Thursday, July 17, 2014

Michigan: Proposed criminal background checks for personal care providers

Following a state audit of the Medicaid-funded Home Help Services Program in Michigan, the Michigan Department of Community Health has proposed new policies for screening personal care providers. This will standardize criminal background checks of all providers of personal care services provided by the Michigan Medicaid State Plan, including the Home Help Program. 

The state audit, released in June 2014, found that of the approximately 70,000 individual providers of Home Help services, 3,786 had felony convictions prior to Jan. 2, 2013. "This included…572 convictions for violent crimes ranging from assault to homicide; 285 convictions for sex-related crimes; 1,148 convictions for financial crimes such as fraud, identity theft and embezzlement; and 2, 020 convictions for drug related offenses."

The proposed criminal background check policy will apply to all providers of Home Help Services, including parents and other family members who provide these services. According to Brian Barrie at the state Medical Services Administration, screenings will be done as part of the provider enrollment process.  All providers will be placed in the CHAMPS system [CHAMPS is the state computerized Medicaid Processing System]  and the screenings will be done then.  Any additional cost will be absorbed by MDCH.

Comments on the proposed policy are due by July 25, 2014.

Mail comments to:

Brian Barrie
Bureau of Medicaid Policy and Health System Innovation
Medical Services Administration
P.O. Box 30479
Lansing, Michigan 48909-7979

Telephone Number: (517) 335 - 5131
Fax Number: (517) 241-7816
E-mail Address:

The effective date of the policy is September 1, 2014.

The proposed criminal background checks are required by the Affordable Care Act. Section 1128(a) of 42 U.S.C.1320a-7 (the Social Security Act) prohibits individuals or entities from participating in programs funded under the Act if they have been convicted of any of the Mandatory Exclusion offenses outlined in the policy.

Here are excerpts from the proposed policy:

Mandatory Exclusions: Providers (any individual or entity) MUST be screened for and, as required by the State of Michigan, MUST disclose the following excludable convictions. Any applicant or provider found to meet one of these four categories is prohibited from participating as a service provider for Medicaid or the Home Help program. The mandatory exclusion categories are:

  1. Any criminal convictions related to the delivery of an item or service under Medicare (Title XVIII), Medicaid (Title XIX) or other state health care programs (e.g., Children's Special Health Care Services, Healthy Kids), (Title V, Title XX, and Title XXI)
  2. Any criminal convictions under federal or state law, relating to neglect or abuse of patients in connection with the delivery of a health care item or service.
  3. Felony convictions occurring after August 21, 1996, relating to an offense, under federal or state law, in connection with the delivery of health care items or services or with respect to any act or omission in a health care program (other than those included in number 1 above) operated by or financed in whole or in part by any federal, state, or local government agency, of a criminal offense consisting of a felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct
  4. Felony convictions occurring after August 21, 1996, under federal or state law, related to unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
Criminal Background Screening: All providers and applicants covered under this policy must agree to a criminal background screening…Individual provider applicants must agree to a criminal history screening by completing and submitting MSA-4678 Medical Assistance Home Provider Agreement to MDCH. Approved and existing individual providers will be periodically reviewed and rescreened by MDCH.

Provider agencies will be held to the same requirements for their employees.

Sanctions: For any provider found to be in violation of any of the four mandatory exclusions listed above, MDCH may terminate or deny enrollment in the Michigan Medicaid program.

Providers will be notified within 90 days of initiation of a payment suspension. The notification will include the general allegations as the to nature of the suspension action, the period of suspension, and the circumstances under which the suspension will be terminated. Providers may submit written evidence for consideration through the administrative appeal process. All payment suspensions will include referral to the Office of Health Services Inspector General.

For complete information on criminal convictions, sanctions, appeals processes, etc., refer to the proposed policy.

Michigan: HCBS Waiver Conference - 11/18-19/2014

This is a conference on Home and Community Based Medicaid Waivers sponsored by the Michigan Department of Community Health and the Michigan Association of Community Mental Health Boards (MACMHB).


The Michigan Department of Community Health & The Michigan Association of CMH Boards Present:


November 18 & 19, 2014
Kellogg Hotel & Conference Center
55 South Harrison Road, East Lansing 48823

Children s Waiver Program (CWP)
Habilitation Supports Waiver (HSW)
Autism Applied Behavior Analysis (ABA) Benefit

Conference Objective: This conference will provide technical assistance and training on the implementation and maintenance of the Children s Waiver Program (CWP) and the Habilitation Supports Waiver (HSW), clinical issues, and administrative functions relevant to these waivers. Additionally, this conference will provide training in ASD, evidence based services, highlight programs across the state, and provide technical assistance on implementation of the Medicaid/MIChild Autism Benefit.

Technical assistance and training on implementation and maintenance of the Waiver for Children with Serious Emotional Disturbance (SEDW) will now occur as a part of the annual Wraparound Conference to be held at Shanty Creek Resort on August 18-20, 2014.

Who Should Attend: Case managers, supports coordinators, clinicians, behavior analysts, administrative staff, providers, autism coordinators, people receiving services and family members.

Special Rate: A special $20 conference rate will be offered for people receiving waiver services and their family members. A limited number of scholarships are available to people who receive services and their families. Scholarships may cover registration fees, overnight rooms, travel expenses, meals and child care. Deadline to request scholarship: September 12, 2014. To request a scholarship form, contact Chris Ward at or 517-374-6848.

Continuing Education Credits for Licensed Social Workers: The Michigan Association of Community Mental Health Boards (MACMHB), provider #1140, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB), through the Approved Continuing Education (ACE) program. MACMHB maintains responsibility for the program. ASWB Approval Period: 11/10/13-11/10/16. Social workers should contact their regulatory board to determine course approval. Exact hours are pending.

Overnight Accommodations/Directions: The Kellogg Hotel & Conference Center is located in East Lansing adjacent to Michigan State University. Our special guestroom rate is $75 per night. For specific directions or to reserve a room, please call 517/432-4000 and mention that you are attending the C-Waiver Conference.

Conference Brochure & Registration Materials: Conference details and registration will be available on our website,; if you have any questions, please call (517) 374-6848.

Christina Ward, Administrative Executive Michigan Association of Community Mental Health Boards
426 S. Walnut Street, Lansing, MI 48933
(517) 374-6848 phone
(517) 374-1053 fax

Friday, June 27, 2014

Michigan Home Help Program Audit finds Felons on the Payroll

The Home Help Program audit conducted by the Michigan Office of the Auditor General looked at the criminal records of individual providers, direct care workers providing services in clients' homes. Of the approximately 70,000 individual providers, 3,786 had felony convictions prior to Jan. 2, 2013. "This included…572 convictions for violent crimes ranging from assault to homicide; 285 convictions for sex-related crimes; 1,148 convictions for financial crimes such as fraud, identity theft and embezzlement; and 2, 020 convictions for drug related offenses." 

About 75% of the elderly or disabled clients employ family members or close friends to provide care. According to the audit report, it could not be readily determined how many of the providers with felonies were related to the clients they served. The report says, "…the client's ability to hire a relatives poses a unique circumstance in that clients may be fully aware of their relatives' criminal history. Although we concur that client choice should be encouraged and honored, it should be made with full disclosure, balanced with client safety and security, and consideration of the potential liability to the State." 

The overall recommendation of the auditor is that, "DCH and DHS should consider conducting criminal history checks for individual providers and requiring agency providers to conduct criminal history checks for their employees and/or subcontractors. By not conducting criminal history checks, DCH and DHS may be unaware of unsuitable individuals who may harm to their vulnerable client population." [emphasis added]…"Of particular concern are providers who are not related to the clients they serve because the clients are less likely to be aware of the providers' criminal past."

In response, DCH and DHS agree that they should be conducting criminal history background checks for individual and agency providers.

According to the report, DCH has developed a criminal history background check policy. The draft policy is under review and will be impemented once the review process is complete. They will also seek legislative solutions "that potentially could warrant disqualification as a provider."

See also this article from USA Today, 6/17/14, "Felons on Michigan payroll as home caregivers"

More on the Michigan Audit of Home Help Services

"I read audits so you don't have to."

Reading reports such as the "Performance Audit of the Medicaid Home Help Program", is tedious at best, but they often reveal nuggets of useful and interesting information that you rarely find in one place. Below are some of those nuggets:

Home Help Services are a dual responsibility of the Michigan Department of Community Health (DCH) and the Michigan Department of Human Services (DHS) and are paid for by a combination of federal and state funds.

The overall conclusion of the report is that "DHS and DCH efforts to operate HHP consistent with selected laws, rules, regulations, and policies were not effective." 

Findings in the audit include improper payments for Home Help Services of an estimated $160 million, 17.9% of the $893.7 million HHP expenditure from 10/1/10 to 9/30/13. Also, "…DCH and DHS could not ensure that clients timely received the most appropriate type and quantity of services for their conditions."

Qualifying for Home Help Services

According to the audit (page 9), services are available to people who have functional limitations resulting from a medical or physical disability or cognitive impairment who live in settings other than nursing homes, licensed group homes, mental institutions, or homes for the aged. They provide personal assistance to individuals with "activities of daily living" (ADLs) and "instrumental activities of daily living" (IADLs). ADL services include assistance with eating, toileting, bathing, grooming, and mobility. IADL services offer help with medication, meal preparation, shopping, and light housework. In addition, complex care services are available for clients with certain medical conditions.

To qualify for services (page 10), an individual must be an active Medicaid recipient, obtain a certification of medical need from a physician, and have a need for services indicating a functional need of 3 or greater for at least one ADL [activity of daily living]. A local DHS office must receive a referral for the prospective client. The DHS office contacts the client to obtain a certification of medical need. An adult services worker (ASW) from DHS conducts a functional assessment rating for each activity, with 1 being independent and 5 being dependent. The ASW allocates time for each task assessed at 3 or greater based on the actual time required for completion of the task. DCH and DHS can place limits on the amount of time allocable for each Instrumental Activity of Daily living, except medication.

(Having gone through this process many years ago with my older son and hearing from other parents who have done the same, the assigning of numbers and time allocations to various tasks can seem arbitrary and subjective, although the use of numbers provide a veneer of scientific objectivity.)

Lack of staffing likely contributed to many of the problems revealed in the report

This is brought up a number of times in responses to the audit by DCH and DHS. The state agencies were constrained by limited resources and staff to carry out functions required by Medicaid policies. Inadequate staffing and systems for cross-checking data from different departments in state government likely resulted in improper payments of Medicaid funds.

For example, on page 71 of the report, is Exhibit 6, showing Adult Services Clients and Adult Services Worker (ASW) Counts from 1999 through 2013:

The number of  Home Help Services clients increased steadily from 46,309 in 1999- 2000. Adult Protective Services clients are also served by ASWs and the figures for both are combined to show a total increase in clients from 55,373 in 1999-2000 to 85,710 in 2012 - 2013.

While the number of clients served increased steadily from 1999 to 2013 by 54.8%, the number of Adult Services Workers decreased by 25.3%, from 541 in 1999 to 404 in 2013.

In 2013 there were 404 Adult Services Workers. As of March 2014,153 of the Adult Services Workers had caseloads of over 200 clients. 60 had caseloads of 300 or more clients.
[DCH and DHS note that not all caseloads are the same. Therefore the data cannot be used to compute meaningful average caseload sizes per ASW.]

Pay rates for Home Help Providers 

During the audit period pay rates ranged from $8 to $11 per hour for individual providers and from $13.50 to $15.50 per hour for agency providers.

Perspective on Medicaid Expenditures for Home Help Services

Medicaid Expenditures by Category
October 1, 2010 through September 30, 2013

Page 65 of the report, Exhibit 3, shows a colorful pie chart of Medicaid expenditures. While the flaws in the Home Help Program are significant, it helps to put the program in perspective by comparing it to the total expenditures for Medicaid over the three year period that the audit covers:

  • Hospital costs and Medicaid Health Plans make up 49% of Medicaid expenditures with over $5 billion spent on hospitals and over 12 billion for Medicaid Health Plans.
  • Community Mental Health services constitute 18% of expenditures at over $6 billion.
  • Long Term Care accounts for 14% of expenditures at over $5 billion.
  • The Home Help Program constitutes 2% of expenditures at $894 million.
For my money, anything that can reduce costs for medical care through the Medicaid Health Plans and hospitalizations would offer the most bang for the buck, but it is  often the case that there is less of an appetite to focus on spending that involves powerful political and financial interests than to concentrate on services to low-income people with disabilities.

Home Help Program for people with disabilities: Michigan audit finds shoddy oversight, poor management, and improper payments

Michigan's Medicaid-funded Home Help Program that provides services to elderly and disabled people in their own homes is fraught with problems, according to a perfomance audit by the Michigan Office of the Auditor General.

According to the Lansing State Journal from 6/17/14, "Audit: Michigan improperly spent $160M on Medicaid", expenditures on improper payments (where the state failed to obtain sufficient documentation from service providers) accounts for 18% of the $894 million spent on the Home Help program that served about 67,000 people per year over a three year period.

In addition, "...Auditors said nearly 3,800 of roughly 70,000 home health providers had felony convictions, including 572 convictions for violent crimes…"

According to the  Lansing State Journal: 

"The audit also found that the state:

  • overpaid 80 agencies $6.8 million by not making sure they met requirements to get higher fees than individual aides.
  • hired a contractor in 2008 for $1.4 million to visit DHS [Department of Human Services] county offices over three years to review home health cases, yet the case file reviews were not forwarded to the offices for corrective action on time. The Community Health Department blamed a lack of staff for the delay.
  • inappropriately paid $3.5 million for home services when the patients were instead being hospitalized or in nursing homes.
  • did not review thousands of W-2 forms returned as undeliverable, missing a chance to crack down on clients fraudulently getting services or their relatives providing a false address to avoid cuts in the clients’ authorized service level.
  • failed to create a process for caseworkers to refer suspected fraud to the attorney general’s office."
What is the significance of a dysfunctional Home Help Program?
Home Help Services are mandatory under Medicaid, meaning that they must be available to all eligible individuals. Medicaid funding for Home Help Services, paid for by both federal and state governments, is a significant factor in allowing many people with developmental and other disabilities to live in their own homes. It is almost always a component of providing care in unlicensed supported living settings. The findings in the audit of Michigan's program, however, exemplify problems more generally with community care, especially for those with severe, profound, and complex disabilities: funding and the provision of services is so fragmented that the system of care is often unmanageable. This is aggravated in this case by cuts in funding to state government that, if they had not been a legislative priority, might have allowed more and better oversight, ultimately saving taxpayers money and improving the lives of people with disabilities.

Under these conditions, accountability for the provision of services and the expenditure of funds, in addition to assuring the health and safety of the people receiving services, is illusory at best. Federally-funded disability advocacy groups and the Centers for Medicare and Medicaid Services (CMS), the federal agency that regulates Medicaid and Medicare, are pressuring states to turn away from any kind of congregate care and service settings (settings that serve more than three people with disabilities together), just when innovative care in congregate settings and maintaining high quality care in settings that are considered "institutional", might be a solution to the problems of fragmentation, mismanagement, and lack of accountability. Those who choose and would benefit from care in congregate settings, usually people with more severe and complex disabilities, also cost more to care for regardless of where they live. Congregate settings that offer economies of scale contribute to cost-efficiency and better use of taxpayers' money.

Sunday, May 25, 2014

The Kalamazoo Promise: Genorosity trumps the pervasive mood of mean-spiritedness

These are gloomy days for anyone trying to understand where and when we took a turn for the worse and began to see dependence, unemployment, poverty, disability, and mental illness as an affront to our way of life, worthy of scorn and contempt.

People with developmental disabilities are not immune from this meanness of spirit, even within the "disability community". Federally-funded disability advocacy groups along with our misguided U.S. Department of Justice, seem hell-bent on bringing down the infra-structure of specialized services and residential options, especially those for people with the most severe disabilities, in the name of freedom and integration. Parents, other family members, and friends are dismayed by the seeming lack of understanding and compassion for their loved-ones. They are casually dismissed as interfering with the judgment of professionals, left out of decisions affecting their family members, and even blamed for keeping people with permanent life-long disabilities in a state of dependence.

This story from the Detroit Free Press,  "Kalamazoo Promise has changed more lives than just the students'" by Bob Jorth, 5/24/14, has nothing directly to do with developmental disabilities, but it is an example of how a small city in southwestern Michigan took on the daunting challenge of providing their children who graduate from Kalamazoo's public high schools with scholarships to any of Michigan's state colleges and universities. 65% to 100% of tuition, depending on the number of years of attendance in the public school system, is paid by anonymous donors to the Kalamazoo Promise .

According to the Detroit Free Press article, the Kalamazoo Promise benefits more than just the students:

"… Students graduating from Kalamazoo Public Schools will be graduating with the Kalamazoo Promise and its assurance that they can go to any of the 43 state-supported universities and community colleges tuition-free. This gift will allow them to focus on their dreams and passions rather than concentrate on how to pay for their education. To date, about 40% of Promise graduates are earning their degrees debt-free, and the median debt for others is less than $5,000

"We’ve seen improvements in K-12 test scores, average grade-point average, behavior and attitudes of students, parents and school staff and a decline in the drop-out rate. There is a 20% improvement in student performance at Kalamazoo Valley Community College, where many first-generation students begin. And more than 90% of all graduates are now starting college in a district where 70% of its students receive free and reduced lunch." [emphasis added]

"…Measuring the full impact of the Kalamazoo Promise has just begun, and the work is difficult at best. Enrollment in the Kalamazoo Public Schools has increased nearly 25% since the announcement of the Promise."

And that is how generosity of spirit overcomes the impulse to turn away from our problems and lash out at our fellow citizens.

More on the Kalamazoo Promise from the New York Times, 9/13/12: "Why These Kids Get a Free Ride to College" by Ted Fishman.

Monday, May 5, 2014

H.R. 831 : Protecting disabled workers or eliminating options for DD?

H.R. 831 is a bill in the U.S. Congress that would phase out special wage certificates under the Fair Labor Standards Act of 1938 under which individuals with disabilities may be employed at subminimum wage rates.

Workers with disabilities who are able to engage in competitive employment, with or without supports, should not be exploited in workplaces that profit off their labor but pay the workers sub minimum wages. The special wage certificates that are now issued, however, allow people with more severe cognitive and other disabilities to work at their own pace in skill development centers (sheltered workshops, usually in community settings) and receive pay adjusted to their abilities and how fast they work. To eliminate the special certificates would apparently, in effect, also eliminate this important option for people who can and want to work but would otherwise be unlikely to obtain employment in regular competitive workplaces. In the opinion of many who benefit from these programs, too little consideration has been given to what will happen to these people other than many more of them sitting at home with nothing to do.

This is an Action Alert from ACCSES, a national provider organization for employment programs for people with disabilities that opposes the bill:

Action Alert
NFB Push on H.R. 831

Next week, the National Federation of the Blind will be coordinating several action days to rally support for H.R. 831.
  • Tuesday, May 6 – Twitter Tuesday
  • Wednesday, May 7 – Call Wednesday
  • Thursday, May 8 – Email Thursday
We strongly encourage you to get the word out to your parents and allies regarding these action dates. Organizations like the NFB do not speak for all people with disabilities. Let your representatives know that skill development centers are needed and wanted and that you do not support H.R. 831.

We also want to alert you to a free webinar featuring New York Times columnist Dan Barry that will be taking place on Tuesday, May 6th. This webinar is hosted by the National Center on Disability and Journalism and will cover Barry’s recent New York Times piece, “The Boys’ in the Bunkhouse.” Barry will be discussing how he developed the story and will be offering “advice for others covering disability issues or people with disabilities.” While Mr. Barry produced an outstanding article, we are deeply troubled by the media’s negative focus on skill development centers and want to ensure that journalists in attendance know that the full story is not being told. The types of abuse that occurred at Henry’s Turkey Farm and in Rhode Island is already illegal and should be investigated and the organizations and individuals responsible should be punished, but that if legislation like H.R. 831 is passed, they will be telling an equally troubling story about jobs, paychecks, and social networks for people with the most severe disabilities disappearing.