Purpose

To determine whether State agencies, particularly the New York State Office for the Aging (NYSOFA) and the Department of Health (DOH), are effectively overseeing Social Adult Day Services (SADS) programs to ensure that providers comply with regulations related to client eligibility, service plans, staffing, training, and physical safety. The audit covers the period April 1, 2011 through March 26, 2015.

Background

SADS programs are structured, comprehensive programs that provide functionally impaired adults with services such as socialization, supervision and monitoring, personal care, and nutrition in a protective setting. Each participant should receive services in accordance with an individualized service plan, based on a personalized assessment. The programs may also provide support services, such as information, transportation, and caregiver assistance.

NYSOFA currently has oversight responsibility for 17 SADS programs that it directly funds through contracts. Certain other programs are funded at least partially through counties and are overseen at the local level by 59 county Area Agencies on Aging (AAAs). NYSOFA’s regulations establish minimum standards for program eligibility, service plans, staffing, training, and physical safety. SADS is also a benefit available under the State’s Medicaid Managed Long-Term Care (MLTC) model. DOH, as the Medicaid administrator, is responsible for supervising and overseeing Medicaid as a whole. However, it is not specifically required to oversee individual component services offered through MLTC plans, including SADS. Instead, DOH relies on MLTC plans themselves to oversee the programs at the local level. More than 15,000 New Yorkers receive Medicaid-funded SADS services each year.

In fiscal year 2014-15, NYSOFA provided $1.1 million in funding to its 17 SADS contractors, while AAAs provided an additional $4.5 million of direct funding to the SADS operating in their counties. According to DOH officials, for the two calendar years 2013 and 2014, SADS providers received over $175 million in Medicaid funding for services delivered through MLTC plans.

Key Findings

• Because SADS programs are not currently licensed or registered by any one government agency, unless a program receives some form of direct government funding, program oversight is not guaranteed. Our research suggests a material number of unregulated providers operating in the State. Absent more comprehensive oversight by stakeholder agencies, their precise number, cost, and, most importantly, who is running them and the quality of their services are unknown.
• NYSOFA program regulations, which were originally designed over 20 years ago to define a base level of minimum requirements, lack specific measures needed to effectively evaluate program quality and performance in today’s environment.
• In general, we found NYSOFA fulfills its responsibility to oversee compliance with regulations by the SADS providers that it funds, either directly or through the county AAAs. However, we identified opportunities for NYSOFA to further enhance its efforts, specifically in terms of the frequency of on-site monitoring visits and its control over their tracking as well as better use of a standardized monitoring tool at the county level.
• DOH is not mandated by law to directly oversee SADS programs that provide services to Medicaid participants. Rather, officials assert that the MLTCs are responsible for overseeing the programs with which they contract. Even so, DOH has provided guidance and direction to the MLTCs, and is independently assessing the extent to which New York City-based programs comply with NYSOFA’s regulations. Based on our own field visits, it appears such compliance may have improved in recent years, although problems continue to exist.

Key Recommendations

• Relevant stakeholder agencies should carefully consider the risks identified in this report in deciding whether a more comprehensive system of regulation, such as licensing, registration, or mandated inspection, is warranted as the SADS program moves forward.
• NYSOFA should consider updating program regulations and/or providing supplemental guidance that more specifically defines expectations for factors that directly impact program quality and performance.
• NYSOFA should take steps to improve existing oversight and monitoring programs, including conducting on-site monitoring of each of its direct SADS contractors at least annually, making provisions for unannounced site visits, and ensuring consistent evaluation of program compliance at the county level.
• Stakeholder agencies should work together to implement a comprehensive program to oversee Medicaid-funded SADS programs, which includes the oversight actions recently developed as well as procedures to verify the accuracy of the annual SADS self-assessment certifications.