OPWDD AUDIT PROTOCOL COMMUNITY HABILITATION

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

COMMUNITY HABILITATION

SERVICES

Effective January 1, 2020

Audit protocols assist the Medicaid provider community in developing programs to evaluate compliance with

Medicaid requirements under federal and state statutory and regulatory law, and administrative procedures

issued by the New York State Office for People with Developmental Disabilities (OPWDD). The protocols

listed

are intended solely as guidance in this effort. This guidance does not constitute rulemaking by OPWDD

and may

not be relied on to create a substantive or procedural right or benefit enforceable, at law or in equity,

by any person.

Furthermore, nothing in the protocols alters any statutory, regulatory or administrative

requirement and the

absence of any statutory, regulatory or administrative citation from a protocol does not

preclude OPWDD from

enforcing a statutory, regulatory or administrative requirement. In the event of a

conflict between statements

in the protocols and statutory, regulatory or administrative requirements; the

requirements of the statutes,

regulations and administrative procedures govern.

A Medicaid provider’s legal obligations are determined by the applicable federal and state statutory and

regulatory law. Audit protocols do not encompass all the current requirements for payment of Medicaid

claims

for a particular category of service or provider type and therefore are not a substitute for a review of

the statutory

and regulatory law or administrative procedures.

Audit protocols are applied to a specific provider or category of service(s) in the course of an audit and

involve OPWDD’s application of articulated Medicaid agency policy and the exercise of agency discretion.

Audit

protocols are used as a guide in the course of an audit to evaluate a provider’s compliance with

Medicaid

requirements and to determine the propriety of Medicaid expended funds. In this effort, OPWDD

will review and

consider any relevant contemporaneous documentation maintained and available in the

provider’s records to

substantiate a claim.

New York State, consistent with state and federal law, can pursue civil and administrative enforcement

actions against any individual or entity that engages in fraud, abuse, or illegal or improper acts or

unacceptable practices perpetrated within the medical assistance program. Furthermore, audit protocols do

not

limit or diminish OPWDD’s authority to recover improperly expended Medicaid funds and OPWDD may

amend

audit protocols as necessary to address identified issues of non-compliance. Additional reasons for

amending

protocols include, but are not limited to, responding to a hearing decision, litigation decision, or

statutory or

regulatory change.

Note:

Per ADM 2018-06R, As of July 1, 2018, individuals new to the OPWDD system (i.e., on or after July 1, 2018),

will have Life plans developed and finalized in accordance with the CCO/HH Manual. Finalized Life Plans for

newly enrolled CCO members (i.e., members enrolled after 10/1/2018) are due no later than 90 days after

CCO enrollment or HCBS waiver enrollment, whichever comes first.

Per ADM 2018-06R, For Life Plans finalized on or before December 31, 2019 (i.e., the transition period),

OPWDD is suspending service documentation requirements for documenting the Waiver service name,

frequency, duration, and effective date in the Life Plan. Instead, only the name of the service provider and the

service name must be identified in the Life Plan.

Service providers are responsible for reviewing the finalized, acknowledged and agreed to Life Plan. Providers

may occasionally find inaccuracies in the finalized, acknowledged and agreed to Life Plan. Providers should

demonstrate due diligence in working with the Care Manager, CCOs, OPWDD and/or others to correct the Life

Plan as soon as possible. Service providers should document their timely efforts to correct any errors in the

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Life Plan. Examples of this documentation may include notes in the individual’s monthly summary, e-mails,

phone calls, etc.

All Life Plans created or amended after the transition period must comply with all regulatory and policy

standards.

Per ADM 2018-09R, As of March 1, 2020, At the time of transition to the Life Plan, Habilitation Plans must

transition to Staff Action Plans. All individuals transitioning from an ISP to a Life Plan who receive habilitation

services must have a staff Action Plan no later than March 1, 2020.

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Missing Record

OPWDD

Audit Criteria

If no record is available for review, claims for all dates of service associated with the

individual will be disallowed.

Regulatory

References

18 NYCRR Section 504.3(a)

18 NYCRR Section 540.7(a)(8)

No Documentation of Service

OPWDD

Audit Criteria

If the record does not document that a Community Habilitation service was provided, the

claim will be disallowed.

Regulatory

References

18 NYCRR Section 504.3(a)

18 NYCRR Section 517.3(b)

No Determination of a Developmental Disability

OPWDD

Audit Criteria

The claim for services provided in the absence of a clinical assessment substantiating a

specific determination of developmental disability will be disallowed.

Regulatory

References

14 NYCRR Section 635-10.3(a) and (b)(1)

14 NYCRR Section 671.4(b)(1)(i)

Missing or Inadequate Life Plan (LP)

OPWDD

Audit Criteria

A copy of the individual's Life Plan (LP), covering the time period of the claim, must be

maintained by

the agency. The claim will be disallowed in the absence of a Life Plan (LP).

If the Life Plan (LP) is not in place

prior to the service date and in effect for the service date,

the claim will be disallowed.

Regulatory

References

14 NYCRR 635-10.2(a)

OPWDD ADM #2015-01, p. 8

OPWDD ADM #2018-06R, pp. 1-2

Unauthorized Community Habilitation Services Provider

OPWDD

Audit Criteria

The claim will be disallowed if the Life Plan (LP) does not:

• Identify Community Habilitation as the service to be provided.

• List the provider as the authorized provider for a specific service.

• Have an effective date for Community Habilitation services that is on or before the

first day of service for which the agency bills for services.

Regulatory

References

14 NYCRR Section 635-10.2(a)

OPWDD ADM #2015-01, p. 8

OPWDD ADM #2018-06R, pp. 3-4,7

Identification of Frequency and Duration of Service

OPWDD Audit

Criteria

The claim will be disallowed if the Life Plan (LP) does not:

• Specify that the frequency for Community Habilitation is “hour or hourly”.

• Specify the duration for Community Habilitation is “ongoing”.

Regulatory

References

OPWDD ADM #2015-01, p. 8

OPWDD ADM #2018-06R, pp. 3-4,7

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Missing Community Habilitation Plan/Staff Action Plan

OPWDD

Audit Criteria

The claim will be disallowed in the absence of a Community Habilitation plan/staff

action plan. If no

Community Habilitation plan/staff action plan is in place prior to the

service date and in effect for the service

date, the claim will be disallowed.

Regulatory

References

OPWDD ADM #2012-01 p. 7

OPWDD ADM #2015-01, p. 8

OPWDD ADM #2018-09R p. 12

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Missing Required Elements of the Community Habilitation Plan/Staff Action Plan

OPWDD

Audit Criteria

The claim will be disallowed if any of the required elements are missing in the

Habilitation Plan:

1. The individual’s name.

2. The individual’s Medicaid Identification Number (CIN), if the person is a Medicaid

enrollee.

3. The habilitation service provider’s agency name.

4. Identification of the habilitation service(s) provided.

5. The date on which the Habilitation Plan was reviewed.

6. Identification of at least one valued outcome that is derived from the individual’s

ISP (valued outcomes do not need to be verbatim from the ISP).

7. Description of the services and supports the habilitation staff will provide to the

person.

The safeguards (health and welfare) that will be provided by the habilitation

service provider.

9. The printed name, signature and title of the staff who wrote the Habilitation Plan.

10. The date that staff signed the Habilitation Plan.

The Staff Action Plan must contain these required elements:

1. Individual’s name;

2. Individual’s Medicaid Client Identification Number (CIN) (if the individual is enrolled

in the OPWDD HCBS Waiver);

3. Habilitation service provider’s agency name;

Name of habilitation service(s) provided (e.g., Residential Habilitation or Day

Habilitation);

5. Date (day, month, and year) of the Life Plan meeting, or Staff Action Plan review,

from which the Staff Action Plan was developed/revised;

Identification of the goals/valued outcomes (My Goal) from the individual’s Life

Plan;

Identification of the provider assigned (habilitative/safeguard) goal(s) and/or

support(s) from the individual’s Life Plan;

8. Description of the service(s) and support(s) and identification of the frequency from

Section II or III of the Life Plan (e.g., teaching laundry skills weekly) the habilitation

staff will provide to the individual;

9. Safeguards (i.e., compilation of all supports and services needed for an individual

to remain safe, healthy and comfortable across all settings) that will be provided by

the habilitation service provider, which may be a reference to internal guidance

documents that further define the safeguards;

10. Printed name(s), signature(s) and title(s) of the staff who wrote the Staff Action

Plan;

11. Date (day, month, and year) that staff signed the Staff Action Plan; and

12. Evidence demonstrating the Staff Action Plan was distributed no later than 60 days

after: the start of the habilitation services; the life plan review date; or the

development of a revised/updated Staff Action Plan, whichever comes first (which

may include, but is not limited to: a monthly narrative note; a HITS upload; or e-

mail).

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Missing Community Habilitation Plan/ Staff Action Plan Review

OPWDD

Audit Criteria

Claims will be disallowed if the relevant Habilitation Plan(s) is not developed, reviewed

revised as necessary at a minimum of at least once annually. At least annually, one of

the

community habilitation plan reviews must be conducted at the time of the ISP meeting.

There must be evidence that the Staff Action Plan was reviewed at least twice annually.

Evidence of a review may include but is not limited to a: 1) Review sign-

in sheet; 2)

Service note indicating a review took place; and/or 3) Revised/updated Staff Action Plan.

Regulatory

References

OPWDD ADM #2012-01, p. 7

OPWDD ADM #2015-01, p. 8

OPWDD ADM #2018-09R, p. 13

10.

Missing Required Elements of the Community Habilitation Plan/Staff Action Plan

Review

OPWDD

Audit Criteria

Habilitation Plan:

There must be evidence that the Habilitation Plan was reviewed within 12 months prior

to the month in which the service occurs. Evidence of a review may include, but is not

limited to, a review sign-in sheet, a service note indicating a review, or revised/updated

Habilitation Plan.

Evidence of reviews must include:

1. the individual’s name,

2. the habilitation service(s) under review,

3. the staff’s signature(s) from the habilitation service,

4. the date of the staff’s signature,

5. date of the review.

Staff Action Plan:

Evidence of reviews must include the: 1) Individual’s name; 2) Habilitation service(s)

under review; 3) Staff signature(s) from the habilitation service(s); 4) Date of the staff

signature(s); and 5) Date of the review.

The claim will be disallowed if one or more of the required elements of the review are

missing.

Regulatory

References

14 NYCRR Section 635-99.1(bk)

OPWDD ADM #2012-01, pp. 3, 7

OPWDD ADM #2018-09R, p. 13

11.

Failure to Write the Initial Community Habilitation Plan/Staff Action Plan Within 60

Days

OPWDD Audit

Criteria

For Community Habilitation services, the initial Habilitation Plan must be written within

60 days of the start of the habilitation service and forwarded to the Medicaid Service

Regulatory

References

OPWDD ADM #2012-01, p. 7

OPWDD ADM #

2015-01, p. 8

OPWDD ADM #2018

-09R, pp. 12-13

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

Coordinator (MSC). The claim will be disallowed if the plan is not written within 60 days

of the start of the habilitation service.

The initial Staff Action Plan must be in place no later than 60 days of the start of the

habilitation service, or the Life Plan review date, whichever comes first. Therefore,

services that are provided no later than the first 60 days of the start of the habilitation

service might not have a Staff Action Plan in place.

Regulatory

References

OPWDD ADM #2012-01, pp. 2-3, 7

OPWDD ADM #2018-09R, p. 13

12.

Failure to Forward Revised Habilitation Plan/Staff Action Plan for Community

Habilitation Within Required Time Frames to the Service Coordinator/Care

Manager

OPWDD

Audit Criteria

For service dates April 1, 2012, and after, a revised Community Habilitation Plan must

sent to the recipient's service coordinator no more than 30 days after either (a) an ISP

review date, or (b) the date on which the habilitation service provider makes a significant

change to the plan.

The claim will be disallowed if the revised plan was not forwarded within 30 days to the

service coordinator.

A revised Staff Action Plan

, written by the habilitation service provider, must be provided

to the Care Manager. Staff Action Plans must be provided to the Care Manager no more

than 60 days after either: (a) a Life Plan review date; or (b)

the date on which the

habilitation service provider makes a change to the Staff Action Plan

Regulatory

References

14 NYCRR Section 635-99.1(bk)

OPWDD ADM #2012-01, pp. 3-4

OPWDD ADM #2018-09R, p. 13

13.

Missing Community Habilitation Service Documentation

OPWDD Audit

Criteria

For each continuous period of service delivery (or “session”), the provider must document

the delivery of at least one individualized face-to-face service provided by community

habilitation staff that is based on the individual’s Community Habilitation Plan. The claim

will be disallowed in the absence of such documentation.

Regulatory

References

14 NYCRR Section 635-10.5(ab)(4)

14 NYCRR Section 635-10.5(ab)(9)

OPWDD ADM #2015-01, pp. 3-4

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

14.

Missing Required Elements for Community Habilitation Service Documentation

OPWDD Audit

Criteria

The claim will be disallowed in the absence of one or more of the following required

elements in the Community Habilitation daily service note:

1. Individual’s name and Medicaid Number;

2. Identification of waiver service provided;

3. A daily description of at least one face-to-face service provided by staff during

each “session”;

4. Documentation of start and stop times;

5. Documentation of the staff-to-individual ratio;

6. Individual’s response to the service (unless this in noted in the monthly note);

7. Date the service was provided;

8. The primary service location;

9. Verification of service provision by the CH staff person delivering the service;

10. The signature and title of the CH staff person documenting the service; and,

11. The date the service was documented and signed by the Community Habilitation

staff person (completed contemporaneously).

Regulatory

References

14 NYCRR Section 635-10.5(ab)(9)

18 NYCRR 504.3

OPWDD ADM #2015-01, pp. 6-7

15.

Missing or Inadequate Community Habilitation Monthly Summary Note

OPWDD Audit

Criteria

The claim will be disallowed in the absence of the required response to service, whether

written in the daily note or the monthly note format (completed contemporaneously). In

addition, at least monthly there must be a note that: a) summarizes the implementation

of the recipient’s habilitation plan; and b) addresses the recipient’s response to the

services provided.

Regulatory

References

18 NYCRR 504.3

OPWDD ADM #2015-01, p. 7

16.

Units of Service Billed Exceeded Units of Service Documented

OPWDD Audit

Criteria

The provider must document the service start time and service stop time for each

Community Habilitation “session.”

The unit of service for Community Habilitation services is an hour. Services are billed in

15-minute increments, with a full 15 minutes of service required to bill a single increment

(i.e., there is no “rounding up”).

The claim will be disallowed if the number of 15-

minute increments billed are not

supported by the service start and stop times documented for the Community Habilitation

service. Billing unit errors will be disallowed to the extent of the difference between the

amount claimed and the actual amount.

Regulatory

References

14 NYCRR Section 635-10.5(ab)(9)(i)

14 NYCRR Section 635-10.5(ab)(10)

OPWDD ADM #2015-01, pp. 3-4

OPWDD AUDIT PROTOCOL

This

document

intended

solely

for

guidance.

statutory

regulatory

requirement(s)

are

any

way

altered

any

statement(s)

contained

herein.

This

guidance

does

not

constitute

rulemaking

OPWDD

and

may

not

relied

to create

substantive

procedural

right

benefit

enforceable,

law

equity,

any

person.

17.

Billing for Non-Reimbursable Service Time

OPWDD Audit

Criteria

If the Community Habilitation claim included time for non-reimbursable services, the time

for the non-reimbursable portion of the claim will be disallowed.

Regulatory

References

14 NYCRR Section 635-10.5(ab)(7)

14 NYCRR Section 635-10.5(ab)(8)

14 NYCRR Section 635-10.5(ab)(11)

OPWDD ADM #2015-01, pp. 4-6

18.

Incorrect Staff to Individual Ratio

OPWDD Audit

Criteria

Community Habilitation has six different fee structures based on the staff to individual

ratio at the time of service delivery and the residential setting of the individual(s).

• For CH delivered to individuals residing outside of OPWDD-certified settings,

there are four fee structures:

 one staff to one individual;

 one staff to two individuals;

 one staff to three individuals; and

 one staff to four individuals.

• For CH delivered to individuals residing in a qualifying OPWDD-certified setting,

there are two fee structures:

 one staff to one individual; or

 one staff to group (consisting of between two and four individuals).

The claim will be disallowed if the billed staff to individual ratio was not in accordance

with the service record.

Regulatory

References

14 NYCRR Section 635-10.5(ab)(5)

OPWDD ADM #2015-01, p. 3

19.

Billing for Services Not Authorized by Operating Certificate

OPWDD Audit

Criteria

The claim will be disallowed if the agency does not have an operating certificate

identifying certification for Community Habilitation services.

Regulatory

References

New York State Mental Hygiene Law, Section 16.03(a)(4)

14 NYCRR Sections 619.2(d)

14 NYCRR Sections 619.3