Home-care system leaves elderly at risk, auditor says

The report also noted that the Medicaid program is one of only four out of 238 programs nationwide with no job requirements for personal care attendants.

The audit drew criticism from state health officials because it surveyed only 30 patients, whose cases had been previously reviewed for fraud by the federal government.

But State Auditor A. Joseph DeNucci said the findings illustrate why the state should establish job requirements for attendants, including training, education, and criminal background checks, which nearly every other program in the country requires.

“What we have found is that there are serious problems in the program,’’ DeNucci said in a phone interview. “We have to strengthen protections for vulnerable people. I think it’s very important.’’

The state now pays about 25,000 attendants - more than double the number of a decade ago - to help the medically needy remain in their homes by assisting them with medication, bathing, dressing, preparing meals, and shopping, among other things. Attendants, unlike visiting nurses or other home health care workers, are unlicensed.

In a survey of patients in the program, the report found that some of the attendants are continuing to defraud the system. Overpayments on Medicaid claims “continue to be a significant problem.’’

Over a four-year period, the report found $207,283 in overpayments for those 30 patients. The payments were for services said to be provided in the home, but the patients were actually at a medical facility at the time, auditors found.

“If there’s fraud here, we expect it’s got to be other places’’ in the program, DeNucci said.

The report also found that 14 of the 30 patients had hired attendants who either had been convicted of a felony or a court had found sufficient evidence to find them guilty. Of the 82 attendants who worked for the 30 patients between 2004 and 2008, seven had been in prison, 12 were involved in violent crimes, nine had been convicted of drug offenses, 10 committed robbery, nine had restraining orders against them, and four had outstanding warrants.

In all, auditors found 41 acts of violence, 29 crimes of theft, and 26 drug crimes, including heroin distribution and trafficking cocaine in a school zone.

Personal care assistants “have unsupervised contact with vulnerable elderly and disabled consumers in the privacy of their homes, and they should be held to the same standards as other healthcare workers,’’ DeNucci said. “The personal safety and security of our most vulnerable citizens should not be jeopardized.’’

State health officials said the audit should not be used to undermine a program that has increased the independence of thousands of residents who might otherwise be living in a nursing home or another medical facility. They insisted the state does provide training and noted that the audit did not randomly sample the patients who were audited. The audit chose from a sample of patients provided to them by federal officials, who had been reviewing the 30 patients for potential fraud.

“We disagree with the methodology that was used, and we’re concerned about extrapolating about a very small number of people over a four-year period,’’ said Dr. Jean McGuire, assistant secretary for disability policy and programs in the Executive Office of Health and Human Services. “We think the findings presented are inconsistent with how we would characterize the overall experience of the program, which we’re really proud of.’’

While the state does not mandate training for attendants, McGuire said, it provides comprehensive training to the patients, who are expected to train their attendants. “The consumers know what they need,’’ she said.

She said the administration is working to overhaul the state’s system for criminal background checks and hopes to make such searches available to all patients in the program, but she would not say when. Patients must now contend with a bureaucratic process and pay about $30 for each criminal background check.

The report was issued a year after another state audit estimated that MassHealth, the state Medicaid program, overpaid at least $610,000 for personal care attendant services in fiscal 2005. One case referred to prosecutors last year involved one attendant filing false time sheets amounting to $193,000.

It also is being released as the state has sought to clamp down on fraud and abuse in the program. In the first half of fiscal 2009, the state prosecuted cases worth more than $1 million, double what it collected during the same period in the last three years and more than it recouped in each of those years.

The Medicaid program, which provides health care services to the poor and disabled, increased spending on personal care attendants in Massachusetts from about $100 million a decade ago to more than $330 million this year, growth that reflects the state’s efforts to care for an increasingly older population in their homes, rather than at hospitals, where costs are higher.

The lack of regulations has sparked the attention of lawmakers on Beacon Hill, where at least one bill proposing tighter regulation has surfaced.

State Representative Barbara L’Italien, an Andover Democrat and former attendant, introduced a bill this year that would allow patients to run a free criminal background check on attendants they hire, create an online database to help consumers find attendants, and establish a surrogate program to help those who cannot oversee attendants on their own. The bill has yet to emerge from committee.

“The hope is we can work to legislatively address the concerns that auditors have brought forward,’’ L’Italien said.

Mike Fadel, executive vice president of Local 1199 of SEIU, the union that represents personal care attendants, said the union supports L’Italien’s bill.

“The PCA Improvement Act would provide optional [criminal background] checks for consumers and promote new stopgaps against abuse by providing surrogates for consumers who need additional supports,’’ he said.

He said the union supports the audit’s call for more training of attendants, who earn a state-mandated $11.60 an hour.

“The national trend is certainly toward additional training, and Massachusetts PCAs are very open to that,’’ he said. “Additional training has the potential to help address current problems in the system, while also professionalizing home care jobs, which for too long have been overlooked and underpaid, making it difficult for consumers to find and keep the quality care they need.’’

He added that the fraud unfairly gives a bad name to the many attendants who provide an essential service. “Any individual who is exploiting a home care program or breaking the law is hurting the thousands of Massachusetts residents who depend on home care to keep themselves or their loved ones healthy, independent, and safe,’’ he said.

David Abel can be reached at dabel@globe.com.