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ODP ACADEMY For Administrative Entities …Changing Practices,
Unchanged Values
Administrative Entity Oversight Monitoring
Process
Pennsylvania Department of Public WelfareOffice of Mental Retardation
2 ODP Academy: AE OversightMarch 2007
ODP Academy
Overview of the new AE Oversight Monitoring Process– Development & Implementation– Structure of the Tool– Elements of the Tool
3 ODP Academy: AE OversightMarch 2007
Why Develop a New Administrative Entity Oversight Monitoring Process?
In order to meet CMS assurances, ODP needs to:– Retain ultimate authority and responsibility for the
operation of the waivers – Exercise oversight over the performance of
waiver functions by other agencies
4 ODP Academy: AE OversightMarch 2007
How Did ODP Develop the Process?
A core group of ODP staff detailed the process using input received from AEs, the Regions, and Central Office staff.
ODP Academy sessions are then used to relay information
5 ODP Academy: AE OversightMarch 2007
How Did ODP Develop the Process?
ODP developed the AE Monitoring tool using requirements found in: – The Operating Agreement– CMS Assurances– Bulletins– ODP Monitoring of Counties (OMOC)– ODP Initiatives
6 ODP Academy: AE OversightMarch 2007
Considering the AE’s capacity to meet the new business practices, the AE Monitoring tool was reduced to the following items:
– Operating Agreement (OA) requirements– CMS Assurances (CMS-A)– ODP Initiatives– Data Integrity
How Did ODP Develop the Process?
7 ODP Academy: AE OversightMarch 2007
What’s Different
The OMOC Process was valid from 2002 until 3/31/07.
With the approval of the Consolidated Waiver the AE Oversight Monitoring Process begins 4/1/07.– Continuous systemic review– Greater focus on quality– Accessibility to and utilization of a wider variety of
data sources
8 ODP Academy: AE OversightMarch 2007
Continuous Evidence Based Oversight
Monthly reports sent to Administrative Entity Reports due to Regional Office every three
months Regional and AE risk management activities Quarterly reports due to CMS regarding the
CMS assurances
9 ODP Academy: AE OversightMarch 2007
How Will ODP Implement the New AE Oversight Process?
The Regions will develop monitoring schedules Regional Teams will share oversight
responsibilities
Teamwork
10 ODP Academy: AE OversightMarch 2007
AE OVERSIGHT MONITORING LEAD
Each region has identified an AE Oversight Monitoring Process lead.
The Regional Lead will: – Serve as the Regional contact for the AE Oversight
Monitoring Process– Coordinate the AE Oversight Monitoring Process to ensure
consistency with the Statewide standards.– Provide technical assistance to Regional and AE staff– Four regional leads and the central office point person will
be the keepers of the process
11 ODP Academy: AE OversightMarch 2007
Where and How Will Monitoring be Completed?
Regional reports reviews Home and Community Services Information
System (HCSIS) Onsite
– Reviews– Interviews
12 ODP Academy: AE OversightMarch 2007
How Will Monitoring be Conducted?
90 days prior to onsite review, Regional Teams will: – Pull all reports and samples– Share reports with AEs
60 days prior to onsite review, Regional Teams will review samples and reports using information from: – Regional Offices– HCSIS
13 ODP Academy: AE OversightMarch 2007
How Will Monitoring be Conducted?
Two weeks prior to onsite reviews, Regional Teams will provide AEs with names of individuals in the sample
In order to initiate the new AE Oversight Process, these time frames will be shortened during the first year (9 month vs. 12 month).
14 ODP Academy: AE OversightMarch 2007
How Will Monitoring be Conducted?
At first, ODP Regional Teams will record and tally their findings off-line
Once the process becomes finalized, HCSIS will be used to record findings
15 ODP Academy: AE OversightMarch 2007
How Will Scores be Determined?
100% compliance will be required for some items
A Compliance Scale will be used for other items 90 to 100% = Fully Compliant 80 to 89% = Mostly Compliant 70 to 79% = Somewhat Compliant Below 70% = Noncompliant
Any score below 90% will require a Corrective Action Plan
16 ODP Academy: AE OversightMarch 2007
What Will Happen After Onsite Reviews are Completed?
Regional team members will collaborate to complete summary reports
Summary reports will be:– Shared with Regional and Central Office staff
within 45 days of review– Approved by Regional Program Manager– Sent to the AEs
17 ODP Academy: AE OversightMarch 2007
What Will Happen After Onsite Reviews are Completed?
The AE will develop a Corrective Action Plan if needed, based on the findings in the summary reports.
The Corrective Action Plan must be submitted to the Regional Office within 45 calendar days of the receipt of the finding report
Each Regional team will review the AE’s Corrective Action Plan and develop a validation plan
18 ODP Academy: AE OversightMarch 2007
Structure of the AE Oversight Monitoring Tools
Review of the guidelines, worksheets and scoring tool
19 ODP Academy: AE OversightMarch 2007
Data and Policy Guidelines
5. Critical revisions, annual reviews, quarterly reviews, and general updates are completed as needed and required and entered into HCSIS.
A. ISPs are updated/revised on at least an annual basis.B. ISPs are updated/revised when necessary to address changes.C. Quarterly reviews are completed every 90 days.
Individual Sample: Yes Compliance Score: 100% for A & B, Scale for C
Review Frequency: Monthly for A& B (for BHA), During OMP for B and C
CMS Assurance: H.1.b (Service Plan)
Rules SourceDocument(s):
Operating Agreement A.5.9,B.5.9.6, C. 5.9.2
ComplianceDate:
07/01/2006
A. ISPs are updated / revised on at least an annual basis.
The Regional Oversight Monitoring Lead wil l retrieve the exception report for ISP’s byindividual by funding stream that were not completed within 365 days of the review dateon a monthly basis for each AE from ECM. These will be distributed to the individualAE with both the percentages and the names of the individuals for whom the ISP was notcompleted timely. The Regional AE Oversight Lead will be provided copies of thereports with the percentages to be maintained as part of the AE file. At the time thereview process begins by notifi cation of the AE of the onsite monitoring date, theRegional AE Oversight Lead will review the report for the previous month (for example,if the notifi cation to the AE is in March, review the February report). Determine thepercentage of compliance for Base, Consolidated and PFDS and indicate the score on thescoresheet. Notice of which report was used for this item should be provided to the AE inthe monitoring report.Compliance with this item is 100%. If the percentages from the report are 100%, for eachcategory non-waiver, consolidated or PFDS indicate a C for compliance in each categoryon the scoresheet.If the percentages are less than 100%, mark a NC for non-compliance in each category onthe score sheet.
B. ISPs are updated / revised when necessary to address changes in need. (monthly review)
On a monthly basis, the Regional AE Oversight lead wil l review any final appealdecisions from the Bureau of Hearings and Appeals to determine if a change in need hasbeen indicated. If yes, indicate the name of the individual on the worksheet, date of thefinal appeal decision, and the date that a service change should have been implemented.
20 ODP Academy: AE OversightMarch 2007
Reviewer’s Name: __________________ Review Start Date: __________
* Denotes items that are reviewed onsite and not in HCSIS.
5. Critical revisions, annual reviews, quarterly reviews, and general updates are completed as needed and required and entered into HCSIS.
A. ISP Exception Report
a) Using the ISP exception report indicate the review month/year usedto identify compliance scores.___________________________________________
b) Base: ______________________________________c) Consolidated Waiver: __________________________d) P/FDS Waiver: _______________________________
B. Hearing and Appeal Decisions
a) Indicate the time period in which Hearings and Appeals werereviewed.
________________________________________
b) Number of decisions reviewed.________________________________________
c) A critical revision to the ISP been completed for all individualswhere a change in need was indicated by the Hearing Decision.
Y N
_________ Score
21 ODP Academy: AE OversightMarch 2007
22 ODP Academy: AE OversightMarch 2007
SIX OVERALL ELEMENTS
Quality of Life Administrative Entity Capacity Provider Qualifications/Monitoring Rights Eligibility/Level of Care Other Administrative Functions
23 ODP Academy: AE OversightMarch 2007
Elements of the Oversight Monitoring Process
Requirements are not new Regions & County/AEs have been
responsible for these items for some time
24 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – Individual Support Plan (ISP) Reviews
Implemented according to time frames in Operating Agreement (OA & CMS-A)
Address all assessed individual needs (OA & CMS-A) Document Services
– Frequency– Amount– Duration– Provider type for each service (OA & CMS-A)
Outcomes relate to preferences and needs (OA & CMS-A)
25 ODP Academy: AE OversightMarch 2007
Timeliness of ISP Process (OA & CMS-A)– Updated/revised at least annually or if there is a
change in the service need
Team members invited to ISP meetings (OA)
Services authorized prior to receipt of services (OA & CMS-A)
Quality of Life Issues – Individual Support Plan (ISP) Reviews
26 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – Supports Coordination (SC)
Monitoring of individuals according to schedule (OA & CMS-A)
PUNS– Reviewed annually (OA)– Updated accordingly (OA)– Completed for those with unmet need (OA)– Signed and distributed (OA)
27 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – SC Review - Data Integrity
Mandatory fields completed in HCSIS– Demographics– Eligibility– Enrollment information.
Data integrity is crucial to the process.
28 ODP Academy: AE OversightMarch 2007
Quality of Life Issues - Quality Management (QM) Requirements
Quality Management/ Quality Implementation (QM/QI) plan written (OA)
QI actions (OA)
29 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – Incident Management (IM)
These items are all in relation to the implementation of the Incident Management bulletin.
Corrective action is implemented (CMS-A) AE investigates incidents according to
Certified Investigation manual (CMS-A)
30 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – Incident Management (IM) (cont’d)
Appropriate actions are taken within 24 hours of incidents (CMS-A)
Local policies and procedures are in place to implement IM Bulletin (CMS-A)
Semi-annual qualitative reports are issued (CMS-A)
31 ODP Academy: AE OversightMarch 2007
Quality of Life Issues – Independent Monitoring for Quality (IM4Q)
AE assures providers address considerations (OA) AE informs IM4Q when action is taken on a
consideration (OA) AE uses sharing process (OA) AE, with IM4Q, addresses major health and safety
concerns (OA) AE uses IM4Q reports for evaluation and quality
improvement (OA)
32 ODP Academy: AE OversightMarch 2007
ODP Initiatives - Employment
AE documents OVR funding availability (OA)
– Initial referral is in individual’s file
HCSIS Functional Level Employment screen is completed
AE follows ODP expected employment practices
– Each region has an employment point person
33 ODP Academy: AE OversightMarch 2007
ODP Initiatives
Lifesharing– AE follows ODP expected Lifesharing practices
Restraint Reduction– AE achieves annual statewide restraint reduction
goal
34 ODP Academy: AE OversightMarch 2007
AE Capacity
ISP completed in HCSIS for everyone receiving ODP services (OA & CMS-A)
AE has a designated PUNS Point Person (OA)
AE has a designated IM4Q Point Person (OA)
35 ODP Academy: AE OversightMarch 2007
AE Capacity
Bureau of Hearings & Appeals orders are implemented within 30 calendar days (OA & CMS-A)
Provider dispute findings are implemented within calendar 30 days (OA & CMS-A)
36 ODP Academy: AE OversightMarch 2007
AE Capacity
Designated AE staff register for and participate in ODP Academy (OA)
37 ODP Academy: AE OversightMarch 2007
AE Capacity
AE has a designated Employment Point Person
AE has a designated Lifesharing Point Person
38 ODP Academy: AE OversightMarch 2007
Provider Monitoring
All licensed/certified and non-licensed providers meet waiver qualification standards (OA & CMS-A)
39 ODP Academy: AE OversightMarch 2007
Provider Monitoring
All Waiver providers, except unlicensed individuals working through Vender Fiscal/Employment Agent, Intermediary Service Organization (VF/EA ISO), have a signed MA Agreement (OA)
AE Waiver Provider contract is signed by all providers, except unlicensed individuals working through VF/EA ISO (OA)
40 ODP Academy: AE OversightMarch 2007
Provider Monitoring
Provider training is conducted according to state and waiver requirements (CMS-A)
All providers meet licensing and certification standards (OA & CMS-A)
41 ODP Academy: AE OversightMarch 2007
Rights – Due Process
Individuals/families are notified of waiver eligibility appeal rights (OA)
Notice of due process and appeal rights is provided as required (OA)
Individuals receive required written notice of changes in waiver services (OA)
– Denials– Reductions– Terminations
42 ODP Academy: AE OversightMarch 2007
Rights – Due Process
AE assists individuals/families to file appeals as needed (OA)
Waiver services under appeal continue as required (OA)
43 ODP Academy: AE OversightMarch 2007
Rights – Choice
Individuals/families have choice of services (OA & CMS-A)
Individuals/families have choice of providers (OA & CMS-A)
44 ODP Academy: AE OversightMarch 2007
Rights – Service Review
Service Review findings are implemented within 30 days (OA)
45 ODP Academy: AE OversightMarch 2007
Eligibility/Level of Care (LOC)
LOC determinations are completed for everyone likely to receive services (OA & CMS-A)
Persons determined to be not qualified for ICF/MR LOC are provided due process as required (OA)
All waiver participants are eligible for ICF/MR LOC (OA)
46 ODP Academy: AE OversightMarch 2007
Eligibility/Level of Care (LOC)
Qualified Mental Retardation Professionals (QMRP) complete the certification of need consisting of:
– Individual/family interview– Social/psychological review– Current medical evaluation (OA & CMS-A)
47 ODP Academy: AE OversightMarch 2007
Eligibility/Level of Care (LOC)
QMRP’s certification of need is based on standardized adaptive behavior assessment that shows significant limitations in:
– Age standards– Three or more areas of major life activity (OA &
CMS-A)
48 ODP Academy: AE OversightMarch 2007
Eligibility/Level of Care (LOC)
LOC re-determinations are completed annually (OA & CMS-A)
County Assistance Office is notified of changes in assets affecting eligibility within 10 days of the change or as required (OA)
Eligibility information is maintained in files (CMS-A)
49 ODP Academy: AE OversightMarch 2007
Financial Management - General
Waiver funds are used only for eligible services (OA & CMS-A)
Waiver funds are used only for eligible recipients (OA & CMS-A)
Claims are verified for eligibility and authorization (OA & CMS-A)
Payments for waiver services are made only to qualified providers and vendors (OA & CMS-A)
50 ODP Academy: AE OversightMarch 2007
Financial Management - General
Ineligible services are excluded from Federal Financial Participation (FFP) (OA)
Clean claims are paid within 30 days (OA) DPW is notified within 10 days of
overpayments (OA) Paid claims do not exceed limits or caps
(OA) Audits are completed as required (OA)
51 ODP Academy: AE OversightMarch 2007
Rates are established by DPWs Rate Setting Methodology and/or approved by DPW
Financial Management – Rate Setting
52 ODP Academy: AE OversightMarch 2007
Financial Management – Reports
Quarterly expenditure reports are submitted to ODP within 14 days of the end of the quarter. (OA & CMS-A)
Annual waiver reports submitted by September 15th for the previous Fiscal Year. (OA & CMS-A)
Annual income and expenditure reports submitted by September 15th for the previous Fiscal Year unless otherwise directed by ODP. (OA & CMS-A)
53 ODP Academy: AE OversightMarch 2007
Financial Management – Individual Emergency Services Form (IESF)
IESFs are submitted as required (OA)
54 ODP Academy: AE OversightMarch 2007
Other Administrative Functions – Record Retention
Records are retained according to specified time requirements (OA)
Waiver records are safeguarded per HIPPA regulations (OA)
55 ODP Academy: AE OversightMarch 2007
Other Administrative Functions – Self-Assessments
Self-assessments are completed annually (OA)
– Corrective actions are submitted to ODP within 30 days of completion of the Self-Assessment. (OA)
– Corrective activities are completed and validated by the AE. (OA)
– Self-assessment records are maintained for three years (OA)
56 ODP Academy: AE OversightMarch 2007
Other Administrative Functions – Fully Served
All Consolidated Waiver participants are fully served (OA & CMS-A)
All Person/Family Directed Support (P/FDS) Waiver participants are fully served. (OA & CMS-A)
57 ODP Academy: AE OversightMarch 2007
Other Administrative Functions – Personal Funds
Individual’s personal funds are managed as required by the current bulletin (CMS-A)– “Administration and Management of Client
Funds”, bulletin number 6000-88-08, issued October 5, 1988
58 ODP Academy: AE OversightMarch 2007
Other Administrative Functions – Departmental Monitoring
Corrective Action Plans to the Department’s AE Oversight Monitoring Process are completed by the AE within 45 calendar days (OA)
59 ODP Academy: AE OversightMarch 2007
Next Steps
Assure all necessary data reports are available to support the AE Oversight Monitoring Process
Determine the sample size Monitor and evaluate the AE Oversight
Monitoring Process to make changes and improvements as needed.
60 ODP Academy: AE OversightMarch 2007
AE Oversight Monitoring Mailbox
All questions go to the mailbox Regional AE Leads and Central Office Point
person develop answers Answers sent out to list serve members Mailbox address is: