The Centers for Medicare and Medicaid (CMS) have announced enforcement actions against two Medicare Advantage Program for All-Inclusive Care for the Elderly (PACE) contractors. Both Silver Star Health Network in Lubbock, TX, and Alexian Brothers Community Services in St. Louis, MO, received civil monetary penalties of $25,000 each for non-compliance of Medicare regulations. Formal letters notifying the Medicare Advantage Plans of the penalty were sent out August 1, 2013.
PACE is a special Medicare Advantage program established to serve the needs of individuals with chronic medical conditions in a community setting. Usually the Medicare beneficiary involved in a PACE program is also enrolled in their respective state’s Medicaid program. Medicare reimburses the Medicare Advantage plan contractors several thousand dollars a month to provide complete medical care in a community setting.
Because individuals enrolled in these plans don’t necessarily have the means or access to file a grievance for problems with their medical care, CMS auditors will visit the communities to make sure the Medicare Advantage plans are complying with the PACE program. The PACE programs received the following information regarding their violations in letters from CMS
Alexian Brothers Community Services,
Ms. Beverly White
Interim Chief Executive Officer
CMS has determined that Alexian failed substantially to provide its participants with medically necessary items and services that are PACE covered services and such failure has adversely affected (or had the substantial likelihood of adversely affecting) the participants.
Summary of Noncompliance
CMS and state regulators have been on site at Alexian three (3) times for monitoring visits/audits since May of 2012. These audits were conducted to determine if Alexian is in compliance with PACE regulations and guidelines.
CMS has determined that Alexian failed to monitor or assess the medical needs of Medicare and Medicaid enrollees, failed to develop and implement a patient care plan that met the needs of each participant’s medical requirements and failed to maintain a single comprehensive medical record for each participant. Alexian’s failures violate CMS requirements contained at §§ 1894 and 1934 of the Social Security Act; 42 C.F.R. Part 460, 130 Subparts E, F and L.
The CMS report included specific instances where Alexian failed to comply with program regulations.
Noted deficiencies include, participants diagnosed with diabetes not receiving HgA1C
blood sugar monitoring, or micro albumin urine testing, participants diagnosed with
asthma or chronic obstructive pulmonary disease (COPD) not being provided lung
function or blood oxygen saturation tests, and in one (1) instance a patient experienced
significant weight loss (25 pounds) in three (3) weeks and was not assessed by the
Primary Care Physician for proper treatment.
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Silver Star Health Network,
Ms. Cathy Pope Chief Executive Officer
CMS has determined that Silver Star failed substantially to provide its participants with medically necessary items and services that are PACE covered services and such failure has adversely affected (or had the substantial likelihood of adversely affecting) the participants.
Summary of Noncompliance
CMS conducted a total of five (5) monitoring visits/audits from December 2010 through April 2013. These audits were conducted to determine if Silver Star is in compliance with PACE regulations and guidelines.
CMS determined that Silver Star failed to implement an adequate infection control plan, failed to ensure a safe and sanitary environment, failed to have required and properly trained personnel, and failed to properly document information in medical records. Silver Star’s failures violate CMS requirements contained at §§ 1894, 1934 and of the Social Security Act; 42 C.F.R. Part 460,130 Subparts E, F, and L.
The CMS report included specific instances where Silver Star failed to comply with program regulations.
During the most recent audit, several failures were identified including improperly labeled supplies of medications, improper storage and care of medications and medical supplies and expired medications included in supplies of available medications.
Failure to implement an adequate plan to properly ensure that infections are controlled, and to take protections to limit exposure to infections in violation of 42 C.F.R. §460.74. These failures resulted in numerous PACE participants being exposed to a highly contagious, potentially deadly infection of Clostridium Difficile (C. Diff) in December 2012 and January 2013.
PACE, special medical and community care for chronically ill
PACE programs are designed to provide a range of integrated preventative, acute care, and long-term care services to manage the often complex medical, functional, and social needs of the frail elderly. Health care services are designed to meet the following objectives:
- Enhance the quality of life and autonomy for frail, older adults;
- Maximize dignity of, and respect for, older adults;
- Enable frail, older adults to live in the community as long as medically and socially feasible; and
- Preserve and support the older adult’s family unit.
PACE organizations must provide all Medicare and Medicaid covered items and services as authorized by the interdisciplinary team, as well as additional medically necessary services not covered by Medicare or Medicaid to participants in all settings. PACE organizations must establish and implement a written plan to furnish care that meets the needs of each participant including medical, health and social services that integrate acute and long term care services.
Both Silver Star and Alexian have 60 days to file a request for a hearing if they disagree with the finding of the audit that triggered the $25,000 fines. They don’t request an appeal the civil monetary penalties are due October 2, 2013 and may be deducted from Medicare’s monthly payment to them.
Download CMS letter to Alexian Brothers regarding $25,000 fine
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Download CMS letter to Silver Star regarding $25,000 fine.
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