Approximately 60,000 of the over 600,000 SSI-SSP recipients in California were receiving homemaker and chore services as of December 31, 1974. The disabilities of these clients prevent them from performing household tasks and caring for some of their bodily functions. Because the disabilities vary so widely from client to client, a county social worker evaluates each client in order to authorize the proper kind and level of supportive service. For example, many clients have permanent mental infirmities due to senility or alcoholism; other clients are mentally alert but have permanent physical infirmities due to disease or accident-related disabilities ranging from minor limb impairments to total paralysis; still other clients are temporarily disabled while recovering from a disease or accident. Homemaker and chore services include, but are not limited to, the performance of household cleaning, essential shopping, cooking, laundry, and nonmedical personal care such as bowel and bladder care. These tasks are performed by homemaker and chore providers. Over 72 percent (see table 1 [p. 182]) of these providers are employed directly by the client for whom they are providing the service. Other providers work for county welfare departments and still others work for proprietary profitmaking or nonprofit corporations which contract with the counties and which provide some of the administrative services necessary to operate the program. Throughout this report we have used the term "provider" to refer to the individual workers regardless of their employment status, the term "contract agency" to refer to the proprietary and nonprofit corporations, and the term "county agency" to refer to the county welfare departments. The homemaker-chore services program is funded jointly by the Federal and State Governments with 75 percent of the costs funded from a portion of the Federal title VI (Social Security Act) allocation for social services. Federal regulations require that 25 percent of the program cost be provided by local governments to match the 75 percent Federal moneys. The State has elected to provide the 25 percent matching moneys for the homemaker-chore services program and has required the counties to provide the 25 percent matching moneys for "other" social services authorized by title VI. "Other" social services include child and adult protection services, child support, family planning, money management, employment and rehabilitation services, and county social services administration. For the 1974-75 fiscal year the State allocated to the counties a total of $65 million to pay for the delivery of homemaker and chore services. The counties used such funds to pay for the costs of their own staff providers, as well as disbursing such funds to client-employed providers and to contract agencies. At the end of the second quarter, 31 counties were expending at a rate which cause them to exceed their allocations before the end of the fiscal year. Based on a projection of the first and second quarter claims, the counties were expected to overexpend their allocation for the year by $12.2 million. In light of this, the Governor, on March 13, 1975, transferred an additional $12.4 million into the program. In addition, legislation has been enacted which appropriates another $2.7 million to the program. This amount raises the total available moneys to $80.1 million. The Homemaker-Chore Services Task Force (a joint committee of State and county staff) has concluded that $81 million will be needed by the counties to provide services at the necessary level through the 1974-75 fiscal year. The Social Security Amendments of 1974 (title XX) may require changes in the homemaker-chore services program, but until Federal regulations to implement the amendments are published, it is not possible to assess the full effect of title XX. Initial reviews of the amendments indicate that eligibility for the program may be widened and that new payment procedures may be required. Both of these changes would increase program costs to the State. However, because of their tentative nature, we did not attempt to analyze these increased costs. In the course of our review we: -Interviewed appropriate department of health personnel, --Analyzed pertinent program and fiscal documents in the department of health, the department of benefit payments, and the selected counties, -Attended the meetings of the Homemaker-Chore Services Task Force, -Reviewed the operations of the following county welfare departments, which provide service to 64 percent of the total homemaker-chore clients in the State: -Interviewed clients and independent providers in eight counties, -Completed a telephone survey of all 58 counties to compile pertinent statistical data. -Interviewed the homemaker services staff of the Nevada State Department of Human Resources, Welfare Division. -Sent questionnaires to 15 States to assess the feasibility of alternative program and funding approaches. We received excellent cooperation from the department of health and from the administrative staff of the counties that we visited. We also wish to thank the social services staff from the State of Nevada for their cooperation. FINDINGS THE DEPARTMENT OF HEALTH HAS NEITHER ADEQUATE REGULATIONS NOR APPROPRIATE MANAGEMENT TOOLS TO EFFECTIVELY SUPERVISE THE COUNTIES' ADMINISTRATION OF THE HOMEMAKER-CHORE SERVICES PROGRAM. AS A RESULT, THE ADMINISTRATION AND COST OF THE PROGRAM VARIES SIGNIFICANTLY FROM COUNTY TO COUNTY. State and Federal laws require the department of health to supervise the counties' administration of the homemaker-chore services program. Our review has disclosed that the department has not met its responsibility in the following areas: -Specifying those services available to homemaker versus chore recipients. -Controling the costs of service delivery. -Establishing a management information system and a staff capable of enforcing existing regulations and detecting potential problems. The department of health has not specified which services are to be made available to homemaker recipients versus which services are to be made available to chore recipients The department of health has the responsibility to develop regulations which provide for the effective administration of the homemaker-chore services program by the counties. Department regulations do not clearly define the difference between homemaker and chore services nor do they specify which services are to be made available to homemaker recipients versus chore recipients. The only operable distinction is furnished in the department's manual of policies and procedures, which basically defines a client in need of chore services as not requiring the services of a "trained homemaker or other specialist", and defines a client needing homemaker services as requiring a “trained and supervised homemaker" (emphasis added). However, the duties of a "trained and supervised homemaker" and criteria that could be used to determine which clients are eligible to receive the services of a homemaker and which clients are eligible to receive the services of a chore provider are not further described. (Refer to appendix A [p. 192] for a possible set of definitions describing the various functions of persons providing in-home supportive services.) The need for a clear distinction between these two types of service is important because it provides the framework necessary for the counties to effectively administer their programs, both from the standpoint of fiscal responsibility and from the standpoint of providing proper services. Without this distinction, the counties have no systematic way to properly classify the type of service their clients need and what they should pay for that service. Because of the training component, homemaker services are more expensive. In those counties included in our review where a distinction was made, the hourly cost of providing homemaker services exceeded the hourly cost of providing chore services by approximately $1.50 per hour. During our review, we found that because of the absence of a basic definition, the counties have established a variety of homemaker-chore services programs which operate at a wide range of monthly costs. However, our observations and subsequent verification in discussions with county administrative and staff personnel showed that there is virtually no difference between the tasks provided to the client regardless of whether the task is labeled "homemaker" or "chore." Some counties offer only "chore" services; others offer only "homemaker" services. In those counties offering both, the methods of evaluating the clients' needs often result in inappropriate services. The range of tasks being provided is illustrated by the following cases. In 5 of the 10 counties we visited, a provider is authorized to perform "simple supervision," which is defined as simply having a provider available on the client's premises in case he falls, wanders off, or fails to take medication. In three counties, interviews with county officials disclosed that some providers are performing tasks which they are not qualified to perform and which are inconsistent with the duties of either a homemaker or chore provider, such as blood pressure readings, colosstomy irrigations, and catheter changes, even though these activities are not officially sanctioned by the counties. The department of health has not established adequate regulations to effectively control the costs of service delivery The department of health has not established adequate regulations which would provide for a controlled range of rates for each delivery method. As a result, the costs of providing necessary services vary from county to county. For example, in our visits to the counties we found two clients having nearly identical needs for meal preparation. In one county, the client was receiving "homemaking" services from a contract agency at an hourly cost of $6. In the other county, the client was receiving "chore" services from a client-employed provider at an hourly cost of $2.50. While no difference in the quality of service being provided could be discerned, the cost of service in the first county was 140 percent higher than the cost in the second county. Further, the rates vary even when counties use the same service delivery method. The following table identifies the variations in rates and provider salaries: TABLE 1.-HOMEMAKER-CHORE SERVICES PROGRAM, HOURLY RATE RANGES, PROVIDER SALARY RANGES, NUMBER OF COUNTIES, AND NUMBER OF CLIENTS SERVED BY SERVICE DELIVERY METHOD AS OF DEC. 31, 1974 1 These rates should not be considered as comparable because none of the administrative overhead is included in the client-employed provider category. A part of the administrative overhead is included in the contract agency category, and all of the administrative overhead is included in the county staff category. County cost allocation systems did not permit comparable allocations of overhead. 2 Exceeds 58 due to multiple delivery methods within some counties. See appendix B, [p. 194] for a county-by-county breakdown. Since rates have not been established, the counties are allowed to bargain with prospective providers in the establishment of payment rates. This is a procedure which has both resulted in payment rates below the minimum wage and payment rates to contract providers as high as $7.75 per hour. In counties using the services of a contract agency, the agency-employed provider receives a wage approximately 21 percent to 46 percent higher than the client-employed provider. In addition to paying higher wage rates, contract Inconsistent Evaluation of Client Needs Evaluation of client needs under the homemaker-chore services program is inconsistent in that some clients receive insufficient services and others receive too much. A primary cause of this inconsistency is the lack of communication between the social workers and the client, and between the provider and the contract agencies. State regulations require all clients, except those judged to be severely impaired, to be evaluated every 6 months by the county welfare department to determine their current need for homemaker or chore services. Our review of the program in 10 counties disclosed that the frequency of reevaluation of nonseverely impaired clients ranged from 1 month to over 1 year. Those counties which exceed a 6-month reevaluation period are out of compliance with State regulations. In those counties that complied with the 6-month review requirement, we found that semiannual reevaluations were often not sufficient to adequately monitor the client's condition. Some clients required more attention than the social workers could afford because of their growing caseloads or inability to keep up with the clients' changing conditions. An example of this involved a 74-year-old client in one county with a duodenal ulcer whose physician recommended the services of a provider solely for the purpose of meal preparation. The county authorized 9 hours of service a week and, in violation of State regulations, did not review the client's situation for a year. At the time of our review, it was determined that for the past year the client had been taking his meals two or three times a day at a local diner and having the homemaker clean his studio apartment rather than prepare meals. Since the client needed only 9 hours of service per week, the county had contracted with a proprietary agency at the rate of $6 per hour for the service. The annual cost was $2,808. While this was an extreme example of the 90 clients receiving homemaker or chore services, whom we interviewed in their homes, it is illustrative of the abuses and excessive levels of care that can occur in the absence of proper administration. An example in the other direction involved a couple who were both receiving "chore" services and who had been visited twice annually by their social worker. On a regular reevaluation visit, the social worker found that the health of both the husband and wife had deteriorated. The social worker then authorized an increase in the amount of service. The social worker said that the couple could have qualified for the increased service much earlier if she had been aware of their need. While the conditions of certain types of recipients of homemaker and chore services are not reviewed often enough, review requirements provided by statute for the severely impaired are excessive and costly. Section 12304 (f) of the Welfare and Institutions Code requires county social workers to visit clients classified as "severely impaired" once every 3 months. A severely impaired client is defined by law as someone who requires at least 20 hours per week of personal care. These clients have acute physical disabilities, such as paralysis, and are usually confined to a wheelchair or bed. In the course of our study, social workers and severely impaired clients agreed that this legal requirement forced unnecessary visits to the client and inefficient use of social worker time. Generally, severely impaired clients have been allowed to live independently only after lengthy hospitalization and only after expert medical testimony that their condition will not deteriorate. These clients have stable and well-defined disabilities. Revising existing law to reduce the number of mandated visits to one per year would save an estimated $252,000 of social services money annually. In counties where a contract agency provides program services, it is more difficult for the social worker to maintain contact with the clients. Social workers are still required to make the specified reevaluations and we found that this regulation is generally being followed. However, because the client deals almost exclusively with the agency-employed provider, effective commuication between the client and the social worker is restricted. This results in the provision of inadequate or excessive services to the client. An example of this involves an elderly client who was assigned a provider from a contract agency. Although the provider performed her duties to the satisfaction of her employer and the client, the client's condition steadily and a systematic review of the county homemaker-chore services program had not been undertaken by the department as of January 1975. As of April 18, 1975, the department had reviewed homemaker and chore service operations in two counties. The fact that San Francisco County was overpaying on three of its contracts with contract agencies (as discussed previously) could have been detected if a management information system had been implemented and sufficient staff had been assigned the responsibility to monitor the program. Conclusion The department of health has not issued adequate definitions of services relating to homemaker activities versus chore activities. The department has not promoted fiscal responsibility in the homemaker-chore services program as evidenced by its failure to effectively control provider payment rates by the counties. Finally, the department has not instituted a management information system capable of generating sufficient program data and has not required periodic monitoring of the program. Recommendations We recommend that the department of health: -Establish a listing of those services which would be available to clients eligible to receive "homemaker services" and to clients eligible to receive "chore services." -Establish a range of provider payment rates, to be paid by counties to client-employed providers and to provider agencies under contract with the counties. -Establish regulations requiring the periodic monitoring of contracts between counties and provider agencies. -Implement a management information system that would enable it to meet its obligations to effectively supervise the county administration of the homemaker-chore services program. —Require the counties to submit comprehensive social service delivery plans which would include the following: Projected population served. Methods of service delivery and number and description of recipients of each service. Costs of providing service and method used to establish rates of payment. Method of supervising the program (numbers and qualifications of supervising staff). Training program used. Availability of and use of community resources. -Transfer sufficient department of health staff to the service operation section to permit the development of adequate regulations, county consultation, and compliance monitoring. Benefits and Savings Implementation of these recommendations will provide the department of health with the management tools necessary to effectively supervise the administration of the homemaker-chore services program and to insure that the services are being offered at the most economic cost. The enforcement of the regulations it has issued could result in a reduction of expenditures of $271,000 annually in San Francisco County with a possible greater reduction statewide. DEFICIENCIES IN COUNTY ADMINISTRATION OF THE HOMEMAKER-CHORE SERVICES PROGRAM HAVE RESULTED IN INCONSISTENCIES RELATING TO EVALUATIONS OF CLIENT NEEDS, PAYMENTS TO RELATIVE-PROVIDERS, METHODS OF TREATING SOCIAL SECURITY CONTRIBUTIONS FOR INDIVIDUAL PROVIDERS, AND THE USE OF EXISTING COMMUNITY RESOURCES In the absence of adequate and effective regulations from the department of health, as previously discussed, the counties' administration of the homemaker chore services program has produced inconsistencies. |