Presentation Transcript

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
51. Item 10: As required by Clinical Coverage Policy, there is documentation that coordination of care is occurring between providers involved with the individual. CCPs 8A through 8P (8C 7.2.2 for LIPs) Sample is same 30 service events as in Item 1 Coordination of Care requirements vary per service definition Evidence must be written Common requirements include but are not limited to: case management; coordination with medical, psychiatric or other providers; coordination in crisis or discharge planning; participation in child & family teams If individual does not agree to contacting other providers, refusal must be documented.
52. Item 11: There is evidence that the provider serves as the first responder or has made access to behavioral health crisis services available 24/7/365 either provided directly by the agency or through written agreements. – CCP 8A, 8C 7.4 Sample is same 30 service events as in Item 1 Providing 24/7/365 per service definition Documentation will vary: first responder procedures and staffing logs, written arrangements with other entities for crisis services; notification to individuals of how to access services in a crisis
53. THE FOLLOWING ITEMS, #s 12 & 13 , APPLY ONLY TO 24 HOUR FACILITIES THAT SEE AN INDIVIDUAL FOR MORE THAN 30 DAYS, INCLUDING UNLICENSED AFLS.
54. Protection of Property & Management of Funds
55. Item 12: The agency has a current policy that outlines how the requirements for protecting an individual's property in accordance with 10A NCAC 27F .0104are met. Pre-Site Review: Review policies and procedures to ensure that property is safe from theft, damage, destruction, loss and misplacement. To be completed at LME-MCO. This is a policy review only, but all areas must be covered for this item to be rated as “Met.”
56. Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105. Sample is 1-5 records of individuals whose funds are managed by the agency. If less than 5 individuals in home, review records for all. Review most recent quarterly accounting statement for all records in the sample to ensure they reflect all transactions. (Note - these records may not be kept in the clinical/service record as they contain financial information.) Ensure that each person's money is managed separately from the agency's funds and accounts.
57. Item 13: Quarterly, the individual or LRP is provided with a financial record containing an accurate accounting of deposits, withdrawals, fund status, interest earned, specific expenditures, type, amount and date of disbursements. 10A NCAC 27F .0105CONTINUED There must be an accounting statement for each person which at a minimum summarizes the financial transactions to rate this item “Met.” Additionally, 85% must be achieved across the sample (4 of 5 records met) for this item to be scored as met.
58. Medication Review
59. Item 14: Medications are stored appropriately, including separate storage for each service recipient, separately for each type of use, in refrigerator, behind secure lock, and secured for individuals self-administering. 10A NCAC 27G .0209. Sample is 5 records from individuals who receive medication from the agency. Inspect medication storage area to ensure that medications are stored appropriately, and consistent with the requirements in the rule. Medication storage may include separate Ziploc bags, boxes, or other containers, as long as the labels with the person's name remain intact for each medication. Any medication samples received from the physician must be stored in the same way as other medications. 100% must be achieved for each item for the record to be rated “Met”.
60. Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender.10A NCAC 27G .0209. Sample is same 5 records from item 14. Review the record to ensure there is a written order that has been signed or countersigned and dated by the responsible physician/physician extender. Enter the number of medications for both prescribed and over the counter medications as the number of possible items on the Medication Review Sheet.
61. Item 15: All orders for medication are signed or countersigned and dated by the prescribing physician/physician extender.10A NCAC 27G .0209CONTINUED If an individual receives psychotropic drugs, his/her drug regimen must be reviewed by a pharmacist or physician at least every 6 months. 100% compliance must be achieved for this item to be rated “Met” (per individual).
62. Item 16: The medication label matches the physician's order.10A 27G .0209. Sample is same 5 records from item 14. Ensure label on bottles/packaging matches the physician's order. In some cases, the brand name of the drug will have been dispensed, in other generic per order. 100% must be achieved for each item for the record to be rated as “Met.”
63. Item 17: The medication listed on the MAR matches the physician's order.10A 27G .0209. Sample is same 5 records from item 14. Ensure that each physician's order is listed within the MAR. Any medication samples received from the physician are recorded in the same way on the MAR. If an individual administers his/her own medication at an agency site, the medication must be listed on the MAR. 100% must be achieved for each item for the record to be rated “Met.”
64. Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff.10A NCAC 27G .0209. Sample is same 5 records from item 14. Documentation of medication education provided to the individual/LRP should be reviewed for each prescribed or over-the-counter medication if ordered by the agency physician.
65. Item 18: For each service recipient receiving medication, the individual/LRP shall receive education regarding medication prescribed. All instances of medication education are documented by staff. CONTINUED Medication education may be given orally or in writing documentation may be in the prescribing physician's note may be documented in writing according to agency policy Medication education is required for all medications prescribed by the provider agency’s physician. 100% must be achieved for each item for record to be rated “Met”
66. Post-Payment Review Tools for IDD Services
67. Organization of PPR Tools The PPR Tool questions address these areas: Authorizations/Consents/Eligibility/ Service Orders/Plans Service Documentation Qualifications/Training of Service Providers/Record Checks/Supervision
68. The Post-Payment Review Tools Available for Provider Agencies Child & Adolescent Day Treatment Diagnostic Assessment Innovations Waiver Outpatient Opioid Treatment Psychiatric Residential Treatment Facility (PRTF) Residential Treatment Generic – used for all services other than those in 1 – 6 above.
69. PPR Tools for Providers of IDD Services Some providers offer a wide array of cross-disability services. The specific PPR tool(s) that will be used during a review is based on the service array represented in the sample of paid claims. The PPR tools are based on service definition-specific requirements including staff qualifications. The Generic Tool and the PPR Tool for the Innovations Waiver would typically be used to review IDD services. Most questions on the Generic Tool are also found on the other 6 agency tools.
70. Basic Components of the Post-Payment Review Tools Consents Referrals Authorizations Eligibility Service Orders Service Plans
71. Basic Components of the Post-Payment Review Tools Service Documentation Staff Qualifications Training of Service Providers Health Care Registry Check Criminal Background Check Supervision
72. Post-Payment Review Tool for the Innovations Waiver Authorizations/Continued Need Review/Plan of Care Valid ISP for the date of service Service Documentation Valid consent for treatment Valid signature of the person who provided the service Interventions/Treatment for the duration of the service billed Qualifications/Supervision/Record Checks
73. Post-Payment Review Tool for the Innovations Waiver Optional Questions Documentation includes an assessment of progress towards goals Documentation indicates the requirements of the service definition were met Documentation in the quarterly summary reflect the individual’s progress toward the short-range goals and the long-range projections listed in the ISP
74. Basic Components of the Post-Payment Review Tools The Generic Post-Payment Review Tool
75. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Is there a valid consent for treatment in the service record? 10A NCAC 27G.0205; CCP 8C Q1 on the Generic Agency Tool Q3 on the LIP Tool Review for a consent for treatment signed by the individual or LRP on or prior to the date of service being reviewed. A separate consent for treatment form is not necessary if the individual/LRP has signed the PCP/service plan.
76. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans The individual/LRP signature on the treatment plan or PCP is sufficient to demonstrate consent.  If written consent is not obtained, the provider must produce a written statement as to why consent could not be obtained.
77. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a referral from an approved source prior to the date of service, if applicable? CCP 8C 5.4.1, 5.4.2 and 7.3.6 Children under 21 need an individual verbal or written referral from a CCNC/CA (Carolina Access) primary care provider, the LME-MCO or a Medicaid-enrolled psychiatrist. Referrals may be accepted from schools or DSS, but must still be supported by one of the referral sources above.
78. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED Documentation of the verbal or written referral includes the name and NPI # of the individual or agency making the referral Services provided by a physician do not need a referral Individuals 21 or over may be self-referred or referred by another source. If not self-referred, referral must be documented.
79. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid utilization management authorization for the service billed, if applicable? Prior approval needed after: 16 unmanaged visits/calendar year for children under 21 8 unmanaged visits/calendar year for adults 21 or over If unmanaged visits were exceeded review for LME-MCO authorization that covers date of service E&M codes for medication management do not require prior authorization.
80. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Does the recipient meet entrance criteria per the service definition?CCP 8A Q3 on Generic Agency Tool Do the results of the Comprehensive Clinical Assessment (CCA) support the level of care for the treatment service recommended? CCP 8C Q14 on the LIP Tool
81. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED Review the Entrance Criteria listed in the service definition against the CCA. The CCA must support the required criteria. The CCA must support the level of care (CALOCUS, CASII, LOCUS, ASAM) for the treatment service recommended.
82. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service Plans Is there a valid service order for the service billed, if applicable? CCP 8C Q5 on the LIP Tool The need for a service order matches the need for an authorization. If needed, service must be ordered on or before date of service. If a PCP is not required, a separate service order form can be used. See Service Plan question for services ordered via PCPs.
83. Consents/Referrals/Authorizations/Eligibility/Service Orders/Service Plans Is there a valid/appropriate service plan current for the date of service? CCP 8A, 8C. Q2 on Generic Agency Tool Q4 on the LIP Tool The format required by service definition is used. Plan is rewritten annually and/or updated/ revised: If the needs of the person have changed On or before assigned target dates When a new service is added When a provider changes
84. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED If the plan is a PCP, the service must be identified in the Action Plan to be ordered via appropriate signature on the PCP. If the service does not require a PCP, a separate service order form is acceptable.
85. Consents/Referrals/Authorizations/Eligibility/ Service Orders/Service PlansCONTINUED Dated Signatures Medicaid-funded services must be ordered by a licensed MD or DO, licensed psychologist, licensed nurse practitioner or licensed physician’s assistant unless otherwise noted in the Service Definition. Each service order must be signed and dated by the authorizing professional. Dates may not be entered by another person or typed in. No stamped signatures unless there is a verified Americans with Disabilities Act [ADA] exception.
86. Service Documentation Is the documentation signed by the person who delivered the service? CCP 8A, 8C – 7.3 Q4 on the Generic Agency Tool Q7 on the LIP Tool Signature includes credentials, license, or degree for professionals; position name for paraprofessionals. Credentials/job titles may be typed, stamped or handwritten. Do not rate “Not Met” if credentials are missing. If it is a systemic issue, require a Plan of Correction.
87. Service DocumentationCONTINUED The note is written and signed by the person who provided the service [full signature, no initials]. “Written” means “composed.” If a signature is questionable, request the provider’s signature log to validate the signature. Documentation is completed within 24 hours of the day the service is provided.
88. Service DocumentationCONTINUED In order for a service to be billable, the note must be written or dictated within 7 working days (for the staff who provided the service). After the 24-hour time frame, the note shall be entered as a “late entry” and include a dated signature. If an electronic note is used and late entries are tracked/stamped in the system, this will meet documentation requirements. If there is no note for the date being audited, then audit questions related the qualifications, training, supervision, record checks of the staff who provided the service are rated “N/A.”
89. Service DocumentationCONTINUED If there is an unsigned note, review and rate other questions related to the note accordingly. Questions related to the staff person remain rated as “N/A." Do not assume based on handwriting that you can identify the service provider.
90. Service Documentation Does the service note relate to goals listed in the service plan? CCP 8C Q8 on the LIP Tool Note reflects purpose of the intervention Note states, summarizes and/or relates to a goal or references a goal # in the service plan. Goal is not expired or overdue for review If goal does not match the goal # indicated, review all goals to see if it relates to another goal
91. Service Documentation Does the service documentation include an assessment of progress toward goals? CCP 8C Q9 on the LIP Tool Optional – Q14 on Generic Agency Tool Service note needs to indicate progress made toward the goal/effectiveness (how it turned out for the person; how did he/she respond to the intervention) If the information is not in the traditional section of the note, read the entire narrative note to determine if it was addressed.
92. Service Documentation Does the documentation reflect the specific service billed? CCP 8C Q10 on LIP Tool Service documented must match procedure code billed. Intervention must match procedure code billed. No provider may bill H codes.
93. Service Documentation Does the documentation reflect treatment for the duration of the service billed? CCP 8A, 8C Q5 on Generic Agency Tool Q12 on the LIP Tool Intervention relates to the stated purpose of goal Intervention/Treatment documented justifies amount of time billed – reasonably took place in the amount of time documented There is actual treatment reflected in the intervention related to goals, symptoms, diagnoses
94. Service DocumentationCONTINUED The following are not billable: Verifying eligibility and obtaining prior approval Completing NCTOPPS Internal agency supervision
95. Service Documentation Is the service note individualized specific to the date of service? CCP 8A, 8C Q6 on Generic Agency Tool Q11 on the LIP Tool Review notes around the date of service. Notes should vary from day to day and person to person No xeroxed notes with dates or signatures changed No handwritten notes copied throughout with different service dates
96. Service DocumentationCONTINUED Look very closely if you see any of the following: Exact wording across 2 or more notes for one person or across records Conflicting pronouns (he/she, him/her) The name or identifying information of another individual is found within the service note.
97. Service Documentation Do the units billed correspond to the duration documented on the service note? Provider Participation and Electronic Claims System agreements Q7 on Generic Agency Tool Duration of periodic services must be documented Billing and duration must be an exact match, however, if fewer units are billed than documented do not rate “Not Met”
98. Service Documentation Does the documentation indicate that the requirements of the service definition/rule were met? CCP 8A Optional – Q13 on Generic Agency Tool Review CCP 8A for service definition Each service definition include allowable activities, team composition (if applicable) and other critical elements
99. Service Documentation Is there documentation that coordination of care is occurring with both medical and non-medical providers involved with the individual receiving services? CCP 8C Q15 on LIP Tool May be found in service notes, summary reports, documentation of telephone calls, Tx planning notes Coordination of Care expected as applicable for example with primary care, LME-MCO, other mh/dd/sa service providers
100. Qualifications/Training of Service Providers/Record Checks/Supervision Is there documentation that the staff is qualified to provide the service billed? Q8 on Generic Agency Tool Q13 on LIP Tool Review personnel record for each person who provided a service Verify both required education and experience are evident Use Qualification Checklist (there is one for each PPR Tool) which lists education and training required for the service
101. Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED If service provider is unknown (note not signed or illegible or unverifiable my signature log), rate all staff related questions as “N/A.” Do not assume based on handwriting in a note that you can identify the provider of an unsigned note. If staff name is typed but not signed, review for qualifications but rate “Not Met” for the question about the note being signed.
102. Qualifications/Training of Service Providers/Record Checks/Supervision Is the staff supervision plan implemented as written? 10A NCAC 27G .0104, .0203 Q9 on Generic Agency Tool Supervision plan must be in place for Associate Professional and Paraprofessional staff. If staff is a QP or licensed, rate this item “N/A.” Evidence of implementation is based on requirements of the plan. For example, most plans include the frequency/duration of required supervision. Determine if documentation of supervision matches with the supervision plan requirements. An agency policy on supervision, even if it includes frequency/duration of supervision is not acceptable as an individual supervision plan
103. Qualifications/Training of Service Providers/Record Checks/Supervision Was there a Health Care Registry check completed for the staff prior to this event’s date of service [unlicensed employees only]? GS 131E-256, 10A NCAC 27G .0202 Q10 on Generic Agency Tool There may be no substantiated findings of abuse or neglect. Ensure the registry check belongs to the staff being reviewed (check name, SSN if available, etc.)
104. Qualifications/Training of Service Providers/Record Checks/Supervision Did the provider agency require disclosure of any criminal conviction by the staff person(s) who provided this service? [for unlicensed services and staff hired to provide licensed services prior to 3/24/05] 10A NCAC 27G .0202 Q11 on Generic Agency Tool Disclosure statements most often found on employment application or in a separate statement completed during application process. If no disclosure statement, a request for a criminal record check prior to the date of service is acceptable
105. Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED If disclosures are not in place and is a systemic issue, assign a POC even if background checks are evident. The criminal record disclosure must have occurred prior to the date of service.
106. Qualifications/Training of Service Providers/Record Checks/Supervision Was the appropriate criminal record check completed prior to this date of service? GS 122-80 Q12 on Generic Agency Tool Not required for licensed staff Determine date of hire General Statute Requires the Following: If applicant had been a resident of NC for less than 5 years, must have consent for a State and National background check before conditional employment If applicant had been a resident for 5 years or more, must have consented to a State check before conditional employment.
107. Qualifications/Training of Service Providers/Record Checks/SupervisionCONTINUED The provider, within 5 days of conditional employment must submit request to the DOJ to conduct the criminal background check. A NC county or company with access to the Division of Criminal Information data bank may conduct the check. You do not need to see the actual background check results, auditors need only see the request. For purposes of the PPR, the request must occur prior to the date of service. Do not rate “Not Met” if the request did not occur prior to conditional employment. Rate “Not Met” only if it did not occur prior to the date of service or not at all.
108. Specialized Tools
109. Specialized Tools for Provider Agencies Unlicensed AFL Review Tool Looks at health and safety issues and compliance with the personnel and training requirements of providers and staff Is required to be completed annually for AFL services under the Innovations Waiver Is completed every two years for all other unlicensed AFL sites
110. Specialized Tools for Provider Agencies Unlicensed AFL Review Tool Home Environment Medical preparedness plan; emergency information First aid supplies; storage of medication Availability of meals, food, water, individual privacy Accessible transportation Safety and cleanliness of facility and grounds Personnel – background checks; backup staffing plan Training on individual-specific needs and the required skills/competencies for staff position/role
111. Specialized Tools for Provider Agencies Health, Safety and Compliance Review Tool Is only for the initial review of services that operate out of a setting that is not licensed by DHSR (e.g., Unlicensed Supervised Living Programs). Is used when an unlicensed service moves to a new location which is not co-located with a licensed service. Subsequent reviews of these services would utilize the Routine Review Tool.
112. Specialized Tools for Provider Agencies   Health, Safety and Compliance Review Tool Medical preparedness plan, fire and disaster plan and drills First aid supplies Availability of meals, food, water Safety and cleanliness of facility and grounds Provision for individual privacy Emergency information: first aid, CPR poison control protocol posted or easily accessible
113. Some Monitoring Process Points
114. Sample Selection The sample that is selected to conduct the majority of the routine review is based on paid claims. The exceptions are incidents, restrictive interventions, complaints, funds management and medication review which may fall outside of the service events selected from paid claims. 114
115. Selection of the Review Period For the majority of the review, the sample of paid claims will be based on claims paid starting 6 months before the scheduled on-site visit through the next 3 months (~ 90 days). Example: If the date of the on-site is May 1, the sample will drawn from randomly selected claims that were paid between December 1 – February 28. The timeframe for incidents, restrictive interventions, complaints, funds management and medication review can go back up to 1 year in order to obtain an adequate sample. 115
116. Notification of Routine Monitoring Provider agencies and LIPs will be notified in writing 21 – 28 calendar days prior to the date of review. Provider agencies and LIPs will be notified of specific service records needed for review no less than 5 business days prior to the date of review. 116
117. During Monitoring LIPs and Agencies should have staff available to help navigate records/documentation if needed. It is not required to be present during the review, but having staff available can enhance the process. If documentation for a specific item is not immediately available, it will be accepted at any time during the on-site review. 117
118. Exit Interview An Exit Interview will occur following the on-site review to provide the LIP or agency with some immediate feedback: General impressions on preparedness and results of the review General information on any major findings, trends, etc. Expectations, if any, for technical assistance needed, plan of correction and follow-up Verify contact(s) for receipt of report: Name, Mailing Address, Email Address. 118
119. Reports and Plans of Correction Comprehensive findings will be reported by the LME-MCO within 15 calendar days. Ensure POC is specific, detailed and addresses each of the systemic areas noted in the findings. Fully implement the POC – seek technical assistance as warranted. 119
120. Scoring & Weighting
121. Scoring The three (3) scoring options are: Met Not Met Not Applicable (N/A) 121
122. Scoring Enhanced Guidelines: More specific More pertinent to general program operations 122
123. Scoring The threshold for passing each section of the routine review tool is 85%. (Exception: On the Agency Tool, if the Restrictive Interventions item is missed, the entire section on Incidents, Restrictive Interventions and Complaints is failed). The minimum overall score for the routine review tool is also 85%. 123
124. Weighting The weight for any item scored as “N/A” is distributed across the other items in that section.
125. Weighting Non-compliance on certain items results in the individual record being scored as “Not Met:” Authorization to Release Records All elements required by rule must be included in the record release form in order for this item to be scored as “Met.” [See Record Release Checklist] Medication Review Tool If any of the following requirements is out-of-compliance, the individual record is “Not Met.” [see Medication Review Checklist] Medication Order Properly Signed/Countersigned by Prescribing Physician Medication Label Matches the Medication Order List of Medications on the MAR match the Medication Order Documentation that Medication Education Occurred
126. Weighting Non-compliance on certain items results in the entire section to be scored as “Not Met:” Restrictive Interventions If the Restrictive Intervention question is “Not Met” for any event reviewed, the entire section on Incidents, Restrictive Interventions and Complaints is failed.
127. What happens if a provider agency does not pass the monitoring or review?
128. LME-MCO Responsesto Unsuccessful Monitoring One or more of the following may occur, specific to individual LME-MCO policy. Technical Assistance Plan of Correction Recoupment (for Post-Payment Reviews only) Targeted Investigation LME-MCOs will inform providers and LIPs of their process for appeal or reconsideration.
129. Internal Quality Assurance ….will only involve review of documents needed to determine the met/not met/NA status for the review tool questions ….less anxiety-provoking when providers (LIPs and agencies) use the tool as a pre-review self-assessment.
130. Internal Quality Assurance The best offense is a good defense. Do you have a system in place that ensures audit-readiness at all times?
131. Transparency
132. Internal Quality Assurance
133. Internal Quality Assurance Be Proactive
134. Internal Quality Assurance Do you have a system in place that ensures audit-readiness at all times?

135. Customer Service One to Another

136. Important Things to Remember:
137. Providers Remain abreast of applicable policies, rules, regulations, standards and other information provided by the Division of MH/DD/SAS Administrative Publications and all other standards established by the Federal Government, State of NC or LME-MCO per contractual agreement. Comply with contractual obligations as denoted in individual contracts with respective LME-MCOs. Provide services as delineated in individual contracts with respective LME-MCOs. Use Provider Monitoring Tool for agency auditshttp://www.ncdhhs.gov/mhddsas/providers/providermonitoring/tools.html
138. Managed Care Organization (LME/MCO) Develop and manage service benefit plans; coordinate and monitor services provided. Use DHHSProvider Monitoring Tools for agency audits http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/tools.html. Also completes fiscal and billing audits (Post-Payment Reviews). Reviews when complaints are received. Targeted/Focused Monitoring. Incident Report reviews.
139. General Monitoring Courtesies
140. Remember to: Greet and welcome. Make introductions. Demonstrate respect. Be professional. Be calm and friendly. Discuss openly when there is disagreement.
141. Remember to: Ask questions. To share, without hesitation, if the review becomes too disruptive for the participants. Demonstrate integrity throughout the process. Ensure transparency.
142. Other Reminders: The process is not personal; it is a system – we all have shared accountability. Providers need to ensure preparedness, and LME-MCOs need to demonstrate patience, e.g. information may not be readily available and/or resources may be limited.
143. Other Reminders: We must all work collaboratively. Collaboration will ensure an effective, efficient, and successful process. Assume positive intent - monitoring is a learning experience, not a punitive exercise. Be engaged in the information and dialogue.
144. Other Reminders: Complete the survey as means to further improve the process. Most importantly, remember the primary objective is to ensure the health and safety of all the participants supported in the MH/I/DD/SAS system.
145. Asking and Answering Questions: Ask questions when indicated. Provide responses to questions. Ensure responses are accurate and to the point. Stick to the question; do not talk around it. Responses should be referenced-based as needed.
146. Asking and Answering Questions: Make sure the question is understood in its entirety. Recognize the difference between “I think” and “I know.”
147. Seek Recourse When: Efforts to resolve at the lowest possible level have proved ineffective. There is lack of professionalism. Actions are not in accordance with standard operating practices for the MCO or Provider. There is continued disagreement concerning a particular issue. Additional support is warranted.
148. Partners Making a Difference 148
149. Parking Lot Issues
150. More to Do… This is a developing list of things to accomplish: Will there be a standard monitoring report from the LME-MCOs? Will there be a standard response to unsuccessful monitoring? Review and revise as needed, the POC policy Advanced levels of Provider Monitoring development Determine lead LME-MCO More research needed on ability to do PPRs on TFC
151. We want to hear from you!! 151
152. Questions Please send any questions or comments about the Provider Monitoring Tools or process to the following mailbox: provider.monitoring@dhhs.nc.gov Please put either “FEEDBACK” or “QUESTION” in the subject line!
153. Additional Information & Updates Additional background information about the DHHS Provider Monitoring Process can be found on the Provider Monitoring web page: http://www.ncdhhs.gov/mhddsas/providers/ providermonitoring/index.htm Check the Announcements page for new postings.
154. Continued Collaboration
155. DHHS-LME/MCO-Provider Collaboration Workgroup Provider Organizations Janet Breeding, NC Providers Council Sally Cameron, PAC Celeste Dominguez, Benchmarks Caroline Fisher, Benchmarks Lakisha Marelli, Benchmarks Margaret Mason, NC Providers Council
156. Leslie Gerard, CenterPoint Beth Lackey, Partners Rhonda Little, Cardinal Innovations Eugene Naughton, CenterPoint Alison Rieber, Alliance Sherry Reece-Cota, Partners Carol Robertson, Sandhills Center Karen Salacki, Eastpointe Claudia Salgado, CenterPoint Onika Wilson, Cardinal Innovations DHHS-LME/MCO-Provider Collaboration Workgroup NC Council of Community Programs
157. Beverly Bell, DMA Cynthia Coe, DMH/DD/SAS Stephanie Gilliam, DHSR Vince Newton, DMH/DD/SAS Patrick Piggott, DMA Sandee Resnick, DMH/DD/SAS Nancy Rogers, DMH/DD/SAS Michael Schwartz, DMH/DD/SAS Adolph Simmons, DMA Glenda Stokes, DMH/DD/SAS Robin Sulfridge, DHSR Suzanne Thompson, DMH/DD/SAS Mary Tripp, DMH/DD/SAS PeiChi Wu, DMH/DD/SAS DHHS-LME/MCO-Provider Collaboration Workgroup DHHS Staff
158. Helpful Information DMH/DD/SS Provider Monitoring link for tools, guidelines and updated information: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/index.htm Records Management and Documentation Manual: http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/rmdmanual-final.pdf DMA Clinical Coverage Policies: http://www.ncdhhs.gov/dma/mp/ DMH/DD/SAS Plan of Correction Policy and forms: http://www.ncdhhs.gov/mhddsas/providers/POC/ index.htm DHSR Mental Health Licensure Section: http://www.ncdhhs.gov/dhsr/mhlcs/mhpage.html
159. Transparency The Key to Positive Outcomes and Accountability 159