Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs
Published: 2016-11-23T00:00:00

Fast Facts:
Personal care attendants help older and disabled Americans with daily tasks—such as bathing or eating. How do states ensure that care provided through Medicaid is safe, and that attendants aren't paid for phantom services?
While all states we reviewed monitored for safety, the frequency and means of check-ins varied across states, and sometimes within a state across personal care programs. We also found variation in states' safeguards against paying for services that weren't provided.
On the federal side, we found the Medicaid rules varied across different types of personal care programs. We recommended reducing that variation.

Highlights:
section_title: Why GAO Did This Study
paragraphs: The number of people receiving in-home personal care services—such as assistance with bathing and dressing—from Medicaid is expected to grow. States can offer these services through one or more programs under which home- and community-based services can be provided, each with different federal requirements. The provision of personal care in beneficiaries' homes can pose risks to safety, and these services have a high rate of improper payments, including instances where services for which the state was billed were not provided. In recent years Congress has directed HHS to improve coordination of these programs, which could harmonize requirements—that is, implement a more consistent administration of policies and procedures—and enhance oversight.
GAO was asked to review oversight of Medicaid personal care services. GAO examined: (1) how selected states ensure that beneficiaries receiving services are safe from harm and that billed services are provided; and (2) steps CMS has taken since 2010 to improve oversight and harmonize requirements across programs. GAO reviewed policies in four states with varied programs; reviewed laws, guidance and documents; and interviewed CMS officials.
section_title: What GAO Found
paragraphs: Four states that GAO reviewed varied in how they implemented safeguards to protect beneficiaries receiving in-home personal care services from harm and in their methods to help ensure billed services were actually provided. For example, to help keep beneficiaries safe, the four selected states—California, Maryland, Oregon, and Texas—reported that they monitored beneficiaries by having case managers or nurses periodically check in with beneficiaries, but the frequency and means, such as in-person or by phone, varied among the states and in some cases across programs within a state. The four states also reported using different methods to help ensure that billed services were actually provided. For example, to track attendants' work time, two states required beneficiaries to sign paper timesheets for the attendants, and two states used electronic visit verification timekeeping systems for some or all programs.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), has taken several steps to improve oversight of states' personal care service programs and harmonize requirements but has not collected required state reports or addressed significant differences in program requirements. Since 2010, CMS steps to improve oversight of states' programs include enhancing guidance and conducting webinars to help states address improper payments. To manage risk inherent in the provision of these services, and in keeping with statutory direction to improve coordination of these programs, CMS has taken steps to better harmonize requirements across programs including directing states to follow agency guidance issued for one type of program when implementing a similar type of program. However:
CMS has not systematically collected required states' reports on personal care services provided under two programs, although CMS stated that guidance for states to submit the reports is under development. Collecting these reports could improve oversight by providing CMS and Congress with information on programs' effects on beneficiaries' health and welfare.
CMS harmonization efforts have not addressed the significant differences across federal program requirements specific to beneficiary safety and ensuring that billed services are provided. Consequently, the safeguards and level of assurance that CMS has regarding states' beneficiary protections and oversight of billed services can vary by program. For example, one reviewed state requires quarterly or biannual beneficiary monitoring for most programs; but one program monitors annually as federal requirements do not require more frequent monitoring. Similarly, requirements to help ensure billed services are actually provided vary widely among states and programs, contributing to uneven assurances and oversight across programs.
Home- and community-based services, including personal care services, are growing in significance and in demand. A more consistent administration of policies and procedures across programs could help the federal government and states better manage risks to beneficiaries and protect the integrity of the program.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Acting Administrator of CMS (1) collect and analyze required state reports on personal care services and (2) take steps to further harmonize federal program requirements, as appropriate, across programs providing these services. HHS concurred with both recommendations

section_title: Letter
paragraphs: Medicaid, a federal-state health financing program for low-income and  medically needy individuals, is the nation’s primary payer of long-term  care services and supports for people with disabilities and aged  individuals. Medicaid spending on long-term care services and supports is  significant, representing about one quarter of Medicaid spending  annually. The majority of Medicaid long term care spending is for home  and community-based services (HCBS)—that is, services and assistance  provided to beneficiaries in their homes or communities rather than in  institutional settings such as nursing homes. Personal care services  (PCS) are a significant component of HCBS. PCS provide assistance to  beneficiaries who have limited ability to care for themselves because of  physical, developmental, or intellectual disabilities or conditions. These  nonmedical services assist beneficiaries with activities of daily living such  as bathing, dressing, and toileting. Such assistance can enable people  with disabilities and aged beneficiaries to remain in their homes, maintain  their independence, and participate in community life to the fullest extent  possible. In calendar year 2015, reported federal and state Medicaid  expenditures for fee-for-service PCS—those not provided through  managed care delivery systems—totaled about $15 billion. Expenditures  associated with PCS provided in managed care delivery systems are  unknown. The demand for PCS is expected to increase as a result of the  aging of the nation’s population, increased life expectancy, and increased  opportunities for aged and individuals with disabilities to live in their  homes instead of institutions. The federal cost of long-term services and  supports is estimated to increase from $75 billion in 2015 to $111 billion  in 2026.
Although PCS are an important support for Medicaid beneficiaries that  can enable them to remain in their homes and communities, provision of  PCS is not without risk, both for beneficiary safety and for improper  Medicaid payments. Regarding safety, beneficiaries receiving PCS  include aged individuals and individuals with physical, developmental, or  intellectual disabilities, some of whom can be vulnerable. Also, when PCS  is provided in a private home, other providers or community members  may not be present to help discourage or report on questionable  activities. Moreover, depending on the state and the PCS program,  personal care attendants (attendants) who provide PCS may not be  required to have a credential from an organization that trains workers for  certain qualifications. The provision of PCS is also at high risk for  Medicaid improper payments. The Centers for Medicare & Medicaid  Services (CMS), an agency within the U.S. Department of Health and  Human Services (HHS), estimated that about 6 percent of all states’  payments for PCS in 2014 were improper and that the projected dollar  amount of payment errors was over $2 billion, the third highest of all types  of Medicaid services. The HHS Office of the Inspector General (OIG) has  also identified $582 million in questioned PCS costs in seven states from  2009 through 2012, such as instances in which PCS providers received  payments from state Medicaid agencies for services that were not  provided. While ensuring that billed services are provided protects against  Medicaid fraud, it also protects health and welfare by making sure  beneficiaries receive the services they need to remain safely in their  homes and communities.
PCS are one of the many types of services states may provide under their  Medicaid programs, which are administered by states and overseen by  the federal government. CMS is responsible for broad oversight of  Medicaid. To implement various provisions of federal law, CMS issues  program requirements in the form of regulations and guidance, approves  changes to states’ Medicaid plans, provides technical assistance to  states, collects and reviews required information and data from states  and, in some cases, reviews individual state programs. Under broad  federal requirements, states are responsible for the day-to-day  administration of their Medicaid programs. States have considerable  flexibility to establish multiple Medicaid PCS programs under different  provisions of federal law that authorize different types of PCS programs.  These different types of programs were enacted at different times and  offer states different options for serving beneficiaries; for example, some  types of programs allow states to limit services to only beneficiaries who  need an institutional level of care. The different types of programs have  different requirements under federal statute, regulation, and guidance.  States are responsible for establishing state policies and procedures in  accordance with these requirements. The Patient Protection and  Affordable Care Act directed HHS to take steps to improve the  coordination among, and the regulation of, all providers of home- and  community-based services. PCS programs have different statutory  requirements that CMS lacks authority to alter. However, harmonization  of requirements across programs can improve coordination of program  services and potentially facilitate improved oversight to better ensure  beneficiary health and safety and that billed services are actually  provided. Harmonization does not entail complete consistency but a more  consistent administration of policies and procedures across programs in  relation to the provision of such services. Given the projected increase in  the volume and costs of PCS, the potential vulnerability of program  beneficiaries, the risk of improper payments, and the challenge of  overseeing different PCS programs with different federal requirements,  you asked us for information on federal and state policies administering  PCS. This report examines:  1.  how selected states ensure that beneficiaries receiving PCS are safe  from harm and that billed services are provided; and  2.  recent steps CMS has taken, if any, to improve oversight of states’  PCS programs and to harmonize requirements across the programs.
To examine how selected states ensure that beneficiaries receiving PCS  are safe from harm and that billed services are provided, we selected a  nongeneralizable sample of four states to review the policies and  procedures they used to administer and oversee their Medicaid PCS  programs: California, Maryland, Oregon, and Texas. We selected states  that offer PCS under more than one type of Medicaid PCS program;  states that provide PCS under the Community First Choice option (the  newest type of program that states can use to provide PCS); and states  that provided geographic diversity. In each state and for each PCS  program reviewed, we administered a structured questionnaire and  reviewed the responses and documentation on state oversight  requirements, such as laws, policies, and procedures. We also  interviewed state Medicaid officials who administer PCS programs and  other state and local officials, such as officials from Adult Protective  Services agencies. In each state, we reviewed PCS programs  administered under a fee-for-service basis and did not review programs  administered on a managed care basis. We excluded managed care  arrangements because we limited our scope to PCS programs in which  the state was directly responsible for administering the programs. Further,  we limited our scope to reporting on state practices as reported by states  but did not verify implementation of these practices or assess CMS’s  oversight of these practices or their compliance with any applicable  federal requirements. In addition, we interviewed officials from four private  entities that provide PCS or administer long term care programs that  reimburse participants for PCS. In addition to one private entity that  administers a national long term care program, we chose three entities  suggested by national HCBS experts that operated within our selected  states. We asked officials at these entities about the policies and  procedures they use to keep clients safe in their homes and to ensure  that services for which states were billed were actually provided.
To examine recent steps CMS has taken, if any, to improve oversight of  states’ PCS programs and to harmonize requirements across PCS  programs, we reviewed applicable federal laws, regulations, and  guidance specific to Medicaid PCS programs, including reporting  requirements. We also obtained reports by CMS and HHS OIG, and we  interviewed officials with CMS. We focused our review on steps taken  since 2010, the year in which the Patient Protection and Affordable Care  Act was enacted and added a new PCS program option for states, the  Community First Choice program. In addition, we reviewed relevant  standards for internal control in the federal government and risk  management standards published by an international standard-setting  organization.
We conducted this performance audit from July 2015 to November 2016  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Medicaid is a federal-state health care program for low-income and  medically needy individuals. For fiscal year 2015, estimated Medicaid  spending totaled about $554 billion, and for fiscal year 2014, Medicaid  data show it served about 78 million individuals. States administer their  Medicaid programs within broad federal rules and according to a state  plan approved by CMS, the federal agency that oversees Medicaid. In  addition to providing PCS under their state plans, states can also seek  permission from CMS to provide PCS under waivers of traditional  Medicaid requirements, for example, in order to provide services to a  segment of the state’s eligible population. Medicaid is jointly financed by  the federal government and the states, with the federal government  matching most state Medicaid expenditures using a statutory formula  generally based on each state’s per capita income relative to the national  average.
subsections: section_title: Medicaid Long-Term Services and Supports
paragraphs: Factors That May Affect Growth of Care in  Home and Community Settings  Changes to federal Medicaid law in the last 35  years have expanded states’ options for  providing long term care services and  supports, including personal care services, in  home and community settings. Factors driving  these changes may include the desire and  increased ability of beneficiaries who are aged  and disabled to live in their homes and  communities and the Supreme Court’s 1999  Olmstead decision, which held that states  must serve individuals with disabilities in  community-based settings under certain  circumstances. (Olmstead v. L.C., 527 U.S.  581 (1999)).
Medicaid is the largest funding source for long-term services and  supports in the United States. In fiscal year 2014 (the most recent year for  which data are available), total Medicaid spending for long-term services  and supports was estimated at $152 billion. Long-term services and  supports represent a broad range of health and health-related services  and non-medical supports for individuals of all ages that these individuals  need over an extended period of time. Long-term services and supports  are generally provided in two settings: institutional facilities, such as  nursing homes; and home and community settings, such as individuals’  homes or assisted living facilities. Although states’ Medicaid coverage of  long-term care services provided in nursing homes is generally  mandatory and coverage of these services in home and community  settings is generally optional, spending on these services in the home and  community setting has increased and now exceeds spending on these  services in institutions (see fig. 1). All 50 states and the District of  Columbia provide long-term care services to some Medicaid beneficiaries  in home and community settings, according to a report produced under  contract with CMS.
section_title: Medicaid Personal Care Services
paragraphs: Medicaid PCS are a key component of Medicaid long-term services and  supports and include assistance with activities of daily living, such as  bathing and dressing, and in some cases instrumental activities of daily  living, such as preparing meals and housekeeping. PCS are typically non- medical services provided by attendants—home-care workers who may  or may not have specialized training, depending on specific state and  federal requirements. Attendants may be employed by a provider agency  or self-employed. In some cases, they are friends or family members of  the beneficiary and, under certain types of Medicaid PCS programs, can  be spouses, parents, or other legally responsible relatives.
States can use different delivery models to provide PCS to beneficiaries.  Under an agency-directed model, a provider agency employs attendants.  The provider agency hires, fires, pays, and trains the attendant to provide  PCS services to Medicaid beneficiaries. Under a participant-directed  model, beneficiaries or their representatives have more choice and  control over the PCS the beneficiary receives and have the authority to  manage PCS services by selecting, hiring, firing, and training attendants  themselves. States can implement hybrid forms of these models as well;  for example, by using an attendant from a provider agency but allowing  the beneficiary to be involved in directly managing the attendant by doing  such things as scheduling services, providing training on the beneficiary’s  specific needs, and, if needed, discharging the attendant.
With approval from CMS, states can choose to provide PCS under one or  more types of programs authorized over the past 41 years under different  sections of the Social Security Act. The various types of programs provide  states with options for permitting participant direction and choices about  how to limit services, among other things. For example, two types of PCS  programs (HCBS Waiver and Community First Choice programs) only  serve beneficiaries who are eligible for an institutional level of care; that  is, beneficiaries must have needs that rise to the level of care usually  provided in a nursing facility, hospital, or other institution. Some types of  PCS programs require the state to provide PCS to all Medicaid  beneficiaries who are eligible (PCS State Plan and Community First  Choice programs), while other programs (HCBS waivers and State Plan  HCBS programs) allow the state to target certain beneficiary populations  (see table 1). Appendix I provides more details on the PCS programs  offered by the selected states included in our review.
Some beneficiaries receiving PCS can be at risk for unintentional harm as  well as potential neglect, abuse, and exploitation by their attendants  because of their underlying conditions. In October 2016, the HHS OIG  reported cases of beneficiaries being abused or neglected by their  attendants. For example, one beneficiary was hospitalized for  dehydration and malnourishment after her attendant neglected her care.  In 2010, the HHS OIG reported that of 55 PCS beneficiaries or their  family members interviewed in New York, there were 11 reports of a  beneficiary being subject to theft, 5 reports of physical abuse or threats,  and 2 reported that they were abandoned by their attendant.  Beneficiaries may also be at risk of unintentional physical harm from  falling, particularly when the attendant cannot safely transfer clients  effectively from a bed to a chair. Some beneficiaries receive care from a  friend or family member, but these relationships may not always protect  vulnerable beneficiaries from abuse. In addition, beneficiaries may be at  risk for self-neglect or other health challenges if their attendants do not  show up to provide services when scheduled or are not trained to identify  signs of diminished health. A beneficiary’s capacity to manage finances  and secure possessions may decline with age, onset of dementia, or  other cognitive disabilities, and put them at risk of theft or financial  exploitation from unscrupulous attendants for example, the unauthorized  use of a beneficiary’s credit cards by an attendant.
section_title: Federal Program Requirements for Maintaining Beneficiary Safety and Ensuring That Billed Services Are Provided
paragraphs: The federal Medicaid program requirements governing the provision of  PCS derives from statutes enacted at different times in Medicaid’s history  (see table 1). CMS has implemented these different statutory  requirements by issuing regulations, as well as guidance to help states  implement their Medicaid programs in accordance with applicable  statutory and regulatory requirements. Guidance can include letters to  state Medicaid directors, program manuals, and templates to help states  apply for CMS approval to provide certain services like PCS. Together  with federal statutes, the regulations and guidance issued by CMS  establish a broad federal framework for the provision of PCS. States are  responsible for establishing and administering specific policies and  programs within the federal parameters laid out in this framework.  Medicaid program requirements vary by the type of PCS program, but  may include the following types of protections depending on the type of  program:  screening attendants to see if they are excluded as Medicaid  providers; developing minimum qualification standards for attendants; establishing quality assurance processes to ensure the services  provided protect the health and welfare of beneficiaries;  identifying and reporting cases of potential abuse, neglect, or other  events that harm, or could result in harm to beneficiaries; establishing policies and processes to ensure that services for which  the state has been billed were actually provided; and  reporting on the health and welfare of beneficiaries to CMS on a  regular basis.
section_title: States’ Implementation of Personal Care Services
paragraphs: The Social Security Act requires each state to designate a single state  agency to administer or supervise its Medicaid program. States may  designate other state and local agencies to administer and oversee the  entirety of their PCS programs, or certain functions, including beneficiary  enrollment or beneficiary case management. States may administer  different PCS programs because the programs were designed for certain  types of beneficiaries. For example, one state administers one PCS  program for beneficiaries with developmental disabilities and another  PCS program for those with physical disabilities. Sometimes county or  other local governments provide certain Medicaid services under state  Medicaid agency oversight. For example, many Medicaid programs  employ county case managers who help beneficiaries gain access to  needed services, including PCS. Other state or local government  programs may be involved with Medicaid PCS beneficiaries, but do not  directly participate in a Medicaid program. For example, almost all states  have Adult or Child Protective Services, agencies that investigate and  take action when allegations of maltreatment are reported. Generally,  Adult Protective Service officials may work with both Medicaid  beneficiaries and non-Medicaid clients, but are generally not located  within a state’s Medicaid office according to an expert.
In fee-for-service arrangements, attendants receive payment by  submitting claims to state Medicaid agencies for the PCS they provided.  Independent attendants—those who do not work for a provider agency— submit claims directly to a state Medicaid agency. Attendants who work  for a provider agency typically give that agency information on the  services rendered, and then the provider agency submits claims on behalf  of the attendant. Both types of claims submitted to state Medicaid  agencies generally identify the dates of the service, the types of services  provided, and the Medicaid beneficiaries who received the services.  Claims for PCS are often paid based on the duration of care.
States must seek approval from CMS to implement one or more types of  PCS programs by submitting proposals to CMS that explain how the state  will comply with federal requirements. Upon CMS’s approval and  consistent with any applicable federal requirements, states may impose  additional state requirements to implement the programs. While states’  policies and procedures for providing PCS can vary across states and  within a state across different PCS programs, several key steps are  generally involved. As illustrated in figure 2, for Medicaid beneficiaries,  states must determine beneficiaries’ eligibility for PCS, arrange for the  development of a plan of service, and help connect beneficiaries to an  attendant who is authorized to provide services. To oversee PCS  provided to beneficiaries, states may perform a number of functions such  as screening and requiring training of attendants and overseeing the  delivery of services.
section_title: Selected States Varied in How They Implemented Beneficiary Safeguards and Ensured Billed Personal Care Services Were Provided Selected States Employed Beneficiary Safeguards in Three Common Areas, but Implementation Methods Varied Among and Sometimes Within States
paragraphs: All four selected states—California, Maryland, Oregon, and Texas— reported employing safeguards to protect beneficiaries from harm and  had methods in place to ensure billed services were actually provided, but  the states varied in how they implemented them and, in some cases,  variations existed within states across PCS programs. The four states  also reported using different methods to help ensure billed services were  provided (see Appendix I for the types of PCS programs reviewed in each  state).
All four selected states reported employing safeguards in three common  areas to help ensure Medicaid beneficiaries receiving PCS in their homes  are safe from harm: (1) attendant screening and training; (2) beneficiary  monitoring; and (3) addressing unusual incidents. However, states’  specific safeguard implementation methods and requirements varied by  state and, in some cases, varied within a state across PCS programs.  According to state Medicaid officials, many factors may affect the  methods states choose to implement beneficiary safeguards, such as  beneficiary risk levels, the extent to which beneficiaries are responsible  for managing their own services, how state Medicaid programs are  structured, input from stakeholders such as consumer advocacy groups,  and state and federal requirements.
subsections: section_title: Attendant Screening and Training
paragraphs: All four selected states reported that attendants are required to undergo  some form of background screening in all their PCS programs, but the  specific background information checked varied by state. Background  screenings could entail, for example, a criminal background check or a  determination of whether the individual was listed on certain federal or  state lists or registries, such as the HHS OIG list of excluded providers or  a state’s list of excluded providers. All four selected states reported that  attendants in all PCS programs are required to undergo a criminal  background check. Three of the four states also required checking  attendants against HHS’s OIG list of excluded providers in all state PCS  programs; under Oregon’s Participant-Directed Option, the beneficiary or  a representative is responsible for screenings beyond the criminal  background check. Each of the four selected states also required some  additional background screenings in all or most PCS programs, including  checking other federal databases, and three states required checks  against state administered provider lists and registries (see table 2). With  the exception of the Community First Choice Option, federal PCS  program requirements generally leave it to the states to establish specific  attendant screening requirements.
The four selected states varied as to how they used the results of criminal  background checks. Beneficiaries under California’s PCS program can  hire their preferred attendant in some cases if the attendant has been  convicted of certain types of felonies, such as fraud against a social  services program. Oregon Medicaid officials reported that they exclude  attendants convicted of certain crimes, such as murder, robbery, and  rape. The state has a weighing process for some crimes, such as theft or  financial crimes, to determine whether or not the attendant should be  excluded from providing services, according to officials. Texas Medicaid  officials reported that under all state PCS programs, the state bars  employment of attendants convicted of certain crimes, such as homicide  and arson. Maryland Medicaid officials reported that under all state PCS  programs, provider agencies decide if they want to hire a particular  attendant.
Balancing Attendant Qualifications with  Supply of Attendants  In deciding what, if any, training to require of  attendants, states may balance making sure  attendants are qualified to provide care with  the need for an adequate supply of attendants  to support the demand for in-home PCS.  While more training can be beneficial for  beneficiaries, training requirements can pose  a barrier to participation for some attendants  and diminish the supply of attendants.
Regarding attendant training, each of the four selected states reported  requiring that attendants receive initial training or complete an orientation  for all or most state PCS programs, but specific requirements varied by  state and in some cases within a state by PCS program. Under four PCS  program types (State Plan PCS, HCBS Waivers, State Plan HCBS, and  Community First Choice programs delivering PCS through provider  agencies) states may define qualifications for attendants. The Participant- Directed Option program and Community First Choice program permit the  beneficiary to train their attendants in their specific areas of personal  assistance needs. Some of the selected states may require attendants to  complete an orientation, but do not consider to be training. For example,  California officials reported that while they require attendants in all  programs to complete an orientation, they do not have initial training  requirements. Oregon officials also reported that while they have no initial  training requirements, they do require attendants to complete an  orientation. Attendants may be required to receive additional training if  they are going to provide certain healthcare services to beneficiaries,  such as medication administration. All four selected states reported that  attendants are permitted to perform such services in at least some  programs but generally only after they are trained by nurses or other  health professionals to perform the specific task. In three selected states  this was done through nurse delegation, which allows nurses to delegate  specific tasks to unlicensed individuals, accompanied by concomitant  training and supervision. California does not permit nurse delegation, but does allow a licensed nurse or other healthcare professional to train  an attendant to provide certain services, such as medication  administration. All four selected states reported that in all or most PCS  programs attendants were required to be trained in, or receive information  on, their responsibilities regarding critical incidents, such as whether they  are mandated to report incidents and how to recognize and report critical  incidents. Critical incidents are events or situations that cause or may  cause harm to a beneficiary’s health or welfare, such as abuse, neglect,  or exploitation. Texas required attendants to undergo periodic renewal or  refresher training in some programs, although requirements vary by  program. For example, under the State Plan PCS program provided to  beneficiaries under age 21, provider agencies must ensure a continuing  systematic training program for all attendants. In addition, Maryland  requires attendants to receive training on cardiopulmonary resuscitation  every two years. Table 3 shows the type of training or orientation  requirements in selected states.
All four selected states reported that beneficiaries’ health and welfare is  monitored in part by having case managers or nurses periodically check  in with beneficiaries, but the frequency and means, such as in-person  versus by phone or electronic message, varied among the four states and  in some cases within states across PCS programs. States generally  have flexibility on how they monitor beneficiaries, as Medicaid PCS  program monitoring requirements are broad and do not prescribe specific  frequencies or means for checking in with beneficiaries beyond  requirements for annual reassessments or annual reviews of beneficiary  plans of care (see table 4).
State beneficiary monitoring requirements may be based on such factors  as federal Medicaid PCS program requirements, as well as on state goals  for balancing beneficiaries’ safety with respecting beneficiaries’  autonomy. Some selected states based the frequency of beneficiary  monitoring on the risk level of the beneficiaries. For example, according to  officials, Oregon’s State Plan PCS program serves beneficiaries who do  not need an institutional level of care, and Oregon state officials  determined that certain beneficiaries receiving services under this  program could be safe with less monitoring than beneficiaries in PCS  programs that serve those with greater health needs.
When beneficiaries need healthcare services, such as medication  administration, attendants may be allowed to provide these services;  doing so may result in additional beneficiary monitoring in some states.  Three of our four selected states permitted nurse delegation under all or  some PCS programs. These three states—Maryland, Oregon, and  Texas—required post-delegation follow-up by a nurse in these cases. For  example, if an attendant administers medication to a beneficiary under  nurse delegation in Maryland, a nurse must conduct an in-home visit at  least every 45 days (see table 5).
California does not permit nurse delegation, which places ongoing  responsibilities on the nurse, such as monitoring. Instead, California  permits attendants to perform certain services that a nurse might perform,  called “paramedical services,” once they are ordered by a licensed  professional and the beneficiary (or an authorized representative) has  provided informed consent. After training the attendant, the health  professional is not required to perform ongoing monitoring of the  attendant.
section_title: Addressing Unusual Incidents
paragraphs: All four selected states reported that systems were in place to address  unusual incidents, including provider back-up plans and tracking critical  incidents involving beneficiaries. Unusual incidents are events that  adversely affect or have the potential to adversely affect beneficiary  health and safety, such as an attendant missing an appointment, as well  as critical incidents. In general, a back-up plan is part of a customized  service plan designed to ensure that an individual beneficiary receives the  services and supports they need to remain safely in their homes. The  plan identifies situations that could jeopardize a beneficiary’s safety and  establishes a strategy to prevent or manage such situations. A back-up  plan typically identifies individuals who may be called if an attendant does  not show up as scheduled. Critical incidents include abuse, neglect, or  other events that harm, or could result in the harm of, beneficiaries.
All four selected states reported requiring individualized provider back-up  plans for beneficiaries in all or most of the PCS programs they administer.  California and Maryland require provider back-up plans for beneficiaries  in all state PCS programs. Oregon requires provider back-up plans under  the Participant-Directed Option and Community First Choice, but not  under State Plan PCS. Oregon Medicaid officials explained that this is  because the majority of beneficiaries receiving services under State Plan  PCS receive a small number of hours—typically 20 hours or less—of  services per month. Texas requires provider back-up plans under all state  PCS programs delivered under the agency-provider model. Under  programs operating under Texas’s participant-directed model, according  to officials, the beneficiary or beneficiary representative must develop a  provider back-up plan under some circumstances, such as when having a  back-up plan is required by the rules of the program.
All four selected states reported that the state tracked information about  critical incidents involving Medicaid beneficiaries receiving PCS; however,  what information they tracked and the type of data system or systems  varied by state and in some cases within states by PCS program. With  the exception of State Plan PCS, states are required to implement  processes or systems to address critical incidents in PCS programs.  One way states can attempt to assure that beneficiary safeguards are  working is by tracking information such as the frequency and type of  reported incidents. Tracking incident information can also promote  beneficiary safety by making it easier for states to identify trends or  patterns that can lead to improved program safety.
All four selected states reported that they tracked information on incidents  that they define as critical, and all four states’ definitions of critical  incidents included, at a minimum, beneficiary abuse and neglect.  California, Maryland, and some programs in Oregon and Texas, however,  added other types of incidents to their definitions of critical incidents, such  as accidental injuries. Two states, Oregon and Texas, defined critical  incidents differently under different types of PCS programs. For example,  Oregon operates PCS programs through separate departments that serve  different beneficiary populations. The department that serves  beneficiaries who are aged or those with physical disabilities includes  abuse, neglect, and exploitation. The department serving individuals who  have intellectual or developmental disabilities includes additional  incidents such as serious illness or accidents. Three states—Maryland,  Oregon, and Texas—identified and tracked in their data systems the type  of critical incident that occurred. How states tracked information also  varied by state, with two of the four states (California and Maryland) using  a single statewide case management data system to track critical  incidents, and the other two states (Oregon and Texas) using multiple  systems (see table 6).
Critical incidents involving Medicaid PCS beneficiaries can be reported to  and investigated by entities other than state Medicaid agencies, such as  Adult Protective Services for adult beneficiaries. Adult Protective Services  officials are generally not located within a state’s Medicaid office; as a  result, Medicaid staff may not learn of incidents involving Medicaid PCS  beneficiaries that are reported directly to Adult Protective Services unless  Adult Protective Services staff share this information. We asked Medicaid  officials in each of the four selected states about the extent to which state  Adult Protective Services staff share information with state Medicaid staff  when Adult Protective Services investigates a case involving a Medicaid  PCS beneficiary. California officials reported that while there is no policy  requiring Adult Protective Services to share such information, such  communication is allowed. Maryland officials reported that there is no  statewide policy requiring Adult Protective Services to communicate  information and findings to Medicaid case managers, but that they can  generally find out whether an allegation is substantiated or not. Oregon  officials told us that there can be an ongoing dialog between Adult  Protective Services and case managers about beneficiaries, and it is  expected that Adult Protective Services will notify a beneficiary’s case  manager when there is a substantiated finding against the beneficiary’s  attendant. The case manager then notifies the Medicaid program to take  action against the attendant. In Texas, Adult Protective Services reports  the results of its investigations to Medicaid officials at the originating state  agency, according to state officials.
Medicaid officials in each of the four selected states described whether  they permitted the state Medicaid agency to terminate an attendant if the  attendant poses a risk to the beneficiary yet has not been convicted of a  crime. Maryland and Oregon (in some programs) permitted termination.
In California, an attendant can be terminated if the attendant has been  convicted of certain types of crimes. Texas Medicaid officials reported  that the attendant’s employer, not the Medicaid agency, makes  employment decisions based on the results of an Adult Protective  Services investigation. The attendant can either be employed by a  provider agency or by the beneficiary or beneficiary representative.
section_title: Selected States Used Various Methods to Ensure Attendants Provide Billed Services, including Newer Technology to Verify Visits Electronically
paragraphs: The four selected states in our study reported using various methods to  ensure attendants provided billed services to beneficiaries. For example,  for at least some PCS programs, two states required beneficiaries to sign  timesheets, two states used electronic visit verification timekeeping  systems, and all four states performed quality assurance reviews for  some PCS programs to ensure billed services are received. Among our  four selected states, Maryland and Texas used electronic verification  systems in at least some programs, Oregon is in the process of acquiring  a system, and California does not use such a system (see table 7).
Electronic visit verification timekeeping systems are newer, technology- based systems that electronically record when attendants begin and end  providing services to a beneficiary. Such systems may include features  to verify the attendant’s location and make sure the attendant is in the  beneficiary’s home. These systems require a device like a phone,  computer, or other device to track attendants’ start and stop times. For  example, HHS reported on one electronic visit verification system. The  system relied on attendants clocking in and out via a telephone in the  beneficiary’s home, and if the attendant did not clock in within 15 minutes  of the scheduled visit, an electronic alert was sent to the provider  agency.
Private Sector Use of Electronic Visit  Verification Systems  Three out of the four private entities we spoke  with cited electronic visit verification, among  other safeguards, as a key practice that helps  both to keep clients safe and to ensure that  billed serviced are provided. Some private  sector entities we spoke with said they used  electronic visit verification to track and verify  attendants’ check-in and check-out times to  help ensure that they are showing up to  deliver services. For example, the systems  allowed one entity to compare hours billed to  those worked, and another entity to review  daily log notes, such as the tasks performed,  to gather details on specific shifts. An  electronic visit verification system can  generate alerts when an attendant’s time-in or  time-out recordings fail to match a client’s  schedule or the scheduled duration of  services, when an attendant records visit  information in a location other than a client’s  home, or when the tasks performed do not  match the signed authorization. One private  entity we spoke with uses a system that has  more sophisticated capabilities; for example,  attendants can use the system to report  clients’ changes in health condition—such as  a decline in the client’s ability to perform an  activity of daily living—and can send  messages to a third party, such as the client’s  case manager, when further assistance or  consultation is needed.  One private sector entity reported that  electronic visit verification decreased costs.  An official from this entity stated that the  technology helped reduce costs related to  travel time by 10 percent because the system  resulted in more accurate time and travel  reporting. The official stated that the  technology creates efficiencies; for example, it  streamlines processes, allowing  administrative staff to focus on quality rather  than on paperwork. In addition to direct  financial savings, this official believed that  electronic visit verification may deter people  with nefarious intentions from seeking home  care employment because of the level of  monitoring these systems add.
Medicaid officials from Maryland and Texas described the benefits they  found using electronic verification systems:
Maryland Medicaid officials cited four benefits of electronic visit  verification: (1) more accurate and valid reporting of time; (2) realizing  cost savings because the state is only paying for services when the  attendant has verified through the system that they are in the  beneficiary’s home; (3) collecting data, which allows the state to more  easily review trends and identify potential service issues; and (4)  absolving beneficiaries from the responsibility for verifying that an  attendant’s timesheets are correct.
Texas Medicaid officials reported they were motivated to use  electronic visit verification because fraud is a concern, noting that the  system captures when attendants actually start and stop providing  services. Officials explained that attendants could easily record on  paper timesheets the times they were supposed to provide services  instead of the times they actually provided services. Officials reported  that the use of an electronic visit verification system has saved the  state money.
Oregon Medicaid officials reported that the state is in the process of  acquiring an electronic visit verification system and anticipate that the  system will be able to track attendants’ time more accurately than paper  timesheets. California Medicaid officials reported that they have no  current plans to use electronic visit verification. California officials  explained that they do not think this is an effective option because a high  percentage of attendants in the state’s PCS program are friends or family  members, some of whom live with the beneficiary.
Three of the four private-sector entities we interviewed named electronic  visit verification systems as a key practice for ensuring billed services are  provided (see Text Box, “Private Sector Use of Electronic Visit Verification  Systems”). Other practices used by these entities include: communicating  with clients and their families, conducting unannounced monitoring visits,  training attendants, and conducting attendant background checks. The  private entities reported providing PCS to clients in multiple states, but  have established some similar policies and procedures to use regardless  of location.
section_title: CMS Has Taken Steps to Improve Oversight of States’ Personal Care Services Programs and Harmonize Requirements, but Issues Remain
subsections: section_title: CMS Has Taken Steps to Improve Oversight through Guidance and Program Reviews but Does Not Collect Required State Information
paragraphs: Since 2010, CMS has taken several steps to improve oversight of states’  PCS programs to help ensure that beneficiaries are safe and that billed  services are provided. CMS has taken the following steps:  Issued guidance to strengthen HCBS Waiver requirements. In March  2014, CMS issued guidance to strengthen requirements for  beneficiary health and welfare and ensure that billed services are  provided in HCBS Waiver programs by adding more detailed  requirements. For example, CMS added requirements that states  ensure that an incident management system is in place to address  incidents that could harm beneficiaries and provide evidence that  payments are only made for services rendered.
Reviewed annual HCBS Waiver information submissions. In  September 2014, CMS contracted with a private company to review  information states submit to CMS on HCBS Waiver programs. The  information includes measures that states track to ensure the health  and welfare of beneficiaries and that billed services are provided.  The contractor identified concerns such as variation in both the  frequency and methods states used to monitor attendants. The  contractor also noted positive findings such as states’ implementation  of policies and processes to verify that attendants have provided care.
Developed a toolkit, webinars, and training for states on how to  prevent improper payments. Since 2010, CMS has also taken several  steps to assist states’ efforts to reduce PCS improper payments. CMS  issued a toolkit and conducted three webinars that describe program  integrity concerns and best practices for addressing them. In addition,  CMS’s program integrity training center for state officials, the Medicaid  Integrity Institute, has held a number of courses on issues related to  PCS or HCBS. For example, in June 2013 the Institute held a course  on fraud related to personal care attendants.
Reviewed state PCS programs. Since 2013, CMS has assessed and  issued reports on three state PCS programs. All three reviews  identified vulnerabilities to improper payments and two identified  vulnerabilities in beneficiary safeguards. Findings included attendants  being paid for more hours than authorized, billing for services not  rendered, a lack of a process to track attendants that have been  subject to disciplinary actions, and infrequent updates to attendant  background checks and screenings. CMS made a number of  recommendations to individual states, such as: refunding the federal  share of one state’s overpayments; requiring background screenings  at least once every five years; and tracking attendants who have  received disciplinary sanctions.
In contrast to the steps CMS has taken to improve oversight of states’  PCS programs, as of August 2016 CMS had not systematically collected  all required state information and measures of beneficiaries’ health and  welfare for the Participant-Directed Option and Community First Choice  programs, nor had CMS implemented a process for states to submit the  information to CMS for these programs. CMS officials told us that they are  working to develop guidance for states to submit some of the information.  In addition, CMS also had not exercised its authority to request  information that states are required to maintain on the quality measures  they use to evaluate their PCS programs, as of August 2016. CMS is  responsible for monitoring and overseeing states’ implementation of  federal requirements.
Required reporting. Federal law requires states to report certain  information related to the health and welfare of beneficiaries to CMS  for two PCS programs. This required reporting will help inform CMS  and Congress about the health and welfare of beneficiaries receiving  services from these programs. CMS officials told us that they are  working on developing guidance for states to submit the required  information.
For the Participant-Directed Option program, CMS has not  collected the evaluations states are required to provide every 3  years. States are required to provide an evaluation of the overall  impact of the program on the health and welfare of participating  beneficiaries compared to non-participants. The first state was  approved for a Participant-Directed Option program in 2007, and  eight other states were subsequently approved, all in 2008  through 2010. In 2008, CMS stated that it would issue further  guidance on the requirement, but this guidance has not been  completed. Officials from one state told us that although CMS did  not request the required information, the state submitted it to  CMS. CMS officials stated that they have not analyzed the data  from that state as of June 2016.
For the Community First Choice program, CMS has collected data  once in the 4 years that states have been approved to provide  PCS under Community First Choice, despite the requirement for  states to submit the data annually. HHS collected required state  data on the physical and emotional effects of the programs on  beneficiaries; these data were summarized in a report on  Community First Choice released in 2016. CMS officials told us  in August 2016 that they are working on developing guidance for  states to submit the required information and expect to issue  guidance for the Community First Choice program in 2016.
Reporting measures. CMS may collect other information on the  Participant-Directed Option and Community First Choice programs.  States are required to track quality measures on an ongoing basis as  part of their quality assurance systems. The measures must be made  available to CMS upon request.
For the Participant-Directed Option program, CMS officials told us  that they were not aware of any CMS requests for information  from states on the quality of care measures they use to monitor  the performance of their PCS programs, such as the percentage  of beneficiaries’ cases reviewed in which a critical incident  occurred.
For the Community First Choice program, officials told us that  CMS has not requested information from states on the measures  they use to assess beneficiaries’ outcomes resulting from the PCS  services they receive, particularly for health and welfare. CMS  officials have stated, however, that the measures are an important  component to help ensure quality, and plan to collect the  information after guidance related to collecting the measures is  issued.
Because CMS does not collect or analyze the required reports on  beneficiary outcomes or the available data on quality measures used,  CMS may not know the effects that these programs are having on  beneficiaries’ well-being and may not be able to assess the extent to  which the quality measures being used by states actually reflect the  quality of care beneficiaries receive.
section_title: CMS Has Taken Steps to Harmonize Requirements for Beneficiary Safeguards and Fiscal Oversight across PCS Programs, but Significant Differences Remain
paragraphs: CMS officials cited some steps the agency has taken to harmonize  requirements across the different types of PCS programs. Agency  officials described CMS’s efforts towards harmonization of requirements:
CMS issued a final rule in 2014 that will help result in some  harmonization across HCBS Waiver programs, State Plan HCBS  programs, and Community First Choice programs, agency officials  told us. The rule established new requirements for what constitutes a  home- and community-based setting, among other things. For  example, the 2014 final rule provides clarification and guidance to  determine what community care settings other than a beneficiary’s  home—such as assisted living facilities—can be considered non- institutional settings and be eligible for home and community-based  services. The rule also required that beneficiaries’ plans of care reflect  risk factors and have measures in place to minimize them, including  back-up plans for beneficiaries who need them. These requirements  were new for HCBS Waivers and State Plan HCBS program.  Community First Choice programs had already been required to  address risk factors. For HCBS Waiver, State Plan HCBS, and  Community First Choice programs, the rule added requirements that  states assure that services and supports will not harm beneficiaries.
CMS’s contractor’s ongoing review of states’ annual HCBS Waiver  reports could result in some harmonizing between programs that  provide PCS. As CMS’s contractor develops findings on how states’  compliance with HCBS Waiver requirements, CMS officials stated that  where information can be shared across authorities to ensure  efficiencies and consistencies, CMS will do so in the future.
CMS has implemented an effort to harmonize requirements for two  types of PCS programs. CMS officials stated that states seeking  approval for a State Plan HCBS program are directed to requirements  in CMS guidance for HCBS Waivers. CMS officials said that State  Plan HCBS and HCBS Waivers offer many of the same services and  it makes sense to oversee them in a similar manner. CMS has not  issued the guidance directing states to use HCBS Waiver guidance as  of August 2016, but rather, CMS regional office staff communicate the  requirements for HCBS Waivers to those states requesting approval  for State Plan HCBS programs, according to CMS officials.
However, we found that CMS’s efforts have not addressed the significant  differences across federal program requirements specific to PCS related  to beneficiary safety and ensuring that billed services are provided. For  example, states implementing an HCBS Waiver program or a State Plan  HCBS program must describe to CMS how the state Medicaid agency will  determine that it is assuring the health and welfare of beneficiaries. To do  so, states must describe: the activities or processes related to assessing  or evaluating the program; which entity will conduct the activities; the  entity responsible for reviewing the results; and the frequency at which activities are conducted. In contrast, this level of detail on the evaluation  process is not required for states implementing a State Plan PCS  program or a Community First Choice program.
Similarly, states implementing an HCBS Waiver program or a State Plan  HCBS program must demonstrate that an incident management system is  in place, which requires states to document and provide the following  details to CMS:  indicate whether the state operates a critical incident reporting and  management process;  list and define critical incidents;  identify entities or individuals who must report critical incidents and  the reporting method (for example, phone or web-based reporting  system);  specify the timeframe within which critical incidents must be reported  and the entity to which reports are made for each type of incident;  identify the entities responsible for evaluating reports of critical  incidents and how the incidents are evaluated;  identify the entity responsible for following up on investigations of  critical incidents and the time frame for completing an investigation;  and explain the process and time frames for informing the beneficiary and  other relevant parties of the results of an investigation.
In contrast, states implementing a State Plan PCS program or a  Community First Choice program are not required to provide similar  information on their critical incident management process but, more  generally, are required to describe their “process for the mandatory  reporting, investigating and resolution of allegations of neglect, abuse, or  exploitation.” The State Plan PCS program does not have incident  management reporting requirements. Other significant differences among  PCS program requirements relate to ensuring that billed services are  provided. States implementing HCBS Waiver programs and State Plan  HCBS programs are required to provide evidence that the state is only  paying claims when services are actually rendered, while the State Plan  PCS and Community First Choice programs are not required to do so.
See table 8 for state Medicaid program requirements for ensuring the  health and welfare of PCS beneficiaries and that billed services are  provided.
Based on numerous reviews of state PCS programs, the HHS OIG  recommended that CMS issue regulations to reduce the significant  variation in states’ PCS requirements for documenting claims for payment  for services, supervision of attendants, and attendant qualification  standards. Harmonizing requirements across similar programs is also consistent with federal internal control standards. These standards state  that agencies should establish control activities that appropriately cover  the objectives and risks of an entity’s operations. Further, risk  management standards published by an international standard-setting  organization suggest that a consistent process and comprehensive  framework can help to ensure that risk is managed effectively, efficiently,  and coherently. In the case of PCS, a consistent internal control process  could include having policies and processes in place that would provide  comparable assurances for protecting Medicaid beneficiaries from harm  and ensuring that state and federal funds are paid only when services are  actually provided, regardless of the program in which beneficiaries are  enrolled.
In addition, the Patient Protection and Affordable Care Act directed HHS  to take steps to improve the coordination among and regulation of all  providers of home- and community-based services—which includes PCS  provided under different federal authorities—to achieve a more consistent  administration of policies and procedures across programs. Our prior  review of selected states’ implementation of HCBS options also suggests  that states could benefit from more harmonization of HCBS guidance, as  officials in selected states noted the complexity of operating multiple  programs. In that review, officials from one state reported that the  complexity resulted in a siloed approach, with different enrollment,  oversight, and reporting requirements for each program. The  administration and understanding of the programs available to  beneficiaries is difficult for state staff and beneficiaries, according to  officials in another state. The officials indicated that they would prefer  CMS issue guidance on how states could operate the different HCBS  program types together, rather than issuing guidance on each program  separately.
CMS officials told us the agency is not currently taking additional steps to  harmonize requirements—within the limits of the various statutes—in response to the Patient Protection and Affordable Care Act, but may  make federal guidance more similar in the future. First, officials said that  they want to provide states with flexibility to implement programs that  meet each state’s needs. Second, CMS officials said that the statutes  authorizing the programs are different. CMS officials also stated that in  the future, where the statute and regulations are similar across programs,  they will work on making federal policy the same or similar. In addition,  officials stated that when CMS identifies a good oversight policy or  practice being used by a state for one type of PCS program, CMS can  discuss best practices that may be applicable to other authorities, but  CMS cannot suggest that such best practices are required.
In addition to creating complexities for states and others in understanding  federal requirements governing different types of HCBS programs,  including PCS, the differing federal requirements across the different  types of PCS programs may result in significant differences in beneficiary  safeguards and fiscal oversight:
Beneficiaries may experience different health and welfare safeguards  depending on the program in which they are enrolled. For example, in  one state we reviewed, the state requires quarterly or biannual  monitoring of beneficiaries for most of its PCS programs. For a State  Plan PCS program, the state requires only annual monitoring  contacts. Officials told us that the reason for this difference was due to  the lack of a requirement that states provide assurances to CMS that  they will safeguard beneficiaries’ health and welfare. CMS may also  have fewer assurances that similar beneficiaries’ safety is protected.  Three of the four states we reviewed—Maryland, Oregon, and  Texas—transitioned coverage of PCS for beneficiaries who need an  institutional level of care from PCS programs with relatively more  stringent federal beneficiary safety requirements to programs with  relatively less stringent requirements. Specifically, the states  transitioned PCS from HCBS Waiver programs to Community First  Choice programs. In doing so, state officials in the three states  reported that the state chose to apply the same quality assurance  measures to services received under both the HCBS Waiver program  and the Community First Choice program. Officials in two of the states  said that maintaining the processes was the best way to ensure safety  for beneficiaries. The states were not required to apply the same  quality measures across programs, and CMS has no assurance that  states that transition PCS from HCBS Waivers to Community First  Choice in the future will make the same decisions.
States can use different processes for each PCS program to ensure  that billed services are actually provided, and some programs may not  be subject to federal PCS requirements explicitly in this regard. For  example, in one state we reviewed, steps taken to ensure billed  services are provided under some types of PCS programs are not  required in another of the state’s programs. The state reported that it  used its quality assurance process in some of its PCS programs to  meet with and verify service delivery with the beneficiary in an effort to  ensure that billed services are provided. For example, in one PCS  program, a supervisor must visit the beneficiary and document  whether the attendant is delivering the authorized PCS tasks. In  training materials, CMS recommended states take such an approach  to detect fraud in PCS programs. The state did not apply the same  process to a State Plan PCS program, and federal requirements for  State Plan PCS do not include requirements that states help ensure  that PCS billed services are provided specifically.
section_title: Conclusions
paragraphs: Over the years, federal laws have given states a number of different  options and incentives to provide Medicaid home- and community-based  services. PCS are important to beneficiaries and amount to billions of  dollars and expected rising costs to the federal government and states.  As the federal government continues to encourage states to offer  Medicaid services in community settings and as demand for such  services continues to grow, CMS could do more to obtain and use  information from states about their programs. CMS has not collected  information states are required to prepare on two PCS programs that  would inform the agency of the effects that certain PCS programs are  having on beneficiaries’ well-being. Although these programs have not yet  been widely adopted by states, it is likely these will grow in prevalence  given incentives for states to adopt certain programs and provide more  home- and community- based services. Without the required information,  CMS is missing opportunities to monitor states’ programs to ensure that  potentially vulnerable beneficiaries are receiving quality care.
Although the various options for providing PCS have helped facilitate and  encourage states to provide care for more beneficiaries in their homes,  they have also resulted in a patchwork of federal requirements among  programs, resulting in varying levels of beneficiary safeguards and  requirements to ensure that billed services are actually provided. As a  result, beneficiaries with similar needs could be receiving services in  programs with significantly different safeguards in place depending on the  program. Similarly, the type of fiscal controls required to prevent improper  payments for these services can vary based on the type of program.
Congress and others have called on HHS to take steps to improve the  coordination and administration of home- and community-based services.  HHS could do more towards this end by, within limits of existing law,  harmonizing the patchwork of federal program requirements. A more  consistent administration of policies and procedures across programs  could ease some of the differences and provide some comparable  approaches to safeguards and assurances and help the federal  government and states better manage risks to beneficiaries and to protect  the integrity of the program.
CMS has taken some needed steps to harmonize requirements across  the program authorities; however, significant differences remain in the  federal program requirements that serve as the basis for state oversight  policies and protections for their different PCS programs.
section_title: Recommendations for Executive Action
paragraphs: To achieve a better understanding of the effect of certain PCS services  on beneficiaries and a more consistent administration of policies and  procedures across PCS programs, we recommend the Acting  Administrator of CMS take the following two actions:  collect and analyze states’ required information on the impact of the  Participant-Directed Option and Community First Choice programs on  the health and welfare of beneficiaries as well as the state quality  measures for the Participant-Directed Option and Community First  Choice programs; and  take steps to harmonize requirements, as appropriate, across PCS  programs in a way that accounts for common risks faced by  beneficiaries and to better ensure that billed services are provided.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for comment.  HHS concurred  with our recommendations and noted efforts to address them. HHS stated  that it plans to issue guidance for states to submit information on  Community First Choice programs and is exploring the value of collecting  information from states on Participant-Directed Option programs. HHS  stated it will continue to take steps to assess areas to harmonize program  requirements across PCS programs, including soliciting information from  states, stakeholders, and the public on ideas for doing so. On November  9, 2016, CMS published in the Federal Register a request for information  on numerous topics related to Medicaid home and community-based  services, including input on how to ensure beneficiary health and safety  and program integrity across different types of PCS programs. Input  received could lead to harmonizing some program requirements. HHS  also provided technical comments, which we incorporated as appropriate.  HHS’s comments are reprinted in appendix II.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of Health  and Human Services, relevant state agencies, and interested  congressional committees. In addition, the report will be available at no  charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or iritanik@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last   page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Description of Selected States’ Fee-for-Service Personal Care Services Programs
subsections: section_title: California
paragraphs: California provides personal care services (PCS) to Medicaid  beneficiaries under the following programs: State Plan PCS, Participant- Directed Option (paired with the State Plan PCS program), and  Community First Choice (see table 9). California operates these three  programs together in a program called In-Home Supportive Services. The  California Department of Social Services oversees In-Home Supportive  Services, which is generally administered by staff in each county.
In-Home Supportive Services operates almost entirely under a  participant-directed delivery model. Many beneficiaries choose a relative  or friend to be their attendant: 69 percent of attendants in In-Home  Supportive Services were a friend or family member of the beneficiary;  and 58 percent of attendants live with the beneficiary. Other beneficiaries  seek an attendant through county-maintained registries of attendants who  are seeking positions.
In 2011, California became the first state to adopt a Community First  Choice program. At the time, some beneficiaries previously served  through In-Home Supportive Services under State Plan PCS were  transitioned into Community First Choice. Officials told us that the  Community First Choice program provides an opportunity for California to  enhance the state’s PCS services, and gain the enhanced federal  matching rate.
section_title: Maryland
paragraphs: Maryland provides PCS to Medicaid beneficiaries under both State Plan  PCS and Community First Choice (see table 10). Maryland operates  these two programs (called Community Personal Assistance Services  and Community First Choice) under the Maryland Department of Health  and Mental Hygiene. Generally, county-based agencies assess Medicaid  eligible beneficiaries for their PCS needs, and case managers and nurses  monitor beneficiaries.
In 2015, Maryland implemented changes to its two PCS programs to  make all PCS delivered through provider agencies. However,  beneficiaries may still choose a relative or friend to be their attendant. To  do so, officials told us that case managers direct friends and relatives to  PCS provider agencies that may hire them as attendants. Officials  estimated that before the change, about one-third of beneficiaries  received services through the participant-directed model.
Before its Community First Choice program was approved in 2014,  Maryland provided PCS under HCBS Waiver and State Plan PCS.
Maryland continues to provide certain services, such as case  management, to some beneficiaries under an HCBS Waiver, but provides  PCS through Community First Choice. Officials told us that, when  transitioning to Community First Choice, close to 90 percent of State Plan  PCS beneficiaries were found to need an institutional level of care. These  beneficiaries now receive PCS through Community First Choice, while  beneficiaries who do not require an institutional level of care receive  services through State Plan PCS.
section_title: Oregon
paragraphs: Oregon provides PCS to Medicaid beneficiaries under State Plan PCS,  Participant-Directed Option (paired with an HCBS Waiver), and  Community First Choice (see table 11). Two departments implement the  programs: Aging and People with Disabilities generally serves seniors  and people with physical disabilities through all three programs; and the  Office of Developmental Disability Services serves people with intellectual  or developmental disabilities, through State Plan PCS and Community  First Choice programs.
Oregon’s PCS programs operate almost entirely under a participant- directed model. Officials told us that many beneficiaries select either a  family member or friend to serve as their attendant. Oregon maintains a  registry of attendants, called the Registry and Referral System. Officials  told us that all attendants must enroll in the registry, including family  members and friends who serve as attendants. The state agency that  oversees the registry, the Oregon Home Care Commission, also provides  an orientation to new attendants and offers ongoing training. The  Commission also serves as the employer of record for purposes of  collective bargaining.
In 2013, Oregon became the second state to adopt the Community First  Choice program. The state transitioned all PCS out of its HCBS Waiver  into Community First Choice, although Oregon provides some other  services—such as case management—under an HCBS Waiver to some  Community First Choice beneficiaries. In transitioning to Community First  Choice from an HCBS Waiver, Oregon officials chose to maintain some of  the same quality assurance processes of previous HCBS Waiver  programs; 15 of the HCBS Waiver quality assurance measures were  incorporated into Community First Choice. Officials told us that  Community First Choice also has additional quality assurance measures  that were not part of the previous HCBS Waivers. Community First  Choice provides PCS to those who need an institutional level of care,  while officials told us that State Plan PCS provides PCS to those who  have do not require an institutional level of care.
section_title: Texas
paragraphs: Texas provides PCS to Medicaid beneficiaries under four types of  programs and, in some cases, administers separate programs within the  same type. Texas operates: two State Plan PCS programs (one is for  participants under age 21 and one is for participants age 21 or older);  Participant-Directed Option (paired with State Plan PCS); and Community  First Choice. Texas also operates an additional PCS program that is  unique to Texas. Authorized by Section 1929(b) of the Social Security  Act, Texas uses the Community Attendant Services program to provide  PCS to beneficiaries who have incomes that are too high to qualify for  other Medicaid services, according to officials. Texas is the only state that  has adopted such a program. The programs are operated within different  departments of the Texas’s Health and Human Services Commission,  which operates one of two State Plan PCS programs, while one of its  operating departments, the Department of Aging and Disability Services,  operates another State Plan PCS program, Community First Choice, and  the 1929(b) program.
Texas’s PCS programs deliver PCS both through provider agencies and  through a participant-directed model. Participants in each PCS program  who wish to exercise more control over their services may operate under  a set of requirements known as the consumer-directed services option.  According to officials, many of the PCS services in Texas are now being  provided by a managed care company (We excluded this type of  arrangement from our study).
Texas is the most recent state to adopt the Community First Choice  program, as of April 2016. The state transitioned all PCS out of five of its  HCBS Waivers into Community First Choice. In so doing, Texas  maintained certain features of four of the five programs, including  retaining the same service providers, such as attendants. For example,  Texas transitioned the PCS in its HCBS Waiver program called the  Community Living Assistance and Support Services into Community First  Choice. This HCBS Waiver had served beneficiaries who have  developmental disabilities. After the transition to Community First Choice,  beneficiaries receive generally the same services through the same  providers, and the claims for the services are attributed to Community  First Choice.
section_title: Appendix II: Comments from the Department of Health & Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Tim Bushfield, Assistant Director;  Anna Bonelli, Analyst-in-Charge; Christine Davis; Barbara Hansen; Laurie  Pachter; Vikki Porter; Bryant Torres; and Jennifer Whitworth also made  key contributions to this report.