Quality Assessment & Improvement (QA&I) Process Cycle 1 Year 2 ( ) Questions and Answers

Transcription

1 Quality Assessment & Improvement (QA&I) Process Cycle 1 Year 2 ( ) Contents: GENERAL PROCESS QUESTIONS... 1 GENERAL SELF-ASSESSMENT QUESTIONS... 1 AE SPECIFIC QUESTIONS... 3 AE General Questions... 3 AE Self-Assessments... 3 AE Onsite Review of Providers... 3 AE Questions Tool... 4 SCO SPECIFIC QUESTIONS... 5 SCO General Questions... 5 SCO Self-Assessment... 5 SCO Questions Tool... 5 PROVIDER SPECIFIC QUESTIONS... 6 Provider General Questions... 6 Provider Self-Assessment... 6 Provider Questions Tool... 7 Quality Management Plan Questions... 11

2 GENERAL PROCESS QUESTIONS 1. Our agency received an onsite review in Cycle 1 Year 1 but we were contacted about scheduling an interview for an individual we serve. 2. How do I provide or update the primary and secondary contacts for the QA&I process? QA&I Individual interviews are offered to all individuals in the core sample which is based on the Administrative Entity an individual receives support in. This does not mean that the Provider of supports will receive another onsite review. Reference ODP Announcement for instructions on updating contacts and the location of the contact form. 3. What tasks are required for the onsite review? Does the entity complete file reviews and attempt to remediate or wait to hear from the onsite team? Remediation is not completed until after the onsite review. Reviewing the QA&I Process Document that was just updated to MyODP is recommended. It outlines the steps of the process. GENERAL SELF-ASSESSMENT QUESTIONS 4. When are self-assessments due for Self-assessments are due by August 31 st. Cycle 1 Year 2? 5. If I have a question that needs remediation, do I mark the appropriate remediation action that I took or do I need to do all of the remediations listed? 6. How are responses to be entered into QuestionPro? I see the requirement that they be entered into QuestionPro within 7 days of the interview. QuestionPro requires that we complete the questions in sequential order and cannot skip ahead to certain portions. Is there a separate link for entering responses to the self-assessment interviews? Choose the remediation option that was completed. QuestionPro entries for the self-assessment have to be completed by 08/31 for your entity. There is a QA&I Review Spreadsheet for all entities posted on MyODP. It will help answer all of the questions prior to QuestionPro entry. Using the QA&I review spreadsheet will allow you to work on answering all questions in stages and then transferring the answers into QuestionPro. Completing individual interviews are optional during the self-assessment. Providers who choose to complete individual interviews for the self-assessment portion are only required to use the QA&I Interview Questions Tool, a separate link for entry into QuestionPro will not be given. 1

3 7. I m trying to add names to the QA&I Review Spreadsheet and it says the cells are locked. The names and MCI numbers can be added to the cells are boxed in red in the picture below. 8. When can we expect to receive our sample? 9. Does the self-assessment have to be electronically filled out? For self-assessment, all entities will choose their sample which will include 1% with a minimum of 5 and a maximum of 10 records. These will include a crosssection of individuals served, funding/program types, and locations and types of services. For onsite, entities will receive the sample from their Regional QA&I Coordinator, or AE for Providers, two weeks prior to the onsite. The self-assessment consists of two parts. You must complete the QA&I Review Spreadsheet that is available on MyODP. Additionally, you must submit the results of your work electronically in QuestionPro. (You should have received the link for QuestionPro on 7/1). All entities getting an onsite must submit the completed QA&I Review Spreadsheet to the appropriate person (ODP Regional Coordinators for AEs and SCO and the Assigned AEs for Provider). If you are NOT scheduled this year, no submission is required. 10. When submitting the QM plan, should we submit the plan document and the action plan document or just the plan? 11. Can an entity potentially have 2 separate samples one for the record review and one for the interview? The plan and action steps. No. During the self-assessment review, if an entity chooses to complete individual interviews, those interviews should be completed with individuals from the selected sample and not a different set of individuals. 2

4 AE SPECIFIC QUESTIONS AE General Questions 12. AE Self-Assessments 13. AE Onsite Review of Providers 14. When will the list of Assigned AEs for Providers be posted on the MyODP website? A list of all entities who are receiving an onsite review will be posted on MyODP by August 1 st. 15. Will the entrance and exit agendas be posted soon? 16. The CAP template posted to MyODP is blank but last year the Applicable Requirement and Applicable Section were completed. Will the CAP in MyODP be updated? They will be posted soon. Notification of posting will be sent out. This is being worked on and will be posted soon. Notification of posting will be sent out. 3

5 AE Questions Tool 17. Q12 The QA&I Review Spreadsheet Answer "Yes", "No" or "NA" to the 5 criteria ( ) and then the answer is showing FALSE. for Q 12 will populate. The answer is listed as "FALSE" until all 5 criteria are 18. Q39 States the individual was newly enrolled in the last fiscal year does this also apply to an individual who changed waivers or strictly an individual who is being enrolled in a waiver for the first time? Same question applies to individuals that may have gone into Reserve Capacity due to an extended stay in a hospital/rehab facility. answered. Newly enrolled are not people who transfer from one waiver to another or when they come off reserved capacity. 4

6 SCO SPECIFIC QUESTIONS SCO General Questions 19. SCO Self-Assessment 20. For the desk review, are we to be using the names that were used for the QA&I Individual Interview Presurvey? Does the SCO and AE agree upon names? Or does ODP send us the 10 they picked from the presurveyed? No, we ask that you choose a different sample outside of the list of individuals identified for interviews. All entities choose their own sample for selfassessments. No agreement or approval is needed. SCO Questions Tool 21. Can you provide clarification on what ODP is looking for on Question #10 on the self-review? Is a statement of what we are doing sufficient for a Yes? This is an exploratory question. Meaning not scored just to get an idea of what current processes and policies you have in place to collaborate with OVR. 22. Q54 How would I score for any individuals who have gestural communication? The answer is based on how the SC communicates with the individual. If the person communicates via gestures and no additional support is needed mark NA. If the person needs additional support and all options were explored mark Yes. I would say you mark no if there is a need for communication assistance and no further options were explored. 5

7 PROVIDER SPECIFIC QUESTIONS Provider General Questions 23. Provider Self-Assessment 24. After completing QuestionPro selfassessment, if I m getting an onsite review this year, I should send the completed QA&I Provider Review Spreadsheet to my AE? After that, because it s an onsite year, I should wait to hear from my Assigned AE for a date and a list of individuals for a new sample? Yes, you must send the completed QA&I Provider Review Spreadsheet to your Assigned AE as well as forward the response from QuestionPro with your self-assessment entry. The AE will then contact you to schedule the onsite visit and provide you with the names of individuals they will be reviewing. 25. Training requirements for a Provider (a) states that a provider s training should consist of "Department policy on intellectual disability principles and values." Is there an ODP policy specific to that or is the Provider responsible for creating their own policy? 26. Should we answer questions only for services that we provide, or do we need to answer the questions for all services we are qualified to provide? 27. If we aren t getting an onsite this year we do not need to send any documentation upon completion of the self-assessment? Your agency is responsible for creating your own training curriculum based on the guidance put out by the Department s Policy. It is recommended to use the Everyday Lives document to guide your training. The Data and Policy questions are agency specific, if you have been determined eligible or qualified to provide a service the question applies. The individual record review questions have a N/A option for you to select when the question does not apply. The requirement is that you complete the self-assessment process and forward the confirmation page from your entry into QuestionPro to the AE. The spreadsheet and any other documentation used to complete the self-assessment is required to be kept and provided only if requested. 6

8 28. If an agency is currently the Provider of a number of different services through ODP, ALL services would have their data reported within the one self-assessment for that agency? If your agency has multiple MPI numbers, each MPI # is required to submit a separate self-assessment. The Provider Tool has questions that encompass the different services, so different entries are not needed for each service. The provider questions have N/A options so that if your agency does not render the service you have an option to select. 29. We understand that we must audit 1% with a minimum of 5 and a maximum of 10 records as part of our self-evaluation of performance, but I wanted to check and see if there were a total amount of Staff members that we will need to audit as part of the self-evaluation? 30. We are unable to enter numbers (applicable and verified) into as it indicates the cell is protected and we need a password in order to unprotect them. The total number of staff that have to be reviewed as part of your selfassessment is dependent on the question in the self-assessment tool. The guideline for each question provides clarity. Instructions on how to answer Q42-67 are included in the How To tab on the spreadsheet. Provider Questions Tool 31. In the Person-Centered Planning sections, all questions refer to the sample individuals only? A few questions are unclear and we were unsure if they apply across the board or only to the selected sample individuals. Review the Spreadsheet Column B Question Type. The Question Type Data & Policy are those questions which refer to the entire agency / all provider sites. The Question Type Record Review are those questions which only refer to the sample records. Also, on the spreadsheet, if the cells I through U are black, they are not record review questions. The guidance on Tab 3 of the Provider QA&I Review Spreadsheet may also be of help. 32. Q13 We have a policy regarding freedom of choice and access but there is no specific mention of access to food. However, we do not service anyone with a restrictive procedure in place. Do we need to add access to food to the policy? The policy should be updated to include all required elements. 7

9 33. Q16 - Says to mark N/A if the Provider does not provide Behavioral Support Services. Should this question be reviewed if they provide residential services, since they are bundled now? This question should be reviewed for the Provider with the Behavior Supports authorization regardless of where the individual lives. 34. Qs Can you please advise whether these questions pertain to all provider sites or only the sites with sample consumers? 35. Qs What about people who leave our service and go into nursing homes for skilled care or hospice? 36. Q 33 This question says All staff who work directly with the individuals in the sample. Does this mean all staff during the training year or all staff at a given point of time? 37. Qs 33 and 34 - Can you please elaborate on Mark NA if the training occurs at a date later than the review period. I understand the training year may differ from provider to Provider, but isn t the expectation that all staff should be trained on this within the last year from the onsite date? So how would that ever fall later than the review period? 38. Qs 34, 38, 39, 40 Guidance states This number should not exceed ten direct support professionals. Is this referring to 10 per individual in the sample, or 10 total staff? 39. Qs and These autopopulate Yes on the spreadsheet and then asks for the number of staff. Review the Spreadsheet Column B Question Type. The Question Type Data & Policy are those questions which refer to the entire agency / all provider sites. The Question Type Record Review are those questions which only refer to the sample records. Also, on the spreadsheet, if the cells I through U are black, they are not record review questions. The guidance on Tab 3 of the Provider QA&I Review Spreadsheet may also be of help. The source document for these questions is 55 Pa Code Chapter 51 Section 51.31, which specifies willing and qualified provider so these questions apply when individual transitions to a new ODP Provider. All staff that work with the individuals in the selected sample during the 12 months must be reviewed for Q 33. This question is not limited to 10 staff because of the need for all staff to have information about recognizing and reporting incidents. The mark NA language was added this year due to feedback received from internal staff and external stakeholders to address times when an annual training may be scheduled to take place after the review period. For instance, if a training is usually done in December of every year and the AE reviews the Provider in September a staff may not have received the training yet because it is scheduled for December. So, a new hire staff may not have received the training yet. In regards to training during orientation, as of right now, there aren t any questions in the Provider Tool regarding new hire staff and the training they receive at orientation. This is referring to 10 total staff members. If there are 10 individuals in the sample, the reviewer should review at least one staff member for each individual not to exceed 10. For example, in a sample of 10 individuals, if an individual has 2 staff, only one staff person needs to be included. This is the way the spreadsheet was created. The number of staff reviewed and the number of staff verified needs to be entered, if the numbers don t match it will change to N. 40. Qs and Some questions limit the number of staff but not all. Correct, not all of the questions are limited to 10 staff members. Questions that are limited to 10 staff members are clearly identified as such. If there is no statement about being 10 staff members only, it should be answered based upon all applicable staff members. 8

10 41. Qs and Should we limit the review to the staff who work with our sample for all the questions? 42. Q 34 Please explain why this question is limited to 10 direct support professionals and the other questions do not include the same limit. 43. Qs 35 and 36 - CPS training- one remediation option 35/36b is to void claims. Should we expect all Providers to void claims if the training was not completed, in addition to having staff complete the training moving forward? Or can they choose one or the other? 44. Qs 35 and 36 - CPS training - the ODP CPS training Community Participation Support for Direct Support Professionals should be completed by Program Specialists and Supervisors, for all agencies qualified for CPS, even if there is no sample/ authorizations, correct? 45. Q 41 - All administrative staff receive deaf services training- I see the definition for who is an administrative staff, but can you please provide guidance on how to determine who exactly is involved in the provision of services to deaf participants? Can this be a conversation with the provider to get clarification? This will be complicated for large agencies in multiple service systems. Would we look to see if the hospital owner, CEO, etc. received the training, or is it enough if the day program director completed it (along with DSPs completing the DSP training)? No, just like the limitation of 10 staff members, the questions should only be limited to the sample when the guidance indicates that. The language actually appears in several questions, specifically, #34, 38, 39 and 40. For questions where is does not appear, it is either a policy question, like #40 and #37, or does not apply, like #35 and 36 where we didn t want to limit the sample given the newness of CPS. During last year, we didn t limit the sample. Consequently, after Year 1, during the comment period, we heard that a limit on the sample would be appreciated. The Provider should be voiding the claim(s) and are in the process of obtaining the training certification for staff. The first remediation option of voiding the claim should be selected for anyone who did not get training completed by 07/01/18 and is voiding claims with the expectation that they then obtain the training certification. The waiver says All Staff need to complete the training by 07/01/2018 or within 60 days of hire. If they register to provide the service, they have to follow all qualifications as if they were providing the service. This is a question where ODP expects management, directors and executives to complete the deaf services training in order to serve people with ID who are deaf. If they oversee a department that serves individuals with ID then the administrative staff need to complete the training. In addition, any staff that would have interaction with individuals who are deaf (for example clerical staff who might answer a phone call from an individual who is deaf) need to complete the training. 9

11 46. Qs individuals who are deaf - Are these related to the whole agency or just individuals in the sample? 47. Is this for the individuals in the sample only? Or should I pull all of my Harry M individuals as well? 48. Qs employment - Are these related to the whole agency or just individuals in the sample? 49. Q 58 - There is no time frame listed for this question. Are we to look at the entire 12-month period of daily service notes, or is it the previous 3 months from the date of the onsite? These questions are specific to the individuals in the sample selected. This is more apparent when you utilize the Provider review spreadsheet to answer the questions. These questions only apply to individuals in the selected sample. These questions are specific to the individuals in the sample selected. This is more apparent when you utilize the Provider review spreadsheet. All questions, except those with a specified timeframe, should use the 12-month period. 10

12 Quality Management Plan Questions 50. How often must AEs, SCOs, and Providers update QM Plans and accompanying Action Plan? ODP requires AEs, SCOs, and Providers to identify opportunities for improvement based on their performance data; choose priority areas to work on; develop goals, desired outcomes, target objectives and performance measures using QM Plans; and write action steps to achieve improvement in accompanying Action Plans. Current Chapter 51 regulations require SCOs and Providers to update QM Plans at least every two years, while Chapter 6100 regulations, when promulgated, will require SCOs and Providers to update QM Plans at least every three years. In alignment with the QA&I cycle and in anticipation of the promulgation of the 6100 regulations, ODP is enforcing the requirement for QM plan updates occur at a minimum of every 3 years. As ODP trains during QM Certification Classes, a QM Plan may remain relevant over a period of years but should be reviewed at the beginning of each fiscal year to determine if any updates are needed at that point in time. For example, based on performance during the previous fiscal year, a target objective may need to be revised, or responsible parties in the organization may have changed. As ODP QM Staff explains further during QM Certification Classes, Action Plans that support QM plans are living documents that should be reviewed and updated during the course of each fiscal year as strategies are implemented and the results are evaluated--the Check step in the Plan-Do-Check-Act or PDCA Cycle for Improvement. Action steps may need to be revised or added depending on progress made and evaluated monthly and quarterly using data throughout each year. 51. What are ODP's requirements for stakeholders to attend QM Certification Classes? ODP encourages all stakeholders--aes, SCOs, and Providers--to send staff involved in the QA&I Process to QM Certification Classes. Achieving QM Certification enables staff to apply quality management principles, practices, and tools while interacting and networking with other stakeholders during class. Participants are then able to take this learning back to their respective locations and be in a much better position to use the quality tools in the interest of people we support. ODP requires that at least one member of the AE Review Team that monitors Providers using QA&I Process becomes QM Certified by December 31, In order to track the completion of this requirement, ODP uses the list of Primary and Secondary Contacts for QA&I submitted by AEs. If an AE wishes to designate staff other than Primary or Secondary Contacts who are on the QA&I Process Review Team to attend class and meet this requirement, the AE should make known to ODP the name of the AE staff person who is designated. As stated- 11

13 above, ODP encourages stakeholders to send staff to become QM Certified. ODP offers multiple classes each Spring and Fall in order to partner with stakeholders to spread continuous quality improvement throughout the system. 12