1. SOURCE (Service Options Using Resources In Community Environments)
GACCP Summer Conference 2011

2. Presenters Heather Fries, BA, MS Edith DeLoach, LPN John Albright, MHA
CEO of Nightingale Services
GACCP Board Secretary
Chairman of Billing Committee
Edith DeLoach, LPN
Director of Quality Assurance for Nightingale Services
John Albright, MHA
Director of Licensure & Expansion for Nightingale Services

3. Presentation Overview
Required Documentation for Community Service Providers
17 GMCF UCR Criteria for Source PSS Audit
Specific SOURCE Forms Reviewed by GMCF
Policy Requirements for Onsite Review
Recoupable Deficiencies
Appeals Process
Post SOURCE Audit

4. SOURCE PROVIDED DOCUMENTATION
Source Chapter 903.5(A) Program Admission Upon completion of enrollment and initiation of services, case manager will provide the following completed documents to all community service providers:
MDS-HC, SOURCE Assessment Addendum, and MDS-HC signature page (Apx. T)
RN signature and date
SOURCE Level of Care Placement Instrument (Apx. F)
Must contain Physician and RN signatures with dates
Level of Care Justification
The SOURCE Carepath
Member Version of Carepath
Rights and Responsibilities
Authorization for Release
Member Referral Form
Member Information Form (MIF)
Advance Directives (If Applicable)
Direction’s to the Member’s Home
All Services Ordered Must Be Listed on the Appendix F….ONLY EXCEPTION is if the member is not due for a reevaluation and the new service ordered does not require a reevaluation/reassessment….The services added on the Carepath and indicated as ordered by physician.

5. 17 UCR Medical Record Audit Criteria
Member Version of the Care Path
MDS-HC
Provider Referral Form
Supervisory Visits
Clinical Progress Notes
Service Record Form
Services and Frequency of Visits According to P.O.C
Provider/Nursing Care Plan
Quality of Care
Emergency Procedure Plan
Advance Directives
Directions to Client’s Home
Recommendations
Other Deficiencies
Billing Discrepancies
Level of Care Criteria
Correction/Alteration of Records

6. 1. Member Version (Pg 1)

7. Member Version (Pg 2)

8. 2. MDS - HC
****MDS-HC: Multi Data Set – Home Care*****

9. 3. Provider Referral Form

10. Clinical Progress Notes
4. Supervisory Visits > Every 62 days for clients receiving more than 24 units of service per week > Every 92 days for clients receiving 24 units or less of services per week
Clinical Progress Notes
> RN must review, sign, and date all entries made by non-licensed staff

11. 6. Service Record Form (Task Sheet)
> Documentation adequately supports the services billed
7. Services and Frequency of Visits According to P.O.C > All services must be rendered with a certified LOC and be reflected on the Member Referral Form and MIF

12. 8. Provider/Nursing Care Plan > Must Reflect SOURCE Care Plan and be formulated by an RN and reviewed during each Supervisory Visit.
Quality of Care
> Must meet professionally recognized standards of health care.

13. 10. Emergency Procedure Plan > Must have written plan
Advance Directives
> Must have documentation in the clinical record indicating whether or not an AD has been executed

14. 12. Directions to Client’s Home > Must Be Specific and Up to date
Recommendations
> DMA’s UR may recommend a reduction in the level of services

15. Billing Discrepancies
14. Other Deficiencies > Provider must comply with all of the Department’s requirements applicable to the category of service in which the provider participates
Billing Discrepancies
> Documentation supports every unit billed

16. 16. Level of Care

17. 17. Correction/Alteration of Records > Must be corrected according to current standards of medical practice. > Corrections shall evidence the error, the correction, the initials of the corrector, and the date of the correction. Example: PSS 3x/wk PSS 2x/wk (3/21/2011)

18. UCR Audit Policy Requirements
Maintain Clinical Records of All Members
RN’s MUST Have a Current Unrestricted License
LPN’s MUST Have a Current Unrestricted License
CNA‘s must have Current Unrestricted Certification or 40 Hrs of Training Documented in the Personnel File with Current CPR and First Aid Certification
Provider’s must be currently, fully licensed by DCH
CPR and First Aide Certification Must Have Both on the Card

19. UCR Audit Policy Requirements
Program Evaluations Done Annually
Provider’s P&P’s comply with Requirements as outlined by:
Part I: Medicaid/PeachCare for Kids P&P’s (Ch 100 – 500)
Part II: CCSP PSS P&P’s (Ch 600 – 1000)
Providers will not be reimbursed for services furnished, ordered, or prescribed in relation to an individual or entity who has been terminated from the SOURCE Program. Providers may not employ or contract with a person, partnership, or corp. previously terminated
****6**** Program Evals must be maintained and used to improve the quality of services provided

20. Recoupable Deficiencies
Possible Recoupment
Supervisory Visits
Not Conducted within the Required Timeframe
Service Record Form (Task Sheet)
Quality of Care
Correction/Alteration of Records
Level of Care
Expired or Member Doesn’t Meet Requirements
Member under Appeals Process
Guaranteed Recoupment
Billing Deficiencies
Over Bill, No Supporting Documentation
Service Record Form is directly tied to Billing Deficiencies…..Must have documentation to support every unit that was billed
Quality of Care Must Meet Current professional standards of health care
Correction/Alteration of Records must be done in the correct format
Level of Care…..Must meet the qualifications for Nursing Home Placement, Signed by Physician and Certified by the SOURCE RN

21. Appeals Process SOURCE MEMBER IN APPEAL
Continue Services if Member is in the Appeal Process
You will continue to be reimbursed while appeal is in place
If recipient is denied the LOC at the appeal, then you would discharge at that time
If the reviewer looks at a record that is in appeal for LOC denial and there is no current LOC, then the reviewer will not recoup on the absence of the LOC
See CCSP manual Section 605.1D EXCEPTION (April 1, 2011…pg VI-39 top of page), of which SOURCE is bound to this policy statement)

22. Post SOURCE UR Audit Plan of Correction Recoupment Payment
Must be Done within 15 Days of receipt of Final Report
All Deficiencies must be addressed, regardless if Administrative Review is requested
Recoupment Payment
Payment must be made within 30 Days of receipt of Final Report
Administrative Review
Only Pertains to Recoupment Amount
Must be Requested within 30 Days
Do Not Issue Payment Until Admin Review Decision is Granted
I STRONGLY RECOMMEND…AT ANY TIME DURING AN AUDIT IF YOU HAVE QUESTIONS…PLEASE CONTACT MR LEROY ALTMAN FOR CLARIFICATION

23. Questions?