Routine Review Tools for Provider Agencies

1. Routine Review Tools for Provider Agencies Presented by: Margaret Mason COO, HomeCare Management Corp. Representing the NC Providers Council Carol Robertson QM Director, Sandhills Center for MH/DD/SAS Representing the NC Council of Community Programs Revised 3-4-14 Developed by the NC DHHS-LME/MCO-Provider Collaboration Workgroup February 2014

2. Routine Monitoring of Provider Agencies • Occurs at a minimum of every two years • Includes use of a Routine Review Tool and a Post-Payment Review. They may be used together or separately. .

3. Remember… This is about Routine Monitoring only Any monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns

4. Routine Monitoring of Provider Agencies Includes: • All GS §122C MH/IDD/SA services that are not licensed by DHSR (e.g., Supervised Living, Unlicensed AFLs). • All GS §122C MH/IDD/SA services that are licensed by DHSR, but are not surveyed annually (e.g., PSR, Day Treatment, ADVP-IDD, SAIOP, SACOT, etc.). See “Licensed MH/DD/SA Services and Frequency of Surveys Conducted by DHSR Mental Health Licensure and Certification Section” in the Provider Agency workbook.

5. No Monitoring by LME-MCOs The following services are referred to the appropriate licensing agency: Therapeutic Foster Care (Licensed by DSS under GS §131D) Hospitals (Licensed by DHSR Acute and Home Care Licensure Section) ICF-IID -formerly ICF/MR- (Licensed by DHSR Mental Health Licensure Section)

6. Limited Monitoring by LME-MCOs PRTF – Post-payment and reported health and safety issues Licensed Residential Facilities – Post-payment and reported health and safety issues Opioid Treatment – Post-payment and reported health and safety issues

7. The Who-What &When of the Review Tools The Agency Review Tool is used with provider agencies that provide any service(s) other than outpatient services exclusively.

8. Historical Context • Agencies have a history of Routine Monitoring, i.e. endorsement, FEM, etc.

9. Internal Quality Assurance Routine Monitoring…. • ….will only involve review of documents needed to determine the met/not met/NA status for the review tool questions • ….is less anxiety-provoking when providers use the tool as a pre-review self-assessment.

10. Routine Monitoring of Provider Agencies Two Components: Routine Tool Post-Payment Review Tool Other Specialized Tools Unlicensed AFL Provider Review Tool Health, Safety and Compliance Review Tool

11. Routine Monitoring of Provider Agencies • Rights Notification • Service Availability • Coordination of Care • Incidents • Restrictive Interventions

12. Routine Monitoring of Provider Agencies CONTINUED Complaints Protection of Property (as applicable) Funds Management (as applicable) Medication Review (as applicable)

13. Specialized Tools for Provider Agencies • Unlicensed AFL Review Tool • Health, Safety and Compliance Review Tool

14. Routine Review Tools

15. How to Navigate the Excel Workbook andClinical Coverage Policies

16. Rights Notification

17. Item 1: There is evidence that the individual or LRP has been informed of their rights.10A NCAC 27D .0201. Sample is 30 service events Notification includes: • Rules to be followed and possible penalties. • How to obtain a copy of one’s service plan • Information received within 3 visits or 72 hours (for residential) • How to contact Disability Rights North Carolina • All areas above must be met to rate this item “Met”

18. Item 2: The individual has been informed of the right to consent to or to refuse treatment. 42 CFR 438.100 (Enrollee Rights), G.S. 122C-57(d); 10A NCAC 27D .0303 (c) Sample is same 30 service events as in Item 1 • Review documentation indicating the individual or LRP has been informed of the right to consent to or refuse treatment. • Signed consent must be present for each record in the sample to rate this item “Met”

19. Item 3: The individual is informed of right to treatment, including access to medical care and habilitation, regardless of age or degree of disability. G.S. 122C-51 Sample is same 30 service events as in Item 1 • Must specifically inform, in writing, of right to Tx, including access to medical care and habilitation, regardless of age or disability. • Right to an individualized written treatment plan and right to access medical care. • All records in the sample must have the above to rate this item “Met.”

20. Item 4: The individual has been notified that release/ disclosure of information may only occur with a consent unless it is an emergency or for other exceptions. G.S. § 122C-55 or in 45 CFR 164.512 of HIPAA. 10A NCAC 26B .0205 Sample is same 30 service events as in Item 1 • Confidential information may not be released without written consent except in the case of an emergency. • Each element of the required notice listed in Statute must be explained in writing or verbally, but individual must sign that they have been explained. • Each record in the sample must have the above to rate this item “Met.”

21. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202 Sample is the same 30 service events as in Item 1 Individual’s name Name of facility releasing information Name of individual(s), facility(ies) to whom information is released Specific information to be released Purpose of the release

22. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202CONTINUED Length of time consent is valid Statement that consent can be revoked Date consent signed Must include a statement regarding the protection of HIV and SA information and disclosure requirements under 42 CFR Part 2 Each record in the sample must include authorizations with all elements to rate this item “Met.”

23. Incidents, Restrictive Intervention & Complaints

24. Item 6: Level I incidents were classified appropriately and reported in accordance with10A NCAC 27G .0602(3), 10A NCAC 27G .0103(b)(32) and 10A NCAC 27G .0604. Sample is 10 Level I Incident Reports • The reviewer is able to go back up to 1 year in order to obtain the sample. • Determine if each incident was classified appropriately • Incidents related to med errors, restrictive intervention or search and seizure must be included in Level I quarterly report. If not, technical assistance will be provided. • If NO incidents, item is rated “N/A.” • All incidents must be classified correctly to rate this item “Met.”

25. Item 7: For all Level II and Level III incidents reported, follow-up was conducted and recommendations were implemented in accordance with 10A NCAC 27G .0603 - .0604. Sample is 10 Level II and III Reports • Pre-site: Review incidents in IRIS to determine if follow-up completed and recommendations implemented. • On-site: Review provider documentation for follow-up and implementation of recommendations for outstanding Level IIs and IIIs. • Review incident log or list against IRIS to determine if all incidents were submitted. • Each incident must have been reported, follow-up occurred and recommendation implemented to rate this item “Met.”

26. Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. Sample is 10 Incidents of Restrictive Intervention Pre-site: • Review policy & procedure on Restrictive Intervention and determine if all elements of rule are included. • Each RI sampled must be in the submitted corresponding Quarterly Summary and in IRIS • On-site: Review RI log to ensure compliance with rule

27. Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. CONTINUED 38 • Agency policy and procedure must meet requirements of rule; and • Each RI in sample must be conducted per policy and per elements in rule to rate this item “Met.” • This item requires 100% compliance as part of the assessment for Health & Safety

28. Item 9: The provider is responsive to complaints received per timelines in policy. 10A NCAC 27G .0201 Sample is 10 Complaints • Pre-site: Review provider Complaint Policy & Procedure for addressing and resolving complaints/grievances (elements not in rule). There must be a defined procedure. • On-site: If there are not 10 reports, go back up to 1 year if needed. If still not 10, review the number found. • Policy & Procedure must be present and implemented in all complaints reviewed to rate this item “Met.”

29. Coordination of Care / Service Availability

30. Item 10: There is documentation that coordination of care is occurring between providers involved with the individual. CCPs 8A through 8P Sample is same 30 service events as in Item 1 • Coordination of Care requirements vary per service definition • Evidence must be written • Common requirements include but are not limited to: case management; coordination with medical, psychiatric or other providers; coordination in crisis or discharge planning; participation in child & family teams • If individual does not agree to contacting other providers, refusal must be documented.

31. Item 11: Access to behavioral health crisis services is available 24/7/365 and provided directly by the agency or through written arrangements. CCP 8A Sample is same 30 service events as in Item 1 • Providing 24/7/365 per service definition • Documentation will vary: first responder procedures and staffing logs, written arrangements with other entities for crisis services; notification to individuals of how to access services in a crisis

32. Protection of Property & Management of Funds

33. THE FOLLOWING ITEMS, #s 12 & 13 , APPLY ONLY TO 24 HOUR FACILITIES THAT SEE AN INDIVIDUAL FOR MORE THAN 30 DAYS, INCLUDING UNLICENSED AFLS.

34. Item 12: The agency has a current policy that outlines how the requirements for protecting an individual's property in accordance with 10A NCAC 27F .0104are met. • Pre-Site Review: Review policies and procedures to ensure that property is safe from theft, damage, destruction, loss and misplacement. To be completed at LME-MCO. • This is a policy review only, but all areas must be covered for this item to be rated as “Met.”

35. Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105. Sample is 1-5 records of individuals whose funds are managed by the agency. If less than 5 individuals in home, review records for all. • Review most recent quarterly accounting statement for all records in the sample to ensure they reflect all transactions. (Note - these records may not be kept in the clinical/service record as they contain financial information.) • Ensure that each person's money is managed separately from the agency's funds and accounts.

36. Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105CONTINUED There must be an accounting statement for each person which at a minimum summarizes the financial transactions to rate this item “Met.” Additionally, 85% must be achieved across the sample (4 of 5 records met) for this item to be scored as met.

37. Medication Review

38. Item 14: Medications are stored appropriately, including separate storage for each service recipient, separately for each type of use, in refrigerator, behind secure lock, and secured for individuals self-administering. 10A NCAC 27G .0209. Sample is 5 records from individuals who receive medication from the agency. • Inspect medication storage area to ensure that medications are stored appropriately, and consistent with the requirements in the rule. Medication storage may include separate Ziploc bags, boxes, or other containers, as long as the labels with the person's name remain intact for each medication. • Any medication samples received from the physician must be stored in the same way as other medications. • 100% must be achieved for each item for the record to be rated “Met”.

39. Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender.10A NCAC 27G .0209. Sample is same 5 records from item 14. • Review the record to ensure there is a written order that has been signed or countersigned and dated by the responsible physician/physician extender. • Enter the number of medications for both prescribed and over the counter medications as the number of possible items on the Medication Review Sheet.

40. Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender.10A NCAC 27G .0209CONTINUED If an individual receives psychotropic drugs, his/her drug regimen must be reviewed by a pharmacist or physician at least every 6 months. 100% compliance must be achieved for this item to be rated “Met” (per individual).

41. Item 16: The medication label matches the physician's order.10A 27G .0209. Sample is same 5 records from item 14. • Ensure label on bottles/packaging matches the physician's order. • In some cases, the brand name of the drug will have been dispensed, in other generic per order. • 100% must be achieved for each item for the record to be rated as “Met.”

42. Item 17: The medication listed on the MAR matches the physician's order.10A 27G .0209. Sample is same 5 records from item 14. • Ensure that each physician's order is listed within the MAR. • Any medication samples received from the physician are recorded in the same way on the MAR. • If an individual administers his/her own medication at an agency site, the medication must be listed on the MAR. • 100% must be achieved for each item for the record to be rated “Met.”

43. Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff.10A NCAC 27G .0209. Sample is same 5 records from item 14. • Documentation of medication education provided to the individual/LRP should be reviewed for each prescribed or over-the-counter medication if ordered by the agency physician.

44. Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff. CONTINUED • Medication education may be given orally or in writing • documentation may be in the prescribing physician's note • may be documented in writing according to agency policy • Medication education is required for all medications prescribed by the provider agency’s physician. • 100% must be achieved for each item for record to be rated “Met”

45. Specialized Tools

46. Specialized Tools • Unlicensed AFL Review Tool • Looks at health and safety issues and compliance with the personnel and training requirements of providers and staff • Is required to be completed annually for AFL services under the Innovations Waiver • Is completed every two years for all other unlicensed AFL sites

47. Specialized ToolsCONTINUED • Health, Safety and Compliance Review Tool • Is only for the initial review of services that operate out of a setting that is not licensed by DHSR (e.g., Unlicensed Supervised Living Programs). • Is used when an unlicensed service moves to a new location which is not co-located with a licensed service. • Subsequent reviews of these services would utilize the Routine Review Tool.

48. Questions If you have any questions about how the use the automated workbook and review tools, please send your questions to the Provider Monitoring mailbox: provider.monitoring@dhhs.nc.gov Please include in the Subject line the nature of your question.