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Office of Developmental Programs
QA&I for HCBS Services
PROVIDER SESSION
July 19, 2017
Farm Show Complex, Harrisburg PA
7/17/2017 1
Self Assessment
• Opportunity for entities to evaluate their own
performance each year
• The focus is “Everyday Lives: Values in Action”
• The self-assessment tool will mirror the QA&I
tool
• Self-assessment will be used to inform and
build quality improvement activities for the
remainder of the QA&I cycle
• All entities are expected to remediate issues
discovered during the self assessment process
7/17/2017 2
Brief Review of Self-Assessment Tools
• Individual’s experience of the system through
interviews
• Provider Tool– 49 Questions
– Focus areas: Quality Improvement; Person Centered Planning,
Service Delivery & Outcomes; Health & Safety
• Example Questions
– The Provider develops and implements a process that ensures
that the QMP is revised and analyzed within the specified
timeframes.
– Staff receive training to meet the needs of the individual they
support as identified in the current, approved Individual Support
Plan (ISP) before providing services to the individual.
– If an event occurred requiring the implementation of the back-up,
plan, the Provider implemented the individual’s back-up plan as
designed.
7/17/2017 3
AE and SCO Annual Sample
7/17/2017 4
• Selected alphabetically with representation from each region
• Separate number of individuals selected to capture Level of Care performance
AE
• Identified based on individuals selected in the core sample
• The SCO that is authorized in the individual’s ISP
SCO
QA&I Sampling – Provider Selection
7/17/2017 5
• For onsite review, Providers selected using last digit of MPI #
• New providers will be assigned onsite review
• AEs conduct the review using their own selection of individuals
• Provider qualification is aligned with onsite year
Provider
QA&I Annual Timeline
7/17/2017 6
Onsite
Selections
Announced
June 15
June 30
ODP Issues
Statewide
QA&I Report
• Self
Assessments
Begin
• AE& SCO
Desk Reviews
Begin
July 1
July 15• ODP Notifies
AEs of
Provider Pool;
• Provider Desk
Reviews
Begin
Self
Assessments
Deadline
August 1*(8/31 for 2017)
August 31*(9/30 for 2017)
ODP Issues Self
Assessment
Statewide
Aggregate
Report
All Onsite
Reviews Begin
September 1
November 30Finalize All
Desk Reviews
All Onsite
Reviews
Completed
December 31
January 31All
Comprehensive
Reports Issued
Comp Report
Responses
Complete
including
Corrective Action
& Quality
Improvement
February 28
April 30All
Updated
QM Plans are
Submitted
Annual Timeline – Providers
• All self-assessments begin July 1 and are
due on August 1 each year
– EXCEPTION! Self-assessments are due August
31 for 2017
• Dates in timeline are targets for entire
process
– Each Provider will have specific deadlines
depending on:
1. Scheduling of the onsite review, and
2. Completion and closure of the QA&I Comprehensive
Report
7/17/2017 7
Annual Timeline – Providers (continued)
7/17/2017 8
Comprehensive Report Issued Electronically
[30 Days Following Onsite Visit]
Entity Responds with Proof of Remediation
and PPRs
[30 Days Following Comprehensive Report]
Closure of Comprehensive
Report with Approval of Remediation & PPR
[20 Days Following Entity Response]
QM Plan Submission & PPR Update
[30 Days After
Comprehensive Report Closure]
QA&I Team Review & Informal Feedback of
QM Plan and PPR Update
[30 Days of QM Plan Submission]
Submission of Evidence for Extended
Timeline PPRs
ODP Communication that All Improvement is Completed/Acceptable
Self Assessment Document of
Improvement Impact; QM Plan Adjustment
7/17/2017 9
QUESTIONS
Desk Review Process – Providers
• A review of available documentation by the
Assigned AE prior to the onsite review to:
– inform the overall QA&I process
– determine focus areas for the onsite review
• The desk review will use all available data
sources
• Findings from the QA&I desk review may
identify areas that will require additional
follow-up before or during the onsite review
7/17/2017 10
QA&I Individual Interviews – Providers
7/17/2017 11
• Individual interviews are considered a critical component of the QA&I
process.
• ODP or its designee will conduct interviews for the sample prior to, during,
or after the onsite review.
• AEs will conduct individual interviews as part of onsite review.
• Where appropriate, a person familiar with the individual will be asked to
assist in the interview. The individual may choose who is present during
the interview.
• There will be a period of the interview where paid supports will not be
present.
• In keeping with person-centered practices, the individual may choose not
to participate in the interview or can opt to discuss their experience by
phone.
• Any person conducting an interview must ensure follow-up and reporting,
as appropriate, of any issue related to health and safety or service quality.
Onsite Review Process – Providers
7/17/2017 12
• Onsite visits begin September 1 and are completed by
December 31.
• Assigned AE designation to conduct Provider onsite review is
determined by ODP and is the AE with the most individuals
authorized with the Provider.
• By December 31, 2018, at least one member of the AE QA&I
team will possess QM Certification
• Visits will occur over a 2-day period.
• A confirmation letter of the onsite review will be sent to
Providers two weeks prior to the visit.
Onsite Review Process – Providers (continued)
7/17/2017 13
• Entrance Conference
– Overview of QA&I Process & Timelines
– Opportunity for Provider to Share Organizational Overview
– Onsite Visit Expectations
• Onsite visit will consist of record reviews, individual
interviews and discussions with Provider staff
• Exit Conference
– Onsite Review Overall Experience & Impressions
– Highlights of Best or Promising Practices
– Highlights of Remediation and Improvement Identified
– Expectations for Corrective Action and Final QA&I
Comprehensive Report
QA&I Comprehensive Report – Providers
7/17/2017 14
• A written report issued for each reviewed entity in no more
than 30 calendar days of the onsite review completion
• AEs will share a copy of each Provider report with ODP upon
finalization and approval of the Corrective Action Plan
• The compilation of official findings from:
– Desk review
– Onsite review
– Face-to-face interviews with individuals and staff
– Self-assessments
• Overall contains positive performance points and
opportunities for improvement, not just presentation of raw
results
QA&I Comprehensive Report – Providers (continued)
7/17/2017 15
• Providers will have 30 calendar days to review and
respond, including:
– Evidence of remediation completed within 30 days of
discovery, and Plans to Prevent Recurrence
– Any points of disagreement with the report findings
including appropriate evidence justifying the disagreement
• AEs will close or request further clarification within 20
calendar days of receipt of the Provider’s response
• Providers will have 30 calendar days from the date of
closure to submit the QM Plan and/or Action Plan,
updated as a result of the QA&I review.
• Main body of the reports will be posted on MyODP.org
QA&I Questions – Providers
7/17/2017 16
• Focused more on Everyday Lives: Values in Action
• Emphasis on gathering information about the
individual’s experience
• Questions are more consistent across Providers,
SCOs and AEs
• QuestionPro is the platform for data entry
• Questions include both scored and non-scored
questions. Non-scored questions are identified on
the tools.
QA&I Guidance – Providers
• Question tools all contain guidance for how
the question is to be interpreted
• QA&I Tool also:
– point to source documents pertaining to each
question
– specify those questions that are considered
exploratory
7/17/2017 17
QA&I Guidance Example – Providers
• Question/Outcome #31 The Provider provides communication
assistance as indicated in the ISP.
• Guidance:
– For the sample selected, the reviewer determines if the ISP identifies any
communication assistance.
– The reviewer determines if daily documentation and progress notes
reflect that the communication assistance identified in the ISP is being
provided to the individual.
• Mark YES if the daily documentation and progress notes reflect how
the Provider implemented the communication assistance that was
identified in the individual’s ISP.
• Mark NO if the daily documentation and progress notes did not reflect
how the Provider implemented the communication assistance or if
the Provider did not implement communication assistance as
prescribed in the ISP.
• Mark NA if the ISP does not have any communication assistance
identified for the individual.
7/17/2017 18
Corrective Action Plan – Providers
• A catalog of those instances requiring remediation, as
well as a PPR including a QM Plan and/or Action Plan,
where necessary.
• An attachment to the QA&I Comprehensive Report, on
an ODP approved template.
• If the QA&I Comprehensive Report includes instances of
not meeting the standard, the entity must remediate each
one and develop a PPR, if applicable.
– Proof of remediation and a Plan to Prevent Recurrence,
including where QM Plans and/or Action Plans will be
developed, must be submitted within 30 calendar days of
receipt of the QA&I Comprehensive Report.
7/17/2017 19
Remediation – Providers
7/17/2017 20
• Instances in which an entity has not met the standard of
a particular QA&I question or series of questions
• These instances must be corrected, either upon
discovery or within 30 days of discovery
– There will be occasions when remediation must occur
immediately due to concerns for health and safety.
– Otherwise, remediation must occur within 30 days
following electronic issuance of the Comprehensive Report
by the AE.
• The instances for remediation will be:
– Summarized within the QA&I Comprehensive Report
– Specified in the accompanying Corrective Action Plan
Remediation – Providers (continued)
7/17/2017 21
• Each entity is required to include in its response to the
QA&I Comprehensive Report
– Proof of remediation already completed, including the date
of completion - and/or -
– A Plan to Prevent Recurrence (PPR) for each instance
noted in the Corrective Action Plan
– Identification of areas in which a QM Plan and/or Action
Plan will be developed
• Any exceptions to completion of remediation within 30
days of discovery must be negotiated with ODP or the
AE, as appropriate
Plans to Prevent Recurrence (PPR) - Providers
• PPR outlines actions that will be taken to ensure
future instances of non-compliance do not occur.
• A PPR is required when
– the compliance score for the requirement falls below 86%
OR
– 9 or fewer records were reviewed and there are 2 or more
instances of non-compliance.
• For any PPR activity requiring longer than 3 months
to implement, the entity is responsible to provide an
update on the progress of such activity(s) within 30
days of the QA&I Comprehensive Report to the AE
Onsite Review Team.
7/17/2017 22
Validation - Providers
• Providers are responsible for submitting evidence
of remediation and implementation of PPRs.
• ODP or the AE will review and approve all
remediation and PPR activities in order to close the
QA&I Comprehensive Report.
• Each year in the self-assessment process,
Providers are expected to address the impact of
PPR activities completed within the past year.
7/17/2017 23
Directed Corrective Action Plan (DCAP) - Providers
• May be required for ongoing engagement with ODP
or the AE, as appropriate, until such issues
identified in the DCAP are resolved to the
satisfaction of the QA&I Review Team.
• A DCAP through mandatory technical assistance
may be required, at a minimum, when:
– The entity fails to respond to imminent risk for one or more
individuals;
– The entity demonstrates repeated non-compliance in one
or more areas;
– The entity’s performance is below 86% for 5 or more
designated questions, if the sample is greater than 10; or
– Performance for one or more designated questions is
below 50% performance.
7/17/2017 24
7/17/2017 25
BREAK
7/17/2017 26
Quality Improvement & QM Plans
Quality Improvement & QM Plans - Key Points
• How QA&I Process enhances and supports ODP’s
system-wide Quality Strategy – Everyday Lives:
Values in Action
• Using QA&I Process and Results to develop QM
Plans and Action Plans
– What’s the same?
– What’s new?
7/17/2017 27
ODP Goals for QA&I
7/17/2017 28
• Measure progress toward systems
improvement based on Everyday
Lives: Values in Action ISAC
recommendations
• Gather timely & useable data to
manage the ODP system performance
• Use data to manage the service
delivery system with a continuous
quality approach
• Demonstrate AE outcomes with
operating agreement
• Collect data for Waiver performance
measures
• Verify that SCOs and Providers comply
with 6100 regulations
Purpose of Revised QA&I Process
7/17/2017 29
• Eliminate multi-layered
process and unnecessary
duplication
• Create more time to focus on
quality improvement and the
experience of individuals
• Desire to move away from
hierarchical compliance and
remediation toward
collaborative partnerships that
foster technical assistance and
shared learning
• Improve methods for collecting
and using data in a timely way
Quality of
the
Individual’s
Experience
Compliance
How QA&I Process enhances ODP’s Quality Strategy
• QA&I Questions will inform QM Planning:
– Tied to Everyday Lives: Values in Action
• Assuring Effective Communication
• Promoting Self-Direction, Choice and Control
• Increasing Employment
• Supporting Families
• Promoting Health, Wellness, and Safety
• Supporting People with Complex Needs
• Increasing Community Participation
– Focus on determining the individual’s experience with
services and supports
– Emphasize:
• Person-centered practices
• Service delivery
• Health & safety
7/17/2017 30
How QA&I Process enhances ODP’s Quality Strategy
• QA&I Questions will inform QM Planning:
– Tied to Everyday Lives: Values in Action
• Develop and Support Qualified Staff
• Improve Quality
• Performance results will assist ODP, AEs, SCOs, and
Providers:
– Determine priorities for improvement
– Develop baselines and target objectives for QM Plans
7/17/2017 31
How QA&I Process enhances ODP’s Quality Strategy
7/17/2017 32
• At least one ODP team member will possess QM
Certification
• By December 31, 2018, at least one member of the AE
onsite review team will possess ODP QM Certification
• Entrance Conference offers:
– Opportunity for entity leadership to share mission, vision,
successful and in-process quality improvement projects,
discuss challenges and identify areas for technical assistance
• Exit Conference offers:
– Highlights of best or promising practices
– Highlights of remediation and improvement identified
– Expectations for corrective action, quality improvement, and
Final QA&I Comprehensive Report
Program
Design..Discovery..Remediation..Improvement
(DDRI)
DESIGN
Plan for and set stage for
achieving positive outcomes
DISCOVERY
Find positive and negative
outcomes in a systematic,
timely manner
REMEDIATION
Address negative outcomes
in a timely manner
IMPROVEMENT
Improve quality via systemic
changes
CONTINUOUS CYCLE
This is
where
data
analysis
comes in
33
QM Planning: What’s the same?
7/17/2017 34
QM Plan Template Year:
Entity Name: Focus Area:
Goal Outcome Target Objective Performance Measure/
Data Source/Responsible
Person
QM Planning: What’s the same?
MyODP @ https://www.myodp.org/course/index.php?categoryid=264
Click on: Quality Management Planning and Implementation Documents
7/17/2017 35
Action Plan Template
Entity Name: Focus Area:
Desired Outcome:
Target Objective:
Performance Measure (s):
Data Source (s):
Responsible Person:
Action Item Responsible
Person (Name)
Target
Date
Status Completion Date
QM Planning: What’s the same?
MyODP @ https://www.myodp.org/course/index.php?categoryid=264
Click on: Quality Management Planning and Implementation Documents
Recommended QM Plan Components:
– Goals
– Desired Outcomes
– Target Objectives and Baselines
– Performance Measures
– Data sources used to measure performance
– Person Responsible for the QM Plan
Recommended QM Action Plan Components:
– Action Item
– Responsible Person
– Target Date
– Status
– Completion Date
7/17/2017 36
QM Planning: What’s the same?
QM Planning: What’s new?
Identifying Opportunities for Improvement
• Choose Focus Areas and Goals considering:
– ODP’s Everyday Lives priorities
– your mission, role, and the services and
supports you offer in light of Everyday Lives
priorities
– input and feedback offered by ODP and/or
the AE in identifying systemic opportunities
for improvement
• Everyday Lives Publications support the QM
Planning process:
– Everyday Lives: Values in Action
– Recommendations, Strategies, and
Performance Measures
7/17/2017 37
MyODP @ https://www.myodp.org/mod/page/view.php?id=7775
QM Planning: What’s new?
Identifying Opportunities for Improvement
• QA&I Results will be available to each entity
– Performance data in areas supported by exploratory
questions will support QM Planning
– Plans to Prevent Recurrence (PPRs) will foster prioritization of
focus areas
• When performance falls below the threshold of 86%, evaluate
whether the cause for poor performance represents a systemic
problem in need of a quality improvement project supported by a QM
Plan and Action Plan
– Review of QA&I data will allow for development of baselines and
realistic target objectives
7/17/2017 38
• QM Plans will be submitted and reviewed as part of the QA&I Process.
• If you have a QM Plan and accompanying QM Action Plan already in place and findings from the QA&I Process prompt you to update these documents,
– Update your existing Action Plan until it’s time to develop your new Fiscal Year QM Plan and Action Plan
– Update your QM Plan and Action Plan to begin July 1
• If you discover an area where you need to develop a new QM Plan and accompanying Action Plan,
– Add a new Focus Area, Goal and Target Objective to the existing QM Plan that will carry you to June 30th of the following fiscal year
– Add Action Plan steps to achieve the Target Objective– Implement the new work immediately with continuation in the following
fiscal year
7/17/2017 39
QM Planning: What’s new?
• Using the QA&I tool, AEs, SCOs and Providers are expected
to conduct a self-assessment of their performance annually to
inform and build quality improvement activities, evaluate
progress on implementing the QM Plan and determine the
effectiveness and impact of action steps.
• Organizations not slated for onsite QA&I review until years 2
and 3 are expected to use their self-assessment results to
prioritize and engage in improvement activities while awaiting
the onsite review.
• It is the intention that AEs, SCOs and Providers will continue
to engage in quality improvement activities during the two-
year period between formal QA&I onsite reviews.
7/17/2017 40
QM Planning: What’s new?
• ODP and AEs will follow up with the entity on progress
in implementing QM Plans and provide technical
assistance as needed during the course of the QA&I
Cycle.
• Technical assistance by either ODP or AEs will focus on
quality improvement.
7/17/2017 41
QM Planning: What’s new?
• Statewide Reports
– Self-Assessments
• Annually, at the completion of the self-assessment
process for all entities, ODP will issue an aggregate
report of self-assessment results and analysis
statewide. This report will be used to inform the QA&I
process throughout the year and technical assistance
targeted to AEs, SCOs and Providers.
– Annual QA&I Report
• Annually, ODP will compile all data collected from the
QA&I process into a report that represents statewide
performance of AEs, SCOs and Providers and the
overall system as it relates to quality of services and
supports and person-centered best practices.
7/17/2017 42
QM Planning: What’s new?
• Requirements for ODP QM Certification
– At least one ODP team member will possess QM
Certification
– By December 31, 2018, at least one member of the AE
onsite review team will possess ODP QM Certification
• ODP QM Certification
– Complete prerequisites
– Application and registration process
– In-person class:
• September 13 and 14, 2017 in Ebensburg
• October 11 and 12, 2017 in Chester County
• October 31 and November 1, 2017 in Mechanicsburg
7/17/2017 43
QM Planning: What’s new?
MyODP @ https://www.myodp.org/course/index.php?categoryid=214
QM Planning: What’s new?
7/17/2017 44
QM Planning: What’s new?
7/17/2017 45
7/17/2017 46
QUESTIONS
ODP Contact Information
7/17/2017 47
ODP QA&I Process Mailbox:
7/17/2017 48
THANK YOU!
