Designing A Quality Process

1. “Quality in health care means doing the right thing, at the right time, in the right way, for the right person; and having the best possible results.”* *Agency for Health Care Quality and Research Designing A Quality Process

2. Provider accountability Identify Training Needs Meet audit requirements Improve Consumer Outcomes Create a constant feedback loop Goals of the Quality Assurance Process

3. Quality: Provider Role • Your job is to ensure: • Service plan meets consumer’s needs according to program policy • Required documentation and paperwork is completed • proper authorization prior to service delivery • What is authorized on the service plan is generally what is provided to the consumer and what is billed by your agency • Coordinate effectively with MPQH and other community resources

4. Quality: Dept. Role • Provide Information about Policy and Procedure • Manuals • Semi-annual trainings • Local training • One-on-one training • Case Consultation • Be Consistent • And more!

5. External APS Check Fraud Check Reference Check Home Visits (50% of on-site review sample) QAMS Quality Assurance Communications (Point Sheets) Serious Occurrences Previous QAR Provider Case reviews (optional) Provider Prepared Standards Dept. On-Site Chart Review Review Standards Must review 10-15% of consumer charts, depending upon standard Minimum 3 charts Components of a Quality Assurance Review

6. Agency QAR Schedule • Six month -3 year cycle • Based on outcome of the review • Lead reviewer notifies agency of the time frame for next review (identified by fiscal year) in the QAR closure letter • Dept can decide to change the review schedule, regardless of cycle: • Agency Staff turnover - QACs -Department Resources • Serious Complaints -Billing • Agency is notified by the lead reviewer at least one month prior to scheduling the review

7. Four Types of QAC Assurances • Performance- S : Agency acts outside program policy around a review standard • Performance-O : Agency acts outside program policy not related to a review standard • Other : RPO would like to collect information around a quality component • Positive : RPO wants to commend the agency

8. QAR QACS Information the Reviewer Captures: • Identify the issue and how it was discovered • Refer to review standard (when applicable) • Reference manual Agency Response: • Cause: Describe the cause, be specific to the individual circumstance and also think broadly about system issues that may have caused the issue • Action: Describe the agency’s follow-up action, which should be related to addressing the specific QAC issue, but also preventing future issues from emerging and ensuring program compliance in the future • Feel free to submit additional documentation and material, i.e., in-service training, compliance tool, letter, updated chart notes, updated service plan, modified agency policy, etc.

9. Quality Improvement The RPO reviews according to specific standards, if the standard is unmet for a specific consumer chart the RPO generates a QAC • The QAC Assurance will list “Performance-S” • The QAC standard will identify the standard that was unmet • The QAC outcome will indicate “non-compliance with Policy”

10. On-Site Standards Goal: Consumer authorized services according to individual need Standard: • Authorization documentation • High Risk authorization • Amendments and temporary authorizations • Health Care Professional authorization (SDPAS)

11. On-Site Standards Cont. Goal: Consumer Receiving Services According to Authorization Standard: • SDR Reflects the Profile authorization Goal: Agency Provides Appropriate Follow-up to Ensure Consumer Health and Safety Standard: - Agency Responsibility for Program Oversight/Nurse Supervision

12. On-Site Standards Cont. Goal: Provider Billing Consistent with Medicaid Practice Standard: • PAS services billed correctly • HCBS services billed correctly Goal: Provider Forms and Documentation Complies Standard: • Required documentation (aside from auth) in chart • Principles of charting

13. Meeting a Standard In order to meet a standard a consumer chart must contain all of the required components - If any of the required components are missing the consumer chart is “unmet” for that standard - Performance-S QAC is written In order to pass a standard for the review a pre-determined percent of the consumer charts must meet the standard - Depending on the standard 75%-100% compliance is necessary to meet the standard

14. Types of QAR • Full Review • All of the required standards will be reviewed • Consumer interviews, provider reference checks, provider prepared standards and on-site standards • Targeted Review • Only Specific standards will be selected for review • RPO will identify the specific standards in the review closure letter

15. Review Schedule Criteria • Three Year Full Review • All standards met on current review • QAR history is strong (previous review 2 or 3 years) • Two Year Full Review • Majority of the standards met on current review • QAR history is strong (previous review 2 or 3 years) - or- • All standards met on the current review • QAR history is weak (previous review targeted or one-year or a new agency)

16. Review Schedule Criteria cont. • One Year - Full • Majority of the standards unmet • QAR history weak (previous review was targeted or one year or a new agency) • Possible sanctions • One Year - Targeted • Two or more of the standards unmet • QAR history weak (previous review was targeted or one year or a new agency) • Possible sanctions

17. Possible Sanctions • Program participation • Suspension of program participation • Unable to admit new consumers • Required attendance at provider education sessions • Required prior authorization to provide services, including: • Review of new intakes • Review of temporary authorizations/amendments • Attendance at all new intake or 180-day visits • Review of all training records and competency evaluation (ABPAS)

18. Factors that are Considered • Seriousness of Offense • Extent of violation • History of prior violations • Prior implementation of sanctions • Prior provision of agency education • Agency willingness to comply with program rules • Whether a lesser sanction will be sufficient to remedy the situation

19. Dept. Sanction Process • Notification during the QAR exit interview • Written notification within 10 days following the exit interview that includes: • Details of the sanction • Rational for sanction • Corrective action plan • Length of sanction • Evaluation method to remove sanction • Fair hearing rights

20. Tips Prior to the Review • Internal Agency Audits • Spend time reviewing your own records • Review according to the quality review standards • Review for the required documentation to bill for services • Review previous review QACs and make sure you have addressed the issue • We are happy to see case notes that reflect changes due to oversight or error • Follow-up accordingly • SDR Review • Identify and resolve issues • Return SDRs if documentation is incomplete • Train new staff and review their work according to quality assurance standards • Know who is responsible for every quality aspect of your agency and ensure the work and follow-up work is being done • Ask Your RPO • Request an RPO to conduct an educational review

21. Tips for the Review • Make sure you know where all appropriate documentation is located. Many of you keep the billing records separate, which is fine, but we need timely access. • Provide SLTC staff with private and ample workspace. (Makes for happy reviewers.) • Don’t be afraid to ask questions • Submit your provider prepared standards by the deadline. Make sure to provide detail and attachments, as necessary. • Understand review dates are tentative and may be moved due to staff conflicts and/or bad roads. • This is a learning experience for all of us. We collect lots of data that helps us make program changes.