DPSS ePolicy

Converted document, no content change. 

Revision of existing policy and/or form(s)

What changed?

Releases policy and procedures to In-Home Supportive Services (IHSS) Quality Assurance (QA) staff on the Case Management, Information and Payrolling System (CMIPS) IHSS In‑Patient Hospitalization Report.

This Administrative Release also releases revisions that align with CMIPS enhancements/changes.

Note: Changes are shown highlighted in grey throughout the document.

County staff are required by the California Department of Social Services (CDSS) to utilize statewide standard protocols to ensure consistency in the implementation of IHSS program integrity (PI) activities by:

1. Attending PI training;
   
   
2. Conducting Unannounced Home Visits (UHVs);
   
   
3. Conducting Directed Mailings (DMs);
   
   
4. Reviewing the IHSS In-Patient Hospitalization Report for duplication of paid services;
   
   
5. Investigating other data matches which may result in potential overpayments (OPs) and/or fraud referrals; and
   
   
6. Collaborating across jurisdictions (federal, state, and county), as applicable, when referring a case for fraud investigation.
   

Assembly Bill 19, Fourth Extraordinary Session required CDSS to establish a state and county stakeholders’ workgroup to address key requirements pertaining to IHSS PI.

In 2004, Senate Bill 1104 (Chapter 229, Statutes of 2004) added Section 12305.71 to the Welfare and Institutions Code (WIC) with the goal of improving the quality of the IHSS program.  This QA/Quality Improvement (QA/QI) initiative resulted in the implementation of various state and county QA/QI measures.

The California WIC Section 12305.71 mandates that each county has a dedicated QA function or unit that performs specific activities.  The policies set forth in the CDSS IHSS QA/QI Policy Manual are the minimum requirements necessary to fulfill that mandate.

In October 2009, CDSS established 78 PI full-time staff positions statewide (four for Los Angeles [L.A.] County) to conduct PI and anti-fraud activities in the IHSS Program specific to the anti-fraud initiative.

The 78 positions and their scope of responsibilities differ from those held by QA staff and from positions associated with the state‑approved county anti‑fraud plans.

In March 2010, CDSS formed a workgroup that included representatives from CDSS, the Department of Health Care Services (DHCS), the California Department of Justice Bureau of Medi-Cal Fraud and Elder Abuse, county program staff, District Attorney offices, IHSS recipients, and recipient and provider advocacy groups.

The goal of the workgroup was to develop protocols clarifying state and county roles and responsibilities for developing uniform statewide protocols for the implementation and execution of standardized PI measures in the IHSS Program.

The workgroup completed the protocols in March 2013.

CDSS

The California Department of Social Services a state agency responsible for oversight of the IHSS Program and CMIPS.

CDSS Quality Assurance and Improvement Bureau

A section within CDSS that provides ongoing technical assistance to counties on the Uniform Statewide Protocols.

CMIPS

The State’s web-based case management system that tracks case information and processes payments for the IHSS Program.

Complaint

Any PI concern or allegation identified or received by the State or County.

DM

A CDSS-developed standard template letter with required information and customizable areas that includes county contact information and a plain-language reason why the provider received the letter.  CDSS uses DMs to reach out to providers associated with cases that appear to suggest a specific PI concern (whether founded or not), and proactively educating providers on common PI errors.

DM Indicators

CDSS-developed reasons why an IHSS provider would receive a DM.  Reasons include, but are not limited to:

1. “…all providers who work for more than one recipient.”
   
   
2. “…all providers who submit timesheets inconsistently.”
   
   
3. “…all providers who are also recipients.”
   

Fraud 

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person, and includes any act that constitutes fraud under applicable federal or state law.

Fraud Referral

A complaint that has been triaged by designated county staff and determined appropriate for referral to a law enforcement agency for fraud investigation.

IHSS In-Patient Hospitalization Report

A monthly report from DHCS that lists IHSS cases with in‑patient hospital or Long-Term Care (LTC) admission with a duration greater than two days for which a Medi-Cal Service Match record has been received.  An IHSS provider may have submitted a timesheet(s), and the report must be utilized to investigate data matches which may result in potential OPs and/or fraud referrals.

Management Information and Evaluation (MIE) Section

Departmental section responsible for PI activities in L.A. County.

Point of Contact (POC)

Individual designated as the departmental PI liaison responsible for communicating PI issues to CDSS, receiving UHV and DM listings, and compiling and reporting PI findings to CDSS. 

Note: L.A. County’s POC is the MIE Section Director.

PI Training

CDSS-developed module that provides PI-specific training and technical assistance to PI staff, for the implementation of the Uniform Statewide Protocols for PI Activities in the IHSS Program; includes mandatory participation in a webinar session and completion of a seven-hour classroom session.

PI Social Worker (PI SW)

SW who reports to MIE and is assigned to the UHV unit.

Statewide Coordination and Cooperation (SCC)

A coordinated and standard process for fraud referrals and investigation that fosters collaborative working relationships across jurisdictions (federal, state, and county) that includes a standard policy for deciding when to refer a case for a fraud investigation.

 Triage

The process whereby designated county staff reviews a complaint of suspected fraud and determines whether or not the complaint will become a fraud referral.

UHV

A visit to the IHSS recipient’s home, whereby recipient is not given prior notice for the purpose of ensuring that services authorized are consistent with the recipient’s needs at a level that allows them to remain safely in their own home, and to validate the information in the case file.

UHV Questionnaire

Questionnaire completed by PI SW on all UHVs; includes areas on the type, amount, and quality of IHSS services an IHSS recipient is receiving.

 Zero Results Data (ZRD)

 Term used when a data pull, using CDSS-approved indicators, returns no results.

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