Compliance Checklist for Medicaid Waiver Programs

This checklist serves as a comprehensive guide for agencies to ensure compliance with Medicaid waiver program requirements. Complete each section thoroughly to verify that your agency meets state and federal regulations for Medicaid-funded services.

Agency Information

• Agency Name: _____________________________
• Medicaid Provider Number: ___________________
• Contact Person: ____________________________
• Date of Review: ____________________________

1. Client Intake and Eligibility Verification

Eligibility Documentation
☐ Verified each client’s Medicaid eligibility status and waiver eligibility.
☐ Collected required income and asset documentation.

Assessment and Service Needs
☐ Completed initial assessment of client’s needs and health status.
☐ Documented the client’s specific service needs in an Individualized Service Plan (ISP).

2. Individualized Service Plans (ISP)

Development of ISP
☐ Created a comprehensive ISP for each client, detailing specific goals and services.
☐ Updated ISPs annually or as needed per changes in client’s condition or services.

Client & Caregiver Involvement
☐ Documented client and/or caregiver involvement in ISP development.
☐ Obtained client or authorized representative’s signature on ISP.

3. Staffing and Training Requirements

Staff Credentials and Background Checks
☐ Verified qualifications and credentials for each staff member providing direct care.
☐ Conducted required background checks for all care staff and documented in employee files.

Staff Training
☐ Completed all state-required trainings (e.g., CPR, First Aid, abuse reporting) for new hires.
☐ Documented ongoing training requirements, including specific training related to Medicaid waiver services.

4. Quality Assurance and Incident Reporting

Quality Assurance Program
☐ Established and documented a quality assurance plan to monitor and evaluate services.
☐ Regularly reviewed client satisfaction and outcome measures.

Incident Reporting
☐ Implemented a process for documenting and reporting incidents according to state guidelines.
☐ Maintained a log of incidents, investigations, and outcomes.

5. Record-Keeping and Documentation

Client Files
☐ Maintained organized client records, including intake forms, assessments, ISPs, and progress notes.
☐ Documented services provided, client responses, and any notable events for each visit.

Service Documentation
☐ Maintained service delivery records for each Medicaid billable hour and service.
☐ Collected and stored required signatures for verification of services provided.

6. Compliance with Medicaid Billing Requirements

Billing and Claims Submission
☐ Verified service eligibility and documentation before submitting Medicaid claims.
☐ Ensured accurate billing codes and documentation per each service billed.

Financial Documentation
☐ Kept records of payments received, denials, and adjustments for Medicaid claims.
☐ Reviewed claims regularly to identify and correct any billing discrepancies.

7. Emergency Preparedness and Risk Management

Emergency Plans
☐ Developed a written emergency preparedness plan, including procedures for natural disasters, evacuations, and communication.
☐ Conducted regular training and drills for staff on emergency procedures.

Risk Assessments
☐ Conducted environmental risk assessments for each client’s home and documented findings.
☐ Maintained records of risk mitigation strategies and monitoring activities.

8. Client Rights and Grievances

Client Rights
☐ Provided clients with a written statement of their rights and responsibilities.
☐ Obtained a signed acknowledgment from each client confirming receipt of rights and responsibilities.

Grievance Procedure
☐ Established a documented grievance process for clients and caregivers.
☐ Maintained a log of grievances and resolutions as part of compliance records.

9. Audit Readiness

• Audit Preparation
  ☐ Ensured all documents are accessible and properly organized for potential audits.
  ☐ Completed internal compliance checks monthly or quarterly to address any gaps in documentation or process.

ITEMS #10 TO 19 NOT INLCUDED IN THIS TEMPLATE.

Compliance Review Certification

• Review Completed By: _____________________________
• Position: _____________________________
• Signature: _____________________________
• Date: _____________________________

Additional Assistance

For a customized compliance checklist tailored to your state's specific Medicaid waiver regulations, please reach out to us. Call 302.888.9172 or email licensing@waivergroup.com for assistance. You can also visit our Policy and Procedure page for detailed resources, including expert support through Waiver Consulting Group’s services to help you maintain comprehensive compliance.