Use the links below to skip to the specific response you wish to view:
- California Department of Social Services
- California State Auditor’s Comments on the Response From the California Department of Social Services
- Butte County Employment and Social Services
- Kern County Aging and Adult Services
- County of San Diego Health and Human Services Agency
- Stanislaus County Counsel
February 3, 2021
Ms. Elaine M. Howle, CPA
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
SUBJECT: CDSS RESPONSE TO CALIFORNIA STATE AUDITOR’S REPORT
Dear Ms. Howle:
Below you will find the California Department of Social Services (CDSS) response to the recommendations for CDSS in the California State Auditor’s (CSA) Report on the In-Home Supportive Services (IHSS) Program.
CSA Recommendations for CDSS:
To help ensure that all recipients throughout the State receive prompt approval for services and receive all approved services, by August 2021 and annually thereafter, Social Services should require counties to submit required annual plans. These plans should include, at a minimum, a description of how each county will ensure that services are promptly approved and that recipients promptly receive the approved services.
To help counties prepare to meet future needs for IHSS services, Social Services should revise its regulations to require counties to include long-range projections and strategies in their annual plans. For example:
To help ensure that recipients receive timely care, Social Services should by August 2021 begin monitoring counties’ compliance with the following:
- Approval of IHSS applications within 30 days, unless an extension for obtaining a medical certification applies. Prompt approval of IHSS applications for which the 45-day extension for a medical certification applies.
- Provision of services within 15 days of application approval. For counties that struggle to comply with its regulations regarding providing timely services, Social Services should require—and regularly follow up on—corrective action plans from these counties.
CDSS agrees with the goal of ensuring that all recipients throughout the State receive prompt approval for services and receive all approved services. CDSS plans to repeal the regulation that requires counties to submit annual county plans. The requirement for county plans is an outdated regulation from when services were primarily provided by county homemakers that are employed and directed by the county. As the program evolved to a self-directed model, and recipients became responsible for the hiring and directing of the care provider, county plans were no longer meaningful as the county does not control the service provision of the program.
CDSS plans to also repeal the regulation regarding 15 days from application to provision of services. As a self-directed program, IHSS recipients are responsible for managing their own care. Recipients sign an SOC 332 (IHSS Recipient/Employer Responsibility Checklist) at their assessment that states it is the recipient's responsibility to hire and manage their own provider and direct how and when they receive their services. Counties have no authority to hire a provider for a recipient. The county ensures recipients are assessed and authorized for services; it then becomes the recipient’s responsibility to hire a provider.
Regarding the requirement to approve IHSS applications in 30 days, CDSS is in the process of revising regulations to include the new statutory requirements for an IHSS applicant to complete a Medi-Cal eligibility determination and health care certification prior to authorization of IHSS. Both requirements allow 45 days for the applicant to complete and run concurrently.
Lastly, CDSS has established Quality Assurance and Monitoring Units and a Program Integrity Unit (PIU) which is responsible for monitoring counties in the areas which they are responsible for (application processing, assessing recipients and authorizing hours correctly, conducting reassessments timely, etc.) and will continue to do so.
The additional responses below provide clarification on the IHSS Program.
The following topics are addressed:
- IHSS Public Authorities
- IHSS recipients not receiving services;
- Data referenced;
- IHSS Maintenance of Effort;
- Preparation for the future; and
- IHSS Program Background.
IHSS PUBLIC AUTHORITIES
Page 9, “Most counties have established public authorities – entities separate from the counties that are deemed the employer of IHSS caregivers to perform various functions related to caregivers.”
Public Authorities (PA) are the employer of record only for purpose of collective bargaining. They are not the employer for any other purpose, the recipient is. Counties and PAs provide supports to assist recipients in their role as employer, such as maintaining a provider registry (operated by the county IHSS PA) to assist recipients in finding a provider if necessary, provider and recipient training, etc.; but counties are not providers’ employer for the purpose of ensuring the provision of services.
IHSS RECIPIENTS NOT RECEIVING SERVICES
Page 3, “From January 2015 through December 2019, the number of recipients statewide who lacked care grew from 33,000 to more than 40,000 on average each month…County administrators provided several reasons why a recipient would not receive services, including extended hospitalizations, the inability to hire a provider, and recipients moving to a new location and requiring a new provider.”
Page 3, “The number of recipients already exceeds the number of caregivers, and as that gap widens, it will likely increase the number of recipients who go without services.”
Calculating the number of recipients who did not receive needed in-home care each month by comparing paid hours versus authorized hours is not an accurate methodology for determining this. Recipients and providers are usually made eligible retroactively. Hours not claimed in a particular month can be claimed in a later month. Furthermore, there are providers who save their timesheets and claim all of their hours in December, causing paid hours to be over 100% of authorized hours in that month. Just because a timesheet was not submitted on time does not mean that a recipient didn't receive care.
CDSS would like to supply additional information regarding the reasons provided in the Report for why a recipient would not receive services for clarification. When an IHSS recipient is hospitalized, IHSS services are paused because it would be a duplication of services as the individual is not needing care in the home during that time period. Not receiving services through the IHSS program while a recipient is in the hospital does not mean that the individual wasn’t receiving needed services. It is the recipient’s responsibility as the employer to hire an IHSS provider. Hours can be claimed at a later date, so when hours are not claimed, it does not necessarily mean services were not received.
Many providers that work for multiple recipients. The number of providers has always been lower than recipients. The total number of IHSS providers being lower than the total number of IHSS recipients does not indicate that recipients are going without services.
Data tables provided in appendices. Throughout the report, it refers to data derived from these tables.
CDSS Response & Questions:
The source listed for Tables B.1, B.2, B.3, B.4, B.5 is, “Auditor analysis of Social Services' CMIPS II data.” The columns in the data tables aren’t defined and the source of the data used (fields and tables within CMIPS) is not clearly stated.
It is unclear how CSA derived the following:
- The 18% of recipients who did not have familial status providers
- Number of “new recipients” in each table (it seems to differ)
- The calculation of “Average Days from Application to Approval”
- The calculation of “Average Days from Approval to First Day of Service”
- The Total number of recipients and providers in Table B5
The following issues have been identified with the data:
- It is unclear if the totals are averages or aggregates in the tables. This is problematic and doesn’t provide a complete picture, particularly with authorized versus paid data, considering there are certain months of the year where providers submit timesheets they save. To truly get a picture of what is happening with recipients, and whether or not they are receiving their services, takes much more than authorized versus paid data.
- The number of “new” recipients differs in Tables B.3 and B.4. To measure how long it takes for “new recipients” to get from application to authorization, and also measure how long it take them to get services, then averages are needed for the entire population. The number of “new recipients” in Table B.4 is different than the number of “new recipients” in Table B.3. There is nothing in the report that states Table B.4 is a subset of the data included in Table B.3.
- In Table B.3 the 2019 Total Number of “new recipients” is 87,711. In Table B.4 is states the 2019 number is 11,143, with a footnote that states there was no data for 12,700. This leaves a discrepancy of 63,868 if the Total line is meant to be a total in Table B.4 and not an average.
- In Table B.5 the report states that in 2019 there was 701,548 recipients and 628,281 providers. These numbers are higher than the data CDSS has on both a monthly and yearly basis.
- If Table B.4 is an average, it is does not align with the average when the 2015 and 2019 data are compared.
- The total lines in each table do not seem to align. At first glance it seems as though the auditor is using a total in B.3 and B.5, and average in B.4, but the numbers are not correct.
CDSS compared the data provided in the tables for Alpine and Sierra counties to the number of applicants in CMIPS. The following was found:
- The number of applicants match the numbers included in Table B.3 for Alpine. However, when the data for each of the 4 cases were reviewed in the payroll system, all 4 cases authorized in 2019 have hours paid to the first date when services were authorized. Table B.4 states that there was 1 “new recipient” in Alpine in 2019 and it took 334 days to receive their first service. CDSS could find no recipient where that was the case. When paid hours were reviewed for all 4 cases, there was no recipient who didn’t have timesheet activity dating all the way back to the first pay period they were authorized services. Therefore, the data in Table B.4 is incorrect.
- In Table B.3 the report states there were 8 “new recipients” for Sierra. When CDSS reviewed the monthly data in CMIPS, there were 14 applicants in 2019 and of those 10 became eligible for services. Table B.4 states that there was only 1 “new recipient” and it took them 6 days to receive their first services. All cases had timesheet activity back to the first pay period their cases were authorized. Therefore, the data in Table B.4 is incorrect.
- Based on the data for just these two counties, it would seem the auditor’s premise that there is a delay between the time a recipient is approved and the day they receive their first services is false and that there is most likely more data issues. The data does not support that there was any delay in services a recipient received when there are timesheet records that claim time back to the first authorized pay period. The timesheet is the proof that the services were provided. It is also important to note that a recipient does not necessarily need to receive services from Day 1 of their authorization. Their services could have started on a Monday, but they scheduled their provider to start on Wednesday. This does not mean that a recipient didn’t receive the services that they needed on Monday and Tuesday; it could be that they didn’t need services those days.
IHSS MAINTENANCE OF EFFORT (PROGRAM FUNDING, INCENTIVE TO NEGOTIATE WAGE INCREASES)
Page 27, “The State’s decision in fiscal year 2012-13 to adjust the contribution each county pays toward the IHSS program by a set percentage—or inflation factor—each year rather than updating each county’s contribution based on its proportion of the IHSS program’s costs has resulted in some counties paying significantly more than their proportional share while others pay less. This approach has effectively increased the State’s share of program costs and penalized counties whose programs did not expand as rapidly as others did.”
Page 21, “The State’s Funding Structure and Recent Shortfalls in County Funding Sources Create a Disincentive to Increase Caregiver Pay.”
Maintenance of Effort (MOE) Background:
The 2012 funding structure was a part of the Coordinated Care Initiative (CCI) which contained a trigger that would end it if Department of Finance (DOF) determined that it was not at least cost neutral to the state. In January 2017, DOF made this determination and CCI ended. That legislation included language that if CCI ended the IHSS funding structure would return to the previous sharing ratios. When the trigger was pulled this would have shifted $600 million back to the counties based on the previous sharing methodology. At the time DOF made the decision, they also committed to working with the counties to mitigate this impact. Subsequent discussions between DOF and county representatives resulted in a continued MOE structure that began in FY 2017-18.
Under the 2017 County IHSS MOE, the counties’ share of IHSS costs was reset to reflect the counties’ share of estimated 2017-18 IHSS costs based on historical county cost-sharing levels. The 2017 County IHSS MOE increased annually by: (1) counties’ share of costs from locally established wage, health benefit, or non-health benefit increases; and, (2) an annual inflation factor of zero to 7 percent based on 1991 Realignment revenues.
In January 2019, the Department of Finance (DOF) found that 1991 Realignment could no longer support county costs of IHSS in its Senate Bill 90: 1991 Realignment Report. As a result, Welfare and Institutions Code (WIC) sections 12306.1 and 12301.16 (SB 80, Chapter 27, Statutes of 2019) were enacted and the new County IHSS MOE became effective on July 1, 2019.
Changes to the County IHSS MOE included:
- Reduction of the County IHSS MOE base from $2.06 billion to $1.56 billion;
- Allocation of state General Funds (GF) for IHSS County and PA administration with no county share up to the allocation amount and 100 percent county cost for the non-federal share of any expenditures above the allocation amount;
- Annual inflation factor of 4 percent beginning July 1, 2020 and annually thereafter;
- The non-federal sharing ratio will change for any locally established increase in wages or benefits on or after the state minimum wage reaches $15.00 per hour from 65 percent state and 35 percent county to 35 percent state and 65 percent county and the state participation cap is eliminated.
Incentives for Counties to Negotiate include:
- Wage Supplements - If a county negotiates a wage supplement, the County IHSS MOE shall include a one-time adjustment for the county share. Subsequent application of the wage supplement to the new state minimum wage will not adjust the County IHSS MOE.
- 10% option - For a county that is at or above the current state participation cap in combined wages and health benefits, the county may negotiate a contract for combined wages and benefits, and the state shall participate, splitting the cost of the non-federal share 65 percent state and 35 percent county, in a cumulative total of up to 10 percent of the sum of the combined total of changes in wages, health benefits, or both within a three-year period and upon request by the county.
- State Participation Cap - The state shall participate in a total of individual provider wages and health benefits up to one dollar and ten cents ($1.10) per hour above the state minimum wage until the state minimum wage reaches $15.00. Once the state minimum wage reaches $15.00, there will be no cap on state participation for approved locally negotiated increases in provider wages and individual health benefits
The MOE does not penalize certain counties or disincentivize counties to negotiate wage increases for IHSS providers.
The 2019-20 base MOE is based on each county’s expenditures. The annual inflation factor is to cover caseload growth (caseload growth exceeds the inflation factor, so the state picks up the difference). Some counties are not paying significantly more than their proportional share due to the annual inflation factor because the MOE is based on each county’s expenditures. The items that would potentially create disparities among the counties is the way the offsets, 991 realignment funds and county and PA administration allocations were distributed. The distribution for each of these items was negotiated by the California State Association of Counties (CSAC) and the DOF. CSAC negotiates, on behalf of the counties, how funding for the IHSS program should be distributed; therefore, essentially, the counties have determined how the funding is split between themselves for MOE off-sets, realignment funding and IHSS County and PA admin.
Counties have always had a share in the costs of the program. Prior to the MOE, counties paid a percent of all program costs. With the implementation of the MOE, the only adjustments to the amount they pay is the annual inflation factor and a share of any locally bargained increase to wages and benefits. No counties were penalized. Most counties have paid less than they previously would have because the state has covered minimum wage increases and has an increased share of cost via the 10% and wage supplement options. Counties negotiated above minimum wage in prior years because there was no legislation in place for the minimum wage increases that is in place now. Due to this, many counties have utilized the supplemental wage referenced above to continue to pay above the minimum wage with no additional cost to the county.
PREPARATION FOR THE FUTURE
Report:Page 12, “Providing timely IHSS care may become more difficult, as the number of recipients is expected to increase dramatically over the next 10 years. Despite the pending increase, the counties and the State have not planned for this influx of older Californians needing care.”
The State is constantly planning and preparing for the future to ensure Californians receive needed services. Most recently the IHSS program and its future has been a primary topic of the Master Plan for Aging stakeholder committee that was established by executive order of the Governor. These conversations will continue as a part of ongoing planning.
Report & CDSS Response:
Page 7, “IHSS provides services based upon the needs of each recipient, which may include bathing, bowel and bladder care, feeding, and accompaniment to health-related appointments.”
Domestic and related services should be mentioned here as the majority of IHSS recipients receive those services.
Page 7, “State law allows up to 195 hours per month of care, or 283 hours of services each month for severely impaired individuals.”
The statutory maximum is 283 hours. The statutory maximum is 283 hours. However, the maximum number of hours a recipient can receive varies depending on whether they are severely impaired of non-severely impaired, and which Medi-Cal program funds their services. (See WIC §§12303.4, 14132.95, 14132.952 and 14132.956.)
RESPONSE FOLLOW UP
Questions or requests for clarification regarding the information in this letter should be directed to Debbie Richardson, Chief, Office of Audit Services at Debbie.Richardson@dss.ca.gov.
California State Auditor’s Comments on the Response From the California Department of Social Services
To provide clarity and perspective, we are commenting on the response to our audit report from the California Department of Social Services (Social Services). The numbers below correspond with the numbers we have placed in the margin of its response.
The “For example:” in Social Services’ response appears to be an error. Our recommendation does not include an example.
Social Services cannot simply repeal its regulations and thereby eliminate counties’ and its responsibilities related to annual plans. State law requires counties to submit annual plans. Specifically, Welfare and Institutions code §12302 states that each county is obliged to ensure that services are provided to all eligible recipients during each month of the year in accordance with the county plan. Moreover, state law requires Social Services to review such plans for compliance with certain other requirements.
Although Social Services has failed for decades to comply with state law intended to ensure that counties conduct appropriate planning for people dependent on the IHSS program, the need for such planning is not outdated. As we note here, as of 2019, more than 40,000 recipients on average did not receive in home care each month. Further, as indicated here, 32 of the 51 counties responding to our survey stated that they lacked a sufficient number of caregivers to provide all approved services to each IHSS recipient. Additionally, other county level planning to ensure IHSS care is provided to all recipients is not occurring. For example, of the counties we surveyed only two indicated that they performed any analysis to identify the number of caregivers needed currently or in the future. Similarly, only four counties indicated that they had created a plan to account for future growth in the number of IHSS recipients. Clearly, the need for planning persists.
Social Services is using recipients’ responsibilities under the IHSS program as an excuse for it to not hold counties accountable for their responsibilities. In particular, although state law allows recipients to hire their caregivers, as we note here, it also requires counties to conduct planning necessary to ensure care is provided. Further, counties can take a variety of measures to ensure that recipients receive care. For example, three of the four counties we reviewed indicated that they would arrange short‑term care for recipients through contracted local providers when necessary.
Social Services decision to repeal its longstanding regulation requiring counties to ensure IHSS recipients receive care within 15 days of approval is concerning. As we discuss here, the majority of recipients enter the IHSS program with a caregiver. However, during the period we reviewed nearly 58,000 did not. On average these recipients wait over 100 days after their approval to receive services. Delays of this magnitude put Californians who qualify for in home care at risk.
Social Services decision to change its 30‑day IHSS application processing requirement to longer than that timeframe is disappointing, particularly given that in 2019 no counties in California met the current requirement, instead taking 72 days on average. We believe Social Services’ decision to increase the processing time requirement does not demonstrate appropriate urgency in providing care for Californians.
Although Social Services has established quality assurance and program integrity units, they have failed to monitor compliance with state law related to county planning, application processing, and the legal requirement that counties ensure care is provided to recipients within 15 days of approval. Similarly, here we note that Social Services advised us that it does not track compliance with its regulations related to the time between approval and care for recipients.
We informed Social Services prior to it submitting its response to our draft report that we had already clarified text here regarding this point.
We accounted for the timing of timesheet submission by care providers in our analysis. We understand that providers may delay submitting timesheets which show when authorized services were provided; thus we included all timesheet data that providers submitted to Social Services for payment through June 2020. However, we limited our analysis to the services which would have been rendered through December 2019. Thus, providers had at least six months to submit their timesheets before we received the data for analysis. We believe this is a reasonable time period to expect that the majority of providers would submit their timesheets for payment, particularly since Social Services’ data experts asserted that around 90 percent of all timesheets are completed within 10 days of the timesheet period.
Social Services’ response is misleading. Here we note that more than 40,000 IHSS recipients, on average, per month in 2019 did not receive monthly IHSS care. As we indicate here, County administrators detailed several reasons a recipient might not receive monthly care. Some are troubling, such as the inability to hire a caregiver, or delays in obtaining a new caregiver after moving. Others such as hospitalizations may be unavoidable. As such we simply note that gaps in care can represent periods of increased risk of injury or other hardships for IHSS’s elderly and disabled beneficiaries. We note that Social Services did not dispute that gaps in care can result in increased risks to recipients generally.
Social Services is correct to point out that many caregivers serve multiple recipients. However, its response fails to acknowledge two critical points. As we note here, expected rapid growth in the number of recipients will likely place increased strain on the IHSS program in the near future. Further, as we note here, this period of rapid growth, which we estimate could result in a 52 percent increase in recipients, coincides with a period where family members will be less available to provide care due to changing demographics. Further, 32 counties responding to our survey have already indicated they lack a sufficient number of caregivers to provide all approved services to each IHSS recipient.
It is not our practice to include the detailed steps we take in performing our analysis in the report. However, we worked with Social Services to understand the available data. Social Services referred us to its contracted data experts when we had specific questions related to the system and specific data elements. We worked closely with the contractor and Social Services throughout the audit as we developed our methodology and performed our analysis. Additionally, we shared the results of our analysis with the four counties we reviewed and they did not question the validity of the results.
We stand by our analysis. To address this issue and provide additional clarity on our methodology, we included further context for the totals of the tables in Appendix B, beginning here.
As we state in the title and footnote for Table B.4 here, the table only includes recipients who began receiving IHSS services after the county approved their case. Further as the title indicates, Table B.3 relates to all new recipients.
Social Services did not explain how it calculated the numbers in its response. Our analysis on Table B.5 here contains the number of caregivers and recipients who either provided or received IHSS care at any point in calendar years 2015 and 2019. We worked closely with Social Services and their contracted data experts throughout the audit as we developed our methodology and performed our analysis.
Social Services’ concern is unclear. Each table in Appendix B stands on its own and covers the information presented in the title.
The totals in all the tables in Appendix B are correct. However, to provide additional clarity, we included further context for the totals of the tables in Appendix B beginning here.
We worked with Social Services to investigate the Alpine case. The research that Social Services conducted in February 2021 showed that the recipient’s providers turned in their timesheets after we obtained the data. As discussed in the Scope and Methodology, Social Services furnished us with a copy of its program data in June 2020. It is reasonable that current data may differ from the June 2020 copy of the data we received and analyzed.
The data that Social Services used to draw its conclusions were more current than what we analyzed. Additionally, while these timing issues may affect a limited number of cases, we stand by our analysis and it is unreasonable to discount an entire table that shows more than 11,000 individuals who were approved for care during 2019 but had not received care by June 2020.
We stand by our analysis. While there may be a limited number of issues with the timing of when services were reported to Social Services, there is sufficient evidence in total to support our conclusion that there is a delay in providing services for a large number of new recipients.
Any county that negotiated a caregiver wage increase before the wage supplement law went into effect in 2017, or which could not take advantage of that law after 2017, is paying an ongoing increase to their county contribution. Such counties will continue to pay more for those wage increases even after the state minimum wage catches up. We provide an example of the fiscal impact of this state law here.
Social Services is incorrect. According to the methodology developed by the California State Association of Counties, the fiscal year 2019–20 county contribution amounts are based on the prior fiscal year’s contribution, with adjustments for any locally negotiated wage increases, and a 2 percent reduction per county. As of January 2021 Social Services had not yet published the final fiscal year 2019–20 county contribution amounts. Further, as we indicate here and here, county contributions are based largely on fiscal year 2011–12 county costs, as adjusted for locally negotiated wage increases, and an inflation factor. This does not result in county contributions based on their actual expenditures. Instead, some counties pay more than their proportional share because their IHSS costs grew more slowly than the inflation factor, while others pay less than their share because their costs grew more quickly than the inflation factor.
In 2017 the offsets and adjustments which Social Services describes amounted to less than $200 million of the $1.4 billion in county contributions for fiscal year 2017–18. The remaining $1.2 billion was based on the State’s prior methodology.
Social Services provides no evidence for its assertion that counties negotiated wages higher than the state minimum in prior years because of a lack of legislation for increases to the minimum wage. If a county’s IHSS caregiver wages are above minimum wage, it was because that county and its IHSS caregivers agreed during collective bargaining that the caregivers should be paid a wage that was above the minimum wage. Moreover, if Social Services assertion was correct, we would not have expected to see the reduced number of counties paying above minimum wage as shown in Figure 4 here.
Our remarks, which we have clarified, referenced failures by the counties and Social Services to complete mandatory IHSS county plans for decades. However, our review of The Master Plan for Aging, signed by the Governor and issued in January 2021, indicates that the State acknowledges the need to explore options to increase the stability of IHSS beneficiaries through backup provider systems and registries. Such planning is in line with our recommendations to Social Services here, which includes requiring counties to complete and expand their mandatory planning to include items such as long‑range projections and strategies.
The examples provided are intended to give readers an understanding of the services provided by the IHSS program and are not meant to be exhaustive.
February 2, 2021
Ms. Elaine Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
Thank you for your review and recommendations to improve the In-Home Supportive Services (IHSS) Program in Butte County. The In-Home Supportive Services Program: It is not providing needed services to all Californians approved for the program, is unprepared for future challenges, and offers low pay to caregivers (Audit 2020-109) audit report takes a constructive look at the IHSS program which helps individuals remain in their homes and prevent more costly institutionalization.
The Department of Employment and Social Services (DESS) is proud to be a partner in the service of its IHSS recipients and providers with our State oversight agency, the California Department of Social Services (CDSS), our County oversight body, the Butte County Board of Supervisors, and the California State Auditor. We strive to provide the highest caliber of services along with other County departments and community partners.
DESS generally agrees with the finding and recommendation of the audit report. Our comments on the specific item are enclosed. We appreciate the collaborative manner in which your staff conducted the work leading to this report. We welcome the opportunity to examine our practices and implement the change as prescribed by the California State Auditor. If you have any additional questions, I can be reached at (530) 538-7891.
Shelby Boston, MSW
February 1, 2021
Elaine Howle, CPA
California State Auditor
621 Capitol Mall Ste. 1200
Sacramento, CA 95814
Dear Ms. Howle:
We appreciate you and your team’s effort in evaluating the In Home Supportive Services (IHSS) program in its entirety. Kern County Aging and Adult Services Department (KCAASD) has reviewed the draft report on its IHSS program and this letter serves as our written response to the draft report.
In reviewing the report, KCAASD agrees that the IHSS program will continue to grow in number of IHSS recipients as well as care providers. The report outlines California seniors will increase from 6 million in 2019 to 8.5 million by 2030. For Kern, this growth began prior to 2019. This growth is reflected in the increase in Kern’s IHSS caseload which the report states increased over 100% over the last five years.
The report identifies that the number of recipients who lacked services increased from 296 to 923. As the report states, there are varying reasons as to why recipients do not receive services ranging from hospitalization to not finding a care provider they like. We have recently put a measure in place that will follow up with IHSS clients not using the services to ensure that they maximize the services that were approved and authorized for them.
As it relates to new applications, the report states it took Kern an average of 83 days to approve applications. Although Kern is unsure how the 83 days was arrived at, we will continue to evaluate our intake process to determine inefficiencies. Kern will also continue to look at staffing ratios, reallocation of staff, and operational work flow to streamline the number of days to approve applications.
Using a Massachusetts Institute of Technology (MIT) living wage model, the report states that Kern’s living wage is $18.84, and IHSS caregivers earn minimum wage. The gap between the living wage and minimum wage is a disparity that exist in each county, and will continue to be an issue depending on the fiscal challenges each county faces. Unfortunately, this issue is prevalent in other occupations and industries throughout the state.
We continuously work with IHSS care providers in collaboration with the United Domestic Workers (UDW) union. In 2015-2016, Kern offered and provided classroom training to IHSS care providers, but without additional fiscal incentive, IHSS care provider participation in those classes were very low. As an alternative resource for training, KCAASD’s website has various videos on caregiving classes, as well as resources for other classes offered in the community that are designed to support and assist a caregiver. Recently, we have partnered with the UDW in the distribution of Personal Protective Equipment (PPEs). Kern understands and agrees with the need to recruit additional non family care providers and will work towards additional outreach and other opportunities to increase available care providers in general. This includes evaluating other county’s best practices in this area for potential implementation in Kern.
The report states that Kern received a proportionally greater state subsidy. Kern’s county contribution, as stated in the report, has increased every year from $7.46 million in 2012 to $11.16 million in 2019. It is also important to emphasize the growth of Kern’s IHSS program, as stated earlier, has dramatically increased by over 100% which impacts the overall cost. While the growth and cost of the program increased, Kern’s administrative costs remained at 7% of the program cost in FY 18-19.
Kern’s IHSS program is audited and evaluated annually by the California Department of Social Services (CDSS). Although there have been no significant findings, we continually look for opportunities to improve the program and services to our clients and care providers. This includes looking for efficiencies within our operations to provide services in a more efficient and effective manner. As the program continues to grow, Kern will strive to enhance and improve its operations for IHSS clients and care providers and report our plans and outcomes to CDSS. Thank you for the opportunity to allow us to respond. If you have any questions, please contact me at (661) 868-1052.
February 2, 2021
Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Re: California State Audit No. 20-109
Dear Ms. Howle:
The County of San Diego (“County”) has reviewed a draft of California State Audit No. 20-109. We are pleased that the California State Auditor highlighted some of the many services provided by the County to enhance the In-Home Supportive Services (“IHSS”) program. Specifically we appreciate your recognition of: the County’s program to render care when a recipient’s regular caregiver is ill or temporarily unavailable; the County’s building better health plan to improve the health of our elderly population; the County’s self-imposed goal to complete IHSS assessments within 45 days; and the County’s voluntary 18-hour advanced training course for IHSS caregivers.
The County values the importance of the IHSS program to our community and welcomes the opportunity to further improve our program whenever possible.
Enclosed please find the response to the sole recommendation directed towards San Diego County.
Acting Agency Director
“San Diego … should, by August 2021 and annually thereafter, complete required plans that include, at minimum, specific provisions for how [the] county will ensure prompt approval of services and that recipients promptly receive the approved services.”
The California Department of Social Services (CDSS) has communicated a performance standard of approving applications within 90 days.We note that the CDSS Manual of Policies and Procedures still reflects the decades old standard of 30 days, which was not formally changed following the imposition of additional legal requirements for applications. This year, the County of San Diego (“County”) has processed 99.2% of applications within this timeframe—exceeding the statewide average of 92.2%. San Diego’s approval process includes the following efficiencies:
- Assign applications to a social worker within one business day of receipt.
- Assign applications with a pending Medi-Cal determination to a specialized social worker to track and monitor for Medi-Cal approval; and once approved by Medi-Cal, complete the initial assessment.
- To further reduce wait times, social workers schedule and complete initial assessments promptly and do not wait for a completed SOC 873 Health Care Certification from the applicant’s physician. If the applicant’s physician is not timely in sending the SOC 823, the social worker will communicate directly with the physician to resolve the delay and will utilize a Public Health Nurse if needed to assist with complex medical situations.
- Social workers will evaluate for the need exception to a SOC 873 to further reduce wait times.
- Provide supervisors with monthly and cumulative reports on pending applications to track efficiency.
- If overflow exists for a particular office, implement mitigation plans that may include the reassignment of assessments to other regional offices to expedite pending applications.
The County believes that just meeting, or even exceeding these standards, is not enough—we must always look for ways to improve.
Although this audit discusses a required annual county plan, our understanding is that CDSS does not currently require county plans. See In-Home Supportive Services: Past, Present, and Future, California Welfare Directors Association, January 2003, (“Consistent with all public entitlement programs, IHSS provides applicants certain rights - timely decision of eligibility, timely notice of change in eligibility or service, and an appeals process to dispute eligibility decisions. California Welfare and Institutions Code Section 12302 states, ‘Each county is obligated to ensure that services are provided to all eligible consumers during each month of the year in accordance with the county plan...’ While the state no longer requires counties to submit an annual plan, the obligations remain.” (Emphasis added.)) However, the County understands the intent of this recommendation. The County will collaborate with CDSS to ensure that they have all necessary documentation regarding the specific actions the County takes to ensure prompt approval, and receipt, of services.
February 1, 2021
C/O Nick Phelps, Team Leader
CALIFORNIA STATE AUDITOR
621 Capitol Mall, Ste 1200
Sacramento, CA 95814
Re: State Auditors’ Draft Report and Certificate of Compliance
Dear Elaine Howle,
I am in receipt of the draft report titled, "In-Home Supportive Services Program: It Is Not Providing Needed Services to All Californians Approved for the Program, Is Unprepared for Future Challenges, and Offers Low Pay to Caregivers” which you provided to me via email on January 27, 2021, at 1:37 p.m. Our authorized recipients have reviewed the contents and note that there is only one recommendation in the Draft addressed to the County of Stanislaus. We have no objection to the single recommendation and have no other comment on the remainder of the document. If you have any questions you may contact me at the number above.
There will be an attachment, I think titled, “Certification of Compliance With Government Code sections 8545 and 8545.l(b)(2)”.
Thomas E. Boze