHV Findings & Recommendations

Recommendations, andComments.

16Unannounced home visits17In 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 recipientA telephone call to the recipientA second UHV attemptA second telephone callA third UHV attemptTermination Notice of ActionNotice of Action to the RecipientIf, 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 recipients 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. Procedures

No Contact or Entry denied

In the event that contact is not made or entry is denied, UHV staff must closely adhere to the minimum follow-up protocols and thoroughly document each step on the form:

A letter to the recipient Well discuss this letter in a minuteA telephone call to the recipientA second UHV attemptA second telephone callA third UHV attemptTermination NOA Currently in development, requested for January, 2014. All of these steps will be documented in the NOA.

CLARIFICATION: County may make additional efforts to accomplish the UHV at any point throughout the 60 day period; these steps represent the minimum required follow-up protocols.

Details about the UHV process can be found on page 6 of ACL 13-83.17Unannounced home visits18Procedures (cont.)

States the Purpose of the Home VisitExplains the requirement to cooperate with a Home VisitProvides Important Educational RemindersProvides an Opportunity for the Consumer to Contact the County

The UHV follow-up letter is for use in the event that the first UHV attempt does not result in a completed UHV.

It is designed specifically to:include the purpose of the home visit, explain the requirement to cooperate with the home visit, educate recipients about fraud and its related consequences, and provide an opportunity for the consumer to contact the county.

The text in red is for county modification.

This letter is Attachment A to the protocols (ACIN I-13-13)

If you need assistance, email IHSS-PI@dss.ca.gov .18DIRECTED MAILINGS19

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.

The third measure of the protocols is Directed Mailings.

Directed mailings are-standardized letters sent by the counties no less than once per year to a group of providers based on some attribute that they share

As a quick note, Directed Mailings are no longer referred to as Targeted Mailings except in the Welfare & Institutions Code.

19DIRECTED MAILINGSProcedures20Provides the Reason the Letter Was SentAddressed to the IHSS Provider

Copied to the IHSS ConsumerProvides Important Program Integrity RemindersProvides an Opportunity for the Provider to Contact the County

This is the template for the Directed Mailing letter.

This letter is to be addressed to the individual provider and copied to the consumerIt provides a plain-language reason the letter was sent, includes important PI reminders, and provides an opportunity for the provider to contact the county.

Again, the text in red is for county modification.

This letter is Attachment C to the protocols (ACIN I-13-13)

20DIRECTED MAILINGSProcedures (cont.)21

Some possible reasons that could be inserted into a directed mailing letter-

If you are an IHSS provider, you are receiving this letter because we are providing program information to all providers

Who work so many hours.

Or

who request more replacement timesheets than most.

21DIRECTED MAILINGS22Counties 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. Procedures (cont.)

GeneralCounties 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

As mentioned, Directed Mailings are to be conducted at least once a year by each county.

Counties will select their own indicators from a list provided by CDSS.Counties will then conduct data pulls to make up a mailing list of providers who share the indicator.The county will send the proposed mailing list to CDSS for review.Once CDSS has returned the reviewed provider mailing lists, counties will mail letters to providers and send copies to the consumers associated with these providers.

22DIRECTED MAILINGSProcedural Exceptions

Unforeseeable CircumstancesIf 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 PullIf 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.

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If a county experiences an unforeseeable emergency, then it can request for CDSS to conduct the data pull or mailing on its behalf.

If a county conducts a data pull and gets no results, it is required to conduct a second, and even a third, data pull based on a different indicator, or a different combination of indicators.

After the third try using different indicators and with no results, the county will need to work directly with CDSS.

ACL 13-83 restates the Zero-Result Data Pull procedures established in the protocols

23PROGRAM INTEGRITY TRAININGSocial Worker Training AcademyUpcoming CoursesJanuary 16, 2014Shasta County ReddingSacramento County SacramentoRiverside County Moreno Valley

January 30, 2014Stanislaus County CeresFresno County FresnoOrange County OrangeRegistration & Training RequestsUse the Current County Registration Process

To Request Additional Training Options, Email:IHSS-Training@dss.ca.gov

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The fourth measure of the protocols is Program Integrity training. Program Integrity classroom training helps county IHSS staff:Understand fraud and how it differs from inadvertent mistakes. Identify their roles and responsibilities in IHSS fraud and error prevention, detection, referral, investigation, and prosecution. Understand directed mailings and unannounced home visits as part of the states and the counties efforts to deter fraud and ensure program integrity and be familiar with the process for each. Describe why documentation is important in the program integrity and fraud investigation process, and key information to include in documentation.

Upcoming Program Integrity training sessions will be held on January 16 and on January 30, 2014. County IHSS staff wishing to attend this training should use their standard county approval process.

We highly recommend those on your county Program Integrity staff to attend one of the in-class trainings.

To request additional training options, county IHSS staff can email:

IHSS-Training@dss.ca.gov.

2425IHSS Uniform Statewide ProtocolsQuestions?

Questions Can Be Emailed to:IHSS-PI@dss.ca.gov

This concludes the IHSS Program Integrity Webcast.

If you need technical assistance regarding the protocols, email state IHSS Program Integrity staff at:

IHSS-PI@dss.ca.gov25