Administrative Entity Operating Agreement · as a required need by the Participant’s team responsible for developing the ISP. Bi-annual Review – The category field in HCSIS used

AE Operating Agreement Effective July 1, 2013

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Administrative Entity Operating Agreement

This Agreement is effective as of July 1, 2013, for the purposes of ______________ ________________________________________, hereinafter referred to as the “Administrative Entity (AE)”, conducting the administrative functions of the Consolidated (CMS # PA.0147) and Person/Family Directed Support (P/FDS)(CMS # PA.0354) Waivers for individuals and Waiver Participants with intellectual disabilities. WITNESSETH: WHEREAS, the Department retains the authority and responsibility to implement, administer and oversee the Consolidated and P/FDS Waivers, hereinafter referred collectively to as the “Waivers”, except where otherwise specifically named. WHEREAS, the AE is responsible for the Waiver administrative functions as defined in Appendix A to this Agreement. WHEREAS, authorization has been given for the Waivers as a result of federal approval under Section 1915 (c) of the Social Security Act. WHEREAS, federal approval was conditioned on assurances that the expenditure of Waiver funds be governed by the Waivers, including the criteria set forth in Appendix A to this Agreement. WHEREAS, the Pennsylvania Mental Health and Intellectual Disability Act of 1966 creates a dynamic relationship in administrative oversight in the delivery of publicly funded community behavioral health and intellectual disabilities services. WHEREAS, the Department has offered the county program the right of first opportunity to provide certain administrative services for the Waivers, in order to better coordinate care with other publicly funded community human services. NOW THEREFORE, the AE intending to be legally bound to perform AE administrative functions agrees as follows:

1. That the allocation of administrative funding is conditional upon the AE’S compliance with the Waivers and Agreement conditions.

2. That this Agreement shall remain in full force and effect until it is:

a. Altered by a change in law, b. Altered by an approved Waiver amendment or Waiver, c. Superseded by another agreement or amendment to this Agreement,

or d. Terminated as outlined in Sections and Subsections 9.0 through

9.3.2.1 of this Agreement.


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Signature of Person with legal authority to bind the Department to the terms of this Agreement: ________________________ ______________________ ________________ Typed or Printed Name Signature Date Signature(s) of persons with legal authority to bind the AE to the terms of this Agreement: ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date ________________________ ______________________ ________________ Typed or Printed Name Signature Date


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Table of Contents

Section Section Title Page Table of Contents 3 Appendix A: Operating Agreement Terms and Conditions 5 1.0 Definition of Terms 5 2.0 General Scope of the Operating Agreement 13 2.1 Sovereign Immunities 13 2.1.1 Authority of the Department 13 2.1.2 Authority of the Administrative Entity (AE) 13 2.2 Indemnification 13 3.0 Administrative Functions 14 3.1 Delegated or Purchased Administrative Functions 14 3.1.1 Authorization to Delegate or Purchase Administrative

Functions 15 3.1.1.1 Monitoring of Delegated or Purchased Administrative Functions 18 3.2 Financial Administration Requirements 19 3.2.1 Financial Liability for the Waiver Program 19 3.2.2 Administrative Payments to the AE 19 3.2.3 Ineligible Waiver Expenditures 20 3.2.4 Financial Liability of Waiver Participants 21 3.2.5 Financial Audits 21 3.2.6 Desk Review 21 3.2.7 Claim Resolution Support 21 3.3 Waiver Records 21 3.3.1 Waiver Participant Records 22 3.3.2 Other Waiver Records 22 3.3.3 Safeguarding Waiver Records 23 3.3.4 Access to Waiver Records 23 3.4 Waiver Capacity Management 24 3.4.1 Waiver Capacity Commitment 24 3.4.2 Waiver Residential Vacancy Management 25 3.4.3 Reserved Capacity Due to Hospital or Rehabilitation

Care 25 3.4.4 Unanticipated Emergencies 26 4.0 Meeting the Needs of Waiver Participants 26 4.1 Prioritization of Urgency of Need for Services (PUNS) 26 4.2 Service Delivery Preference 27 4.3 Eligibility and Enrollment for Waiver Services 27 4.3.1 Level of Care 27 4.3.2 MFP Consent 28 4.3.3 Financial Eligibility 28


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4.3.4 Consolidated Waiver Enrollment 28 4.3.5 Person/Family Directed Support (P/FDS) Waiver

Enrollment 28 4.3.6 Waiver Transfers 29 4.4 Offering Free Choice of Willing and Qualified Providers 29 4.5 Financial Management Services (FMS) 30 4.6 Service Initiation upon Waiver Enrollment 30 4.7 Statewide Needs Assessment 30 4.7.1 Statewide Needs Assessment Contractor 30 4.8 Individual Support Plans (ISPs) 31 4.8.1 Review, Approval and Authorization of Individual Support

Plans (ISPs) and Waiver Services 31 4.8.2 Additional Prerequisites for Service Authorization 32 4.8.2.1 Residential Services 33 4.8.3 Implementation of Individual Support Plans (ISPs) 34 4.8.4 Service Requests 34 4.9 Fair Hearing and Appeal 35 4.9.1 Notice of Fair Hearing Rights 35 4.9.2 Continuation of Waiver Services 36 5.0 Waiver Providers 36 5.1 Provider Recruitment and Enrollment 36 5.2 Qualification of Waiver Providers 36 5.3 Ineligible Waiver Providers 37 6.0 Monitoring Waiver Requirements 37 6.1 Monitoring of Waiver Providers 37 6.2 Correction of Issues and Non-Compliance 39 6.3 Administrative Review 39 6.4 Implementation of Department Decisions and Findings 40 7.0 Quality Management (QM) 41 7.1 Quality Management (QM) Plan 41 7.1.1 Utilizing Department Information to Enhance Quality 42 7.1.2 Functions of the AE’s QM Point Person(s) 42 7.2 Incident Management 42 7.3 Independent Monitoring for Quality (IM4Q) 42 8.0 Training and Technical Assistance 42 8.1 Participation in Training 42 8.2 Technical Assistance 43 9.0 Operating Agreement Remedies and Termination 43 9.1 Agreement Remedies 43 9.2 Agreement Termination 45 9.2.1 Enforcement 45 9.3 Transition Plan and Closeout Procedures for

Agreement Termination 45 9.3.1 Transition Plan for Agreement Termination 45 9.3.2 Closeout Procedures for Agreement Termination 46 9.3.2.1 Enforcement 47


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Appendix A

Operating Agreement Terms and Condition

1.0 Definition of Terms

The following capitalized terms as used in this Agreement are defined as set forth below: Administrative Entity: County/AE (AE) – A county/joinder or non-governmental entity that enters into and maintains a signed current agreement with the Department to perform administrative functions delegated by the Department, as the Department’s designee, in compliance with the Department’s approved Consolidated and P/FDS Waivers, Written Policies and Procedures and Departmental Decisions. AE Oversight Monitoring (AE OM) Process – A process including ODP’s continuous review of specific indicators with a formal onsite review of the AE conducted annually aimed at assessing the AE’s ability to conduct Waiver operational and administrative functions and a subsequent development of a Findings Report summarizing the onsite review. Agency With Choice (AWC) – A type of Financial Management Services (FMS) Provider acting as the Common-Law Employer which provides an administrative service that supports a Participant or Participant’s Surrogate acting as the Managing Employer in the management of the Participant’s Support Service Workers (SSW’s) and supports and services authorized in the Participant’s Individual Support Plan (ISP). Annual Review Update – The category field in the Home and Community Services Information System (HCSIS) used to document the results of an ISP annual review meeting. The annual review update date is the end date of the current ISP. Approved Program Capacity – The individual capacity established by the Department for each Waiver-funded residential service location licensed under 55 Pa. Code Chapters 6400 (relating to Community Homes for Individuals With Mental Retardation). Assessed Needs – Needs of Waiver Participants identified through the Statewide Needs Assessment or other valid assessments that have been conducted based on the Participant’s unique circumstances, documented in writing including frequency and duration, when applicable prescribed by a licensed medical professional, and identified as a required need by the Participant’s team responsible for developing the ISP. Bi-annual Review – The category field in HCSIS used to document the results of the


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six month review for certain class members and waiver participants receiving a service(s) that requires a six month review. Bureau of Hearings and Appeals (BHA) – The Departmental entity charged with conducting administrative hearings and timely adjudication of appeals which are filed in accordance with state and federal regulations. Centers for Medicare & Medicaid Services (CMS) – The agency in the federal Department of Health and Human Services that is responsible for federal administration for Medicaid, Medicare, and State Children’s Health Insurance programs. Claim – A bill for a service(s) or a line item of service within a bill for a service(s) provided to a Waiver Participant that is submitted through the Provider Reimbursement and Operations Management Information System in electronic format (PROMISe™) Common-Law Employer – The individual or Provider that is the legal employer, also known as “employer of record” of the staff hired to support the Participant. Corrective Action Plan (CAP) – A plan to address issues of noncompliance or a Health and Welfare risk of a Participant. Cost Report – An annual report of revenue and expenses required of Providers rendering specified services to Waiver Participants which is then used by the Department to develop prospective rates for those Waiver services. County Assistance Office (CAO) – The county offices of the Department that administer public assistance benefits including determining and maintaining recipient Medicaid Waiver eligibility. County/Joinder Mental Health/Intellectual Disabilities (MH/ID) Board – The board established by a county, joinder or city of the first class as per Section 302 of the Mental Health and Intellectual Disability Act of 1966, 50 P.S. §§ 4101-4704. Critical Revision – The category field in HCSIS used to add, delete or modify the level of a service in a current ISP based on the Participant’s Assessed Needs which requires approval and re-authorization of the service in the ISP. Department – The Pennsylvania Department of Public Welfare (DPW) and the state program offices under the heading of this Department, including ODP, except where some other subdivision is specifically named. Departmental Decisions – Written determinations made by the Department including but not limited to: service review findings, Provider dispute resolution findings, BHA decisions, reconsiderations made by the Secretary of DPW, decisions made by the Deputy Secretary of ODP, Provider qualification and disqualification actions, licensing actions, interpretations of policy, findings resulting from an investigation completed by


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an ODP regional certified investigator, Findings Reports related to AE performance and responses to a CAP or Directed Corrective Action Plan (DCAP). Desk Review – The review designed to identify errors in a Cost Report and to determine whether or not a Cost Report has been completed in accordance with the Cost Report instructions. Directed Corrective Action Plan (DCAP) – A document developed or approved by the Department or the Department’s designee to resolve noncompliance. Factoring – The act of an individual, service Provider or organization such as a collection agency or service bureau, which advances money to a Provider for accounts receivable that the Provider has assigned, sold or transferred to the individual or organization for an added fee or deduction of a portion of the accounts receivable. Factoring does not apply to a business agent, such as a billing service or an accounting firm that furnishes statements and receives payments in the name of the Provider, if the organization’s compensation for this service is:

1. Related to the cost of processing the billing. 2. Not related on a percentage or other basis to the amount that is billed or

collected. 3. Not dependent upon the collection of the payment.

Financial Management Services (FMS) – A type of Provider (either AWC or Vendor Fiscal/Employer Agent (VF/EA) that provides administrative support to a Waiver Participant who self-directs all or some of their HCBS services and fulfills specific employer or employer agent responsibilities for that Participant. Findings Report – A report detailing issues identified through the monitoring of each AE conducted by the Department during the AEOM Process to ensure compliance with this Agreement, Written Policies and Procedures and Departmental Decisions. Fiscal Year (FY) – The period of time extending from July 1 of one calendar year through June 30 of the next calendar year. Fiscal Year Renewal – The category field in HCSIS used to create a renewal of the ISP for the next FY with a begin date of July 1 and an end date of June 30. General Update – The category field in HCSIS used to update content in an ISP that does not impact services or funding. Health and Welfare – Health and Welfare relates to the assurances outlined in the federal code of regulations at 42 CFR 441.302, through applicable state and federal laws and Written Policies and Procedures. Home and Community Services Information System (HCSIS) – The secure internet


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information system serving the DPW state program offices that oversee Medicaid Waivers. Independent Monitoring for Quality (IM4Q) – A survey and interview instrument focusing on the quality of services and supports for individuals and Participants with intellectual disabilities which provides a source of data to support ODP quality initiatives. Individual Support Plan (ISP) – The comprehensive decisions agreed upon by the Participant’s team and documented on the form designated by the Department which identifies outcomes and needed services and supports provided to an individual. Ineligible Provider – A Provider identified on one of the following lists or databases:

Excluded Parties List System (EPLS) – This system includes information regarding entities debarred, suspended, proposed for debarment, excluded or disqualified under the non-procurement common rule or otherwise declared ineligible from receiving federal contracts, certain subcontracts and certain federal assistance and benefits. List of Excluded Individuals/Entities (Maintained currently in the System for Award Management or SAM) – A database maintained by the Office of Inspector General for use by the public, health care providers, patients and others which provides information relating to parties excluded from participation in Medicare, Medicaid and all federal health care programs. Medicheck – A list identifying providers, individuals and other entities precluded from participation in the Commonwealth of Pennsylvania Medical Assistance Program.

In addition, a Provider that expresses interest in delivering Waiver services that has not completed the Department’s Provider qualification process is also considered an Ineligible Provider of Waiver services until such time the Provider meets the qualification criteria, completes the qualification process and is determined by the Department to be a Qualified Provider. Jurisdiction of the Administrative Entity – The geographic area and/or specific Participants the AE is responsible for when providing Waiver functions as identified in Appendix A to this Agreement and the approved Waivers. Managing Employer – The Participant or Surrogate who agrees to enter into a joint-employer arrangement with the AWC FMS. Medicaid or Medical Assistance (MA) – The program authorized under Title XIX of the federal Social Security Act, 42 U.S.C. 1396 et seq., and regulations promulgated thereunder.


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Office of Developmental Programs (ODP) – The Pennsylvania state program office within DPW that oversees ODP Waivers, sets policy, provides funds and administers services for individuals with intellectual disabilities and autism. Organized Health Care Delivery System (OHCDS) – The arrangement in which a Provider that renders at least one direct Waiver service also chooses to offer vender services by subcontracting with a Vendor in order to facilitate the delivery of vendor services. The OHCDS Provider enrolls, qualifies and monitors that the subcontracted Vendor is in compliance with all state and federal laws and regulations, the current Provider Agreement, Written Policies and Procedures and Departmental Decisions. Participant – An individual determined to meet eligibility criteria and who is enrolled in either the Consolidated or P/FDS Waiver. Person/Family Directed Support (P/FDS) Cap – The per Participant limitation for Waiver services funded through the P/FDS Waiver during a state FY, excluding costs for supports coordination services. Plan Creation – The category field in HCSIS used for the initial creation of an ISP or to create an ISP for a Participant without a current ISP in HCSIS. Prioritization of Urgency of Need for Services (PUNS) – The strategic planning tool and current process used to categorize an applicant’s need for services prior to enrollment in one of the Waivers which is then reviewed at least annually thereafter. Provider – An entity or individual that enters into and maintains a signed Provider Agreement with the Department to render a Waiver service(s), which meets the definitions of both a Willing Provider and a Qualified Provider. Provider Agreement for Participation in Pennsylvania’s Consolidated and Person/Family Directed Support Waivers (Waiver Provider Agreement) – The ODP agreement signed by a Waiver service Provider as per 42 CFR 431.107, under which the Provider agrees to furnish services to Medicaid Waiver Participants in compliance with state and federal requirements, including Waiver requirements approved by CMS. Provider Reimbursement and Operations Management Information System in electronic format (PROMISe™) – A secure internet tool that allows Providers, managed care organizations and drug labelers or manufacturers to submit a Claim, check a Claim’s status, access real time eligibility verification information, access web-based training courses, review and download user manuals and Claim forms. Qualified Intellectual Disability Professional – A person who meets and maintains acceptable professional standards, has at least one year of experience working directly with individuals with intellectual disabilities or other developmental disability and holds a valid certification, licensure or degree in an applicable field of study as identified in 42 CFR 483.430 (a)(2)(i)(ii) and 483.430 (b)(5)(i)-(ix), as well as any related academic


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disciplines associated with the study of: human behavior (e.g., psychology, sociology, speech communication, gerontology, etc.), human skill development (e.g., education, counseling, human development), humans and their cultural behavior (e.g., anthropology), or any other study of services related to basic human care needs (e.g., rehabilitation counseling) or the human condition (e.g., literature, the arts). Qualified Provider – A Provider qualified to render a specific Waiver service that meets state and federal laws and as per Written Policies and Procedures and Departmental Decisions relating to qualification, requalification and disqualification of Waiver Providers. Quality Management (QM) Plan – A written plan describing how the AE will measure, remediate and improve its performance in a manner consistent with the Department’s QM Strategy to ensure sustained compliance with Waiver assurances and to contribute towards achieving the Department’s identified priorities for improvement. Quality Management (QM) Strategy – The structure, process, roles, responsibilities and methods the Department uses to manage its performance to achieve quality results including continuous cycles of performance measurement (discovery), correction of individual problems (remediation) and implementation of system-wide change as needed (improvement). Reserved Capacity – The portion of the approved waivers that are reserved for the enrollment of specified groups or targeted purposes. Statewide Needs Assessment – The assessment designated by the Department to be used during the ISP process to determine the individual’s or Participant’s needed services. Substantial Failure – A repeated pattern of noncompliance with the AE’s responsibilities outlined in this Agreement, non-adherence with Written Policies and Procedures and Departmental Decisions, inability to develop and /or implement an approved CAP or DCAP to remedy noncompliance areas, and/or an egregious noncompliance issue that jeopardizes Participant Health and Welfare and/or overall state compliance with federal Waiver requirements approved by CMS. Support Service Worker (SSW) – A person hired by a Waiver Participant or Participant’s Surrogate who is managing services through one of the self-directing options. Supports Coordination Organization (SCO) – A type of Waiver Provider with the primary responsibilities of locating, coordinating and monitoring needed services and supports for Waiver Participants. Supports Coordinator (SC) – An employee of a SCO with the primary responsibilities of locating, coordinating and monitoring needed services and supports for Waiver


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Participants. Surrogate – A person identified under state law to make decisions for a Participant who is incompetent or incapacitated. A surrogate can have various legal titles, but for the purposes of this Agreement, this person will be referred to a Surrogate. A Surrogate includes one of the following:

• A parent of a child under 18 years of age under the common law and 35 P.S. § 10101.

• Legal custodian of a minor as provided in 42 Pa. C.S. § 6357. • A health care agent and representative for an adult as provided in 20 Pa.

C. S. Ch. 54. • A guardian of various kinds as provided in 20 Pa. C. S. Ch. 55 (as limited

by 20 Pa. C.S. § 5521 (f)). • A holder of powers of attorney of various kinds as provided in 20 Pa. C.S.

Ch. 56. • A guardian of a person by operation of law in 50 P.S. § 4417 (c)

Any of these would be considered a legal representative under applicable law. For a surrogate performing the function of Common-Law Employer or Managing Employer in one of the FMS options, additional persons can be designated as a Surrogate by a Participant 18 years of age and older. Unanticipated Emergency – An occurrence when an individual or P/FDS Waiver Participant has an imminent risk of: institutionalization within twenty-four (24) hours, substantial self-harm or substantial harm to others; if the individual does not immediately receive services and this imminent risk is precipitated by at least one of the following situations:

• The illness or death of a caretaker. • The sudden loss of the individual’s home (for example, due to fire or

natural disaster). • The loss of the care of a relative or caregiver, without advance warning or

planning. To be considered by the Department to be an Unanticipated Emergency, the AE and the County Program must have no other resources available to address the individual’s immediate Health and Welfare needs. Vendor – An entity that provides general goods or services and possesses the following distinguishing characteristics: goods/services are provided within normal business operations, similar goods/services are provided to many different purchasers, and the Vendor operates in a competitive environment providing goods/services to the general public.


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Vendor Fiscal/Employer Agent (VF/EA) – A type of FMS Provider acting as the fiscal agent which provides an administrative service that supports a Participant or Participant’s Surrogate acting as the Common-Law Employer to hire and manage SSWs. Under the VF/EA FMS model, the Participant or Surrogate retains full and legal responsibility for all aspects of being the Common-Law Employer, with the exception of processing payroll for the SSWs, withholding and reporting taxes, obtaining and processing workers’ compensation and insurance payments and processing payment of all invoices. Waivers – The current approved Consolidated and P/FDS Waivers, except where otherwise specifically named herein. Waiver Administration Allocation – The administrative funds allocated to oversee and provide Waiver administrative functions as per this Agreement, Written Policies and Procedures and Departmental Decisions. Waiver Capacity Commitment – The number of Participants the AE may enroll in a specified Waiver at any given point in time during a FY, as approved by the Department. Waiver Capacity Commitment Notification – A notification that designates the Department’s current approved maximum number of Participants within the Jurisdiction of the AE that may be enrolled in each Waiver at any given point in time during a FY. There are two numbers designated in the Waiver Capacity Commitment Notification. One reflects the number of Participants that may be enrolled in the Consolidated Waiver and one reflects the number of Participants that may be enrolled in the P/FDS Waiver during a FY. Waiver Capacity Management – The overall process of properly maintaining the AE’s Waiver Capacity Commitment which includes following Department-approved policies and procedures relating to Waiver Capacity Commitment, Maintaining Reserved Capacity (including the tracking of individuals due to hospitalization or rehabilitation care), Waiver Residential Vacancy Management and management of Unanticipated Emergencies. Waiver Residential Vacancy Management – The process of identifying and managing a vacancy in a service location licensed under 55 Pa. Code Chapter 6400 (relating to Community Homes for Individuals with Mental Retardation) within the service location’s Approved Program Capacity. Willing Provider – A provider that agrees to serve Waiver Participants, to accept the Department’s payment as payment in full for rendering a Waiver service and to abide by all of the Medicaid Waiver Provider requirement, including entering into and maintaining a signed current Waiver Provider Agreement with the Department. Written Policies and Procedures – CMS-approved Waivers, Waiver amendments,


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rules, regulations, policies, policy clarification, bulletins, directives, procedures and any Department-approved revisions specific to Medicaid Waivers that are developed and overseen by the Department. This includes written correspondence signed by the Secretary of DPW or the Deputy Secretary of ODP. 2.0 General Scope of the Operating Agreement

2.1 Sovereign Immunities Nothing herein is intended to limit, modify, alter or impair, directly or indirectly, the sovereign immunities of the Commonwealth, the Department or AE respectively, including but not limited to such immunities as applicable to dealings with third parties.

2.1.1 Authority of the Department The Department retains the authority to exercise discretion in the administration and supervision of all Waiver-related matters including the terms and conditions of this Agreement and to issue Departmental Decisions and Written Policies and Procedures related to the Waivers. An AE does not have the authority to change or disapprove any administrative Departmental Decisions or otherwise substitute its judgment for that of the Department with respect to the application and implementation of Written Policies and Procedures and Departmental Decisions. 2.1.2 Authority of the Administrative Entity (AE)

The authorities of the AE are as set forth herein and shall include the authority to enter into and maintain subcontracts with other entities, as reverenced in Section 3.1 and Subsection 3.1.1 of this Agreement, for the administrative functions hereunder and the other authorities of the AE as set forth herein.

2.2 Indemnification

Without waiving any immunity conferred by statute or common law, the AE shall hold the Commonwealth of Pennsylvania and by extension, the Department and ODP, harmless from and indemnify the Commonwealth of Pennsylvania, the Department and ODP against any and all claims, demands and actions based upon or arising out of any activities performed under this Agreement or nonperformance under this Agreement by the AE, any agent of the AE, any subcontractor or anyone directly or indirectly employed by the AE or an agent or subcontractor of the AE and shall, at the request of the Commonwealth, Department or ODP, defend any and all actions brought against the


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Commonwealth, Department or ODP based upon any such claims, demands and actions.

3.0 Administrative Functions All Waiver services and administrative functions must be provided in compliance with federal and state statutes and regulations that apply to the Waiver Programs and waiver Participants, the conditions of this Agreement, litigation affecting waiver enrollment or waiver Participants, Written Policies and Procedures and Departmental Decisions.

3.1 Delegated or Purchased Administrative Functions

The AE may delegate or purchase administrative functions in accordance with applicable provisions of Pennsylvania statute and regulation. Please see Subsection 3.1.1 of this Agreement for a list of AE functions that may and may not be delegated or purchased. The AE shall continue to retain responsibility for compliance with this Agreement, Written Policies and Procedures and Departmental Decisions when it delegates to or purchases administrative functions from an entity. The AE shall ensure that any delegated or purchased administrative functions are established in writing pursuant to a subcontract or agreement. If administrative functions identified in this Agreement are delegated to or purchased from an entity, the AE shall ensure Pursuant to a subcontract or agreement with that entity, the administrator or director of that entity shall also be responsible for the terms and conditions attached to those administrative functions as per this Agreement, Written Policies and Procedures and Departmental Decisions. All subcontracts and agreements for delegated or purchased administrative functions must comply with 42 CFR 434.6 and 42 CFR 434.10 and must allow for periodic inspections by the Department, the Commonwealth of Pennsylvania, the United States Comptroller General, the United States Department of Health and Human Services and the authorized representatives of any of the agencies listed in this Section, to validate the quality, appropriateness and timeliness of services performed as part of the subcontract or agreement. The Department retains the authority to provide the AE with direction that must be followed related to the selection of an entity performing delegated or purchased administrative functions. Subsection 3.1.1, further addresses delegated or purchased functions. For all administrative functions performed by or subcontracted to an entity, the AE shall submit to the appropriate regional ODP on an annual basis, by April 1 for the upcoming fiscal year:


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1. A list of the administrative functions the AE will continue or begin to delegate or purchase from an entity during the next FY.

2. A brief statement describing each specific administrative function the AE will delegate to or purchase from an entity or proposes to delegate or purchase during the next FY and the current entity or proposed entity that will provide those administrative functions for the AE during the next FY.

3. Procedures the AE has or will put in place to monitor the completion of those delegated or purchased administrative functions during the next FY.

4. A list of related subcontracts or agreements to be effective during the next FY.

This shall include a description of the tasks/functions delegated, specific work requirements for each delegated function, reporting requirements and process to address any performance issues. The AE may submit the written subcontract or agreement that it has with the entity as an alternative when it includes this information. The monitoring protocols must include:

• Frequency of AE review and the staff (positions/titles) responsible for

monitoring. • A description of the method to be used. This must address all

requirements of the delegated function.

If the AE does intend to subcontract or delegate administrative functions in accordance with the conditions referenced in Subsection 3.1.1, the AE shall submit the information outlined in #1-4 above with this signed Agreement.

If the AE proposes to make a change to its delegated or purchased administrative functions, the AE shall notify the appropriate regional ODP in writing at least thirty (30) calendar days prior to initiating the change and in compliance with the additional conditions referenced in Subsection 3.1.1 of this Agreement. If the AE proposes to begin delegating or purchasing a new administrative function to a current subcontracted entity or new entity after the submission of the information outlined in #1-4 above with this signed Agreement or after the annual re-submission of delegated or purchased administrative functions information as outlined in #1-4 above, the AE shall submit the information outlined in #1-4 above in relation to the new proposal to the appropriate regional ODP prior to entering into a new subcontract or agreement and in compliance with the additional conditions referenced in Subsection 3.1.1 of this Agreement.

3.1.1 Authorization to Delegate or Purchase Administrative Functions

The AE shall notify the Department prior to delegating or purchasing administrative functions from an entity. Upon notification to the


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Department, the purchase or delegation of administrative functions referenced in “List A” of this Subsection is not subject to Department approval, except relating to the Department retaining authority to provide direction regarding selection of the subcontracted entity. However, the AE shall remain responsible for the conditions referenced in Section 3.1 including the responsibility of prior notification to the appropriate regional ODP and retaining its responsibilities and authorities as set forth herein. List A – Once prior notification is given to the appropriate regional ODP, the administrative functions which have been designated as AE responsibilities within the following Sections and Subsections, may be delegated to or purchased from an entity:

1. Section 4.2, Service Delivery Preference. 2. Subsection 4.3.1, Level of Care; related to the certification by

the Qualified Intellectual Disability Professional. 3. Subsection 4.3.3 , Financial Eligibility. 4. Section 4.7, Statewide Needs Assessment. 5. Subsection 4.9.1, Notice of Fair Hearing Rights; however, the

AE must conduct the issuance of adverse actions. 6. Section 5.1, Provider Recruitment and Enrollment; however, if

delegated to or purchased from an entity, the AE remains responsible to notify the contracted entity of service gaps due to absence of choice of Providers.

7. Section 6.4, Implementation of Departmental Decisions and Findings; however, the AE is responsible for review, approval and authorization of Waiver services and Departmental Decisions directly related to the AE.

8. Section 8.2, Technical Assistance; unless directly related to an activity required to be conducted by the AE.

Prior approval must be obtained from the Department when the AE wants to delegate or purchase one or more of the responsibilities referenced in “List B” of this Subsection. However, the AE shall remain responsible for the conditions referenced in Section 3.1 including the responsibility for prior notification to the appropriate regional ODP and retaining its responsibilities and authorities as set forth herein. Prior approval requests shall be submitted in writing to the appropriate regional ODP to delegate or purchase any of the following responsibilities. List B – Once prior approval to delegate or purchase the administrative functions to an entity has been obtained from the Department, the administrative functions which have been designated as AE responsibilities within the following Sections and Subsections may be delegated to or purchased from and entity:


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1. Subsection 3.2.6, Desk Review. 2. Subsection 3.2.7, Claim Resolution Support. 3. Subsection 3.3.1, Waiver Participant Records. 4. Subsection 3.3.2, Other Waiver Records. 5. Subsection 3.3.3, Safeguarding Waiver Records. 6. Subsection 3.3.4, Access to Waiver Records. 7. Section 3.4, Waiver Capacity Management. 8. Subsection 3.4.1, Waiver Capacity Commitment. 9. Subsection 3.4.2, Waiver Residential Vacancy Management. 10. Subsection 3.4.3, Reserved Capacity Due to Hospital or

Rehabilitative Care. 11. Subsection 3.4.4, Unanticipated Emergencies. 12. Section 4.1, Prioritization of Urgency of Need for Services

(PUNS). 13. Subsection 4.3.1, Level of Care, related to the determination by

the AE. 14. Subsection 4.3.4, Consolidated Waiver Enrollment; however,

the AE must make the final decision regarding an individual’s enrollment.

15. Subsection 4.3.5, Person/Family Directed Support (P/FDS) Waiver Enrollment; however, the AE must make the final decision regarding an individual’s enrollment.

16. Subsection 4.3.6, Waiver Transfers; however the AE must make the final decision regarding the transfer.

17. Section 4.4, Offering Free Choice of Qualified and Willing Providers.

18. Section 4.5, Financial Management Services (FMS), however, the AE must conduct the review, approval and authorization of Waiver services.

19. Section 4.6, Service Initiation upon Waiver Enrollment. 20. Subsection 4.7.1, Statewide Needs Assessment Contractor. 21. Section 4.8, Individual Support Plans (ISPs); however the AE

must conduct the review, approval and authorization of Waiver services.

22. Subsection 4.8.1, Review, Approval and Authorization of Individual Support Plans (ISPs) and Waiver Services; however, the AE must conduct the review, approval and authorization of Waiver services.

23. Subsection 4.8.2, Additional Prerequisites for Service Authorization; however, the AE must conduct the review, approval and authorization; however, the AE must conduct the review, approval and authorization of Waiver services.

24. Subsection 4.8.2.1, Residential Services; however, the AE must conduct the review, approval and authorization of Waiver services.

25. Section 4.8.3, Implementation of Individual Support Plans


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(ISPs). 26. Section 4.8.4, Service Requests. 27. Section 4.9, Fair Hearing and Appeal 28. Subsection 4.9.2, Continuation of Waiver Services. 29. Section 5.2; Qualification of Waiver Providers; however the AE

must make the qualification recommendation to the appropriate regional ODP.

30. Section 6.0, Monitoring Waiver Requirements. 31. Section 6.1, Monitoring of Waiver Providers; however, the AE

must approve and issue the monitoring findings. 32. Section 6.2, Correction of Issues Identified During AEOMP,

External Reviews, Provider Monitoring, Targeted Reviews and Audits; however, the AE remains responsible to develop, submit and implement a CAP directly related to an AE issue.

33. Section 6.3, Administrative Review. 34. Section 7.1, Quality Management (QM) Plan; however the AE

must sign-off on the QM Plan. 35. Section 7.2, Incident Management 36. Section 7.3, Independent Monitoring for Quality (IM3Q). There are AE responsibilities referenced throughout Appendix A which the AE may never delegate to or purchase from and entity. If an administrative function in this Agreement is not included in List A or B above, or has an identified restriction in List A or B above, the AE shall not delegate or purchase those administrative functions from an entity.

3.1.1.1 Monitoring of Delegated or Purchased Administrative Functions

Monitoring of delegated or purchased administrative functions as referenced in this Agreement is a separate and discrete function from the AE monitoring of provider requirements as referenced in Sections 6.0 and 6.1 of this Agreement. If the AE delegates or purchases an administrative function that has been designated as a responsibility of the AE to an entity, the AE shall monitor that delegated or purchased administrative function to ensure compliance with written Policies and Procedures, Departmental Decisions, state and federal laws and the terms and conditions of this Agreement. The AE shall use the form issued by the Department to record and report the monitoring findings. The AE shall be held responsible for the quality, compliance and completion of an administrative function which has been delegated to it


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by the Department, even when the AE delegates or purchases that administrative function to an entity through a subcontract or agreement. The Department will utilize a variety of means to ensure compliance with Agreement requirements, Written Policies and Procedures and Departmental Decisions, when the AE demonstrates a Substantial Failure to monitor and ensure delegated or purchased administrative functions are conducted in compliance with the terms and conditions of this Agreement. The Department will pursue remedial actions as needed to resolve any outstanding performance concerns and violations with the Agreement. The application of remedies shall be a matter of public record once an acceptable CAP has been developed by the AE. AE noncompliance will be addressed through remedial efforts as referenced in Section 9.1 of this Agreement. While remedies will generally follow a progressive path, the Department reserves the right to deviate from this path for significant issues of noncompliance as determined by the Department. In the event that the Department finds there has been Substantial Failure of the AE to ensure adherence and compliance, through the monitoring of delegated and purchased administrative functions, with the responsibilities and functions outlined in this Agreement or Substantial Failure of the AE to monitor Waiver services, for compliance with the terms and conditions of this Agreement, when provided to Participants in the Pennsylvania ODP service system through the delegation or purchasing of an administrative function to an entity, the Department may provide notice of termination as referenced in Section and Subsections 9.2 through 9.3.2.1 of this Agreement.

3.2 Financial Administration Requirements 3.2.1 Financial Liability for the Waiver Program

The ultimate financial liability to meet the needs of Waiver Participants rests with the Department, within the scope of the approved Waivers, and to exceed the limits of the state appropriation.

3.2.2 Administrative Payments to the AE


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Contingent of state budget approval, the Department shall make advance quarterly payments of Waiver administration funds necessary to comply with the requirements outlined in this Agreement to the county or county/joinder. The first quarterly installment shall be for the quarter of the FY beginning July 1 and ending September 30. The second installment shall be for the quarter October 1 ending December 31. The third installment shall be for the quarter beginning January 1 and ending March 31. The fourth installment shall be for the quarter beginning April 1 and ending June 30. The Department will provide the final allocation no later than September 30. The Department reserves the right to review advance installments against actual expenditures at any time, and to make appropriate adjustments in subsequent advances. If an overpayment cannot be recovered through an adjustment, the Department shall request a refund from the AE. The Department will evaluate increases and decreases in the AE’s workload and reserves the right to adjust the allocation to the AE via an updated notice indicating its Waiver Administration Allocation. This will occur up to the state appropriation. The Department will evaluate the Waiver Administration Allocation against the terms of the Agreement to assure there are sufficient allocations to perform all terms. If the state appropriation is not sufficient to allow all terms of the Agreement to be completed, the Department will prioritize the terms of the Agreement and notify the AE regarding this prioritization. To the extent that the AE requests additional funds for inclusion in its Waiver Administration Allocation, the Department shall notify the AE of its decision in writing within thirty (30) calendar days of receipt of a request. 3.2.3 Ineligible Waiver Expenditures

The AE shall ensure that the following are not authorized as Waiver services: 1. The purchase of Waiver ineligible service(s). 2. Service(s) or benefit(s) to an individual who is ineligible for Waiver

service(s) or benefit(s) 3. The purchase of a Waiver service(s) rendered by a Provider that is

restricted or sanctioned by the Department. 4. The purchase of a Waiver service(s) rendered by a Provider that is not

qualified to render a Waiver service(s). 5. The purchase of a Waiver service(s) rendered by an Ineligible

Provider.


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3.2.4 Financial Liability of Waiver Participants The AE may not require a Participant to pay a cost share or co-pay for Waiver-eligible service(s), unless otherwise specified in the approved Waivers.

3.2.5 Financial Audits

The AE shall comply with all applicable federal audit requirements, including the Single Audit Act, as amended; the revised Office of Management and Budget Circular A-133, titled: Audits of Stated, Local Governments and Non-Profit Organizations; 45 CFR 74.26 and any other applicable law or regulation promulgated by the federal government.

The AE shall assist the Department as requested with the review and follow up of Provider audits.

3.2.6 Desk Review

The AE shall collect data to support rate setting activities for Waiver service(s) when requested and in accordance with instructions issued by the Department.

The AE shall conduct a Desk Review of the Provider Cost Reports as per instructions issued by the Department. 3.2.7 Claim Resolution Support The AE shall use the Claim resolution support process issued by the Department to assist Providers in the timely resolution of a denied Claim resulting from issues with ISPs and /or discrepancies between HCSIS and information maintained by the Department’s CAO. The AE shall designate staff to serve as the point of contact for Claim resolution support issues and shall advise the appropriate regional ODP and Waiver Providers of this staff designation.

3.3 Waiver Records

The AE shall preserve Waiver records and documents until the expiration of five


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(5) years after the Waiver Participant’s case has been permanently closed or the Waiver-funded service was furnished. Records that relate to litigation, audit exceptions or the settlement of a Claim related to performance or expenditures under this Agreement shall be retained by the AE until such litigation, exception or Claim has reached final disposition. 3.3.1 Waiver Participant Records

The AE shall maintain the following Waiver service and financial records that separately identify Waiver Participants, funds and Waiver services:

1. Documentation of initial level of care determinations, including all supporting documentation necessary to certify level of care.

2. Documentation of the choice between institutional and home and community-based services.

3. Documentation of the initial financial eligibility determination made by the County Assistance Office, such as the initial PA-162 form.

4. Documentation of level of care re-determinations, including all supporting documentation necessary to recertify level of care.

5. OVR referral and response letters, if applicable. 6. Service review findings letter(s) issued by the Department. 7. Requests for fair hearings, including supporting documentation. 8. Documentation of meetings related to service disputes. 9. Service requests and responses. 10. Requests for extensions to service limitations and responses. 11. Requests for services requiring prior authorization and the ODP

response related to such requests. 12. ISP Review Checklist(s) 13. Correspondence/documentation related to the transfer of a

waiver participant to the AE. 14. Required documentation related to incidents and incident

investigation. 15. Money Follows the Person (MFP) consents.

3.3.2 Other Waiver Records The AE shall maintain the following other Waiver Records:

1. Subcontracts or agreements with entities paid with administrative funds (i.e., entities providing delegated or purchased administrative functions, Health Care Quality Unit (HCQU), IM4Q contracts, etc.).

2. Records of AE monitoring of delegated or purchased administrative functions, including any associated Corrective Action Plans and verification of remediation.


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3. Records to substantiate waiver administrative costs and methodology.

4. Invoices and billing records for administrative functions. 5. Any documentation related to Cost Report Desk Reviews

completed by the AE. 6. Provider audits, for time periods prior to July 1, 2009, or as

specified by the Department. 7. Documentation relating to monitoring of Waiver Providers. 8. Correspondence and documentation relating to an AE

developed CAP or DCAP. 9. Correspondence and documentation relating to the

development, modification or remediation of an approved CAP or DCAP for Waiver Providers.

10. Documentation of the verification of Provider qualification standards, including any supporting information.

11. Provider disputes, for actions which took place prior to July 1, 2009, or as specified by the Department, including supporting documentation.

12. Correspondence and/or documentation of issues identified and resolved through Waiver service monitoring.

13. AE QM Plans and associated reports.

3.3.3 Safeguarding Waiver Records The AE shall develop and implement a written protocol relating to safeguarding Waiver records and shall include the restriction or disclosure of information concerning Waiver applicants and Waiver Participants that is consistent with 42 CFR 431, subpart F. 3.3.4 Access to Waiver Records The AE shall develop and implement a written protocol relating to full and free access to all records pertaining to Waiver applicants, Participants, services and payments for services; thereby allowing for the evaluation, through inspection or other means of the quality, appropriateness and timeliness of services performed under this Agreement. Said access shall be granted to the following:

1. The Department. 2. The Commonwealth of Pennsylvania. 3. The United States Comptroller General. 4. The United States Department of Health and Human

Services. 5. The Authorized representatives of any of the agencies

listed in this Section.


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3.4 Waiver Capacity Management

The AE shall comply with the Waiver Capacity Management process as approved by the Department which includes the policies and procedures relating to Waiver Capacity Commitment (including management of reserved capacity), Waiver Residential Vacancy Management in settings licensed under 55 Pa. Code Chapter 6400 and management of Unanticipated Emergencies. The AE shall cooperate with filling a vacancy as per Department-established policies and procedures, including remaining within the Provider’s Approved Program Capacity. For a residential service location licensed under 55 Pa. Code Chapter 6400 that receives Waiver funding, the Department shall establish an Approved Program Capacity. Once established, the Approved Program Capacity is the maximum number of individuals who may receive services at that service location of any given day throughout the FY, regardless of the service type or funding used to pay for that service. The total number of Participants in the Consolidated or P/FDS Waiver during a FY may not exceed the approved number of Waiver Participants in the AE’s current Waiver Capacity Commitment. The AE shall be notified in writing if its Waiver Capacity Commitment is increased or decreased. 3.4.1 Waiver Capacity Commitment

The AE shall provide administrative functions to ensure that Waiver services are provided to Waiver Participants, while not exceeding the maximum number of Participants identified in the AE’s current Waiver Capacity Commitment, subject to the requirements outlined in Sections and Subsections 3.4 through 3.4.4 of this Agreement. For example, if the AE’s Waiver Capacity Commitment for the Consolidated Waiver is thirty (30), the AE may only have thirty (30) Participants enrolled in the Consolidated Waiver at any point in time during the FY. The Department will designate the number of new participants the Department expects the AE to enroll in one of the Waivers as part of the waiting list initiative or other reserved capacity category, if applicable. The AE shall identify those individuals using the designation made and instructions given by the Department. The waiting list and/or other reserved capacity categories will be identified separately from the Waiver Capacity Commitment. The Department reserves the right to adjust the number of Participants in the AE’s Waiver Capacity Commitment in either Waiver based on budgetary, utilization or other considerations.


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The AE shall only enroll an individual with an emergency need as defined in PUNS into one of the Waivers, except for individuals designated in a reserved capacity category. If the AE is unable to provide services to the number of Waiver Participants identified in its Waiver Capacity Commitment Notification by filling the capacity with an individual in emergency PUNS, it shall notify the appropriate regional ODP per established procedures and notify the appropriate regional ODP per established procedures and instructions. If the AE has enrolled or fails to enroll all individuals within the Jurisdiction of the AE with an emergency PUNS into one of the Waivers, the Department retains the authority to release the capacity for use by an individual within the Commonwealth who does have an emergency PUNS. If the AE needs to increase the number of Participants it serves over its current Waiver Capacity Commitment for either Waiver due to an Unanticipated Emergency, a written request to increase the Waiver Capacity Commitment must be submitted to the appropriate regional ODP. The AE may not enroll Participants in excess of its current Waiver Capacity Commitment. 3.4.2 Waiver Residential Vacancy Management The AE shall develop and maintain an implementation protocol in accordance with the Department’s Waiver Residential Vacancy Management established policies and procedures. The AE shall assign a staff point-person to implement the Waiver Residential Vacancy Management activities identified in the AE’s protocol and in accordance with the Department’s established policies and procedures. Providers of Waiver-funded residential habilitation settings licensed under 55 Pa. Code Chapter 6400 may only render services to participants up to the Approved Program Capacity of the service location. Therefore, the AE shall only approve and authorize Waiver services for Participants in residential settings licensed under 55 Pa. Code Chapter 6400 that are within the service location’s Approved Program Capacity except as approved by ODP. The AE shall also ensure it remains within its approved current Waiver Capacity Commitment. 3.4.3 Reserved Capacity Due to Hospital or Rehabilitation Care The AE shall develop and implement a written protocol to monitor the status of former waiver Participants whose enrollment in the waiver is being reserved because of a short-term stay in a hospital or rehabilitation care facility.


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When a Participant is in reserved capacity status due to a hospital or rehabilitation care stay extending more than 30 consecutive days, the AE shall review team recommendations regarding the participants return to the community on at least a monthly basis. This may include recommendations from medical providers about the Participant’s progress, the possibility of a return to the former residence, changes in level of support, any adaptations required, and whether natural, family and community supports can assist the Participant in returning to the community. 3.4.4 Unanticipated Emergencies An individual in need of services may be unknown to an AE; an individual may not be identified correctly through the PUNS process; or the individual’s PUNS does not yet accurately reflect an unanticipated change in circumstances. All of these factors may lead to the occurrence of an Unanticipated Emergency as defined in Section 1.0. The AE shall develop and implement a protocol to manage Unanticipated Emergencies efficiently and in the best interest of the individual in need of services. This protocol shall include activities to be implemented in the event that the individual is not enrolled in one of the Waivers. The AE shall work cooperatively with the County Program to address the individual’s needs. The AE shall develop and implement the protocol as directed in established policies and procedures and as approved by the Department.

4.0 Meeting the Needs of Waiver Participants All needs of Waiver Participants shall be provided in compliance with this Agreement, Written Policies and Procedures and Departmental Decisions 4.1 Prioritization of Urgency of Need for Services (PUNS)

The AE shall assign at least one (1) point person for PUNS. The PUNS point person is responsible for PUNS related activities and ongoing local training of the AE staff, SCOs and intake/registration workers. The AE shall develop and implement a written protocol consistent with the current PUNS bulletin and manual to include the following:

1. The initial completion of the PUNS in consultation with the Waiver applicant and/or applicant’s Surrogate and obtaining signature of such participation.

2. The Waiver applicant is placed in the appropriate category of need in


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the PUNS. 3. The PUNS is reviewed and updated at least annually. 4. The PUNS is updated within thirty (30) calendar days of an identified

change in need. 5. The PUNS in entered in HCSIS.

If the AE identifies performance issues of a SCO through the PUNS review, the AE shall notify the SCO of the issues. The AE shall request the submission of a CAP from the SCO to address the AE’s findings. If after consultation with the SCO, the AE finds that the SCO’s CAP is unsatisfactory, the AE shall notify the appropriate regional ODP. Except as provided through the designation in reserved capacity status, the AE shall ensure that all Waiver applicants most in need with an emergency need identified in PUNS, within the Jurisdiction of the AE, are enrolled in one of the Waivers prior to investigating the enrollment of an applicant with a different PUNS assessed category. The AE shall only enroll an applicant who is assessed as having an emergency need, as defined in PUNS, into one of the Waivers, and as referenced in Section 4.3 and corresponding Subsections. If the AE cannot identify an individual in emergency need within the Jurisdiction of the AE, the AE shall notify the regional Waiver Capacity Manager related to the AE’s capacity. The AE may not admit a Waiver applicant into a Waiver based on financial contributions or other types of enrollment fees paid by the applicant, a representative of the applicant or on behalf of the applicant to the AE, Waiver Providers or any other entity. 4.2 Service Delivery Preference The AE shall monitor compliance with the service delivery preference process established by ODP in Written Policies and Procedures and Departmental Decisions relating to service delivery preference. 4.3 Eligibility and Enrollment for Waiver Services 4.3.1 Level of Care

The AE shall complete the determination and re-determination of level of care as specified in the approved Waivers. The AE shall maintain a complete record of level of care determinations and re-determinations as per Section and Subsections 3.3 through 3.3.4 of this Agreement. The AE shall apply the process and instruments described in Written Policies and Procedures and Departmental Decisions relating to individual eligibility for Medicaid Waiver services.


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4.3.2 MFP Consent

The AE is responsible to ensure that MFP eligible participants are provided with “Informed Consent for Participation in the Money Follows the Person Rebalancing Initiative” upon enrollment. The AE shall notify the CAO if consent is obtained and shall maintain MFP records. 4.3.3 Financial Eligibility The AE shall cooperate with the Department’s CAO in determining an individual’s initial and continuing financial eligibility for Waver services in accordance with procedures established by the Department in Written Policies and Procedures and Departmental Decisions relating to individual eligibility for Medicaid Waiver services.

4.3.4 Consolidated Waiver Enrollment

As part of its continuous responsibility for safeguarding the Health and Welfare of Waiver Participants, the AE shall ensure, as identified through the approval, authorization and implementation of Waiver service outlined in Section and Subsections 4.8 through 4.8.3 of this Agreement, that the Assessed Needs and Health and Welfare of existing Consolidated Waiver Participants are fully addressed. Needs may be addressed through Waiver services, generic resources, community opportunities and family and natural supports. The AE will also ensure that it remains within its approved current Waiver Capacity Commitment for the Consolidated Waiver.

4.3.5 Person/Family Directed Support (P/FDS) Waiver Enrollment

As identified through the approval, authorization and implementation of Waiver services outlined in Section and Subsections 4.8 through 4.8.3 of this Agreement, the AE shall ensure that the Assessed Needs and Health and Welfare of existing P/FDS Waiver Participants are addressed within the P/FDS Cap prior to enrolling a new applicant into the P/FDS Waiver. Needs may be addressed through Waiver services, generic resources, community opportunities and family and natural supports. The AE will also ensure that it remains within its approved current Waiver Capacity Commitment for the P/FDS Waiver.

The AE shall only enroll a new applicant into the P/FDS Waiver it the following apply:

1. Assessed Needs identified through the planning process can be addressed within the P/FDS Cap.


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2. An unaddressed need(s) does not relate to Health and Welfare and the applicant agrees to receive only those needed services that can be provided within the P/FDS Cap.

3. A need(s) not addressed within the P/FDS Cap will be addressed using non-Waiver funded resources and /or supports.

When a P/FDS Waiver Participant experiences a change that results in an emergency need for services which will cause the Participant to go over the P/FDS Cap, the AE shall:

1. Explore alternative, more cost-effective ways to provide services, including the use of less-costly Providers and generic, community-based resources.

2. Determine if failure to provide the additional service(s) presents a Health and Welfare issue. If the Participant’s Health and Welfare will be at jeopardy without the additional service(s), the AE shall, in the following order:

a. Authorize non-Waiver funds, as available, to address the

outstanding needs. b. Evaluate whether the Participant should be enrolled in

the Consolidated Waiver. If the AE does not have available Waiver Capacity to enroll a Participant into the Consolidated Waiver, it shall request an increase to its current Waiver Capacity Commitment as per Subsection 3.4.1 of this Agreement.

4.3.6 Waiver Transfers In the event of a transfer request, there are two circumstances that may occur as specified in AE letter #6 and any subsequent revision. The sending AE shall provide the receiving AE with participate records. The receiving AE shall accept the transfer within 60 days of the date of the relocation or discovery unless there are concerns regarding the current eligibility of the participant based on the documents submitted. The determination made by ODP will be implemented. Upon acceptance of the transfer by the receiving AE, capacity will be increased by one. The sending AEs waiver capacity will be reduced by one.

4.4 Offering Free Choice of Willing and Qualified Providers The AE shall validate that applicants are offered free choice of Willing and Qualified Providers for each service or support the AE approves and authorizes on an ISP, including the free choice of all SCO’s willing to provide services in the geographic area by ensuring that the SCO Directory, maintained by ODP, is


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shared. The AE shall initiate recruitment of Provider activities as referenced in Section 5.1, when there is an absence of choice of Willing and Qualified Providers. 4.5 Financial Management Services (FMS) The Department shall maintain an administrative contract with a VF/EA FMS. The AE shall make information on FMS and Participant direction available to Waiver applicants at Waiver enrollment. The AE shall ensure adherence to the requirements outlined in Written Policies and Procedures and Departmental Decisions relating to AWC FMS. When aware or notified of concerns regarding the performance of a common law employer, the AE shall try to resolve the issue and provide technical assistance to avoid any recurrence. If these efforts are unsuccessful, the AE shall notify the regional office of ODP. 4.6 Service Initiation Upon Waiver Enrollment The AE shall develop and implement a written protocol to monitor that Waiver services are initiated within forty-five (45) calendar days after the effective date of Waiver enrollment for a Waiver Participant. Upon identification of delays in service initiation, the AE shall submit a written request for an extension to the appropriate regional ODP. The written request must include the reason for the delay and the AE’s efforts to resolve the issues, including evidence of offering the choice of other Willing and Qualified Providers. The extension request must include documentation of the AE’s efforts to resolve service delays, including the barriers to service initiation. 4.7 Statewide Needs Assessment The Department is responsible for implementing a Statewide Needs Assessment ensuring the assessment of all current Waiver Participants as per the Department’s Written Policies and Procedures. The AE shall complete its required functions related to completion of the Statewide Needs Assessment in accordance with Written Policies and Procedures and Departmental Decisions relating to the Statewide Needs Assessment. When an individual is identified for enrollment in a waiver, the AE shall initiate an urgent request to have the Statewide Needs Assessment conducted in accordance with Departmental instructions so the SIS can be completed prior to the receipt of waiver services. If a SIS cannot be completed prior to enrollment in the waiver because an individual requires the immediate initiation of waiver services to ensure their health and safety, the regional office must be notified for approval to request that the SIS be completed within 30 days after the start date of waiver enrollment.


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4.7.1 Statewide Needs Assessment Contractor

The AE shall notify the appropriate regional ODP of any concerns regarding the performance of the Statewide Needs Assessment contractor. Such concerns may include, but are not limited to timeliness of assessments, conduct of assessors and scheduling. Concerns shall be submitted in writing to the appropriate ODP regional program manager.

4.8 Individual Support Plans (ISPs) The AE shall initially review, approve and authorize a written ISP prior to each Participant’s receipt of Waiver service(s)), and at least annually thereafter. A subsequent Critical Revision must also receive the AE’s review, approval and authorization, within the Department’s approved timelines. The AE shall approve and authorize Fiscal Year Renewal ISPs prior to July 1 of each year. When an objection is raised in regards to the content of the ISP, the Department has the final responsibility for the content of ISPs, including directing the content of the services and supports in an ISP.

4.8.1 Review, Approval and Authorization of Individual Support plans (ISPs) and Waiver Services The AE shall have a written protocol to ensure that the review, approval and authorization of services in ISPs are conducted as per Written Policies and Procedures, Departmental Decisions and this Agreement. Prior to authorizing a service in an ISP, the AE shall validate that:

1. Any required prior authorization or ODP approval of an exception to service limits was obtained through the established prior authorization or exceptions process.

2. All Assessed Needs as identified through the Statewide Needs Assessment instrument, other assessments as appropriate and the planning process are included in the ISP.

3. The outcomes listed in the ISP relate to an identified need. 4. The outcomes listed in the ISP relate to an identified preference. 5. Services are identified to support outcomes. 6. Services paid for through the Waivers must be identified to

support outcomes based on Assessed Needs, which are required by the Participant.

7. The ISP reflects the full range of a Waiver Participant’s needs and therefore must include all Medicaid and non-Medicaid services, including informal, family and natural supports and supports paid by other service systems to address those needs.

8. The ISP includes the type of services to be provided; the


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amount, duration and frequency of each Waiver-eligible service and the Provider to furnish each service.

9. Services are consistent with the approved Waivers and current Waiver service definitions.

10. The ISP is documented on the Department-approved format in HCSIS.

11. Providers are identified for each Waiver service. 12. The identified Providers are Willing and Qualified 13. The ISP checklist is completed, when and as required.

The AE shall authorize supported employment, vocational (including prevocational Services and transitional work services) and education support services as per federal and state requirements, Written Policies and Procedures, Departmental Decisions and only when the local district OVR has documented that OVR funding is not available. The required documentation must be obtained prior to the initial authorization of supported employment, vocational and education support services. The AE may only authorize therapy and nursing services through the Waivers if there is documentation that the service is medically necessary and not covered through the Medical Assistance State Plan, which includes Early Periodic, Screening, Diagnosis and Treatment (EPSDT), Medicare and /or private insurance. Therapy and nursing must be provided under the State Plan (which includes EPSDT), Medicare and/or private insurance plans until the plan limitations have been reached and documentation is secured by the Supports Coordinator. The AE shall ensure that the authorization of a Waiver service in an ISP is continuously updated to reflect changes in a Participant’s Assessed Needs. If an update to an ISP includes a Waiver service or a Waiver-funding change, it will require review, approval and authorization by the AE.

4.8.2 Additional Prerequisites for Service Authorization

The AE shall ensure that Waiver service authorization is not effective until the Participant’s Waiver effective start date and after all of the following state assurances are met:

1. The Department’s CAO has provided notice of the Waiver

Participant’s eligibility for services. The AE also may access the eligibility information using PROMISe™, as long as the eligibility


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confirmation is printed and maintained in the Participant’s record maintained by the AE.

2. The Waiver Participant has exercised freedom of choice of Willing and Qualified Providers in accordance with federal law and Department established policy.

3. All ISPs must be written in accordance with Waiver requirements, including those referenced in Section and Subsections 4.8 through 4.8.3.

4. The AE has authorized Waiver-funded services as necessary to address documented and current Assessed Needs.

5. The AE shall ensure that Waiver-funded services furnished to a Waiver Participant are not authorized if the services are rendered through a Factoring arrangement, either a direct arrangement or through a power of attorney.

6. Waiver Providers, including Providers of Vendor services and vendors contracted through an OHCDS, are appropriately qualified to render waiver services as referenced in Section 5.2 of the Agreement and as per Written Policies and Procedures and Departmental Decisions relating to qualification and disqualification of Waiver Providers.

7. The standardized statewide needs assessment has been completed or, when the person’s health and safety requires, approval has been obtained from the Department to proceed with enrollment.

A Provider of vendor services includes a provider who is acting in accordance with OHCDS requirements and a VF/EA (fiscal agent) to offer and pay vendor services. For Vendor services, the AE is responsible to verify and document that the Vendor rate entered by the SC on the ISP does not exceed the rate charged to the general public plus any allowable administration fee, prior to authorizing the Vendor service in the ISP. The AE is also responsible to verify that the administrative charge is an allowable administrative charge and does not exceed the ODP established rate as per Written Policies and Procedures related to the provision of Vendor services. The AE shall verify that services, including Vendor services are added and authorized in an ISP in accordance with directions issued by the Department related to the provision of Vendor services.

4.8.2.1 Residential Services The AE shall only approve and authorize a service to be provided in a licensed or unlicensed residential service setting that is agency-owned, leased, rented or operated, if the residential service setting is located throughout the community in noncontiguous and non-campus settings. Locations that share one common party wall are not considered contiguous.


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The AE shall review requests for clearance of new residential service settings to ensure the proposed location meets waiver standards and applicable guidelines for program capacity and provide ODP with the findings and a recommendation. The AE shall provide a recommendation to the regional ODP regarding requests to change approved program capacity of homes licensed under Chapter 6400.

4.8.3 Implementation of Individual Support Plans (ISPs)

The AE shall ensure that ISPs are reviewed and approved, that Waiver-funded services are authorized prior to implementation and that those Waiver-funded services are furnished in accordance with the approved and authorized ISP, Written Policies and Procedures, Departmental Decisions and the terms and conditions of this Agreement. The AE shall implement immediate corrective action if a Participant’s Health and Welfare is at risk. This requirement also applies to situations when a Provider is unavailable or unable to deliver authorized services. If the AE is unable to resolve delays in implementing an ISP by the service start date, the AE shall immediately notify the appropriate regional ODP.

4.8.4 Service Requests

Upon receipt from a SCO of a request to initiate or alter service(s) in an ISP, the AE shall use information resulting from documentation, assessment or reassessment evaluations to determine whether the identified service(s) is necessary to address a current Assessed Need(s). If the AE determines the identified service(s) is not needed or not Waiver eligible, the AE shall provide written denial of the service(s) to the Participant, along with notice of the Participant’s fair hearing rights within thirty (30) calendar days of the receipt of the service request. If the AE determines the service(s) is necessary, the AE shall consistent with the Waivers and this Agreement:

1. Notify the SCO of the approval of the service request,

instruct the SCO to update the ISP as necessary and submit for approval and authorization to the AE.

2. Approve and authorize the updated ISP within thirty (30) calendar days of receipt of the service request. This function must be conducted by the AE.

3. Notify the involved Provider(s) and ensure that the service(s) is implemented as written and by the service start date in the ISP.

If there are delays in implementing service(s), the AE shall immediately


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notify the appropriate regional ODP. The AE shall implement immediate corrective action if the Participant’s Health and Welfare is at risk.

4.9 Fair Hearing and Appeal

The AE is responsible to ensure that fair hearing and appeal activities are conducted in compliance with this Agreement, Written Policies and Procedures and Departmental Decisions. The AE shall cooperate with the Department as requested, regarding the Department’s service review of formal fair hearing requests to ensure compliance. Once the Department distributes its findings of the service review to the Waiver Participant and/or Participant’s Surrogate, AE, and SCO, the AE shall ensure that the findings and all Departmental Decisions are implemented as written. The AE shall notify the appropriate regional ODP if it is unable to resolve issues that cause the implementation of Departmental Decisions and findings to be delayed. The Department will review requests for extensions should an AE experience difficulty in implementing Departmental Decisions and findings. The Department shall approve or deny such requests within ten (10) days of receipt of the request. ODP reserves the right to approve or deny such requests. 4.9.1 Notice of Fair Hearing Rights

The AE shall have a written protocol to validate Waiver applicants are provided with fair hearing rights and appeal information as per Written Policies and Procedures and Departmental Decisions relating to due process, fair hearing rights and appeals for Waiver applicants and Participants.

The AE shall develop and implement a written protocol to validate Waiver applicants receive the assistance needed to complete and file and appeal as per Written Policies and Procedures and Departmental Decisions relating to appeals. For appealable and non-appealable circumstances refer to Written Policies and Procedures relating to appeals.

When the AE makes a determination to deny, suspend, terminate or reduce a Waiver service or Waiver service request, the AE shall provide the required written notice to the Waiver Participant and/or the Participant’s Surrogate.

The AE shall participate in fair hearings and appeals that involve Waiver applicants, Participants and/or services. If the fair hearing and appeal is regarding a service that required prior authorization or exception approval by the Department, as defined in the approved Waiver service definitions, ODP may directly participate at the hearing. The Department and ODP


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retain the authority to attend any and all fair hearings and appeals involving Waiver applicants, Participants and/or services.

4.9.2 Continuation of Waiver Services

In the event a fair hearing request is filed within 10 calendar days of the mailing date of the written notification from the AE, the AE shall ensure that current approved and authorized services remain in the ISP and the authorization of services provides for continuation of those Waiver services pending a final administrative action on such a request in accordance with Written Policies and Procedures and Departmental Decisions relating to due process, fair hearing and appeals.

5.0 Waiver Providers 5.1 Provider Recruitment and Enrollment

The AE shall support the development of a network of Waiver Providers through recruitment and other capacity building efforts. The AE shall initiate recruitment of Providers when there is the absence of Provider choice. The AE shall provide ongoing technical support to Providers utilizing ODP’s Provider Handbook on enrollment, qualification and HCSIS and PROMISe™ processes. This support includes, but is not limited to:

1. The provision of information regarding the Provider application, enrollment, and qualification processes. The information must be developed or approved by ODP.

2. The provision of “hands-on” technical support or referral to the appropriate entity for enrollment support.

3. Communication to the appropriate regional ODP regarding issues related to Provider recruitment and enrollment processes.

4. Oversight of transition planning in the event of provider closure or notification that a provider is no longer willing to provide supports to a Participant. This shall include actions to ensure that any affected waiver Participant(s) is afforded choice of provider.

5. The provision of information regarding ODP required provider orientation and training.

6. Orientation or training of providers, when approved or requested by the Department.

5.2 Qualification of Waiver Providers This Section applies to all Waiver Providers, with the exception of SCO’s and the statewide VF/EA FMS. The AE shall complete the Waiver Provider Qualification process as instructed by ODP and as outlined in Written Policies and Procedures


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and Departmental Decisions relating to qualification, requalification and disqualification of Waiver Providers. If a vendor is contracted through an OHCDS, the AE shall monitor that the Provider acting as the OHCDS and subcontracted vendor are qualified per Written Policies and Procedures, and Departmental Decisions. The AE may not impose any additional requirements beyond these established by the Department relating to qualification and disqualification of Waiver Providers. If an AE identifies that a Qualified Provider may meet the criteria for disqualification or restriction included in Written Policies and Procedures and Departmental Decisions relating to qualification, requalification and disqualification of Waiver Providers, the AE shall immediately notify the appropriate regional ODP of its recommendation to disqualify or restrict the Provider. The AE shall not authorize Waiver services to be delivered by a non-qualified Provider. 5.3 Ineligible Waiver Providers The AE shall not authorize services to be provided by an Ineligible Provider. Upon receipt of notification of such terminations and exclusions by the Department, the AE may not approve or authorize said ineligible Provider to render a Waiver service.

As directed and instructed by the Department, the AE may not authorize or shall terminate the provision of Waiver services by an Ineligible Provider or a Provider suspected of fraud or willful misrepresentation.

In the event that Provider terminations or exclusions effect the provision of service(s) in an ISP, the AE shall immediately notify the appropriate SCO and in collaboration with the SCO, shall make revisions to the ISP accordingly.

6.0 Monitoring Waiver Requirements

The AE shall conduct provider monitoring of the cost based and fee schedule waiver Providers and providers of vendor services selected by ODP for on-site review during the annual review cycle. This shall exclude SCOs. The AE shall provide support and technical assistance to SCOs to help assure adherence with waiver requirements, 55 Pa. Code 51, written Policies and Procedures and Departmental decisions.


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6.1 Monitoring of Waiver Providers

The AE shall conduct monitoring using the Department’s standardized monitoring tool and process in order to ensure ongoing adherence to the approved Waiver qualification standards, ongoing compliance with the provisions of 55 Pa. Code, Chapter 51, the terms and conditions of this Agreement, any amendments to this Agreement, Written Policies and Procedures and Departmental Decisions. When a provider renders services in multiple AEs, the on-site audit is conducted by the lead AE, along with Reviewing AEs conducting on-site audits for those waiver Participants in the sample registered with them. The Lead AE is designated by ODP based on the AE with which the most individuals served by the provider are registered. ODP shall reassess the designation of the Lead AE or reviewing AEs at the beginning of each monitoring cycle.

Lead and Reviewing AEs shall conduct on-site audits of all providers designated by ODP on an annual basis. Reviewing AEs will submit the provider monitoring results electronically to the lead AE. The lead AE shall consolidate the reviewing AEs’ provider monitoring results into one AE audit report. The AE shall request a CAP from the Provider within 15 days of notification to address issues identified during the Provider monitoring. If the CAP submitted by the Provider does not appropriately address the identified issues, the AE shall initiate remediation efforts and notify the appropriate regional ODP. The AE shall notify the appropriate regional ODP if initial remediation efforts are unsuccessful relating to the following:

1. Failure to meet Waiver qualification standards. 2. Failure to comply with the provisions in the Waiver Provider

Agreement. 3. In a significant number or proportion of cases:

a. The Provider has furnished Waiver services at a frequency or amount not consistent with authorized ISPs.

b. The Provider has furnished Waiver services of a quality that does not meet professionally recognized standards of health care, as defined in 42 CFR 1001.2.

c. The Provider has failed to comply with Departmental Written Policies and Procedures.

d. Commission of a violation as listed in 55 Pa. Code 1101.75 and 1101.77 (related to provider prohibited acts)

e. Failure to complete provider qualification status within the required timeframes.

f. Submission of false information for qualification g. Conviction of illegal business activities

The Department shall, in collaboration with the AE, follow up on remediation


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efforts, issue a DCAP which must be implemented as directed, and/or initiate sanctions. 6.2 Correction of Issues and Non-Compliance The AE is responsible to complete and submit a CAP to address issues resulting from external reviews, monitoring and audits. Unless otherwise specified, the completed CAP must be submitted within 15 days of notification of the issue(s). The AE shall validate and document all actions taken to fix the identified issues.

For AEOMP, the AE must document that how each instance of non-compliance has been fixed/remediated using the AEOMP database. For situations involving imminent Health and Welfare issues, the AE shall implement immediate corrective action to address the issues and notify appropriate regional ODP.

If the Department submits questions or concerns to the AE in response to a submitted CAP, the AE shall respond to those questions or concerns within the specified time frame provided. For issues related to non-compliance with Waiver requirements, the Department reserves the right to provide a Directed CAP to the AE, if the AE’s follow-up submissions and/or response to questions or concerns do not fully address the issues or noncompliance areas. The AE is responsible for implementation of the CAP upon the approval from the Department or upon receipt of a DCAP from the Department, as referenced in Section 6.4 of this Agreement. In the event a non-compliance issue(s) identified through the monitoring of Waiver requirements involves issues related to the performance of a Provider, including a SCO, the AE shall request the CAP be completed within 15 days unless a shorter deadline is necessary to allow the AE to submit its CAP to the Department. If after consultation with the Provider, the AE finds that the Provider’s CAP is unsatisfactory, the AE shall notify the appropriate regional ODP. The Department will, in collaboration with the AE, address an unsatisfactory Provider CAP. If the AE identifies Provider performance issues through its validation efforts, the AE shall make efforts to resolve the issues and shall notify the appropriate regional ODP. Notification to the regional ODP must include documentation of the remediation efforts. The Department will assist the AE in addressing Provider performance issues as needed. Remediation actions, whether requiring action by the AE or a provider, should be completed within 30 days but no later than 90 days from the date of notification of the issue. The AE shall validate and document all corrective actions. 6.3 Administrative Review


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When directed by the Department, the AE shall conduct an administrative review of the services provided using the monitoring procedures outlined in ODP’s AE OM Process, with the exception of the sample size and interviews with Waiver Participants. The review shall include an analysis of the data collected and the implementation of procedures that assure Waiver compliance. The review shall include a minimum sample of five (5) percent of Waiver Participants under the Jurisdiction of the AE, but shall include not less than a minimum number of five (5) records and a maximum of thirty (30) records per Waiver. In addition, selection of the sample must be proportionally represented by each SCO providing services to Participants under the Jurisdiction of the AE. If the SCO provides services to five (5) or less Participants under the Jurisdiction of the AE, every record shall be reviewed.

The AE shall conduct all monitoring of Participants as specified in the current AE OM Process. In the conduct of the administrative review, the Department reserves the right to require that the AE conduct face-to-face interviews.

Upon completion of the administrative review, the AE shall promptly forward the summary results and analysis of the administrative review no later than thirty (30) calendar days after the completion of the review. The AE shall also submit any necessary CAP(s) no later than fifteen (15) calendar days after the completion of the review to the appropriate regional ODP.

6.4 Implementation of Departmental Decisions and Findings

The AE shall implement Departmental Decisions and findings. If the AE determines it has been unable to resolve its questions or concerns related to Department Decisions and findings through routine and standard communications, the AE shall direct its questions, concerns and issues related to Department Decisions and findings in writing to the appropriate Department staff (DPW-ODP Regional Program Manager) with copies to the DPW-ODP Director of the Bureau of Supports for People with Intellectual Disabilities, the DPW-ODP Deputy Secretary and the DPW Secretary. A written response from the Department will be issued within fifteen (15) calendar days. At the direction of the Department, the AE shall continue to implement Departmental Decisions and findings until the Department’s response is provided to the AE. If the findings or Departmental Decisions involve issues related to the performance of a Provider including AWC FMS providers, providers of vendor services, Providers acting as OHCDS Providers for the delivery of vendor services, and SCOs, the AE shall notify the Provider of the findings or Departmental Decisions. The AE shall monitor the Provider to ensure the implementation of an ODP-approved CAP to address the findings or Departmental Decisions. If monitoring of the Provider reveals unsatisfactory performance, the AE shall notify the appropriate regional ODP. ODP will assist the AE in addressing Provider performance issues as further provided herein


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Sections 6.1 and 6.2 of this Agreement. The Department reserves the right to issue a DCAP which must be implemented as directed. For all findings and/or Departmental Decisions requiring the provision of a service, such service shall be provided within thirty (30) calendar days of the finding/decision notification or as directed by the Department when related to a risk to a Participant’s Health and Welfare. When implementing services related to fair hearing decisions, the AE shall provide services as per Written Policies and Procedures and Departmental Decisions relating to due process, fair hearing and appeals. The AE shall approve and authorize the service and monitor service implementation. The AE shall notify the appropriate regional ODP when:

1. There is a delay in the implementation of authorized services or 2. There is a need for an extension of time to implement the

Departmental Decisions and findings

The AE shall work with the responsible Provider or Provider of Vendor services to ensure the provision of the authorized service, document the interaction with the Provider and notify the appropriate regional ODP. The AE may make a written request for an extension and ODP will review requests for extensions should an AE experience difficulty in implementing Departmental Decisions and findings. ODP will notify the AE of its decision within five (5) calendar days of receipt of said request.

7.0 Quality Management (QM)

7.1 Quality Management (QM) Plan

The AE shall have a written QM Plan that implements the Department’s QM Strategy related to the methodology, accountability, responsibility and ongoing review of QM activities. The AE shall review and analyze data and performance over time, direction from the Department regarding priorities and any feedback received from the Department to improve internal QM processes and build or refine objectives for the next QM plan year. AEs shall maintain documentation of the process used to select these opportunities for improvement.

The AE’s QM Plan shall be developed to extend for two years from July 1 through June 30. The QM Plan shall contain:


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1. Measurable objectives that relate to the identified goals and outcomes. 2. Performance measures that support each objective. 3. The data source for each performance measure. 4. The person or persons responsible for QM Plan improvement.

The AE shall provide evidence of implementation of its QM Plan. 7.1.1 Utilizing Department Information to Enhance Quality

The Department shall provide information to the AE to enhance the quality of the AE’s administrative functions. Information will include, but not be limited to: AE Letters, alerts, informational memos and packets, summary reports, data reports, policy and procedure clarifications and general information. The AE shall utilize the information to support its administrative functions outlined in this Agreement.

7.1.2 Functions of the AE’s QM Point Person(s)

The person(s) filling the AE QM personnel position shall be responsible to ensure that the conditions identified in Section 7.1 are met and to fulfill requirements as defined by the Department.

7.2 Incident Management

The AE shall conduct incident management activities in accordance with ODP requirements. 7.3 Independent Monitoring for Quality (IM4Q) The AE shall comply with the responsibilities outlined in the current IM4Q Protocol and Guidelines. The AE shall assign at least one (1) AE representative to serve as the coordinator or point person for activities related to IM4Q. The AE shall have a written procedure for implementing the IM4Q “closing the loop” process.

8.0 Training and Technical Assistance 8.1 Participation in Training

In order to ensure consistent application of Waiver requirements, Written Policies and Procedures and Departmental Decisions, the AE shall attend and participate in the ODP Academy and any other training session determined by the Department as a mandatory training. At a minimum, the AE shall ensure that the management position(s) designated by ODP attend, participate and complete the ODP Academy and training deemed mandatory for attendance by the AE.


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The Department retains the authority to designate a specific training session as mandatory and designate specific AE functional lead(s) and staff that must attend.

8.2 Technical Assistance

The AE shall request support, training and technical assistance as needed. Upon such request, the Department shall provide support, training and technical assistance as determined necessary by the Department to ensure compliance with this Agreement, Written policies and Procedures and Departmental Decisions. The Department shall contact the AE within thirty (30) calendar days to respond to the AE’s request to provide support, training or technical assistance.

9.0 Operating Agreement Remedies and Termination 9.1 Agreement Remedies

The Department will utilize a variety of means to ensure compliance with Agreement requirements, Written Policies and Procedures and Departmental Decisions. The Department will pursue remedial actions as needed to resolve any outstanding performance concerns and violations with the Agreement. The application of remedies shall be a matter of public record once an acceptable CAP has been developed by the AE.

AE noncompliance with the Agreement will be addressed through the following remedies. While remedies will generally follow a progressive path, the Department reserves the right to deviate from this path for significant issues of noncompliance as determined by the Department. The Department may utilize the following actions:

1. Notify the AE in writing of the Agreement violation and conditions with

copies to the County Mental Health/Intellectual Disabilities administrator and executives, administrator of the County/Joinder, County Commissioners/County Council/Executive Directors and/or Boards of Directors of the AE and the County/Joinder MH/MR Advisory Board.

2. Require a CAP including a detailed work plan outlining specific corrective activities. Specified status reports will be required for continuance of the Agreement.

3. The AE shall be required to conduct at least one administrative review of the services provided using the monitoring procedures outlined in ODP’s AEOM Process, with the exception of the sample size and interviews with Waiver Participants. The review shall include an analysis of the data collected and the implementation of procedures that assure Waiver compliance.

4. Revise the AE’s Waiver Capacity Commitment.


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5. Provide a DCAP to the AE, including specific required training and/or technical assistance activities.

6. Require attendance and participation of the AE in directed-technical assistance and required trainings.

7. Validate corrective actions and intensity monitoring of the performance of the AE, which may include onsite performance monitoring and a requirement for regular written and/or oral status updates.

8. Adjust the Waiver Administration Allocation commensurate with non-delivered functions and failure to perform the terms and conditions of this Agreement, Written Policies and Procedures and Departmental Decisions.

9. Termination of the Agreement.

The Department reserves the right to make adjustments to the AE’s Waiver Capacity Commitment or Waiver Administration Allocation. The implementation of remedial actions does not require an amendment to the Agreement. The remediation notice to the AE is sufficient authority according to this provision.

The following are examples of compliance or performance problems for which remedial actions can be applied to address areas of non-compliance. This listing is not meant to be exhaustive, but only representative:

1. Failure to document efforts to address Waiver Participant Health and

Welfare. 2. Failure to be responsive to the concerns of Waiver Participants. 3. Failure to conduct the review, approval and authorization of Waiver

services in ISPs as per Written Policies and Procedures, Departmental Decisions and this Agreement.

4. Failure to properly manage administrative funds. 5. Failure to perform efficiently and effectively. 6. Failure to comply with the Waiver Capacity Commitment approved by the

Department. 7. Failure to make appropriate and timely level of care determinations and

re-determinations. 8. Failure to make correct or timely service determinations. 9. Failure to demonstrate the ability to meet the responsibilities outlined in

this Agreement 10. Failure to comply with Department requirements related to Claim

resolution. 11. Failure to comply with Written Policies and Procedures. 12. Failure to implement Departmental Decisions. 13. Submission of inaccurate, incomplete or late reports.

In the event that the Department finds there has been Substantial Failure of the AE to adhere to the responsibilities and functions outlined in this Agreement including applicable Written Policies and Procedures and Departmental Decisions or Substantial Failure to perform or provide services to Participants in


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the Pennsylvania ODP service system, the Department may provide notice of termination as referenced in Section and Subsections 9.2 through 9.3.2.1 of this Agreement.

9.2 Agreement Termination

Either party may terminate this Agreement without cause with at least one hundred twenty (120) calendar day prior written notice given to the other party and the relevant county/joinder Commissioners. The parties may terminate this Agreement without cause with less than one hundred twenty (120) calendar day notice, only if an agreement to do so is in writing and signed by both parties.

The Department may terminate this Agreement for material cause with no less than one hundred twenty (120) calendar day prior written notice. 9.2.1 Enforcement

Failure of either party to provide the prior written notice required by Section 9.2 shall permit the other party to seek specific performance in a court of competent jurisdiction for up to one hundred twenty (120) calendar days following any notice of failure to perform.

9.3 Transition Plan and Closeout Procedures for Agreement Termination 9.3.1 Transition Plan for Agreement Termination

In the event that this Agreement is terminated as per Section and Subsections 9.2 through 9.3.2.1 of this Agreement, the Department and the current AE shall cooperate to develop a plan for transitioning administrative activities related to Waiver Participants to the successor AE. The transition plan must be developed within thirty (30) calendar days of written notice of termination and will span the remainder of the one hundred twenty (120) calendar days. The current AE shall cooperate with the Department to implement the plan. The Department shall have the sole authority to approve the adequacy of the transition plan, including providing for the financing of said plan. The current AE shall ensure continuity of care for all Participants being served under this Agreement until all Waiver Participants are being served under the Jurisdiction of the AE selected by the Department. The current AE will cooperate with the Department in developing a transition plan for the maintenance of Participant eligibility and the provision of services during the transition period, including the systematic transfer of each Waiver Participant and Participant’s record from the responsibility of the current AE to the Successor AE. The transition period may be extended at the Department’s discretion. The current AE will cooperate with the successor AE regarding the transfer of records and services.


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9.3.2 Close out Procedures for Agreement Termination If this Agreement is terminated, the following shall take effect:

1. Within thirty (30) calendar days following the notification of termination of this Agreement, or as otherwise approved in writing by the Department, the AE shall provide to the Department all financial, performance and other reports required by this Agreement.

2. Within thirty (30) calendar days following the notification of termination of this Agreement or as otherwise approved in writing by the Department, the current AE will supply to the Department and/or the successor AE all material necessary for continued operation of payment and related systems, including:

a. Computer programs. b. Data files c. User and operation manuals. d. System and program documentation e. Training programs of Waiver functions for responsible

staff, staff agents or designees, related to the operation and maintenance of the payment system.

If the AE possesses the proprietary rights to such materials, the AE shall permit the Department to purchase the materials or purchase the use of the materials through leasing or other means.

3. The portion of all funds accumulated by the AE that are comprised of Waiver administrative funds and related interest must be refunded to the Department within thirty (30) calendar days after the notification of termination of this Agreement, less amounts needed to cover an outstanding Claim or liability, unless otherwise directed in writing by the Department.

4. All financial, administrative and clinical records under the AE’s responsibility must be retained by the current AE for a period of five (5) years from the termination of this Agreement. The current AE shall provide copies of all necessary records to the successor AE as part of a transition plan.

5. The records required to be retained and provided, as per Section and Subsections 3.3 through 3.3.4 shall continue to be retained and provided by the current AE for a period of five (5) years from the termination of this Agreement. The current AE shall provide copies of all necessary records to the successor AE as part of the transition plan.


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The transition plan will include financing arrangements with the successor AE, which may utilize remaining Waiver-related funds held by the previous AE and owed to the Department.

Should additional statistical or management information be required by the Department after this Agreement has been terminated, the AE will be given at least forty-five (45) calendar days’ notice to provide the required information.

9.3.2.1 Enforcement

The obligations in Subsections 9.3.1 or 9.3.2 shall be enforceable through an action for specific performance in a court of competent jurisdiction.

Documents

Administrative Entity Operating Agreement · as a required need by the Participant’s team responsible for developing the ISP. Bi-annual Review – The category field in HCSIS used