AE On-Site Audit. Welcome to the AE On Site Audit training. Course #

Transcription

1 Welcome to the AE On Site Audit training. Course #

2 This webcast includes spoken narration. To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation. The written version of the narration appears to the right of the screen. Course #

3 My name is TaWanda Jackson. I m the ODP Lead for Provider Monitoring. This training is one of several updated webcasts that are being provided to assist in preparations for each stage of the Provider Monitoring Process. These presentations are specifically targeted to the Provider and AE administrative staff responsible for completing the monitoring process for licensed and unlicensed Providers of Waiver funded services for at least one person. ODP is planning to offer targeted conference calls where participants will be able to interact with ODP staff, seek additional clarifications and share information related to the implementation of the revised process. Registration information and links for these calls will be made available through ODP Announcements, distribution lists and will be posted in the same location on the Provider Information Center where this webcast was accessed. Course #

4 Just as a reminder, the Provider Monitoring Process is divided into three phases: Performance Review, Provider Self Reporting and AE On Site Audit. In this presentation we will focus on the AE On Site Audit phase. At this time, Robin Levine from the ODP Consulting System will continue this presentation. Course #

5 Thank you TaWanda. Let s start by reviewing and defining a few terms that will be used in this presentation. As explained in other webcasts, a Lead AE is designated by ODP. The Lead AE is designated by ODP based on the AE with which the most individuals served by the Provider are registered. The Reviewing AE is the AE or AEs where Waiver participants of a multi county Provider are registered, but the total number of Waiver participants is fewer than the Lead AE. During the AE On Site Audit Phase, the Reviewing AEs conduct portions of the Provider s on site review for the sample individuals served in the Reviewing AEs jurisdiction. The term AE On site Audit refers to the entire process of this phase, from the review of the submitted provider Self Review, to the validation of the information during the On Site Audit, to the development of the AE Audit Report and Corrective Action Plan. The term On site Audit describes the review of information by the Lead or Reviewing AE at the Provider s offices or service sites to validate the information entered in the Provider s Self Review. Single AE Providers refers to those Provider organizations that as of June 30 th, are providing authorized services to individuals in only one AE. Multi AE Providers are providing authorized services to individuals in more than one AE. Course #

6 Within this presentation we will be talking about a number of tools or forms that will be used. The Provider Monitoring Tool is a document of the entire Tool, for the Lead AE to use to compile the information prior to submitting the Zoomerang Tool. The MCI Tracker Tool is a document used by the Provider and the AE to compile the information they are responsible to collect during the AE On site Audit. The Provider Monitoring Guidelines is a document which identifies the Oversight Area, Compliance Standard and the Source Document for each question. The guidelines provide guidance to assist the reviewer when answering each question as well as suggestions for remediation of non compliance. The AE Audit Report is a letter sent by the Lead AE to the provider to summarize the findings from the On Site reviews. If there are areas of non compliance, the AE Audit Report will also include the CAP form listing specific areas of non compliance. An electronic copy of the AE Audit Report shall be submitted to ODP after the CAP is approved. The Corrective Action Plan (CAP) is a document used by the Provider to respond to the AE Audit Report and identify what will be done by the Provider, by when, in response to the findings in the AE Audit Report. The approved CAP is submitted to ODP. Course #

7 There are approximately 600 enrolled Waiver Providers in Pennsylvania who had authorizations in HCSIS. Of these Providers, ½ will be selected for an AE On site Audit this year. The AE On Site Audit phase begins in January of each year and will end by June 30 th. The AE On site Audit for each Provider includes an On site Audit, which the Lead AE conducts at the Provider s location, submission of the AE Audit Report and completion of any needed Corrective Action Plan or CAP. These On site audits are to be completed no later than the date indicated on this slide and the AE Audit Reports should be submitted to the provider within 30 days of the on site audit. Approved Corrective Action Plans along with the completed AE Audit Report should be submitted to ODP no later than the date indicated on this slide. Course #

8 For the moment we will focus on the process for the On site audit of Providers whose services are limited to within a single AE. The next couple of slides will provide an overview of the process to be followed. The following slides will provide more information regarding each of these steps. We will discuss the differences in the process for Providers whose services are provided in more than one AE, later in this presentation. Please note that it is important that all parties maintain open communications throughout the entire process. Course #

9 For single AE Providers, the AE On Site Audit process begins after ODP notifies the Lead AE of the Provider s sample and the Lead AE notifies Providers that they are going to be audited that year. The Lead AE then schedules the starting date for their On Site Audit, and ODP shares with the Lead AE the Self Review submitted by the Provider. Course #

10 The Lead AE then conducts the On Site Audit, which includes the review of the Self Review and available documentation prior to the scheduled visit as well as during the scheduled visit. Following the scheduled on site audit, and based on their findings, the Lead AE uses this information to complete and submit the Zoomerang Monitoring Tool. The Lead AE then creates and provides the AE Audit Report to the Provider and requests a Corrective Action Plan, if needed. The Provider submits any required corrective action plans to the Lead AE. So, let s take a closer look at each of these steps. Course #

11 The first step in the AE on site audit process was to identify the list of Providers to be audited on site. This is completed in August of each year, based on the Providers identified as having provided services as of June 30th. ODP then provides this list to the AEs along with the sample of MCI numbers to be used by the Providers during the Self Review and during the AE On site Audit phase. Course #

12 Step 2 is for the Lead AEs to contact and schedule the date or dates for the On site Audit for each of the Providers identified for this review. Please review this slide for the specific dates related to each step. By October 31 st, Lead AEs finalize the sample of individuals that providers used for their self assessment and establish a schedule for an on site audit with providers. From January 1 st through May 15 th, Lead AEs will conduct on site audits. By May 31 st, Lead AEs must submit the electronic version of the Provider Monitoring Tool to ODP for all assigned providers. By June 30 th, Lead AEs must submit AE audit reports and approved corrective action plans to the Regional ODP Provider Monitoring Lead. Course #

13 All Providers are required to complete a Self Review and submit the Self Review to ODP. ODP will distribute the Self Reviews completed by the Providers to the Lead AEs prior to start of On Site Audits. As part of the AE On Site Audit phase, the Lead AEs role includes validating the Self Review information submitted by the Providers. Course #

14 During the AE On Site Audit phase, Lead AEs will use the monitoring tool used by the Providers to complete the self review, and rely on the information supplied by the Provider during the on site review as well as information available in HCSIS. AEs will also use the MCI Tracker tool to gather information specific to the sample of individuals. To help prepare for the AE On Site audit, the Lead AE s review of HCSIS information could include; a review of Incident Management Reports to ensure appropriate actions were taken, including ensuring the immediate Health & Safety of the individual, a review of the ISP for background information and context to ensure healthcare management, staff ratios, technology and adaptation needs are being addressed by the Provider A review of SC Monitoring forms, specifically any identified concerns related to the Provider s services And a review of the Services and Supports Directory to help ensure this information is up to date. In reviewing the reports, Lead AEs will use the same time frames that were used by the Provider during the Provider Self Review phase to validate the information submitted. Lead AEs will note any discrepancies between the Self Review and their own results in the comments section of the monitoring tool or MCI Tracker as applicable. It is important to note that depending on the amount of time that has elapsed between the submission of the Provider Self Review, the completion of the AE On Site Audits, and the refreshing of data in HCSIS, some of the data used by the Lead AE may vary from the data submitted by the Provider. Course #

15 To successfully complete this process, Lead AEs should download and share the Provider Monitoring Tool, Provider Monitoring Guidelines and MCI Tracker Tool with their staff who need to be included and ensuring that they understand the information needed to be gathered. These documents can also be used to record the specific responses to each question prior to the responses being entered into Zoomerang by the primary responsible person. The MCI Tracker Tool will be used by the AE to gather and maintain information specific to the sample of individuals. Review the questions and make sure everyone involved understands what is being asked. Links for Zoomerang will be provided to the AE by the start of the AE On Site Audit phase. Zoomerang is used to transfer information collected to the web based tool and should be submitted to ODP within 30 days of the last On site Audit date, but no later than May 31 st. Course #

16 A link to the tool will be ed to the AE s identified primary contact at the beginning of the Provider Self Review phase. The same link is used for all Providers, however, the tool must be completed and submitted for one Provider before entering information on the next Provider. By using the link provided in the , AEs will be able to save partially completed work and return to complete the tool at a later date. Course #

17 Because of the set up required for this tool, this screen identifies several cautions to be aware of. It is strongly recommended that access to these links be limited and one person be identified to complete the forms. This will help ensure that each report is completed before starting the next and avoid any possible confusion or entry of one Provider s information on another Providers report. If completion of this survey is to be delegated to someone other that the primary contact to whom the link was ed, the can be forwarded to the delegated person and they can use the link in the . If the AE is unaware of who their identified primary contact person is, a list of the Primary contacts for each AE is posted on the AEIC where this webcast was accessed. If the primary contact did not receive this information or is not listed and the AE needs a link ed, a request can be sent to the Provider Monitoring Mailbox at the address listed on this slide. This address is also provided at the end of this presentation. Course #

18 Following the completion of the AE On Site Audit and the Provider Monitoring Tool, the Lead AE will prepare an AE Audit Report that summarizes the findings from the On Site Audit. This report is sent to the Provider within 30 days of the last On Site Audit date. Included in the AE Audit Report will be a summary of the findings from the on site audit. If there are areas of non compliance, the AE Audit Report will also include the CAP form listing specific areas of non compliance. An electronic copy of the AE Audit Report shall be submitted to ODP after the CAP is approved. Course #

19 If a provider wishes to have an Exit Conference, this request should be made to the Lead AE during the on site audit. Any questions regarding the final AE Audit report should be directed to the Lead AE. Course #

20 Upon receipt of the AE Audit Report, where a CAP is required, the Provider has 15 calendar days to provide a response to the Lead AE for approval. This response must address all noncompliances identified in the AE Audit Report, identifying how each specific instance is being addressed/remediated and what is being done to ensure on going compliance, including by whom, and by when. The response can be sent in writing via or postal mail. (Time of submission will be based on the time stamp or postal cancelation.) Providers can dispute the findings in the AE Audit Report to the Lead AE, but they will still need to comply with the established timelines for the Corrective Active Plan (CAP) Process while this is being reviewed. When applicable, the Lead AE will forward the dispute the Regional Provider Monitoring Lead within 60 days of the on site review. The CAP is a standardized, ODP guided process. More information regarding this content of the CAP, and the CAP Process is provided in a separate webcast. Course #

21 Now let s look at the AE On Site Audit process for Providers who serve individuals in more than one AE. Because of the involvement of Lead and Reviewing AEs in this process, it is important that the Lead and Reviewing AEs and Provider coordinate the on site review activities to allow each AE an appropriate amount of time to conduct and complete the AE audit activities within the given timeframes. The next few slides highlight the additional considerations for conducting an On Site Audit for Multi AE Providers. Changes or additions related to audits of Multi AE Providers are underlined and in blue. Course #

22 In step 1, ODP will identify the Lead AE for Providers selected for the On site Audit that provide services in more than one AE. Based on the sample information, the Reviewing AEs that will be part of the AE On Site Audit process will also be identified. The Lead AE, in step 2, will coordinate the scheduling of the On Site Audit with both the Reviewing AEs and the Provider. The Lead AE is also responsible to share the Provider Self Reviews supplied by ODP in step 3, with the Reviewing AEs. Course #

23 In Step 4, both the Lead AE and the Reviewing AEs will be involved in the record reviews and On site audit. In Step 5, AEs will complete the MCI Tracker Tool once they have completed their On Site audit. Reviewing AEs provide a copy of the completed MCI Tracker Tool directly to the Lead AE. In order to comply with HIPAA regulations, the Reviewing AE shall delete all individual names from the tool prior to submitting the tool to the Lead AE. The Lead and Reviewing AEs should coordinate the submission of these tools to allow the Lead AE sufficient time to complete the process within the established timeframes. A copy of the MCI Tracker tool is available on the PIC where this webcast was accessed. The Lead AE will then compile the information from all the Reviewing AEs to submit the Zoomerang Monitoring Tool to ODP. Course #

24 The Lead AE uses the compiled information gathered during their On Site Review with the information gathered by the Reviewing AEs in step 6 and provides a copy of the AE Audit Report to the Provider and the Reviewing AEs within 30 days of the last on site visit, but no later than June 30th. Finally, in Step 7, when the Provider submits the CAP to the Lead AE, the Lead AE will share this with the Reviewing AEs and both may need to be involved in monitoring the implementation of the CAP by the Provider. Course #

25 This slide represents the basic timeline for the AE On Site Audit process. During the On Site Review period, Lead and Reviewing AEs complete their On site Reviews and Reviewing AEs submits the MCI Tracker Tool to the Lead AE. Reviewing AEs should submit the MCI Tracker Tool electronically to the Lead AE within 15 days from the on site audit date. The Lead AE submits the Provider Monitoring Tool to ODP within 30 days of the last on site review date. The AE Audit Reports are also completed within 30 days of the last on site visit. This timeline will ensure that the Provider s response, due within 15 days of the completed Audit Report and the Lead AEs review and response to the submitted CAP, due within 15 days are approved before the end of the process. It is important to note that the timeline for each step depends on the date the previous step was completed. For example, if the Provider is a single AE Provider and the On Site Audit is conducted on March 1 st, the AE Audit Report would be due to the Provider by April 1 st. If the AE Audit Report is provided to the Provider on March 15 th, the 15 days for the Provider to respond would start then on the 15 th, and would now be due by April 1 st. The Lead AE would then review and act upon the response/cap by April 16 th. For Multi AE Providers, let s say providing services in 3 AEs, if the On site Audits are conducted on February 12 th by Reviewing AE #1, February 19 th by the Lead AE and March 1 st by Reviewing AE #2, the last On site review is March 1 st. The Lead AE and Reviewing AEs need to communicate with each other to ensure that the Reviewing AE submits the Reviewing AE Monitoring Tool in time so that the AE Audit Report can be completed by April 1 st. If the Lead AE provides the Final Report on March 15 th, the 15 days for the Provider to respond would start then on the 15 th, and the response or CAP would now be due by April 1 st and the Lead AE would then review and act upon the response/cap by April 16 th. Course #

26 Again, because of the involvement of multiple AEs and the needs of the Providers, coordination and communication between all parties in the completion of these activities is very important. As noted earlier, it will be important that all parties maintain open communications throughout the process. Course #

27 Target dates for remediation or corrective action plans should be within 30 days whenever possible, not to exceed 90 days unless an exception is approved through documentation by the Lead AE. The Lead AE and Reviewing AE(s) will validate correction of non compliances on site if documentation was not submitted with the CAP to confirm remediation. If the provider is required to submit a CAP, the Lead AE reviews the CAP upon receipt and determines if further action is required by the provider. The Lead AE should consult with the Reviewing AE(s) to ensure that the CAP sufficiently addresses all non compliances. Course #

28 While the AEs will schedule and monitor the Providers selected by ODP each year, ODP and the AE may also choose to conduct an unscheduled On site Audit of any Provider during the year. The next few slides will look at this process. Course #

29 In these cases, the abbreviated process would include the conducting of the On site Audit, the submission of the AE Audit Report to the Provider and the response by the Provider, including a Corrective Action Plan unless the AE develops and requires specific actions to be taken (Directed Corrective Action Plan or DCAP). Course #

30 An unscheduled On Site Audit of a Provider could occur if there is a significant concern at any time the AE or ODP suspects non compliance to the regulations or requirements or when there is concern over the health and safety of the individuals served. The AE must notify ODP in advance, when an unscheduled review is being conducted. Course #

31 At any time, ODP or the AE will direct the Provider to take immediate corrective actions if there is a clear and imminent threat to the health and welfare of an individual. Course #

32 When an unscheduled On Site Audit is held, the AE can choose to use specific sections of the audit tool (related to the current concern) or they can choose to complete the tool in its entirety depending on the circumstances and reasons for the unscheduled On Site Audit. An unscheduled On Site Audit is completed entirely offline. Course #

33 Because of the reasons for conducting an Unscheduled Audit and the implications for those receiving services, the timely completion of the process is critical. The provision of the Final Report, CAP submission and approval, as well as implementation of the CAP must be a priority for ODP, the AE and the Provider and provided and responded to as quickly as possible. Course #

34 In the event that a Provider does not submit, or implement a CAP or implement a DCAP within the expected time frames, the Provider will be considered to be in Follow up Status and could be subject to closer scrutiny by the AE or ODP. A separate webcast reviewing the specific requirements of the CAP/DCAP process is available and ODP encourages the viewing of this webcast. Course #

35 Under follow up status, the AE or ODP may require additional actions from the Provider, including but not limited to: Attendance and participation in enhanced training and technical assistance and/or Implementation of a DCAP. Course #

36 The AE may: Provide a DCAP or request assistance from ODP with developing a DCAP for the Provider to implement Review the Provider s qualifications Recommend to ODP, the Provider be subject to on site review more often than once every two years and/or Recommend to ODP, the restriction or disqualification of the Provider. Course #

37 ODP may also: Require the Provider to participate in the on site review phase more than once every two years Implement sanctions including, but not limited to freezing or altering waiver enrollment or approved program capacity Refer the Provider to the appropriate licensing unit for further review and/or Implement restriction of the Provider to deliver some or all waiver services. Course #

38 As a reminder this slide lists the Regional ODP Leads for Provider Monitoring. Questions regarding the Provider Monitoring Process should be directed to the Provider Monitoring mailbox address at the bottom of this slide or to the identified regional leads. Course #

39 Thank you for viewing this webcast. Please be sure to view the other Provider Monitoring webcasts on the Provider Information Center. Questions or clarifications related to the On Site Audit should be sent to the Provider Monitoring Mailbox at the address on the previous slide. Course #