OMIG AUDIT PROTOCOL OPWDD IRA RESIDENTIAL

OMIG AUDIT PROTOCOL

OPWDD IRA RESIDENTIAL HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

REVISED September 17, 2021

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

with Medicaid requirements under federal and state statutory and regulatory law. Audit protocols are

intended solely as guidance in this effort. This guidance does not constitute rulemaking by the New York

State Office of the Medicaid Inspector General (OMIG) 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

audit protocols alters any statutory or regulatory requirement and the absence of any statutory or regulatory

requirement from a protocol does not preclude OMIG from enforcing the requirement. In the event of a

conflict between statements in the protocols and either statutory or regulatory requirements, the

requirements of the statutes and regulations 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. OMIG cannot provide individual advice or counseling, whether medical,

legal, or otherwise. If you are seeking specific advice or counseling, you should contact an attorney, a

licensed practitioner or professional, a social services agency representative, or an organization in your

local community.

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

involve OMIG’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, OMIG

will review and consider any relevant contemporaneous documentation maintained and available in the

provider’s records to substantiate a claim.

OMIG, 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 OMIG’s authority to recover improperly expended Medicaid funds and OMIG 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.

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

Missing Recipient Record

OMIG Audit

Criteria

If the recipient record is not available for review, claims for all dates of service

associated with the recipient record will be disallowed.

Regulatory

References

18 NYCRR § 504.3(a)

18 NYCRR § 540.7(a)(8)

No Documentation of Service

OMIG Audit

Criteria

If the residential habilitation service documentation was not available or missing, the

claim will be disallowed.

Regulatory

References

18 NYCRR § 504.3(a)

18 NYCRR § 517.3(b)(2)

No Diagnosis of Developmental Disability

OMIG Audit

Criteria

Claims for services provided in the absence of a clinical assessment substantiating a

specific diagnosis of developmental disability will be disallowed.

Regulatory

References

14 NYCRR § 635-10.3(a) and (b)(1)

14 NYCRR § 671.4(b)(1)(i)

Missing Copy of Individualized Service Plan (ISP)

OMIG Audit

Criteria

A copy of the recipient's ISP covering the time period of the claim must be maintained

by the agency. If the copy of the ISP covering the time period of the claim is missing,

the claim will be disallowed.

Regulatory

References

14 NYCRR § 635-10.2(a)

14 NYCRR § 635-10.5(b)(6)

OPWDD Administrative Memorandum #2014-01, page 6

Unauthorized IRA Residential Habilitation Services Provider

OMIG Audit

Criteria

If the provider is not listed on the ISP as the authorized provider for Residential

Habilitation, with an effective date on or prior to the date of service, the claim(s) will be

disallowed.

Regulatory

References

14 NYCRR § 635-10.2(a)

14 NYCRR § 635-99.1(bk)

OPWDD Administrative Memorandum #2014-01, page 5

OPWDD Administrative Memorandum #2010-04, page 2

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

Missing Required Elements on the Individualized Service Plan (ISP)

OMIG Audit

Criteria

The ISP must contain the following elements:

1. The category of waiver service provided (that is, Residential Habilitation) and

identification of the Residential Habilitation Agency delivering the service as

provider of the service.

2. Valued Outcomes of the person receiving services.

3. Frequency. The ISP must specify that the frequency of Residential Habilitation

is “day” or “daily.”

4. Duration. The ISP must specify that the duration as “ongoing.”

5. The effective date for Residential Habilitation services (that is, the date the

person was enrolled in Residential Habilitation services). This date must be

on or before the first date of service that the Residential Habilitation agency

bills for Supervised IRA-RH services

If one or more of the required elements are missing on the ISP, the claim will be

disallowed.

Regulatory

References

14 NYCRR § 635-10.2(a)

OPWDD Administrative Memorandum #2014-01, page 5

Missing Residential Habilitation Plan

OMIG Audit

Criteria

The claim will be disallowed if the relevant Residential Habilitation Plan is missing. If

no Residential Habilitation Plan is in place on or prior to the service date and in effect

for the service date, the claim will be disallowed.

Regulatory

References

14 NYCRR Section 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, pages 2-3

OPWDD Administrative Memorandum #2014-01, pages 3, 5, and 6

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

Missing Required Elements of the Residential Habilitation Plan

OMIG Audit

Criteria

The IRA residential habilitation plan must contain these required elements:

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.

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.

If one or more of the required elements is missing, the claim will be disallowed.

Regulatory

References

14 NYCRR Section 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, page 7

OPWDD Administrative Memorandum #2014-01, page 5

Missing Residential Habilitation Plan Review

OMIG Audit

Criteria

Claims will be disallowed if the relevant habilitation plan(s) was not developed,

reviewed or revised as required where at least

annually one of the residential

habilitation plan reviews was conducted at the time of the ISP meeting.

Regulatory

References

14 NYCRR § 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, pages 3 and 7

OPWDD Administrative Memorandum #2014-01, page 5

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

10.

Missing Required Elements of the Residential Habilitation Plan Review

OMIG 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.

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

missing.

Regulatory

References

14 NYCRR § 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, pages 3 and 7

11.

Failure to Write the Initial Habilitation Plan for Residential Habilitation Service

Within 60 Days

OMIG Audit

Criteria

For residential 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

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

of the start of the habilitation service.

Regulatory

References

14 NYCRR § 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, pages 2-3

OPWDD Administrative Memorandum #2014-01, page 5

12.

Failure to Forward Revised Habilitation Plan for Residential Habilitation Service

Within 30 Days to the Service Coordinator

OMIG Audit

Criteria

Revised Habilitation Plans, which are also written by the habilitation service provider,

must be sent to the person’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 in the Habilitation Plan. The claim will be disallowed if the revised

Residential Habilitation Plan was not forwarded to the MSC within 30 days.

Regulatory

References

14 NYCRR § 635-99.1(bk)

OPWDD Administrative Memorandum #2012-01, pages 3-4

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

13.

Missing Documentation of Presence

OMIG Audit

Criteria

The unit of service for supervised IRA residential habilitation services is daily. The

provider must document the day present in the IRA by denoting lodging.

There are two other types of days (in addition to service days) that a Supervised IRA-

RH provider must document to be eligible for payment: Retainer Day/Medical Leave

Day and Therapeutic Leave Day. A Retainer/Medical Leave Day is a day during which

an individual is on medical leave from the IRA or associated days where any other

institutional or in-patient Medicaid paymen

t is made for providing services to the

individual. A Therapeutic/Non-Medical Leave Day is a day when the individual is away

from the supervised residence and is not receiving services from paid residential

habilitation staff.

The claim will be disallowed in the absence of documentation to indicate the correct

presence of the individual for either a service day, retainer/medical leave day, or

therapeutic leave day.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(a)

14 NYCRR § 641-1.6

OPWDD Administrative Memorandum #2014-01, pages 3-5

14.

Missing Documentation of Residential Habilitation Service (Per Diem)

OMIG Audit

Criteria

On any countable service day residential habilitation staff must deliver and document

at least one individualized face-to-face service or staff action which is drawn from the

Habilitation Plan and ISP.

The claim will be disallowed in the absence of such

service provision and

documentation.

Note: Services provided on a day of hospital admission may not be counted; however,

the day of hospital discharge can be counted so long as eligible services were provided

and documented.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(b)

OPWDD Administrative Memorandum #2014-01, pages 3 and 5

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

15.

Missing Required Elements in the IRA Residential Habilitation Service Note (Per

Diem)

OMIG Audit

Criteria

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

1. recipient's name and CIN number;

2. identification of category of waiver service provided;

3. description of the individualized service provided based on residential habilitation

plan;

4. recipient's response to the service;

5. date the service was provided;

6. primary service location;

7. verification of service provision by the staff person delivering the service;

8. signature and title of the staff person writing the note; and,

9. date the note was written.

Regulatory

References

OPWDD Administrative Memorandum #2014-01, page 6

16.

Missing IRA Residential Habilitation Monthly Summary Note

OMIG Audit

Criteria

The monthly summary note must discuss any issues or concerns and summarize the

implementation of the individual’s Residential Habilitation Plan, and address how the

individual responded to the services provided during the month. Claims will be

disallowed in the absence of a monthly summary note.

Regulatory

References

OPWDD Administrative Memorandum #2014-01, pages 5 and 6

17.

Incorrect Rate Code Billed for Supervised IRA Residential Habilitation

OMIG Audit

Criteria

There are three rate code types for supervised IRA residential habilitation: Service day,

Therapeutic/Non-Medical Leave day, and Retainer/Medical Leave Day.

The claim will be disallowed if the documentation does not support the rate code type

billed.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(a) and (b)

14 NYCRR § 641-1.6

OPWDD Administrative Memorandum #2014-01, page 3

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

18.

Improper Countable Service Day Billed

OMIG Audit

Criteria

For service days, the recipient may not receive another Medicaid–funded residential or

in-patient service on that day

(e.g., hospital, nursing home, ICF or other certified,

licensed or government funded residential setting).

The claim will be disallowed if

another Medicaid–funded residential or in-patient service was provided on that day.

Note: Services provided on a day of hospital admission may not be counted; however,

the day of hospital discharge can be counted so long as eligible services were provided

and documented.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(a)(1)

OPWDD Administrative Memorandum #2014-01, page 3

19.

Improper Billing for Retainer/Medical Leave Day

OMIG Audit

Criteria

For Retainer/Medical leave days, the claim will be disallowed if documentation does not

support the individual’s medical leave for purposes of receiving services from a hospital,

or from another other institutional or in-patient setting.

Note: Services provided on a day of hospital admission may not be counted; however,

the day of hospital discharge can be counted so long as eligible services were provided

and documented.

Note: A provider is limited to payment for up to 14 Retainer Days per rate year, per

individual. All retainer days must be documented.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(a)(1)

OPWDD Administrative Memorandum #2014-01, pages 4-5

20.

Improper Billing for Therapeutic Leave Day

OMIG Audit

Criteria

For therapeutic/non-medical leave days, the recipient may not receive another

Medicaid–funded residential or in-patient service on that day (e.g., hospital, nursing

home, ICF or other certified, licensed or government funded residential setting). The

claim will be disallowed if another Medicaid–funded residential or in-patient service was

provided on that day.

Note: Services provided on a day of hospital admission may not be counted; however,

the day of hospital discharge can be counted so long as eligible services were provided

and documented.

Regulatory

References

14 NYCRR § 635-10.5(b)(12)(i)(a)(1)

OPWDD Administrative Memorandum #2014-01, page 4

OMIG AUDIT PROTOCOL – OPWDD IRA RESIDENTIAL

HABILITATION

FOR SERVICE DATES 7/01/2014 - 6/30/2018

Revised 09/17/2021

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 the OMIG and may not be relied on to create a

substantive or procedural right or benefit enforceable, at law or in equity, by any person.

21.

Staff Member Delivering the Residential Habilitation Service Absent on Date of

Service

OMIG Audit

Criteria

Claims will be disallowed when the provider’s time and attendance records indicate that

the residential habilitation direct care worker documented as delivering the residential

habilitation service was absent on the date of service.

Regulatory

References

OPWDD Administrative Memorandum #2014-01, page 3