Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency

1. Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency Presented by Mary T. Tripp Policy Unit Leader DMH/DD/SAS Accountability Team on behalf of the NC DHHS-LME/MCO-Provider Collaboration Workgroup at the NC Association of Rehabilitation Facilities Annual Leadership Conference May 1, 2014

2. Focus of this Workshop • The Impetus for Streamlining Provider Monitoring • An Introduction to the New Tools for Routine Monitoring of LIPs and Provider Agencies • Achieving Increased Accountability and Positive Outcomes Through Partnerships

3. Streamlining Provider Monitoring

4. What happened to Gold Star, and what led to this new way of monitoring? • Waiver Expansion • Continuous Quality Improvement • Reduce Administrative Burden on Providers and LME-MCOs per Session Law 2009-451 (SB 202) • Business Practices Sub-Committee of the LME-MCO & Provider Standardization Committee

5. What happened to Gold Star, and what led to this new way of monitoring?CONTINUED • A greatly streamlined, non-duplicative, standardized process needed for local monitoring. • The Provider Monitoring Workgroup expanded to include representatives from: • NC Council of Community Programs Business Practices Sub-Committee • NC Providers Council • Benchmarks • Professional Association Council

6. We heard you!!

7. Stakeholder Groups • Benchmarks • N C Council of Community Programs • NC Providers Council • Professional Association Council

8. Professional Association Council • Addiction Professionals of NC • Licensed Professional Counselors Assoc. of NC • National Association of Social Workers-NC Chapter • NC Association for Marriage & Family Therapy • NC Counseling Association • NC Nurses Association • NC Psychiatric Association • NC Psychological Association • NC Society for Clinical Social Work

9. NC Council PAC Benchmarks Individuals & Families DMA DMH/DD/SAS NC Prov. Council DHSR LME-MCOs

10. Quality Providers = Quality Services = Best Possible Outcomes for Individuals and Families

11. The Who-What &When of the Review Tools • The Routine Review Tools are used with two provider types: • LIP Review Tool is used with LIPs in a solo or group practice where only outpatient / basic benefit services are provided. • Agency Review Tool is used with provider agencies that provide any service(s) other than outpatient services exclusively.

12. Routine Monitoring • Includes: • Routine Review • Post-Payment Review • May be used together or separately. • State-funded and Medicaid-funded services

13. Remember… Any of the monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns

14. 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.

15. 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)

16. 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

17. Semantics • Decision made to stop using Gold Star as the name of the NC provider monitoring process. • Confusion between Gold Star, the process, and Gold Star, the highest level to be achieved. • Gold Star as a term remains as the highest level achievable.

18. What’s New or Different NC Provider Monitoring Process Gold Star Provider Monitoring

19. What’s New or Different Frequency: • Routine monitoring occurs on a 2-year cycle as opposed to annually.

20. What’s New or Different • The scoring and weighting of the review items has been revised.

21. What’s New or Different • Each of the following areas has a clearly defined sample size: • Incident Reporting • Restrictive Interventions • Complaints • FundsManagement • Medication Management

22. What’s New or Different • Plans of correction are used to address systemic issues rather than individual non-compliance items.

23. What’s New or Different • AFLs that are not under the waiver are reviewed every 2 years (previously those sites were reviewed based on the profile level. • (AFLs under the Innovations Waiver are still required to be reviewed annually).

24. What’s New or Different • The minimum overall passing score for routine monitoring increased to 85% from 75%.

25. What’s New of Different • The initial on-site Health and Safety Review is not required if the service is located in a site that is licensed by DHSR.

26. What’s Been Accomplished? • Routine Provider Agency Tool reduced from 158 items to 18 items • Agency Post-Payment tools were reduced from an average of 16 to an average of 12 items • LIP Review Tools (routine, office site and post- payment) went from 63 items to 49

27. What’s Been Accomplished? • Focus is on rules related to systemic trends and quality of care • Elimination of duplication by using existing data such as review of IRIS reports, review of provider policies, submitted reports

28. What’s Been Accomplished? • Tool has been developed to obtain feedback from providers via SurveyMax (to be implemented May 1, 2014). • Webinars are being taped as a follow-up to statewide training. • FAQs from training and provider monitoring mailbox are posted on the Provider Monitoring web page for broad dissemination.

29. Provider Monitoring Survey • Notification • Received notification of date of on-site review in accordance with guidelines • Information needed for the review was included in the notification letter

30. Provider Monitoring Survey • Process • Reviewers introduced themselves in a professional manner. • Reviewers were knowledgeable about the services that were reviewed. • Reviewers followed the guidelines for scoring the items on the tools. • Was able to have an open discussion with reviewers. • Had adequate time to provide the requested information.

31. Provider Monitoring Survey • Results • A clear explanation was given for all non-compliances found. • Specific areas of non-compliance found during the routine review and the post-payment review • Did the review result in a payback? • Did the review result in a plan of correction? • Does the provider plan to appeal any non-compliant findings?

32. Routine Review Tools For Provider Agencies (Emphasis on IDD Services)

33. Routine Monitoring of Agencies that Provide IDD Services • Two Components: • Routine Review Tool • Post-Payment Review Tool • Innovations Waiver PPR Tool • Other Specialized Tools • Unlicensed AFL Provider Review Tool • Health, Safety and Compliance Review Tool

34. Routine Review Tool • Basic Elements: • Rights Notification • Service Availability • Coordination of Care • Incidents • Restrictive Interventions • Complaints

35. Additional Elements on Routine Review Tool • Protection of Property (as applicable) • Funds Management (as applicable) • Medication Review (as applicable)

36. How to Navigate the Excel Workbook, RM&DM andClinical Coverage Policies

37. Rights Notification

38. 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”

39. 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”

40. 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.”

41. 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.”

42. 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

43. 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.”

44. Incidents, Restrictive Intervention & Complaints

45. 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.”

46. 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.”

47. 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

48. Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. CONTINUED • 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

49. 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.”

50. Coordination of Care / Service Availability