State of Illinois
WILLIAM G. HOLLAND
Iles Park Plaza
Senate Resolution Number 207 directed the Auditor General's Office to complete a program audit of the new universal screening program by June 30, 1998, to determine the cost effectiveness of the universal screening mandate. This mandate became effective July 1, 1996, when the Nursing Home Care Act was amended to require universal prescreening for all individuals seeking admission to a nursing facility (210 ILCS 45/2-201.5). Responsibility for the mandate is shared among the Departments on Aging, Human Services, and Public Health. In our review of the new program we determined that:
The Nursing Home Care Act now requires screenings for all individuals seeking admission to a nursing facility, regardless of payment source.
The universal screening program was mandated by Public Act 89-21 and requires that all individuals seeking admission to a nursing facility be screened prior to admission regardless of income, assets, or funding source (210 ILCS 45/2-201.5). Before July 1, 1996, only individuals seeking Medicaid assistance were required to be screened, and private pay individuals could enter a nursing facility without being screened. Screenings for those not seeking Medicaid are advisory; the individual still makes the decision to go to a nursing facility or remain in the community.
As a result of the universal screening requirement, the Department on Aging did 332 percent more nursing facility prescreenings during Fiscal Year 1997 than in the prior year. In Fiscal Year 1997, Aging paid for 62,747 screenings performed for individuals 60 years of age or older for a total cost of $3.6 million. Of the 62,747 screenings performed, 51,189 resulted in the person being placed in a nursing facility.
The universal screening program has been cost effective even though only a small proportion of individuals screened were deflected from nursing facility care to less expensive community based care. We estimate that during Fiscal Year 1997, an average of 741 additional people were in the State Community Care Program each month because of universal screening with an estimated State cost savings of approximately $2.8 million for the year.
There are other cost saving aspects of the program, including federal savings from delayed nursing facility care. Some other cost savings aspects are difficult to quantify. For example, individuals who are deflected to less expensive private pay home care may delay nursing facility admission and thus delay the time when they will need the State's assistance to pay for nursing facility care.
The universal screening requirement also applied to individuals under age 60 seeking nursing facility admission. The requirement had little impact on this portion of the program which is administered by the Department of Human Services. These clients are screened by Human Services' division of rehabilitation services or its division of mental health and developmental disabilities.
Not all individuals admitted to nursing facilities were screened prior to admission as required by Public Act 89-21. Although an exact match of data was not available, there were nearly twice as many admissions to nursing homes in the 12 month period of calendar year 1996 as there were screenings resulting in a nursing home placement during Fiscal Year 1997 (July 1, 1996 to June 30, 1997). The Department of Public Health has the authority to enforce this provision but had not taken steps to do so.
Some weaknesses were identified in Aging's management controls over payments for screenings. We identified over $16,000 of duplicate bills submitted by one community agency that did screenings. After we identified these questionable billings, Aging notified the agency, the agency acknowledged the problem and returned the amount in error. Errors we identified at screening entities resulted in total recoveries of $19,896. Although the percentage of inappropriate bills was small, changes in the control system could help to guard against future errors or inappropriate bills.
Few significant delays in providing service were noted in the first year of the universal screening program. One delay noted by a nursing home association was for Medicaid clients who were discharged from a hospital and clearly needed nursing home services. In a few cases, the screening was not conducted until several days after the patient had been admitted to a nursing home. When the screening is delayed, Public Aid rules require that payment cannot be made for services provided before the screening was performed.
The data for the first half of Fiscal Year 1998 show that the number of screenings is comparable to Fiscal Year 1997 and the number of Community Care Program clients is also staying constant. If the number of people deflected to community care decreases, the continued cost effectiveness of the screening program may become questionable.
On May 23, 1996 the Illinois Senate adopted Senate Resolution Number 207 directing the Auditor General's Office to conduct a program audit of the universal screening program. The Resolution required that the audit commence on July 1, 1997, and report to the General Assembly no later than June 30, 1998. The Resolution asked us to determine the cost effectiveness of the universal screening mandate including but not limited to:
AGENCIES INVOLVED IN UNIVERSAL SCREENING
The universal screening program was mandated by Public Act 89-21 and requires that all individuals seeking admission to a nursing facility be screened prior to admission. Before July 1, 1996, only individuals seeking Medicaid assistance were required to be screened, and private pay individuals could enter a nursing facility without being screened.
Digest Exhibit 1
FY97 SCREENINGS BY TYPE
Source: Agency data analyzed by OAG.
Aging does screenings for individuals age 60 or older
The universal screening program is administered mainly by the Department on Aging (Aging) with assistance for certain screenings from two divisions of the Department of Human Services. These are the division of rehabilitation services and the division of mental health and developmental disabilities. The division of rehabilitation services conducts screenings for individuals 18 to 59 years of age. The division of mental health and developmental disabilities conducts screenings for individuals who are developmentally disabled or have mental illness, regardless of age. Aging is responsible for screening all individuals 60 years of age or older. The number of screenings performed by each of the three entities is shown in Digest Exhibit 1.
The mandate for universal screening is located in the Nursing Home Care Act (210 ILCS 45/2-201.5). The Department of Public Health is responsible for administering the provisions of this licensing Act. All individuals seeking admission to a nursing facility licensed by Public Health under this Act must be screened to determine the need for nursing facility services prior to being admitted.
In addition, the Department of Public Aid has been involved in development of the program because of the potential for impact on Medicaid long term care payments. Public Aid pays for nursing home care for people who are eligible for Medicaid. In addition, under a federal waiver, Medicaid money through Public Aid is used to pay for community care for individuals who qualify for Medicaid. The agencies involved with universal screening refer to the program as "Choices for Care."
The screening is an assessment of the need for long term care placement, regardless of payment source. The assessment evaluates the mental, physical, and economic status of the individual seeking nursing facility placement. The assessment used by Aging determines whether an individual needs nursing home care, and if they do, whether those needs could be met with home based services. (pages 3 to 4)
Department on Aging
The universal screening program at Aging appears to have been cost effective during the first year. Even though only a small proportion of individuals screened were deflected from nursing facility care to less expensive community based care, we estimated that during Fiscal Year 1997, approximately $2.8 million was saved by the State with Aging's screenings.
In the first year of the universal screening mandate, Aging's Case Coordination Units (CCUs) conducted significantly more screenings than in the prior year. In Fiscal Year 1997, CCUs conducted and were reimbursed for 62,747 screenings on 57,959 individuals. CCUs are local entities that Aging contracts with to do the screenings. In Fiscal Year 1996 there were 14,526 paid screenings. This change shows a 332 percent increase in Fiscal Year 1997 over Fiscal Year 1996 screenings. Total reimbursed costs for Fiscal Year 1997 screenings were $3,602,054, an increase of $3,028,087 over the prior year's costs.
Digest Exhibit 2
DEPARTMENT ON AGING
|Source: Aging data summarized by OAG.|
We identified over $16,000 of overpayments to one community agency that did
screenings. When we notified Aging, they contacted that agency and recovered the total
Public Health had not established controls to assure that all individuals admitted
to nursing facilities are screened.
Human Services screens individuals 18 to 59 plus anyone with a mental illness or a developmental disability.
The 14,526 screenings conducted in Fiscal Year 1996 were for applicants to nursing facilities who sought to have Medicaid pay for their care. Therefore, most of the increase in Fiscal Year 1997 can be attributed to the new private pay/non-Medicaid population required to be screened as a result of the mandate. (pages 11 to 14)
Few significant delays in providing services were noted in the first year of the universal screening program. One delay noted by a nursing home association was for Medicaid clients who were discharged from a hospital and clearly needed nursing home services. In a few cases, the screening was not conducted until several days after the patient was admitted to a nursing home. When the screening is delayed, Public Aid rules prohibit payment for nursing facility services provided before the screening has been performed. We recommended that Public Aid assure that screenings are completed before Medicaid payments are made to a nursing facility. (pages 27 to 28)
We analyzed Aging's computer system and found that it lacked edit checks to adequately track, monitor, and control the universal screening program. In our analysis we identified over $16,000 of duplicate bills submitted by one community agency that did screenings. After we identified these questionable billings, Aging notified the agency, the agency acknowledged the problem and returned the amount in error. Errors we identified at this and other CCUs resulted in total recoveries of $19,896 during the audit. (pages 40 to 43)
Department of Public Health
The Department of Public Health has not established a control to assure that all individuals admitted to nursing facilities are screened to determine the need for nursing facility services prior to admission. Public Health, through the Nursing Home Care Act, is the agency responsible for licensing nursing facilities and assuring that the universal screening mandate is implemented (Nursing Home Care Act 210 ILCS 45/1-109).
Based on data from Public Health, there were 99,820 admissions to nursing facilities in Calendar Year 1996. Based on Fiscal Year 1997 data from Aging and Human Services, there were a total of 58,065 screenings performed which resulted in nursing facility placement. Although Public Health data are not available for Fiscal Year 1997 admissions, it is apparent that there are many individuals admitted to nursing facilities without the required screening. Because Aging focuses its efforts on people at risk, many of the missed admission screenings may be the people who are capable of remaining in the community with the assistance of State or private home care services.
The Department of Public Health already conducts site visits of nursing facilities and has rules that a nursing facility must follow to maintain its license. Although law and administrative rules have established that Aging and Human Services are responsible for doing the screenings, those agencies have little power to compel nursing facilities to assure screenings are done as required by the law. We recommended that Public Health take steps necessary to assure screenings are performed. (pages 37 to 39)
Department of Human Services
We concluded that the new universal screening mandate had minimal impact on the Department of Human Services. Human Services conducts two different types of screenings relating to the mandate. The screenings conducted by the mental health and developmental disabilities division are also required by federal law and would need to continue even without the mandate. The screenings of other individuals aged 18 to 59 are the responsibility of the division of rehabilitation services. However, because these screenings are performed by hospital discharge planners at no cost to the State or by Department employees who were already on staff, there were no additional costs to do the universal screening. Screenings performed by Human Services are discussed in greater detail in Chapter Two of this report. (pages 16 to 19)
The audit report contains seven recommendations, five for the Department on Aging and one each for Public Aid and Public Health which have been mentioned in this Digest. We recommend that Aging:
The agencies generally concurred with the recommendations. Agency responses to individual findings have been incorporated in the report and the complete responses are included as Appendix G of the audit report.