PACE organizations are regulated by the Centers for Medicare and Medicaid Services (CMS), NC Division of Health Benefits (DHB), NC Adult Day Health and Randolph County Department of Social Services. The audit process and findings for 2018 are noted in this document.
Upon receipt of the audit engagement letter, the PACE organization has 20 days to submit seven templates of six months of data for participant appeals, participant grievances, personnel of the organization, participant medical records data, organization’s on call documentation, participant service delivery requests and the organization’s quality program and initiatives.
The PACE audit process is a two week audit (one week consists of an offsite audit of the submitted templates, then the second week consists of an onsite audit) of the PACE organization. The PACE organization is audited by both CMS representatives (3-4 representatives) and the NCDHB, North Carolina Division of Health Benefits, representatives (2-3 representatives). The first week of audit consists of the PACE organization providing a presentation to CMS and DHB via a formal presentation by webinar. This presentation includes the vision and mission of the organization, the PACE organization’s staffing model in addition to the PACE organization’s model to provide exceptional care to the participants. CMS and DHB completes week one auditing by perform testing of participant cases using submitted data via a tracer methodology. The second week of the PACE audit consists of CMS and DHB testing of the data provided by onsite observations (participant home visits, skilled nursing facility visits, observation of the transport of participants, clinical participant care provided by MD/NP/RNs, and participant interviews).
At the conclusion of the PACE two-week audit, CMS/DHB provide an exit conference with PACE leadership regarding any findings of the PACE organization’s audit. The CMS onsite audit representatives then submit all information to the PACT (PACE Audit Consistency Team) which completes an audit of the overall PACE organization’s audit to ensure consistency in auditing across PACE organizations.
Once all audits are completed, CMS will compile audit results and publish results for all PACE organizations.
Randolph Health StayWell Senior Care’s audit results for 2018, published in March 2020, noted of 120 PACE organizations Randolph Health StayWell Senior Care was ranked second based on the final audit score of 0.4, zero is the lowest score attainable in the auditing of the PACE organizations.