Office of Developmental Programs

Transcription

1 Office of Developmental Programs QA&I for HCBS Services PROVIDER SESSION July 19, 2017 Farm Show Complex, Harrisburg PA 7/17/2017 1

2 Self Assessment Opportunity for entities to evaluate their own performance each year The focus is Everyday Lives: Values in Action The self-assessment tool will mirror the QA&I tool Self-assessment will be used to inform and build quality improvement activities for the remainder of the QA&I cycle All entities are expected to remediate issues discovered during the self assessment process 7/17/2017 2

3 Brief Review of Self-Assessment Tools Individual s experience of the system through interviews Provider Tool 49 Questions Focus areas: Quality Improvement; Person Centered Planning, Service Delivery & Outcomes; Health & Safety Example Questions The Provider develops and implements a process that ensures that the QMP is revised and analyzed within the specified timeframes. Staff receive training to meet the needs of the individual they support as identified in the current, approved Individual Support Plan (ISP) before providing services to the individual. If an event occurred requiring the implementation of the back-up, plan, the Provider implemented the individual s back-up plan as designed. 7/17/2017 3

4 AE and SCO Annual Sample AE Selected alphabetically with representation from each region Separate number of individuals selected to capture Level of Care performance SCO Identified based on individuals selected in the core sample The SCO that is authorized in the individual s ISP 7/17/2017 4

5 QA&I Sampling Provider Selection Provider For onsite review, Providers selected using last digit of MPI # New providers will be assigned onsite review AEs conduct the review using their own selection of individuals Provider qualification is aligned with onsite year 7/17/2017 5

6 QA&I Annual Timeline Self Assessments Begin AE& SCO Desk Reviews Begin July 1 Self Assessments Deadline August 1 *(8/31 for 2017) All Onsite Reviews Begin September 1 All Onsite Reviews Completed December 31 Comp Report Responses Complete including Corrective Action & Quality Improvement February 28 Onsite Selections Announced June 15 June 30 ODP Issues Statewide QA&I Report July 15 ODP Notifies AEs of Provider Pool; Provider Desk Reviews Begin August 31 *(9/30 for 2017) ODP Issues Self Assessment Statewide Aggregate Report November 30 Finalize All Desk Reviews January 31 All Comprehensive Reports Issued April 30 All Updated QM Plans are Submitted 7/17/2017 6

7 Annual Timeline Providers All self-assessments begin July 1 and are due on August 1 each year EXCEPTION! Self-assessments are due August 31 for 2017 Dates in timeline are targets for entire process Each Provider will have specific deadlines depending on: 1. Scheduling of the onsite review, and 2. Completion and closure of the QA&I Comprehensive Report 7/17/2017 7

8 Annual Timeline Providers (continued) Comprehensive Report Issued Electronically [30 Days Following Onsite Visit] Entity Responds with Proof of Remediation and PPRs [30 Days Following Comprehensive Report] Closure of Comprehensive Report with Approval of Remediation & PPR [20 Days Following Entity Response] Submission of Evidence for Extended Timeline PPRs QA&I Team Review & Informal Feedback of QM Plan and PPR Update [30 Days of QM Plan Submission] QM Plan Submission & PPR Update [30 Days After Comprehensive Report Closure] ODP Communication that All Improvement is Completed/Acceptable Self Assessment Document of Improvement Impact; QM Plan Adjustment 7/17/2017 8

9 7/17/ QUESTIONS

10 Desk Review Process Providers A review of available documentation by the Assigned AE prior to the onsite review to: inform the overall QA&I process determine focus areas for the onsite review The desk review will use all available data sources Findings from the QA&I desk review may identify areas that will require additional follow-up before or during the onsite review 7/17/

11 QA&I Individual Interviews Providers Individual interviews are considered a critical component of the QA&I process. ODP or its designee will conduct interviews for the sample prior to, during, or after the onsite review. AEs will conduct individual interviews as part of onsite review. Where appropriate, a person familiar with the individual will be asked to assist in the interview. The individual may choose who is present during the interview. There will be a period of the interview where paid supports will not be present. In keeping with person-centered practices, the individual may choose not to participate in the interview or can opt to discuss their experience by phone. Any person conducting an interview must ensure follow-up and reporting, as appropriate, of any issue related to health and safety or service quality. 7/17/

12 Onsite Review Process Providers Onsite visits begin September 1 and are completed by December 31. Assigned AE designation to conduct Provider onsite review is determined by ODP and is the AE with the most individuals authorized with the Provider. By December 31, 2018, at least one member of the AE QA&I team will possess QM Certification Visits will occur over a 2-day period. A confirmation letter of the onsite review will be sent to Providers two weeks prior to the visit. 7/17/

13 Onsite Review Process Providers (continued) Entrance Conference Overview of QA&I Process & Timelines Opportunity for Provider to Share Organizational Overview Onsite Visit Expectations Onsite visit will consist of record reviews, individual interviews and discussions with Provider staff Exit Conference Onsite Review Overall Experience & Impressions Highlights of Best or Promising Practices Highlights of Remediation and Improvement Identified Expectations for Corrective Action and Final QA&I Comprehensive Report 7/17/

14 QA&I Comprehensive Report Providers A written report issued for each reviewed entity in no more than 30 calendar days of the onsite review completion AEs will share a copy of each Provider report with ODP upon finalization and approval of the Corrective Action Plan The compilation of official findings from: Desk review Onsite review Face-to-face interviews with individuals and staff Self-assessments Overall contains positive performance points and opportunities for improvement, not just presentation of raw results 7/17/

15 QA&I Comprehensive Report Providers (continued) Providers will have 30 calendar days to review and respond, including: Evidence of remediation completed within 30 days of discovery, and Plans to Prevent Recurrence Any points of disagreement with the report findings including appropriate evidence justifying the disagreement AEs will close or request further clarification within 20 calendar days of receipt of the Provider s response Providers will have 30 calendar days from the date of closure to submit the QM Plan and/or Action Plan, updated as a result of the QA&I review. Main body of the reports will be posted on MyODP.org 7/17/

16 QA&I Questions Providers Focused more on Everyday Lives: Values in Action Emphasis on gathering information about the individual s experience Questions are more consistent across Providers, SCOs and AEs QuestionPro is the platform for data entry Questions include both scored and non-scored questions. Non-scored questions are identified on the tools. 7/17/

17 QA&I Guidance Providers Question tools all contain guidance for how the question is to be interpreted QA&I Tool also: point to source documents pertaining to each question specify those questions that are considered exploratory 7/17/

18 QA&I Guidance Example Providers Question/Outcome #31 The Provider provides communication assistance as indicated in the ISP. Guidance: For the sample selected, the reviewer determines if the ISP identifies any communication assistance. The reviewer determines if daily documentation and progress notes reflect that the communication assistance identified in the ISP is being provided to the individual. Mark YES if the daily documentation and progress notes reflect how the Provider implemented the communication assistance that was identified in the individual s ISP. Mark NO if the daily documentation and progress notes did not reflect how the Provider implemented the communication assistance or if the Provider did not implement communication assistance as prescribed in the ISP. Mark NA if the ISP does not have any communication assistance identified for the individual. 7/17/

19 Corrective Action Plan Providers A catalog of those instances requiring remediation, as well as a PPR including a QM Plan and/or Action Plan, where necessary. An attachment to the QA&I Comprehensive Report, on an ODP approved template. If the QA&I Comprehensive Report includes instances of not meeting the standard, the entity must remediate each one and develop a PPR, if applicable. Proof of remediation and a Plan to Prevent Recurrence, including where QM Plans and/or Action Plans will be developed, must be submitted within 30 calendar days of receipt of the QA&I Comprehensive Report. 7/17/

20 Remediation Providers Instances in which an entity has not met the standard of a particular QA&I question or series of questions These instances must be corrected, either upon discovery or within 30 days of discovery There will be occasions when remediation must occur immediately due to concerns for health and safety. Otherwise, remediation must occur within 30 days following electronic issuance of the Comprehensive Report by the AE. The instances for remediation will be: Summarized within the QA&I Comprehensive Report Specified in the accompanying Corrective Action Plan 7/17/

21 Remediation Providers (continued) Each entity is required to include in its response to the QA&I Comprehensive Report Proof of remediation already completed, including the date of completion - and/or - A Plan to Prevent Recurrence (PPR) for each instance noted in the Corrective Action Plan Identification of areas in which a QM Plan and/or Action Plan will be developed Any exceptions to completion of remediation within 30 days of discovery must be negotiated with ODP or the AE, as appropriate 7/17/

22 Plans to Prevent Recurrence (PPR) - Providers PPR outlines actions that will be taken to ensure future instances of non-compliance do not occur. A PPR is required when the compliance score for the requirement falls below 86% OR 9 or fewer records were reviewed and there are 2 or more instances of non-compliance. For any PPR activity requiring longer than 3 months to implement, the entity is responsible to provide an update on the progress of such activity(s) within 30 days of the QA&I Comprehensive Report to the AE Onsite Review Team. 7/17/

23 Validation - Providers Providers are responsible for submitting evidence of remediation and implementation of PPRs. ODP or the AE will review and approve all remediation and PPR activities in order to close the QA&I Comprehensive Report. Each year in the self-assessment process, Providers are expected to address the impact of PPR activities completed within the past year. 7/17/

24 Directed Corrective Action Plan (DCAP) - Providers May be required for ongoing engagement with ODP or the AE, as appropriate, until such issues identified in the DCAP are resolved to the satisfaction of the QA&I Review Team. A DCAP through mandatory technical assistance may be required, at a minimum, when: The entity fails to respond to imminent risk for one or more individuals; The entity demonstrates repeated non-compliance in one or more areas; The entity s performance is below 86% for 5 or more designated questions, if the sample is greater than 10; or Performance for one or more designated questions is below 50% performance. 7/17/

25 BREAK 7/17/

26 Quality Improvement & QM Plans 7/17/

27 Quality Improvement & QM Plans - Key Points How QA&I Process enhances and supports ODP s system-wide Quality Strategy Everyday Lives: Values in Action Using QA&I Process and Results to develop QM Plans and Action Plans What s the same? What s new? 7/17/

28 ODP Goals for QA&I Measure progress toward systems improvement based on Everyday Lives: Values in Action ISAC recommendations Gather timely & useable data to manage the ODP system performance Use data to manage the service delivery system with a continuous quality approach Demonstrate AE outcomes with operating agreement Collect data for Waiver performance measures Verify that SCOs and Providers comply with 6100 regulations 7/17/

29 Purpose of Revised QA&I Process Eliminate multi-layered process and unnecessary duplication Create more time to focus on quality improvement and the experience of individuals Desire to move away from hierarchical compliance and remediation toward collaborative partnerships that foster technical assistance and shared learning Improve methods for collecting and using data in a timely way Compliance Quality of the Individual s Experience 7/17/

30 How QA&I Process enhances ODP s Quality Strategy QA&I Questions will inform QM Planning: Tied to Everyday Lives: Values in Action Assuring Effective Communication Promoting Self-Direction, Choice and Control Increasing Employment Supporting Families Promoting Health, Wellness, and Safety Supporting People with Complex Needs Increasing Community Participation Focus on determining the individual s experience with services and supports Emphasize: Person-centered practices Service delivery Health & safety 7/17/

31 How QA&I Process enhances ODP s Quality Strategy QA&I Questions will inform QM Planning: Tied to Everyday Lives: Values in Action Develop and Support Qualified Staff Improve Quality Performance results will assist ODP, AEs, SCOs, and Providers: Determine priorities for improvement Develop baselines and target objectives for QM Plans 7/17/

32 How QA&I Process enhances ODP s Quality Strategy At least one ODP team member will possess QM Certification By December 31, 2018, at least one member of the AE onsite review team will possess ODP QM Certification Entrance Conference offers: Opportunity for entity leadership to share mission, vision, successful and in-process quality improvement projects, discuss challenges and identify areas for technical assistance Exit Conference offers: Highlights of best or promising practices Highlights of remediation and improvement identified Expectations for corrective action, quality improvement, and Final QA&I Comprehensive Report 7/17/

33 QM Planning: What s the same? Design..Discovery..Remediation..Improvement (DDRI) This is where data analysis comes in IMPROVEMENT Improve quality via systemic changes Program DESIGN Plan for and set stage for achieving positive outcomes CONTINUOUS CYCLE DISCOVERY Find positive and negative outcomes in a systematic, timely manner REMEDIATION Address negative outcomes in a timely manner 33

34 QM Planning: What s the same? QM Plan Template Entity Name: Focus Area: Year: Goal Outcome Target Objective Performance Measure/ Data Source/Responsible Person Click on: Quality Management Planning and Implementation Documents 7/17/

35 QM Planning: What s the same? Action Plan Template Entity Name: Desired Outcome: Target Objective: Performance Measure (s): Data Source (s): Responsible Person: Action Item Responsible Person (Name) Focus Area: Target Date Status Completion Date Click on: Quality Management Planning and Implementation Documents 7/17/

36 QM Planning: What s the same? Recommended QM Plan Components: Goals Desired Outcomes Target Objectives and Baselines Performance Measures Data sources used to measure performance Person Responsible for the QM Plan Recommended QM Action Plan Components: Action Item Responsible Person Target Date Status Completion Date 7/17/

37 QM Planning: What s new? Identifying Opportunities for Improvement Choose Focus Areas and Goals considering: ODP s Everyday Lives priorities your mission, role, and the services and supports you offer in light of Everyday Lives priorities input and feedback offered by ODP and/or the AE in identifying systemic opportunities for improvement Everyday Lives Publications support the QM Planning process: Everyday Lives: Values in Action Recommendations, Strategies, and Performance Measures 7/17/

38 QM Planning: What s new? Identifying Opportunities for Improvement QA&I Results will be available to each entity Performance data in areas supported by exploratory questions will support QM Planning Plans to Prevent Recurrence (PPRs) will foster prioritization of focus areas When performance falls below the threshold of 86%, evaluate whether the cause for poor performance represents a systemic problem in need of a quality improvement project supported by a QM Plan and Action Plan Review of QA&I data will allow for development of baselines and realistic target objectives 7/17/

39 QM Planning: What s new? QM Plans will be submitted and reviewed as part of the QA&I Process. If you have a QM Plan and accompanying QM Action Plan already in place and findings from the QA&I Process prompt you to update these documents, Update your existing Action Plan until it s time to develop your new Fiscal Year QM Plan and Action Plan Update your QM Plan and Action Plan to begin July 1 If you discover an area where you need to develop a new QM Plan and accompanying Action Plan, Add a new Focus Area, Goal and Target Objective to the existing QM Plan that will carry you to June 30 th of the following fiscal year Add Action Plan steps to achieve the Target Objective Implement the new work immediately with continuation in the following fiscal year 7/17/

40 QM Planning: What s new? Using the QA&I tool, AEs, SCOs and Providers are expected to conduct a self-assessment of their performance annually to inform and build quality improvement activities, evaluate progress on implementing the QM Plan and determine the effectiveness and impact of action steps. Organizations not slated for onsite QA&I review until years 2 and 3 are expected to use their self-assessment results to prioritize and engage in improvement activities while awaiting the onsite review. It is the intention that AEs, SCOs and Providers will continue to engage in quality improvement activities during the twoyear period between formal QA&I onsite reviews. 7/17/

41 QM Planning: What s new? ODP and AEs will follow up with the entity on progress in implementing QM Plans and provide technical assistance as needed during the course of the QA&I Cycle. Technical assistance by either ODP or AEs will focus on quality improvement. 7/17/

42 QM Planning: What s new? Statewide Reports Self-Assessments Annually, at the completion of the self-assessment process for all entities, ODP will issue an aggregate report of self-assessment results and analysis statewide. This report will be used to inform the QA&I process throughout the year and technical assistance targeted to AEs, SCOs and Providers. Annual QA&I Report Annually, ODP will compile all data collected from the QA&I process into a report that represents statewide performance of AEs, SCOs and Providers and the overall system as it relates to quality of services and supports and person-centered best practices. 7/17/

43 QM Planning: What s new? Requirements for ODP QM Certification At least one ODP team member will possess QM Certification By December 31, 2018, at least one member of the AE onsite review team will possess ODP QM Certification ODP QM Certification Complete prerequisites Application and registration process In-person class: September 13 and 14, 2017 in Ebensburg October 11 and 12, 2017 in Chester County October 31 and November 1, 2017 in Mechanicsburg 7/17/

44 QM Planning: What s new? 7/17/

45 QM Planning: What s new? 7/17/

46 7/17/ QUESTIONS

47 ODP Contact Information ODP QA&I Process Mailbox: 7/17/

48 7/17/ THANK YOU!