1). Under an agency-directed model, a provider agency employs attendants. Medicaid program requirements vary by the type of PCS program, but  may include the following types of protections depending on the type of  program:  screening attendants to see if they are excluded as Medicaid  providers; developing minimum qualification standards for attendants; establishing quality assurance processes to ensure the services  provided protect the health and welfare of beneficiaries;  identifying and reporting cases of potential abuse, neglect, or other  events that harm, or could result in harm to beneficiaries; establishing policies and processes to ensure that services for which  the state has been billed were actually provided; and  reporting on the health and welfare of beneficiaries to CMS on a  regular basis. Selected States Varied in How They Implemented Beneficiary Safeguards and Ensured Billed Personal Care Services Were Provided Selected States Employed Beneficiary Safeguards in Three Common Areas, but Implementation Methods Varied Among and Sometimes Within States

All four selected states—California, Maryland, Oregon, and Texas— reported employing safeguards to protect beneficiaries from harm and  had methods in place to ensure billed services were actually provided, but  the states varied in how they implemented them and, in some cases,  variations existed within states across PCS programs. The four states  also reported using different methods to help ensure billed services were  provided (see Appendix I for the types of PCS programs reviewed in each  state). All four selected states reported that beneficiaries’ health and welfare is  monitored in part by having case managers or nurses periodically check  in with beneficiaries, but the frequency and means, such as in-person  versus by phone or electronic message, varied among the four states and  in some cases within states across PCS programs. For example,  for at least some PCS programs, two states required beneficiaries to sign  timesheets, two states used electronic visit verification timekeeping  systems, and all four states performed quality assurance reviews for  some PCS programs to ensure billed services are received. CMS Has Taken Steps to Improve Oversight of States’ Personal Care Services Programs and Harmonize Requirements, but Issues Remain

		CMS Has Taken Steps to Improve Oversight through Guidance and Program Reviews but Does Not Collect Required State Information

Since 2010, CMS has taken several steps to improve oversight of states’  PCS programs to help ensure that beneficiaries are safe and that billed  services are provided. Reviewed state PCS programs. Required reporting. This required reporting will help inform CMS  and Congress about the health and welfare of beneficiaries receiving  services from these programs. CMS officials told us that they are  working on developing guidance for states to submit the required  information. However, we found that CMS’s efforts have not addressed the significant  differences across federal program requirements specific to PCS related  to beneficiary safety and ensuring that billed services are provided. Harmonizing requirements across similar programs is also consistent with federal internal control standards. For example, in  one state we reviewed, the state requires quarterly or biannual  monitoring of beneficiaries for most of its PCS programs. Similarly, the type of fiscal controls required to prevent improper  payments for these services can vary based on the type of program. Congress and others have called on HHS to take steps to improve the  coordination and administration of home- and community-based services. A more  consistent administration of policies and procedures across programs  could ease some of the differences and provide some comparable  approaches to safeguards and assurances and help the federal  government and states better manage risks to beneficiaries and to protect  the integrity of the program. CMS has taken some needed steps to harmonize requirements across  the program authorities; however, significant differences remain in the  federal program requirements that serve as the basis for state oversight  policies and protections for their different PCS programs. Recommendations for Executive Action

To achieve a better understanding of the effect of certain PCS services  on beneficiaries and a more consistent administration of policies and  procedures across PCS programs, we recommend the Acting  Administrator of CMS take the following two actions:  collect and analyze states’ required information on the impact of the  Participant-Directed Option and Community First Choice programs on  the health and welfare of beneficiaries as well as the state quality  measures for the Participant-Directed Option and Community First  Choice programs; and  take steps to harmonize requirements, as appropriate, across PCS  programs in a way that accounts for common risks faced by  beneficiaries and to better ensure that billed services are provided. HHS concurred  with our recommendations and noted efforts to address them.
Why GAO Did This Study

The number of people receiving in-home personal care services—such as assistance with bathing and dressing—from Medicaid is expected to grow. States can offer these services through one or more programs under which home- and community-based services can be provided, each with different federal requirements. The provision of personal care in beneficiaries' homes can pose risks to safety, and these services have a high rate of improper payments, including instances where services for which the state was billed were not provided. In recent years Congress has directed HHS to improve coordination of these programs, which could harmonize requirements—that is, implement a more consistent administration of policies and procedures—and enhance oversight.
GAO was asked to review oversight of Medicaid personal care services. GAO examined: (1) how selected states ensure that beneficiaries receiving services are safe from harm and that billed services are provided; and (2) steps CMS has taken since 2010 to improve oversight and harmonize requirements across programs. GAO reviewed policies in four states with varied programs; reviewed laws, guidance and documents; and interviewed CMS officials.

What GAO Found

Four states that GAO reviewed varied in how they implemented safeguards to protect beneficiaries receiving in-home personal care services from harm and in their methods to help ensure billed services were actually provided. For example, to help keep beneficiaries safe, the four selected states—California, Maryland, Oregon, and Texas—reported that they monitored beneficiaries by having case managers or nurses periodically check in with beneficiaries, but the frequency and means, such as in-person or by phone, varied among the states and in some cases across programs within a state. The four states also reported using different methods to help ensure that billed services were actually provided. For example, to track attendants' work time, two states required beneficiaries to sign paper timesheets for the attendants, and two states used electronic visit verification timekeeping systems for some or all programs.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), has taken several steps to improve oversight of states' personal care service programs and harmonize requirements but has not collected required state reports or addressed significant differences in program requirements. Since 2010, CMS steps to improve oversight of states' programs include enhancing guidance and conducting webinars to help states address improper payments. To manage risk inherent in the provision of these services, and in keeping with statutory direction to improve coordination of these programs, CMS has taken steps to better harmonize requirements across programs including directing states to follow agency guidance issued for one type of program when implementing a similar type of program. However:
CMS has not systematically collected required states' reports on personal care services provided under two programs, although CMS stated that guidance for states to submit the reports is under development. Collecting these reports could improve oversight by providing CMS and Congress with information on programs' effects on beneficiaries' health and welfare.
CMS harmonization efforts have not addressed the significant differences across federal program requirements specific to beneficiary safety and ensuring that billed services are provided. Consequently, the safeguards and level of assurance that CMS has regarding states' beneficiary protections and oversight of billed services can vary by program. For example, one reviewed state requires quarterly or biannual beneficiary monitoring for most programs; but one program monitors annually as federal requirements do not require more frequent monitoring. Similarly, requirements to help ensure billed services are actually provided vary widely among states and programs, contributing to uneven assurances and oversight across programs.
Home- and community-based services, including personal care services, are growing in significance and in demand. A more consistent administration of policies and procedures across programs could help the federal government and states better manage risks to beneficiaries and protect the integrity of the program.

What GAO Recommends

GAO recommends that the Acting Administrator of CMS (1) collect and analyze required state reports on personal care services and (2) take steps to further harmonize federal program requirements, as appropriate, across programs providing these services. HHS concurred with both recommendations