OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
1
DAY 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
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
2
Plan as soon as possible. Service providers should document their timely efforts to correct any errors in the
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
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
3
1.
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)
2.
No Documentation of Service
OPWDD
Audit Criteria
If the record does not document that a Day Habilitation service was provided, the
claim
will be disallowed.
Regulatory
References
18 NYCRR Section 504.3(a)
18 NYCRR Section 517.3(b)
3.
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)
4.
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 #2006-01, p. 6
OPWDD ADM #2018-06R, pp. 1-2
5.
Unauthorized Day Habilitation Services Provider
OPWDD
Audit Criteria
The claim will be disallowed if the Life Plan (LP) does not:
• Identify Day Habilitation as the service to be provided.
• List the provider as the authorized provider for a specific service.
• Have an effective date for Day 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 #2006-01, p. 6
OPWDD ADM #2018-06R, pp. 3-4,7
6.
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 Day Habilitation is “day”.
• Specify the duration for Day Habilitation is “ongoing”.
Regulatory
References
OPWDD ADM #2006-01, p. 6
OPWDD ADM #2018-06R, pp. 3-4,7
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
4
7.
Missing Day Habilitation Plan/Staff Action Plan
OPWDD
Audit Criteria
The claim will be disallowed in the absence of a Day Habilitation plan/staff action
plan. If no
Day 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 #2006-01, p. 6
OPWDD ADM #2012-01, pp. 2-3
OPWDD ADM #2018-09R, p. 12
8.
Missing Required Elements of the Day 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.
8.
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;
4. Name of habilitation service(s) pro
vided (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;
6. Identification of the goals/valued outcomes (My Goal) f
rom the individual’s Life
Plan;
7.
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;
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
5
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).
Regulatory
References
OPWDD ADM #2012-01, p. 7
OPWDD ADM #
2006-01, p. 6
OPWDD ADM
#2018-09R, pp. 12-13
9.
Missing Day Habilitation Plan/ Staff Action Plan Review
OPWDD
Audit Criteria
Claims will be disallowed if the relevant Habilitation Plan(s) is not developed, reviewed
or
revised as necessary at a minimum of at least once annually. At least annually, one of
the
day 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
14 NYCRR Section 635-99.1(bk)
OPWDD ADM #2012-01, p. 7
OPWDD ADM #2018-09R, p. 13
10.
OPWDD
Audit Criteria
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:
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
Regulatory
References
OPWDD ADM #2012-01, pp. 3, 7
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
6
11.
OPWDD Audit
Criteria
of the start of the habilitation service and forwarded to the Medicaid Service 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
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 #2006-01, p. 6
OPWDD ADM #2012-01, pp. 2-3, 7
12.
Within Required Time Frames to the Service Coordinator/Care Manager
OPWDD
Audit Criteria
to the recipient's service coordinator no more than 30 days after either (a) an ISP
date, or (b) the date on which the habilitation service provider makes a significant
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
than 60 days afte
habilitation service provider makes a change to the Staff Action Plan
Regulatory
References
OPWDD ADM #2012-01, p. 3
OPWDD ADM #2018-09R, p. 13
13.
Missing Day Habilitation Service Documentation (Group/Supplemental Group)
OPWDD
Audit
Criteria
The claim will be disallowed in the absence of documentation to support the number of
individualized face-to-face Group Day Habilitation services to a recipient during the program
day and the documentation of the program day duration.
Regulatory
References
14 NYCRR Section 635-10.5(c)(6)(i)
OPWDD ADM #2006-01, p. 3
14.
Missing Required Elements in Day Habilitation Service Documentation
(Group/Supplemental Group)
OPWDD
Audit
The claim will be disallowed in the absence of one or more of the required 10 elements in
the day habilitation service documentation as listed in OPWDD ADM #2006-01 (checklist
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
7
Criteria
or narrative note):
1) recipient's name and CIN;
2) identification of category of waiver service provided;
3) a daily description of the required minimum number of face-to-face services;
4) documentation that the minimum service duration requirement was met;
5) recipient's response to the service;
6) the date the service was provided;
7) the primary service location;
8) verification of service provision by the Group Day Habilitation staff person delivering the
service;
9) the signature and title of the Group Day Habilitation staff person documenting the service;
and,
10) the date the service was documented (completed contemporaneously).
Regulatory
References
18 NYCRR 504.3
OPWDD ADM #2006-01, pp. 3-5
15.
Missing or Inadequate Day 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)
, 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 #2006-01, p. 5
16.
Billing for Non-reimbursable Service Time (Group/Supplemental Group Day
Habilitation)
OPWDD
Audit
Criteria
If non-reimbursable program day duration events were counted towards the group or
supplemental group day habilitation billable service time, a portion of the claim will be
disallowed.
Regulatory
References
14 NYCRR Sections 635-10.5(c)(6)(ii)
OPWDD ADM #2006-01, p. 3
17.
Incorrect Rate Code Billed for Group/Supplemental Group Day Habilitation Services
OPWDD
Audit
Criteria
The claim will be reduced if a full unit of service was billed when a half unit of service was
documented for group or supplemental group day habilitation services. The difference
between the amount of the full unit of service and the amount of the half unit of service will
be disallowed.
Regulatory
References
14 NYCRR Sections 635-10.5(c)(6)(i)
OPWDD ADM #2006-01, p. 3
18.
Failure to Meet Minimum Duration Requirements for Group/Supplemental Group
Services
OPWDD
Audit
Criteria
A claim for a group or supplemental group day habilitation service of less than 2 hours in
duration will be disallowed.
OPWDD AUDIT PROTOCOL
This
document
is
intended
solely
for
guidance.
No
statutory
or
regulatory
requirement(s)
are
in
any
way
altered
by
any
statement(s)
contained
herein.
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.
8
Regulatory
References
OPWDD ADM #2006-01, pp. 3 & 4
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 Day 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