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Quality Assurance Overview

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Quality Assurance System Overview FY 04/05- new Quality Assurance tools

implemented included CMS Quality Framework and expectations

FY 05/06- revisions to Quality Assurance tools deletion / addition of some QA Indicators and

reorganization of some Outcomes, scoring revision, modification of performance levels

06/07 - 2015- minimal changes to the Quality Assurance tools Continuing to compare data / performance across

extended periods of time

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Impact of Quality Assurance Data Provides an overview of system performance

Viewed and utilized by a wide audience Data utilized by DIDD Central Office, Regional Offices, Quality Management Committees, court monitors

Facilitates change throughout the service delivery system and decision making Data is used in assessing progress and to

identify areas needing corrective intervention

Special Reporting Focused review of Domains, Outcomes and

Indicators Review of provider performance by provider-

type and regionally Comparison of performance across years

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Quality Assurance System Overview Quality Assurance Survey Process:

Consultative Reviews Annual Review except for some clinical providers and those providers

achieving 3 or 4 Star status Sample Selection Notification / document request On-site review Conciliation process Report of findings Reporting through Regional and Statewide Quality Management

Committees Quality Improvement Planning

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Quality Assurance System Overview Quality Assurance Tools:

Organizational: Day-Residential / Personal Assistance / Clinical Independent Support Coordination (organizational

practices & utilizing data from waiver Individual Record Reviews)

Individual: Day-Residential Personal Assistance Behavioral Nursing Therapy

Performance Levels: Exceptional Performance Proficient Fair Significant Concerns Serious Deficiencies

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Quality Assurance System Overview Quality Assurance Tool Structure:

Domains- scored as either Substantial Compliance, Partial Compliance, Minimal Compliance or Non-compliance

1. Access and Eligibility2. Individual Planning and Implementation3. Safety and Security4. Rights, Respect and Dignity5. Health6. Choice and Decision Making7. Relationships and Community Membership8. Opportunities for Work9. Provider Capabilities and Qualifications10. Administrative Authority and Financial Accountability

Outcomes- scored as either Substantial Compliance, Partial Compliance, Minimal Compliance or Non-compliance

Indicators- scored as either Yes, No or NA Guidance and Provider Manual References

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Outcome 2B. Services and supports are provided according to the person’s plan.

Indicators Results Guidance Comments *2.B.5. Provider documents provision of services and supports in accordance with the plan.

Y N NA IJ

For all Providers: Provider documentation systems are developed to support the delivery of services. Practices include oversight to ensure staff understand responsibilities for documentation. Provider Manual Reference: 3.17; 6.11; 8.7.a.; 8.9.e.; Chapter 11; 12.9.; 12.10.; 13.14.; 13.15; 15.2; 15.3

Outcome 2D. The person’s plan and services are monitored for continued appropriateness and revised as needed.

Indicators Results Guidance Comments 2.D.5. The provider has a process for reviewing and monitoring the implementation of the plan and progress toward desired goals.

Y N NA IJ

For all Providers: The provider has developed an ongoing, systematic review process that promotes identification, tracking and coordination of activities related to implementation of each person’s plan and any needed follow-up activities. For Clinical Providers: The provider has a process to prepare a review of progress and an updated justification for services at the time of the annual ISP review. Day-Residential and PA Provider Manual Reference: 3.10.f.; 3.15.; 3.17.; 3.18.; 3.19.; 6.5. 13); 6.6.f.; 10.6.c.; Chapter 11 Clinical Provider Manual Reference: 3.10.f.; 3.15.; 3.17.; 3.18.a.,b.; 8.9.f.; 12.10.; 13.12.; 13.14.; 13.15.; 14.5.; 15.2.; 15.3.

*2.D.6. Provider documentation indicates appropriate monitoring of the plan's implementation.

Y N NA IJ

For all Providers: Providers utilize resolution processes if needed to ensure supports and services are provided in accordance with the ISP. The provider agency ensures that systems developed to verify service delivery are effective.

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Quality Assurance System Overview Quality Assurance Scoring & Domain

Applicability: Domains Applicable by Provider Type:

Day-Residential: 2, 3, 4, 5, 6, 7, 8, 9, 10 Personal Assistance: 2, 3, 4, 5, 6, 9, 10 Support Coordination: 1, 2, 3, 9, 10 Behavioral: 2, 3, 4, 6, 9, 10 Nursing: 2, 3, 4, 5, 6, 9, 10 Therapy: 2, 3, 4, 6, 9, 10

On the web: QA and Waiver Review Tools Report Card Listing Star Listing & Criteria Resource / Reference Documents

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Star Providers- 2, 3 & 4 Star Awards 4-Star Status:

96% (Exceptional) or above compliance on QA surveys for 2 years; All Domains scoring at least Partial Compliance Must achieve Substantial Compliance in Domain 3 Substantial Compliance in selected Domains, Outcomes and Indicators

from QA tools. No preventable egregious events resulting in death of individual for one year; Providers of Day Services must provide employment; No sanction or systemic recoupment for one year; Annualized substantiated investigation rate of 10 substantiations per 100

persons supported (10:100) or less for one year; Approval for four-star status is by the Regional Quality Management

Committee, followed by submission to State-wide Quality Management Committee for final approval.

4-Star Award recipients skip a survey year.

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Star Providers- 2, 3 & 4 Star Awards 3-Star Status:

85% (Proficient) or above compliance on QA surveys for 2 years; All Domains scoring at least Partial Compliance Must achieve Substantial Compliance in Domain 3 Substantial Compliance in selected Domains, Outcomes and Indicators

from QA tools. No preventable egregious events resulting in death of individual for one year; Providers of Day Services must provide employment; No sanction or systemic recoupment for one year; Annualized substantiated investigation rate of 10 substantiations per 100

persons supported (10:100) or less for one year; Approval for three-star status is by the Regional Quality Management

Committee, followed by submission to State-wide Quality Management Committee for final approval.

3-Star Award recipients skip a survey year.

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Star Providers- 2, 3 & 4 Star Awards 2-Star Status:

Proficient performance for two years; All Domains scoring at least Partial Compliance Must achieve Substantial Compliance in Domain 3

No preventable egregious events resulting in death of individual for one year; Providers of Day Services must provide employment; Annualized substantiated investigation rate of 10 substantiations per 100

persons supported (10:100) or less for one year; Approval for two-star status is by the Regional Quality Management

Committee, followed by submission to State-wide Quality Management Committee for final approval.

2-Star Award recipients do not skip a survey year.

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Waiver Monitoring Overview DIDD implements three HCBS Waivers under the administrative oversight of

TennCare: Self-Determination Waiver State-wide Waiver Comprehensive Aggregate Cap Waiver

Each waiver entails annual monitoring as performed by Quality Assurance, with follow-up remediation and validation activities as coordinated by regional Operations / Provider Support Teams.

Monitoring for each waiver consists of administration of two review tools Qualified Provider Individual Review (involves identification of a state-wide sample which is selected at the

beginning of each waiver-year)

All findings / issues are expected to be remediated with provider and systemic trends identified and addressed.

Findings / issues are reviewed and discussed by both the Regional Quality Management Committees and the State-wide Quality Management Committee.