Cloud Object Storage | Store & Retrieve Data …€¦ · Web viewDuring the onsite visit, the reviewer selects 3 providers qualified by that AE by choosing (1) an Agency with Choice

Pennsylvania Office of Developmental ProgramsQuality Assessment & Improvement (QA&I) Questions Tool for Administrative Entities

Overview of the Quality Assessment & Improvement Process

The mission of the Office of Developmental Programs (ODP) is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.

ODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.

The Quality Assessment & Improvement Process is a way for ODP to evaluate our current system and identify ways to improve it for all individuals.

General Instructions

1. In preparation for completing the QA&I Tool, Administrative Entities (AEs), Supports Coordination Organizations (SCOs) and Providers should review all relevant materials regarding the QA&I process that are posted on the MyODP Training & Resource Center at https://www.myodp.org.

2. In case of questions, issues or concerns related to the questions asked in the tool or the QA&I Process, please contact the ODP QA&I Process Mailbox at [email protected] and copy the ODP Regional QA&I Lead.

3. If an incident is discovered during the course of the QA&I process that has not been reported, the incident must be immediately reported in the Enterprise Incident Management (EIM) system and Incident Management procedures should be followed. The AE, SCO and Provider shall ensure the health and welfare of individuals at all times. If any entity determines there is an imminent threat to the health and welfare of the individual, immediate steps should be taken to ensure the health and welfare of the individuals and the appropriate regional ODP office should be contacted. Based on circumstances, the entity shall proceed according to the policy established in ODP Bulletin #6000-04-01, Incident Management and as determined appropriate by the regional ODP office.

Tool Completion Instructions

The following guidelines are intended to help a user and complete this tool successfully.

1. All questions applicable to the entity have to be answered before the tool can be submitted.

*KEY – Desk Review (D); Onsite Review (O); Remediation (R) 1Last updated: 8/21/2017

mailto:[email protected]

https://www.myodp.org/

2. The timeframe for each question is 12 months from the date of the review unless otherwise specified. When looking back 12 months, always go to the 1st day of the month i.e. the review begins on July 15, 2017, look back to July 1, 2016.

3. It is strongly recommended that the guidelines associated with each question is reviewed before answering the question as the guidelines will assist you in your responses.

4. When responding to questions, the entity MUST retain all related documentation, including policy & procedure documentation, training curriculum, records and other training documentation as well as documentation associated with service/supports delivery. This documentary evidence along with this tool must be retained and made available to ODP or the AE upon request.

5. Questions that are labeled as exploratory are intended to inform the entity of new changes and requirements which may begin July 1, 2017.


# Question Type Guidance Source DocumentsADMINISTRATIVE AUTHORITY – The individual has a determination of urgency of need.01.00.00. The AE reviews the PUNS report on a monthly basis to ensure individuals have a determination of urgency of need.01.0A.00

The AE reviews the PUNS report on a monthly basis.

O The reviewer determines if the AE reviews the PUNS report and works with the appropriate SCOs (if applicable) to ensure PUNS are completed/updated within 365 days as needed.

PUNS report is loaded into AE Docushare on a monthly basis Mark YES if the PUNS Review process is completed monthly by the AE. Mark NO if there is no evidence of PUNS Reviews being completed, no evidence

of communication to the SCO or if the PUNS Review is not being completed on a monthly basis.

Consolidated and PFDS waivers

01.0A.00.R

The AE reviews the PUNS report on a monthly basis

R Consolidated and PFDS waivers

01.0A.00.R1

AE provides documentation that PUNS review process is occurring as required.

R The AE locates documentation that the PUNS review is occurring. Mark YES if the AE locates documentation of the PUNS review occurring as

required. Mark NA if no remediation actions were required or another remediation action

was selected.


01.0A.00.R2

Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the AE to comply with the requirements of the Operating Agreement.

The reviewer records in comment field the REMEDIATION ACTION (RA) taken by the AE to remediate. Mark YES if the AE submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


01.0A.00.R3

If YES, when: R The reviewer calculates the number of days between the notification date to the AE and the remediation action date.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if no remediation action was necessary or if no remediation action was

taken by the AE.


01.0A.00.R4

Remediation action outstanding - referred to appropriate staff for follow up.

R Mark YES if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.

Mark NA if the issue was remediated or if no remediation was required.



# Question Type Guidance Source DocumentsADMINISTRATIVE AUTHORITY - The individual receives information about fair hearing and appeal rights.02.00.00. Individuals/representatives must receive notice of due process rights and instructions for filing an appeal: at waiver enrollment and upon notification of a denial, reduction or termination of waiver services. The individuals in the sample were issued rights to fair hearing and appeals when the individual was determined likely to require ICF/ID or ICF/ORC level of care and upon notification of a denial, reduction or termination of waiver services.02.0A.00

The AE provides notification of Due Process Rights at waiver enrollment (during the last FY).

O For individuals in the sample who were enrolled in waiver services in the last FY. The reviewer determines if notification of Due Process rights was provided.

Acceptable documentation MUST include an indication that a copy of the rights was distributed to the individual/family/surrogate (currently DP 458). Mark YES if there is evidence that notification was provided. Mark NO if there is no evidence that it was provided. Mark NA if the person did not enroll within the twelve months prior to the start

of QA&I process.

Consolidated and PFDS waivers Bulletin 00-08-05, Due Process and Fair

Hearing Procedures for Individuals with Mental Retardation

02.0A.00.R

The AE provides notification of Due Process Rights at waiver enrollment.

R Consolidated and PFDS waivers Bulletin 00-08-05, Due Process and Fair


02.0A.00.R1

Written notice of Due Process rights was obtained and the information entered into HCSIS.

R The AE locates written notice of Due Process rights and enters the information into HCSIS. Mark YES if the written notice of due process rights was located and HCSIS was

updated. Acceptable documentation MUST include an indication that a copy of the rights was distributed to the individual/family/surrogate (currently DP458).

Mark NA if no remediation actions were required or another remediation action was selected.



02.0A.00.R2.



selected.



02.0A.00.R3.



taken by the AE.




# Question Type Guidance Source Documents02.0A.00.R4.






02.0B.00.

The individual has an identified change in need.

Non-Scored

D The reviewer determines if a change in need was identified based on a review of service notes, Individual Monitoring Tools and the ISP.

The reviewer notes the date the change in need was identified. A change in need is a change that impacts the currently authorized services and/or

funding Mark YES if a change in need was documented. Mark NA if a change in need was not documented.

55 Pa. Code Chapter 51 Bulletin 00-10-06, Supports

Coordination Services ISP Manual

02.0C.00.

Due process rights information was provided to the individuals with a change in service need.

O The reviewer determines if written notice of Due Process Rights was provided and accompanied by the DP458. Mark YES if there is written notification accompanied by the DP458. Mark NO is there is no written notification or DP 458. Mark NA if there was no service change resulting in reduction, suspension and/or

termination of services.

Consolidated and PFDS waivers AE OA Bulletin 00-08-05, Due Process and Fair


02.0C.00.R.

Due process rights information was provided to the individuals with a change in service need.

R Consolidated and PFDS waivers Bulletin 00-08-05, Due Process and Fair


02.0C.00.R1.

Written notice of Due Process rights was obtained.

R The AE locates written notice of Due Process rights. Mark YES if the written notice of due process rights was located. Acceptable

documentation MUST include an indication that a copy of the rights was distributed to the individual/family/surrogate (currently DP458).

Mark NA if no remediation actions were required or another remediation action was selected.



02.0C. Written notice of Due Process rights R The AE provides written notification of Due Process Rights to the Consolidated and PFDS waivers


# Question Type Guidance Source Documents00.R2. was completed. individual/surrogate.

Acceptable documentation MUST include an indication that a copy of the rights was distributed to the individual/family/surrogate (currently DP458) and a transmittal letter explaining that the distribution of the information is late.

NOTE: A record may have numerous situations where Due Process rights were not provided to the individual. Notification one time constitutes remediation action for all situations where failure to provide Due Process rights was cited as non-compliant. Mark YES if the notification of Due Process has been distributed. Mark NA if no remediation actions were required or another remediation was

selected.

Bulletin 00-08-05, Due Process and Fair Hearing Procedures for Individuals with Mental Retardation

02.0C.00.R3.


The reviewer records the REMEDIATION ACTION (RA) taken by the AE to remediate in the comment field. Mark YES if the AE submitted remediation documentation. Mark NA if no remediation actions were required or another remediation was

selected.



02.0C.00.R4.



taken by the AE.



02.0C.01.R5.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.



02.0C.01.R6.


R Mark Yes if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.




QUALITY MANAGEMENT - There are systemic efforts to continuously improve quality.


# Question Type Guidance Source Documents03.00.00. AE has a Quality Management Plan (QMP) that implements the Departments QM Strategy. The AE's must have a written Quality Management Plan that includes ODP's Mission, Vision and Values. The QMP is the planned, systemic organization-wide approach to the monitoring, analysis and improvement of organizational performance, thereby continually improving the quality of supports and services provided and the likelihood of desired outcomes for recipients. Methodology for the QMP includes a continuous improvement process, a cycle of assessment, analysis and action for improvement. AEs are required to update their QM Plans at least every two years. 03.0A.00.

AE has a Quality Management Plan that reflects ODP's Mission, Vision and Values.

O The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.ODP’s vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.The values articulated as principles in the Everyday Lives document and the values articulated in the Autism Task Force Report set the direction for the developmental disability service system. They provide context and guidance for policy development, service design and implementation, and decision-making.

The reviewer determines if the AE’s QMP reflects ODP’s Mission, Vision and Values by reviewing the QMP.

Examples of what could be worked on in the QMP include:- Assuring effective communication- Increasing employment- Increasing community participation- Ensuring ISPs are updated timely when there is a change in need- Ensuring individuals are free from abuse, neglect and exploitation- Ensuring people with complex needs have supports they need

Mark Yes if the QMP reflects the Mission, Vision and Values. Mark No if the QMP does not reflect them.

** Identify what is missing from the QMP.

AE OA Info Memo 038-15 AE Letter #5

03.0A.00.R.

AE has a Quality Management Plan that reflects ODP's Mission, Vision and Values.

R AE OA Info Memo 038-15 AE Letter #5

03.0A.00.R1.

The AE updated the plan to reflect ODP's Mission, Vision, and Values.

R The AE will update QMP to reflect ODP's Mission, Vision and Values. Mark YES if the AE updated their QMP. Mark NA if no remediation action is required or another remediation action was

selected.


03.0A. Other remediation action R The reviewer can accept documentation of “other” remediation actions taken by the AE OA


# Question Type Guidance Source Documents00.R2. AE to comply with the requirements of the Operating Agreement.

The reviewer records the REMEDIATION ACTION (RA) taken by the AE to remediate in the comment field. Mark YES if the AE submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.

Info Memo 038-15 AE Letter #5

03.0A.00.R3.


The reviewer chooses the appropriate time frame from the drop down. Mark NA if no remediation action was necessary, or if no remediation action was

taken by the AE.


03.0A.00.R4.





03.0B.00.

The AE reviewed and evaluated performance data in selecting priorities for the QMP.

O The reviewer determines if the AE used performance data to develop their QMP based on a review of the QMP.

o Performance data can include but is not limited to: - Performance results from QA&I self-assessments and full reviews,

including individual interviews, targeting those areas where performance falls below 86%

- Employment Data - IM4Q Data- Data on individual with communication needs- Community Participation data- Data on self-direction, choice and control- Data on management of incidents of abuse, neglect, exploitation and

unexplained deaths- Data on use of restrictive interventions including restraints

Mark YES if the AE used performance data in the development of the QMP. Mark NO if the AE did not use performance data.

AE OA Info Memo 038-15 AE Letter # 5

03.0B.00.R.

The AE reviewed and evaluated performance data in selecting

R AE OA Info Memo 038-15


# Question Type Guidance Source Documentspriorities for the QMP. AE Letter # 5

03.0B.00.R1.

Documentation was obtained. R The AE has located evidence that they have reviewed and evaluated performance data in selecting priorities for the QMP. Mark YES if the AE has obtained the documentation. Mark NA if no remediation action is required or another remediation action was

selected.


03.0B.00.R2.

AE staff is retrained as appropriate on QMP requirements.

R The AE provides/ensures retraining of the appropriate AE staff regarding the QMP requirements. The AE provides notification to ODP that the AE staff was retrained. Mark YES if AE provides notification to ODP of retraining provided to the AE staff. Mark NA if no remediation action is required or another remediation action was

selected.


03.0B.00.R3.



selected.


03.0B.00.R4.



taken by the AE.


03.0B.00.R5.





03.0C.00.

The AE measures progress towards achieving identified QMP goals and objectives.

O The reviewer determines if the AE engages in the practice of quarterly data reporting.

The reviewer should review the QMP and ensure that quarterly data reporting is occurring. Mark YES if quarterly reporting is occurring. Mark NO if the AE does not have documentation of quarterly reporting.

Exploratory AE OA AE Letter # 5

03.0C.00.R.

The AE measures progress towards achieving identified QMP goals and objectives.

R AE OA AE Letter # 5


# Question Type Guidance Source Documents03.0C.00.R1.

Documentation was located. R The AE has located the quarterly reports. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA AE Letter # 5

03.0C.00.R2.

A reporting calendar is developed. R A reporting calendar is developed and shared within the organization to establish the frequency of reporting for responsible parties. Mark YES if the AE develops and shares a reporting calendar. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA AE Letter # 5

03.0C.00.R3.


R The AE provides/ensures retraining of the appropriate AE staff regarding the QM Plan requirements.

The AE provides notification to ODP that the AE staff was retrained. Mark YES if AE provides notification to ODP of retraining provided to the AE staff. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA AE Letter # 5

03.0C.00.R4.



selected.

AE OA AE Letter # 5

03.0C.00.R5.



taken by the AE.

AE OA AE Letter # 5

03.0D.00.

The AE promotes employment as a priority

Non-Scored

O The reviewer determines if the AE promotes employment as a priority. NOTE: The reviewer will use comment field to record AE activities around

Employment. Mark YES if the AE promotes employment. Mark NO if the AE does not promote employment.

Exploratory Employment First Executive Order Plan

2016-03

03.0E.00.

The AE analyzes and revises the QMP at least every two years.

O The reviewer determines if the QMP was revised every 2 years based on a review of the QMP. Mark YES if the QMP was revised every 2 years.


*KEY – Desk Review (D); Onsite Review (O); Remediation (R)10

Last updated: 8/21/2017

# Question Type Guidance Source Documents Mark NO if the QMP was not revised every 2 years.

03.0E.01.

If No, how late:

Non-Scored

O The reviewer calculates the number of days the service was late based on the date of waiver enrollment.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if service initiation was timely or if the individual was not newly

enrolled.


03.0E.00.R.

The AE analyzes and revises the QMP at least every two years.

R AE OA Info Memo 038-15 AE Letter #5

03.0E.00.R1.

Documentation was obtained. R The AE has located evidence that they have reviewed and evaluated performance data in selecting priorities for the QMP. Mark YES if the AE has obtained the documentation. Mark NA if no remediation action is required or another remediation action was

selected.


03.0E.00.R2.


R The AE provides/ensures retraining of the appropriate AE staff regarding the QMP requirements.


selected.


03.0E.00.R3.



selected.


03.0E.00.R4.



taken by the SCO.


03.0E.00.R5.






# Question Type Guidance Source Documents Mark NA if the issue was remediated or if no remediation was required.

04.00.00. Qualification of waiver providers is conducted using qualification criteria as outlined in the current approved waiver. During the onsite visit, the reviewer selects 3 providers qualified by that AE by choosing (1) an Agency with Choice (AWC), then (2) a large provider (50 or more individuals) and (3) a small provider (less than 50 individuals). Select 2 large or 2 small if a large and a small are not qualified by that AE. The reviewer assures that the AE reviewed the qualification criteria using ODP approved methods.04.0A.00.

The AE qualifies AWC utilizing ODP standardized procedures.

O The reviewer determines if the Agency with Choice was qualified by reviewing qualification packets.

The reviewer assures that the AE reviewed the qualification submissions using ODP approved methods, which may include:

- Onsite Review - Review of qualification materials at the Provider's site - Review of Submitted Materials - Review of information submitted by the

Provider.

Mark YES if documentation indicates that the process was followed. Mark NO if there is no documentation and/or the process was not followed.

**The reviewer must IMMEDIATELY notify the regional Provider Qualification Lead.

Mark NA if the AE does not qualify an AWC/FMS.

Consolidated and PFDS waivers AE OA Info Memo 044-16

04.0A.00.R.

The AE qualifies AWC utilizing ODP standardized procedures.

R Consolidated and PFDS waivers AE OA Info Memo 044-16

04.0A.00.R1.

The AE provides documentation that the AWC/FMs provider was qualified in accordance with ODP's standardized procedures.

R The AE contacts the AWC and collects any/all missing documents to ensure qualification was completed according to ODP Standards. Mark YES if demonstrated. Mark NA if no remediation action is required or another remediation action was

selected.


04.0A.00.R2.

The AE must notify ODP for further review and potential action if the required documents are not promptly obtained or the documents obtained do not result in qualification.

R The AE contacts ODP for further review and potential action if required documents are not obtained or the documents obtained do not result in qualification. Mark YES if the AE notifies ODP. Mark NA if no remediation action is required or another remediation action was

selected.


04.0A.00.R3.


The reviewer records in comment field the REMEDIATION ACTION (RA) taken by the




# Question Type Guidance Source DocumentsAE to remediate. Mark YES if the AE submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.04.0A.00.R4.



taken by the AE.


04.0A.00.R5.





04.0B.00.

The AE qualifies PROVIDER 1 utilizing ODP standardized procedures.

O The reviewer determines if the provider was qualified by reviewing qualification packets.


- Onsite Review - Review of qualification materials at the Provider's site - Review of Submitted Materials - Review of information submitted by the

Provider.

Mark YES if documentation indicates that the process was followed. Mark NO if there is no documentation and/or the process was not followed. Mark NA if the AE does not qualify any providers.



04.0B.00.R.



04.0B.00.R1.

The AE provides documentation that Provider 1 was qualified in accordance with ODP’s standardized procedures.

R The AE contacts the provider and collects any/all missing documents to ensure qualification was completed according to ODP Standards. Mark YES if demonstrated. Mark NA if no remediation action is required or another remediation action was




# Question Type Guidance Source Documentsselected.

04.0B.00.R2. The AE must notify ODP for further

review and potential action if the required documents are not promptly obtained or the documents obtained do not result in qualification.


selected.


04.0B.00.R3.



selected.


04.0B.00.R4.



taken by the AE.


04.0B.00.R5.



Mark N/A if the issue was remediated or if no remediation was required.


04.0C.00.


O The reviewer determines if the provider was qualified by reviewing qualification packets.





# Question Type Guidance Source Documents- Onsite Review - Review of qualification materials at the Provider's site - Review of Submitted Materials - Review of information submitted by the

Provider.

Mark YES if documentation indicates that the process was followed. Mark NO if there is no documentation and/or the process was not followed. Mark NA if the AE does not qualify any providers.


04.0C.00.R.



04.0C.00.R1.

The AE provides documentation that Provider 2 was qualified in accordance with ODP’s standardized procedures.

R The AE contacts the provider and collects any/all missing documents to ensure qualification was completed according to ODP Standards. Mark YES if demonstrated. Mark NA if no remediation action is required or another remediation action was

selected.


04.0C.00.R2. The AE must notify ODP for further

review and potential action if the required documents are not promptly obtained or the documents obtained do not result in qualification.


selected.


04.0C.00.R3.



selected.


04.0C.00.R4.






# Question Type Guidance Source Documentstaken by the AE.

04.0C.00.R5.





05.00.00. Provider Monitoring is conducted using the standard tool and monitoring processes. The AE shall conduct Provider Monitoring using the departments standardized oversight tool and process in order to ensure ongoing adherence to the approved waiver qualification and monitoring standards, ongoing compliance with the provision of 55 PA. Code, Chapter 51, the terms and conditions of the Operating Agreement and any amendments to written Policies, Procedures and Departmental Decisions.05.0A.00.

The AE conducts Provider Monitoring (QA&I Process effective 7/1/2017) using the standard tool and monitoring processes.

O The reviewer validates that the AE completed the QA&I review provider monitoring using the standard tool and monitoring processes.

The reviewer should review all, but not more than 10 randomly chosen, monitorings conducted by the AE for the previous full fiscal year. Mark YES if ALL 3 criteria for provider monitoring are met. Mark NO if any of the three criteria are not met. Mark NA if the AE has not been assigned any providers to monitor by ODP.

** Identify which of the criteria is not met.

Consolidated and PFDS waivers AE OA QA&I process

05.0A.01.

CRITERIA 1 - AE uses ODP's standard tool.

O The reviewer validates that the AE completed the QA&I review provider monitoring using the standard tool. Mark YES if the standard monitoring tool has been completed for all, or no more

than 10 randomly selected, providers. Mark NO if the standard monitoring tool was not used. Mark NA if the AE has not been assigned any providers to monitor by ODP.

Consolidated and PFDS waivers AE OA QA&I Process

05.0A.02.

CRITERIA 2 - The AE monitors all providers as assigned by ODP.

O The AE monitors all providers as assigned by ODP. The reviewer should first identify the number of providers that the AE has been

assigned (by ODP). The reviewer should review all, but not more than 10 randomly chosen, monitorings

conducted by the AE for the previous full fiscal year to determine if monitoring has been completed. Mark YES if monitoring has been completed. Mark NO if monitoring has not been completed. Mark NA if the AE has not been assigned any providers to monitor by ODP.


05.0A.03.

CRITERIA 3 - AE notifies all providers of the results of the monitoring within 30 calendar days.

O The reviewer validates that the AE submitted the AE Review Report (QA&I Comprehensive Report effective 7/1/17) to the provider within 30 calendar days of the last on-site review completion date.

The reviewer should review all, but no more than 10 randomly chosen, onsite




# Question Type Guidance Source Documentsreviews conducted by the AE from the Provider Monitoring sample for the previous fiscal year. Mark YES if the AE submitted the AE Review Report to the provider within 30

days. Mark NO if the provider was not notified within 30 days. Mark NA if the AE has not been assigned any providers to monitor by ODP.

05.0A.04.

CRITERIA 4 – AE completes any follow-up actions with all providers based on the AE Review Report (QA&I Comprehensive Report effective 7/1/17)

O The reviewer validates that the AE has completed any follow-up actions with all providers based on the AE Review Report (QA&I Comprehensive Report effective 7/1/17).

This includes and is not limited to: - Approval of the corrective action plan- Review of documentation submitted- Technical assistance to provider, etc.

Mark YES if the AE completed follow-up actions with the providers. Mark NO if the AE did not complete follow-up actions with the providers. Mark NA if the AE has not been assigned any providers to monitor by ODP.


05.0A.00.R.

The AE conducts Provider Monitoring (QA&I Process effective 7/1/2017)

R Consolidated and PFDS waivers AE OA ODP Provider Monitoring Process

05.0A.00.R1.

Documentation was located. R The AE has located evidence that documents their monitoring of all providers assigned by ODP. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.

Consolidated and PFDS waivers AE OA ODP Provider Monitoring Process

05.0A.00.R2.



selected.


05.0A.00.R3.



taken by the AE.








05.0A.00.R5.


R Mark YESs if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.



06.00.00. The AE's IM4Q process is implemented. The AE shall comply with responsibilities with the current IM4Q protocol and guidelines as set forth in the IM4Q Manual and any other applicable ODP procedures.06.0A.00.

The AE ensures the loop is closed on considerations and all required elements are included.

O The reviewer determines if the AE has a written procedure for implementing the IM4Q “Closing the Loop Process”.

The reviewer confirms that the supporting evidence showing the loop has been closed is in place. Mark YES if the AE has implemented their IM4Q Closing the Loop Process. Mark NO if the AE has not implemented their IM4Q Closing the Loop Process.

AE OA IM4Q Manual 2016

06.0A.00.R.

The AE ensures the loop is closed on considerations and all required elements are included.

R AE OA IM4Q Manual 2016

06.0A.00.R1.

Documentation was located. R The AE has located the protocol AND it contains all required elements. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


06.0A.00.R2.

The AE develops a process to ensure the loop is closed.

R The AE develops a process to ensure the loop is closed for all IM4Q considerations. Mark YES if the process was developed. Mark NA if no remediation action is required or another remediation action was

selected.


06.0A.00.R3.







06.0A.00.R4.



taken by the AE.


06.0A.00.R5.





06.0B.00.

The AE uses a process to share IM4Q information with stakeholders.

O The reviewer requests documentation from the previous 12 months that indicates the Policy and Procedure established by the AE is being implemented for sharing information with stakeholders.

The reviewer should look for information as specified by the AE’s policy. o Examples might include:

- board reports- Letters- Logs- Emails- meeting minutes

Mark YES if documentation is available that the AE shared IM4Q information with stakeholders.

Mark NO if there is no documentation of the AE sharing IM4Q information.


06.0B.00.R.

The AE uses a process to share IM4Q information with stakeholders.

R AE OA IM4Q Manual 2016

06.0B.00.R1.

Documentation was located R The AE has located the documentation from the previous 12 months that indicates the Policy and Procedure established by the AE is being implemented. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


06.0B.00.R2.

The AE develops a process for sharing IM4Q information with stakeholders.

R The AE develops a process with timeframes to ensure IM4Q information is shared with all stakeholders.




# Question Type Guidance Source Documents Mark YES if the process was developed. Mark NA if no remediation action is required or another remediation action was

selected.06.0B.00.R3.



selected.


06.0B.00.R4.



taken by the AE.


06.0B.00.R5.





07.0A.00.

An improvement plan resulting from the previous QA&I process is fully implemented.

Non-scored in Cycle 1 Year 1

O The reviewer will determine if the AE completed all improvement activities and provided documentation of each action taken. Mark Yes if there is documentation that the AE has completed activities as

described in their Improvement Plan. Mark No if there is no documentation indicating that the AE completed

improvement activities. Mark NA if no improvement plan resulted from the previous QA&I process (all of

Cycle 1).

ODP Announcement 093-13 AE OA Waiver

07.0A.00.R

The AE implements an improvement plan.

R ODP Announcement 093-13 AE OA Waiver

07.0A.00.R1

Documentation located R The AE has located evidence that documents the completion of all improvement activities. Mark YES, if documentation was located. Mark N/A, if no remediation action is required or another remediation action

was selected.




# Question Type Guidance Source Documents

07.0A.00.R2

All corrective actions are completed and evidence to support that completion is provided.

R The AE completes all corrective actions, and provides evidence to support that completion to the reviewer. Mark YES, if documentation is provided. Mark N/A, if no remediation action is required or another remediation action

was selected.


07.0A.00.R3.



selected.


07.0A.00.R4.



taken by the AE.


07.0A.00.R5.





The County completes OBRA related responsibilities in accordance with Federal requirements under the Omnibus Budget Reconciliation Act (OBRA) of 1987. The Regional Office of Developmental Programs is responsible for determining the need for nursing facility services for individuals with intellectual disabilities. The determination is based on an evaluation of the individual's total needs, including health and age-related needs, in consultation with the responsible County ID Program, individual, family and providers of service. 08.0A.00.

The County submitted an OBRA preliminary report, together with the County's concurrence/non-concurrence to the Regional Office of Developmental Programs within the

O The OBRA Lead for the Regional Office will provide the QA&I Lead with a list of the OBRA Determinations on Need for Nursing Home Services issued for this County within the last six months prior to the start of the most recent QA&I cycle (January - June). Mark YES if the County submitted an OBRA preliminary report, together with the

PASRR document OBRA Bulletin 00-93-30



# Question Type Guidance Source Documentslast six months.

Non-Scored

County's concurrence/non-concurrence to the Regional Office of Developmental Programs within the last six months.

Mark NA if no OBRA preliminary reports were completed by the county in the last six months.

08.0B.00.

The commitment screen in HCSIS reflects the OBRA Determination on Need for Nursing Home Services.

D The OBRA Lead for the Regional Office will provide the QA&I Lead with the OBRA Determination on Need for Nursing Home Services within the last six months prior to the start of the most recent QA&I cycle. (January - June).

The reviewer determines if the enrollment screen in HCSIS reflects "intent to enroll" status.

PATH: Individual > Eligibility > Eligibility determination > Waiver/program enrollment.

The reviewer should review ALL but no more than ten OBRA Determinations. Mark YES if the HCSIS enrollment screen has intent to enroll. Mark NO if the HCSIS enrollment screen does not have “intent to enroll”. Mark NA if no OBRA preliminary reports were completed by the county in the

last six months or if the person was not waiver eligible prior to nursing home placement.

AE OA AE Letter #4 Course # 009-05-01- Reserved Capacity

2013 update Part 1

08.0B.00.R



2013 update Part 108.0B.00.R1.


R The County will update the HCSIS enrollment screen to reflect the placement in nursing home as well as subsequent changes to reflect current situation. Mark YES if the County updates the HCIS screen for all applicable records. Mark NA if no remediation actions is required or another remediation action was

selected.


2013 update Part 1

08.0B.00.R2.

Other remediation action R The reviewer can accept documentation of "other" remediation actions taken by the county to comply with ODP Policies and Procedures.

The reviewer records in comment field the REMEDIATION ACTION (RA) taken by the county to remediate. Mark YES if the county submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


2013 update Part 1




08.0B.00.R3.

If YES, when: R The reviewer calculates the number of days between the notification date to the county and the remediation action date.


taken by the county.


2013 update Part 1

08.0B.00.R4.





2013 update Part 1

08.0C.00.

The County has identified the need for a specialized service other than supports coordination.

Non-Scored

O The reviewer discusses with the county their process used to identify specialized services.

In the event the county has identified the need for a service other than supports coordination, or has ONLY identified supports coordination, how were those determinations made? Mark YES if the county process results in services other than supports

coordination. Mark NO if the county only identifies supports coordination. Mark NA if there are no specialized services identified.


08.0D.00.

The County authorizes the specialized services as identified in the OBRA Determination on Need for Specialized Services.

O The reviewer determines if the county authorized the specialized services as identified in the OBRA Determination on Need for Specialized Services.

Specialized services are authorized by the responsible County Program for individuals with intellectual disabilities who are residents of a nursing facility when the individual's needs are such that continuous supervision, treatment, and training by qualified intellectual disability personnel are necessary. Mark YES if the county authorized specialized services as determined for all

reviewed. Mark NO if the county did not authorize specialized services as determined.




# Question Type Guidance Source Documents Mark NA if no OBRA preliminary reports were completed by the county in the

last six months or no Determinations on Need for Specialized Services were issued by the Regional Office.

08.0D.00.R.

The County authorizes the specialized services as identified in the OBRA Determination on Need for Specialized Services.

R PASRR document OBRA Bulletin 00-93-30

08.0D.00.R1

The County authorizes specialized services.

R The County provides documentation that specialized services are now authorized. Mark YES if the County submitted all remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


08.0D.00.R2


The reviewer records in comment field the REMEDIATION ACTION (RA) taken by the county to remediate. Mark YES if the county submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


08.0D.00.R3





08.0D.00.R4





08.0E.00.

All services as identified in the Determination on Need for Specialized Services were received.

O The reviewer determines if all services identified in the Determination on Need were received.

The reviewer looks at the paid claims, authorizations or whatever means the County uses to record service utilization. Mark YES if there is documentation that services have been received. Mark NO if no documentation that services were received.




# Question Type Guidance Source Documents Mark NA if no OBRA preliminary reports were completed by the county in the

last six months or no Determinations on Need for Specialized Services were issued by the Regional Office.

08.0E.00.R.

All services as identified in the Determination on Need for Specialized Services were received.

R PASRR document OBRA Bulletin 00-93-30

08.0E.00.R1.

Services are initiated as per the Determination on Need for Specialized Services.

R The County will provide documentation as evidence of service delivery. Mark YES if the County provides documentation of service delivery. Mark NA if no remediation action was necessary or another remediation action

was selected.


08.0E.00.R2.

Documentation was located. R The County has located evidence that supports that specialized services were received. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


08.0E.00.R3.


Reviewer records in comment field the REMEDIATION ACTION (RA) taken by the county to remediate. Mark YES if the county submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


08.0E.00.R4.





08.0E.00.R5.





LEVEL OF CARE - Individuals new to an ODP waiver receive a level of care evaluation and determination.Level of Care (LOC) determinations are completed according to ODP policies and procedures. For those people enrolled in the waiver within the LAST FISCAL YEAR the reviewer should



# Question Type Guidance Source Documentsdetermine if the appropriate LOC determination form is used and completed. The reviewer uses the initial DP 250 ONLY (even if there is a revaluation on file). The required form is considered to meet criteria only if both signatures and both dates are completed and legible.09.0A.00.

The individual was newly enrolled (IN THE LAST FISCAL YEAR) in the waiver.

Non-Scored

D The reviewer determines if the individual was enrolled in waiver during the last Fiscal Year (FY).

PATH: HCSIS > Individual > Eligibility > Eligibility Documentation > Waiver/Program Enrollment (drop down on right side).

An individual is newly enrolled in the waiver if the date on the Waiver/Program Enrollment screen is within the last FY (7/1-6/30). Mark YES if the individual was enrolled during the last FY. Mark NA if the individual was not enrolled during the last FY.

**Include the date of enrollment in the comment field.

Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver

Services

09.0B.00.

The AE completed the initial level of care evaluation and determination prior to entry into the waiver.

O The reviewer determines if the date of the DP 250 (with AE signature and date) is prior to the date on the PA 162 to ensure determination of eligibility was prior to waiver enrollment.

Persons entering the waiver directly from a state center or private ICF/ID can substitute the required documents with a Utilization Review (UR) form. Mark YES if the date on the DP 250 is on or before the date on the PA 162. Mark NO if the date on the DP 250 is AFTER the date on the PA 162. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year.


Services

09.0B.00.R.

The AE completed the initial level of care evaluation and determination prior to entry into the waiver.

R Consolidated and PFDS waivers AE OA Bulletin 00-08-04 Eligibility for Waiver

Services09.0B.00.R1.

Missing documentation is located R The AE has located the completed LOC determination. Mark YES if Missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0B.00.R2.

The AE notifies any/all waiver providers to void incorrect billing.

R The AE notifies any/all waiver providers of discrepancy with dates and ensures that any billing that occurs due to this error is voided. Mark YES if the AE provides evidence of notification to waiver providers. Mark NA if no remediation action is required or another remediation action was

selected.


Services



# Question Type Guidance Source Documents09.0B.00.R3.


The reviewer records in the comment field the REMEDIATION ACTION (RA) taken by the AE to remediate. Mark YES if the AE submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0B.00.R4.



taken by the AE.


Services

09.0B.00.R5.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0B.00.R6.





Services09.0C.00.

Certification of Need for ICF/ID or ICF/ORC LOC DP 250 completed (signed and dated).

O The reviewer determines if the DP 250 is signed and dated by the QDDP and the County MH/MR Program/AE.

Persons entering the waiver directly from a state center or private ICF/ID can substitute the required documents with a Utilization Review (UR) form. Mark Yes if both signatures and both dates are completed on the DP 250. Mark No if the QDDP or County MH/MR Program /AE signature is missing, the

QDDP or County MH/MR Program /AE date is missing or if the DP 250 is not available.

Mark NA if the individual was not enrolled in the waiver within the last fiscal year.


Services

09.0C. Certification of Need for ICF/ID or R Consolidated and PFDS waivers



# Question Type Guidance Source Documents00.R. ICF/ORC LOC DP 250 completed

(signed and dated). AE OABulletin 00-08-04 Eligibility for Waiver Services

09.0C.00.R1.

Missing documentation is located R The AE has located the completed LOC determination. Mark YES if Missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0C.00.R2

The LOC evaluation form was corrected to include both legible signatures and dates.

R The LOC form is considered to meet criteria only if both signatures and both dates are obtained and legible. Mark Yes, if the form is properly completed. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0C.00.R3

LOC form was completed indicating person meets eligibility requirements.

R The AE must complete a LOC determination. If the determination is that the person meets eligibility criteria, the LOC form is

considered COMPLETE only if both signatures and both dates are completed and legible. Mark Yes, if the form is properly completed. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0C.00.R4.

LOC was completed, eligibility criteria was not met, and disenrollment procedures have been initiated as per ODP policies and procedures, and HCSIS amended as appropriate.

R The AE must complete a LOC determination. If the determination is that the person DOES NOT meet eligibility criteria, the AE

must initiate disenrollment procedures per ODP policies and procedures, which includes notification to the person of hearing and appeal rights. Mark Yes if HCSIS eligibility screen is amended to reflect disenrollment. Mark NA if no remediation action is required or another remediation action was

selected.


Services

09.0C.00.R5.


The reviewer records in the comment field the REMEDIATION ACTION (RA) taken by the AE to remediate. Mark YES if the AE submitted remediation documentation.


Services



# Question Type Guidance Source Documents Mark NA if no remediation action is required or another remediation action was

selected.

09.0C.00.R6.



taken by the AE.


Services

09.0C.00.R7.


selected.


Services

09.0C.00.R8.





Services10.00.00. The Medical evaluation includes a recommendation for an ICF/ID or ICF/ORC LOC. For those people enrolled in the waiver within the LAST FISCAL YEAR, the reviewer determines if the medical evaluation includes a recommendation for ICF/ID or ICF/ORC LOC. The medical evaluation may be the medical evaluation approved by the Department (Form MA 51) or an examination that is completed by a licensed physician, physician’s assistant or nurse practitioner that states the individual is recommended for an ICF/ID or ICF/ORC LOC.10.0A.00.

The medical evaluation includes a recommendation for an ICF/ID or ICF/ORC LOC.

O The reviewer determines if the medical evaluation states the individual is recommended for an ICF/ID or ICF/ORC LOC.

The medical evaluation may be the MA 51 or an examination that is completed by a licensed physician, physician’s assistant, or nurse practitioner. Mark YES if the LOC recommendation is indicated on the medical evaluation. Mark NO if the LOC recommendation is not indicated on the medical evaluation

or the medical evaluation is not in the file. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year.

Bulletin 00-08-04 Eligibility for Waiver Services

10.0A. The medical evaluation includes a R Bulletin 00-08-04 Eligibility for Waiver



# Question Type Guidance Source Documents00.R. recommendation for an ICF/ID or

ICF/ORC LOC.Services

10.0A.00.R1.

Missing documentation was located. R The AE has located the medical evaluation/physician statement which includes the ICF/ID or ICF/ORC LOC recommendation. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


10.0A.00.R2.

Medical evaluation is completed and includes a recommendation for ICF/ID or ICF/ORC LOC.

R The AE has obtained a completed the medical evaluation which includes the ICF/ID or ICF/ORC LOC recommendation. Mark YES if medical evaluation obtained. Mark NA if no remediation action is required or another remediation action was

selected.


10.0A.00.R3.

Medical evaluation was completed, eligibility criteria was not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE must obtain a completed medical evaluation. If the determination is that the person DOES NOT meet eligibility criteria, the AE

must initiate disenrollment procedures per ODP policies and procedures, which includes notification to the person of hearing and appeal rights. Mark YES if HCSIS eligibility screen is amended to reflect disenrollment. Mark NA if no remediation action is required or another remediation action was

selected.


10.0A.00.R4.



selected.


10.0A.00.R5.



taken by the AE.





10.0A.00.R6.


selected.


10.0A.00.R7.





11.00.00. The Medical evaluation occurs within the 365-day period prior to the QDDP signature on the LOC DP 250 Form. For those people enrolled in the waiver within the LAST FISCAL YEAR, the reviewer determines if the medical evaluation occurred within the 365-day period prior to the QDDP signature on the LOC DP 250. The medical evaluation must state that the individual is recommended for an ICF/ID or ICF/ORC LOC and be dated within 365 days PRIOR to the DATE of the QDDP signature.11.0A.00.

The medical evaluation occurs within the 365-day period prior to the QDDP signature on the LOC DP 250 Form.

O The reviewer determines if the medical evaluation is dated within 365 days PRIOR to the date of the QDDP signature.

Persons entering the waiver directly from a state center or private ICF/ID can substitute the required documents with a Utilization Review (UR) form.

The medical evaluation may be the MA 51 or an examination that is completed by a licensed physician, physician’s assistant, or nurse practitioner. Mark YES if the medical evaluation is within the 365 days prior to the QDDP

signature. Mark NO if the medical evaluation is not within the 365 days prior to the QDDP

signature. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year.




# Question Type Guidance Source Documents11.0A.00.R.

The medical evaluation occurs within the 365-day period prior to the QDDP signature on the LOC DP 250 Form.

R Bulletin 00-08-04 Eligibility for Waiver Services

11.0A.00.R1.

Missing documentation was located. R The AE has located the medical evaluation that is dated within 365 days of the QDDP signature on the LOC determination. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected


11.0A.00.R2.

Medical evaluation was completed, eligibility criteria was met, LOC completed and HCSIS amended as appropriate.

R The AE has obtained a completed the medical evaluation and the QDDP completes a LOC determination. Mark YES if LOC completed and HCSIS amended. Mark NA if no remediation action is required or another remediation action was

selected.


11.0A.00.R3.


R The AE must obtain a completed medical evaluation. If the determination is that the person DOES NOT meet eligibility criteria, the AE

must initiate disenrollment procedures per ODP policies and procedures, which includes notification to the person of hearing and appeal rights. Mark YES if HCSIS eligibility screen is amended to reflect disenrollment. Mark NA if no remediation activity is required.


11.0A.00.R4.



selected.


11.0A.00.R5.



taken by the AE.





11.0A.00.R6.


selected.


11.0A.00.R7.





12.00.00. The Psychological evaluation includes the results of a standardized general intelligence test that certifies the individual has a diagnosis of intellectual disability/significantly sub-average intellectual functioning. For those people enrolled in the waiver within the LAST FISCAL YEAR, the reviewer determines if the psychological evaluation includes the results of a standardized general intelligence test that certifies the individual has a diagnosis of intellectual disability/significantly sub-average intellectual functioning.12.0A.00.

The psychological evaluation meets ODP standards.

O The reviewer determines if the psychological evaluation meets ODP standards. ODP standards are:

- The results of a standardized general intelligence test - A statement by a certifying practitioner that certifies the individual has a

diagnosis of intellectual disability/significantly sub-average intellectual functioning.

Mark YES if the psychological meets ODP standards. Mark NO if the psychological does not meet ODP standards. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year. **Reason for non-compliance must be indicated in the comment field for this question.





12.0A.00.R

The psychological evaluation meets ODP standards.


12.0A.00.R1.

Missing documentation was located. R The AE has located the psychological evaluation which includes the results of a standardized general intelligence test and a statement that certifies the individual has a diagnosis of intellectual disability/significantly sub-average intellectual functioning. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


12.0A.00.R2.

Psychological evaluation is completed. R The AE has obtained a completed psychological evaluation which includes the results of a standardized general intelligence test and a statement that certifies the individual has a diagnosis of intellectual disability/significantly sub-average intellectual functioning. Mark YES if documentation was completed. Mark NA if no remediation action is required or another remediation action was

selected.


12.0A.00.R3.

Psychological evaluation was completed, eligibility criteria was not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE must complete a psychological evaluation. If the determination is that the person DOES NOT meet eligibility criteria, the AE


selected.


12.0A.00.R4.



selected.


12.0A. If YES, when: R The reviewer calculates the number of days between the notification date to the AE Bulletin 00-08-04 Eligibility for Waiver



# Question Type Guidance Source Documents00.R5. and the remediation action date.


taken by the AE.

Services

12.0A.00.R6.


selected.


12.0A.00.R7.





12.0B.00.

A QDDP certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning.

O The reviewer determines if a QDDP certified that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning.

Persons entering the waiver directly from a state center or private ICF/ID can substitute the required documents with a Utilization Review (UR) form.

Impairments are either:- Significant limitation in meeting the standards of maturation, learning, personal

independence, or social responsibility of his or her age and cultural group.- Substantial functional limitation in three or more of the following areas of

major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, economic self-sufficiency.

Mark YES if there is documentation of the QDDP certification. Mark NO if there is no documentation of the QDDP certification in the file. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year.




# Question Type Guidance Source Documents12.0B.00.R.

A QDDP certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning.


12.0B.00.R1.

Missing documentation was located. R The AE has located the standardized adaptive assessment. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


12.0B.00.R2.

Standardized adaptive assessment is completed and indicates impairments in adaptive behavior.

R The AE has obtained a completed standardized adaptive assessment that indicates impairments in adaptive behavior. Mark YES if documentation was obtained. Mark NA if no remediation action is required or another remediation action was

selected.


12.0B.00.R3.

Standardized adaptive assessment was completed, eligibility criteria were not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE must obtain a standardized adaptive assessment. If the determination is that the person DOES NOT meet eligibility criteria, the AE

must initiate disenrollment procedures per ODP policies and procedures, which includes notification to the person of hearing and appeal rights. Mark Yes, if HCSIS eligibility screen is amended to reflect disenrollment. Mark N/A if no remediation action is required or another remediation action was

selected.


12.0B.00.R4.



selected.


12.0B.00.R5.






# Question Type Guidance Source Documentstaken by the AE.

12.0B.00.R6.


selected.


12.0B.00.R7.





12.0C.00.

The record contains evidence that the intellectual disability manifested during the developmental period which is from birth up to the individual’s 22nd birthday.

O The reviewer determines if the record contains documentation that the individual has these conditions of intellectual and adaptive functioning manifested during the developmental period which is from birth up to the individual's 22nd birthday.

The results of both the Standardized Adaptive Assessment and the Psychological testing may include a statement providing this documentation

The reviewer utilize any records to substantiate that these conditions manifested during the developmental period. Mark YES if records contains documentation of manifestation during birth to 22nd

birthday. Mark NO if the record does not contain the documentation. Mark NA if the individual was not enrolled in the waiver within the last fiscal

year.


12.0C.00.R.

The record contains evidence that the intellectual disability manifested during the developmental period which is from birth up to the individual’s 22nd birthday.


12.0C.00.R1.

Missing documentation was located. R The AE has located the evidence substantiating manifestation of intellectual disability during the developmental period. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.





Documentation was obtained. R The AE has obtained the evidence substantiating manifestation of intellectual disability during the developmental period. Mark YES if documentation was obtained. Mark NA if no remediation action is required or another remediation action was

selected.


12.0C.00.R3.

Documentation located/obtained, eligibility criteria was not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE must obtain a Standardized Adaptive Assessment. If the determination is that the person DOES NOT meet eligibility criteria, the AE


selected.


12.0C.00.R4.



selected.


12.0C.00.R5.



taken by the AE.


12.0C.00.R6.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status or transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation action is required or another remediation action was

selected.





12.0C.00.R7.





LEVEL OF CARE - The individual has a LOC evaluation updated annually.13.00.00. The Annual Recertification of Need for ICF/ID or ICF/ORC Level of Care (DP 251) is completed. The first reevaluation of need for an ICF/ID or ICF/ORC level of care is to be made within 365 days of the individual's initial determination (date on the current DP250) and subsequent reevaluations are made within 365 days of the individual’s previous reevaluation. The annual reevaluation must be signed and dated by the QDDP and AE designee for compliance.13.0A.00.

The DP 251 form is complete. O The reviewer determines if the DP 251 was signed and dated within the past year at the time of the QA&I review.

The annual reevaluation must be signed and dated by the QDDP and AE designee for compliance.

THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO THE LAST FISCAL YEAR Mark YES if the DP251, signed and dated within the past year at the time of the

QA&I process, is found in the on-site file. Mark NO if the DP251is missing either the signature or date or is not found in the

on-site file. Mark NA if the individual was newly enrolled (enrolled in the last fiscal year).

Consolidated and PFDS waivers AE OA Bulletin 00-08-04, Eligibility for Waiver

Services

13.0A.00.R.

The DP 251 form is complete. R Consolidated and PFDS waivers AE OA Bulletin 00-08-04, Eligibility for Waiver

Services13.0A.00.R1.

Missing documentation was located. R The AE has located the completed reevaluation. If reevaluation was completed and eligibility criteria were not met, the reviewer

ensures that disenrollment procedures have been initiated as per ODP policies and




# Question Type Guidance Source Documentsprocedures, and HCSIS amended as appropriate. Mark YES if missing documentation was located. Mark NA if no remediation activity was necessary.

Services

13.0A.00.R2.

LOC reevaluation form (DP 251) was created and includes both legible signatures and dates.

R LOC reevaluation form (DP251) is considered to meet criteria only if both signatures and both dates are obtained and legible.

If reevaluation was completed and eligibility criteria were not met, the reviewer ensures that disenrollment procedures have been initiated as per ODP policies and procedures, and HCSIS amended as appropriate. Mark YES if the form is properly completed. Mark NA if no remediation activity is required.


Services

13.0A.00.R3.

LOC reevaluation form (DP 251) was corrected and includes both legible signatures and dates.

R The most recent LOC reevaluation form (DP 251) is considered to meet criteria only if both signatures and both dates are obtained and legible.

If reevaluation was completed and eligibility criteria were not met, the reviewer ensures that disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate. Mark YES if the form is properly completed. Mark NA if no remediation activity is required.


Services

13.0A.00.R4.



selected.


Services

13.0A.00.R5.



taken by the AE.


Services

13.0A. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate Consolidated and PFDS waivers



# Question Type Guidance Source Documents00.R6. the non-compliance due to death, moving out of state, inactive record status, or

transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA Bulletin 00-08-04, Eligibility for Waiver

Services

13.0A.00.R7.





Services

13.0B.00.

The DP 251 is timely. O The reviewer determines if the DP 251 is timely “Timely” is defined as the first reevaluation of need for an ICF/ID or ICF/ORC level of

care is to be made within 365 days of the individual's initial determination (date on the current DP250) and subsequent reevaluations are made within 365 days of the individual’s previous reevaluation.

THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO THE LAST FISCAL YEAR Mark YES if the appropriate documentation to re-certify ICF/ID or ICF/ORC LOC is

timely. Mark NO if the DP 251 is not timely or is not in the file. Mark NA if the individual has been newly enrolled.


Services

13.0B.01.

If the DP 251 was not timely, how late: O The reviewer calculates the number of days the recertification was late based on the QDDP signature date.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if the DP 251 in the file was NOT within the last 12 months, NOT late or

if the individual was newly enrolled.


Services

13.0B.00.R.

The DP 251 is timely. R Consolidated and PFDS waivers AE OA Bulletin 00-08-04, Eligibility for Waiver

Services13.0B. Missing documentation was located. R The AE has located the completed reevaluation. Consolidated and PFDS waivers



# Question Type Guidance Source Documents00.R1. REMEDIATION WILL ONLY BE CONSIDERED FOR THOSE DP 251s NOT COMPLETED AT

THE TIME OF QA&I REVIEW. If reevaluation was completed and eligibility criteria were not met, the reviewer

ensures that disenrollment procedures have been initiated as per ODP policies and procedures, and HCSIS amended as appropriate. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


Services

13.0B.00.R2.

The DP 251 form was created and includes both legible signatures and dates.

R The DP 251 form is considered to meet criteria only if both signatures and both dates are obtained and legible.

REMEDIATION WILL ONLY BE CONSIDERED FOR THOSE DP 251s NOT COMPLETED AT THE TIME OF QA&I REVIEW.

If reevaluation was completed and eligibility criteria were not met, the reviewer ensures that disenrollment procedures have been initiated as per ODP policies and procedures, and HCSIS amended as appropriate. Mark YES if the form is properly completed. Mark NA if no remediation action is required or another remediation action was

selected.


Services

13.0B.00.R3.



selected.


Services

13.0B.00.R4.



taken by the AE.


Services

13.0B. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate Consolidated and PFDS waivers




transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation action is required or another remediation action was

selected.


Services

13.0B.00.R6.





Services

13.0C.00.


O The reviewer determines if the medical evaluation includes a recommendation for ICF/ID or ICF/ORC LOC.

THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO THE LAST FISCAL YEAR.

The medical evaluation may be the MA 51 or an examination that is completed by a licensed physician, physician’s assistant, or nurse practitioner.

A medical evaluation is not needed for individuals who received a reevaluation after July 1, 2017. Mark YES if LOC recommendation is indicated on the medical evaluation. Mark NO if the medical evaluation does not have a recommendation for ICF/ID

or ICF/ORC LOC or the medical evaluation is not in the file. Mark NA if the individual has been newly enrolled or the reevaluation occurred

after July 1, 2017.


Services

13.0C.00.R.


R Consolidated and PFDS waivers AE OA Bulletin 00-08-04, Eligibility for Waiver

Services13.0C.00.R1.

Missing documentation was located. R The AE has located the medical evaluation/physician statement which includes the ICF/ID or ICF/ORC LOC recommendation. Mark YES if missing documentation was located.





selected.Services

13.0C.00.R2.

Medical Evaluation is completed and includes a recommendation for ICF/ID or ICF/ORC LOC.

R The AE has obtained a completed medical evaluation which includes the ICF/ID or ICF/ORC LOC recommendation. Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.


Services

13.0C.00.R3.

Medical Evaluation was completed, eligibility criteria was not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE has obtained a completed medical evaluation. If the determination is that the person DOES NOT meet eligibility criteria, the AE


selected.


Services

13.0C.00.R4.



selected.


Services

13.0C.00.R5.



taken by the AE.


Services

13.0C.00.R6.



Services




13.0C.00.R7.





Services

13.0D.00.

The medical evaluation occurs within the 365-day period prior to the QDDP signature on the DP 251 Form.

O The reviewer determines if the medical evaluation is timely. “Timely” is defined as the medical evaluation must occur within the 365-day period

prior to the QDDP signature on the DP 251 Form. THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO

THE LAST FISCAL YEAR The medical evaluation may be the MA 51 or an examination that is completed by a

licensed physician, physician’s assistant, or nurse practitioner. A medical evaluation is not needed for individuals who received a reevaluation after

July 1, 2017.

Mark YES if the medical evaluation is dated within 365 days prior to the QDDP signature.

Mark NO if the medication evaluation is not dated within 365 days prior to the QDDP signature or it is not in the file.

Mark NA if the individual has been newly enrolled or the reevaluation occurred after July 1, 2017.

Bulletin 00-08-04, Eligibility for Waiver Services

13.0D.00.R.

The medical evaluation occurs within the 365-day period prior to the QDDP signature on the DP 251 Form.

R Bulletin 00-08-04, Eligibility for Waiver Services

13.0D.00.R1

Missing documentation was located. R The AE has located the medical evaluation/physician statement that is dated within 365 days of the QDDP signature on the most recent LOC determination. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.




# Question Type Guidance Source Documents13.0D.00.R2

Medical evaluation was completed, eligibility criteria was met, LOC completed, and HCSIS amended as appropriate.

R The AE has obtained a completed medical evaluation. QDDP completes a level of care determination.

Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.


13.0D.00.R3


R The AE has obtained a completed medical evaluation. If the determination is that the person DOES NOT meet eligibility criteria, the AE


selected.


13.0D.00.R4



selected.


13.0D.00.R5



taken by the AE.


13.0D.00.R6


selected.


13.0D Remediation action outstanding - R Mark YES if referred for appropriate follow-up as a result of no remediation Bulletin 00-08-04, Eligibility for Waiver



# Question Type Guidance Source Documents.00.R7 referred to appropriate staff for follow

up.action within 90 days of notification of the review findings. Utilize the comment field to record follow-up action.


Services

13.0E.00.

The AE used the Waiver reevaluation tool to complete the reevaluation process.

O The reviewer determines if the Waiver reevaluation tool using SIS scores was completed for the reevaluation.

THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO THE LAST FISCAL YEAR

The SIS tool is only completed for reevaluations that occur after July 1, 2017. Mark YES if the SIS tool was used. Mark NO if the SIS tool was not used. Mark NA if the individual has been newly enrolled or the reevaluation occurred

before July 1, 2017.

New bulletin

13.0E.00.R.

The AE used the Wavier reevaluation tool to complete the reevaluation process.

R New bulletin

13.0E.00.R1.

Missing documentation was located. R The AE has located the completed Waiver reevaluation tool. Mark YES if missing documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.

New bulletin

13.0E.00.R2.

Waiver reevaluation tool was completed, eligibility criteria was met, LOC completed, and HCSIS amended as appropriate.

R The AE completed a Waiver reevaluation tool. QDDP completes a level of care determination.

Mark YES if completed. Mark NA if no remediation action is required or another remediation action was

selected.

New bulletin

13.0E.00.R3.

Waiver reevaluation tool was completed, eligibility criteria was not met, disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R The AE completed a Waiver reevaluation tool. If the determination is that the person DOES NOT meet eligibility criteria, the AE


selected.

New bulletin

13.0E.00.R4.


The reviewer records in comment field the REMEDIATION ACTION (RA) taken by the AE to remediate.

New bulletin



# Question Type Guidance Source Documents Mark YES if the AE submitted remediation documentation. Mark NA if no remediation action is required or another remediation action was

selected.13.0E.00.R5.



taken by the AE.

New bulletin

13.0E.00.R6.




New bulletin

13.0F.00.

The annual reevaluation date is entered into HCSIS.

D The reviewer determines if the AE or delegated entity entered the annual reevaluation date (Form DP 251) into HCSIS.

PATH: HCSIS > Individual > Eligibility > Eligibility Documentation. THIS QUESTION IS ONLY ANSWERED FOR THOSE INDIVIDUALS ENROLLED PRIOR TO

THE LAST FISCAL YEAR Mark YES if the most current date is entered into HCSIS in the correct location. Mark NO if there is no date in HCSIS or if the date is incorrect (old). Mark NA if the individual is newly enrolled.

None

13.0F.00.R.

The annual reevaluation date is entered into HCSIS.

R None

13.0F.00.R1.

The reevaluation date is entered into HCSIS.

R The AE/SCO enters the most current annual reevaluation date (Form DP 251) into HCSIS.

PATH: HCSIS > Individual > Eligibility > Eligibility Documentation. Mark YES if the most current date is entered into HCSIS in the correct location. Mark NA if no remediation action is required or another remediation action was

selected.

None

13.0F.00.R2.



None




13.0F.00.R3.



taken by the AE.

None

13.0F.00.R4.


selected.

None

13.0F.00.R5.




None

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The system of support is straightforward.14.00.00. Waiver services are initiated within forty-five (45) calendar days. FOR NEWLY ENROLLED INDIVIDUALS ONLY--The AE shall 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 Individual. The AE must provide documentation that they have implemented their protocol, and ensured timely service initiation. 14.0A.00.

Waiver services are initiated within forty-five (45) calendar days.

O The reviewer determines if the waiver services were initiated within forty-five (45) calendar days of waiver enrollment.

The waiver enrollment date is found at PATH: Individual > Eligibility > Eligibility determination > Waiver/program enrollment.

The reviewer uses the waiver enrollment date and the date on the PA 162 to calculate if the services were initiated within 45 days.

The reviewer accepts any documentation (which may include billing, SC notes, spreadsheets, etc.) that the AE has to show that they implemented their protocol and ensured timely service initiation.

The documentation will be specific to the AE and may vary.

Mark YES if the documentation produced by the AE confirms that service(s) started within 45 days of waiver enrollment or the AE has a written request for

AE OA



# Question Type Guidance Source Documentsan extension.

Mark NO if the documentation does not confirm timely start of service(s). Mark NA if the individual was not newly enrolled.

14.0A.01.

If NO, how late:

Non-Scored

O The reviewer calculates the number of days the service was late based on the date of waiver enrollment.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if service initiation was timely or if the individual was not newly

enrolled.

AE OA

14.0A.00.R.

Waiver services are initiated within forty-five (45) calendar days.

R AE OA

14.0A.00.R1.

Waiver services are initiated. R The AE provides documentation that service(s) are initiated. Mark YES if documentation is provided. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

14.0A.00.R2.

Disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R If the individual is determined not to need waiver services (other than supports coordination) the AE must document that the individual is disenrolled from the waiver.

If the determination is that the person does not need waiver services, the AE must initiate disenrollment procedures per ODP policies and procedures, which includes notification to the person of hearing and appeal rights. Mark YES if HCSIS eligibility screen is amended to reflect disenrollment. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

14.0A.00.R3.



selected.

AE OA

14.0A.00.R4.


AE OA



# Question Type Guidance Source Documents The reviewer chooses the appropriate time frame from the drop down.

Mark NA if no remediation action was necessary, or if no remediation action was taken by the AE.

14.0A.00.R5.


selected.

AE OA

14.0A.00.R6.




AE OA

15.00.00. The AE provided individuals and families information in language understood by the individual/family/designee. The AE is required to have policies and procedures for ensuring language assistance services to people.15.0A.00.

The individual’s primary language is English.

Non-Scored

D The primary language is noted in the demographics page in HCSIS. Mark YES if the primary language is identified as English. Mark NO if the primary language is identified as something other than English.

** Identify the primary language if other than English.

Bulletin 00-14-04, Accessibility of ID Services for Individuals Who Are Deaf ODP

Bulletin 00-04-13 Limited English Proficiency

15.0B.00.

The AE provided individuals and families information in language understood by the individual/family/designee.

O The reviewer ensures that the most recent DP 251/DP 250 was provided to the individual/family designee in their primary language, ex. DP 251-S. Mark YES if the DP 251 was provided in their primary language. Mark NO if the DP 251 was not provided in their primary language. Mark NA if their primary language is English.



15.0B.00.R.

The AE provided individuals and families information in language understood by the individual/family/designee.

R Bulletin 00-14-04, Accessibility of ID Services for Individuals Who Are Deaf ODP


15.0B.00.R1.

Missing documentation was located. R The AE has located the DP 251/DP 250 in the individual/family designee’s primary language. Mark YES if missing documentation was located.





selected. Bulletin 00-04-13 Limited English

Proficiency15.0B.00.R2.

The AE updates their policy/procedure.

R The AE is required to have policies and procedures for ensuring language assistance services to people who have limited English proficiency. Mark YES if the AE updated their policy/procedure. Mark NA if no remediation action is required or another remediation action was

selected.



15.0B.00.R3.

AE provides training. R The AE will provide documentation that training has been conducted.

Mark YES if the AE completed the training and submitted documentation. Mark NA if no remediation was required or another remediation action was

selected.



15.0B.00.R4.



selected.



15.0B.00.R5.



taken by the AE.



15.0B.00.R6.






PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual’s assessed needs are addressed in the ISP through waiver-funded services or other funding sources or natural supports.16.00.00. ISP addresses all assessed needs through waiver funded services or other funding sources. The AE shall review, approve, and authorize each service included in the ISP. The review and approval of an ISP shall validate that the ISP is based on all (formal and informal) assessments. The ISP reflects the full range of a Waiver individual's need and therefore must include all Medicaid and non-Medicaid services, in addition to informal supports, that are necessary to support the individual's needs.16.0A.00.

Annual Review Update Date: D The reviewer determines the Annual Review Update Date. The reviewer uses the most current plan for this review.

AE OA ISP Manual



# Question Type Guidance Source DocumentsNon-Scored PATH: Plan > Plan Admin > Print > Plan Summary Page

Record the date listed in Annual Review Update Date field. 16.0B.00.

Plan Last Updated Date:

Non-Scored

D The reviewer determines the plan last updated date. The reviewer uses the most current plan for this review. PATH: Plan > Plan Admin > Print > Plan Summary Page

Record the date listed in Plan Last Updated Date field.

AE OA ISP Manual

16.0C.00.

All assessed needs are addressed in the ISP.

D The reviewer determines if the AE approved and authorized an ISP that is based on all formal and informal assessments based on a review of the service notes, Individual Monitoring Tool and the SIS.

The ISP reflects the full range of a Waiver individual's need and therefore must include all Medicaid and non-Medicaid services, in addition to informal supports, that are necessary to support the individual's needs. Mark YES if the plan contains evidence that all assessed needs have been

reviewed and/or addressed. Mark NO if there are identified assessed needs that have not been reviewed

and/or addressed.

** Identify what assessed needs were not included.

AE OA ISP Manual

16.0C.00.R.

All assessed needs are addressed in the ISP.

R AE OA ISP Manual

16.0C.00.R1.

ISP amended as appropriate to reflect all assessed needs.

R The AE will provide the reviewer with the ISP "Plan Status-Approved" date that reflects the changes made to the ISP. Mark YES if the Plan has been amended to reflect all assessed needs. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA ISP Manual

16.0C.00.R2.



selected.

AE OA ISP Manual

16.0C.00.R3.


The reviewer chooses the appropriate time frame from the drop down.

AE OA ISP Manual



# Question Type Guidance Source Documents Mark NA if no remediation action was necessary or if no remediation action was

taken by the AE.16.0C.00.R4.


selected.

AE OA ISP Manual

16.0C.00.R5.




AE OA ISP Manual

17.00.00. The AE approved and authorized the ISP within 365 days of the prior annual ISP. The AE shall initially review, approve and authorize a written ISP prior to each Individual’s receipt of Waiver service(s) and at least annually thereafter.17.0A.00.

An Annual ISP (Annual Review Update) exists in HCSIS for this individual.

D The reviewer determines if there is an Annual Review Update ISP in HCSIS. PATH: HCSIS > Plan > History > Summary > Annual Review Update

Mark YES if there is an Annual Review ISP in HCSIS. Mark NO if there is not an Annual Review ISP in HCSIS. Mark NA if the ISP is an Initial ISP.

Consolidated and PFDS waivers AE OA ISP Manual

17.0B.00.

Annual ISP (Annual Review Update) approved and authorized within 365 days of the prior Annual ISP.

D The reviewer determines if the annual review ISP was approved and authorized within 365 days of the prior annual ISP based on a review of the ISP.

The reviewer ensures the Annual Review Update ISP was approved and authorized (Approved) within 365 days of the previous Annual Review Update ISP.

PATH: HCSIS > Plan > History > Summary > Annual Review Update > “Approved” date is the date the AE approved/authorized the ISP.

Mark YES if the AE approved the ISP within 365 days. Mark NO if the AE did not approve the ISP within 365 days. Mark NA if the Annual Review was not due.


17.0B.01.

If NO, how late:

Non-Scored

D The reviewer calculates the number of days the Annual Review ISP was late based on the Annual Review Update Date.

The reviewer chooses the appropriate time frame from the drop down. Mark NA if the ISP is an Initial ISP or if it was not late.

** Please note in comment reason for NA.




# Question Type Guidance Source Documents17.0B.00.R.

Annual ISP (Annual Review Update) approved and authorized within 365 days of the prior Annual ISP.

R Consolidated and PFDS waivers AE OA ISP Manual

17.0B.00.R1.

An Annual ISP (Annual Review Update) exists in HCSIS for this individual

R The AE must ensure that an Annual Review ISP is approved and services are authorized. Mark YES if the Annual Review ISP is approved and authorized. Mark NA if no remediation action is required or another remediation action was

selected.


17.0B.00.R2.

The ISP is approved. R The AE must ensure that an Annual Review ISP is approved and services are authorized. Mark YES if the Annual Review ISP is approved and authorized. Mark NA if no remediation action is required or another remediation action was

selected.


17.0B.00.R3.



selected.


17.0B.00.R4.



taken by the AE.


17.0B.00.R5.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation action was

selected.


17.0B.00.R6.

Remediation action outstanding - referred to appropriate staff for follow

R Mark YES if referred for appropriate follow-up as a result of no remediation action within 90 days of notification of the review findings. Utilize the comment

Consolidated and PFDS waivers AE OA



# Question Type Guidance Source Documentsup. field to record follow-up action.

Mark NA if the issue was remediated or if no remediation was required. ISP Manual

18.00.00. The AE authorizes services consistent with the service definitions. While the Department holds the ultimate responsibility for the content of Person-Centered Support Plans, the Administrative Entity is responsible to implement their ISP review, approval and authorization protocol as directed in written policies and procedures, Departmental decision, and the Operating Agreement.18.0A.00.

The AE authorizes services consistent with the service definitions.

D The reviewer determines if the services authorized by the AE are consistent with the current ODP service definitions based on a review of service notes, Individual Monitoring Tools and the ISP. Mark YES if the reviewer determines that the services authorized are consistent

with the current service definitions. Mark NO if the services authorized are not consistent with current service

definitions.

** Identify what is not consistent.

AE OA ISP Manual

18.0A.00.R.

The AE authorizes services consistent with the service definitions.

AE OA ISP Manual

18.0A.00.R1.

Service provided meets service definitions and ISP amended via critical revision within 21 days.

R The AE will provide evidence demonstrating that the services provided are now compliant with service definitions.

Evidence may include but is not limited to: critical revision to the ISP end-dating an authorization. Mark YES if the ISP was amended within 21 days of notification. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA ISP Manual

18.0A.00.R2.



selected.

AE OA ISP Manual

18.0A.00.R3.


AE OA ISP Manual



# Question Type Guidance Source Documents The reviewer chooses the appropriate time frame from the drop down.

Mark NA if no remediation action was necessary or if no remediation action was taken by the AE.

18.0A.00.R4.


selected.

AE OA ISP Manual

18.0A.00.R5.




AE OA ISP Manual

19.00.00. The AE has Auto-authorization Protocols required in the Operating Agreement. The AE shall comply with the Auto-authorization process as outlined in the Operating Agreement.19.0A. The AE has Auto-authorization O The reviewer determines if the AE has a protocol for Auto-Approved and Authorized AE OA



# Question Type Guidance Source Documents00. protocol as required in the Operating

Agreement.ISPs.

The protocol must include how the AE will ensure completion of a quality review of a sample of plans that have been Auto-Approved and Authorized and quality assurance oversight of plans that includes:

- Any required prior authorization of ODP approval of an exception to service limits was obtained through the established process

- All identified assessed needs and planning process are in the ISP- Outcomes listed in the ISP relate to an identified need- Outcomes listed in the ISP relate to an identified preference- Services are identified to support outcomes- Services paid through the Waiver must be identified to support

outcomes based on assessed needs- ISP reflects the full range of needs and includes all Medicaid and non-

Medicaid services, including informal, family and natural supports and supports paid by other service systems

- ISP includes the type of services to be provided; the amount, duration, and frequency of each Waiver-eligible service and the Provider to furnish each service

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

- The ISP is documented on the Department-approved format in HCSIS- Providers are identified for each Waiver service- The identified providers are willing and qualified.

Mark YESs if the AE has a protocol that contains all required elements. Mark NO if the AE does not have a protocol or not all required elements exist.

** Identify whether there is no protocol or what elements are missing.19.0A.00.R.

The AE has Auto-authorization protocol as required in the Operating Agreement

R AE OA

19.0A.00.R1.

Documentation was located. R The AE has located the Auto-authorization protocol. Mark YES if documentation was located.

AE OA




selected.19.0A.00.R2.

The AE develops a protocol that contain all required elements

R The AE develops a protocol that contains all the required elements as outlined in the Operating Agreement. Mark YES if the AE develops a protocol that contain all required elements. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

19.0A.00.R3.



selected.

AE OA

19.0A.00.R4.



taken by the AE.

AE OA

19.0A.00.R5.




AE OA

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual has personal choice and control.20.00.00. The AE offers choice of willing and qualified providers at initial enrollment. Individuals/families are afforded choice of providers including SCO's. In accordance with 42 CFR §431.151, an individual may select any provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.20.0A.00.

There is documentation that indicates choice of willing and qualified service providers was offered to the individual/family upon initial enrollment and upon waiver enrollment (if applicable).

O The reviewer determines if choice was offered among willing and qualified service providers to the individual/family at the time of initial enrollment and at waiver enrollment (if applicable) based upon document the AE has.

The reviewer accepts whatever documentation the AE provides. Mark YES if there is documentation that choice of willing and qualified providers

was offered at initial enrollment. Mark NO if there is no documentation.


20.0A.00.R.

There is documentation that indicates choice of willing and qualified service

R Consolidated and PFDS waivers AE OA



# Question Type Guidance Source Documentsproviders was offered to the individual/family upon initial enrollment and upon waiver enrollment (if applicable).

ISP Manual

20.0A.00.R1.

Documentation was located. R The AE has located their documentation of choice offering at initial enrollment. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.


20.0A.00.R2

Documentation is completed R The AE has offered choice, and documentation is on file. Mark YES, if completed. Mark N/A if no remediation action is required or another remediation action was

selected.


20.0A.00.R3.



selected.


20.0A.00.R4.



taken by the AE.


20.0A.00.R5.


selected.


20.0A.00.R6.





21.00.00. The AE initiate recruitment of provider activities when there is an absence of choice of willing and qualified Provider. 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.



# Question Type Guidance Source Documents21.0A.00.

The AE provides ongoing technical support to providers.

Non-Scored

O The reviewer determines if the AE provides technical support to providers utilizing ODP’s Provider Handbook on enrollment, qualification and HCSIS and PROMISe™ processes, Everyday Lives and Life Courses tools.

This support includes, but is not limited to: - The ongoing engagement of the provider network though outreach,

meetings, and technical assistance. - The provision of information regarding the Provider application,

enrollment, and qualification processes. The information must be developed or approved by ODP.

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

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

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

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

- Orientation or training of providers using the Department’s developed curriculum, when approved or requested by the Department.

Mark YES if the AE provides technical support to providers. Mark NO if the AE is not providing needed technical support.

Exploratory AE OA

22.00.00. Individuals/families are afforded choice of services. Individuals are afforded choice between waiver services and institutional care, and between/among waiver services and providers.22.0A.00.

MEDICAL ASSISTANCE (MA) - Y or N

Non-Scored

Base only

D The reviewer determines if the individual has Medical Assistance. PATH: HCSIS > Individual > Demographics > Medicaid.

Mark YES if the individual has an MA. Mark NO if the individual does not have MA.


22.0B.00.

Individuals/families are afforded choice between waiver services and

O The reviewer determines if the AE offered choice among services to the individual/family by reviewing the Service Delivery Preference Form (DP 457).

Consolidated and PFDS waivers AE OA



# Question Type Guidance Source Documentsinstitutional care (Service Delivery Preference) at the time of enrollment.

The following obsolete forms, Beneficiary of Choice, and or Service Preference MR 257, signed prior to January 1, 2008, and/or the current DP 457 are acceptable.

The "obsolete" forms are accepted as verification if completed prior to January 2008. Mark YES if the DP 457 was completed. Mark NO if the DP 457 was not completed. Mark NA if the individual is not an MA Recipient.

ISP Manual

22.0B.00.R.

Individuals/families are afforded choice of services.

R Consolidated and PFDS waivers AE OA ISP Manual

22.0B.00.R1.

Documentation was located. R The AE has located the completed Service Delivery Preference Form (DP 457). Mark YES if documentation was located. Mark NA if no remediation activity was necessary or another remediation action

was chosen.


22.0B.00.R2.

Service Delivery Preference Form (DP 457) is completed.

The AE has obtained a completed Service Delivery Preference Form (DP 457). Mark YES if completed. Mark NA if no remediation activity was required or another remediation action

was chosen.


22.0B.00.R3.



selected.


22.0B.00.R4.



taken by the AE.


22.0B.00.R5.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or transferring to another AE. Mark YES if remediation by exception applies.




# Question Type Guidance Source Documents Mark NA if no remediation was required or another remediation action was

selected.

22.0B.00.R6.





23.00.00. The AE promotes experiences and services that enables individuals to obtain and benefit from competitive integrated employment. The first consideration and preferred outcome for individuals enrolled in ODP Waivers should be competitive integrated employment.23.0A.00.

The individual is authorized for supported employment services.

Non-Scored

D The reviewer determines if the individual has been authorized for a Supported Employment service.

PATH: HCSIS > Plan > Serv & Supp > Serv Dtls Mark YES if a Supported Employment service is authorized. Mark NA if there is no Supported Employment Service.

** Identify if the service is Job finding or Job support.

Bulletin 00-16-02, OVR Referral Process for Employment Related Services

Info Memo 008-17

23.0B.00.

The individual is authorized for Community Participation Supports in a prevocational setting.

Non-Scored

D The reviewer determines if the individual has been authorized for Community Participation Supports in a prevocational setting.

PATH: HCSIS > Plan > Serv & Supp > Serv Dtls. The information may or may not be in the current ISP. The reviewer is responsible to determine when the INITIAL authorization occurred,

and the age of the individual. ONLY for those individuals under the age of 25, the reviewer indicates in the

comment field the date of the initial authorization and if it occurred prior to August 28, 2015. Mark YES if a Prevocational service is authorized. Mark NA if there is no Community Participation Supports.


23.0C.00.

The letter of eligibility/ineligibility from OVR is in the individual’s record for those ISPs with Supported Employment/Prevocational Services.

O The reviewer determines if the letter of eligibility/ineligibility from OVR is in the AE's individual file. Mark YES if the AE has a copy of the OVR letter in the individual’s file. Mark NO if there is no OVR letter in the file. Mark NA if the individual does not receive a supported

employment/prevocational service or has a prevocational service that was


Info Memo 008-17



# Question Type Guidance Source Documentsinitially authorized prior to August 28, 2015.

23.0C.01.

If yes, the service is eligible for waiver funding.

O The reviewer determines if the service is eligible for waiver funding based on the guideline outlined in Bulletin 00-16-02 OVR Referral Process for Employment Related Services. Mark YES if the service is eligible for waiver funding. Mark NO if the service is not eligible for waiver.

** Identify why the service is not eligible. Mark NA if the individual does not receive a supported

employment/prevocational service, or has a prevocational service that was initially authorized prior to August 28, 2015.


23.0C.01.R.

The service is eligible for waiver funding.

R Bulletin 00-16-02, OVR Referral Process for Employment Related Services

23.0C.01.R1

Documentation is located. R The OVR letter of eligibility/ineligibility is located and placed in the individual's record. Mark YES if the OVR letter has been placed in the record. Mark NA if no remediation action is required or another remediation action was

selected.


23.0C.01.R2

Documentation is completed. The OVR letter of eligibility/ineligibility is completed and placed in the individual's record. Mark YES if the OVR letter has been completed and placed in the record. Mark N/A if no remediation action is required or another remediation action was

selected.


23.0C.01.R3.



selected.


23.0C.01.R4.



taken by the AE.


23.0C. Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate Bulletin 00-16-02, OVR Referral




transferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation was required or another remediation was selected.

Process for Employment Related Services

23.0C.01.R6.





23.0D.00.

The AE has a designated employment lead.

O The reviewer determines if the AE has an employment lead. Mark YES if the AE has an employment lead. Mark NO if the AE does not have an employment lead.

Exploratory Pathways of Employment guidance

document Executive Order 2016-03

24.00.00. Health Evaluation services are current prior to AE authorizing the Initial/Annual ISP. As part of its continuous responsibility for safeguarding the health and welfare of Waiver individuals, the AE shall ensure, as identified through the approval and authorization, that the health and welfare of individuals are fully addressed.24.0A.00.

Health Evaluations are current prior to AE approving and authorizing the Initial/Annual ISP.

D The reviewer determines if the health evaluations in the ISP are current. The reviewer compares the appraisal date/frequency with the Initial/Annual ISP’s

pending approval date to make a determination. The reviewer uses the Initial/Annual ISP to measure compliance with this question. PATH: HCSIS > Plan > Medical> Health Evaluations. The Health Evaluation section includes the Type of Appraisal, Date of Appraisal and

Frequency of Appraisal. When appraisals are included in the ISP, the timeframe must be current and match

the frequency listed. Mark YES if the AE ensured that the frequency of all appraisals identified in the

ISP are within the timeframe prior to authorizing the ISP. Mark NO if the AE approved the ISP without current health evaluations.

** Identify the appraisal/timeframe non-compliance.

None

24.0A.00.R.

Health Evaluations are current prior to AE approving and authorizing the Initial/Annual ISP.

R None

24.0A.00.R1.

AE authorizes an ISP that reflects current Health Evaluation.

R The AE will provide the reviewer with the ISP "Plan Status-Approved" date that reflects current health evaluations. Mark YES if the Plan has been updated to include all Health Evaluation Services. Mark NA if no remediation action is required or another remediation action was

selected. (Path: Plan>History>Summary)

None




24.0A.00.R2.



selected.

None

24.0A.00.R3.



taken by the AE.

None

24.0A.00.R4.


None

24.0A.00.R5.




None

24.0B.00.

All Other Non-Medical Evaluations are documented in the ISP at the time of approval/authorization.

D The reviewer determines if the Other Non-Medical Evaluations were documented in the ISP at time of AE approval and authorization.

The reviewer should use the INITIAL/ANNUAL ISP to measure compliance with this question.

PATH: HCSIS > Plan > Func Info > Other Non-Medical Evaluations. The reviewer compares the appraisal date/frequency with the Initial/Annual ISP’s

pending approval date to make a determination. Mark YES if all Other Non-Medical Evaluations are documented in the ISP at the

time of approval/authorization. Mark NO if an Other Non-Medical Evaluation was completed and not

None



# Question Type Guidance Source Documentsdocumented in the ISP at the time of approval/authorization. ** Identify the specific evaluation that is missing from the ISP.

Mark NA if the individual has no Other Non-Medical Evaluations.24.0B.00.R.

All Other Non-Medical Evaluations are documented in the ISP at the time of approval/authorization.

R None

24.0B.00.R1.

AE authorizes an ISP that reflects current Other Non-Medical Evaluations.

R The AE will provide the reviewer with the ISP "Plan Status-Approved" date that reflects Other Non-Medical Evaluation Services. Mark YES if the AE approves an ISP that has been updated to include all Other

Non-Medical Evaluation. Mark NA if no remediation action is required or another remediation action was

selected.

None

24.0B.00.R2.



selected.

None

24.0B.00.R3.



taken by the AE.

None

24.0B.00.R4.


None

24.0B.00.R5.




None



# Question Type Guidance Source DocumentsPERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual has an active life in the community.25.00.00. The AE reviews and authorizes plans that have evidence that the individual is provided with on-going opportunities and support necessary to participate in community activities necessary to participate in community activities of person's choice. ODP supports Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives. ODP's vision is to continuously improve an effective system of accessible services and supports that are flexible, innovative and person-centered.25.0A.00.

The ISP has evidence that the individual has opportunities for community activities of their choice.

D The reviewer determines if the AE approved an ISP that includes opportunities for the individual to engage in community activities (i.e. church, shopping, social clubs, restaurants, etc.) based on a review of the current ISP. Mark YES if the ISP documents community activities of their choice. Mark NO if the ISP does not document community activities of their choice.

Everyday Lives 2016 CMS Final Rule

25.0B.00.

The ISP has evidence of necessary supports to participate in community activities.

D The reviewer determines if the AE approved an ISP that includes supports needed for the individual to participate in community activities that they choose (formal and informal supports) based on a review of the current ISP. Mark YES if the ISP documents supports are available. Mark NO if the ISP does not document that supports are available. Mark NA if no supports (formal or informal) are needed.

Everyday Lives 2016 CMS Final Rule

25.0C.00.

The AE promotes community access as defined in the CMS Final Rule.

O The reviewer determines if the AE promotes the same degree of community access and choices as an individual who is similarly situated in the community who does not have a disability and who does not receive an HCBS.

o Examples can include but are not limited to:- Outreach to individuals and families- Provider Meeting Notes

Mark YES if the AE is promoting community access as outlined in the CMS Final Rule.

Mark NO if the AE is not promoting community access.

CMS Final Rule

25.0D.00.

The AE identifies a need for technical assistance related to HCBS setting rule to providers, individuals, and families.

O The reviewer determines if the AE identified a need for technical assistance related to the HCBS and provided the needed technical assistance to provider, individual or families.

The AE should identify and provide technical assistance for matters relating to state or federal regulations that establish program, operational and/or payment requirements to providers. Mark YES if a need has been identified and technical assistance was provided. Mark NO if a need was identified but no technical assistance was provided. Mark NA if no need has been identified.

CMS Final Rule

PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual is supported to communicate.



# Question Type Guidance Source Documents26.00.00. The AE is responsible to provide and fund communication assistance as needed. The Administrative Entity is responsible to implement their communication protocol(s) as directed in written policies and procedures, Departmental decision, and the Operating Agreement.26.0A.00.

The AE pays for communication assistance as required.

O The reviewer determines if the AE has identified a need and paid for necessary communication assistance.

Acceptable evidence includes: paid involves, billing statements, etc. Mark YES if the AE paid for necessary communication assistance. Mark NO if the AE did not pay for communication assistance. Mark NA if there were no identified needs.



26.0A.00.R.

The AE pays for communication assistance as required.



26.0A.00.R1.

Documentation is located. R Documentation is provided showing the AE paid for communication assistance. Mark YES if documentation has been provided. Mark NA if no remediation action is required or another remediation action was

selected.



26.0A.00.R2.

AE staff is retrained as per protocol. R The AE provides/ensures retraining of the appropriate AE staff regarding the AE's protocol.


selected.



26.0A.00.R3.



selected.



26.0A.00.R4.


The reviewer chooses the appropriate time frame from the drop down.




# Question Type Guidance Source Documents Mark NA if no remediation action was necessary, or if no remediation action was

taken by the AE. Bulletin 00-04-13 Limited English

Proficiency

26.0A.00.R5.






26.0B.00.

The AE pays for communication assistance for the performance of Support Coordination Service

O The reviewer determines if the AE has identified a need and paid for necessary communication assistance for the performance of Supports Coordination services.

Acceptable evidence includes: paid invoices, billing statements, etc. Mark YES if the AE paid for necessary communication assistance for Supports

Coordination services. Mark NO if the AE did not pay for necessary communication assistance for

Supports Coordination services. Mark NA if there were no identified needs or the SCO did not request

communication assistance.



26.0B.00.R.

The AE pays for communication assistance for the performance of Support Coordination Service



26.0B.00.R1.

Documentation is located. R Documentation is provided showing the AE paid for communication assistance. Mark YES if documentation has been provided. Mark NA if no remediation action is required or another remediation action was

selected.



26.0B.00.R2.

AE staff is retrained as per protocol. R The AE provides/ensures retraining of the appropriate AE staff regarding the AE's protocol.

The AE provides notification to ODP that the AE staff was retrained. Mark YES if the AE provides notification to ODP of retraining provided to the AE

staff. Mark NA if no remediation action is required or another remediation action was

selected.






26.0B.00.R3.



selected.



26.0B.00.R4.



taken by the AE.



26.0B.00.R5.






PERSON-CENTERED PLANNING, SERVICE DELIVERY & OUTCOMES – The individual’s family receives the supports needed.27.00.00. The AE has a policy which provides information and resources to individuals and families upon intake/eligibility and ongoing. Families need support in order to make an everyday life possible. Families need information, resources, and training. They need connections with other families and support services.27.0A.00.

The AE provides information and resources to individuals and families upon intake/eligibility and ongoing.

O The reviewer determines if the AE provided information and resources to individuals and families.

Information can include local resources, fairs, calendar of awareness events, leaflets, etc. Mark YES if the AE provided information. Mark NO if the AE did not provide information.

Everyday Lives 2016

27.0A.00.R.

The AE provides information and resources to individuals and families upon intake/eligibility and ongoing

R Everyday Lives 2016




Documentation was located. R The AE has located the protocol. Mark YES if documentation was located. Mark NA if no remediation action is required or another remediation action was

selected.

Everyday Lives 2016

28.0A.00.R2.

The AE develops a protocol. The AE develops a protocol. Mark YES if the protocol was developed and contains all required elements. Mark N/A if no remediation action is required or another remediation action was

selected.

Everyday Lives 2016

27.0A.00.R3.



selected.

Everyday Lives 2016

27.0A.00.R4.



taken by the AE.

Everyday Lives 2016

27.0A.00.R5.




Everyday Lives 2016

HEALTH & WELFARE – Individuals with complex physical and behavioral needs receive appropriate supports.28.00.00. The AE supports people with complex needs. People with disabilities who have both physical and behavioral health needs receive the medical treatment and supports needed throughout their lifespans. Opportunity for a full community life are dependent on adequate supports and the commitment to build capacity within the larger human service delivery system.28.0A.00.

The AE provides the SCO and providers with assistance to support people with complex physical and behavioral

O The reviewer determines if the AE provided assistance to the SCO and providers to support people with complex physical and behavioral needs.

o Assistance may or may not include

Exploratory Everyday Lives 2016



# Question Type Guidance Source Documentsneeds.

Non-Scored

- Resources- Training- Collaboration with HCQU- Technical assistance - Building capacity to serve people with complex physical and/or

behavioral needs. Mark YES if the AE has provided the SCO and providers with assistance. Mark NO if the AE has not provided assistance.

HEALTH & WELFARE – The individual has wellness opportunities.29.00.00. The AE works with Providers and SCO to ensure wellness resources are available. Promoting physical and mental health, wellness and personal safety for every individual and their family. Promoting physical and mental health means providing information about health and wellness, emotional support, and encouragement.29.0A.00.

The AE promotes wellness.

Non-Scored

O The reviewer determines if the AE promotes wellness. Promoting physical and mental health means providing information about health

and wellness, emotional support, and encouragement Information can include local resources, fairs, calendar of awareness events, HCQU

collaborations, H&W months, leaflets, etc. Mark YES if the AE has provided information to promote wellness. Mark NO if AE has not provided information to promote wellness.

Exploratory Everyday Lives 2016

HEALTH & WELFARE – The individual’s restrictive intervention followed proper procedure.30.00.00. The AE Human Rights Committee (HRC) reviews and authorizes all restraint and restrictive interventions. The Human Rights Committee is to safeguard the human rights of people receiving services. The HRC will provide a review of restrictive procedures proposed or occurring within the supports provided by the service system.30.0A.00.

The individual has a restrictive Behavior Support Plan.

Non-Scored

D The reviewer determines if the individual has a restrictive behavior support plan. PATH: HCSIS > Plan > Health & Safety > Behav. Sup. Plan

Mark YES if the individual has a restraint or restrictive plan. Mark NA if there is no restrictive plan.

AE OA

30.0A.01.

If YES, the AE HRC conducted a systemic review of the restraint/restrictive intervention.

O The reviewer determines if the AE HRC conducted a systemic review of the restrictive plan.

The AE HRC’s review will ensure the use of restraints and restrictive interventions are appropriate and necessary as well as to ensure strategies exist and are being achieved to reduce or eliminate the need for the use of a restraint or restrictive

AE OA



# Question Type Guidance Source Documentsintervention. Mark YES if there is documentation that the AE HRC conducted a systemic review

of the restraint/restrictive intervention. Mark NO if there is no documentation that the AE HRC conducted a systemic

review of the restraint/restrictive intervention. Mark NA if the individual does not have a restrictive plan or the restrictive plan

was created prior to July 1, 2017.

30.0A.01.R.

If YES, the AE HRC conducted a systemic review of the restraint/restrictive intervention.

R AE OA

30.0A.01.R1.

Documentation is located. R Documentation is provided showing the AE HRC completed a systemic review of the restrictive Behavior Support Plan. Mark YES if documentation has been provided. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

30.0A.01.R2.

THE AE HRC reviews the restrictive Behavior Support Plan

R The AE provides documentation that the restricted Behavior Support Plan was reviewed by the AE HRC. Mark YES if the plan has been reviewed and authorized. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

30.0A.01.R3.



selected.

AE OA

30.0A.01.R4.



taken by the AE.

AE OA

30.0A.01.R5.

Remediation by exception. R Remediation CAN BE completed by exception, meaning there is no way to remediate the non-compliance due to death, moving out of state, inactive record status, or

AE OA



# Question Type Guidance Source Documentstransferring to another AE. Mark YES if remediation by exception applies. Mark NA if no remediation was required.

30.0A.01.R6.




AE OA

31.00.00. The AE analyzes systemic concerns related to restrictive procedures and restraints. The AE HRC shall analyze systemic concerns including a review of policies, procedures, trends and patterns, individual situations and plans that authorize the use of interventions that have the potential to impact an individual’s rights.31.0A.00.

The AE analyzes systemic concerns related to restrictive procedures and restraints.

O The reviewer determines if the AE HRC analyzes systemic concerns related to restrictive procedures and restraints.

The AE HRC shall analyzes systemic concerns including a review of policies, procedures, trends and patterns, individual situations and plans that authorize the use of interventions that have the potential to impact an individual’s rights. Mark YES if they analyzed the data. Mark NO if they did not analyze the data. Mark NA if they did not identify a systemic concern.

AE OA

31.0A.00.R.

The AE analyzes systemic concerns related to restrictive procedures and restraints.

R AE OA

31.0A.00.R1.

Documentation was obtained R The AE has located evidence that they have reviewed and analyzed systemic concerns. Mark YES if the AE has obtained the documentation. Mark NA if no remediation action is required or another remediation action was

selected.

AE OA

31.0A.00.R2.

AE HRC members are retrained as per requirements stated in the AE Operating Agreement.

R The AE provides/ensures retraining of the appropriate AE HRC staff regarding requirements as outlined in the AE OA.


selected.

AE OA






selected.

AE OA

31.0A.00.R4.



taken by the AE.

AE OA

31.0A.00.R5.




AE OA

FINANCIAL ACCOUNTABILITY32.00.00. The AE maintains documentation of financial eligibility for waiver services. The AE shall cooperate with the Department’s CAO in determining an individual’s initial and continuing financial eligibility for Waiver 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.32.0A.00

The AE maintains documentation of financial eligibility for waiver services.

O The reviewer determines if the AE maintains documentation of an individual’s financial eligibility for waiver services (eligible or ineligible).

o Documentation can include:- PA 162- CIS documentation- Any document that show the CAO confirmed financial eligibility.

Mark YES if the AE has documentation of financial eligible. Mark NO if the AE does not have documentation of financial eligibility. Mark NA if TSM or Base.

Consolidated and PFDS waivers AE OA Bulletin 00-08-04, Individual Eligibility

for Medicaid Waiver Services

32.0A.00.R.

The AE maintains documentation of financial eligibility for waiver services

R Consolidated and PFDS waivers AE OA



# Question Type Guidance Source Documents Bulletin 00-08-04, Individual Eligibility

for Medicaid Waiver Services32.0A.00.R1.

Documentation is located R The documentation is located and placed in the AE file. Mark YES if the documentation has been placed in the AE file. Mark NA if no remediation action is required or another remediation action was

selected.


for Medicaid Waiver Services32.0A.00.R2.

PA 162 was completed, eligibility criteria was not met – disenrollment procedures have been initiated as per ODP policies and HCSIS amended as appropriate.

R If the determines is that the individual DOES NOT meet financial eligibility criteria, the AE must initiate disenrollment procedures per ODP policies and procedures. Mark YES if HCSIS eligibility screen is amended to reflect disenrollment. Mark NA if no remediation action is required or another remediation action was

selected.



32.0A.00.R3.



selected.



32.0A.00.R4.

If YES when: R The reviewer calculates the number of days between the notification date to the AE and the remediation action date.


taken by the AE.



32.0A.00.R5.


selected.



32.0A.00.R6.




AE OA

SELF-ASSESSMENT – The AE completes an annual QA&I self-assessment.



# Question Type Guidance Source Documents33.00.00. The AE self-assessment is completed annually. The AE shall conduct a self-assessment as outlined in the ODP's QA&I process.33.0A.00.

The AE self-assessment is completed annually.

D The reviewer determines if the AE completed their self-assessment in the ODP specified tool. Mark YES if there is evidence that the AE has completed a self-assessment

annually. Mark NO if there is no evidence indicating the self-assessment has been

completed.

Consolidated and PFDS waivers QA&I Process

33.0A.00.R.

The AE self-assessment is completed annually.

R Consolidated and PFDS waivers QA&I Process

33.0A.00.R1.

The AE completes their annual self-assessment.

R The reviewer should check the ODP specified tool for evidence that the AE has completed their current annual self-assessment. Mark YES if the AE has completed their annual self-assessment for the current

fiscal year. Mark NA if no remediation actions were required or another remediation action

was selected.


33.0A.00.R2.

The AE participates in an onsite visit. R The AE participates in an onsite visit during a year the AE is not already scheduled. Mark YES if the AE participates in an onsite visit on a non-QA& review year. Mark NA if no remediation actions were required or another remediation action

was selected.


33.0A.00.R3.



selected.


33.0A.00.R4.



taken by the AE.


33.0A.00.R5.







# Question Type Guidance Source DocumentsQUALITY MANAGEMENT – There are systemic efforts to continuously improve quality.34.00.00. The AE demonstrates continuous quality improvement.34.0A.00.

The AE uses the self-assessment results to work on quality improvement annually.

Non-Scored

O The reviewer determines if the AE used their self-assessment results to work on quality improvement.

The reviewer will discuss how the AE is using their self-assessment results. The AE’s Quality Management Plan may include self-assessment data.

Mark YES if the AE used their self-assessment results to work on quality improvement.

Mark NO if the AE did not use their self-assessment results to work on quality improvement.

QA&I Process Document

