2017 Audit Guidance: Preparation, Experiences, and Lessons Learned. NPA Quality Symposium Friday, June 9 th

Transcription

1 2017 Audit Guidance: Preparation, Experiences, and Lessons Learned NPA Quality Symposium Friday, June 9 th

2 Objectives Discuss preparing for the audit Review and discuss the work of the Audit Task Force Record Layout (Universe) templates Risk Assessments Operational Guide Discuss the tracer methodology and how it applies to the CMS audit Discuss two audit experiences 2

3 CMS PACE Conference July 8, 2016 Goal in restructuring PACE audit: Make PACE audits more outcomes-based Focus on access and the participant experience Reduce the administrative burden of PACE organizations Drive improvements in the quality of care for participants 3

4 Outcome Focused Audits Measuring a clinical outcome against well-defined standards set on the principles of evidence-based medicine in order to identify the changes needed to improve the quality of care. Purpose is to highlight the discrepancies between actual practice and standard in order to identify the changes needed to improve the quality of care. Improvements Monitor and Maintenance Data Analysis and Implementation of Changes Determine Audit Focus Data Collection Set Criteria and Standards 4

5 Audit Elements Audit Elements (with Naming Conventions) Service Delivery Requests, Appeals and Grievances (SDAG) Did the PO appropriately process service delivery requests, appeals and grievances? Clinical Appropriateness and Care Planning (CPAP) Did the PO develop and document an appropriate plan of care for the participants? Personnel Records (PER) Do personnel have appropriate licensure, were OIG exclusions checks performed, were background checks completed, evidence of competency evaluation, health records. Onsite Review (ON) Observe 3 to 5 participants (1 who receives care from home and one who receives care at the center), transportation vehicle and emergency equipment. Quality Assessment (QA) Did the PO develop and/ or implement an effective, data driven quality assessment and performance improvement program? Did the PO ensure that the appropriate staff were involved in the development and implementation of QAPI activities? The PACE Audit Process and Data Request Document and all Attachments can be found: Audits/PACE_Audits.html 5

6 Pre-Audit Document Submissions Pre-Audit Disclosed Issues of Non-Compliance PO to provide a list of all disclosed issues of non-compliance that are relevant to the audit elements. Use Excel template (Pre-Audit Issue Summary) provided by CMS Attachment III included with Audit Process and Data Request protocol sent 4/11/2017 Disclosed issue: one that is disclosed to CMS prior to the receipt of the audit engagement letter. 6

7 Pre-Audit Document Submissions Pre-Audit Universe uploads to HPMS Requires specific naming conventions of documents as specified in Appendix N (sent to PO through HPMS after audit engagement letter) SDAG (Service Delivery Requests, Appeal, and Grievance) 1. [PO Name]-[SDAG]-[SDR]--[Universe]-[Version Number] (e.g. OnLok-SDAG-SDR Universe-Version 1) 2. [PO Name]-[SDAG]-[AR]-[Universe]-[Version Number] 3. [PO Name]-[SDAG]-[GR]-[Universe]-[Version Number] CPAP (Clinical Appropriateness and Care Planning) 1. [PO Name]-[CPAP]-[LOPMR]-[Universe]-[Version Number] 2. [PO Name]-[CPAP]-[OCU]-[Universe]-[Version Number] PER (Personnel Records) 1. [PO Name]-[PER]-[LOP]-[Universe]-[Version Number] ON (Onsite Element) No universes will be submitted for this element. Participants will be selected from the CACP list of participants. QA (Quality Assessment) 1. [PO Name]-[QA]-[QAIR]-[Universe]-[Version Number] 7

8 Pre-Audit Universe Questions Grid Upload to HPMS Pre-Audit Document Submissions Use Excel template provided by CMS (PO Questions for CMS) Appendix V sent to PO through HPMS after audit engagement letter Naming convention required [PO Name]-[Questions for CMS]-[Date] Question # Element 1 2 Universe/Table / Record Layout (ifapplicable) PACE Organization (PO) Questions CMS ' Response (e.g. OnLok-Questions for CMS xlsx) 8

9 Pre-Audit Document Submissions PACE Supplemental Questions Attachment II provided with Audit Process and Data Request protocol sent 4/11/2017 Grievance information Emergency medications readily available Emergency and disaster preparedness training Staff vaccinations Driver communication EMR information (access remotely?) Service delivery request definition and policy 9

10 Responding to Documentation Requests During the Audit Sample Case Supporting Documentation Uploads to HPMS PO must upload all sample case supporting documentation requested during the audit to HPMS by selecting: Naming conventions and instructions detailed in Appendix N 10

11 Audit Findings and Corrective Action CMS will determine if each condition cited is: An Observation 0 points Corrective Action Required (CAR) 1 point Immediate Corrective Action Required (ICAR) 2 points All points related to CARs and ICARs will be added then divided by the number of audit elements (5 audit elements) tested to determine the PO s overall PACE audit score. 11

12 Development of the NPA Audit Materials Began with an initiative involving MI PACE programs. Through the NPA Regulatory Compliance Quality Subcommittee, an Audit Task Force was developed with participants from each of the CMS regions. Purpose of developing the audit materials: Assist POs in collecting and submitting data universes required for revised CMS audits beginning 2017; Support POs compliance efforts and ability to identify compliance issues in real time and in advance of audits; Support POs efforts in identifying opportunities for system improvements resulting from analyses of the data universes; Identify where the data universe elements overlap with HPMS PACE Quality Data Level I reporting requirement; Assist EHR vendors to understand the audit process and related data requirements; and Support CMS efforts to assure consistency in audit practices. NPA Operational Guide should be used concurrently with CMS's Programs of All-Inclusive Care for the Elderly (PACE) Audit Process and Data Request document issued April 11, 2017 Although CMS has responded to specific questions related to the templates for the audit data universes, the templates, risk assessment tools and the operational guide referenced in this presentation have not been reviewed or approved by CMS. NPA disclaims all liability with respect to these materials. Members use them at their discretion.

13 Audit Data Universe Record Layout Templates The 7 data universes are related to the 5 audit elements: 1. Service Delivery Requests, Appeals and Grievances; 2. Clinical Appropriateness and Care Planning; 3. Quality Assessment; 4. Personnel Records; and 5. Onsite Review 7 record layouts to be used in providing the data universes to CMS: 1. Service Delivery Requests (SDR); 2. Appeal Requests (AR); 3. Grievance Requests (GR); 4. List of Personnel (LOP); 5. List of Participant Medical Records (LOPMR); 6. Quality Assessment Initiatives Records (QAIR); and 7. On-call Universe (OCU) The NPA Record Layouts, Risk Assessment, Opertaional Guide, and recent recorded webinar may be found: 13

14 Audit Data Universe Record Layout Templates The 7 record layout templates have the following features: For ease of use, the templates include the description of each data element and the number of characters allowed within each field. Additional reference information for POs consideration (e.g. definitions for subjective data, list of dementia diagnoses that correspond with HCC51 and HCC52, etc.). Dropdown responses for many data fields to facilitate data entry. The Service Delivery Requests, Appeal Requests, and Grievance Requests templates include an analytics function that identifies potential compliance problems. The Appeal and Grievance Requests templates include HPMS PACE Quality Data Level I to avoid maintaining similar data in multiple places. Data integrity functions provided by CMS to ensure the data entered are consistent with CMS specifications. Password: 2017Audit 14

15 Risk Assessment Tools To assure ongoing compliance with critical PACE regulatory requirements and to assist POs in assessing their compliance in the 5 audit areas, the following 5 Risk Assessment tools were created: Service Delivery Requests Risk Assessment Appeal Requests Risk Assessment Grievance Requests Risk Assessment Clinical Appropriateness and Care Planning Risk Assessment Personnel Records Risk Assessment 15

16 Risk Assessment Tools Each Risk Assessment exists within an Excel workbook consisting of an Audit Totals worksheet and 20 numbered spreadsheets. Each of the 20 numbered spreadsheets refers to an individual audit observation (i.e. a service delivery request, an appeal, a grievance, a participant medical record, or a personnel record). After completing a workbook for a probe sample of 20 observations (random or targeted), the Audit Totals worksheet will help to identify areas of overall compliance/noncompliance. Each risk assessment tool contains a set of compliance standards with a corresponding reference to the applicable PACE regulation. Each audit observation requires a scoring mechanism and provides a space to make comments specific to noncompliance observed. 16

17 Impact Analysis Impact Analysis: identifies who was subjected to and in what ways an issue of non-compliance effected the outcome (i.e. identifying the consequences of non-compliance). 15 CMS templates provided with Audit Process and Data Request protocol sent 4/11/2017 Appeal template Grievance template Personnel template Root cause template Service delivery template 10 Clinical appropriateness templates PO must upload all IAs requested during the audit through HPMS Naming conventions and instructions provided in Appendix N (sent to PO through HPMS after audit engagement letter) 17

18 Tracer Methodology Tracer methodology uses organizational information to follow the experience of care, treatment, or services. Allows for the identification of performance issues in one or more steps of a process or interfaces between processes. Individual Tracers (participant focused) Designed to trace the care experience of a participant in the PACE program. Analyzes the PO s system of providing care, treatment or services using actual participants to assess compliance to standards. Participants selected are typically high risk or medically complex System Tracers (process focused) Trace a process or system within the PO (use individual tracer information). Evaluates the system or process, integration of processes, coordination and communication among disciplines and departments within the system/process. Relies upon the use of quality data in performance improvement. 18

19 Tracer Methodology Involves talking with multiple staff, the participant, and caregivers to learn details about the individual experience. Identify gaps or risk points that could affect quality or safety of care. Learn from individuals directly involved in providing or receiving services about how the process actually works. Evaluate the following: Compliance with standards and evidence based principles. Consistent adherence to policy and implementation of procedures. Communication within and between departments, disciplines, and services/providers. Staff competency for assignments and workload capacity. The physical environment. 19

20 Purpose of Tracers Retrospective Learn more about why a process didn t work or was successful. Prospective Evaluate a process identified as problematic, determine current practice around new regulatory standards, evaluate high risk participants or processes with poor outcomes. 20

21 How to Apply a Tracer What would you like to know more about in your program? What worries you? What keeps you awake at night? What does your data show as potentially problematic? Clinical outcomes Grievances PAC feedback Contracted provider feedback 21

22 Assemble the team determine who should be on the team related to skills, experience, expertise, etc. Assure objectivity. Planning Tracers Identify a team leader to manage the process. Provide the necessary guidance and training for tracer team. Communicate with leadership and personnel. Determine the goal of the tracer: Is it driven by a level II or significant event? Confirm practices of key policies and systems? Identify key practices that increase the success or effectiveness of a process? Preparing for strategic program growth or development? Evaluating outcome of recent performance improvement efforts? 22

23 Performing the Tracer Identify the pool of applicable participants and select participants for tracer Random or targeted selection Trace processes of care not clinical appropriateness Review applicable policies and procedures Review applicable standards, regulations, evidence based practices, etc. Create tracer tool to ensure interrater reliability and standard application of observations and interviews similar to the audit risk assessments. Provides a means of documenting the process. 23

24 Participant Name Date grievance was made Date grievance was resolved Creating a Tracer Tool A B (b) (b) Universe Compliance Standard Grievance Requests A PO must determine the timeframe for resolving grievances in their internal policies and procedures Scoring Key 0 = Noncompliant 1 = Partial Compliance 2 = Full Compliance Blank = Not Applicable Score Comments (Required for any score of Possible Actual 1 or0): Upon enrollment, was the participant given written information regarding the grievance process? 0 Was the participant given written information regarding the grievance process annually after enrollment? 0 C (c)( Is there documentation showing that the grievance was resolved timely 3) and consistent with the program's policy? (If the response is "2", skip question D. 0 D N/A If no, was the root cause determined and addressed? 0 E (c)( Is the participant's grievance documented and does documentation 2) show that all issues were addressed? 0 F (e) Is there documentation showing that the participant was notified of the grievance outcome? 0 G (d) Is there documentation showing that the program continued to furnish all required services to the participant during the grievance process? 0 Total

25 Performing the Tracer Interview staff involved in the process you are tracing Maintain an open tone Listen attentively Restate and clarify responses Ask open ended questions Interview staff directly involved in the process not the manager All interview questions and responses should be documented All interviewees should be asked the same questions Interview applicable participants Review medical records Debrief as a tracer team and review findings Organize and analyze and summarize findings Communicate findings to leadership and staff Develop and implement improvement plans 25

26 Questions Questions before we transition to the discussion of audit experience and lessons? 26