Nizhoni Community Care LLC
April 18, 2017 · Read the full official report (PDF) ↗
Published April 18, 2017 Audit covers July 1, 2011 – June 30, 2016 Under Suzanne M. Bump · 2011–2023
source
“Our audit revealed no significant instances of noncompliance that must be reported under generally accepted government auditing standards.”
Read the plain-English breakdown
This is a state performance audit of Nizhoni Community Care, a private company that provided group adult foster care services paid mostly by MassHealth.
“Nizhoni Community Care LLC (NCC) was established in 2010 as a private for-profit human-service agency.”
The auditor reviewed whether Nizhoni followed the rules for its group adult foster care program and checked its MassHealth claims.
“The purpose of this audit was to determine whether NCC administered its GAFC program in accordance with applicable regulations and contractual requirements.”
This matters because MassHealth spent a very large amount on adult foster care and group adult foster care during the five-year period reviewed.
“MassHealth paid providers approximately $1.4 billion for adult foster care (AFC) and GAFC during the audit period.”
For an ordinary taxpayer or MassHealth member, the key issue is whether public healthcare dollars are paying only for allowed services and whether the state could save money without cutting needed care.
“This audit was conducted as part of OSA’s ongoing efforts to audit human-service contracting activity by state agencies and to promote accountability, transparency, and cost-effectiveness in state contracting.”
The auditor concluded Nizhoni’s program administration was generally proper, but pointed readers to additional concerns in the report.
“Did NCC properly administer its group adult foster care (GAFC) program?”
At the time of the report, MassHealth said it planned to issue GAFC regulations and clarify when services would be considered duplicates.
“Finally, MassHealth stated that in fall 2017, it will put forth regulations governing the GAFC program and “will clarify when GAFC services do not duplicate other services a member is receiving.””
The largest concern was that MassHealth may have paid Nizhoni up to $7.8 million for services the auditor considered duplicative and not allowable.
“During the audit period, Nizhoni Community Care LLC (NCC) billed, and received payments totaling as much as $7,821,600 from MassHealth, for group adult foster care (GAFC) services that were duplicative and therefore not allowable under MassHealth regulations.”
ADLs are basic daily tasks like eating, using the bathroom, dressing, bathing, and walking; IADLs are related support tasks like laundry, shopping, cleaning, meals, transportation, and medication management.
“ADLs include activities such as eating, toileting, dressing, bathing, and walking.”
4 figure(s) pending source verification - not shown
What the Auditor checked
- Complied Did NCC properly administer its group adult foster care (GAFC) program?
What the Auditor found
Why it matters: MassHealth may have paid as much as $7,821,600 for services that were duplicative and not allowable under applicable regulations.
Standard: Section 408.437 of Title 130 of the Code of Massachusetts Regulations; 651 CMR 3.01(2); Group Adult Foster Care Guidelines requiring compliance with Adult Foster Care Program regulations. ( Section 408.437 of Title 130 of the Code of Massachusetts Regulations; 651 CMR 3.01(2); 130 CMR 408.402; 130 CMR 408.415(B) )
1 recommendation
- NCC should collaborate with MassHealth to determine whether MassHealth intends to stop paying for duplicative services.agency: disagreed
Agency response & Auditor reply
Agency: "OSA's determination that Nizhoni was paid for duplicative services appears to be based on a misreading of the applicable regulations."
Auditor: "Although we agree that MassHealth’s regulations allow people in GAFC to receive skilled nursing, we do not agree that they allow it to be provided through a separate program such as the Home Health Services Program."
Why it matters: MassHealth could potentially realize significant savings by using certified nursing assistants certified in medication management instead of paying visiting nurse associations for medication management.
Standard: 105 CMR 700.003(F)(2); Executive Office of Health and Human Services MAP Policy Manual. ( 105 CMR 700.003(F)(2) )
1 recommendation
- MassHealth should investigate whether certified nursing assistants certified in medication management could provide medication management to GAFC members at lower cost.
Agency response & Auditor reply
Agency: "MassHealth appreciates the purpose and intent of the [OSA] recommendation for possible cost savings that might be achieved through a change in the design of the GAFC program."
Auditor: "However, our analysis involved using CNAs who are, by virtue of their training, already certified in medication management to provide both home health and medication management services."