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Medicaid Incidents: To Report or Not To Report?

The answer resides in the injury, not the quality of the care.

A consumer trips and falls at your long term care facility. It is during her personal care services (PCS). Dorothy, a longtime LPN and one of your most trusted employees, is on duty. According to Dorothy, she was aiding Ms. Brown (the consumer who fell) from the restroom when Ms. Brown sneezed multiple times resulting in a need for a tissue. Dorothy goes to the restroom (only a few feet away) when Ms. Brown’s fourth sneeze sends her reeling backward and falling on her hip.

To report or not to report? That is the question. 

Whether ’tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles
And by opposing end them.

What is your answer?

Is Ms. Brown’s fall a Level I, Level II, or a Level III incident? What are your reporting duties?

  • If you answered Level II and no requirement to report – you would be correct.
  • If you answered Level III and that you must report the incident within 24 hours, you would be correct.

Wait, what? How could both answers be correct? Which is it? A Level II and no reporting it or a Level III and a report due within 24 hours?

It depends on Ms. Brown’s injuries, which is what I find fascinating and a little… how should I put it… wrong?! Think about it…the level of incident and the reporting requirement is not based on whether Dorothy properly provided services to Ms.Brown. No…the answer resides in Ms. Brown’s injuries. Whether Dorothy acted appropriately or not appropriately or rendered sub-par services has no bearing on the level of incident or reporting standards.

According to the Department of Health and Human Services’ (DHHS) Incident Response and Reporting Manual, Ms. Brown’s fall would fall (no pun intended) within a Level II of response if Ms. Brown’s injuries were not a permanent or psychological impairment. She bruised her hip, but there was no major injury.

However, if Ms. Brown’s fall led to a broken hip, surgery, and a replacement of her hip, then her fall would fall within a Level III response that needs to be reported within 24 hours. Furthermore, even at a Level III response, no reporting would be required except that, in my hypothetical, the fall occurred while Dorothy was rendering PCS, which is a billable Medicaid service. Assuming that Ms. Brown is on Medicaid and Medicare (and qualifies for PCS), Dorothy’s employer can be reimbursed for PCS; therefore, the reporting requirement within 24 hours is activated.

In each scenario, Dorothy’s actions remain the same. It is the extent of Ms. Brown’s injury that changes.

See the below tables for further explanation:

INCIDENT RESPONSE AND REPORTING MANUAL

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These tables are not exhaustive, so please click on the link above to review the entire Incident Response and Reporting Manual.

Other important points:

  • Use the federal Occupational Safety and Health Administration’s (OSHA) guidelines to distinguish between injuries requiring first aid and those requiring treatment by a health professional. 
  • A visit to an emergency room (in and of itself) is not considered an incident. 
  • Level I incidents of suspected or alleged cases of abuse, neglect or
    exploitation of a child (age 17 or under) or disabled adult must still be reported
    pursuant to G.S. 108A Article 6, G.S. 7B Article 3 and 10A NCAC 27G .0610.

Providing residential services to anyone is, inevitably, more highly regulated than providing outpatient services. The chance of injury, no matter the cause, is exponentially greater if the consumer is in your care 24-hours a day. That’s life. But if you do provide residential services, know your reporting mandates or you could suffer penalties, fines, and possible closure.

Lastly, understand that these penalties for not reporting can be subjective, not objective. If Ms. Brown’s fall led to a broken hip that repaired without surgery or without replacement of the hip, is that hip injury considered “permanent?” 

In cases of reporting guidelines, it is prudent to keep your attorney on speed dial.

 

Adult Medicaid Group Homes: Forgotten Again?

In the wake of such tragedies such as the Colorado movie theatre last July, the Sikh temple in Wisconsin in August, Minneapolis in September, then the unthinkable massacre at the Connecticut elementary school in December, and, of course, the Boston bombing in April, you would think that mental health would be a top priority.

Instead, politicians across America are advocating gun laws.  Without commenting on gun control (as this is a Medicaid blog), mental health seems to be getting placed on the back-burner.

In the North Carolina budget passed by the Senate last week, mental health, in particular, group homes for adults with severe mental illnesses, again, was forgotten.  Whether on purpose or by accident, I have no idea.  But the fact remains a large part of metal health simply was not contemplated in the budget.

I am sure most of you remember the comedy of errors that occurred at the beginning of the year when the criteria for personal care services (PCS) was revised.  Basically in January 2013, the criteria to receive PCS became more stringent.

According to DMA, effective January 1, 2013, PCS “is available to individuals who has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.”

Prior to January 1, 2013, individuals who qualified for Medicaid special room and board assistance were automatically granted approval to receive PCS funding regardless of need. This applied for both in-home and facility-based services.

Due to the more stringent 2013 criteria, thousands of adults in group homes in NC who depended on Medicaid were no longer eligible.  Former Gov. Perdue was forced to shimmy around funds in order to keep these disabled adults from losing their homes.  The whole debacle created terror and stress for those disabled adults whose residences were threatened, for the families of the threatened disabled adults, for the group home executives who did not want to evict these disabled adults, and for any mental health advocate or person with empathy toward the mentally ill.

The trainwreck of the adult PCS group homes only occurred 4-ish months ago.

Yet, lawmakers, seemingly, failed to address the recurrent problem of funding for group homes for adults with severe mental illnesses, who are no longer eligible for PCS, in last week’s budget passed by Senate.

Wednesday afternoon (if you work downtown, then you know what I am talking about) a group of protesters rallied outside the General Assembly clad in blue shirts, holding signs saying, “Save Group Homes!” and “Disaster Relief! Save my Home!,” and some simply said, “Help!”

The Senate’s budget failed to provide funds for approximately 1,450 people living in 6-person group homes.  Each group home resident currently receives $16.14 a day, or about $6,000 a year, from the state program.  The fear is that group homes are so underfunded as it is that any amount, no matter how small, of decreased funds would drive the group homes out of business, forcing residents onto the street.

In general, group homes are not huge money-makers for the owners.  The workers at a group home make approximately $9-10/hour.  Group homes must be staffed 24/hours/day and 365/days/year.  The group homes must use the state-funded money to staff the home, keep up the maintenance of the home, feed all the residents and care for all the residents, plus all overhead (i.e., electricity, heat/air conditioning, any extras for the residents, such as TVs or cable, blankets, etc.).  Plus group homes must provide a small, monthly stipend for the residents in order for the residents purchase medicine (co-pays) and personal hygiene products.

Logically there must be SOME profit in group homes in order for anyone to want to run a group home.  But the profit is minimal.

Similar to the low Medicaid reimbursement rates to physicians, causing physicians to not accept Medicaid, any sort of cut to group home funding (including the residents not qualifying for PCS due to the new criteria and without special funding to cover the difference), group homes will inevitably close.  You simply cannot expect a person to keep a group home open when no profit is made.  Just as if you cannot expect a doctor to accept Medicaid patients if no profit is made.

So, is the State of North Carolina saving money by not providing additional funding to those PCS recipients who no longer qualify for PCS? Hey, the Medicaid budget goes down, right? But what happens to those adults with severe mental illnesses when, because of the lack of PCS funds, the group homes either close or turn out those residents who no longer qualify for PCS?

In a perfect world, I guess the families of the adult Medicaid recipients would take them in and all would be fine.  But I gather there is a reason that these recipients are in a group home and not with family.

No, since this is not a perfect world, most of these adults with severe mental illnesses, without a group home, would be homeless and, eventually, if not immediately, would be hospitalized at a much higher price that a group home.

So these adult Medicaid recipients are stable in a group home. Well-cared for. Most likely, have relationships with the staff and other residents.  But because of the new PCS criteria and the fact that the NC budget does not provide funding for Medicaid residents that no longer qualify for the PCS funding, we will uproot the adults with severe mental illness, send them into the world, expect them to be ok, and, then, later, pay much more money to the hospitals that are forced to take in these Medicaid recipients due to whatever issues caused the hospitalization.

Hmmmm….at least the Medicaid budget is lower.

General Assembly Back: Medicaid PCS Issue is HOT

NC legislators are back at work as of noon today (January 30, 2013). The most pressing issue in Medicaid? Personal Care Services (PCS).

In 2012, when the Medicaid rules changed (The rules didn’t change in 2012. The rules were determined to change in 2013) as to who could receive PCS, thousands of adults receiving PCS in adult care homes, suddenly, did not meet the criteria for PCS. Thousands of Medicaid recipients would no longer receive PCS; therefore, many group homes would go bankrupt.

Just to show the great breadth of this problem: The Office of Administrative Hearings (OAH) received 15,000 appeals this month from Medicaid recipients no longer eligible to receive PCS.

Expect to see a bill with a fix to the group home issue in the House Appropriations Committee on Thursday.

NC Group Home Residents Lose Medicaid Funds: May Lose Homes

NC residents who live in Medicaid-funded group homes suffer mental illnesses or developmental disabilities.  Group homes allow the residents a home-like atmosphere and 24/7 health care and personal care services, such as help with toileting, bathing, and eating.

The federal government informed NC that the state was using the wrong eligibility criteria for Medicaid recipients receiving personal care. Personal care services (PCS) is a paraprofessional service that covers the services of an aide in the recipient’s private residence or group home to assist with the recipient’s personal care needs that are directly linked to a medical condition.

To fix the eligibility problem pointed out by the feds, the General Assembly set up a $39.7 million fund to pay for adult care homes, but group homes were unintentionally excluded. If the legislators did not use the word “only” in the legislation, most likely, group homes would have been covered. But in “only” covering adult care homes, group homes were excluded.

The result of the General Assembly’s oversight is that approximately 1400 people may be homeless starting January 1, 2013.

Despite an outcry from the General Assembly for Purdue to call a special session, Purdue refused. Instead, last week, Purdue announced that she was moving $1 million dollars within the Department of Health and Human Services to pay for group homes through January 2013. This allows the group home residents one extra month before Medicaid funding is gone.

The General Assembly organizes January 9th, but is not scheduled to conduct business until January 30, 2013….the day Medicaid funding will cease for the group homes.

 

20,000~ Medicaid Recipients: Homeless, January 1, 2013

Literally THOUSANDS of mentally disabled, NC Medicaid recipients may be on the streets of NC come January 1, 2013. Perdue claims that her last act as governor will be to prevent this to happen. But can she? No. Not alone.

Due to recently passed federal legislation, The Center for Medicare and Medicaid Services told North Carolina last year that personal care services (such as assistance with daily ADL‘s like eating, bathing, and toileting) must be reimbursed at the same rate for Medicaid patients who live in private homes and for those in group homes. It is estimated that the change in the reimbursement rate would cause $414 million less payments to group homes caring for Medicaid recipients suffering from mental illness. The result of this massive cut in Medicaid payments to group homes will cause most group homes in North Carolina to go bankrupt, resulting in all the Medicaid recipients residing at the group home to be put out on the street.

Group homes must abide by extremely stringent state and federal laws to keep their doors open.  Therefore, group homes are exceedingly expensive to run. Not to mention that group homes must have 24-hour, 365 days/year employees. The cost to run a group home is staggeringly higher to run than a private home. It is illogical why the government would pay a private home and a commercial group home the same Medicaid rate. In a private home, the people live at the home; therefore private homes do not need to pay for numerous employees to work 24-hour, 365 days/year. Yet, due to federal legislation, Medicaid will reimburse group homes the same as private homes.

Can we stop this tomfoolery? It is up to the state legislators. While they relax for Christmas vacation, come New Year‘s approximately 20,000 adult Medicaid recipients may be on the street.  While legislators sip hot toddies with a roof over their heads, 20,000 will be freezing in the middle of winter, homeless, during one of the coldest months of the year. Action is needed. State legislators have advised Perdue to fund these group homes will alternative funding. However, Perdue has stated this is impossible due to the language of statutes. What is needed? A special session! Make the legislators come back for a special session. If the legislators get to ring in the New Year with a roof over their heads, don’t the residents of North Carolina’s group homes deserve the same?