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Before the Board of Supervisors
County of San Joaquin, State of California
B_10_ 807
MOTION: Bestolarides/Ruhstaller/4
APPROVAL OF THE 2018-11 IN-HOME SUPPORTIVE SERVICES FRAUD
INVESTIGATIONS AND PROGRAM INTEGRITY PLAN
THIS BOARD OF SUPERVISORS DOES HEREBY:
1. Approve the 2010-11 In-Home Supportive Services (IHSS) Fraud Investigations and
Program Integrity Plan (a copy of which is on file with the Clerk of the Board); and
2. Authorize and direct the Chairman of the Board to sign the Plan.
I U§Nb'ro CERTIFY that the above order was passed and adopted on
_ _ _ _ _ _ _ by the following vote of the Board of Supervisors, to wit:
AYES: Bestolarides, Ruhstaller, Ornellas, Villapudua
NOES: None
ABSENT: Vogel
ABSTAIN: None
LOIS M. SAHYOUN
Clerk of the Board of Supervisors
County of San Joaquin
State of Califomi a
San Joaquin County
Human Services Agency
and
District Attorney's Office
In-Home Supportive Services Fraud Investigation and
Program Integrity Plan
for
2010/11
July 30, 2010
Enclosure B
COUNTY RESPONSE COVER PAGE
MUST BE FULLY COMPLETED AND SUBMITTED WITH PLAN AND DATA
San Joaquin County is requesting participation in the IHSS Fraud Prevention Program and will
submit a Plan and data as described above, by September 1, 2010.
Board of Supervisors Approval
Approved on AUG 1 0 2010 , 2010, by the County Board of Supervisors
Name of ~ppr"~s Title: Chairman, Board of Supervisors
Signature~_....::::::::::..::=----=-_-=-~s.....l~o.~===~
Board of Supervisors
Name of Representative: Carlos Villapudua Title: Chairman
Telephone #: (209) 468-3113
Email: cvillapudua@sjgov.org
County Welfare Department
Name of Representative: Donna Anderson Title: Division Chief, Department of Aging
Telephone #: (209) 468-0982
Email: danderson@sjgov.org
County District Attorney Office
Name of Representative: Larry Ferrari Title: Chief of Investigations
Telephone #: (209) 468-1882
Email: larry.ferrari@sjcda.org
San Joaquin County -2- July 1,2010
Table of Contents
Background 4
Current Anti-Fraud Activities 6
Proposed Anti-Fraud Activities 8
County Proposed Budget for Utilization of Funds 11
Collaboration and Partnership with the District Attorney's Office 16
Fraud Referrals/Outcomes 18
Collaboration and Partnerships with Department of Health Care Services (DHCS) and the
California Department of Social Services (CDSS) 21
Mechanism for Tracking/Reporting 22
Annual Outcomes Report 23
Enclosure D 24
San Joaquin County -3- July 1,2010
Background
Since the mid-1990s, San Joaquin County Human Services Agency (HSA) has conducted Quality
Assurance (QA) activities to ensure the appropriate expenditure of public funds, and to protect the
interests of the recipients that are served. With the implementation of the Quality Assurance
Initiative in 2004, San Joaquin County (the County) has been committed to the development and
implementation of Statewide QA activities.
With a focus on prevention and early intervention, the County's mission is to assist and support the
In-Home Supportive Services (IHSS) staff to authorize and provide services in a uniform and
accurate manner, while monitoring program delivery to detect and prevent fraud. One of the
County's primary focuses is to ensure that the IHSS recipient's needs are accurately assessed, and
services delivered at a level that allows them to remain safely at home.
As HSA continues to administer IHSS services, elderly and disabled individuals retain the
opportunity to remain securely in their homes. Without these vital IHSS services, recipients
requiring considerable care, would otherwise be at risk of placement in a higher cost institutional
setting.
As with all publicly-funded programs, there exists an opportunity for fraud within IHSS. The
County takes their role as custodian of taxpayer dollars very seriously, and thus performs case
reviews to ensure compliance with program regulations; responds to data claims matches indicating
potential overpayments; implements procedures to identify third party liability; monitors the
program to detect and prevent fraud; conducts joint reviews with State staff; detects error trends;
identifies staff training needs; and participates in activities to ensure program integrity.
IHSS relies strongly on application information and statements by program recipient's and service
providers, and misrepresentations contained in that information could foster fraud. Fraud may be
indicated or demonstrated by the recipient, the provider (IP), or in very rare cases, the social
worker. Individual and collusive acts to secure an undue benefit(s) are constant threats to the
integrity of the IHSS program.
In support of existing QA and fraud prevention activities, the County developed, and is currently
using an IHSS QA computerized program named "Pegasus." Pegasus software is designed to
randomly select cases for QA review, and it also enables the use of laptop computers to conduct
field reviews. The Case Management Information and Payroll System (CMIPS) downloads
information that is utilized to pre-fill a portion of the field and desk review form, such as the
recipient's name, aid code, and case number which must also be checked and verified by the QA
social worker. Once the QA social worker has completed both reviews, this information is
automatically filled into the summary, which writes to a database to track trends.
San Joaquin County -4- July 1,2010
In addition, the IHSS Program Manager reviews data to identify trends in any facet of service
authorization that appears to deviate from the remainder of the data. This data review is used to
detect trends or anomalies within a caseload, determine if further staff training is required, or if an
investigation for potential fraud should occur. Random surveys of recipients and IPs are also
conducted on a monthly basis, for social worker performance, to ensure that home visits are
conducted, and cases are processed appropriately.
The utilization of randomized case selection, coupled with focused reviews, provides a broad-based,
multi-pronged approach to identifying over/under payment issues and fraud. These efforts to ensure
accurate assessment of needs and the delivery of necessary services result in equitable service
delivery to our recipients, while effectively safeguarding public funds. It also provides for strong
internal control to detect both fraud and issues which require focused training for individual social
workers. The random selection of cases by a computerized system eliminates the ability of staff to
control cases selected for review, or the staff person who will conduct the review.
San Joaquin County -5- July 1,2010
Current Anti-Fraud Activities
The County's Fraud Unit (the Unit) is comprised of an HSA QA Staff Analyst II, an IHSS Social
Worker III, the IHSS Program Manager, a Department of Health Care Services Investigator, one
San Joaquin County District Attorney Investigator (DAI), one District Attorney Investigative
Assistant (DAIA), and a Senior Office Assistant (SOA).
The Unit has been very pro-active in detecting and referring suspected fraud for further
investigation and prosecution. The strong collaborative relationships between the Department of
Healthcare Services (DHCS) and the County's District Attorney's Office (DAO) are but one
example of the dedication to minimize, if not eliminate, fraud- within the program. The Unit has
continued to perform data-mining activities; has consulted with other counties regarding best
practices; has consulted with the California Department of Social Services (CDSS) for clarification
and guidance as needed; and continues to train all staff on fraud detection methods.
Even with preventative activities, fraud does occur. Most potential fraud referrals are received from
IHSS social workers, QA staff, other HSA staff, and outside agencies or community members.
When the referral is received, the suspected fraud could involve the recipient, the IP, or both. Once
a report of suspected fraud is received, the following activities occur:
• All suspected fraud is forwarded to the Unit's QA Staff Analyst II
• Department of Health Care Services (DHCS) fraud file is created
• Print outs of all the relevant CMIPs screens (RELA, RELB, RELC, and PELG) are obtained
and placed in the file
• The MC 609, Corifidential Medi-Cal Complaint Report is created
• Information on the alleged suspect is compared to those receiving any additional aid (Cash,
Food Stamps, Medi-Cal) and MEDS
• If the alleged fraud is against the IP, and the IP has not reported their IHSS income to their
Eligibility Worker (EW), the EW is alerted and provided with copies of the IP's IHSS
income verification for a possible AFDC/FS overpayment/over-issuance
• Timesheets and cancelled warrants relevant to the investigation are gathered by the Unit's
SOA
• The IHSS case is retrieved from the social worker, or storage, if case is closed. Copies of
the written case comments and the following forms are obtained:
1. SJ 415 - Acknowledgement of Explanation of Rights and Responsibilities and
Consent to Release Information
2. SOC 295 - Application for Social Services
3. SJ 190 - Voter Application form
4. SOC 426 - Personal Care Services Program Provider/Enrollment Agreement
5. SOC 846 and SOC 332
6. Copies of the IP's photo identification and Social Security card
San Joaquin County -6- July 1,2010
If the fraud referral involves an IHSS overpayment, such as from a hospitalization or a recipient
death, copies ofHSA's overpayment cover letter; the SJ 135 - Overpayment/Repayment Agreement;
copies of the timesheets; and a copy ofthe overpayment calculation sheet are also included.
Findings are recorded and analyzed by the QA Staff Analyst III, and subsequently by the social
worker, supervisor, and/or Program Manager as necessary or appropriate. Once the preliminary
review is completed, a determination is made regarding the next steps to resolve the anomalous
findings. These steps could involve additional education/training of the social worker; further
investigation or interviews with the recipient or IP; training/education of the recipient or IP; request
for restitution of overpayments; or referral for fraud investigation through DHCS, in cooperation
with the local DAD. A copy of the DHCS referral is maintained, with a copy to the IHSS case file.
All the fraud/overpayment information/data is entered onto an Excel spreadsheet to facilitate
tracking and status of each case. Fraud referrals are sealed, and maintained in a secure location.
During the monthly Unit meeting, the DHCS and the DAD staff, determine which agency will take
primary (lead) investigation duties. Both agencies work collaboratively and report all findings back
to the Unit. Copies of the completed investigation and the Complaint Acknowledgement/Status
Report showing whether a violation, criminal filing, etc., has occurred, is provided and maintained
in the file. Any restitution is then referred to the County's Revenue and Recovery Division (R &
R), and tracked on the same spreadsheet until payment has been made in full.
The County will continue to monitor the program internally, to prevent fraud from the program
level, as well as monitor for fraud through the recipient, IP, or any combination thereof.
San Joaquin County -7- July 1,2010
Proposed Anti-Fraud Activities
With the augmented funding, the County will continue to seek new means of monitoring and
preventing fraud. Much was learned from the first months of collaboration - HSA has learned from
the investigators, better investigative questioning techniques; while the investigators began to
understand the intricacies and challenges of the program. Already, this collaboration has succeeded
in many joint investigations. With continued funding for the DAI and a DAIA, the County will be
able to pursue fraud investigations to a point that was not previously possible with only one DHCS
investigator, and the limited IHSS staff. These investigations will include, but not be limited to:
• Protective Supervision cases that lack mandated supervision is suspected
• Functional limitation claims that are suspected to be overstated by the recipient
• Living situations that are suspected to be falsely reported
• Unreported changes in household composition
• Recipient demanding IP share their check
• IP demanding additional payments from the recipient
• Verification of IP performance of services claimed on the timesheet
• Misrepresentation of income
The plan will include unannounced visits by either the social worker, DAI, DAIA, or a combination
of these professionals; surveillance of residences, recipients, and IP's; filing for liens to collect
restitution; increased and detailed focus on review of timesheets; increased review of warrants
issued for payment; increased data collection; and ultimately, increased prosecution and restitution.
The DAO DAI will be fully dedicated to review and investigate fraud within IHSS. This
investigator class works more independently, and possesses the skills to locate, identify, assemble,
preserve, record, and evaluate information and facts related to fraud. This investigator will be
integral to the success of the IHSS quality and integrity efforts, with a strong focus on the
prevention and detection of fraud.
Complex investigations of fraud by a DAI dictate a range of activities, contacts, and evidence
gathering. As such, complete and effective criminal investigations and duties may include:
• Preparation and execution of search warrant(s)
• Physical arrests
• Testifying at trial as to facts
• Unannounced home visits
• Observations to determine if services are actually being provided
• Canvassing/contact in the recipients' neighborhood
• Surveillance of recipients and/or IP activities
• Review of bank reconciliation records
San Joaquin County -8- July 1,2010
• Review/update recipient assets
• Review of fmancial documents to expose unreported income
• Review of vehicle registrations
• Review ofIP's past and current work history
• Review of criminal histories
• Check of calendared appointments
• Conduct interviews with recipients, IPs, family, associates, and acquaintances
• Consider any evidence of non-compliance with regulatory guidelines
The DAIA will be dedicated to performing, under general supervision, the routine technical and
investigative work in support of IHSS investigations. Those tasks may include, but not be limited
to: locating witnesses; maintaining records or reports; preparing documents requesting financial
data records research; and other support activities. This position will afford the DAI the support
necessary to conduct complete and effective investigations.
The IHSS Program Manager, QA Staff Analyst II, Social Worker III, DAI and DAIA will meet on a
regular basis to ensure rapid action, progress, and coordination for the County's focus on the
prevention and detection of fraud within IHSS. Through coordination with the DAO, internal
investigation of potential fraud within the County or program staff will be strengthened via third
party reviews.
Unannounced home visits will be conducted by both DAO and the Social Worker III as determined
through joint consultation. Conducting these visits is an effective tool to confirm the delivery of
services, as well as compliance with regulations by recipients and IPs.
Traditional surveillance and evidence gathering tools, such as digital still, and video cameras, will
continue to be utilized to record the activities of recipients suspected of over-reporting their level of
disability; the presence/absence of 24-hour services for Protective Supervision cases; and digital
voice recorders for memorializing statements made by recipients and IPs.
To optimize coordination and knowledge between the social services and DAO staff, cross training
has, and will continue to occur. The DAO provides focused training on evidentiary documentation
and field safety, etc., and HSA continues to provide focused training on functional impairment;
functional limitations of certain disabilities/diagnoses, and IHSS regulations, etc.
HSA has also worked closely with the County's Public Health Department, and continues to
interface with their database to identify recipient deaths more quickly. This allows the case carrying
social workers to discontinue and/or terminate cases promptly, in efforts to prevent overpayments to
an IP before they can occur. While overpayments will still occur; however, those resulting from a
delay in reporting the death of a recipient, will be significantly reduced.
Presently, we are in the early stages of developing a training and outreach program which will target
Physicians within the County. The purpose of this activity is to educate those responsible for
supplying medical information and medical opinions utilized by the social workers to determine
San Joaquin County -9- July 1,2010
recipient eligibility. This training and outreach program will cover the definitions of functional
impairment and abilities as they relate to the regulations, purpose, and limits ofthe IHSS program.
The State, County, and the IHSS program will benefit from the success of IHSS integrity and fraud
prevention. Overpayments will be recovered; misuse of benefits prevented or detected; non-
compliance issues identified; and internal program integrity preserved. Locally, both the DAO and
HSA are committed to the success of the Fraud Prevention and Investigation Program.
San Joaquin County - 10- July 1,2010
County Proposed Budget for Utilization of Funds
Budget Justification
San Joaquin County's Fraud Funding Plan for FY 2010-11
Budget Section Total
A. Personnel Costs (includes employee benefits) $157,640
B. Operating Expenses $ 5,310
C. Equipment Expenses $0
D. Travel/Per Diem and Training $10,000
1
E. Subcontracts and Consultants $ 245,019
F. Other Costs $4,813
G. Indirect Expenses $ 3,801
Total Expenses I S 426.,583
1
A. Personnel Costs (including employee benefits) Total Budget
Title: Social Worker III $ 92,430
=
Salary Calculation: $2,303.20 x 26 pay periods $59,883 in salaries, parking ($442), UI at
0.3% ($180), Retirement 26% ($15,570), Social Security 6.2% ($3,713), Medicare 1.45%
($868), Life Insurance ($42), Health Ins ($11,050), Dental ($611), Vision ($71)
Duties Description: Social Worker position will perform initial fraud detection, including
unannounced visits, review of timesheets, signatures, and other documents. Coordinate with
San Joaquin County - II - July 1,2010
law enforcement, District Attorney, and other professional staff.
Title: Sr. Office Assistant $ 65,210
Salary Calculation: $1,521.60 x 26 pay periods = $39,562 in salaries, parking ($442), UI at
0.3% ($119), Retirement 26% ($10,286), Social Security 6.2% ($2,453), Medicare 1.45%
($574), Life Insurance ($42), Health Ins ($11,050), Dental ($611), Vision ($71)
Duties Description: Provide assistance in the duties performed by the Social Worker,
including data and document collection, copying, mailing, delivery, and other office support
functions.
Total Personnel Costs: $157,640
B. Operating Expenses Total Budget
Title: Office Supplies & Expenses $1,550
Description: Includes Office Supplies, Printing & Binding, Copier Rental, and Postage
Title: Space Costs & Communications $ 3,760
Description: Space, utilities, maintenance, phone bills and related expenses
Total Operating Expenses: $ 5,310
C. Equipment Expenses Total Budget
Title: $
Description:
San Joaquin County - 12 - July 1,2010
Title: $
Description:
Title: $
Description:
Total Equipment Expenses: $
D. Travel/Per Diem and Training Total Budget
Title: TransportationlTravel/Mileage/Motorpool $10,000
Description: Transportation, Travel, Training, and Motorpool costs related to fraud
prevention activities.
Title: $
Description:
Title: $
Description:
Total Travel/Per Diem and Training: $10,000
E. Subcontracts and Consultants Total Budget
Title: Professional Services - District Attorney Costs $243,556
Description: One District Attorney Investigator and One District Attorney Investigative
Asst., both dedicated to IHSS Fraud Prevention, plus related operational expenses
Title: Professional Services $1,463
San Joaquin County - 13 - July 1,2010
Description: Information Systems staff and other professional services from other
County Departments and/or outside resources
Title: $
Description:
Total Subcontracts and Consultants: $ 245,019
F. Other Costs Total Budget
Title: Data Processing Charges $ 2,074
Description: Cost for County financial and data processing systems
Title: Workers Compensation Insurance $ 2,378
Description: Distributed cost of Workers Compensation Insurance
Title: Casualty Insurance $ 361
Description: Distributed cost of Casualty Insurance
Total Other Costs: $ 4,813
I
G. Indirect Expenses Total Budget I
San Joaquin County - 14- July 1, 2010
Title: County Indirect Charges (A-87) $ 3,801
Description: Indirect allocated expenses related to County Counsel, Human Resources,
County Administrator's Office, etc.
Title: $
Description:
Total Other Costs: $ 3,801
San Joaquin County - 15 - July 1,2010
Collaboration and Partnership with the District Attorney's Office
HSA and the District Attorney's Office (DAO) have a long-standing relationship involving fraud
prevention and investigation. Based on this history, and the positive results obtained, there is an
expectation of continued success. HSA and the DAO have collaborated successfully in areas of
Elder Abuse/Neglect; Child Abuse/Neglect; and Medi-Cal fraud. Individuals benefitting from
varied aid or support services are often crossover clientele. This fact becomes more significant
when data and resources are shared with crossover agencies to provide better information and the
determination of appropriate services.
HSA and the DAO envision a system of shared information that will offer assistance to those who
are most in need. IHSS will be part of a responsive effort with other County teams to accomplish
the task of preventing fraud before it has the chance to occur, and investigating fraud aggressively
when it is identified. The end result will be a system that delivers efficient and appropriate services,
with the ultimate goal being the elimination of fraud.
HSA will continue to focus on the prevention of fraud through the continued training of staff,
elimination of opportunities for fraud, strong internal program reviews, and focus on the delivery
and of quality services to seniors and people with disabilities. The DAO will continue its aggressive
review of suspected fraud cases, conduct subsequent investigations which use effective tools and
deductive processes to produce conclusive facts. The focus of the DAO remains to successfully
prosecute those responsible for fraud, and to anticipate judgments with penalties, fines, and the
restitution of funds.
The mission statement of the DAO has been constant: "A commitment to service the County
responsibly by prosecuting criminal acts aggressively and fairly." The mission statement of HSA
continues to be: "To lead in the creation and delivery of services that improve the quality of life for
our community." Together, these missions commit to ensuring that those in need, receive the
services that support their optimum independence, while preventing those who seek to take
advantage of taxpayer funds through fraud, are aggressively and fairly prosecuted.
The DAO will be dedicating a full-time District Attorney Investigator II (DAI) and a full-time
District Attorney Investigative Assistant (DAIA) to investigate IHSS fraud. In addition, HSA will
be dedicating a full-time Social Worker III and a Senior Office Assistant to collaborate and
coordinate with the DAO staff.
HSA will conduct the initial fraud detection activities that have proven to be successful, including
but not limited to: data-mining; case record review; education/training of social workers, recipients
or IP's; pulling of timesheets; examination of signatures; and staffing of anomalous data or findings.
San Joaquin County - 16 - July 1,2010
In addition, the DAO will review the current practices, and provide suggestions and input to
enhance the current methodologies in place. Case discussions will be held on a monthly basis to:
• Identify and discuss potential fraud cases
• Provide inter-disciplinary updates on current activities
• Provide status of investigations underway
• Consult regarding alternative methods of investigation/data-mining that would improve
efficiency and efficacy
• Track and report outcomes of investigations that have led to prosecution
• Track status of existing, completed, and pending prosecution
• Ensure convicted IPs are placed on the Medi-Cal Suspended and Ineligible Provider List
HSA, the DAO, and the DHCS have held joint conversations regarding the processes by which local
cases with suspected fraud will be handled. At present, IHSS will continue to forward all fraud
referrals to the DHCS as required by regulation. The DHCS will then work collaboratively with
both HSA and the DAO to refer/assign specific cases for local investigation and follow-up. A
strong commitment exists with all parties to coordinate efforts, and foster effective collaboration to
address fraud investigation and prosecution processes.
San Joaquin County - 17 - July 1,2010
Fraud Referrals/Outcomes
Currently, all instances of alleged fraud, including overpayments, are referred for initial review by
the case carrying social worker and their supervisor. This first level review is for the purpose of
determining if an over/under payment has occurred, and what action should be taken to resolve the
issue. A component of this initial review is to determine if the error occurred due to lack of
information/education on the part of the recipient and/or IP, or if there is evidence that fraud has
occurred.
Fraud referrals have been made in the areas of Grand Theft; Conspiracy; Forgery; Health Care
Fraud; Making FalselFraudulent Claims; Presentation of Fraudulent Claims; and Perjury. As
outlined in Attachment D, the County has successfully identified and referred for prosecution, a
large number of suspected fraud cases.
One area of concern is that due to the fact that the DHCS, and periodically the Department of
Justice (DOJ), file charges and pursue the case(s). Oftentimes, the County is not notified of the
actual filing date(s), and the subsequent status and outcomes. It is the intent of the County, through
increased coordination with the DAO, to track this case-specific data with weekly updates.
HSA is also proactive in regards to preventing social worker or other staff fraud, through random
case record checks by supervisors, QA staff, and/or the IHSS Program Manager. As previously
mentioned, this is accomplished through random case reviews selected by Pegasus. This
methodology reduces the potential for specific cases to be protected from review. This protocol also
assists in the detection of training needs for specific social workers, as well as for topics or
assessment errors that require training of multiple social workers.
The County has had multiple fraud referrals to the DHCS resulting in convictions and restitution
being ordered. Restitution is currently being received, and in some cases, restitution has been agreed
upon and paid prior to court appearances, which is also reported to the court.
During the last year, the Unit identified 253 cases of overpayments totaling $180,233.84, in which
$21,117.73 has been recovered to date. Sixty-five (65) of those cases were referred for fraud, and
64 remain as open and pending investigations. Thirty-five (35) cases that were filed with the DAO,
including those from prior fiscal years, remain open and pending investigations, or court
appearances. The nature of the court system is such that cases span multiple years from initiation to
determination; and likewise with the County's R & R system, where repayments are often received
in small, monthly increments and require several years before full payment is received.
San Joaquin County - 18 - July 1,2010
IHSS Overpayments/Underpayments
The County monitors multiple data sources, and networks with other agencies to prevent, detect,
and follow-up on overpayments and underpayments. At present, the following areas are monitored
on an ongoing basis:
• Income Eligibility Verification System (IEVS)
• State Meds Alerts
• Newsprint obituaries
• San Joaquin County Sheriffs Office website - "Who's in Custody"
• Case Management Information and Payroll System (CMIPS) Data for Data Anomalies
• Interface with the Office of Vital Records
• Inter-/Intra- Agency Networking
- Social Security Administration - Liaison and Fraud Division
- Cal-Works
- Medi-Cal
- Medi-Cal Long Term Care
• EDS Reports
- 300 Hour Report
- Death Match
- Long-Term Care Alerts
In working the issues or concerns identified through the State reports for hospitalization(s)/moved
out of state, the following steps are taken by the QA Staff Analyst II:
• Case is retrieved from the case carrying social worker or requested from storage if the case
is closed
• CMIPS data is reviewed
• Timesheets are retrieved by the Unit SOA
• Comparison of the IHSS case file and hours reported on the timesheets to the
hospitalization(s) dates, or the move out of state effective date
• If an overpayment is identified, the Overpayment Recovery Process is implemented.
Overpayment Recovery Process: HSA has determined that most potential overpayments result
from a recipient's hospitalization(s), the recipient's death, and/or IP terminations. Case record
information is compared with the hours reported on the timesheets, and if the IP reported, and is
paid for hours for which they were not entitled, the following occurs:
• An overpayment file is created with the same information as outlined under the current
Anti-Fraud Activities (Page 4) for the DHCS referral
• Case comments regarding the overpayment are entered into the case file
San Joaquin County - 19- July 1,2010
• A request is made to the Unit's SOA to compute an overpayment
• Upon completion of the overpayment calculation, the recipient or IP is sent the following:
1. The County's overpayment cover letter;
2. SJ 135 - Overpayment/Repayment Agreement
3. Copies of the respective timesheets involved
4. Copy of the overpayment calculation
A copy of the overpayment packet is placed in the overpayment file, with a copy to the IHSS case
file. All overpayment information/data is entered onto an Access spreadsheet to facilitate tracking
of the overpayment cases. If the overpayment exceeds $999.00, it is also referred to the DHCS
Investigator as detailed above.
If/when the recipient or IP signs the OverpaymentlRepayment Agreement, they either: 1) send the
repayment in full, 2) provide a partial payment with a schedule for subsequent payments, or 3)
authorize the county to do an IHSS payroll deduction. This information is updated on the Access
spreadsheet; a copy is placed in the overpayment file and the IHSS case file; and the original is
provided to the CMIPs/Fiscal Unit for processing and payment tracking. Should the recipient or IP
refuse to sign a repayment agreement, or remit payment, they are referred to the County's R & R for
collection of the overpayment.
As noted in Enclosure D, and to the extent possible, the County has been extremely pro-active in
identifying and pursuing overpayments/underpayments. In addition, the County participated in the
Data Match Study for Hospital Stays that was conducted in 2006, and again in 2009. The County
has requested from CDSS Quality Assurance, that the County be provided with this data match on a
regular basis, as the process has been productive not only in recovering funds, but in educating
recipients and IP's as to the legality of submitting timesheets during the recipient's hospital stay(s).
We are prepared to implement the Hospital Stays component as soon as issues and concerns related
to the implementation are resolved at the State level.
The County's R & R is being utilized to collect judgments with penalties, fines, and the restitution
of funds determined and ordered through the court process. The coordination between the three
County departments (HSA, DAO, and R & R) provides an efficient, cost-effective process to
identify, investigate, and prosecute fraud, as well recover funds obtained fraudulently.
While every effort is made to prevent underpayments, periodically they do occur. When this is
discovered or reported, the case carrying social worker, in conjunction with their supervisor,
determines the amount of additional payment which is owed. The case carrying social worker
requests appropriate documentation (affidavit from the recipient, timesheets, original application,
etc.), and are reviewed to substantiate the need for additional payment.
Once the underpayment amount is determined, and discussions with the respective parties involved
has occurred, supplemental timesheets are issued. The case carrying social worker documents the
cause of the underpayment in the case record, as well as the remedy which was agreed upon.
San Joaquin County - 20- July 1,2010
Collaboration and Partnerships with Department of Health Care
Services (DHCS) and the California Department of Social
Services (CDSS)
San Joaquin County has referred suspected fraud cases to the Department of Health Care Services
(DHCS) since the inception of our local QA program. At present, a strong collaborative working
relationship has been established between the staff of DHCS and HSA. Currently, a DHCS
investigator confers with QA staff on a weekly basis to receive new referrals, obtain additional
information, and provide an update on existing cases. This DHCS investigator also confers with the
IHSS Program Manager on complex cases, or as needed. The collaborative working relationship
has also resulted in joint meetings between IHSS social workers, recipients, and IP's based on case
needs.
HSA staff also works closely with CDSS staff to clarify regulations, laws, and requirements on an
as-needed basis. The collaborative efforts put forth thus far by County staff, DHCS, and CDSS will
continue to enhance our ability to identify, investigate, prosecute and obtain restitution for IHSS-
related fraud. The County will continue to put safeguards in place to minimize, if not eliminate, the
opportunity for fraud within the IHSS program.
The County will maintain a tracking log that will indicate, at a minimum, as applicable:
• Case demographic/description information
• Summary of suspected fraud
• Current status of investigation/prosecution
• Current lead (agency/individual)
• Pending action
• Court jurisdiction
• Current disposition
• Final disposition
• Restitution determination
• Restitution status/tracking
• Conviction status/term/location
Other data elements will also be gathered as deemed necessary and/or appropriate by County or
State agencies.
San Joaquin County - 21 - July 1,2010
Mechanism for Tracking/Reporting
The County will continue to track case-specific data with all the elements that we currently
anticipate will be advantageous to future information requests, and those required by CDSS. The
County will accurately and fully track all necessary data, and has the ability to submit that data in a
format that will meet CDSS requirements. We encourage CDSS to continue to work collaboratively
with other counties to implement a data collection system that will accurately reflect activities and
outcomes in a uniform, objective, and statistically relevant manner.
As planning for fraud prevention and intervention activities is an ongoing process, we will have the
ability to submit Fraud Prevention & Intervention plans to CDSS on an annual basis, no later than
June I st of each year. The plan will include a summation of activities for the preceding year, as well
as any relevant updates for the upcoming year.
San Joaquin County - 22- July 1,2010
Annual Outcomes Report
By submission of this plan, San Joaquin County commits to the submission of an Annual Outcome
Report by August 1st of each fiscal year. This report will detail activities and data reflective of the
activities that have occurred related to fraud detection, investigation, intervention, and prosecution.
While no information is currently forthcoming regarding the specific format or details that the State
desires in this annual report, the County is confident that it will be in full compliance with the
requirements.
The County will continue to track case-specific data with all elements that we currently anticipate
will be required by CDSS. The County is confident that it will accurately and fully track all
necessary data, and has the ability to submit that data in a format that will meet CDSS requirements,
as we already gather and track a substantial amount of information. We encourage CDSS to
continue to work collaboratively with other counties to implement a data collection system that will
accurately reflect activities and outcomes in a uniform, objective, and statistically relevant manner.
As previously stated, the County will commit to tracking, reporting, and submitting final data
reports to CDSS for the previous fiscal year by August 1st, of each subsequent year.
San Joaquin County - 23- July 1,2010
HSA
HUMAN
SERVICES
AGENCY
SAN JOAQUIN COUNTY JOSEPH E. CHELLI
Director
P.O. Box 201056 102 South San Joaquin Street Stockton. CA 95201·3006
Tel (209) 468 -1000
Fax (209) 468 -1985
Co/WORKs
Head Start
First 5 San Joaquin
Children's Services
Aging and Community Services
Mary Graham Children's She/ter
August 23,2010
Debie Scherer, Analyst
QA Monitoring Unit, CDSS. APB
744 P Street, MS 19-95
Sacramento, CA 95814
RE: SUBMISSION OF SAN JOAQUIN COUNTY'S IHSS FRAUD INVESTIGATION AND
PROGRAM INTEGRITY PLAN FOR FY 2010-11
Dear Ms. Scherer:
Attached please fmd San Joaquin County's IHSS Fraud Investigation and Program Integrity Plan for FY
2010-11, which was approved and signed by our Board of Supervisors on August 10,2010, and one (1)
Board Resolution.
If you require any additional information or have any questions, please feel free to contract Donna
Anderson, Division Chief, Department of Aging and Community Services at (209) 468-0982.
sGt~·
JOSEPH E. CHELLI
Director
San Joaquin County
Human Services Agency
Attachments
Our lIisdon is to lead in the
mation and delivery of services that implllve
the quality of life for our conununity.
