Quality Assessment & Improvement (QA&I) Process Cycle 1 Year 1 ( ) Questions and Answers from the Dedicated Mailbox

Transcription

1 Quality Assessment & Improvement (QA&I) Process Cycle 1 Year 1 ( ) Contents: GENERAL PROCESS QUESTIONS... 1 GENERAL SELF-ASSESSMENT QUESTIONS... 5 AE SPECIFIC QUESTIONS... 8 AE General Questions... 8 AE Self-Assessments... 8 AE Onsite Review of Providers... 9 AE Questions Tool SCO SPECIFIC QUESTIONS SCO General Questions SCO Self-Assessment SCO Questions Tool PROVIDER SPECIFIC QUESTIONS Provider General Questions Provider Self-Assessment Provider Questions Tool Quality Management Plan Questions... 22

2 GENERAL PROCESS QUESTIONS 1. Does the QA&I Process replace Provider Monitoring, SCO Monitoring and AE Oversight? Yes, effective July 1, 2017, the QA&I Process obsoletes (replaces) all three oversight and monitoring processes. 2. Are self-assessments required during the year in which the entity is selected for their onsite or only during the 2 "off" years? All entities must submit a self-assessment annually as part the new QA&I process. 3. When will we learn what 3-year cycle will be an onsite? AEs are selected alphabetically, with A C being in C1Y1. SCOs are based on individuals selected in the ODP sample and the SCO that is authorized in the individual s ISP. Providers are determined by the last digit of the MPI #. Digits 0, 1 and 2 will get an onsite Year 1 Digits 3, 4 and 5 will get an onsite Year 2 Digits 6, 7, 8 and 9 will get an onsite Year When will onsite be for the 1st year? All onsite reviews will occur between September 1st and December 31st of every year. 5. When can we expect to receive our sample? 6. How do we know if we need to do a self-assessment or an onsite each year? 7. I don't know who my QA&I Regional Coordinator is or their contact information. For self-assessment, all entities will choose their sample which will include 1% with a minimum of 5 and a maximum of 10 records. These will include a crosssection of individuals served, funding/program types, and locations and types of services. For onsite, entities will receive the sample from their Regional QA&I Coordinator, or AE for Providers, two weeks prior to the onsite. All entities must submit a self-assessment annually Onsite reviews are: AEs are selected alphabetically, with A C being in C1Y1. SCOs are based on individuals selected in the ODP sample and the SCO that is authorized in the individual s ISP. Providers are determined by the last digit of the MPI #. Digits 0, 1 and 2 will get an onsite Year 1 Digits 3, 4 and 5 will get an onsite Year 2 Digits 6, 7, 8 and 9 will get an onsite Year 3 Central Region Robyn Seville Northeast Region Rachel Toman Southeast Region Roger Crisanty Western Region Renee Bruno In addition, the QA&I Regional Coordinators are listed out in Announcement , along with their addresses. 1

3 8. Will there be a process document that describes timeframes, due dates, expectations for all stakeholders? Yes, the QA&I Process document is available on the MyODP.org website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources) and is titled Office of Developmental Programs Quality Assessment & Improvement Process. 9. Most ODP forms are not printer friendly (even too large to print on legal size paper) are the new forms going to accommodate printing without having to tape together to view the entire form? 10. Are we required to keep all the documentation for the 3 years until an onsite assessment occurs? 11. Are State Centers excluded from this QA&I Process? 12. How does an entity update its primary or secondary contacts for the QA&I process? 13. There is 'talk' that IM4Q teams will be part of the provider monitoring? Is this accurate? 14. Who is training the IM4Q teams on what to monitor and how to monitor it? What tool(s) are they using? 15. Can you describe the desk review process? 16. When will we receive the schedule for onsite reviews so we know where we fall? Yes except for the MCI review spreadsheet, which due to its size will likely not be printer friendly. There is a Provider MCI review spreadsheet and an SCO MCI review spreadsheet. Each one has questions specific to the entity. Yes Yes, state centers are excluded. The new contact information should be sent to the QA&I mailbox at RA- PWQAIPROCESS@pa.gov No, the IM4Q local programs are assisting ODP in completing individual interviews of the ODP sample. The IM4Q local programs are not conducting monitoring. IM4Q local programs are conducting individual interviews based on the Interview document that is available on MyODP.org ( Quality Assessment & Improvement Interview Questions Tool ). Please reference QA&I Process document. It is available on the MyODP.org website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources) and is titled Office of Developmental Programs Quality Assessment & Improvement Process. AEs are selected alphabetically, with A C being in C1Y1. SCOs are based on individuals selected in the ODP sample and the SCO that is authorized in the individual s ISP. Providers are determined by the last digit of the MPI #. Digits 0, 1 and 2 will get onsite Year 1; digits 3, 4 and 5 Year 2; digits 6, 7, 8 and 9 Year 3. For AEs and SCOs, if you are getting an onsite that year, you will receive an from your Regional QA&I Coordinator in the beginning of July. For Providers, if you are scheduled for an onsite that year, the Assigned AE will contact you by the end of July. 2

4 17. During onsite years, is it conceivable that the SCOs and AEs have a selfassessment Yes, the self-assessment sample is different than the samples that ODP will pull to conduct desk and onsite reviews. The AE and SCO are not required to sample list that would be complete a record review of the ODP sample however they will be required to perform any remediation activities if applicable. different from the ODP onsite sample list so that a total of sampled records would be higher than the minimum of 5 maximum of 10? 18. Will the fiscal part of the review remain the same? 19. All AEs, Providers and SCOs pick their own samples for their selfassessment. But for onsite reviews, ODP will pick the SCO and AE sample and the AEs will pick the provider sample? 20. Is it expected that the type of questions will remain the same for at least 3 years? 21. Is there still going to be a separate Agency with Choice monitoring tool? 22. Are we supposed to include any AWC participants in this QA&I sample? 23. The timeframe for each question is 12 months from the date of the review unless otherwise specified. Since, QA&I Process notification was 1 July 2017, does that indicate the date mark to begin the 12-month review? 24. Will the questions that are noted as exploratory be scored? 25. How will the answers to the individual interviews be used? The QA&I Process does not include fiscal oversight. The Bureau of Financial Management and Budget will be performing fiscal oversight. ODP will provide AEs and SCOs with a sample that will be used for desk and onsite reviews conducted by ODP. In addition, ODP will identify which providers receive an onsite based on the last digit of the MPI # and share this list with the Assigned AEs. The Assigned AEs are then responsible for pulling an individual sample for each provider. ODP s expectation is that questions will remain the same from year to year, however, questions may be added or changed to ensure that all new requirements are being met. Yes, at this time, it will be separate. If you have questions about the AWC monitoring process, you can reach out to RA-PWAWCMONITORING@pa.gov If an individual only receives AWC services, they should not be included in the QA&I sample. If an individual receives AWC and additional services, they can be included. If you have questions about the AWC monitoring process, you can reach out to RA-PWAWCMONITORING@pa.gov The 12 months back is from the date you start the review of your entity, not the notification. If you started your review on July 1st, then your 12-month period would go back to July 1, If you start your review any day in July, your 12- month period would go back to July 1, 2016 because the review period should always go back to the first day of the month. Some of the exploratory question will be scored. ODP intends to post another version of the questions that identify the non-scored questions as well as include the remediation questions in the near future. A summary of the individual interview responses will be included in the Comprehensive Report that is sent to entities who get an onsite. If this summary identifies areas where the entity could improve performance, it is expected that the entity looks at incorporating it into their Quality Management Plan. The interview questions are not scored and entities will not get specific answers. 3

5 26. Will ODP be providing or posting the ODP Provider/SCO Mapping Doc with all the contacts? ODP is currently preparing this document for posting to MyODP. We will let the field know when this document, which will have a new name and will include AE contacts, will be posted. 27. Are certificates of participation for the June webinars and the in the person training on July 19th? No, ODP is not issuing certificates for these trainings. 4

6 GENERAL SELF-ASSESSMENT QUESTIONS 28. You said that for FY17-18, selfassessments are due by 8/31/17. What will be the due date for these in the future? Starting FY 18-19, the due date for self-assessments will be July 31st. 29. Since the self-assessment is due 8/31/17, when will we be expecting the list of individuals chosen for this year? 30. What is the criteria for the selfassessment sample? 31. Is there a printable document that mirrors what we will need to submit to QuestionPro and where this is available so we can print it and have it ready to enter into the system in the proper format on August 31st? 32. Were the slides from the 6/23/2017 & 6/26/2017 self-assessment presentations posted for review? All entities will choose their own sample for self-assessment. 1% of individuals served with a minimum of 5 and a maximum of 10 individuals The sample will include a cross-section of individuals served, funding/program types, locations, and types of service The Word document and MCI review spreadsheet are available on the MyODP.org website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources). There is a section with both documents for Providers and a section with both documents for SCOs. The QuestionPro link is only for answering all the questions. Yes. They are available on the MyODP.org website. The path is MyODP.org > Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources. You must be logged in to access the information. 33. How many questions are included in the self-assessment? 34. In looking at the Provider and SCO Self-Assessment tools, not all questions are part of the assessment that are identified in the Questions Tool for Providers? Are not all questions to be self-assessed? AE 70 questions Provider 48 questions SCO 90 questions For both Providers and SCOs there are two tools. The first is a Word document for each ( Quality Assessment & Improvement (QA&I) Questions Tool ). These Word documents have all the questions, the guidance for answering the questions and source documents. The second tool is an Excel spreadsheet ( QA&I MCI Review ). This spreadsheet is to be used to answer all questions related to the record review. The overall percentage from the MCI review spreadsheet is the final answer and what should be entered into the web database. 5

7 35. Do we submit another selfassessment if we submitted one when it was due November 2016? All entities must submit a self-assessment annually as part the new QA&I process. The established timeframe for completion of self-assessment starts July 1, 2017 and ends August 31, Can an entity reuse sample names or is it expected that a unique sample is drawn by each entity each year? 37. If State Centers are excluded should we not pick individuals who reside in a state center as part of our sample? 38. In reference to selecting individuals across funding streams can you clarify what funding streams are included in this? 39. Is there a list of exploratory questions? 40. Do entities need to send the Submission Checklist documents if they are not having an on-site review? 41. Are entities looking for the most recent date of revision/review and training of the Quality Management Plan, Restrictive Intervention Plan and Annual Training Plans? 42. Must the QM Plan be submitted prior to the completion of our self-assessment (can/should it be submitted at the same time as our self-assessment)? 43. What level of remediation is expected to be included by the 8/31/17 due date? It sounds like systemic remediation would be done after the Self-Review is turned in. For the self-review, should individual case remediation be done and included? ODP s expectation is that a unique sample is drawn each year. Correct, the sample should not include individuals who reside in a state center. Consolidated, PFDS and TSM (Base and SC Services Only) There is not a stand-alone listing of exploratory questions. All exploratory questions are identified as exploratory in the last column on each tool. Submission of the checklist documents are only required when entities are scheduled for the full QA&I review, which includes an onsite. Yes, entities should be looking at the most recent versions of the plans listed. Each entity can decide when to submit the required documentation, however all documentation must be submitted no later than August 31 st, All entities are expected to remediate individual record issues during selfassessment. For self-assessment, no remediation information needs to be provided to ODP unless requested so documentation of the remediation should be kept by the entity. 6

8 44. Do all self-assessments have to be completed beginning July 1 and due on August 1 in the future? Or can an entity start the self- assessment process earlier as long as they go back 12 months? The self-assessment must be completed with the most current self-assessment tool. Entities can only start the self-assessment once the current tool is available to them. Entities should not be completing self-assessments prior to the posting of the current year s self-assessment tool. 7

9 AE SPECIFIC QUESTIONS AE General Questions 45. Delegating interviews to IM4Q. Are the AE s going to know the sample ahead of time and it is part of the AE contract? Yes, individual interviews for the QA&I process are part of the AE contract and replace the transition pilot. The AEs will receive notification from ODP in the month of October of the individual interviews that were completed by the IM4Q local programs. 46. Are AEs responsible for coordinating IM4Q interviews? 47. When the ISP is auto-authorized but services were reduced, what is AE expectation? 49. Will there be training on eligibility and reevaluation process? No, AEs are not responsible to coordinate QA&I interviews with the local IM4Q programs, however, the ODP QA&I Regional Coordinator may seek your assistance in scheduling. This only applies to P/FDS. In the fall, more guidance will be coming out. That guidance should address due process. Call the HCSIS helpdesk. This should not be happening. ODP provided a basic overview of the process on an AE webinar, the link is below. ODP intends to provide another training during a future AE webinar. 48. When the ISP is being put into Pending Revision, it s autoauthorized. repository/shared_content/posted+webinars/intake+and+eligibility+- +May+2017/ Intake+and+Eligibility.mp4 AE Self-Assessments 50. Will samples be the same during No, the sample will be different since each entity will be choosing a sample. self-assessment and onsite? 8

10 AE Onsite Review of Providers 51. What is the AE's role in reviewing a Provider self-assessment in years It is the intention that all entities engage in quality improvement activities during the two-year period between formal QA&I onsite review. All entities are required they do not have an Onsite? to review the results of their self-assessments to prioritize QI opportunities. Annually, at the completion of the self-assessment process, 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. 52. Will AEs be selecting samples for providers to use during onsite or will providers be selecting their own samples? The AE will select the sample for QA&I onsite review of Providers. 53. Will there still be Reviewing AEs? ODP no longer uses the terms Lead AE and Reviewing AE. The QA&I Process uses the terms Assigned AE. 54. Is there a projected date AEs will receive the list of providers selected for onsite for year 1? Yes, the projected date is July 15th. 55. How will providers know who their Assigned AE is? 56. Will AEs receive an for the link for QAI Process? The AE with the most individuals authorized with the Provider is designated as the Assigned AE. If the Provider does not serve any individuals, the Assigned AE is the AE that reviewed the Provider s most recent Provider Qualification (PQ) application. At this time, there is no link for AEs who are completing the review of Providers. Only the self-assessment link was sent out to SCOs and Providers. AEs will be completing their self-assessments in the AE Database, which is expected to be available 7/10/2017. For the QA&I onsite review, the primary contact of the Assigned AE will receive a link for QA&I onsite tool before Sept. 1 st. 57. When will the AE s be notified of the providers in the sample? A list of the providers who are due for an onsite this year has been posted on the internal AE DocuShare under the following path: ODP Division of Program Analysis Statewide and AE Summaries HCSIS and EIM QA&I It is also posted on the QA&I Resource page of MyODP and was sent out to all Primary and Secondary AE QA&I Leads. 9

11 58. The AE will select 1% of participants with a minimum of 5 and a maximum of 10 for individuals who are registered with the Assigned AE and are authorized and actively receiving services from the Provider being reviewed. Basically, almost every provider will fall into that maximum of 5 individuals reviewed unless they have more than 600 individuals authorized. And the only providers who will have a sample of 10 reviewed will have over 1000 individuals? 59. Should AEs be using the old Provider Monitoring letters to notify Providers of onsite? 60. Just to clarify, during an on-site visit, I have to complete at least one individual interview but can complete more if I choose to, is that correct? Yes, any provider that serves 500 individuals or less will have the minimum sample size of 5. Providers who serve 1000 or more individuals will have the maximum sample of 10. Any letters from the previous Provider Monitoring cycles should not be used. A new template which will be used by AEs to inform the Providers of an onsite review will be posted on MyODP in the next week or so. Once the updated information is posted, an will be sent out to all AE Leads letting them know that this information is posted. You are correct. For a Provider onsite review, AEs will interview at least one individual from the sample selected. Please note that this should be done for each provider. If you choose to, yes you can complete additional interviews. AE Questions Tool 61. Q 5A - Provider Monitoring process has been revised, do we assess the old process? For this first year, since ODP is looking back over the last 12 months and the QA&I process is new as of 7/1/2017, ODP will be looking to ensure that the AE conducted Provider Monitoring. That is why the question includes both Provider Monitoring and the QA&I process The AE conducts Provider Monitoring (QA&I 62. Q 13 - Recertification vs reevaluation? Process effective 7/1/2017) Reevaluation is the new term for recertification. AEs have the new reevaluation process in the draft Medicaid Eligibility bulletin and they should begin to use it. 63. Q 19A - Speaks to the protocol for reviewing plans that are auto authorized? 64. Q 19A - Is there any guidance for auto authorized ISPs? The new AEOA requires AEs to have a protocol related to the auto-authorization process and it is ODP s expectation that the AE will create this protocol and provide it to ODP during this first year of the QA&I process. Based on the auto-authorization training that was developed, AE s can begin to develop a protocol. Auto approval rules are provided in the Operating Agreement. 10

12 65. Q 19A - For plans that are autoauthorized and part of the sample will AE be responsible? 66. Q 30A Can the Human Rights Committee be delegated? Yes. This relates back to their protocol. They need to develop it in a way that ensures quality outcomes are in auto-authorized plans. QA&I will provide technical assistance around developing the AE protocol if requested. Yes. AE must have an agreement and a process to oversee their delegate. 11

13 SCO SPECIFIC QUESTIONS SCO General Questions 67. Did you indicate that it is not No, the new QA&I Process does replace SCO Monitoring. replacing SCO monitoring? 68. Will SCOs be monitored by every county that we work with or just by the lead county? 69. It appears that the SCO could have a desk review every year if they support individuals in multiple counties and if any of the individuals are chosen for the core sample of an AE which is having their onsite review. 70. IM4Q local programs will be contacting the SCO for background information to complete the individual interviews. Can there be one contact in the SCO? 71. What kind of information will the IM4Q interviewers request? 72. Can the SCO receive a list of IM4Q interviewers? 73. Can we review each other results on MyODP? Just to be clear, ODP conducts the QA&I Review of SCOs. SCOs will be reviewed based on Service Location regardless of lead counties. Yes, the SCO could have a desk review every year if an individual from the SCO is part of the AE sample. A desk review consists of ODP doing the desk review NOT the SCO. The SCO would be required to complete any remediation that may be found during desk review but this is the only responsibly of an SCO during nononsite years. They were given the direct number to the SCO and given the current SC s name. ODP plans to create a pre-survey document similar to the IM4Q pre-survey to help streamline this process next year. The same as the pre-survey information from the IM4Q program. Yes, however it may be a different local program depending on the sample size. Yes, the comprehensive reports will be posted on MyODP without the attachments. 12

14 SCO Self-Assessment 74. Should SCO's coordinate with the AE when pulling sample records or should we each pull separate records? No, SCOs should pull their own sample. 75. Do SCOs have to do anything to initiate receiving this ? 76. Will SCOs receive a unique link via as we did with SCO monitoring to complete this new process and when will we receive this link? 77. When you scroll over the percentage column C a pop up reviewer note appears, however, none of those reviewer notes actually match the questions they are pertaining to. Is there a new version that fixes this? Yes, Providers and SCOs had to confirm their primary and secondary contact information prior to July 1, 2017 in order to get the QuestionPro link for selfassessments. Yes, the unique links were sent out July 1, 2017 to all Providers and SCOs who confirmed their primary and secondary contact information. If a Provider or SCO did not confirm their primary and secondary contact information, please contact the QA&I mailbox at RA-PWQAIPROCESS@pa.gov That is from Cycle 6 of SCOM and there is not a correct version for this year. That can be added next year if it is helpful for SCOs. SCO Questions Tool 78. Some of the yes or no questions require a numerical response. Is that based on 0-100% of the individuals? Some of the questions are based on individual record review and not the entity as a whole. For those questions that are individual record based, you should use the SCO MCI review spreadsheet from the MyODP QA&I resource page. As you fill in the answers for each sample, you will get a percentage in column C. This percentage should be recorded and entered into QuestionPro for these questions. 79. Qs For new SCs for either the calendar year or fiscal year will they be broken out separately as they were last year? Your SCO will need to determine whether new hires prior to 7/1/2107 met the previous requirements (40 hour and look at the calendar year 2016 which ran from 1/1/2016 to 6/30/2017) 80. Qs Are the training records only for current employees? Yes, you should only look at the training records of current employees. 13

15 81. Q 22 - It is stated that to follow the source document Bulletin which states the calendar year and 40 hours of training. The question states 24 hours of training. The bulletin still states calendar year and 40 hours of training. It was used as source document because the waivers were not approved prior to the posting of the QA&I tool. As of July 12017, with the approval of the waiver, this changes to 24 hours a year and a fiscal year. We made the questions reflect the new hours even though we used the previous bulletin as our source document. For your self-assessment this year, you should use the 40-hour requirement and look at the calendar year 2016 which ran from 1/1/2016 to 6/30/2017 in order to account for the change over to the FY starting 7/1/ Q 24 - For Chapter 51 training of SC staff is this for FY , calendar year 2016 or calendar year 2017? For this year, it is calendar year 2016 as the change to fiscal year for training did not occur until 7/1/2017 with the waiver renewal. 83. Q 26 - For the 2017 SC personnel who are new, am I listing all face to face notes, if any, they may have completed prior to the completion of the Orientation course on the training spreadsheet? That column can be left blank by the SCO and will be filled out by the ODP QA&I staff. 84. Q 41 There is currently no guidance or requirement that the annual update meeting to be held within 365 of previous plan meeting as per section 3.10 of the current ISP Manual. The question is not asking about the ARU meeting. It is asking if the SC submitted the ARU ISP within 365 days of the prior annual ISP. There is a requirement that SCs submit the ISP for approval 30 days before the ARUD. Also, there is a requirement that the ARU meeting be held prior to the ARUD, which would fall within 365 days (section 3.10, pg 18, Facilitating the ISP meeting with all team members invited at least 60 calendar days prior to the end date of the ISP. ) 85. Q 43 - The instructions state that the reviewer is to choose the appropriate time frame from the drop down. However, the spreadsheet does not have a dropdown menu. When you enter the self-assessment into QuestionPro, there will be a drop down. The spreadsheet does not have a drop down. Please make note of how late it was so that you can select the correct drop down when you enter the information into QuestionPro. 14

16 86. Q 61 - The guidance for this question directs the reviewer to determine if the SC used the individual monitoring tool to record information about engaging in community activities that align with the individual s preference based on a review of service notes, Individual Monitoring Tools and the ISP. Yes, you can mark this question NA as CPS is a new service as of 7/1/2017. Please note that this question is Exploratory and for this year is meant to let SCOs know that this is ODP s expectation moving forward Due to this service (CPS) not available for the 12-month review period (7/1/16 thru 6/30/17), would the correct response be marked NA? 15

17 PROVIDER SPECIFIC QUESTIONS Provider General Questions 87. Is this replacing Provider Monitoring Yes, the new QA&I Process replaces Provider Monitoring. or is it an additional process? 88. We just completed Provider Monitoring/qualification, why are we doing this again so soon? This is a new process and all entities are required to participate. 89. In a 3-year cycle, how do the Providers know what year of the Cycle we are starting with? 90. Will Provider samples only include individuals from the lead AE or will Providers have to sample individuals from other AEs if Providers render services to them? 91. Will providers have prior notice of the AE selected sample prior to the onsite review? 92. The sampling will be decided based on the last digit of the MPI numberjust as was discussed in PQ? 93. Is this monitoring due every two years like Provider Monitoring was due? Go live of the new QA&I process on July 1, 2017 will start with Cycle 1 Year 1 (C1Y1). All providers must complete a self-assessment annually (all 3 years of a Cycle). Provider on-sites are determined by the last digit of the MPI #. Digits 0, 1 and 2 will get an onsite Year 1 Digits 3, 4 and 5 will get an onsite Year 2 Digits 6, 7, 8 and 9 will get an onsite Year 3. Providers newly qualified will be included in the QA&I Review during the next FY. For self-assessment, the sample should include a cross-section of individuals served, funding/program types, and locations and types of services. The AE will select 1% of participants with a minimum of 5 and a maximum of 10 for individuals who are registered with the Assigned AE and are authorized and actively receiving services from the Provider being reviewed. ODP no longer uses the terms Lead AE and Reviewing AE. The QA&I Process uses the terms Assigned AE. Assigned AE is the AE assigned to monitor and qualify a Provider by ODP. The AE with the most individuals authorized with the Provider is designated as the Assigned AE. If a Provider does not serve any individuals, the Assigned AE is the AE that reviewed the Provider s most recent Provider Qualification (PQ) application. Yes, the provider will be notified of the selected sample two weeks prior to the onsite. Yes No, the new QA&I cycle will occur over a 3-year period with each of the entities receiving a full QA&I review at least once within that period 16

18 94. As a provider, I don't see much of a difference between QA&I and Provider Monitoring. Am I seeing this correctly? ODP s intention with streamlining of the previous AE Oversight, SCO Monitoring and Provider Monitoring processes was to eliminate multi-layered process and unnecessary duplication; create more time to focus on the experience of individuals; create more time to focus on quality improvement; a desire to move away from hierarchical compliance and remediation toward collaborative partnerships that foster technical assistance and shared learning; and improve methods for collecting and using data in a timely way. 95. Will Provider Qualification be eliminated with the new QA&I process? 96. Our agency is licensed under the chapter 6400 regulations and does not follow chapter Can you please advise if this would apply to our agency? No, all Providers who wish to remain a willing and qualified Provider for ODP will need to complete the ODP Provider qualification process. At this time, all qualified and willing Providers with ODP should complete a QA&I self-assessment. 97. It appears providers only have to submit the checklist and supporting documentation when they have an onsite review. Is that correct? 98. The AE is picking a list of 5-10 consumers that they will review for the onsite review of the Provider. Will the Provider know who they are? 99. In the event a provider did PQ in the spring, that provider may very well end up in the Year 1 sample and be required to be qualified again? 100. What s the timeframe for provider qualification? 101. If an individual is pulled in core sample and that provider isn t due for an onsite what happens? 102. How it will be different now for individual interviews? The checklist is for Providers who are part of the QA&I review the QA&I review is a combination of the desk review and onsite review, which occurs at least once for each AE, SCO and Provider during the QA&I cycle. Yes, only Providers who are getting an onsite will need to submit the checklist and supporting documentation. The Provider will be informed 2 weeks before the onsite visit of what sample the AE chose. Yes, in order to roll the provider into the new process, a provider who was qualified in spring could be part of the Year 1 sample. Provider qualification timeframe remains unchanged. It is April 30th and June 30 th. ODP s expectation of providers in the years they are not due for an onsite is to participate in the interview process as applicable and ensure follow-up on any reported issues related to health and safety or service quality if an individual they provide services to is part of the core sample. AEs are expected to conduct at least one interview from the sample selected for a provider. For self-assessments, interviews are optional. In all cases, an individual can opt out of the interview. 17

19 103. If a provider is qualified but not providing services, will they be Yes, a provider who is in qualified status will be included in the QA&I review regardless of whether or not they serve any individuals. included? 104. Timeline clarification for interviews and onsite. 2-day onsite closure. The AE gives me a 2-week window. Could the AE interview someone before I even know the sample? 105. Could you explain more what is going to be posted on My ODP for Providers and AEs? 106. When AE comes to review, they have the capability to look at other counties. What type of releases will we need to prepare for that? Yes, this is possible. All interviews can take place before, during or after an onsite review. After an onsite review is completed for an entity, a copy of the final comprehensive report will be posted on MyODP. This will only include the comprehensive report, not any attachments or appendices. When the Assigned AE is coming to a Provider organization for an onsite review, the individuals selected in the sample would be from the Assigned AE only. Provider Self-Assessment 107. Should provider samples only include individuals with waiver No, the sample should include a cross-section of all individuals served, funding/program types, and locations and types of services. funding? 108. Will this new process include a similar document to the Provider Monitoring AE Tool and Guidelines that was provided in the past? 109. Will the sample that the provider chooses be also used by the Assigned AE for the onsite review? 110. Will Providers receive a unique link via as they did with Provider monitoring to complete this new process and when will Providers receive this link? 111. Do Providers have to do anything to initiate receiving this ? Yes, the documents are similar and are posted on the MyODP.org website (Resources > ODP Information > QA&I Process > Quality Assessment & Improvement Process Resources). No, the Assigned AE will pull a separate sample. Yes, the unique links were sent out July 1, 2017 to all Providers and SCOs who confirmed their primary and secondary contact information. If a Provider or SCO did not confirm their primary and secondary contact information, please contact the QA&I mailbox at RA-PWQAIPROCESS@pa.gov Yes, Providers had to confirm their primary and secondary contact information prior to July 1, 2017 in order to get the QuestionPro link for self-assessments. 18

20 112. We have folks in many programs including bus passes and mileage. Does this sample draw include mileage and bus pass people? 113. I wanted to ask about the submission check list and who exactly the provider should submit that documentation to. It states regional coordinator? 114. Our agency only provides service to 2 individuals. Should the MCI tool be completed for both and is this acceptable since the process doc states minimum of 5? If the only service an individual receives is mileage or bus pass, these individuals should not be a part of your sample. Your sample should include individuals that your agency provides services to more than just mileage or bus pass. The Providers should submit this information to the Assigned AE and not the Regional QA&I Coordinator. You will only use the two individuals that you provide service to. The minimum of 5 is if at least 5 individuals are served One of our centers is being acquired by another company in mid- August. What does that do to our requirement of completing this process by August 31? 116. Is the QA&I form optional and should it be used for Providers to evaluate and look for needed improvements? 117. The QA&I form for Providers is the form we use to input into the online area? 118. The Provider is picking a list of 5-10 consumers that they will review for the QA&I tool. Are these any consumers or only consumers for the lead AE? How does the Provider find out who the lead AE is? 119. How do I add my sample to the Provider QAI MCI spreadsheet and answer Y, N or NA. If your agency will continue to provide services at other centers, you will need to complete the self-assessment. When choosing your sample, please do not choose anyone from the center that is being acquired by another company. A Word document and MCI Review spreadsheet were provided that details the questions, guidance on how to answer them and the source document that the question is based off of. These tools must be used to evaluate your agency s performance. The results should be used to guide your quality improvements The answers that you get on the Word document and MCI Review spreadsheet must be entered into QuestionPro via the unique link that was sent to your agency s primary contact on July 1st. Your agency should have self-identified your primary and secondary contacts prior to July 1st. For self-assessments, all entities must choose their own sample of individuals, a minimum of 5, a maximum of 10, and the sample should include A cross-section of individuals served, including all funding/program types, locations and types of services On the spreadsheet, you will notice that Row #5 under the region information gives you blank columns to enter MCI numbers in beginning with Column G. You should put one MCI number in each cell in row 5 starting with column G. The Yes, No and NA will be answered in the Rows under the MCIs so Question 12 will be answered in Row 7 for each MCI. 19

21 Provider Questions Tool 120. Question 7 to 11 are missing on the Provider QA&I MCI review spreadsheet. For both Providers and SCOs, there are entity specific questions at the beginning of the tools ( Quality Assessment & Improvement (QA&I) Questions Tool for Providers and Quality Assessment & Improvement (QA&I) Questions Tool for Supports Coordination Organizations (SCOs) ). The QA&I MCI Review is only for the questions in the Provider and SCO tools that are specific to the individual record reviews. The Questions Tools should be used to view all the questions along with the guidance on how to answer the questions. The QA&I MCI Review should be used to track the answers for the self-assessment sample record review The instructions say to include documentation for the previous 12 months vs. the last quarter of the fiscal year as has been requested in previous monitoring. Is this correct as there will be multiple 6-inch binders that will need to be reviewed when on site comes to our agency? (We are scheduled for onsite this year) 122. I'm not seeing in the Questions Tool, when I use the MCI review spreadsheet results. When does that come into play? 123. Some of the yes or no questions require a numerical response. Is that based on 0-100% of the individuals? Please read the questions. Numerous questions in the Provider tool only ask for the last 6 months or quarter s worth of information. For any question that does not specify a specific time frame, then you will review the previous 12 months. Please review the Provider MCI review spreadsheet. That MCI review spreadsheet identifies the questions that it should be used to answer. Some of the questions are based on individual record reviews and not the entity as a whole. For those questions that are individual record based, you should use the Provider QA&I MCI review spreadsheet from the MyODP QA&I resource page. As you fill in the answers for each sample, you will get a percentage in column C this percentage should be recorded and entered into QuestionPro for these questions What is the process to determine answers in reference to staff training? Should providers select one staff that works directly with each of the individuals in the sample? 125. Providers are confused with the breakdown in the trainings. Is there a clarification somewhere? Depending on the question, the guidelines specify the staff that should be reviewed. For instance, question #14 states "all new hire staff." Please review the guidance for each question as information is more specific regarding the requirements for the question. 20

22 126. Question about new hires is not specific. If they had 6 new hires in Please review the guidance for each question as information is more specific regarding the requirements for the question. the last year, do they do all 6 new hires? 127. Qs 13 & 14 For these questions should we review staff supporting the sample individuals, or, does the question call for the review of all staff providing direct support hired in the past 12 months? 128. Q 14 - Does this include all staff hired in the last 12 months, still active and only providing direct supports? 129. Q 14 - If the question is calling for the review of all newly hired direct support staff, I have determined that the agency has hired a large number of staff in the last 12 months, most of which are still Q 22 Is this a transition to another provider only? Would it include employment as individual s transition? 131. Q 41 What is a critical incident verses an incident? 132. Q 45 For the sample selected, the reviewer will determine if the Provider's daily documentation reflects that the individual's..." There is no time frame, so I assume you are seeking 12 months. Just for clarification, you want 12 months of daily documentation for all of the consumers in our sample? 2,000 pages? Q 13 is specific to the sample individuals and their staff support. Q 14 is ALL new staff hired within the last 12 months who work with individuals. Yes, only staff hired within the last 12 months and actively working providing direct supports should be included in your count. Your agency will need to review all the staff hired within the last 12 months that are still employed to answer Q 14. This is transition to another provider only when your agency stops providing services to an individual. If your agency continues to provide supports and an individual is getting additional supports from another provider, this answer would be NA. This applies to all services including employment. Critical incidents are defined as incidents in the IM Bulletin (Bulletin , Incident Management) as those requiring an investigation at any level. - Abuse - Neglect - Misuse of funds - Rights Violation - Death Q 45 does not have a specified timeframe, so yes, it is for 12 months. The daily documentation that is being looked at for this question is specific to medical appointments ( regular medical appointments, routine screenings such as mammograms, prostate, etc.; follow-ups as recommended by the treating practitioner as well as screenings for risk factors such as dysphasia screenings for those who demonstrate swallowing difficulties ). Daily documentation that relates to these medical appointments should be maintained. 21

23 Quality Management Plan Questions 133. Is the Quality Management Plan a part of this new process? Yes, just as each entity s QM Plan and accompanying Action Plan was evaluated as part of the previous AE Oversight, SCO and Provider Monitoring Processes, ODP and/or the AE, as appropriate, will continue to review and evaluate each entity s QM Plan and accompanying Action Plan as part of the QA&I Process Will there be a specific due date for the QM Plan? 135. How do I obtain technical assistance in developing QM Plans and Action Plans? In addition, if an area in need of systemic improvement is identified during the QA&I Process and an update is needed to the QM Plan and/or Action Plan in order to address this finding, the entity will be expected to submit an updated QM Plan and/or Action Plan to the Regional QA&I Review Team or AE, as appropriate, as part of its Plan to Prevent Recurrence (PPR). QM Plans and accompanying Action Plans should be maintained ongoing and will continue to follow a Fiscal Year cycle. They will be reviewed by ODP and/or the AE, as appropriate, as part of the QA&I Process during the year each entity undergoes onsite review. When an update to the QM Plan and/or Action Plan is to be submitted as part of the entity s PPR, this documentation will be due to the Regional QA&I Review Team or AE, as appropriate, within 30 days of the date of the closure of the entity s Comprehensive Report. AEs and SCOs The first point of contact for technical assistance in developing QM Plans and Action Plans for AEs and SCOs begins in your organizations with those on staff who have become ODP QM Certified. The second point of contact for AEs and SCOs is their ODP Regional QA&I Coordinator. ODP Regional QA&I Coordinators will collaborate with ODP s QM Staff for input when indicated. Providers The first point of contact for technical assistance in developing QM Plans and Action Plans for Providers begins in your organizations with those on staff who have become ODP QM Certified. The second point of contact for Providers is their AE Review Team Lead. AEs may collaborate with ODP s Regional QA&I Coordinator when indicated. ODP QM Staff continue to offer QM Certification Classes open to Administrative Entities/Counties, Supports Coordination Organizations, Providers, HCQUs and ODP Staff. Three classes will be available in fall Please refer to the ODP Communication Number that outlines dates, locations, and requirements for these classes. ODP QM Staff will schedule additional classes in spring and fall 2018 and ongoing as long as the need for training exists. Please watch for future communications that will include details. 22

24 136. How do I fold a QM Plan and/or Action Plan updated as a consequence of the QA&I Process into the Fiscal Year cycle for QM documents, o Planning? If you have a QM Plan and accompanying QM Action Plan Focus Area already in place and findings from the QA&I Process prompt you to update these Update your existing Action Plan until it s time to develop your new Fiscal Year QM Plan and Action Plan, then o 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 Focus Area, o o o o Add that new Focus Area, Goal and Target Objective to the existing QM Plan that will carry you to June 30th of the following fiscal year This may mean your Target Date is more than 12 months away Add Action Plan steps to achieve the Target Objective Implement the new work immediately with continuation in the following fiscal year 137. How do ODP s priorities published in the PA Bulletin fit into current QM Plans? 138. How and when will the 6100 regulations on Quality Management affect development of QM Plans and Action Plans? ODP s priorities published in the PA Bulletin December 1, 2012 remain relevant. They align with one of ODP s ISAC Recommendations, a CMS Waiver Assurance area, or a health and safety focus area for ODP. Draft regulatory language was provided for public comment. ODP received much input indicating that stakeholders felt this language was overly prescriptive and that designating a department-specified form wasn t necessary. Subsequently, we ve made significant changes. We re hoping that final regulations will be published in December 2017, and the earliest we expect implementation of the QM regulations is July That said, we fully expect the QM Plan and Action Plan developed in QM Certification Class to continue to meet requirements. As we discuss during class, ODP s quality priorities are achieving the ISAC Recommendations, meeting CMS Waiver Assurances, and assuring health and safety all using person-centered feedback and approaches in line with Everyday Lives values. Our QM Plans and Action Plans contain the essential elements we will continue to look for in developing and tracking quality improvement efforts. Templates for QM Plans and QM Action Plans continue to be posted on MyODP.org at Click on Quality Planning and Implementation Documents. 23