odp academy for administrative entities …changing practices, unchanged values administrative...

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


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


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



ODP developed the AE Monitoring tool using requirements found in: – The Operating Agreement– CMS Assurances– Bulletins– ODP Monitoring of Counties (OMOC)– ODP Initiatives


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



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


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


How Will ODP Implement the New AE Oversight Process?

The Regions will develop monitoring schedules Regional Teams will share oversight

responsibilities

Teamwork


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


Where and How Will Monitoring be Completed?

Regional reports reviews Home and Community Services Information

System (HCSIS) Onsite

– Reviews– Interviews


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



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).



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


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


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


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


Structure of the AE Oversight Monitoring Tools

Review of the guidelines, worksheets and scoring tool


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.


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


SIX OVERALL ELEMENTS

Quality of Life Administrative Entity Capacity Provider Qualifications/Monitoring Rights Eligibility/Level of Care Other Administrative Functions


Elements of the Oversight Monitoring Process

Requirements are not new Regions & County/AEs have been

responsible for these items for some time


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)


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


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)


Quality of Life Issues – SC Review - Data Integrity

Mandatory fields completed in HCSIS– Demographics– Eligibility– Enrollment information.

Data integrity is crucial to the process.


Quality of Life Issues - Quality Management (QM) Requirements

Quality Management/ Quality Implementation (QM/QI) plan written (OA)

QI actions (OA)


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)


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)


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)


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


ODP Initiatives

Lifesharing– AE follows ODP expected Lifesharing practices

Restraint Reduction– AE achieves annual statewide restraint reduction

goal


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)


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)


AE Capacity

Designated AE staff register for and participate in ODP Academy (OA)


AE Capacity

AE has a designated Employment Point Person

AE has a designated Lifesharing Point Person


Provider Monitoring

All licensed/certified and non-licensed providers meet waiver qualification standards (OA & CMS-A)


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)


Provider Monitoring

Provider training is conducted according to state and waiver requirements (CMS-A)

All providers meet licensing and certification standards (OA & CMS-A)


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


Rights – Due Process

AE assists individuals/families to file appeals as needed (OA)

Waiver services under appeal continue as required (OA)


Rights – Choice

Individuals/families have choice of services (OA & CMS-A)

Individuals/families have choice of providers (OA & CMS-A)


Rights – Service Review

Service Review findings are implemented within 30 days (OA)


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)



Qualified Mental Retardation Professionals (QMRP) complete the certification of need consisting of:

– Individual/family interview– Social/psychological review– Current medical evaluation (OA & CMS-A)



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)



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)


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)


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)


Rates are established by DPWs Rate Setting Methodology and/or approved by DPW

Financial Management – Rate Setting


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)


Financial Management – Individual Emergency Services Form (IESF)

IESFs are submitted as required (OA)


Other Administrative Functions – Record Retention

Records are retained according to specified time requirements (OA)

Waiver records are safeguarded per HIPPA regulations (OA)


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)


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)


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


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)


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.


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:

[email protected]

odp academy for administrative entities …changing practices, unchanged values administrative...

Documents

new ae oversight process

ae oversight monitoring

ae monitoring tool

odp academy overview

odp academy sessions

process slide

ae staff

oversight monthly reports