A state audit of personal care agencies and the assistants or attendants they provide has raised several concerns about the programs which assist about 25,000 Minnesotans. Lack of state oversight, questions about quality of care and the potential for abuse and fraud were among red flags raised by Legislative Auditor James Nobles during a presentation last month before the Legislative Audit Commission.
Other issues raised by the audit include lack of training for assistants or PCAs, lack of training for agencies and the county workers who evaluate potential clients for PCA services, and potential care problems by PCAs who work long hours. Another issue cited is it may be all too easy to start a PCA provider agency and for questionable agencies to re-start under new names.
However, subsequent media coverage of the audit has in turn been criticized by disability advocates, agencies and persons who receive personal care assistant (PCA) services. They contend that the media coverage focused too much on clerical errors, didn’t consider the scope of the audit and misrepresented audit findings.
In Minnesota about 500 agencies offer services, employing more than 45,000 PCAs. There are about 25,000 Minnesotans utilizing the services, which range from help with day-to-day activities including eating, bathing, dressing, helping with meal preparation and other needs. For some clients PCAs may intervene or redirect a client’s behavior, such as when a child becomes aggressive with a sibling or prevent self abusive behavior like excessive rubbing which causes open wounds which interfere with completing other tasks.
PCA programs help many people who would otherwise live in nursing homes live in their own homes and work in the community.
The audit states that improvement to PCA services is essential because demand for care will grow in the next few years. The audit makes a number of recommendations including supervision requirements, clarification of which agency should investigate maltreatment reports, and the need for more state oversight.
The programs are paid for on a 50-50 basis by Medicaid, with a 50 percent federal match. The program paid out $404 million for PCA services in 2007. That is up from $157 million five years ago. The costs could rise by another $50 million this year. But as a growing number of people receive services, it has resulted in what Nobles described as “unsustainable” growth of the program.
Another concern raised by the audit is in oversight. The agencies that provide PCA services aren’t licensed by the state. The audit cited incomplete records are some agencies and not enough supervision by the Minnesota Department of Human Services.
Nobles’ office found 423 incidents when agencies claimed a care assistant had worked more than 24 hours a day. One headline-grabbing finding was that a single employee worked more than 254 hours in a day and that the agency was paid for that.
But David Hancox, Executive Director of the Metropolitan Center for Independent Living (MCIL), pointed out that the claim for 254 hours in one day was a clerical error. “The provider agency mistakenly filled all of the daily hours for the organization under a single provider number, rather than the individual provider numbers assigned to each worker,” he stated in a letter to the Star Tribune. “In this case, the problem was immediately identified, investigators visited the provider, determined the problem, and it was corrected.” ”Hmm,” Hancox continued. “Provider error revealed, error investigated, error corrected. Seems like the system and its safeguards worked pretty well in this instance.”
Another audit finding that is being debated is that of the extent of fraud or abuse. At the commission meeting on the report, DHS staff indicated that the majority of PCA service providers do a good job. State officials also pointed out that they have identified problems over the years and are working on correcting them. One newly implement changes is a computer program that flags PCAs who claim to work 24 hours a day. Legislation is also in the works to address the issues raised.
State officials also noted that they have had success in collecting improper payments from agencies.
One point of debate since the audit’s release is how representative its data is. Hancox pointed out that the legislative auditor collected data from 25 agencies. That means the report was based on a 5 percent random sample.
“Does fraud exist, probably so,” said Hancox. “Sadly, in our world today, there is always someone who will try to take advantage. And, this admission should not make us complacent or accepting of mediocrity. No, clearly we should continue to exercise appropriate diligence.”
“But we should also remember that the services provided by direct care professionals/professional service attendants are vital to the lives of many individuals. In fact, these services are often the thin line that prevents more costly and unnecessary out-of-home placements in nursing homes and institutional settings.”
The suggestions from Hancox include a need for additional education and training for PCAs, creating training opportunities for provider agencies and continued diligence by DHS to minimize fraud and errors.
Another person who weighed in on the audit and media coverage is Lance H. Hegland, an organizational/health care consultant who relies on PCA services. Hegland, too, emphasized that the amount of fraud found in the report was minimal when the overall program is considered. While saying he agrees for the most part with the report’s findings and recommendations, Hegland did make suggestions as to how the recommendations should move forward. Hegland is calling for steps including development of a sustainable PCA program, stakeholders’ consortium to review the report recommendations and develop implementation strategies. Smaller sub-groups could address needs of specific consumers, professional organizations, third-party payers and other stakeholders. He also suggested that a sustainable PCA program evaluation process be developed.