ODP ACADEMY For Administrative Entities …Changing Practices, Unchanged Values

1. Pennsylvania Department of Public Welfare Office of Mental Retardation ODP ACADEMY For Administrative Entities …Changing Practices, Unchanged Values Administrative Entity Oversight Monitoring Process

2. ODP Academy • Overview of the new AE Oversight Monitoring Process • Development & Implementation • Structure of the Tool • Elements of the Tool ODP Academy: AE Oversight March 2007

3. Why Develop a New Administrative Entity Oversight Monitoring Process? In order to meet CMS assurances, ODP needs to: • Retain ultimate authority and responsibility for the operation of the waivers • Exercise oversight over the performance of waiver functions by other agencies ODP Academy: AE Oversight March 2007

4. How Did ODP Develop the Process? • A core group of ODP staff detailed the process using input received from AEs, the Regions, and Central Office staff. • ODP Academy sessions are then used to relay information ODP Academy: AE Oversight March 2007

5. How Did ODP Develop the Process? • ODP developed the AE Monitoring tool using requirements found in: • The Operating Agreement • CMS Assurances • Bulletins • ODP Monitoring of Counties (OMOC) • ODP Initiatives ODP Academy: AE Oversight March 2007

6. How Did ODP Develop the Process? • Considering the AE’s capacity to meet the new business practices, the AE Monitoring tool was reduced to the following items: • Operating Agreement (OA) requirements • CMS Assurances (CMS-A) • ODP Initiatives • Data Integrity ODP Academy: AE Oversight March 2007

7. What’s Different • The OMOC Process was valid from 2002 until 3/31/07. • With the approval of the Consolidated Waiver the AE Oversight Monitoring Process begins 4/1/07. • Continuous systemic review • Greater focus on quality • Accessibility to and utilization of a wider variety of data sources ODP Academy: AE Oversight March 2007

8. Continuous Evidence Based Oversight • Monthly reports sent to Administrative Entity • Reports due to Regional Office every three months • Regional and AE risk management activities • Quarterly reports due to CMS regarding the CMS assurances ODP Academy: AE Oversight March 2007

9. How Will ODP Implement the New AE Oversight Process? • The Regions will develop monitoring schedules • Regional Teams will share oversight responsibilities Teamwork ODP Academy: AE Oversight March 2007

10. AE OVERSIGHT MONITORING LEAD • Each region has identified an AE Oversight Monitoring Process lead. • The Regional Lead will: • Serve as the Regional contact for the AE Oversight Monitoring Process • Coordinate the AE Oversight Monitoring Process to ensure consistency with the Statewide standards. • Provide technical assistance to Regional and AE staff • Four regional leads and the central office point person will be the keepers of the process ODP Academy: AE Oversight March 2007

11. Where and How Will Monitoring be Completed? • Regional reports reviews • Home and Community Services Information System (HCSIS) • Onsite • Reviews • Interviews ODP Academy: AE Oversight March 2007

12. How Will Monitoring be Conducted? • 90 days prior to onsite review, Regional Teams will: • Pull all reports and samples • Share reports with AEs • 60 days prior to onsite review, Regional Teams will review samples and reports using information from: • Regional Offices • HCSIS ODP Academy: AE Oversight March 2007

13. How Will Monitoring be Conducted? • Two weeks prior to onsite reviews, Regional Teams will provide AEs with names of individuals in the sample • In order to initiate the new AE Oversight Process, these time frames will be shortened during the first year (9 month vs. 12 month). ODP Academy: AE Oversight March 2007

14. How Will Monitoring be Conducted? • At first, ODP Regional Teams will record and tally their findings off-line • Once the process becomes finalized, HCSIS will be used to record findings ODP Academy: AE Oversight March 2007

15. How Will Scores be Determined? • 100% compliance will be required for some items • A Compliance Scale will be used for other items • 90 to 100% = Fully Compliant • 80 to 89% = Mostly Compliant • 70 to 79% = Somewhat Compliant • Below 70% = Noncompliant • Any score below 90% will require a Corrective Action Plan ODP Academy: AE Oversight March 2007

16. What Will Happen After Onsite Reviews are Completed? • Regional team members will collaborate to complete summary reports • Summary reports will be: • Shared with Regional and Central Office staff within 45 days of review • Approved by Regional Program Manager • Sent to the AEs ODP Academy: AE Oversight March 2007

17. What Will Happen After Onsite Reviews are Completed? • The AE will develop a Corrective Action Plan if needed, based on the findings in the summary reports. • The Corrective Action Plan must be submitted to the Regional Office within 45 calendar days of the receipt of the finding report • Each Regional team will review the AE’s Corrective Action Plan and develop a validation plan ODP Academy: AE Oversight March 2007

18. Structure of the AE Oversight Monitoring Tools • Review of the guidelines, worksheets and scoring tool ODP Academy: AE Oversight March 2007

19. ODP Academy: AE Oversight March 2007

20. ODP Academy: AE Oversight March 2007

21. ODP Academy: AE Oversight March 2007

22. SIX OVERALL ELEMENTS • Quality of Life • Administrative Entity Capacity • Provider Qualifications/Monitoring • Rights • Eligibility/Level of Care • Other Administrative Functions ODP Academy: AE Oversight March 2007

23. Elements of the Oversight Monitoring Process • Requirements are not new • Regions & County/AEs have been responsible for these items for some time ODP Academy: AE Oversight March 2007

24. Quality of Life Issues – Individual Support Plan (ISP) Reviews • Implemented according to time frames in Operating Agreement (OA & CMS-A) • Address all assessed individual needs (OA & CMS-A) • Document Services • Frequency • Amount • Duration • Provider type for each service (OA & CMS-A) • Outcomes relate to preferences and needs (OA & CMS-A) ODP Academy: AE Oversight March 2007

25. Quality of Life Issues – Individual Support Plan (ISP) Reviews • Timeliness of ISP Process (OA & CMS-A) • Updated/revised at least annually or if there is a change in the service need • Team members invited to ISP meetings (OA) • Services authorized prior to receipt of services (OA & CMS-A) ODP Academy: AE Oversight March 2007

26. Quality of Life Issues – Supports Coordination (SC) • Monitoring of individuals according to schedule (OA & CMS-A) • PUNS • Reviewed annually (OA) • Updated accordingly (OA) • Completed for those with unmet need (OA) • Signed and distributed (OA) ODP Academy: AE Oversight March 2007

27. Quality of Life Issues – SC Review - Data Integrity • Mandatory fields completed in HCSIS • Demographics • Eligibility • Enrollment information. • Data integrity is crucial to the process. ODP Academy: AE Oversight March 2007

28. Quality of Life Issues - Quality Management (QM) Requirements • Quality Management/ Quality Implementation (QM/QI) plan written (OA) • QI actions (OA) ODP Academy: AE Oversight March 2007

29. Quality of Life Issues – Incident Management (IM) These items are all in relation to the implementation of the Incident Management bulletin. • Corrective action is implemented (CMS-A) • AE investigates incidents according to Certified Investigation manual (CMS-A) ODP Academy: AE Oversight March 2007

30. Quality of Life Issues – Incident Management (IM) (cont’d) • Appropriate actions are taken within 24 hours of incidents (CMS-A) • Local policies and procedures are in place to implement IM Bulletin (CMS-A) • Semi-annual qualitative reports are issued (CMS-A) ODP Academy: AE Oversight March 2007

31. Quality of Life Issues – Independent Monitoring for Quality (IM4Q) • AE assures providers address considerations (OA) • AE informs IM4Q when action is taken on a consideration (OA) • AE uses sharing process (OA) • AE, with IM4Q, addresses major health and safety concerns (OA) • AE uses IM4Q reports for evaluation and quality improvement (OA) ODP Academy: AE Oversight March 2007

32. ODP Initiatives - Employment • AE documents OVR funding availability (OA) • Initial referral is in individual’s file • HCSIS Functional Level Employment screen is completed • AE follows ODP expected employment practices • Each region has an employment point person ODP Academy: AE Oversight March 2007

33. ODP Initiatives • Lifesharing • AE follows ODP expected Lifesharing practices • Restraint Reduction • AE achieves annual statewide restraint reduction goal ODP Academy: AE Oversight March 2007

34. AE Capacity • ISP completed in HCSIS for everyone receiving ODP services (OA & CMS-A) • AE has a designated PUNS Point Person (OA) • AE has a designated IM4Q Point Person (OA) ODP Academy: AE Oversight March 2007

35. AE Capacity • Bureau of Hearings & Appeals orders are implemented within 30 calendar days (OA & CMS-A) • Provider dispute findings are implemented within calendar 30 days (OA & CMS-A) ODP Academy: AE Oversight March 2007

36. AE Capacity • Designated AE staff register for and participate in ODP Academy (OA) ODP Academy: AE Oversight March 2007

37. AE Capacity • AE has a designated Employment Point Person • AE has a designated Lifesharing Point Person ODP Academy: AE Oversight March 2007

38. Provider Monitoring • All licensed/certified and non-licensed providers meet waiver qualification standards (OA & CMS-A) ODP Academy: AE Oversight March 2007

39. Provider Monitoring • All Waiver providers, except unlicensed individuals working through Vender Fiscal/Employment Agent, Intermediary Service Organization (VF/EA ISO), have a signed MA Agreement (OA) • AE Waiver Provider contract is signed by all providers, except unlicensed individuals working through VF/EA ISO (OA) ODP Academy: AE Oversight March 2007

40. Provider Monitoring • Provider training is conducted according to state and waiver requirements (CMS-A) • All providers meet licensing and certification standards (OA & CMS-A) ODP Academy: AE Oversight March 2007

41. Rights – Due Process • Individuals/families are notified of waiver eligibility appeal rights (OA) • Notice of due process and appeal rights is provided as required (OA) • Individuals receive required written notice of changes in waiver services (OA) • Denials • Reductions • Terminations ODP Academy: AE Oversight March 2007

42. Rights – Due Process • AE assists individuals/families to file appeals as needed (OA) • Waiver services under appeal continue as required (OA) ODP Academy: AE Oversight March 2007

43. Rights – Choice • Individuals/families have choice of services (OA & CMS-A) • Individuals/families have choice of providers (OA & CMS-A) ODP Academy: AE Oversight March 2007

44. Rights – Service Review • Service Review findings are implemented within 30 days (OA) ODP Academy: AE Oversight March 2007

45. Eligibility/Level of Care (LOC) • LOC determinations are completed for everyone likely to receive services (OA & CMS-A) • Persons determined to be not qualified for ICF/MR LOC are provided due process as required (OA) • All waiver participants are eligible for ICF/MR LOC (OA) ODP Academy: AE Oversight March 2007

46. Eligibility/Level of Care (LOC) • Qualified Mental Retardation Professionals (QMRP) complete the certification of need consisting of: • Individual/family interview • Social/psychological review • Current medical evaluation (OA & CMS-A) ODP Academy: AE Oversight March 2007

47. Eligibility/Level of Care (LOC) • QMRP’s certification of need is based on standardized adaptive behavior assessment that shows significant limitations in: • Age standards • Three or more areas of major life activity (OA & CMS-A) ODP Academy: AE Oversight March 2007

48. Eligibility/Level of Care (LOC) • LOC re-determinations are completed annually (OA & CMS-A) • County Assistance Office is notified of changes in assets affecting eligibility within 10 days of the change or as required (OA) • Eligibility information is maintained in files (CMS-A) ODP Academy: AE Oversight March 2007

49. Financial Management - General • Waiver funds are used only for eligible services (OA & CMS-A) • Waiver funds are used only for eligible recipients (OA & CMS-A) • Claims are verified for eligibility and authorization (OA & CMS-A) • Payments for waiver services are made only to qualified providers and vendors (OA & CMS-A) ODP Academy: AE Oversight March 2007

50. Financial Management - General • Ineligible services are excluded from Federal Financial Participation (FFP) (OA) • Clean claims are paid within 30 days (OA) • DPW is notified within 10 days of overpayments (OA) • Paid claims do not exceed limits or caps (OA) • Audits are completed as required (OA) ODP Academy: AE Oversight March 2007