Audit: DHS should improve oversight of in-home care
SALEM — Lack of oversight, data gaps, and overworked case managers could continue to put low-income Oregonians receiving in-home care at risk, state auditors said in a Wednesday report.
Auditors from the Oregon Secretary of State's Office said the Oregon Department of Human Services should take "immediate action" to improve in-home care for seniors and people with disabilities in a program serving about 13,000 people.
DHS offers several in-home care programs for seniors and people with disabilities. The program that auditors focused on is the Consumer-Employed Provider, or CEP, program.
About 13,230 people are enrolled in the CEP program, which allows low-income seniors and people with disabilities to choose their own home-care workers.
The program is for people who qualify for Medicaid, which is paid for both by the state and the federal government.
When a person is enrolled in the CEP program, he or she has two main people on their team: a case manager from DHS who handles administrative functions like evaluating the person's needs, and a homecare worker who does the day-to-day work of in-home care, such as preparing meals and administering medications.
A key part of the CEP program is that the people receiving in-home care are also employers: they hire, train and dismiss their own in-home care workers.
But an information vacuum puts the agency at risk of missing when people in the CEP program need more help, according to the audit.
State and federal rules stipulate that case managers monitor CEP program participants, but auditors found that a third of patients they surveyed for the audit didn't get all of the required check-ins from a case manager in 2016.
Two-thirds never received an in-person visit, other than an annual assessment. Home visits by case managers are not required, but can help case managers — and the state — keep closer tabs on whether in-home care recipients are getting what they need.
The agency is required to conduct a risk assessment when it initiates a service plan for an in-home care recipient, but auditors found cases where case managers didn't do an initial risk assessment.
Patients found to be higher-risk require more contacts from case managers.
Auditors said that in the cases they reviewed, "insufficient documentation" prevented them from determining whether high-risk patients got the additional required contact with case managers.
The data that the agency does collect focuses more on case manager performance than on the welfare of people receiving services, auditors said.
"There is no aspect of the quality assurance process or consumer monitoring or assessment reports that looks at consumers' well-being," auditors wrote.
Auditors also recommended that the state's Home Care Commission work with the union representing homecare workers — the Service Employees International Union — to establish basic training requirements.
Homecare workers are given an orientation, and the commission offers voluntary training, but homecare workers are not required to undergo any formal training.
And auditors found that case managers had "excessive" workloads that include duties that some other states don't have their case managers handle. For example, some case managers are required to do time-consuming annual verifications of whether patients qualify for the CEP program and other government benefits like food stamps.
DHS says it is starting to reassign eligibility determination to other staff as part of a pilot program to redesign case manager duties.
Auditors also noted that in recent years, the agency has not filled all of the case manager positions funded by the Legislature.
DHS Director Fariborz Pakseresht wrote in a response to auditors that the agency was working to improve training for case managers, comply with federal requirements regarding contact between case managers and clients, and enhance the agency's data collection and analysis.
The Aging and People with Disabilities division of DHS is also implementing a new data system to centralize investigations of abuse and neglect. It is expected to get fully under way in January.
The Federal Older Americans act requires the state to investigate complaints at licensed care facilities through its long-term care ombudsman, but Oregon law doesn't include address in-home care complaints within the duties of the ombudsman.
The Legislature would have to change the law and provide funding for the ombudsman to serve in-home care patients, auditors said.