Region 2 Area Agency on Aging
Provider Monitoring Tool
In-home Service Provider Monitoring Tool
AGENCY: ____________________________________________________
ADDRESS: ____________________________________________________
DIRECTOR: ____________________________________________________
CONTRACT PERIOD COVERED: ____________________________________
TYPE OF AGENCY: Check all that apply.
( ) Private Duty ( ) Medicare Skilled
( ) Hospital Based ( ) Hospice Certified
( ) Not-for-Profit ( ) Public
( ) Other
SERVICE CATEGORIES BEING MONITORED:
( ) Personal Care ( ) Home Delivered Meals ( ) Adult Day Care
( ) Personal Care Supervision ( ) Chore Services ( ) Counseling
( ) Respite Care ( ) Personal Emergency Response ( ) Private Duty Nursing
( ) Homemaker ( ) Transportation ( ) Other
ASSESSMENT CONDUCTED BY:
PROVIDER PARTICIPANTS:
DATE FEEDBACK SENT:
GENERAL INFORMATION
1. Is the Purchase Agreement contract signed and current (updated)? Y N
a. Assurance of Compliance with Discrimination Laws? Y N
b. Medicaid Provider Enrollment Form? Y N
c. IRS form W-9 Request for Taxpayer Identification Number? Y N
d. Applicable Licenses? Expiration date(s): _______________ Y N
2. Have conditions of Agreement been reviewed with staff to ensure compliance? Y N
3. Are books and records relevant to the Agreement kept for at least six years? Y N
4. Is a copy of OSA standards, the Agreement, and AAA Provider Procedures available? Y N
5. Does the DPOS Provider agency maintain the following insurance? Y N
Expiration Date Y N
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Region 2 Area Agency on Aging
Provider Monitoring Tool
a. Workmen’s Compensation ____________ Y N
b. Unemployment ____________ Y N
c. Property/Theft Coverage(If applicable) ____________ Y N
d. No-fault Vehicle Insurance(For transporting clients) ____________ Y N
e. Fidelity Bonding(For handling cash) ____________ Y N
f. General Liability ____________ Y N
g. Malpractice Liability ____________ Y N
h. Professional Liability ____________ Y N
i. Other ____________ Y N
5. Is Region 2 AAA listed as Certificate Holder and/or as “Another Insured” by Provider’s Insurance Company?
Y N
PROGRAM SPECIFICATIONS
CM Waiver
1. Approximate number of CM/Waiver clients currently being served? _____ / ______
2. What are the procedures for documenting hours of service by employees for billing purposes?
3. How does the agency verify that hours of service are actually being provided?
4. How does agency utilize the CM/Waiver Assessment?
5. Does agency have their own service plan or care plan? Y N
If yes, does service plan correspond to CM/Waiver work order? Y N
6. If the agency is a Medicare/Medicaid certified agency with a private duty component, does the agency bill
either source for nonskilled services provided to waiver clients through “Management & Evaluation?”
Y N
7. Who has access to files?
8. How are confidential client files kept private and secure?
9. Is a business agreement in place to ensure privacy of protected health information? Y N
10. Documentation:
a. How does the Provider specifically identify clients being served through the Area Agency on Aging?
b. Does documentation contain the “Date of Service”, “Type of Service”, a “Written Summary” of services and
tasks performed, and the signature of the employee providing the service? Y N
c. Does Provider furnish services according to CM/Waiver service authorization? Y N
d. Does Provider use and maintain an “In-Home Journal”? Y N
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Region 2 Area Agency on Aging
Provider Monitoring Tool
11. Does program have policies and/or procedures for: (Visually inspect).
a. Client confidentiality? Y N
b. Client appeals/grievance? Y N
c. Client feedback/evaluation? Y N
d. Client’s rights and responsibilities? Y N
e. Emergencies in client’s home? Y N
f. Personnel? Y N
g. Recruitment, training and supervision? Y N
Date of last revision of policy manual? ____________
12. How many mandatory quarterly provider meetings has the provider attended? ____________
STAFFING
1. Is the following information in paid staff employees files:
a. Application for employment? Y N
b. Reference check? Y N
c. TB test results (CARD)? Y N
d. Orientation and In-Services attended? Y N
e. Copy of Certification/License/Registration for professional employees? Y N
f. Copy of valid driver’s license and auto insurance? Y N
g. Evidence of influenza and hepatitis B vaccination? Y N
2. Does provider conduct a “criminal background check” on new employees? Y N
3. What is the procedure for checking references of paid staff who enter client’s homes?
4. Are reference checks done prior to paid staff entering client home? Y N
5. Describe agency’s procedures for introducing caregiver staff to clients.
6. Do caregivers wear pictured identification? What is presented to client? Y N
7. What type of orientation program is set up for new staff? (Visually verify training program)
8. The following applies for Personal Care Aides/Homemaker Aides/Respite Care Aides:
a. Describe the typical tasks performed in the client’s home.
b. How many Personal Care Aides have certifications? ________
c. Does in-service training provided to aides occur at least two times per year? Y N
d. What types of training topics have been covered in the last 12 months?
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Region 2 Area Agency on Aging
Provider Monitoring Tool
e. Is a “Personal Care Aide” training course is provided? Y N
f. What are the credentials of a qualified professional who supervises caregivers?
g. Are aides shown what is on the service authorization before services begin? Y N
h. Is a supervisor available to caregivers at all times by phone? Y N
i. Are supervisory in-home evaluations conducted at least 2 times per year? Y N
j. Do client records reflect documentation of on-site supervisory visits, name and title of person doing
supervising, staff person being supervised and location of on-site supervision? Y N
k. Is there a policy on dispensing of non-prescription and/or prescription medications? Y N
9. The following applies for private duty nursing.
a. Are licenses and/or registrations current and available for viewing? Y N
b. Are LPN’s supervised by RN’s? Y N
c. Are there written procedures to govern administering of medications? Y N
d. Who is authorized to set up and/or administer medications?
SERVICE COORDINATION
1. What is the procedure for notifying care managers of client changes in condition or status?
2. What is the procedure for notifying the care managers of known upcoming appointments?
3. What is the procedure for notifying care managers of discontinued services in the case of:
client not at home, death, institutionalization, hospitalization, and personal choice?
4. What is the policy/procedure for notifying CM when paid staff fail to show up at client’s home?
5. Is the Notice of Non-Service form used when services are not provided as requested? Y N
OTHER
1. Are the agency services available to the general public? Y N
Private pay rate $ ________ R2AAA rate $ _________ Other rate $ __________
2. How are agency services publicized?
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Region 2 Area Agency on Aging
Provider Monitoring Tool
3. Does DPOS Provider have any need for technical assistance or training? Y N
4. Were there any problems encountered during the last 12 months? Y N
CASE RECORDS
NOTE: A complete audit of client case records is to be conducted for those cases being reviewed, verifying the latest
3 months of billing dates/units of services submitted by provider agency and paid by Region 2 AAA with dates in
official client case records.
1. Client records (review 10 files or 10% whichever is greater for the following contents)
Name:
% in compliance
a. Assessment/reassessment __ __ __ __ __ __ __ __ __ __ ______
b. Service Authorization __ __ __ __ __ __ __ __ __ __ ______
c. Worker Log __ __ __ __ __ __ __ __ __ __ ______
d. Progress notes __ __ __ __ __ __ __ __ __ __ ______
e. Invoice __ __ __ __ __ __ __ __ __ __ ______
2. Do progress notes correspond with billing dates of service? Y N
3. Did monitoring reveal any areas of client needs not being adequately addressed through provider’s provision
of service? Y N
COMMENTS RECOMMENDATIONS REQUIREMENTS
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