ROCKY MOUNTAIN OPTIONS FOR LONG TERM CARE

Finding: Internal Control Over Compliance Criteria or Specific Requirement: The Organization is responsible for ensuring that only eligible individuals are receiving services which are federally funded. Thus, changes in eligibility determinations are to be monitored by conducting monthly case audits performed by supervisors or program managers. Condition: During our review of the client chart and provider audit information, we encountered that although management assured that case audits were performed during fiscal year 2019, there was no documentation available to support the assurance. RMO ceased operations on June 30, 2019, therefore employees from RMO were not available to provide to the necessary patient information to substantiate this assurance. Effect: The lack of supporting documentation created an inability to test the occurance of case audits throughout fiscal year 2019. If case audits were not performed, eligibility errors may have occurred resulting in the funding of services for ineligible individuals. Causes: Organization was formed to provide services under a contract with the State of Colorado. The contract ended June 30, 2019, therefore operations of RMO have ceased. The State of Colorado mandated transfer of patient records to the new contract holder, therefore management had limited access to records. Identification as a repeat finding: Not applicable. Recommendation: Not applicable as organization ceased operations. Views of Responsible Officials: The Organization agrees with the finding. See separate auditee document for planned corrective action.

Finding: Eligibility Criteria or Specific Requirement: Federal Medicaid regulations 42 CFR 435.1200 require coordination between State Medicaid Agencies (SMAs) and other insurance affordability programs, including the federal and state exchanges. Medicaid record keeping regulations at 42 CFR 435.914 and 431.17 also require states to include the basis of eligibility and facts to support the agency?s decision on an application in each applicant?s case record or electronic account, as well as require the maintenance of records that include facts essential to the determination of initial and continuing eligibility. The SMA or its designee is required to determine applicant and beneficiary eligibility in accordance with eligibility requirements defined in the approved State Plan (42 CFR 435.10). Per Single Entry Point (SEP) contract, Section 4.4, between the Organization and the Colorado State Department of Health Care Policy and Financing, the Organization shall perform all eligibility determination functions for the operation of a SEP agency in accordance with CRS 25.5-6-104 and 10 CCR 2505-10, 8.360.2 et seq. Condition: The SEP contract specifies each requirement for eligibility determination, documentation, and record keeping. During eligibility compliance testing, documentation could not be obtained, which included completed and approved eligibility determination forms. As RMO ceased operations on June 30, 2019, employees from RMO were not available to provide the necessary patient case information to properly support eligibility. Effect: The lack of supporting documentation created an inability to ensure proper eligibility. If eligibility is not properly determined, this may have resulted in the funding of services for ineligible individuals. Causes: The Organization was formed to provide services under a contract with the State of Colorado. The contract ended June 30, 2019, therefore operations of RMO have ceased. The State of Colorado mandated transfer of patient records to the new contract holder, therefore management had limited access to records. Identification as a repeat finding: Not applicable. Recommendation: Not applicable as organization ceased operations. Views of Responsible Officials: The Organization agrees with the finding. See separate auditee document for planned corrective action.