Grand Jury Report: County-Paid In-Home Care Program (IHSS) “An Open Door for Abuse and Fraud”

IN-HOME SUPPORTIVE SERVICES: An Open Door for Abuse and Fraud

The San Diego County In-Home Supportive Services (“IHSS”) program received another scathing report from the county grand jury on 4/18/11.  Titled “IN-HOME SUPPORTIVE SERVICES: An Open Door for Abuse and Fraud“, the report recommended that the supervisors, who have been critical of IHSS, work with state lawmakers to make several changes to the program.  Those recommendations include:

  • Changing eligibility requirements to ensure recipients”clearly need” such in-home services;
  • revising rules to validate caregiver timecards;
  • form a task force to look for fraud and abuse by caregivers or anyone associated with the program;
  • and hire interns to free up time for caseworkers to pay attention to “at-risk” care recipients.

Here are the reports “facts and findings”:

FACTS AND FINDINGS

Fact: Approximately 25,000 San Diego County residents receive IHSS services; 22,000 caregivers assist them with domestic and personal care.

Fact: The County’s contribution to IHSS in 2009/2010 was approximately 17.5% or $53 million of the $305 million in taxpayer funds spent in the County for caregiver services. According to data provided by the County, costs have increased approximately 9% per year since 2000 and are unsustainable.

Fact: The majority (67%) of caregivers are family members, friends or otherwise known to the consumer.

Fact: The consumer is responsible for hiring, supervising, firing, signing the time card and otherwise serving as the employer of the caregiver.

Fact: A Public Authority manages the caregiver application process, maintains a caregiver registry, handles caregiver payroll and serves as the “employer of record” primarily for these accounting functions.

Fact: IHSS caseworkers and the Public Authority staff are prohibited by law from verifying services were delivered and validating hours worked by caregivers; the unverified data are transmitted to Sacramento and payroll checks are issued to caregivers.

Fact: An IHSS consumer may unknowingly hire a convicted felon as a caregiver who will be paid with taxpayer funds; regulations prevent the County from informing the consumer and disqualifying the provider when a criminal past is discovered during the required background check.

Fact: Temporary restraining orders filed by consumer groups and caregiver unions have prevented the full implementation of IHSS reforms passed by the legislature to control costs and prevent convicted felons from working as caregivers.

Finding 01: State and federal laws regarding the administration of the IHSS program are complex, overlap and contain many loopholes that could lead to fraud and/or abuse and prevent the County from validating that services are delivered to consumers.

Finding 02: Eligibility criteria for IHSS services are imprecise and may not be interpreted uniformly by all counties.

Finding 03: The IHSS program regulations and the enormous caseloads carried by IHSS caseworkers do not allow close monitoring of consumers and caregivers to assure services are delivered appropriately, especially to those consumers receiving the maximum care hours and funding. Such large caseloads may result in the caseworker failing to detect a consumer is being physically or financially abused and/or neglected.

Finding 04: Sheriff’s investigators do not have access to IHSS consumer records to conduct criminal investigations.

Finding 05: The County is required to seek a federal “Medicaid waiver” and state approval to implement a comprehensive, coordinated long-term care program that provides a system of care rather than uncoordinated, stand-alone programs delivering only one mode of care, such as inhome care.

Finding 06: County officials recognize the shortcomings of the IHSS model and have taken steps to improve it within the limitations permitted by state and federal law. This includes instituting the new state-mandated Public Integrity unit to prevent, detect and prosecute fraud, and ensure all caregivers completed a background check by December 31, 2010. However, the state’s failure to provide working protocols for the investigators inhibits the unit’s ability to discover or prevent fraud.

Coming on the heels of a similarly critical grand jury report in 2007, the report underscores how the program is flawed in many ways.  The 2007 report, titled SAN DIEGO COUNTY ELDER CARE PROGRAM: GOLDEN YEARS IN CRISIS, listed the following findings:

FACTS AND FINDINGS

Fact:  The In-Home Supportive Services (IHSS) department of the San Diego County Health and Human Services Agency (HHS) provides services for San Diego County senior citizens.  The program is set up to assist homebound seniors to meet their special needs.

Finding:  This program works well as long as caregivers honestly perform the functions assigned to them.

Fact:  The Public Authority provides a list of caregivers based on the needs of the elderly consumer.

Finding:  The Public Authority does background checks on potential caregivers, but only for offenses committed in California. Thus, elderly consumers are not aware of criminal activity committed in other states.

Fact:  The Public Authority does not have a program to monitor assigned duties by caregivers.  The Public Authority offers a training program for caregivers, but it is not mandatory.

Finding:  Many caregivers are deficient in their ability or desire to perform functions required by the elderly.  Many caregivers falsify hours worked, wasting taxpayer dollars. There are also language difficulties with some caregivers.

Fact:  Elderly consumers are responsible for hiring, training and supervising caregivers.

Finding:  These functions may be beyond their capabilities. Thus, consumers often don’t report abuses for fear of losing the only help that is provided for them.

Fact:  The Quality Assurance Department of IHSS monitors elder care programs, but only in terms of auditing payments to caregivers.  They do not evaluate the quality of the services rendered to the seniors.

Finding:  This leads to the potential for abuse of the quality and quantity of services provided to seniors.

The IHSS program was originally intended to provide a safety net to provide critically needed care services to persons who have virtually no assets or income.
  • Under the program, relatives or friends of the program can be hired to provide the care, and if no one like that is available, the county will provide someone but the care recipient is expected to select their caregiver from a roster maintained by the county.

In the IHSS program, the caregivers are in a particularly odd employment state, in which the clients are supposedly the employers but the payroll and the funding for the payroll all comes from state and federal funds.

  • Naturally, the state and federal governments are exempt from paying the taxes and other mandated expenses incurred by private sector employers, but the state requires the IHSS workers to join unions and therefore essentially underwrites the union dues of all the IHSS workers in the state.

The program, while well-intended, has many known issues, especially when the care is being provided by someone who is not a trustworthy relative or friend.  In theory the caregivers are supervised by county social workers, but those social workers have impossibly huge case loads and are not allowed to make unannounced inspection visits unless a complaint has first been made.  Thus, caregivers from the registry have essentially no supervision other than the supervision that their client is able (or unable) to exercise over the caregiver.

In order to work in the IHSS program, the caregivers, whether friends or relatives or from the county’s registry, must join a union and pay monthly dues.  The last time we inquired, the dues were approximately $35 per month.  That was a few years ago, so the dues may be different now.  In other counties, the IHSS caregivers must also join unions, with the particular union varying from one county to another and with the most prevalent such union being the SEIU.

Not surprisingly, organized labor in California continually pushes an agenda of expanding the IHSS program, using its political clout in Sacramento to promote agendas that would result in more IHSS workers and therefore more dues revenue for the unions.  Almost every year in the California legislature we see union-based legislative initiatives such as allowing IHSS to compete against private sector companies such as our company and charging fees for those services.

However, if that comes to pass the IHSS would be operating with the advantage of significantly lower costs because the state government exempts itself from many of the expensive and onerous requirements that it imposes on private employers in California.  Some examples include:

  • Exemption from some of the most costly provisions of the labor code that private employers are required to obey and which IHSS is free to ignore,
  • exemption from paying unemployment taxes
  • exemption from paying for workers compensation insurance,
  • exemption from income taxes on net profits,
  • as described earlier, almost no caregiver supervision at all, and therefore no significant supervision costs.

Here are links to recent news stories about this new grand jury report.

From the North County Times:  Report criticizes county’s in-home support program

From the San Diego Union Tribune:  Report: In-home services inefficient, ripe for fraud


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Tim Colling

Tim Colling is the founder and President of A Servant's Heart In-Home Care, which provided in-home caregiving services in San Diego County, and also of A Servant's Heart Geriatric Care Management, which provided
professional geriatric care management services and long term care placement services in San Diego County. Tim has more than 30 years of experience in management in a variety of industries. He held a Certified Care Manager credential from the National Academy of Certified Care Managers. Tim is also a Certified Public Accountant (retired), and received his Bachelor’s Degree in Accounting from California State University at San Diego. In addition to writing blog posts here for the Servant’s Heart blog, Tim also is a regular contributor to HealthLine.com and to FamilyAffaires.com as well as blogs of other eldercare services provider companies. Finally, Tim is also the president of A Servant's Heart Web Design and Marketing, which provides home care marketing as well as website design and online marketing for those who serve the elderly and their families.

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